Arthroscopy is a surgical technique that allows the surgeon to diagnose and treat different alterations that may occur in a joint of the body (knee, shoulder, ankle,…). It is accessed through small cuts in the skin, through which an instrument the size of a pencil called arthroscope is introduced, which allows us to have a clear view of the inside of these joints.
Arthroscopy is a technique that is commonly used in knee, shoulder, elbow, hip, ankle and wrist operations, allowing to treat many pathologies that previously could only be solved by opening the joint.
The knee is a joint that is made up of 3 bones: the lower part of the femur, the upper part of the tibia, and the patella. The articular surfaces of these bones are covered by a layer of tissue softer than the bone, but marble-like, called CARTILAGE, through which these surfaces slide to give the bending and extension movement of the knee (the bending and stretching movements).
To make congruent the articular surfaces of the femur (spherical surface) and the tibia (flat surface) there are the MENISCUS, in number of 2: The internal meniscus and the external meniscus.
To give stability to the knee joint there are basically 4 LIGAMENTS:
2 lateral: Internal and external, located on both sides of the knee.
2 crossed: Anterior and posterior, located in the central part of the knee.
Prior to the intervention, the surgeon and/or anesthesiologist will have reviewed the so-called pre-operative tests (blood tests, chest X-ray and ECG) in order to rule out any alteration that involves an added risk to the anesthetic and surgical procedure.
Approximately 6 hours before the intervention the patient must be fasting (he will not be able to eat or drink), and will be admitted to the Hospital 2-3 hours before the intervention.
In knee arthroscopies, the most commonly used type of anesthesia is spinal anesthesia (puncture in the lower back), which allows the legs to be asleep during the intervention, but the patient is awake, so that, if you wish, you can follow the intervention by the TV monitor , at the same time that the surgeon explains everything he is doing at that very moment.
Through a first small incision, we introduce a cannula into the joint, and fill it with serum. By a second small incision, we introduce the device called arthroscope, and start the visualization of the joint.
Knee pathologies that can be treated by arthroscopy are:
1- Ruptures of the meniscus:The meniscus are structures of cartilaginous consistency that, in a number of 2, are located between the femur and the tibia, on both sides of the knee. The meniscus is crescent-shaped, and the most frequent location of the breakage is at the level of its back. When there is a break, the broken meniscus fragment causes the joint not to work properly, so, using arthroscopy and the appropriate instruments, it will trim that fragment, leaving the rest of the meniscus healthy in place.
Sometimes the rupture of the meniscus is very close to its insertion area, so in these cases we perform a repair of said injury, using a technique of suturing the meniscal lesion.
2- Ruptures of the cruciate ligaments: By far, the most frequent rupture is that of the anterior cruciate ligament. This is broken with the movement in which the foot remains fixed and the body rotates on the axis of the knee. This movement is very typical in the practice of sports such as skiing, football and basketball.
The rupture of the anterior cruciate ligament implies that the knee initiates a picture of instability, that is, an anomalous and spontaneous movement appears that the patient notices in the form of failures. Once it ruptures, the anterior cruciate ligament has no capacity for repair of its own (healing), so if the injury is not repaired, this anomalous movement ends up affecting the meniscus (which end up breaking), and later affects the cartilage, which initiates a process of degeneration, at which time the injuries are no longer repairable.
Therefore, today it is widely proven that to avoid the start of this degenerative process, the injury of the anterior cruciate ligament must be repaired.: It should be replaced by a structure that is in the same position and does the same function as that of the injured anterior cruciate ligament. That is why the so-called PLASTIAS are used.
Basically we obtain them from the patient himself, and from 2 main locations: From the patellar tendon of the knee (Bone-Tendon-Bone type plasty) or from the tendons of the semitendinous and internal rectum muscles (Hamstring type plasty), located on the back side of the thigh. The use of one or the other plasty depends on the surgeon’s preference and the patient’s demands (for example, depending on the sport he practices).
The plasty is placed through arthroscopy in the same anatomical position as the original anterior cruciate ligament, and is fixed at the level of the femur and tibia with the so-called fixation systems, which are different depending on the type of plasty used. These fixation systems are located inside the bone, and will not have to be removed later, as they will not produce any discomfort.
Rupture of the posterior cruciate ligament is much better tolerated with a correct recovery regimen (there is usually no feeling of failure on the part of the patient). We will only opt for surgical treatment if there is presence of failures, and the same procedure will be done as in the anterior cruciate ligament: Replacement of the original ligament by a plasty.
3- Presence of free articular bodies:They come from cartilage, and their presence may be due to trauma (osteochondral fracture) or degenerative processes.
4- Certain types of fractures:In fractures basically of the tibial surfaces we can help us with arthroscopy to put in place the fragments of the fracture and fix them with osteosynthesis screws.
The RISKS of knee arthroscopy are as follows:
Anesthetic Risks: Allergic reactions to medications used during the anesthetic procedure, respiratory problems, cardiovascular problems may occur. To avoid to a large extent this type of complications, the so-called preoperative tests are requested prior to the intervention (as discussed above).
Circulatory Problems: Phlebitis, thrombosis, … To avoid this, for a few days after arthroscopy, a subcutaneous medication (low molecular weight heparin) is administered, which has the effect of clarifying the blood to a small degree, so that the risk of suffering this type of complication greatly decreases, but it does not disappear completely.
Presence of Joint Stiffness: After arthroscopy, the knee may react causing internal tissues to become inflamed and harden, rapidly decreasing joint mobility. With the techniques that are currently used the mobility of the knee is practically immediate after the intervention, so that the presence of joint rigidity is less and less frequent.
Joint infection: the incidence is less frequent than in open surgery. It appears at 7-10 days after the intervention, and requires surgical cleanings on the knee combined with intravenous antibiotic treatment.
No complete disappearance of symptoms, especially in arthroscopies performed on degenerative knees, that is, signs of wear and tear are present.
For the little complex surgeries (meniscal ruptures, cartilaginous pathologies) at 6 hours of the intervention we already start the mobilization of the knee, and the patient can start ambulation (without any type of immobilization, only a simple bandage to protect the wounds), although in some cases it may require the help of a crutch to reduce the pain. The patient is discharged from the Hospital in the first 24 hours after the intervention, and a few days later can start a practically normal life (except in the performance of sports activity, in which you must wait between 2 and 4 weeks depending on the type of pathology).
In the most complex procedures (ruptures of cruciate ligaments) it is not until 36-48 hours that we start the flexion and extension movements of the knee, and 2 days after the operation the patient is discharged from the Hospital walking, helped by 2 crutches and supporting the operated leg on the floor, but without ANY IMMOBILIZATION in the knee. At 4 weeks the patient walks normally (without crutches), with a movement of flexion and extension of the knee complete, and at 3 months the recovery pattern ends, and the patient can start certain sports activities (continuous running, cycling and swimming). It will not be until the 6 months that you can perform any type of sport (football, basketball, skiing, tennis …).
The concept is the same as the one we have explained for knee arthroscopy: It consists of the introduction of the arthroscope in the shoulder joint, so that we can visualize its interior through the TV monitor, allowing the diagnosis and treatment of different pathologies.
In the shoulder joint we can perform arthroscopy in 2 locations:
Gleno-Humeral: It is properly the joint, where the movement of the shoulder is performed.
Sub-Acromial: It is a space that is immediately above the gleno-humeral joint, and is where the tendons that allow the arm to rise pass.
The preparation for the intervention is the same as for knee arthroscopy: Request and review of preoperative tests, prior fasting 6 hours before the intervention, and admission to the Hospital 2-3 hours before the intervention.
The type of anesthesia is usually general, reinforced with a type of regional anesthesia called Interscalenic Block: The anesthesiologist, before proceeding to general anesthesia, sleeps the shoulder area, and this anesthesia has an effect of 12-18 hours, so that after the operation the patient presents much less pain. In patients in whom general anesthesia is contraindicated, only this type of regional anesthesia can be performed, but requires a very high level of collaboration on the part of the patient during the intervention.
The pathologies that can be treated with the shoulder arthroscopy technique are divided according to the anatomical location where we do the arthroscopy:
Recurrent Dislocation of the Shoulder: When the joint is dislocated different times (dislocated), the ligaments that usually keep the joint in place are detached from the place where they are attached to the bone (the glena): It is the so-called Bankart injury. What we do is reattach these ligaments in their original place, using 2 or 3 implants (material with which we fix these ligaments, and which is introduced into the interior of the bone).
The fact that the ligaments that maintain the stability of the shoulder are back in their anatomical place will mean that the joint returns to the original stability.
Pathology of the biceps tendon: Of the 2 proximal tendons of the biceps muscle of the arm, there is one that has the origin inside the gleno-humeral joint, and that when there is an injury at this level is called S.L.A.P. injury. Repair of this lesion can also be done by arthroscopy.
Free articular bodies: They usually have the origin in degenerative joint pathologies, where fragments of cartilage are released from the joint.
Joint stiffness: The shoulder is a joint that before certain traumas, after an intervention or without apparent reason (idiopathic origin), the tissue that covers this joint suffers a process of inflammation and shrinks: It is the so-called retractable capsulitis. This means that a significant limitation of shoulder mobility appears progressively, accompanied in the initial phases by intense pain. At first the treatment is medical and with rehabilitation, being able to add a pattern of infiltrations. But in more evolved phases, where previous treatments would not have been effective, a shoulder arthroscopy is performed, and this shrugged tissue is cut, giving mobility to the joint again.
Pathology of the tendons of the Rotators Codex (also called Rotators Cuff): This is the name given to the anatomical structure that form 3 tendons (supraspinatus tendon, infraspinatus tendon and subscapular tendon) at the level of the shoulder, immediately above the head of the humerus, which is where they engage. These tendons are responsible, together with the deltoid muscle, for most of the movements of the shoulder, such as the movements of lifting and rotating the arm.
These tendons can suffer different pathologies:
1- An inflammatory process: We are talking about tendinitis,which can be caused by acute trauma, or by a process of repetitive movements in a shoulder where a phenomenon of compression of the acromion bone occurs on these tendons: This process is called “Impingement”.
The initial treatment of this pathology is conservative: Medical treatment with anti-inflammatories, rehabilitation regimen and infiltration regimen. If all these measures have failed, it is then when we must consider performing an arthroscopy of the affected shoulder, to resect the inflammatory tissue surrounding the tendons, and, in the case of encountering a phenomenon of “impingement”, perform a resection of the bone spicules to thus increase the passage space of the tendon.
2- A rupture of the tendon: The location of the rupture is in the vast majority of cases where the tendon is inserted into the bone of the humerus. These breaks can be of small size (1-2 cm.) the recent ones, or of large size (4 cm. or more) those of long evolution or chronic.
The repair of these breaks is done by placing an implant in the original area of insertion of the tendon, an implant that carries sutures through which we will close the break.
It is important to note that the prognosis of the repair of large (chronic) breaks is worse than that of small breaks, since the tendon ruptured over time degenerates, as well as the muscles responsible for its action, appearing a phenomenon of retraction and healing, a fact that prevents that if we repair the tendon again it has little chance of healing.
Tendon calcifications: There are cases in which calcifications appear within the tendons, basically within the supraspinatus tendon. These calcifications give rise to an irritative process of the affected tendon, which causes significant pain, manifesting itself clinically as tendinitis. With shoulder arthroscopy the intratendinous calcium content can be emptied, thus disappearing the pain.
Involvement of the Acromio-Clavicular joint: This is the joint formed by the clavicle and a part of the scapula called the acromion. This joint has a small movement, and if it is affected, for example by an inflammatory or degenerative process, it causes significant pain. With shoulder arthroscopy we can act on this joint, partially resecting it, thus eliminating the clinical picture.
The RISKS of shoulder arthroscopy are:
Anesthetic Risks: Allergic reactions to medications used during the anesthetic procedure, respiratory problems, cardiovascular problems may occur. To avoid to a large extent these types of complications, the so-called preoperative tests are requested prior to the intervention (as discussed above).
Joint Stiffness: it can range from a minimal degree of limitation of the last degrees of shoulder mobility to a picture of true joint stiffness.
Joint infection: although the risk is very low, when the protocol of action is presented it will be the same as in the case of the knee: Surgical cleanings of the joint combined with an intravenous antibiotic treatment.
Recurrence of treated pathologies: for example, the shoulder treated for recurrent dislocation can be dislocated again (by other trauma), or the tendon of the supraspinatus that has been sutured can be re-ruptured.
The period of admission to the Hospital after the intervention is usually 24 hours. In joint pathologies and in tendon ruptures of small and medium size, the arm is immobilized with a simple sling. On the contrary, in large breaks of the rotator cofia, an immobilization is placed that separates the arm from the body about 15º, in order to leave the suture destensada and reduce the risk of rerotura.
In all cases, a few days after the operation, the pattern of passive mobilization of the shoulder begins: It is a question of moving the arm without the tendons becoming strong. This can be done with the so-called pendular exercises, and helping to move the affected arm with the contralateral arm, this being the one that makes the force.
In cases of treatment of recurrent dislocation and in those of tendinitis, at 4 weeks of the intervention, the affected arm initiates the active mobility regimen: Force movements are already initiated. In tendon sutures, these movements are not performed until 6-8 weeks.
From 3 months, patients begin their normal activity, except in cases of tendon suture, a period that extends to approximately 4-5 months. It will be from 6 months that patients can already practice any type of sport, such as contact sports.