What is Arthroscopy?
Knee arthroscopy is a surgical procedure used to inspect and treat problems inside the knee joint using a tube-like viewing instrument called an arthroscope.
The word arthroscopy comes from two Greek words, “arthro” (joint) and “skopein” (to look). The term literally means “to look within the joint.”
Arthroscopy was popularized in the 1960s and is now commonplace throughout the world. Typically, it is performed by orthopaedic surgeons as a day case procedure. It is one of the most common orthopaedic operations performed in the UK.
The technique of arthroscopy involves inserting the arthroscope (approximately 5 millimetres in diameter, roughly the size of a pencil containing optical fibres and lenses), through tiny incisions in the skin into the knee joint. The arthroscope is connected to a video camera and the interior of the joint is seen on a television monitor.
There are a number of procedures that can be undertaken during the arthroscopy using small specialised instruments. As no big cuts are made there is less tissue trauma, resulting in less pain and a quicker recovery.
Why is Arthroscopy necessary?
Some injuries can be treated by arthroscopic surgery. These include meniscal (cartilage) tears, chondromalacia (wearing or injury to the smooth bone ends), anterior cruciate ligament tears and removal of loose bodies. If the joint lining (synovium) is inflamed a small area of this can be taken (a biopsy) and sent for further investigations. If the patella (knee cap) is very tight causing pain it can be loosened using a procedure called a lateral release. The under surface of the patella can be inspected and any loose cartilage shaved.
Diagnosing knee injuries and disease begins with a thorough medical history and physical examination. Tests such as x-rays, magnetic resonance imaging (MRI) or computed tomography (CT) scans may be needed before undertaking an arthroscopy.
What is done in preparation for Arthroscopy?
It is important that you understand what is involved in an arthroscopy and that you are physically prepared for the operation.
I will explain the procedure to you on the morning of your operation. Arthroscopy has few complications. Even though it is a relatively small procedure, it is important that you understand what is involved.
Any pre-existing medical problems such as diabetes and high blood pressure should be optimized before the operation. Patients who are on anticoagulants (blood thinners) will normally need to stop these before the operation. Please inform me of any medication you take when we first meet and bring them with you when you come to hospital. The anaesthetist will review these.
Any signs of infection in the body (including colds) usually requires the operation to be postpone.
How is arthroscopy performed?
It is usual to have a general anaesthetic. Two or three small stab incisions are made in the front of the knee through which the arthroscope and instruments are passed.
The leg is painted in a dark brown antiseptic solution to reduce the risk of infection. It is best to wear dark coloured underwear as this stains clothes. A tourniquet (a tight bandage) is placed around your thigh and inflated when you are asleep to reduce bleeding and so improve visualization. If the procedure takes a long time this can cause discomfort in the thigh muscles and some numbness in the leg for a few days after the operation.
Fluid is passed into the knee to inflate it, allowing better visualization. A small puncture wound is usually made on the side of the knee to allow this fluid to flow through the joint. At the end of the operation, the fluid is drained from the knee.
Most arthroscopies last between 30-60 minutes depending on what procedure is performed.
Local anaesthetic is injected into the knee to minimise discomfort after surgery. A relatively tight bandage is then applied.
You will then be transferred to a bed and taken out to the recovery room where you will begin to wake up from the anaesthetic. Once the recovery nurse is satisfied you are sufficiently awake you will be taken back to the ward.
Usually in recovery or on the ward the bandages are reduced and a cryocuff applied. This helps reduce swelling and pain.
Stitches are not usually required to close the wounds, sticky tapes or dressings are used to close the incisions.
What are the possible complications?
Arthroscopy is a very common operation and is very safe. However, in order to make an informed decision and give your consent, you need to be aware of the possible side-effects and the risk of complications of this procedure.
These are the unwanted but mostly temporary effects you may get after having the procedure.
You should expect some pain, stiffness, swelling and bruising around your knee. This is likely to last for some weeks and will gradually improve as the knee heals and you get back to your normal day-to-day activities.
Complications are problems that may occur during or after the operation. Most people aren’t affected. Complications occur in less than 1 in 100 cases.
These can be divided into those related to any operation and those related to the arthroscopy operation itself.
Possible complications of any operation
- Reaction to anaesthetic.
- Blood clots – These can form in the legs and travel to the lungs (pulmonary embolus 0.3%) which can be fatal. If they stay in the legs (deep vein thrombosis 0.75%) you will need to be treated with blood thinners for about 3-6 months.
Possible complications of the operation
- Infection in the joint (0.1%) – If this occurs it is usual to wash the joint out in theatre and to be treated with antibiotics.
- Bleeding – This sometimes occurs after surgery and if severe may require a return to theatre for removal of the blood. It occurs in approximately 1 in 100 people.
- Scar/lump under the incision – A small lump normally forms under the stab wound. Once the wound has healed I encourage patients to rub cream into the portal site to soften and desensitize the underlying scar tissue.
- Continued symptoms – Despite a surgeon’s best efforts this procedure may not cure your symptoms. If this is the case other options of treatment will be discussed with you.
- Neurovascular damage – There is often some numbness over the small incisions. This usually improves with time. Accidental damage to structures inside or near to the joint can occur but is very rare.
What are the advantages of arthroscopy?
Because the cuts are smaller, the damage to the tissues around the knee are less, as is the scarring to the knee. Because the damage is less, recovery from the operation is usually quicker.
Most patients have their arthroscopic surgery as day case procedures and are home the same day. Arthroscopic surgery has received a lot of public attention because it is often used to treat well-known athletes. It is an extremely valuable tool for all orthopaedic patients.
What is recovery like after arthroscopy?
Arthroscopy is usually performed as a day case procedure with patients going home the same day.
You will normally be sent home on crutches with a tubigrip (elasticated stocking).
You should keep the incisions clean, dry and covered. They will be covered with tegaderm dressings. The aim of the dressing is to keep the edges of the cuts together, just like any normal cut. Tegaderm dressings allow showering, but not bathing. You should try and maintain the dressings for 10 days. If the dressing is peeling and you are not keen to take it off, then it may be best to reinforce it with a further dressing on top, and try to keep it as dry as possible.
It is important to limit any knee swelling after the operation , less swelling means less pain and a quicker recovery.
- Rest – for 48 hours after the operation only undertaking activities that are necessary.
- Ice – cooling the knee helps reduce swelling and helps with pain control. I encourage the use of a cryocuff which can be used continuously throughout the day, taking it off at night. If you are using ice instead of a cryocuff, always cover the ice with either a towel or pillowcase. Break up the ice and make the towel/pillow case damp. You can “ice” for 10 minutes at a time during the day approximately every 1-2 hours. This helps to reduce pain and inflammation.
- Compression – after 48 hours when you begin to get up and around, a double tubigrip ( elasticated stocking) should be used during the day and taken off at night. Whenever possible take the tubigrip off and use the cryocuff.
- Elevation – when possible after the initial 48 hours rest with your foot up and supported higher than your hip.
Even if you are not in pain, it is best to take anti-inflammatories (if allowed) and pain killers for the first 5 days. Some patients find anti-inflammatories make then nauseous and give them a “stomach upset”. If this happens stop taking them.
Although the puncture wounds are small it takes several weeks for the joint to maximally recover. I usually advise patients to have physiotherapy after the operation as it speeds the rate of recovery and enables patients to achieve their full potential.
Patients usually go back to non-manual work in 7-10 days. Returning to work will depend on the practicalities of getting in and out of work and your work environment. Going back too early may cause the knee to swell and be painful.
Remember that each arthroscopy may be very different and the speed of recovery is very individual.
Do not be afraid to bend your knee but do not force it.
During your follow-up visit, I will inspect the knee and the incisions. Any stitches will be removed. The surgery undertaken will be explained. Physiotherapy is recommended to speed recovery and optimise function.
You can return to driving when you are safe to do so. There is no prescribed time and will depend on the individual and the surgery performed.
If you have any worries or problems, do not hesitate to contact me.
I would like to say a big thank you to you and your anaesthetist, who on the 17th November 2017, performed miracles. I have undergone two operations, but until that day, had never met two amazing men as yourselves. I suffer from migraines on a daily basis, going without food or water for long periods is a recipe for disaster. You brought me to the front of the queue, and I will never forget that kindness, and it didn’t stop there… Thank you both very much to The Three Shires Hospital and to staff. You get my vote every time
SF- The Three Shires Hospital