Arthroscopy

Arthroscopy

Lateral meniscus located between thigh bone (femur, above) and shin bone (tibia, below). The tibial cartilage displays a fissure (tip of teaser instrument).
ICD-9-CM 80.2
MeSH D001182
OPS-301 code 1-697
MedlinePlus 007471

Arthroscopy (also called arthroscopic surgery) is a minimally invasive surgical procedure on a joint in which an examination and sometimes treatment of damage is performed using an arthroscope, an endoscope that is inserted into the joint through a small incision. Arthroscopic procedures can be performed during ACL reconstruction. While commonly used for meniscal injuries to the knee, this use is not supported by the evidence.[1]

The advantage over traditional open surgery is that the joint does not have to be opened up fully. For knee arthroscopy only two small incisions are made, one for the arthroscope and one for the surgical instruments to be used in the knee cavity. This reduces recovery time and may increase the rate of success due to less trauma to the connective tissue. It is especially useful for professional athletes, who frequently injure knee joints and require fast healing time. There is also less scarring, because of the smaller incisions. Irrigation fluid is used to distend the joint and make a surgical space. Sometimes this fluid leaks (extravasates) into the surrounding soft tissue, causing edema.

The surgical instruments are smaller than traditional instruments. Surgeons view the joint area on a video monitor, and can diagnose and repair torn joint tissue, such as ligaments. It is technically possible to do an arthroscopic examination of almost every joint, but is most commonly used for the knee, shoulder, elbow, wrist, ankle, foot, and hip.

Types

Knee

Knee arthroscopy has in many cases replaced the classic arthrotomy that was performed in the past. Arthroscopic knee surgery is one of the most common orthopaedic procedures, performed approximately 2 million times each year.[2] While commonly performed for treating meniscus injury, evidence does not support this practice.[1][3] It is also done to reconstruct the anterior cruciate ligament.

During an average knee arthroscopy, a small fiberoptic camera (the arthroscope) is inserted into the joint through a small incision, about 4 mm (1/8 inch) long. A special fluid is used to visualize the joint parts. More incisions might be performed in order to check other parts of the knee. Then other miniature instruments are used and the surgery is performed.

Osteoarthritis

The BMJ Rapid Recommendations group makes a strong recommendation against arthroscopy for osteoarthritis on the basis that there is high quality evidence that there is no lasting benefit and less than 15% of people have a small short-term benefit.[4] There are rare but serious adverse effects that can occur, including venous thromboembolism, infections, and nerve damage[5][6] The BMJ Rapid Recommendation includes infographics and shared decision making tools to facilitate a conversation between doctors and patients about the risks and benefits of arthroscopic surgery.[7]

A trial of arthroscopic surgery for osteoarthritis of the knee found no benefit for these surgeries.[8] Many payors are reluctant to reimburse surgeons and hospitals for what can be considered a procedure which seems to create the risks of surgery with questionable or no demonstrable benefit. However this is still a widely adopted treatment for a range of conditions including Labral tears, Femoroacetabular impingement, Osteochondritis dissecans.[9]

A 2017 meta-analysis confirmed that there is only a very small and usually unimportant reduction in pain and improvement in function at 3 months (e.g. an average pain reduction of approximately 5 on a scale from 0 to 100).[6] A separate review found that most people would consider a reduction in pain of approximately 12 on the same 0 to 100 scale important -- suggesting that for most people, the pain reduction at 3 months is not important.[10] Arthroscopy did not reduce pain or improve function or quality of life at one year.[6] There are important adverse effects.[6]

Meniscal tears

One of the primary reasons for performing arthroscopies is to repair or trim a painful and torn or damaged meniscus.[11] The surgery is known as an arthroscopic partial meniscectomy (APM). Arthroscopic surgery, however, does not appear to result in benefits in adults with mild osteoarthritis who have a meniscal tear.[6][12] Some professional societies still support the use of arthroscopic partial meniscectomy for meniscal tears, but after evaluating the entire body of evidence, an independent international panel without free from conflicts of interest made a strong recommendation against arthroscopic partial meniscectomy in nearly all patients.[13] The only group of patients who may - or may not - benefit are those with true locked knee.[14]

A torn meniscus is in a majority of cases non-symptomatic.[15]

After surgery

After knee arthroscopy there will be swelling around the knee, which can take anywhere from 7–15 days to completely settle. It is important to wait until there is no swelling before doing any serious exercise or extensive walking, because the knee will not be fully stable; extensive exercise may cause pain and in some cases cause the knee to swell more. The spread of the swell might cause serious problems.

Hip

Hip arthroscopy was initially used for the diagnosis of unexplained hip pain, but is now widely used in the treatment of conditions both in and outside the hip joint. The most common indication currently is for the treatment of femoroacetabular impingement (FAI) and its associated pathologies. Hip conditions that may be treated arthroscopically also includes labral tears, loose / foreign body removal, hip washout (for infection) or biopsy, chondral (cartilage) lesions, osteochondritis dissecans, ligamentum teres injuries (and reconstruction), Iliopsoas tendinopathy (or ‘snapping psoas’), trochanteric pain syndrome, snapping iliotibial band, osteoarthritis (controversial), sciatic nerve compression (piriformis syndrome), ischiofemoral impingement and direct assessment of hip replacement.

Shoulder

Arthroscopy is commonly used for treatment of diseases of the shoulder including subacromial impingement, acromioclavicular osteoarthritis, rotator cuff tears, frozen shoulder (adhesive capsulitis), chronic tendonitis, removal of loose bodies and partial tears of the long biceps tendon, SLAP lesions and shoulder instability. The most common indications include subacromial decompression, bankarts lesion repair and rotator cuff repair. All these procedures were done by opening the joint through big incisions before the advent of arthroscopy. Arthroscopic shoulder surgeries have gained momentum in the past decade. "Keyhole surgery" of the shoulder as it is popularly known has reduced inpatient time and rehabilitation requirements and is often a daycare procedure.

Wrist

Arthroscopic view showing two of the wrist bones.

Arthroscopy of the wrist is used to investigate and treat symptoms of repetitive strain injury, fractures of the wrist and torn or damaged ligaments. It can also be used to ascertain joint damage caused by wrist osteoarthritis.

Spine

Many invasive spine procedures involve the removal of bone, muscle, and ligaments to access and treat problematic areas. In some cases, thoracic (mid-spine) conditions requires a surgeon to access the problem area through the rib cage, dramatically lengthening recovery time.

Arthroscopic (also endoscopic spinal procedures) allow access to and treatment of spinal conditions with minimal damage to surrounding tissues. Recovery times are greatly reduced due to the relatively small size of incision(s), and many patients are treated as outpatients.[16] Recovery rates and times vary according to condition severity and the patient's overall health.

Arthroscopic procedures treat

Temporomandibular joint

Arthroscopy of the temporomandibular joint is sometimes used as either a diagnostic procedure for symptoms and signs related to these joints, or as a therapeutic measure in conditions like temporomandibular joint dysfunction. TMJ arthroscopy can be a purely diagnostic procedure,[17] or it can have its own beneficial effects which may result from washing out of the joint during the procedure, thought to remove debris and inflammatory mediators, and may enable a displaced disc to return to its correct position. Arthroscopy is also used to visualize the inside of the joint during certain surgical procedures involving the articular disc or the articular surfaces, similar to laparoscopy.[18] Examples include release of adhesions (e.g., by blunt dissection or with a laser) or release of the disc.[19] Biopsies or disc reduction can also be carried out during arthroscopy.[17] It is carried out under general anesthetic.[20]

History

Professor Kenji Takagi in Tokyo has traditionally been credited with performing the first arthroscopic examination of a knee joint, in 1919. He used a 7.3 mm cystoscope for his first arthroscopies. Recently it has been discovered that the Danish physician Severin Nordentoft reported on arthroscopies of the knee joint in 1912 at the Proceedings of the 4lst Congress of the German Society of Surgeons at Berlin.[21] He called the procedure (in Latin) arthroscopia genu, and used sterile saline or boric acid solution as his optic media, and entering the joint by a portal on the outer border of the patella. It is not clear if these examinations were of deceased or of living patients.

Pioneering work began as early as the 1920s with the work of Eugen Bircher.[22] He published several papers in the 1920s about his use of arthroscopy of the knee for diagnostic purposes.[22] After diagnosing torn tissue, he used open surgery to remove or repair the damaged tissue. Initially, he used an electric Jacobaeus thoracolaparoscope for his diagnostic procedures, which produced a dim view of the joint. Later, he developed a double-contrast approach to improve visibility.[23] He gave up endoscopy in 1930, and his work was largely neglected for several decades.

While he is often considered the inventor of arthroscopy of the knee,[24] the Japanese surgeon Masaki Watanabe, MD, receives primary credit for using arthroscopy for interventional surgery.[25][26] Watanabe was inspired by the work and teaching of Dr Richard O'Connor. Later, Dr. Heshmat Shahriaree began experimenting with ways to excise fragments of menisci.[27]

The first operating arthroscope was designed by them, and they worked together to produce the first high-quality color intraarticular photography.[28] The field benefited significantly from technological advances, particularly advances in flexible fiber optics during the 1970s and 1980s.

Surgical training

Arthroscopy surgical skills have been traditionally taught in cadaver labs, although the progression to in vivo operations varies from country to country.[29] The International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) holds a list of approved courses for gaining surgical skills.

A new teaching technique uses medical simulation as an alternative to cadaver training. High fidelity simulators range from those that use real surgical tools and passive haptics, such as VirtaMed's ArthroS™, to those that rely on active haptic feedback, such as the Arthro Mentor™ from Simbionix. When studied, passive haptics have shown "high scores in terms of realism" and the ability to differentiate between "varying levels of arthroscopic experience".[30] Reference material, such as the application developed by Touch Surgery, also contains visualization of minimally invasive techniques.

See also

Notes

  1. 1 2 Järvinen, Teppo L N; Guyatt, Gordon H (20 July 2016). "Arthroscopic surgery for knee pain". BMJ: i3934. doi:10.1136/bmj.i3934.
  2. ↑ Siemieniuk RA, Harris IA, Agoritsas T, Poolman RW, Brignardello-Petersen R, Van de Velde S, Buchbinder R, Englund M, Lytvyn L, Quinlan C, Helsingen L, Knutsen G, Olsen NR, Macdonald H, Hailey L, Wilson HM, Lydiatt A, Kristiansen A, et al. (May 2017). "Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline". BMJ. 357: j1982. PMID 28490431. doi:10.1136/bmj.j1982.
  3. ↑ Siemieniuk RA, Harris IA, Agoritsas T, Poolman RW, Brignardello-Petersen R, Van de Velde S, Buchbinder R, Englund M, Lytvyn L, Quinlan C, Helsingen L, Knutsen G, Olsen NR, Macdonald H, Hailey L, Wilson HM, Lydiatt A, Kristiansen A, et al. (May 2017). "Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline". BMJ. 357: j1982. PMID 28490431. doi:10.1136/bmj.j1982.
  4. ↑ Siemieniuk RA, Harris IA, Agoritsas T, Poolman RW, Brignardello-Petersen R, Van de Velde S, Buchbinder R, Englund M, Lytvyn L, Quinlan C, Helsingen L, Knutsen G, Olsen NR, Macdonald H, Hailey L, Wilson HM, Lydiatt A, Kristiansen A, et al. (May 2017). "Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline". BMJ. 357: j1982. PMID 28490431. doi:10.1136/bmj.j1982.
  5. ↑ Siemieniuk RA, Harris IA, Agoritsas T, Poolman RW, Brignardello-Petersen R, Van de Velde S, Buchbinder R, Englund M, Lytvyn L, Quinlan C, Helsingen L, Knutsen G, Olsen NR, Macdonald H, Hailey L, Wilson HM, Lydiatt A, Kristiansen A, et al. (May 2017). "Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline". BMJ. 357: j1982. PMID 28490431. doi:10.1136/bmj.j1982.
  6. 1 2 3 4 5 Brignardello-Petersen R, Guyatt GH, Buchbinder R, Poolman RW, Schandelmaier S, Chang Y, Sadeghirad B, Evaniew N, Vandvik PO, et al. (May 2017). "Knee arthroscopy versus conservative management in patients with degenerative knee disease: a systematic review". BMJ Open. 7 (5): e016114. PMID 28495819. doi:10.1136/bmjopen-2017-016114.
  7. ↑ Siemieniuk RA, Harris IA, Agoritsas T, Poolman RW, Brignardello-Petersen R, Van de Velde S, Buchbinder R, Englund M, Lytvyn L, Quinlan C, Helsingen L, Knutsen G, Olsen NR, Macdonald H, Hailey L, Wilson HM, Lydiatt A, Kristiansen A, et al. (May 2017). "Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline". BMJ. 357: j1982. PMID 28490431. doi:10.1136/bmj.j1982.
  8. ↑ Moseley JB, O'Malley K, Petersen NJ, et al. (July 2002). "A controlled trial of arthroscopic surgery for osteoarthritis of the knee". N. Engl. J. Med. 347 (2): 81–8. PMID 12110735. doi:10.1056/NEJMoa013259.
  9. ↑ "Hip Arthroscopy Surgery in Sydney — From Dr. Sunny Randhawa (June 2015)". Retrieved 2008-01-14.
  10. ↑ Devji T, Guyatt GH, Lytvyn L, Brignardello-Petersen R, Foroutan F, Sadeghirad B, Buchbinder R, Poolman RW, Harris IA, Carrasco-Labra A, Siemieniuk RA, Vandvik PO, et al. (May 2017). "Application of minimal important differences in degenerative knee disease outcomes: a systematic review and case study to inform BMJ Rapid Recommendations.". BMJ Open. 7 (5): e015587. PMID 28495818. doi:10.1136/bmjopen-2016-015587.
  11. ↑ Orthoinfo
  12. ↑ Khan, M; Evaniew, N; Bedi, A; Ayeni, OR; Bhandari, M (7 October 2014). "Arthroscopic surgery for degenerative tears of the meniscus: a systematic review and meta-analysis.". CMAJ : Canadian Medical Association. 186 (14): 1057–64. PMC 4188648 Freely accessible. PMID 25157057. doi:10.1503/cmaj.140433.
  13. ↑ Siemieniuk RA, Harris IA, Agoritsas T, Poolman RW, Brignardello-Petersen R, Van de Velde S, Buchbinder R, Englund M, Lytvyn L, Quinlan C, Helsingen L, Knutsen G, Olsen NR, Macdonald H, Hailey L, Wilson HM, Lydiatt A, Kristiansen A, et al. (May 2017). "Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline". BMJ. 357: j1982. PMID 28490431. doi:10.1136/bmj.j1982.
  14. ↑ Siemieniuk RA, Harris IA, Agoritsas T, Poolman RW, Brignardello-Petersen R, Van de Velde S, Buchbinder R, Englund M, Lytvyn L, Quinlan C, Helsingen L, Knutsen G, Olsen NR, Macdonald H, Hailey L, Wilson HM, Lydiatt A, Kristiansen A, et al. (May 2017). "Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline". BMJ. 357: j1982. PMID 28490431. doi:10.1136/bmj.j1982.
  15. ↑ Englund M, Guermazi A, Gale D, et al. (September 2008). "Incidental meniscal findings on knee MRI in middle-aged and elderly persons". N. Engl. J. Med. 359 (11): 1108–15. PMC 2897006 Freely accessible. PMID 18784100. doi:10.1056/NEJMoa0800777.
  16. ↑ "Minimally Invasive Endoscopic Spinal Surgery". June 20, 2005. Cleveland Clinic contribution to SpineUniverse.com
  17. 1 2 Wray D, Stenhouse D, Lee D, Clark AJ (2003). Textbook of general and oral surgery. Edinburgh [etc.]: Churchill Livingstone. pp. 173–178. ISBN 0443070830.
  18. ↑ Kalantzis A, Scully C (2005). Oxford handbook of dental patient care, the essential guide to hospital dentistry. (2nd ed.). New York: Oxford University Press. pp. 116, 117. ISBN 9780198566236.
  19. ↑ Guo, C; Shi, Z; Revington, P (October 7, 2009). "Arthrocentesis and lavage for treating temporomandibular joint disorders.". Cochrane database of systematic reviews (Online) (4): CD004973. PMID 19821335. doi:10.1002/14651858.CD004973.pub2.
  20. ↑ Kerawala C, Newlands C, eds. (2010). Oral and maxillofacial surgery. Oxford: Oxford University Press. pp. 342–351. ISBN 9780199204830.
  21. ↑ Kieser CW, Jackson RW (May 2001). "Severin Nordentoft: The first arthroscopist". Arthroscopy. 17 (5): 532–5. PMID 11337723. doi:10.1053/jars.2001.24058.
  22. 1 2 CH Bennett & C Chebli, 'Knee Arthroscopy'
  23. ↑ Kieser CW, Jackson RW (2003). "Eugen Bircher (1882–1956) the first knee surgeon to use diagnostic arthroscopy". Arthroscopy. 19 (7): 771–6. PMID 12966386. doi:10.1016/S0749-8063(03)00693-5.
  24. ↑ Böni T (1996). "[Knee problems from a medical history viewpoint]". Ther Umsch (in German). 53 (10): 716–23. PMID 8966679.
  25. ↑ Watanabe M (1983). "History arthroscopic surgery". In Shahriaree H. O'Connor's Textbook of Arthroscopic surgery (1st ed.). Philadelphia: J.B. Lippincott.
  26. ↑ Jackson RW (1987). "Memories of the early days of arthroscopy: 1965–1975. The formative years". Arthroscopy. 3 (1): 1–3. PMID 3551979. doi:10.1016/S0749-8063(87)80002-6.
  27. ↑ Metcalf RW (1985). "A decade of arthroscopic surgery: AANA. Presidential address". Arthroscopy. 1 (4): 221–5. PMID 3913437. doi:10.1016/S0749-8063(85)80087-6.
  28. ↑ Allen FR, Shahriaree H (1982). "Richard L. O'Connor, M.D., 1933–1980" (PDF). J Bone Joint Surg Am. 64 (2): 315.
  29. ↑ COURSE:
  30. ↑ Fucentese, SF; Rahm, S; Weiser, K; Spillmann, J; Harders, M; Kock, PP (Apr 2015). "Evaluation of a virtual-reality-based simulator using passive haptic feedback for knee arthroscopy". Knee Surgery, Sports Traumatology, Arthroscopy. 23: 1077–85. PMID 24519617. doi:10.1007/s00167-014-2888-6.
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