Knee arthroscopy: Preparation-Surgery

 

What is knee arthroscopy?

Knee arthroscopy has contributed to the development of orthopedic knee repair. During arthroscopy, a small camera is attached to an optical fiber lens.

Arthroscopic surgery has contributed to the development of orthopedic knee repair. During arthroscopy, a small camera attached to an optical fiber lens is inserted into the joint and allows the physician to have an intra-articular image without having to perform a surgical incision. The knee was the first joint for the arthroscope to be used, both for diagnostic and for surgical procedures.

 

Anatomy

The knee joint consists of the femur, the tibia and the patella. The patella is also called the sesamoid bone located at the front of the joint and plays an important role in the extension mechanism of the knee. The patella moves on the anterior surface of the knee during flexion/extension. The flexion/extension mechanism includes the following sections:

  • Thigh muscles
  • The tendon of the quadriceps
  • The patella
  • The tendon of the patella

The knee joint is surrounded by a “sealed pocket” called an articular capsule. It is formed by the knee ligaments, connective tissue and the synovial membrane. During arthroscopy, the articular capsule, filled with sterile saline, is expanded and the surgeon can see the interior of the joint and all the parts that constitute it, that is, the articular surfaces of the femur, tibia and patella, the two menisci, as well as both the anterior and the posterior cruciate ligaments.

On each side of the knee joint there is a meniscus. The medial meniscus is located on the inner side of the knee joint and the lateral meniscus on the outside. They are crescent-shaped and, among other things, they protect the articular cartilage on the articular surfaces of the femur and the tibia. The articular cartilage is a smooth, elastic tissue that covers the ends of the bones that make up the joint and prevents friction injuries.

The ligaments are durable collagen fibers that connect the bones to each other.

The anterior cruciate ligament is located in the center of the knee joint; it passes through a notch of the distal femur and is inserted in the tibial spine at the front of the tibia. Thus, it connects the femur to the tibia and stabilizes the joint. The anterior cruciate ligament restricts the forward movement of the tibia in relation to the thigh. If there is excessive forward movement, there is a possibility of rupture of the anterior cruciate ligament. It is also the first to be affected by extension and forceful knee flexion, so if for any reason the knee is over-extended it may again be ruptured.

The posterior cruciate ligament is also located in the center of the knee joint behind the anterior cruciate ligament and joins the medial femoral condyle with the posterior side of the tibia. The posterior cruciate ligament controls the posterior movement of the tibia in relation to the femur. If the tibia moves too far back, the posterior cruciate ligament may be ruptured.

 

What are the goals of the surgeon?

When arthroscopy became widely known in 1970, it was used purely for diagnostic purposes. Today, this procedure involves surgical treatment methods that cover a wide range of knee joint conditions.

 

Knee arthroscopy can be used to treat the following pathological conditions:

  • Meniscectomy and meniscus suture
  • Articular cartilage damage
  • Chondroplasty/ Articular cartilage transplantation
  • Anterior Cruciate Rupture
  • Posterior Cruciate Rupture
  • Patellar dislocation / Realignment

The surgeon aims to eliminate or reduce the problem that the patient is experiencing through appropriate surgery. With the use of the arthroscope, the physician can assess the interior of the joint in magnification by performing small incisions. This results in less tissue injury, resulting in faster recovery. However, the results of a knee arthroscopy depend on the type of disease, the room for improvement after surgery, and the effort the patient will make during recovery.

 

Because arthroscopy is less invasive than traditional surgery, it has several advantages. These include:

  • No muscle or tendon incision
  • Less bleeding during surgery
  • Less scars
  • Smaller incisions
  • Faster healing and return to daily activities
  • Faster recovery

Preparation for Arthroscopy

What a patient should know before arthroscopic surgery?

The patient, in collaboration with the doctor, should decide whether to proceed with the arthroscopic procedure or not. The patient should understand the procedure to be followed as best as possible and in case he/she has any questions he/she should consult the physician.

Once a decision is made about the procedure, the patient should follow certain steps. Initially, the doctor will ask for a series of tests to ensure that the patient is able to undergo surgery (many times these tests are performed on the day of surgery when the patient is admitted to the hospital).

A visit to the physiotherapist who will undertake the rehabilitation program can be done before or after surgery. The purpose of this visit is to inform the patient about the rehabilitation program to follow, but also for the physiotherapist to assess the level of pain (before surgery), the patient’s ability to cope with their activities, to control movement and strength of each knee.

In addition to the rehabilitation program, the physiotherapist should train the patient to walk with crutches, as well as some strengthening exercises that he/she should do on their own during recovery from surgery.

On the day of the surgery the patient will be admitted to the hospital early in the morning and should not have eaten or drunk anything the previous night (preparation for surgery).

 

Surgery – Knee Arthroscopy

What Happens During Surgery?

Before the surgery begins, the patient will get some kind of anesthesia; it may be general, local or epidural anesthesia. In simple cases local anesthesia is sufficient. Before the procedure begins, special brackets are fitted to the operating table so that the physician can move the leg and bend the patient’s knee while operating safely. The operating table is surrounded by the equipment necessary to perform the operation.

The surgeon begins the operation by making two to three small incisions in the knee; these incisions are called “gates”. These gates are used to insert into the knee joint surgical instruments and arthroscopes and care is always taken to protect the surrounding nerves and blood vessels. Then a plastic or metal tube will be inserted inside the joint to provide sterile saline so that the knee joint may be dilated.

The arthroscope is a small tube made of optical fibers, used by the surgeon to view and operate inside the joint, approximately half (0.5) cm in diameter and eighteen (18) inches in length. The camera displays the image it records on a screen monitored by the surgeon performing the operation. The surgeon has the ability to move the arthroscope at various points within the joint.

The development of arthroscopic surgery has led to the use of new, more specialized tools for performing arthroscopic surgeries. Many of the operations that were previously performed through large incisions are now made using this minimally invasive technique, with much smaller incisions, e.g. the removal of a ruptured meniscus can be performed through two 0,5cm incisions. More complicated procedures such as ligament reconstruction may require slightly larger incisions.

Once the surgery is complete, the incisions performed during the arthroscopy are sutured. A large bandage will be placed from the middle of the thigh to the foot. Wrapping the foot with an elastic bandage reduces swelling and helps prevent clot formation in the area. Finally, the patient is transferred to the recovery room.

 

Complications

What can go wrong?

As with all surgeries, there may be complications during knee arthroscopy. Below are some of the most common problems that may occur:

  • Complications of anesthesia
  • Thrombophlebitis
  • Infection
  • Damage to equipment
  • Slow recovery

Arthroscopic surgery has a very low rate of complications (0.01%) over conventional surgical procedures (1%).

 

Postoperative period

What to expect after surgery?

Knee arthroscopy is an operation after which the patient does not need hospitalization and returns home on the same day. In more complex procedures requiring larger incisions, e.g. after rupture of the ligaments or bone-altering procedures, hospitalization may be needed to more effectively and efficiently deal with the pain and allow the patient to be properly monitored. In this case, the patient may begin a hospital rehabilitation program.

The gates are covered with surgical tape, the large incisions are sutured with surgical stitches or sutures and the knee is wrapped with an elastic bandage. After knee arthroscopy, the patient will walk on crutches for as long as the surgeon prescribes. Patients undergoing more complex reconstructions may need to wear an orthopedic splint for a few weeks to ensure the protection of the healing tissues inside the joint. The patient will be able to take off this splint in order to shower

The patient should follow the instructions given by the surgeon as to how much the lower extremity will be burdened when standing or walking. He/she may also need to apply ice to the knee and place the foot raised on a stand when lying down or sitting.

 

Recovery

What will be the recovery procedure following knee arthroscopy?

The recovery will depend on the type of surgery performed. After simple surgeries, a regular rehabilitation program may not be needed, but only some exercises that can be performed at the patient’s home with specific instructions.

Many doctors recommend that the patient should follow a recovery plan regardless of the surgical procedure. In general, the more difficult the intervention, the more specialized and prolonged the physiotherapy program shall be. In the first sessions, the goal is to reduce post-operative pain and edema. The physiotherapist will also inform the patient about the proper foot charge.

Nowadays, the arthroscope is used to perform quite complex reconstructive surgeries using very small incisions. However, it should be noted that just because the incisions are small, this does not mean that the same is true within the joint. If the patient has undergone a major reconstructive procedure, the time it will take to fully recover will be several months.

The goal of the physiotherapist is to keep the pain under control, improve range of motion and strengthen the leg.

When the patient’s condition improves sufficiently, he or she will stop frequent visits to the physiotherapist and follow a home exercise program for as long as necessary.