Knee Arthroscopy by A.Griguolo

Generality

Knee arthroscopy is a minimally invasive surgical technique that allows the diagnosis and treatment of numerous knee problems.

Its execution involves the practice of very small skin incisions at knee level and the use of the arthroscope, a straw-shaped instrument equipped with a camera and a light source.

Knee arthroscopy procedures require some preparation, which however is very simple to implement.

In knee arthroscopy, post-operative phase, healing time and return to daily activities vary depending on the reasons for the implementation of the surgical technique in question.

Short anatomical reference of the knee

The knee is the important synovial joint of the human body, placed between the femur (superiorly), tibia (inferiorly) and patella (anteriorly).

Several anatomical elements take part in its constitution, including:

The articular cartilage, located on the lower surface of the femur;
The synovial membrane, which covers the joint from the inside and produces synovial fluid, a lubricating fluid;
Tendons and ligaments, which guarantee the stability of the joint and the right alignment between the femur and tibia;
Synovial bags, which are small synovial membrane pockets, filled with synovial fluid;
The inner meniscus (or medial meniscus ) and the external meniscus (or lateral meniscus ), which are cartilage cushions located on the surface of the tibia.

What is Knee Arthroscopy?

Knee arthroscopy is a minimally invasive surgical technique, performed under anesthesia, through which the diagnosis and treatment of pathologies and injuries to the knee joint are possible.

Like any type of arthroscopy, knee arthroscopy also involves the use of a particular instrument, called an arthroscope .

What is the arthroscope and what is it used for in arthroscopy of the knee?

The arthroscope is the main and most representative instrument of arthroscopy.

Comparable in length and width to a drinking straw, the arthroscope has, at one end, a network of optical fibers with the dual function of camera and light source, and, almost at the other end, a cable for ignition of the fiber optic network and for connecting the aforementioned camera to a monitor .

During arthroscopic procedures (and therefore also during arthroscopy of the knee), the arthroscope is the instrument that the operating physician introduces, from the side of the camera and the light source, into the knee joint and uses, subsequently, as an exploratory camera capable of transmitting what was filmed in the connected monitor.

Thanks to its straw-like shape, the arthroscope is an extremely handy device capable of wedging itself in every corner of the joint of interest; furthermore, again thanks to its thinned shape, its introduction into the human body does not require the execution of a large incision, but only a small cutaneous opening not exceeding one centimeter.

Who practices knee arthroscopy?

As a rule, knee arthroscopy procedures are the responsibility of an orthopedic doctor who specializes in the diagnosis and treatment of knee joint problems.

Indications

Depending on the circumstances, knee arthroscopy may have diagnostic or therapeutic purpose.

When is it diagnostic?

Orthopedists use knee arthroscopy for diagnostic purposes, when routine and less invasive assessments such as physical examination, medical history and radiological examinations (X-rays and nuclear magnetic resonance) have not provided sufficient data to make a definitive diagnosis, relative to a problem at the knee level.

Therefore, knee arthroscopy with diagnostic purposes is a clarification of uncertain situations. To confer this role of clarifying examination are the advantages coming from the use of a camera as an exploratory probe source of the articulation of interest.

It may happen that knee arthroscopy performed initially for diagnostic purposes turns into therapeutic, at a time when the performing physician has clarified the articular problem present and has deemed it possible to resolve it during the same intervention.

When is it therapeutic?

Knee arthroscopy is used for therapeutic purposes, in the presence of knee problems resistant to non-surgical treatments (which always represent first-line solutions) or in the presence of knee problems that can only be cured by surgery.

What makes it possible to diagnose and treat?

Knee arthroscopy allows you to diagnose and treat:

The rupture of a meniscus (or lesion of a meniscus );
Laceration of the anterior cruciate ligament or posterior cruciate ligament ;
Total or semi-total laceration of the medial collateral ligament or lateral collateral ligament ;
Patellar tendon injuries ;

Defects of articular cartilage ;
A bursitis (inflammation of a synovial bursa) at the knee;
Baker's cyst . Baker's cyst is an abnormal nodule that forms behind the knee, following the release of synovial fluid from the popliteal bursa (a synovial knee bag);
Tibial plateau fractures ;
A synovitis (inflammation of the synovial membrane) of the knee;
Diseases of the patella (patellar dislocation, patellar chondropathy and fractures).

Who are the most common patients?

In general, individuals who, despite themselves, must benefit from the diagnostic and therapeutic potential of knee arthroscopy are:

The sportsmen, in particular the practicing sporting activities that foresee the race with sudden changes of direction and the physical contact;
The elderly, with problems of osteoarthritis or rheumatoid arthritis.

Preparation

At least a couple of weeks before any knee arthroscopy operation (therefore regardless of the diagnostic or therapeutic purpose), the possible future patient must undergo a series of cognitive clinical tests and meet the orthopedist who is treating her, for receive information regarding the methods of intervention and the so - called pre-operative measures .

Cognitive clinical examinations

The cognitive clinical examinations essentially consist of: a thorough physical examination, a complete blood test, a cardiological examination and a thorough evaluation of the clinical history .

The use of these investigations serves to establish whether or not there are the health conditions indispensable for the success of the knee arthroscopy operation.

Information on the methods of the transaction

Provided as a rule at the end of the cognitive clinical examinations, information on the operative modalities of the arthroscopy of the knee concern topics such as:

The main steps in knee arthroscopy procedures;
The approximate duration of the intervention;
The type of anesthesia used;
Rehabilitation exercises to be performed at home in the first days after the procedure;
The duration of post-operative physiotherapy required;
Waiting for complete healing.

Pre-operative measurements

The pre-operative measures are precautions that the patient must follow to the letter, so that the knee arthroscopy is successful.

Also illustrated at the end of the cognitive clinical examinations, they consist of:

Stop any therapy based on anticoagulant drugs, because these drugs tend to favor bleeding on cuts such as surgical incisions.
On the day of the procedure, appear at full fast for at least 8-10 hours. The only food allowed is water, but only a few hours after the operation;
Also on the day of the intervention, be accompanied at home by a family member or friend, because at the conclusion of knee arthroscopy procedures, thanks to anesthesia, attention and vigilance skills are compromised (activities such as driving, therefore, could be very dangerous).

Procedure

Knee arthroscopy operations are outpatient surgery, which can be divided into 3 main moments, which, in chronological order from the first to the last, are: the time dedicated to the preparation and positioning of the patient, the time of anesthesia and the time actual operating.

Knee arthroscopy is an outpatient surgical technique . This means that its execution takes up a total of half a day and does not require hospitalization, except in exceptional cases.

Patient preparation and positioning

During the preparation and positioning phase, the patient will interact with a nurse of the medical staff, who:

He will welcome him when he arrives in the hospital where the knee arthroscopy procedure will take place;
He will take him to a locker room and provide him with a hospital gown to wear for the procedure;
It will remind you of all the steps in the procedure;
He will accompany him to the operating room and, with the help of some of his colleagues, will place him on the operating table, making him take the correct position to receive anesthesia.

Anesthesia

Despite being a minimally invasive technique, arthroscopy of the knee would still be painful, in the absence of anesthesia.

During knee arthroscopy procedures, the types of practicable anesthesia are: local anesthesia, spinal anesthesia and general anesthesia.

Local anesthesia . It involves insensitivity to pain limited to the knee. Thus, during the procedure, the patient is conscious.
Spinal anesthesia . Practiced on the back, near the spinal cord, it leads to insensitivity to pain from the waist down. Thus, even in such circumstances, the patient is conscious during the procedure.

General anesthesia . General anesthesia induces the patient's sleepiness, which, therefore, during the operation, is completely unconscious and insensitive to any type of stimulus (painful or not).

To decide which type of anesthesia to practice are the orthopedist who will perform knee arthroscopy and an anesthesiologist (NB: in every surgery with anesthesia, there is a doctor who specializes in anesthetic and resuscitation practices).

The choice between local, spinal and general anesthesia is influenced by the purpose of knee arthroscopy, the age of the patient and the experience of the orthopedist to work in different circumstances.

Did you know that ...

During knee arthroscopy procedures, the use of general anesthesia is reserved for patients who have an allergy to anesthetics used in local or spinal anesthesia.

Operational moment

The operative moment of the arthroscopy of the knee begins after the confirmation by the anesthesiologist of the successful anesthesia.

This crucial phase of the procedure is entirely up to the orthopedist, who provides, in order, to:

Disinfect the entire knee to minimize the risk of infection;
Make an incision of about one centimeter, at the height of the knee, that allows to "enter" the joint;
Through the incision, inject a saline solution to "clean" the inside of the joint;
Insert the arthroscope into the usual incision and begin to search the knee internally, in search of the problem to be diagnosed or treated;
Practice another couple of small incisions, in order to insert the surgical instruments necessary to treat the problem detected in the previous phase or of which he was aware from the beginning;
At the end of the procedure, extract the arthroscope and, if it has been used, the surgical instruments;
Apply some resorbable sutures on the incisions and a compression bandage around the knee, to protect the latter and avoid the classic post-operative swelling.

When the orthopedist knows right away that he must perform knee arthroscopy for therapeutic purposes, he could practice all the incisions at the same time.

What feelings does the patient feel during the procedure?

The patient feels a discomfort or minimal pain when inserting the needle to inject the anesthetic; after that, he no longer perceives anything that could in any way be unpleasant or problematic.

How long does it last?

Knee arthroscopy procedures can last from 15 to 30 minutes, when they are only diagnostic, and from 40 to 120 minutes, when they are therapeutic (in these circumstances, the complexity of the disease to be treated has a decisive influence).

Post-operative phase

At the end of the knee arthroscopy procedure, medical staff nurses transfer the patient to a comfortable hospital (or clinic) recovery room; here, the newly operated person will finally be able to eat and recover calmly.

The stay in the recovery room lasts a few hours, that is the time necessary for the main effects of anesthesia to disappear; during this time frame, the patient receives several visits from nurses and operating orthopedist, who assess their health status and the response to the procedure.

The resignation takes place exclusively on the indication of the operating doctor.

Important : the use of general anesthesia requires hospitalization for one day.

What are the after-effects of anesthesia?

Intended to gradually fade within 24 hours, the main effects of anesthesia are: fatigue, confusion, dizziness and a sense of dizziness.

What are the after-effects of the actual procedure?

In the first few days after a knee arthroscopy procedure, the operated knee will be painful and swollen.

Pain and swelling must not alarm (unless they are persistent), as they are two normal consequences of incisions and the introduction of surgical instruments into the joint.

As for surgical incisions, they heal within 1-2 weeks.

What can help alleviate pain and swelling?

To rest
Take a painkiller (eg: paracetamol, aspirin and ibuprofen)
Make ice packs (4-5 packs per day lasting 15-20 minutes)
Keep the operated limb raised

Recovery

Recovery times from a knee arthroscopy procedure depend on:

The purpose. Purely diagnostic procedures have much shorter recovery times than therapeutic procedures.
The problem to be treated. For example, reconstruction of the anterior cruciate ligament has a much longer prognosis than the removal of a small piece of injured meniscus (meniscectomy).
Age and health status of the patient.
The work activity performed by the patient. Who practices a sedentary job heals before those who practice a heavy job, because it stresses less the articulation operated.
The attention that the patient has towards himself. Heals first and better those who do not burn the stages, follow the instructions of the doctor and the physiotherapist, and do not miss the periodic checks.

Periodic checks

After each knee arthroscopy procedure, especially if it is therapeutic, the orthopedist sets some periodic checks to monitor the long-term outcome of the procedure.

The number of periodic post-operative controls varies according to the severity of the joint problem under treatment (eg: meniscectomy involves two controls, one after one week and one after one month).

Physiotherapy

After knee arthroscopy procedures, physiotherapy is essential for restoring normal joint mobility. To get the maximum benefits from it, it should start a few days after the operation.

Return to daily and sports activities

After knee arthroscopy procedures, the return to daily activities (eg driving) and sports practice depends on what the intervention specifically envisaged.

Risks and Complications

Knee arthroscopy is a safe technique; in fact, it is rare for it to give rise to complications.

What are the possible complications?

The possible complications of knee arthroscopy can be subdivided into: general complications (these are the complications that can arise from any surgical procedure) and specific complications (these are the complications that can derive specifically from knee arthroscopy).

Under generic complications, there are:

Excessive bleeding during surgery;
Infection of a surgical incision;
Deep venous thrombosis;
Adverse reaction to anesthetics.

Instead, specific complications include:

Bleeding inside the operated joint;
Infection within the operated joint;
Excessive postoperative joint stiffness;
Involuntary damage to a neighboring nerve;
Involuntary damage to a healthy element of the operated joint.

Contraindications

Knee arthroscopy has no particular contraindications.

Results

Both among patients and professionals, knee arthroscopy is a highly appreciated technique, because it combines minimal invasiveness with safety and efficacy.