Arthroscopic surgery

ARTHROSCOPY

What is Arthroscopy ?

Arthroscopic surgery of the knee is an innovative surgical procedure in which the knee joint is viewed by inserting a tube(which is attached with a small camera) into the knee that is called arthroscope,that contains optical fibers and lenses, through tiny incisions in the skin into the joint to be examined.  Knee arthroscopy gives a view of what’s inside the knee joint and allows knee surgeon to diagnose any problems.The arthroscope is connected to a video camera and the interior of the joint is seen on a television monitor. The size of the arthroscope varies with the size of the joint being examine.

If procedures are performed along with examining the joint with the arthroscope, this is called arthroscopic surgery.There are lots of procedures that are performed in this way. If a procedure can be done arthroscopically rather than traditional surgical techniques, it usually reduces tissue trauma, may result in less pain, and may promote a faster recovery.


For what diseases or conditions is arthroscopy performed:-

• Torn floating cartilage (meniscus)
• The cartilage is trimmed to a stable rim or occasionally repaired Torn surface (articular) cartilage 
• Removal of loose bodies (cartilage or bone that has broken off) and cysts 
• Reconstruction of the Anterior Cruciate ligament (ACL) 
• Patello-femoral (knee-cap) disorders 
• Diagnostic knee purposes

Arthroscopy can be helpful in the diagnosis and treatment of many noninflammatory, inflammatory,

 and infectious types of arthritis as well as various injuries within the joint.

Noninflammatory degenerative arthritis, or osteoarthritis, can be seen using the arthroscope as
 frayed and irregular cartilage. A new procedure for the treatment of younger patients with an isolated
 injury to the cartilage covering the bone ends within a joint uses a "paste" of the patient's own cartilage cells.
The cells are harvested and grown in the laboratory and are then reimplanted at a later date in the knee with the use of an arthroscope.

In inflammatory arthritis, such as rheumatoid arthritis, some patients with isolated chronic joint swelling can sometimes benefit by arthroscopic removal of the inflamed joint tissue (synovectomy). The tissue lining the joint (synovium) can be biopsied and examined under a microscope to determine the cause of the inflammation and discover infections, such as tuberculosis. Arthroscopy can provide more information in situations which cannot be diagnosed by simply aspirating (withdrawing fluid with a needle) and analyzing the joint fluid.

Common knee joint injuries for which arthroscopy is considered includes :-

•  cartilage tears (meniscus tears),
•   ligament strains and tears, and
• cartilage deterioration underneath the kneecap (patella).

Arthroscopy is commonly used in the evaluation of knees and shoulders but can also be used to examine and treat conditions of the hips, wrist, ankles, feet, spine, and elbows.

Finally, loose tissues, such as chips of bone or cartilage, or foreign objects, such as plant thorns or needles, which become lodged within the joint can be removed with arthroscopy.


What is done in Arthroscopic surgery?

Most knee arthroscopy procedures are done on an outpatient basis and can be performed under local,
regional or general anesthesia. During the procedure the orthopedic surgeon will make very small incisions in the knee and fill the knee joint with a sterile water solution, allowing for a clear view of the knee.The surgeon will then insert the arthroscope and begin to look for any signs of injury or degeneration.
Once such areas have been identified, the surgeon may remove or repair bone or cartilage, or reconstruct a torn ligament.When the procedure is over, the surgeon will close the incision. The entire procedure may last anywhere from 30 minutes to over an hour.

How long is the recovery time after arthroscopy?

Although patients are up and walking just hours after surgery, it typically takes 2-3 weeks after knee
arthroscopy to return fully to daily activities and it can take three months or longer for athletes to return to sports.
For several days after arthroscopy, patients will commonly be asked to rest and elevate the joint while
applying ice packs to reduce pain and swelling. After surgery, an exercise program is gradually started that strengthens the muscles surrounding the joint and prevents scarring (contracture) of surrounding soft tissues.
The goal of the exercise is to recover stability, range of motion, and strength of the joint rapidly and safely, while preventing the build-up of scar tissue. This program is an essential part of the recovery process for an optimum outcome of this procedure.

Over the years, higher quality fiberoptic equipment has allowed the development of miniature arthroscopes. This has allowed the examination of smaller joints with arthroscopy. Arthroscopy has become an integral tool for orthopaedic surgery and its role will continue to expand as further improvement in arthroscopes and arthroscopicinstruments continues.



Arthroscopic Knee Surgery FAQ’s :-


Q: What are the possible complications can be face by the patient of knee arthroscopy?

A: Complications are uncommon, but possible. Infections are the most common complication but
can be prevented with antibiotics. Other complications are blood clots, excessive swelling or bleeding, and damage to blood vessels or nerves. Such complications occur in less than 1 percent of all arthroscopic procedures.

Q: Is bleeding after arthroscopic knee surgery normal?

A: Mild bleeding through the incision areas is normal. The area must be kept dry and covered, and
reinforced with sterile gauze. If bleeding persists, contact your doctor.

Q: How pain can be manage after knee arthroscopy?

A: Patients are prescribed pain relieving and/or anti-inflammatory medications.Patients may also use
over-the-counter pain relief medications in place of prescribed medications for mild pain.

Q: Will I need physiotherapy after arthroscopic knee surgery?

A: Physiotherapy is important after surgery in order to regain range of motion. Patients may work
with a physiotherapist to regain a full and active range of motion.

ACL injury (tear) and reconstruction

ACL injury :-

 
  Anterior cruciate ligament is the one of the most commonly injured ligaments of the knee, which also called ACL .
In the general population ACL tear is very common. It most probably occure in the  people who participate in high-risk sports, like basketball, football, skiing, and soccer etc. However,ACL injuries are very commonly seen with road traffic accidents also.

As sports activities increase day by day from last few decades, the number of acl injuries increases.
This injury has received a great deal of attention from orthopedic surgeons over the past 15 years,
and now become one of the most successful surgeries in the field of Arthroscopic surgery today.

ACL, is one of four ligaments that are important for the stability of the knee joint. A ligament is a structure which is made of tough fibrous material and connects bone to a bone. There are over 250,000 ACL injuries per year in india.

Structure of knee bone :-

The structure of the knee joint is formed by - the femur, the tibia(shin bone), and the patella (knee cap).

 Four main ligaments within the knee that connect the femur to the tibia and ACL is one of that ligaments.
The knee is essentially a hinged joint that is held together by - 

• Medial collateral (MCL),  
• Lateral collateral (LCL),
• Anterior cruciate (ACL) and
• Posterior cruciate (PCL) ligaments.

 The ACL runs diagonally in the middle of the knee joint, preventing the tibia from sliding out in front of the femur as well as providing rotational stability to the knee.

The weight-bearing surface of the knee is covered by a layer of articular cartilage. On either side of the joint, between the cartilage surfaces of the femur and tibia, are the medial meniscus and lateral meniscus. The menisci act as shock absorber and work with the cartilage to reduce the stress between the tibia and the femur.

What happened when you got ACL injury:-

When a person got  ACL injury, Immediately after the injury, patient usually experience pain and
swelling and the knee feels unstable and patients often have a large amount of knee swelling, a loss
of full range of motion, pain or tenderness along the joint line and discomfort while walking.
this instability caused by the torn ligament leads to a feeling of insecurity and giving way of the knee,
especially when trying to change direction on the knee. The knee may feel like it wants to slip backwards.
The ACL injury is a problem because this instability can make sudden, pivoting movements difficult.
 An ACL injury may also make the knee more prone to develop meniscal and articular cartilage injuries, which can be cause that is turn into the pain in the knee and early arthritis.
The pain and swelling from the initial injury will usually be gone after two to four weeks, but the knee may still feel unstable. The symptom of instability and the inability to trust the knee for support are what require treatment. Also important in the decision about treatment is the growing realization that long-term instability leads to early arthritis of the knee.

In short, symptoms of acl tear are following:-

•  Sudden giving way of the knee
•  Hearing a 'pop' at the time of injury
•  Sudden swelling of the knee joint after an injury
•  Pain in the knee when walking

If an ACL tear is suspected, you will have to return for follow-up evaluation with your orthopaedic surgeon.

Evaluation of ACL tear:-

The mechanism of injury occurs the ACL injury is partially or fully torn. An injury to a ligament is also known as a sprain.The treatment is influence by the severity of the sprain. Severe sprain (complete tear) of the ACL is a problem as the knee has lost one of its main stabilizers.
For an athlete, an injury to the ACL can make continued participation difficult. Many sports require a
functioning ACL to perform common maneuvers such as cutting, pivoting, and sudden turns.
perhaps, Patients is able to function in their normal daily activities without a normal ACL, but in sports activities may prove difficult. Therefore, athletes often decide to undergo surgery in order to get back to their previous level of competition.

ACL tear is non-operated or operated:-

Some patients who experience ACL tears are able to resume normal daily activities without surgical
reconstruction of thier ligament. There are some important factors to consider in making the decision as to whether or not operative treatment of an ACL tear is needed.
The decision whether or not to operate on an ACL tear is dependent on several factors. These factors includes-

•  the age of the patient,
•  the activity level of the patient (both recreational and occupational),
•  the expectations of the patient,
•  the ability and willingness of the patient to participate in post-operative rehabilitation,
•  the degree of instability of the joint and any other associated injuries to the knee (e.g. other ligamentous or menisci problems).

What is the surgical treatment for ACL reconstruction?


ACL tears are not usually repaired using suture to sew it back together, because repaired ACLs
 have generally been shown to fail over time.Therefore, the torn ACL is generally replaced by a substitute graft made of tendon. The grafts commonly used to replace the ACL include:

Patellar tendon autograft (autograft comes from the patient)  Hamstring tendon autograft
Quadriceps tendon autograft
Allograft (taken from a cadaver) patellar tendon, Achilles tendon, semitendinosus, gracilis, or posterior tibialis tendon.
Patients treated with surgical reconstruction of the ACL have long-term success rate. The goal of the ACL reconstruction surgery is to prevent instability and restore the function of the torn ligament, creating a stable knee.
This allows the patient to return to sports. There are certain factors that the patient must consider when deciding for or against ACL surgery.

Rehabilitation program :-

ACL reconstruction is usually not performed until several weeks after the injury. This time allows the
 inflamed and irritated knee to quiet. As the swelling and inflammation decrease, the range of motion of the knee improves. Resolution of swelling and stiffness prior to ACL reconstruction surgery improves the post-operative function of the joint.
Once I have surgery, when can I play again?

ACL reconstruction surgery needs a four to six months rehabilitation program post-operatively. This is usually broken up into three phases with activities increasing with the strength of the healing ligament. It is extremely important to be compliant with the post operative rehabilitation. Engaging in higher stress activities when the tissues are not yet healed and the muscles are not fully functioning can lead to early failure of the ACL. Most athletes are able to return to running at 8 weeks, plyometrics and agilities by 12 weeks and sport at four to six months. Return to sport is evaluated on an individual basis and will ultimately be determined by the surgeon.

How to get rid of shoulder joint pain

Shoulder pain

 There are some general information about shoulder pain and simple exercises

that may help.

Simple exercises

Pendulum exercise

 Stand with your good hand
resting on a chair. Let
your other arm hang down
and try to swing it gently
backwards and forwards
and in a circular motion.
Repeat about 5 times.
Try this 2–3 times a day.







Shoulder stretch
 Stand and raise your shoulders. Hold for 5 seconds. Squeeze your
shoulder blades back and together and hold for 5 seconds.
Pull your shoulder blades downward and hold for 5 seconds. Relax and
repeat 10 times.




Door lean

 Stand in a doorway with
both arms on the wall
slightly above your head.
Slowly lean forward until
you feel a stretch in the
front of your shoulders.
Hold for 15–30 seconds.
Repeat 3 times. This
exercise isn’t suitable
if you have a shoulder
impingement.

Door press

a) Stand in a doorway with  your elbow bent at a right
angle and the back of your wrist against the door
frame. Try to push your arm outwards against the
door frame. Hold for 5 seconds. Do 3 sets of 10
repetitions on each side.

b) Use your other arm and, still with your elbow
at a right angle, push your palm towards the
door frame. Hold for 5 seconds. Do 3 sets of 10
repetitions on each side.

How does the shoulder work?

The shoulder is the most mobile joint in the
body. The main shoulder joint is a ball-and socket
joint, which allows a very wide range
of movement. The joint is surrounded by
a tough fibrous sleeve called the capsule,
which helps to hold the joint together. A group
of four muscles and their tendons make
up the rotator cuff, which controls movement
and also helps to hold the joint together.
There’s another smaller joint where the top
of the shoulder blade meets the collarbone.

What causes shoulder pain?

  There are many causes of shoulder pain, but most cases will only affect a small area and
are relatively short-lived. Shoulder pain may also be part of a general condition such as
rheumatoid arthritis or osteoarthritis.
Shoulder pain isn’t always caused by a problem in the shoulder joint – problems in
the neck can cause pain that’s felt over the shoulder blade or in the upper outer arm.

What can be done to help?

If your pain has a particular cause, like arthritis, treating that condition may help.
Following the self-help tips and exercises here will also help, but if your pain isn’t
improving after about 2 weeks then you should speak to your doctor.

Medication

Painkillers such as paracetamol and ibuprofen may help and you should
use them if you need to. It’s important that you take them regularly and at the
recommended dose to help you control the pain and allow you to continue exercising.
Don’t wait until your pain is severe before taking painkillers. You can also rub antiinflammatory
cream directly onto the painful area.
You shouldn’t take ibuprofen or aspirin if you’re pregnant or have asthma, indigestion
or an ulcer until you’ve spoken to your doctor or pharmacist. Medication can have sideeffects
so you should read the label carefully and check with your pharmacist if you have
any queries.


Physiotherapy

If your shoulder pain is affecting your activity and is persisting, ask your GP about referral
to a physiotherapist. Physiotherapy can help you to manage pain and improve your
strength and flexibility. A physiotherapist can provide a variety of treatments, help you
understand your problem and get you back to your normal activities.

Rest and exercise

Aim for a balance between rest and activity to prevent the shoulder from stiffening.
Pace yourself to start with and try to do a bit more each day. Try to avoid movements
that are most painful, especially those that hold your arm away from your body
and above shoulder height. It’s important to remain active, even if you have to limit
how much you do.

Posture

Don’t sit leaning forwards with your arm held tightly by your side. This position can
make the problem worse, especially if some of the pain is coming from your neck. When
sitting, keep a pillow or cushion behind your lower back with your arm supported on a
cushion on your lap.

Reducing the strain

When raising your arm or lifting objects,reduce the strain or pull on your shoulder by:
• keeping your elbow bent and in front of your body
• keeping your palm facing the ceiling.

To lower your arm, bend your elbow,bringing your hand closer to your body.

Your pain should ease within 2 weeks and you should recover over
approximately a 4–6 week period.
You should carry on with the exercises overleaf for at least 6–8 weeks to help
prevent symptoms returning.
If you have severe pain or your symptoms haven’t improved after
2 weeks, contact your doctor.

Options you need to know before joint replacement

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