Orthopaedic Surgery - Arthroscopy

Introduction

An arthroscopy is a type of keyhole surgery used both to diagnose and treat problems with joints.

The procedure is most commonly used on the knees, wrists, elbows, ankles and shoulders.

If you have problems with your joints, such as swelling or stiffness, and initial imaging tests have not been able to find what is causing the problem, an arthroscopy might be recommended to look at the inside of the joint. As well as allowing a surgeon to look inside a joint, an arthroscopy can also be used to treat a range of problems and conditions. For example, it can be used to:

• Repair damaged cartilage
• Remove fragments of loose bone or cartilage
• Treat frozen shoulder

What happens during an arthroscopy?

During an arthroscopy, a piece of equipment called an arthroscope is used.

An arthroscope is a small, flexible tube that is about the length and width of a drinking straw. Inside there is a bundle of fibre optics. These act as both a light source and a camera. Images are sent from the arthroscope to a video screen or an eyepiece so that the surgeon can see the joint.

It is also possible for tiny surgical instruments to be passed through an arthroscope to allow the surgeon to treat conditions or problems such as those listed above.
 
The surgeon will make a small incision next to the joint so that the arthroscope can be inserted. One or more small incisions will also be made to allow an examining probe or, if necessary, surgical instruments to be inserted.

An arthroscopy is usually carried out under general anaesthetic. This is where the person having the procedure is put to sleep so that they do not feel any pain or discomfort. Occasionally, a local anaesthetic may be used, where the area being treated is numbed.

An arthroscopy is usually performed on an out-patient basis, which means the person being treated can go home on the same day as the surgery.

Safety

An arthroscopy is usually a safe type of surgery and the risk of serious complications developing is low (less than 1 in 100).

However, possible complications include infection and accidental damage to nerves near the affected joint.

Advantages

The advantages of an arthroscopy compared with traditional open surgery include:

• Less post-operative pain
• A faster recovery time
• A lower risk of complications

Recovery

The time it takes to recover from an arthroscopy can vary depending on the joint involved and whether it needs to be repaired.

It is usually possible for a person to do light, physical activities one to three weeks after having surgery. Full physical activities, such as lifting and sport, can often be resumed after six to eight weeks.

Illustration of arthroscopy being performed on the knee joint

Joints

A joint is the point where two or more bones meet. Joints have two main purposes. They act as:

• Hinge, allowing the bones to move
• Bracket, holding the bones in place while also protecting and supporting them

Joints are made up of five different types of tissue:

• Bones
• Tendons - which are made of a tough, stringy tissue that is used to connect muscles to bones
• Ligaments - which are like tendons but are used to connect one bone to another bone
• Cartilage - a tough, spongy tissue that lines the surfaces of bones and acts like a shock absorber within the joint, helping to reduce friction and prevent damage as the bones move
• Synovial fluid - a thick, sticky fluid that acts as a lubricant inside the joint

What is an arthroscopy used for

Diagnosing joint problems

An arthroscopy can be used to help diagnose a number of joints including:

• Unexplained joint pain
• Joint stiffness
• Swelling of the joint
• Limited range of movement within the joint
• The joint giving way at certain times or ‘popping’ out of position

Initial tests for these types of problems usually involve the use of imaging studies such as:

• X-rays - where high energy waves are used to produce an image of the bones
• Computerised tomography (CT) scans - where several x-rays are taken and assembled by a computer to create a more detailed, three dimensional image of the affected joint
• Magnetic resonance imaging (MRI) scans - where strong magnetic fields and radio waves are used to produce detailed scans of the soft tissue of the affected joint.

If these tests don’t find anything it may be necessary to take a direct look at the inside of the joint.

An arthroscopy can also be used to assess the level of joint damage resulting from an injury, such as a sports injury, or from underlying conditions that can cause joint damage, such as:

• Osteoarthritis - where, over time, the joint cartilage becomes damaged
• Septic arthritis - where a joint becomes infected

Treating joint problems and conditions

Surgical instruments can be passed through an arthroscope, making it possible for an arthroscopy to be used to treat a range of joint problems and joint conditions. For example, an arthroscopy can be used to:

• Repair damaged cartilage, tendons and ligaments
• Remove small sections of bone or cartilage that have broken off and are loose within the joint
• Drain away an excess build-up of synovial fluid (fluid that lubricates the joint)

Conditions that can be treated with arthroscopy include:

• Baker’s cyst - where synovial fluid builds up inside a joint, leading to stiffness and swelling
• Frozen shoulder – where the shoulder joint becomes compressed, causing stiffness and pain
• Arthrofibrosis – where excess scar tissue caused by a previous injury disrupts the normal workings of the joint
• Bone spurs - abnormal bone growths that can cause persistent pain
• Synovitis - where the lining of the joint becomes inflamed

Advantages of arthroscopy

An arthroscopy is carried out using keyhole surgery, where only small cuts are made in the skin. This gives the procedure some advantages over traditional, open surgery including:

• Less post-operative pain
• Faster healing time
• Reduced risk of infection
• It can be performed on an out-patient basis, which means that you do not have to spend the night in hospital
• You will be able to resume normal activities more quickly

How an arthroscopy is performed

Preparing for surgery

Before having an arthroscopy, you will usually be given an appointment to attend a preadmission clinic.

During your appointment, your general fitness will be assessed to ensure that you are ready for surgery. You will also be given information about issues such as:

• What and when you are allowed to eat and drink on the day of the surgery
• How long it will take for you to recover from surgery
• Whether you will need to do rehabilitation exercises after surgery

The surgical team will explain the benefits and risks that are associated with having an arthroscopy. You will also be asked to sign a consent form to confirm that you agree to have the operation and that you understand what is involved.

The arthroscopy procedure

An arthroscopy is usually carried out under general anaesthetic, although occasionally it can be performed under local anaesthetic. Your anaesthetist will explain which type of anaesthetic is most suitable for you. In some cases, you may be able to express a preference.

An anaesthetist is a doctor who has received specialist training in giving people anaesthetic.

If you have a local anaesthetic your joint will be numbed so that you do not feel any pain. However, you may still feel some sensations during the procedure, such as a mild tugging, as the surgeon works on the joint.

An arthroscopy will usually take 30 to 40 minutes to complete, although more extensive surgery can sometime last for up to an hour.

An anti-bacterial fluid is used to clean the skin over the affected joint. A small incision, a few millimetres long, will then be made to enable the arthroscope to be inserted.

One or more additional incisions will also be made so that an examining probe, or other instruments that may be required during the procedure, can be inserted.

The surgeon may fill the joint with a sterile fluid to expand it and make it easier to view. The surgeon will be able to see inside your joint using an eyepiece or a video screen. If possible, during the procedure, they will repair any damaged areas and remove any unwanted tissue.

After the procedure is complete, the arthroscope plus any attachments is removed along with any excess fluid from the joint. The incisions will be closed using paper tape or stitches. A sterile dressing will be used to cover the incisions and the joint may also be bandaged.

How the knee works

The knee is the largest joint, and it can be prone to injury. It consists of the lower end of the thigh bone (femur), the upper end of the shin bone (tibia) and the kneecap (patella).

Four bands of tissue – the anterior and posterior cruciate ligaments and the medial and lateral collateral ligaments - connect the femur to the tibia and provide joint stability.

The surfaces where the femur, tibia and patella touch are covered with articular cartilage, which is a smooth substance that cushions the bones.

Semi-circular rings of tough, fibrous tissue (the lateral and medial menisci) act as shock absorbers and stabilisers.

The knee bones are surrounded by a thin, smooth tissue capsule that is lined by a synovial membrane. This releases a special fluid that lubricates the knee to prevent friction.

Recovering from an arthroscopy

After the operation

After the arthroscopy has been completed, you will be taken to a recovery room to recover from the effects of the general anaesthetic, if you have had one.

You may experience some pain in the joint that was operated on. If you do, tell a member of the hospital staff who will be able to give you painkillers.

Most people who have an arthroscopy can leave hospital either on the day of the surgery or the following morning. Before leaving hospital, you may have an appointment with a physiotherapist to discuss exercises for you to do at home.

Recovery advice

It is likely that you will feel tired and light-headed after having a general anaesthetic, so you will need to ask a responsible adult to take you home and to stay with you for the first 24 hours following surgery. Most people will recover from the effects of the anaesthetic within 48 hours.

Any dressings will need to be kept as dry as possible, so you will need to cover them with a plastic bag when having a bath or shower. If your dressings do get wet or fall off, they will need to be replaced.

Exactly how long it will be before you can return to normal activities will depend on the type of surgery that you had, your general health and the type of work that you do.

Most children can return to school within a week of having surgery and most adults are able to return to work within two to three weeks.

You will be able to drive again once it is safe for you to make an emergency stop without damaging the affected joint.

For most people this is one to three weeks after surgery.

Your surgeon will be able to give you a more specific recommendation.

Your surgeon will also be able to advise you about how long it will be before you can undertake strenuous physical activities, such as heavy lifting and sport. For most people this will be around six to eight weeks after surgery.

Follow-up

You will usually be asked to attend a follow-up appointment four to six weeks after the operation to discuss the results of the surgery, your recovery and any additional treatment that you may require.

Complications of an arthroscopy

An arthroscopy is a safe type of surgery and any complications, such as stiffness and swelling in the affected joint, are usually minor and temporary.

More serious complications are much rarer, occurring in less than 1 in 100 cases. They include:

• A blood clot that develops in one of the limbs – this is known as a deep vein thrombosis (DVT) and causes pain and swelling in the affected limb
• Infection inside the joint - this is known as septic arthritis and causes fever, pain and swelling in the joint
• Bleeding inside the joint - which can often cause severe pain and swelling in the joint
• Accidental damage to the nerves that are near the joint - which can lead to numbness and some loss of sensation