Arthroscopic Surgery

Definition
Purpose
Precautions
Description
Diagnosis/Preparation
Aftercare
Risks
Normal results
Alternatives

Definition

Arthroscopic surgery is a procedure that allows surgeons to visualize, diagnose, and treat joint problems. The name is derived from the Greek words arthron, joint, and skopein, to look at. Arthroscopy is performed using an arthroscope, a small fiber-optic instrument that enables a close look at the inside of a joint through a small incision.

Purpose

Arthroscopic surgery is used to diagnose, treat, and monitor joint injuries and diseases that affect the joints. Diagnostic arthroscopic surgery is performed

when the medical history, physical exam, x rays, and bone scanning examinations, such as MRI or CT, do not provide a definitive diagnosis. Corrective arthroscopic surgery is used primarily to remove bone or cartilage or repair tendons or ligaments.

Precautions

Diagnostic arthroscopic surgery is not recommended unless nonsurgical treatment does not fix the problem.

Description

Arthroscopic surgery is performed most commonly on the knees, and also on ankles, shoulders, wrists, elbows, and hips. Knee joints are large enough to allow free movement of arthroscopic instruments and therefore are ideal for the benefits of this type of examination and treatment. The technique is valued because it allows surgeons to see inside the joint through incisions as tiny as a quarter of an inch (about 1 cm) rather than the large incisions that open surgery procedures require. The accuracy of arthroscopy is said to be 100% for diagnosis compared to diagnostic imaging such as MRI. Arthroscopic surgery may be used to relieve mechanical joint problems, such as buckling, stiffness, or locking, and can preclude or delay the need for more aggressive surgery such as a joint replacement.

In arthroscopic surgery, an orthopedic surgeon uses a pencil-sized arthroscope—a fiber-optic instrument fitted with a lens, a light source, and a miniature video camera—to see inside a joint. Advanced fiber optics allow even more detail to be seen than in open surgery, often identifying problems that may have been difficult to diagnose with other methods. The arthroscope transmits highlighted images of the structures to a television monitor in the operating room. The surgeon is able to view the entire examination, getting a full view of the joint, its cartilage, and surrounding tissue. The type and extent of the injury can be determined and repair or correction can be performed if necessary. Some of the most common joint problems diagnosed and treated with arthroscopic surgery are:

• synovitis (inflamed joint lining) of the knee, shoulder, elbow, wrist, or ankle
• injuries to the shoulder, such as rotator cuff tendon tears, impingement syndrome, and dislocations
• injuries to the knee, such as meniscal (cartilage) tears, wearing down of or injury to the cartilage cushion, and anterior cruciate ligament tears with instability
• injuries to the wrist, such as carpal tunnel syndrome
• loose bodies of bone and/or cartilage in the knee, shoulder, elbow, ankle, or wrist
• oint damage caused by rheumatoid arthritis or osteoarthritis

Arthroscopic procedures are performed in a hospital or outpatient surgical facility by an orthopedic surgeon. The type of anesthesia used (local, spinal, or general) varies, as does the length of the procedure; both depend on the joint that will be operated on, the type and extent of the suspected joint injury, and/or

KEY TERMS

Arthroscope— A pencil-sized fiber-optic instrument fitted with a lens, light source, and camera, used for detailed examination of joints.

Cartilage— The slippery tissue that covers the ends of joint bones.

Meniscal— Pertaining to cartilage.

Open surgery— Surgery using a large incision to lay open area for examination or treatment; in joint surgery, the whole joint is exposed.

Osteoarthritis— A degenerative “wear-and-tear” joint disease related to aging.

Rheumatoid arthritis— A chronic autoimmune disease characterized by inflammation of multiple joints and crippling effects.

Synovitis— Inflammation of the synovium, the thin membrane lining the joint.

the complexity of the anticipated repair. Arthroscopic surgery rarely takes more than an hour. Most patients who have arthroscopic surgery, whether diagnostic or corrective, are discharged the same day of the procedure; some patients, depending on the complexity of the surgery or their postoperative condition, may stay in the hospital one or two days.

Considered the most important orthopedic development in the twentieth century, arthroscopic surgery is widely used. The American Association of Orthopedic Surgeons reports that it is performed by 80% of all orthopedic surgeons. The use of arthroscopic surgery on famous athletes has been well publicized. Although arthroscopic surgery was initially only a diagnostic tool used prior to open surgery, the availability of better instruments and techniques has encouraged its use to actually treat a variety of joint problems, often avoiding more complicated surgeries with longer recovery times. New techniques under development are likely to lead to other joints being treated with arthroscopic surgery in the future. Laser technology has been introduced as a treatment option in arthroscopic surgery and other advanced technologies are being explored.

Surgical procedure

After making two small incisions about the size of a buttonhole in the skin near the joint, the surgeon injects sterile sodium chloride solution through one incision into the joint to expand it for better viewing and movement of the instruments. The surgeon will also use this access to irrigate (flood with fluid) the oint area during surgery and to suction blood and debris away from the joint. This irrigation, or “washing” part of the procedure, is believed to be of value in itself, improving joint function. The arthroscope is then inserted into the second incision. While looking at the interior of the joint on the television monitor, the surgeon can determine the extent or type of injury and, if necessary, take a biopsy specimen or repair or treat the problem. A third tiny incision may be made in order to see other parts of the joint or to insert additional instruments, such as laser or tiny scalpels, when repairs or corrections need to be made. Arthroscopic surgery can be used to remove floating bits of cartiage, to debride (clean by removing tissue or bone), and to treat minor tears and other disorders. When the procedure is finished, the arthroscope is removed and the joint is once again irrigated. The site of the incision is dressed with compression bandages (ace bandages).

Diagnosis/Preparation

Prior to arthroscopy, the patient’s medical history will be reviewed and the patient will have a complete physical examination. Standard preoperative blood and urine tests will be done as well as scans of the affected joint, such as MRI (magnetic resonance imaging), CT (computed tomography), and arthrogram (an x ray using dye). In some cases, an exercise regimen or muscle stimulation treatment (TENS) may be recommended to strengthen muscles around the joint prior to surgery. Surgeons may recommend preoperative guidelines, such as:

• Discontinue aspirin and anti-inflammatory medications two weeks before surgery.
• Stop smoking to encourage postoperative healing.
• Inform the surgeon if any fever or other illness occurs, or if cuts, scratches, or bruises appear near the surgical site before the scheduled surgery.
• Do not eat, drink, or chew gum for 12 hours prior to surgery.
• Bring crutches or a walker if hip, knee, or ankle arthroscopy is being performed.
• Wear loose fitting clothing to allow for bulky dressings over the surgical site.

Aftercare

Immediately after the procedure, the patient will spend up to two hours in a recovery area before being discharged. Some patients may be transferred to a hospital room if the surgeon determines overnight care is necessary. The surgical site will be dressed with a compression bandage (ace bandage) or a tightly

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Arthroscopic surgery is performed in a hospital operating room or an outpatient surgical facility by an orthopedic surgeon.

fitting stocking (support hose). An ice pack will be placed on the joint that was examined or treated by arthroscopy. This treatment may continue for up to 72 hours after surgery to keep swelling down and help prevent the formation of clots. Pain medication will be administered if needed, although most patients require little or no medicine for pain. Dressings can usually be removed the morning after surgery and replaced by adhesive strips. The surgeon should be notified if the patient experiences any increase in pain, swelling, redness, drainage or bleeding at the site of the surgery, signs of infection (headache, muscle aches, dizziness, fever), and nausea or vomiting.

It takes several days for the puncture wounds to heal, and several weeks for the joint to fully recover. Many patients can resume their daily activities, including going back to work, within a few days of the procedure. Muscle strength must be regained as soon as possible after surgery to help support the affected joint. A rehabilitation program, including physical therapy, may be suggested to speed recovery and improve the functioning of the joint. The surgeon’s recommendations for recovery may include:

• Keep the surgical site and the dressings clean and dry.
• Use ice packs for up to 72 hours to reduce pain and swelling.
• Elevate the affected joint (wrist, elbow, ankle, knee) on pillows; exercise gently to encourage circulation.
• Use a knee brace or shoulder sling temporarily.
• Allow weight-bearing exercise as able.

Risks

Few complications are to be expected with arthroscopy. Those that may occur occasionally (fewer than 1% of all arthroscopies, according to the American Academy of Orthopedic Surgeons) are infection, blood clot formation, swelling or bleeding, or damage to blood vessels or nerves. Rare instrument breakage during procedures has also been reported.

QUESTIONS TO ASK THE DOCTOR

• Why is arthroscopy necessary for me?
• What kind of anesthesia will I have?
• How often do you perform this procedure? What results are typical?
• How much discomfort can I expect short term? Long term?
• Will physical therapy be necessary after the surgery?
• Will this procedure correct my joint problem?

Normal results

Most patients undergo arthroscopic surgery as an outpatient and are home within hours or at most a day or two. Pain and complications are rare, and most patients will enjoy improved mobility as they recover over a period of days, possibly with the aid of physical therapy and gentle exercise.

Some people undergoing arthroscopy may have preexisting conditions and diseases that will affect the surgical result. Recovery times will vary depending on each patient’s overall condition. Certain problems may need to be treated with a combination of arthroscopic and open surgical procedures.

Alternatives

Alternatives to arthroscopic surgery include:

• changing activities to those less strenuous or demanding
• anti-inflammatory medications
• physical therapy and appropriate, gentle exercise such as yoga
• wearing a brace or using a walking aid
• glucosamine sulfate and chondroitin to reduce pain and stiffness
• therapeutic massage, acupuncture, or other body work

Resources

BOOKS

Canale, S. T., ed. Campbell’s Operative Orthopaedics. 10th ed. St. Louis: Mosby, 2003.

DeLee, J. C., and D. Drez. DeLee and Drez’s Orthopaedic Sports Medicine. 2nd ed. Philadelphia: Saunders, 2005.

PERIODICALS

Committee on Ethics and Standards of the Arthroscopy Association of North America. “Suggested guidelines for the practice of arthroscopic surgery.” Arthroscopy (June 2005): A3668.

ORGANIZATIONS

American Academy of Orthopedic Surgeons(AAOS). 6300 North River Road, Rosemont, IL 60018. (800) 346-AAOS. http://www.aaos.org (accessed March 6, 2008).

Institute for Bone and Joint Disorders. 2222 East Highland Avenue, Phoenix, AZ 85016; 602-553-3113. http://www.ibjd.com (accessed March 6, 2008).

Cooke, K. V. “Arthroscopy for Rheumatoid Arthritis.” September 5, 2002 [cited April 2003]. http://www.laurushealth.com (accessed March 6, 2008).

“Joint Irrigation for Osteoarthritis.” Ivanhoe Newswire 5(2003): 20-26 [cited April 2003]. http://www.ivanhoe.com/newsalert (accessed March 6, 2008).

Lori De Milto

L. Lee Culvert

Rosalyn Carson-DeWitt, MD

Arthroscopic surgery

Definition

Arthroscopic surgery is a procedure that allows surgeons to visualize, diagnose, and treat joint problems. The name is derived from the Greek words arthron, joint, and skopein, to look at. Arthroscopy is performed using an arthroscope, a small fiber-optic instrument that enables a close look at the inside of a joint through a small incision.

Purpose

Arthroscopic surgery is used to diagnose, treat, and monitor joint injuries and diseases that affect the joints. Diagnostic arthroscopic surgery is performed when the medical history, physical exam, x rays, and bone scanning examinations, such as MRI or CT, do not provide a definitive diagnosis. Corrective arthroscopic surgery is used primarily to remove bone or cartilage or repair tendons or ligaments.

Precautions

Diagnostic arthroscopic surgery is not recommended unless non-surgical treatment does not fix the problem.

Description

Arthroscopic surgery is performed most commonly on the knees, and also on ankles, shoulders, wrists, elbows, and hips. Knee joints are large enough to allow free movement of arthroscopic instruments and therefore are ideal for the benefits of this type of examination and treatment. The technique is valued because it allows surgeons to see inside the joint through incisions as tiny as a quarter of an inch (about 1 cm) rather than the large incisions that open surgery procedures require. The accuracy of arthroscopy is said to be 100% for diagnosis compared to diagnostic imaging such as MRI. Arthroscopic surgery may be used to relieve mechanical joint problems, such as buckling, stiffness, or locking, and can preclude or delay the need for more aggressive surgery such as a joint replacement.

In arthroscopic surgery, an orthopedic surgeon uses a pencil-sized arthroscope—a fiber-optic instrument fitted with a lens, a light source, and a miniature video camera—to see inside a joint. Advanced fiber optics allow even more detail to be seen than in open surgery, often identifying problems that may have been difficult to diagnose with other methods. The arthroscope transmits highlighted images of the structures to a television monitor in the operating room . The surgeon is able to view the entire examination, getting a full view of the joint, its cartilage, and surrounding tissue. The type and extent of the injury can be determined and repair or correction can be performed if necessary. Some of the most common joint problems diagnosed and treated with arthroscopic surgery are:

• synovitis (inflamed joint lining) of the knee, shoulder, elbow, wrist, or ankle
• injuries to the shoulder, such as rotator cuff tendon tears, impingement syndrome, and dislocations
• injuries to the knee, such as meniscal (cartilage) tears, wearing down of or injury to the cartilage cushion, and anterior cruciate ligament tears with instability
• injuries to the wrist, such as carpal tunnel syndrome
• loose bodies of bone and/or cartilage in the knee, shoulder, elbow, ankle, or wrist
• joint damage caused by rheumatoid arthritis or osteoarthritis

Arthroscopic procedures are performed in a hospital or outpatient surgical facility by an orthopedic surgeon. The type of anesthesia used (local, spinal, or general) varies, as does the length of the procedure; both depend on the joint that will be operated on, the type and extent of the suspected joint injury, and/or the complexity of the anticipated repair. Arthroscopic surgery rarely takes more than an hour. Most patients who have arthroscopic surgery, whether diagnostic or corrective, are discharged within the same day; some patients, depending on the complexity of the surgery or their post-operative condition, may stay in the hospital one or two days.

Considered the most important orthopedic development in the twentieth century, arthroscopic surgery is widely used. The American Association of Orthopedic Surgeons reports that it is performed by 80% of all orthopedic surgeons. The use of arthroscopic surgery on famous athletes has been well publicized. Although arthroscopic surgery was initially only a diagnostic tool used prior to open surgery, the availability of better instruments and techniques has encouraged its use to actually treat a variety of joint problems, often avoiding more complicated surgeries with longer recovery times. New techniques under development are likely to lead to other joints being treated with arthroscopic surgery in the future. Laser technology has been introduced as a treatment option in arthroscopic surgery and other advanced technologies are being explored.

Surgical procedure

After making two small incisions about the size of a buttonhole in the skin near the joint, the surgeon injects sterile sodium chloride solution through one incision into the joint to expand it for better viewing and movement of the instruments. The surgeon will also use this access to irrigate (flood with fluid) the joint area during surgery and to suction blood and debris away from the joint. This irrigation, or "washing" part of the procedure, is believed to be of value in itself, improving joint function. The arthroscope is then inserted into the second incision. While looking at the interior of the joint on the television monitor, the surgeon can determine the extent or type of injury and, if necessary, take a biopsy specimen or repair or treat the problem. A third tiny incision may be made in order to see other parts of the joint or to insert additional instruments, such as laser or tiny scalpels, when repairs or corrections need to be made. Arthroscopic surgery can be used to remove floating bits of cartilage, to debride (clean by removing tissue or bone), and to treat minor tears and other disorders. When the procedure is finished, the arthroscope is removed and the joint is once again irrigated. The site of the incision is dressed with compression bandages (ace bandages).

Diagnosis/Preparation

Prior to arthroscopy, the patient's medical history will be reviewed and the patient will have a complete physical examination . Standard pre-operative blood and urine tests will be done as well as scans of the affected joint, such as MRI (magnetic resonance imaging ), CT (computed tomography), and arthrogram (an x ray using dye). In some cases, an exercise regimen or muscle stimulation treatment (TENS) may be recommended to strengthen muscles around the joint prior to surgery. Surgeons may recommend pre-operative guidelines, such as:

• Discontinue aspirin and anti-inflammatory medications two weeks before surgery.
• Stop smoking to encourage post-operative healing.
• Inform the surgeon if any fever or other illness occurs, or if cuts, scratches, or bruises appear near the surgical site before the scheduled surgery.
• Do not eat, drink, or chew gum for 12 hours prior to surgery.
• Bring crutches or a walker if hip, knee, or ankle arthroscopy is being performed.
• Wear loose fitting clothing to allow for bulky dressings over the surgical site.

Aftercare

Immediately after the procedure, the patient will spend up to two hours in a recovery area before being discharged. Some patients may be transferred to a hospital room if the surgeon determines overnight care is necessary. The surgical site will be dressed with a compression bandage (ace bandage) or a tightly fitting stocking (support hose). An ice pack will be placed on the joint that was examined or treated by arthroscopy. This treatment may continue for up to 72 hours after surgery to keep swelling down and help prevent the formation of clots. Pain medication will be administered if needed, although most patients require little or no medicine for pain. Dressings can usually be removed on the morning after surgery and replaced by adhesive strips. The surgeon should be notified if the patient experiences any increase in pain, swelling, redness, drainage or bleeding at the site of the surgery, signs of infection (headache, muscle aches, dizziness, fever), and nausea or vomiting.

It takes several days for the puncture wounds to heal and several weeks for the joint to fully recover. Many patients can resume their daily activities, including going back to work, within a few days of the procedure. Muscle strength must be regained as soon as possible after surgery to help support the affected joint. A rehabilitation program, including physical therapy, may be suggested to speed recovery and improve the functioning of the joint. The surgeon's recommendations for recovery may include:

• Keep the surgical site and the dressings clean and dry.
• Use ice packs for up to 72 hours to reduce pain and swelling.
• Elevate the affected joint (wrist, elbow, ankle, knee) on pillows; exercise gently to encourage circulation.
• Use a knee brace or shoulder sling temporarily.
• Allow weight-bearing exercise as able.

Complications

Few complications are to be expected with arthroscopy. Those that may occur occasionally (fewer than 1% of all arthroscopies, according to the American Academy of Orthopedic Surgeons) are infection, blood clot formation, swelling or bleeding, or damage to blood vessels or nerves. Rare instrument breakage during procedures has also been reported.

Normal results

Most patients undergo arthroscopic surgery as an outpatient and are home with hours or at most a day or two. Pain and complications are rare and most patients will enjoy improved mobility as they recover over a period of days, possibly with the aid of physical therapy and gentle exercise.

Some people undergoing arthroscopy may have preexisting conditions and diseases that will affect the surgical result. Recovery times will vary depending on each patient's overall condition. Certain problems may need to be treated with a combination of arthroscopic and open surgical procedures.

Alternatives

Alternatives to arthroscopic surgery include:

• changing activities to those less strenuous or demanding
• anti-inflammatory medications
• physical therapy and appropriate, gentle exercise such as yoga
• wearing a brace or using a walking aid
• glucosamine sulfate and chondroiten to reduce pain and stiffness
• therapeutic massage, acupuncture, or other body work

Resources

books

Andrews, James R. and Laura A. Timmerman. Diagnostic and Operative Arthroscopy. Philadelphia: W. B. Saunders Co., 1997.

Brillhart, Allen T., ed. Arthroscopic Laser Surgery: Clinical Applications. New York: Springer-Verlag, 1995.

Oxford Medical Publications. Oxford Textbook of Sports Medicine. New York: Oxford Medical Publications, 1994.

periodicals

Wilkinson, Todd. "Pop, Crackle, Snap." Women's Sports & Fitness (April 1998): 68.

organizations

American Academy of Orthopedic Surgeons(AAOS). 6300 North River Road, Rosemont, IL 60018. (800) 346-AAOS. <http://www.aaos.org>.

Institute for Bone and Joint Disorders. 2222 East Highland Avenue, Phoenix, AZ 85016; 602-553-3113. <http://www.ibjd.com>.

other

American Academy of Orthopaedic Surgeons. Arthroscopy. April 15, 1998 [cited April 2003]. <http://www.aaos.org>.

The Arthritis Foundation. About Arthroscopic Surgery. [cited April 2003]. <http://www.arthritis.org>.

Cooke, K. V. "Arthroscopy for Rheumatoid Arthritis." Laurushealth.com September 5, 2002 [cited April 2003]. <http://www.laurushealth.com/library>.

"Joint Irrigation for Osteoarthritis." Ivanhoe Newswire 5(2003): 20–26 [cited April 2003]. <http://www.ivanhoe.com/newsalert>.

"Knee Arthroscopy." The Center for Orthopaedics and Sports Medicine. April 15, 1998 [cited April 2003]. <http://www.arthroscopy.com>.

Lori De Milto L. Lee Culvert

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Arthroscopic surgery is performed in a hospital operating room or an outpatient surgical facility by an orthopedic surgeon.

QUESTIONS TO ASK THE DOCTOR

• Why is arthroscopy necessary for me?
• What kind of anesthesia will I have?
• How often do you perform this procedure? What results are typical?
• How much discomfort can I expect short term? Long term?
• Will physical therapy be necessary after the surgery?
• Will this procedure correct my joint problem?

Arthroscopic surgery

Resources

Arthroscopic surgery refers to a type of surgery performed on joints. It is a type of orthopedic surgery that utilizes an instrument called an arthroscope, which allows the surgeon to view the inside of a joint without a large incision. In contrast to joint surgery that used to involve an extensive incision, arthroscopic surgery requires only three small incisions (portals), each about 0.25 inches (6 millimeters [mm]) long. This considerably lessens the chance of post-operative infection and speeds the recovery time. In a famous example, the marathon runner Joan Benoit Samuelson won the 1984 Olympic Trials marathon only 17 days after undergoing arthroscopic knee surgery.

The word arthroscope is from the Greek words meaning “to look at joints.” The arthroscope is made up of a lens and a light source, and is connected to a video camera. The surgeon can view the inside of the joint directly through the arthroscope, or an image may be displayed on a video screen. This image gives the surgeon a clear view of the tissue inside the joint. The surgeon can then use other tiny instruments (on the order of only one-eighth of an inch, or 3–4 mm, in diameter) to perform necessary procedures. Arthroscopic surgery can be used as a diagnostic tool or for corrective procedures ranging from easing the pain of arthritic patients to mending torn ligaments. Indeed, both procedures can sometimes be performed during the same surgical procedure.

A typical arthroscopic procedure takes less than one hour, and the patient can return home the same day. A surgeon may perform an arthroscopic procedure in an office, a hospital, or an outpatient surgery center.

The technique for arthroscopic surgery was first described in the early 1930s, although it was not refined until the 1960s. The arthroscope was first used only to view the inside of the knee. In the 1970s, fiber-optic technology became readily available, and more surgeons began to use the procedure on the hip and shoulder in addition to the knee. In the 1980s, arthroscopic surgery could be performed on smaller joints such as the ankle. As of 2006, more than one million arthroscopic surgeries are performed each year in the United States, with the majority being associated with the sports-related injuries.

Arthroscopic procedures are relatively simple. Before knee, ankle, or hip surgery, a patient may want to practice walking on crutches to make the post-operative recovery more comfortable. Fasting is usually required before the procedure because of the use of anesthetics. Anesthesia is usually local, although in more complicated surgeries general anesthesia can be given. A spinal anesthesia or epidural is given to numb the patient from the waist down if necessary. A patient may also be given a sedative to help with relaxation during the procedure. Hair will typically need to be shaved around the incision sites to lessen the risk of infection. Monitoring devices such as a pulse reader or an electrocardiogram may be attached to the patient in some cases. As with all surgical techniques, instruments and the incision sites are completely sterilized to reduce the risk of infection.

The surgery itself begins when a tourniquet is wrapped around the joint. The limb is then elevated to drain blood away from the joint. Saline solution is injected into the joint through a cannula, or drainage tube, first to distend the joint, or cause it to swell, and then to irrigate it, or flush it during the procedure. Swelling of the joint gives the surgeon more room to operate. The continuous flushing washes away any cartilage or other fragments that might break off into the joint during the procedure. The arthroscope is then inserted, and the surgeon examines the joint using high-resolution imagery. After an initial diagnosis, a surgical procedure may be performed, such as using a cutter to remove tissue. After the procedure is finished, the instruments are removed from the joint and the saline is squeezed out. Sometimes steroids are injected into the joint to reduce inflammation. The incisions are closed with sutures and covered with bandages, thus completing the surgery.

Post-operative procedures include icing the joint and elevating the limb to minimize swelling. Patients are often advised not to drive for 24 hours. Painkillers may be prescribed to alleviate soreness or discomfort. Incisions should be kept clean and dry until they are completely

KEY TERMS

EKG— Abbreviation for electrocardiograph, a device used to record electrical changes during a heartbeat.

Fasting— Abstaining from food.

Fiber optics— A thin plastic or glass tube that transmits light through internal reflection.

General anesthesia— Loss of sensation in the entire body.

Incision— A surgical cut.

Local anesthesia— Loss of sensation in a specific portion of the body.

Orthopedics— A branch of medicine dealing with the prevention or treatment of skeletal deformities.

Saline solution— A saltwater solution.

Sedative— Medicine that has a calming effect and may be used to treat nervousness or restlessness.

Steroids— A group of organic compounds that belong to the lipid family and that include many important biochemical compounds including the sex hormones, certain vitamins, and cholesterol.

Suture— Substance used to close a surgical wound.

Tourniquet— A device used to stop blood flow.

healed. The patient may need to return to the surgeon for removal of sutures. Use of the joint is usually limited for a time after surgery, and physical therapy is often recommended to help restore mobility and strength. Complications are uncommon but may include infection or bleeding in the area of the incision.

Arthroscopy can be used for many different procedures. It can be used in the knee, hip, shoulder, ankle, wrist, or elbow. Diagnoses made with arthroscopes are significantly more accurate than those made based on symptoms alone. One common type of arthroscopic surgery is a meniscectomy; removal of torn cartilage in the knee. Other common procedures in the knee include the repair of torn cartilage or ligaments and removal of scar tissue on the patella, or kneecap. Hip arthroscopies are used to remove loose bodies, pieces of cartilage, or scar tissue that has broken away from surrounding tissue. Other procedures used in the hip joint include removing bone fragments or cartilage build-up. In the shoulder, arthroscopic surgery is used to repair the rotator cuff as well as to remove loose bodies. Arthroscopic procedures can be employed to alleviate the pain of certain types of arthritis. Arthroscopic surgery may also be used with an open surgical procedure, such as an anterior cruciate ligament reconstruction.

Resources

BOOKS

Beach, William R., et al. An Atlas of Arthroscopic Techniques. Abingdon, UK: Taylor & Francis, 2003.

Brunicardi, F. Charles, et al. Schwartz’s Manual of Surgery. New York: McGraw-Hill Professional, 2006.

Kaye, Andrew H., et al. Textbook of Surgery. Boston: Blackwell Publishing, 2006.

Jennifer McGrath

Arthroscopy

Definition

Arthroscopy is the examination of a joint, specifically, the inside structures. The procedure is performed by inserting a specifically designed illuminated device, called an arthroscope, into the joint through a small incision. Arthroscopy may be used to diagnose, as well as treat, conditions. When a repair is performed, the procedure is called arthroscopic surgery.

Purpose

Arthroscopy is used primarily by physicians who specialize in treating disorders of the bones and related structures (orthopedics) to help diagnose joint problems. Once described as essential for those who primarily care for athletic injuries, arthroscopy is now a technique commonly used by orthopedic surgeons for the treatment of patients of all ages. The six joints most frequently examined are:

• knee
• shoulder
• elbow
• ankle
• hip
• wrist

A joint is a complex system. Within a joint, ligaments attach bones to other bones, tendons attach muscles to bones, cartilage lines and helps protect the ends of bones, and a special fluid (synovial fluid) cushions and lubricates the structures. Direct visualization of the joint allows the doctor to see exactly which structures are damaged. Arthroscopy also permits earlier diagnosis of many types of joint problems, including those that had been difficult to detect in previous years.

Precautions

Arthroscopy is contraindicated for patients with ankylosis, due to the stiffness of the joint involved. Arthroscopy is also contraindicated in patients with an existing local infection, due to the potential for sepsis. Because of inflammation after the use of contrast dye, arthroscopy is contraindicated in patients who have recently undergone an arthrogram. Most arthroscopic procedures are performed as same-day surgery and do not require hospital admission. A few hours following the procedure, the patient is allowed to return home, although usually someone else must drive. Depending on the type of anesthesia used, the patient may need to remain NPO (nil per os, nothing by mouth) for several hours prior to the arthroscopy. Before the procedure, the anesthesiologist will ask if the patient has any known allergies to local or general anesthetics. Airway obstruction is always possible in any patient who receives a general anesthesia. Because of this, oxygen, suction, and monitoring equipment must be available. Cardiac status should be monitored in the event that any abnormalities arise during the procedure.

Description

The arthroscope is an instrument used to directly examine the joint. It contains magnifying lenses and glass-coated fibers that send concentrated light into the joint. A camera attached to the arthroscope allows the surgeon to view a clear image of the joint. This image is then transferred to a monitor. By attaching the arthroscope to a monitor, the surgeon is able to view the interior of the joint. This video technology is also important for documentation of the arthroscopic procedure. For example, if the surgeon decides after the arthroscopic examination that a conventional approach to surgically expose or "open" the joint (arthrotomy) must be used, a good photographic record will be useful when the surgeon returns to execute the final surgical plan.

The procedure requires the surgeon to make several small incisions (portals) through the skin's surface into the joint. Through one or two of the portals, the pencil-sized instruments that contain a lens and lighting system to magnify and illuminate the joint structures are inserted. The joint is inflated with a sterile saline solution to expand the joint for viewing. Often, following a recent traumatic injury to a joint, the synovial fluid may be cloudy, making interior viewing of the joint difficult. Therefore, a constant flow of the saline solution may be necessary. In other cases, a tourniquet may be applied in order to distend the joint, rather than use an infusion. The arthroscope is placed through one of the portals to view and evaluate the condition of the joint.

Preparation

The patient should be kept NPO after midnight the day of the procedure. Follow facility procedure for shaving the skin area around the joint, if needed.

Before the arthroscopy, the surgeon completes a thorough medical history and evaluation, which may reveal other disorders of the joint or body parts. Anatomical models and pictures are useful aids to explain to the patient the proposed arthroscopy and what the surgeon may be looking at specifically.

Proper draping of the body part is important to prevent contamination from instruments used in arthroscopy. Draping packs used in arthroscopy usually include disposable paper gowns and drapes with adhesive backing.

General or local anesthesia may be used during arthroscopy. Local anesthesia is preferred because it reduces the risk of lung and heart complications. The local anesthetic may be injected in small amounts in multiple locations in skin and joint tissues in a process called infiltration. In other cases, the anesthetic is injected into the spinal cord or a main nerve supplying the area. This process is called a "block," as it blocks all sensation below the main trunk of the nerve. For example, a femoral block anesthetizes the leg from the thigh down. Most patients are comfortable once the skin, muscles, and other tissues around the joint are numbed by the anesthetic; however, some patients may be given a sedative if they express anxiety about the procedure. It is important for the patient to remain still during the arthroscopic examination.

General anesthesia may be used if the procedure is unusually complicated or painful, or extensive surgery is planned. For example, people who have relatively "tight" joints may be candidates for general anesthesia because the procedure may take longer and cause more discomfort.

Aftercare

The portals are closed by small tape strips or sutures and covered with sterile dressings and a pressure bandage. The patient spends a short amount of time in the recovery room after arthroscopy. Most patients can go home after about an hour in the recovery room. A routine arthroscopy may take from 30 minutes to two hours.

Following the surgical procedure, the patient needs to be aware of the signs of infection, which include redness, warmth, excessive pain, and swelling. The risk of infection increases if the incisions become wet too early following surgery. Patients can cover the joint with plastic (for example, a plastic bag) while showering after arthroscopy. If a knee arthroscopy was performed, the patient should be instructed to elevate the knee while sitting, and to avoid twisting the joint. Ice may be applied to relieve pain and swelling.

The use of crutches is common after arthroscopy of the knee or hip, with progression to independent walking on an "as tolerated" basis by the patient. Generally, a rehabilitation program, supervised by a physical therapist, follows shortly after the arthroscopy to help the patient regain mobility and strength of the affected joint and limb.

Alternative procedures

Alternatives to arthroscopy depend upon the condition, and have limitations. X rays only examine bones, they will not show ligaments or torn cartilages. Magnetic resonance imaging (MRI) will reveal ligaments and cartilages but does not treat the condition. If a torn cartilage were discovered with MRI, an arthroscopy would be performed to correct the problem. Lateral ligament reconstruction for the treatment of ankle injuries is preferred over arthroscopy.

Complications

The incidence of complications is low compared to the number of arthroscopic procedures performed every year. Possible complications include infection, swelling, damage to the tissues in the joint, thrombophlebitis (blood clots in the leg veins), hemarthrosis (leakage of blood into the joint), pulmonary embolus (blood clots that move to the lung), and injury to the nerves around the joint. Low molecular weight heparin has been found to achieve effective prophylaxis for arthroscopy.

KEY TERMS

Ankylosis— A stiff or fixed joint due to disease or surgery.

Hemarthrosis— A condition of blood within a joint.

Pulmonary embolus— Blockage of an artery of the lung by foreign matter such as fat, tumor, tissue, or a clot originating from a vein.

Sepsis— A toxic condition resulting from the spreading of bacteria due to infection.

Synovial fluid— A naturally occurring fluid that lubricates the joints.

Thrombophlebitis— Inflammation of a vein with the formation of a thrombus or clot.

Tourniquet— Something used to stop the flow of blood by pressure applied with an encircling device, such as a bandage twisted with a stick to apply pressure.

Results

Arthroscopy may show normal ligaments, menisci, and articular surfaces. Findings that require further treatment include spur formation, torn meniscus, and torn ligaments. Another finding that may require further treatment include adhesive capsulitis. In this condition, the joint capsule that naturally forms around the joint becomes thickened, forming adhesions, which results in a stiff and less mobile joint. This problem may be corrected by manipulation and mobilization of the joint with the patient placed under general anesthesia.

Arthroscopic examination is often followed by arthroscopic surgery performed to repair the problem with appropriate arthroscopic tools. The optimal result is decreased pain, increased joint mobility, and improved quality of the patient's activities of daily living (ADL).

Health care team roles

Arthroscopy is usually performed on an outpatient basis by a physician, but surgical repair may require hospitalization. In addition to providing assistance during the procedure, nurses monitor vital signs in the recovery room, including blood pressure, pulse, and respiration. They may also monitor circulation and sensation in the area that has been examined and/or operated on. Following arthroscopic surgery, a physical therapist guides the patient in rehabilitation to ensure that the patient regains full functioning in the targeted joint.

Resources

BOOKS

Pagana, Kathleen D., and Timothy J. Pagana. Diagnostic Testing and Nursing Implications. 5th ed. St. Louis: Mosby, 1999.

Scott, Norman W. Arthroscopy of the Knee. Philadelphia: W.B. Saunders Company, 1990.

PERIODICALS

Fink, Brett and Mizel, Mark S. "What's New in Foot and Ankle Surgery." Journal of Bone and Joint Surgery (May 2001): 791-799.

Kelly E.W., Morrey B.F., O'Driscoll S.W. "Complications of Elbow Arthroscopy." Journal of Bone and Joint Surgery (January 2001): 25-34.

Wirth, Thomas. "Prevention of Venous Thromboembolism After Knee Arthroscopy With Low-Molecular Weight Heparin (Reviparin): Results of a Randomized Controlled Trial." Arthroscopy: The Journal of Arthroscopic and Related Surgery (April 2001): 393-399.

ORGANIZATIONS

American Academy of Orthopaedic Surgeons. 6300 North River Road Rosemont, Illinois 60018-4262 (800) 346-AAOS 〈http://www.aaos.org〉.

National Association of Orthopaedic Nurses, National Office. Box 56, Pitman, NJ 08071 (856) 256-2310 〈http://naon.inurse.com〉.

Arthroscopy

Definition

Arthroscopy is the examination of a joint, specifically, the inside structures. The procedure is performed by inserting a specifically designed illuminated device into the joint through a small incision. This instrument is called an arthroscope. The procedure of arthroscopy is primarily associated with the process of diagnosis. However, when actual repair is performed, the procedure is called arthroscopic surgery.

Purpose

Arthroscopy is used primarily by doctors who specialize in treating disorders of the bones and related structures (orthopedics) to help diagnose joint problems. Once described as essential for those who primarily care for athletic injuries, arthroscopy is now a technique commonly used by orthopedic surgeons for the treatment of patients of all ages. This procedure is most commonly used to diagnose knee and shoulder problems, although the elbow, hip, wrist, and ankle may also be examined with an arthroscope.

A joint is a complex system. Within a joint, ligaments attach bones to other bones, tendons attach muscles to bones, cartilage lines and helps protect the ends of bones, and a special fluid (synovial fluid) cushions and lubricates the structures. Looking inside the joint allows the doctors to see exactly which structures are damaged. Arthroscopy also permits earlier diagnosis of many types of joint problems which had been difficult to detect in previous years.

Precautions

Most arthroscopic procedures today are performed in same-day surgery centers where the patient is admitted just before surgery. A few hours following the procedure, the patient is allowed to return home, although usually someone else must drive. Depending on the type of anesthesia used, the patient may be told not to eat for several hours before arriving. Before the procedure, the anesthesiologist will ask if the patient has any known allergies to local or general anesthetics. Airway obstruction is always possible in any patient who receives a general anesthesia. Because of this, oxygen, suction, and monitoring equipment must be available. The patient's cardiac status should always be monitored in the event that any cardiac abnormalities arise during the arthroscopy.

Description

The arthroscope is an instrument used to look directly into the joint. It contains magnifying lenses and glass-coated fibers that send concentrated light into the joint. A camera attached to the arthroscope allows the surgeon to see a clear image of the joint. This image is then transferred to a monitor located in the operating room at the time of the arthroscopy. This video technology is also important for documentation of the arthroscopic procedure. For example, if the surgeon decides after the arthroscopic examination that a conventional approach to surgically expose or "open" the joint (arthrotomy) must be used, a good photographic record will be useful when the surgeon returns to execute the final surgical plan.

The procedure requires the surgeon to make several small incisions (portals) through the skin's surface into the joint. Through one or two of the portals, a large-bore needle, called a cannula, is attached to tubing and inserted into the joint. The joint is inflated with a sterile saline solution to expand the joint and ensure clear arthroscopic viewing. Often, following a recent traumatic injury to a joint, the joint's natural fluid may be cloudy, making interior viewing of the joint difficult. In this condition, a constant flow of the saline solution is necessary. This inflow of saline solution may be through the cannula with the outflow through the arthroscope, or the positions may be reversed. The arthroscope is placed through one of the portals to view and evaluate the condition of the joint.

Preparation

Before an arthroscopy can take place, the surgeon completes a thorough medical history and evaluation. Important for the accuracy of this diagnostic procedure, a medical history and evaluation may discover other disorders of the joint or body parts, proving the procedure unnecessary. This is always an important preliminary step, because pain can often be referred to a joint from another area of the body. Anatomical models and pictures are useful aids to explain to the patient the proposed arthroscopy and what the surgeon may be looking at specifically.

Proper draping of the body part is important to prevent contamination from instruments used in arthroscopy, such as the camera, light cords, and inflow and outflow drains placed in the portals. Draping packs used in arthroscopy include disposable paper gowns and drapes with adhesive backing. The surgeon may also place a tourniquet above the joint to temporarily block blood flow to the area during the arthroscopic exam.

General or local anesthesia may be used during arthroscopy. Local anesthesia is usually used because it reduces the risk of lung and heart complications and allows the patient to go home sooner. The local anesthetic may be injected in small amounts in multiple locations in skin and joint tissues in a process called infiltration. In other cases, the anesthetic is injected into the spinal cord or a main nerve supplying the area. This process is called a "block," and it blocks all sensation below the main trunk of the nerve. For example, a femoral block anesthetizes the leg from the thigh down (its name comes from femur, the thighbone). Most patients are comfortable once the skin, muscles, and other tissues around the joint are numbed by the anesthetic; however, some patients are also given a sedative if they express anxiety about the procedure. (It's important for the patient to remain still during the arthroscopic examination.)

KEY TERMS

Hemarthrosis— A condition of blood within a joint.

Pulmonary embolus— Blockage of an artery of the lung by foreign matter such as fat, tumor, tissue, or a clot originating from a vein.

Thrombophlebitis— Inflamation of a vein with the formation of a thrombus or clot.

General anesthesia, in which the patient becomes unconcious, may be used if the procedure may be unusually complicated or painful. For example, people who have relatively "tight" joints may be candidates for general anesthesia because the procedure may take longer and cause more discomfort.

Aftercare

The portals are closed by small tape strips or stitches and covered with dressings and a bandage. The patient spends a short amount of time in the recovery room after arthroscopy. Most patients can go home after about an hour in the recovery room. Pain medication may be prescribed for a short period; however, many patients find various over-the-counter pain relievers sufficient.

Following the surgical procedure, the patient needs to be aware of the signs of infection, which include redness, warmth, excessive pain, and swelling. The risk of infection increases if the incisions become wet too early following surgery. Because of this, it is good practice to cover the joint with plastic (for example, a plastic bag) while showering after arthroscopy.

The use of crutches is commonplace after arthroscopy, with progression to independent walking on an "as tolerated" basis by the patient. Generally, a rehabilitation program, supervised by a physical therapist, follows shortly after the arthroscopy to help the patient regain mobility and strength of the affected joint and limb.

Risks

The incidence of complications is low compared to the high number of arthroscopic procedures performed every year. Possible complications include infection, swelling, damage to the tissues in the joint, blood clots in the leg veins (thrombophlebitis ), leakage of blood into the joint (hemarthrosis), blood clots that move to the lung (pulmonary embolus), and injury to the nerves around the joint.

Normal results

The goal of arthroscopy is to diagnose a joint problem causing pain and/or restrictions in normal joint function. For example, arthroscopy can be a useful tool in locating a tear in the joint surface of the knee or locating a torn ligament of the shoulder. Arthroscopic examination is often followed by arthroscopic surgery performed to repair the problem with appropriate arthroscopic tools. The final result is to decrease pain, increase joint mobility, and thereby improve the overall quality of the patient's activities of daily living.

Abnormal results

Less optimal results that may require further treatment include adhesive capsulitis. In this condition, the joint capsule that naturally forms around the joint becomes thickened, forming adhesions. This results in a stiff and less mobile joint. This problem is frequently corrected by manipulation and mobilization of the joint with the patient placed under general anesthesia.

Resources

PERIODICALS

Glassman, Scott. "Advances in Treating Shoulder Injuries." Advanced Magazine for Physical Therapists (December 1997): 10-12.