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Recent advances in arthroscopy

Dr. C. Rajavelu. M.S (Ortho); M.Ch Orth (U.K.)

                               
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History

Before the era of arthroscopy, orthopaedic surgery involved major incisions to expose deranged joints. A prolonged period of rehabilitation was needed to recover from the trauma due to surgery. Smaller incisions may result in incomplete diagnosis or surgery, an excessive price to pay for the better cosmesis and less morbidity. Incisions heal, irrespective of size, as they heal from side to side but they hurt end to end. Arthroscopy is a minimally access surgical procedure, allowing excellent visualisation with minimal soft tissue trauma giving the patient the benefits of both the worlds.

Medical endoscopy began in the early 1800s by Bozzini. In 1918, Prof Kenji Takagi of Tokyo University did the first arthroscopy. It was done in a cadaver knee with a cystoscope. Dr. Eugene Bircher was the first to perform and publish the first arthroscopy on live patients. To begin with, it was used to diagnose tuberculosis, which was more prevalent in those days. Since then the developments in arthroscopy have become many fold. The potential for treatment using this technique is enormous.

During the past two decades, arthroscopic procedures have been replacing traditional, more invasive orthopaedic surgical procedures. Today arthroscopy is being done in almost all joints. High performance athletes need a minimal surgical exposure for a faster recovery and quick return to the field with very minimal morbidity. As technology becomes more and more advanced, a greater number of minimally invasive surgical interventions have evolved. Recently, training simulators (Virtual reality) have come into vogue to teach the skills necessary for arthroscopy especially the knee.

Arthroscopy of Knee

Nowadays knee arthroscopy as a diagnostic procedure is done under local anaesthesia in the out patient. Bioabsorbable arrows have been deviced for meniscal repairs. Patellar fractures without major separation and comminution can be reduced under arthroscopic guidance and fixed percutaneously with cannulated screw. This technique is minimally invasive and does not disturb the vascular supply of patella. It allows clear visualization of the reduction and facilitates early mobilisation exercise of the knee.

In Outerbridge grades 2 and 3 lesions, in a properly tracking patella, debridement removes fibrillation and provides a stable rim of chondral tissue. Recent studies suggest that bipolar radiofrequency probes are superior to mechanical shavers for articular cartilage debridement. This procedure is a valuable technique particularly in adolescents and young adults

Until recently, avulsion fractures of the PCL (posterior cruciate ligament) have been repaired with ORIF (Open reduction and Internal fixation). Posterior approach commonly used for open repair is rather extensive, also it does not allow for detection and management of associated intraarticular injuries of the knee.  Recently arthroscopic reduction and retrograde fixation is being done for large fragments through anterior portal.

According to recent research, upto 10 to 12% of individuals present with chondral injuries. When symptomatic, chondral lesions manifest as swelling and knee pain. The loss of cartilage may be partial or complete, and it may affect one or multiple locations. They are classified according to the size, depth and location. The natural history of untreated lesions is progression and increasing disability. Nonsurgical treatment modalities include analgesics, knee brace and physiotherapy. Surgical treatment varies from arthroscopic debridement to implantation of autologous chondrocytes beneath a periosteal patch covering the lesion. The choice of procedure depends on the characteristics of the lesion, patient's symptoms, age and activity level. Autologous chondrocyte transplantation has a durable outcome for as long as 11 years.

For osteoarthritis, in patients around fifty years of age, arthroscopic debridement of the knee is considered before total knee replacement.

Arthroscopic surgery is an option for treating the painful stiff knee joint following total knee replacement. It avoids the potential complications of manipulation or open arthrotomy.

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Arthroscopy of ankle

Selected patients with disabling ankle arthrosis may be more appropriately treated with an arthroscopic arthrodesis than by open surgery. Selected patients include those with only mild angular deformity and avascular necrosis not greater than 30% of the talus. The advantages of the arthroscopic technique include a high fusion rate, decreased time to fusion.

Arthroscopic curettage and drilling are recommended for both primary and revision treatment of an osteochondral defect of the talus. Autologous chondrocyte transplantation is done for osteochondritis dissecans. For unicompartmental defects of articular cartilage, implantation of new chondrocytes, establishes subchondral blood supply, and reconstruction of the articular surface.

Ankle fractures have a high incidence of concomitant occult intra-articular injury with syndesmosis disruption and a high risk of articular surface injury to the talar dome. Arthroscopy is a valuable tool in identifying and treating intra-articular damage that would otherwise remain unrecognized. It also provides prognostic information regarding the functional outcome of these injuries. Arthroscopy is a modality to obtain accurate reduction and fixation of a juvenile Tillaux fracture.

Recent studies suggest that, with the patient in the prone position, arthroscopic equipment may be introduced into the posterior aspect of the ankle without gross injury to the posterior neurovascular structures

Arthroscopy of elbow

Arthroscopic synovectomy is a reliable procedure to alleviate pain in rheumatoid arthritis. A preoperative radiographic Grade of 1 or 2 is a good indication.

The fundamental of arthroscopy is visualization and access. Visualization and access to the ulnohumeral and radiocapitellar articulation is rather difficult. Recent study has come out with a joint jack to widen the ulnohumeral joint space to work better posteriorly.

Arthroscopy of Shoulder

In arthroscopic transhumeral rotator cuff repair the same type of cuff repair can be performed as with an open standard procedure. In trough-tunnel open repair of rotator cuff tears the use ofbioabsorbable plates (Lactosorb) prevents hole migration and potentially poor results or failures of repairs. The plate maintains its strength during the healing period and does not elicit any clinically noticeable inflammatory process.

Many instrument systems and techniques have been developed for performing arthroscopic Bankart repair. The suture anchor procedure relies on a secure knot, which does not become entangled in the anterior portal. Thermal modification of joint capsule and ligamentus tissues, is a recent introduction to medical science. Arthroscopic thermal capsulorrhaphy is one such procedure for treating joint instability. It avoids large incisions and significant shoulder joint trauma. Relatively low-temperature heat is directed to the supportive structures tightening a previously stretched and attenuated shoulder capsule.

Beside electro-thermic procedures (ETACS, LACS) several suture-anchor system for labrum fixation have been developed in the last years. Compared to open procedures the arthroscopic shoulder stabilization has many advantages.

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Arthroscopy of wrist joint

The arthroscopic approach allows a precise reduction and fixation of the articular fragment of capitulum with a better evaluation of associated lesions compared with the open surgery. Arthroscopic fixation minimizes the damage to periarticular soft tissues and has a lower morbidity compared with open surgery.

Acute nondisplaced scaphoid fractures have traditionally been managed with cast immobilization. Prolonged casting may lead to muscle atrophy, joint contracture, disuse osteopenia, and financial hardship. An athlete or worker may be inactive for 6 months or even longer as the fracture heals. Arthroscopic assisted fixation offers a middle ground between traditional cast immobilization and open reduction for scaphoid fractures. The proven benefits of the percutaneous technique include minimal soft tissue dissection, decreased risk of interruption of the tenuous scaphoid blood supply, avoids division of the important radioscaphocapitate ligament, visualization of the fracture, ensures anatomic reduction, and stable fixation. This technique allows for faster and early rehabilitation and an earlier return to work. Nondisplaced fractures that present with delayed or fibrous union without evidence of avascular necrosis, cyst formation, or bony sclerosis may also be treated with this technique.

Imaging techniques are helpful for diagnosing occult fractures and distal radioulnar subluxation, but unsatisfactory for diagnosing ulnocarpal impaction syndrome, tears of the triangular fibrocartilage complex and lunotriquetral ligament, and joint mouse. Therefore, prior to surgical intervention arthroscopy is recommended for patients with persistent ulnar wrist pain that interferes with their daily activity.

Injuries to the scapholunate complex present the surgeon with both diagnostic and treatment dilemmas. The anatomic features, biomechanical properties, radiographic appearance, and surgical treatment algorithms of this small but structurally and kinematically important joint continues to be refined. Arthroscopy is considered the gold standard for complete evaluation of scapholunate interosseous ligament injury and often is performed as a first step before repair or reconstruction. Procedures such as carpal fusions or capsulodesis can limit excessive scaphoid motion, promote wrist stability, and potentially prevent arthritis, but advances continue to be made in direct scapholunate interosseous ligament reconstruction.

Triangular fibrocartilage complex (TFCC) are treated arthroscopically. Carpal detachment injury should be considered when no abnormalities of the TFCC and ligaments were observed. Arthroscopic findings suggested that a portion of TFCC that was originally attached to the ulnar side of the triquetrum had become detached. Resection of meniscus homologue-like tissue which arose from TFCC with a shaver and a punch, may improve the symptoms.

Several reports have shown the superiority of endoscopic carpal tunnel release over open surgery, in particular relating to earlier recovery of hand strength and return to work. A significant reduction in scar tenderness ( pillar pain) and contracture is of particular importance for those who do heavy manual work.

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Arthroscopy for foreign body removal

Synovitis caused by thorn prick injury  is a rare pathology. Thorn prick injury, which is particularly caused by thin palm thorns, is frequently missed in clinical history. Clinical presentation of cases may simulate juvenile rheumatoid arthritis with monoarticular involvement and septic arthritis. Removal of all thorns with partial or total synovectomy is essential in definitive treatment. Arthroscopy is the most valuable method of meeting both diagnostic and therapeutic purposes as it provides the best visibility of the joint and ensuring lower morbidity.

Foreign body, and retained bullets in the hip and knee joints can be retrieved arthroscopically with minimal morbidity and quick complete recovery.

Arthroscopy of Temporomandibular joint

Temporomandibular joint (TMJ) arthroscopy is an appropriate therapeutic modality for patients with TMJ  internal derangements, with reoperation required for only 20% of patients. Arthrocentesis and lavage is effective in reducing pain and increasing mandibular motion in patients with anterior unreduced disc displacement  especially in patients the duration of symptoms being less then 6 months. It is recommended as a simple alternative to more invasive TMJ procedures. TMJ arthroscopic disc traction suture with posterior sclerotherapy and anterior release is effective on disc displacement. Diagnosis, treatment and post-operative evaluation can be performed in the same arthroscopic procedure.