Dr. Samir Pilankar is very famous and renowned specialist in endoscopic Joint Replacement and Arthroscopic surgeries. Below is detail explanation for cause and process of arthroscopic surgeries.
Normal knee – Anatomy and Function
The knee is a hinge type of synovial joint. It consists of the lower end of the thigh bone (femur), the upper end of the shin bone (tibia), and the knee cap (patella), which slides in a groove on the end of the femur. Four bands of tissue, the anterior and posterior cruciate ligaments, and the medial and lateral collateral ligaments connect the femur and the tibia and provide joint stability. Strong thigh muscles give the knee strength and mobility.
The surfaces where the femur, tibia and patella touch are covered with articular cartilage, a smooth substance that cushions the bones and enables them to glide freely. Semicircular rings of tough fibrous-cartilage tissue called the lateral and medial menisci act as shock absorbers and stabilizers.
The bones of the knee are surrounded by a thin, smooth tissue capsule lined by a thin synovial membrane which releases a special fluid that lubricates the knee, reducing friction to nearly zero in a healthy knee.
Knee Problems
Normally, all parts of the knee work together in harmony. But sports, work injuries, arthritis, or weakening of the tissues with age can cause wear and inflammation, resulting in pain and diminished knee function.
ARTHROSCOPY
If you experience recurrent pain, locking, or swelling in your knee, a procedure known as arthroscopy may help relieve these problems.
In Arthroscopy, the surgeon makes small keyhole incisions on the knee through which he introduces pen sized instrument known as arthroscope. This is connected by optic fibres to a camera which in turn transmits this on the TV screen. The image on the TV helps the surgeon to correctly diagnose the knee condition. He can also introduce small instruments through other small keyholes to treat the condition.
Arthroscopy can be used to diagnose and treat many of these problems:
- Torn meniscal cartilage.
- Loose fragments of bone or cartilage.
- Damaged joint surfaces or softening of the articular cartilage known as chondromalacia.
- Inflammation of the synovial membrane, such as rheumatoid or gouty arthritis.
- Abnormal alignment or instability of the kneecap.
- Torn ligaments including the anterior and posterior cruciate ligaments.
By providing a clear picture of the knee, arthroscopy can also help the orthopedic surgeon decide whether other types of reconstructive surgery would be beneficial.
If you have any of the following symptoms you may need arthroscopy
- Persistent swelling,
- Pain,
- Locking of the knee,
- Giving way of the knee.
The Orthopaedic Knee workup
The orthopedic knee workup consists of four components:
- A comprehensive history about the present ailment
- A physical examination to assess your knee motion and stability and muscle strength
- X rays
- MRI – is superior to Xrays as it provides information about the soft tissues in and around the knee. MRI can diagnose meniscal tears, ligament injuries which cannot be picked up on Xrays.
Dr Samir Pilankar will help you for Arthroscopy in Mumbai
During the Arthroscopic Knee Surgery
Suitable anaesthesia is given to make the leg numb.The orthopaedic surgeon will then make a few pencil holel incisions in your knee. A sterile solution will be used to fill the knee joint and rinse away any cloudy fluid, providing a clear view of your knee.
The surgeon will then insert the arthroscope to properly diagnose your problem, using the TV image to guide the arthroscope. If surgical treatment is needed, the surgeon can use a variety of small surgical instruments (e.g., scissors, clamps, motorized shavers, or lasers) through another small incision. This part of the procedure usually lasts 45 minutes to 1 1/2 hours.
Common treatments with knee arthroscopy include:
- Trimming of torn pieces of articular cartilage.
- Removal or repair of torn meniscal cartilage.
- Reconstruction of a torn cruciate ligament.
- Removal of loose fragments of bone or cartilage.
- Removal of inflamed synovial tissue.
ACL Reconstruction
The anterior cruciate ligament is one of the major stabilizing ligaments in the knee. It is a strong rope like structure located in the centre of the knee running from the femur to the tibia.
When this ligament tears unfortunately it doesn’t heal and often leads to the feeling of instability in the knee.
ACL reconstruction is a commonly performed surgical procedure and with recent advances in arthroscopic surgery can now be performed with minimal incisions and low complication rates.
Function
The ACL is the major stabilizing ligaments in the knee. It prevents the tibia (Shin bone) moving abnormally on the femur (thigh bone). When this abnormal movement occurs it is referred to as instability and the patient is aware this abnormal movement.
Often other structures such as the meniscus, the articular cartilage (lining the joint) or other ligaments can also be damaged at the same time as a cruciate injury & these may need to be addressed at the time of surgery.
History of Injury
Most injuries are sports related involving a twisting injury to the knee.
It can occurs with a sudden change of direction, a direct blow e.g., a tackle, landing awkwardly,
Often there is a popping sound when the ligament ruptures
Swelling usually occurs within hours
There is often the feeling of the knee popping out of joint.
It is rare to be able to continue playing sport with the initial injury.
Once the initial injury settles down the main symptom is instability or giving away of the knee. This usually occurs with running activities but can occur on simple walking or other activities of daily living.
Diagnosis
The diagnoses can usually be made on the history alone.
Examination reveals instability of the knee, if adequately relaxed or not too painful.
An MRI (Magnetic Resonance Imaging) can be helpful if there is doubt as well as to look for damage to other structures within the knee.
At times the final diagnoses can only be made by Arthroscopy.
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Treatment
Initial
- Rest
- Ice
- Elevation
- Bandage
Long term
Since episodes of instability can cause further damage to important structures within the knee that may result in early arthritis ; arthroscopic repair is the recommended treatment.
Indications for surgery
- Young patients wishing to maintain an active lifestyle.
- Sports involving twisting activities e.g., Soccer, netball, football Giving way with activities of daily living.
- People with dangerous occupations e.g., Policemen, firemen, roofers, scaffoulders.
- It is advisable to have physiotherapy prior to surgery to regain motion and strengthen the muscles as much as possible.
Surgery
Surgical techniques have improved significantly over the last decade, complications are reduced and recovery much quicker than in the past.
The surgery is performed arthroscopically. The ruptured ligament is removed and then tunnels (holes) in the bone are drilled to accept the new graft. This graft which replaces your old ACL is taken either from the hamstring tendon or the patella tendon. There are advantages & disadvantages of each with the final decision based on surgeons preference.
The graft is prepared to take the form of a new tendon and passed through the drill holes in the bone.
The new tendon is then fixed into the bone with various devices to hold it into place while the ligament heals into the bone (usually 6 months)
The rest of the knee can be clearly visualized at the same time and any other damage is dealt with e.g., meniscal tears
The wounds then closed often with a drain and a dressing applied.
Post-Operation
Surgery is performed as a day only procedure or an overnight stay.
- You will have pain medication by tablet or in a drip (Intravenous)
- Any drains will be removed from the knee.
- A splint is sometimes used for comfort
- You will be seen by a physiotherapist who will teach you to use crutches and show you some simple exercises to do at home.
- Leave any waterproof dressings on your knee until your post-op review.
- You can put all your weight on your leg
- Avoid anti-inflammatories or aspirin for 10 days.
- Put ice on the knee for 20 minutes at a time, as frequently as possible.
- Post-op review will usually be at 7-10 days
- Physiotherapy can begin after a few days or can be arranged at your first post-op visit.
- If you have any redness around the wound or increasing pain in the knee or you have temperature or feel unwell, you should contact your surgeon as soon as possible.
Rehabilitation
Physiotherapy is an integral part of the treatment and is recommended to start as early as possible. Preoperative physiotherapy is helpful to better prepare the knee for surgery. The early aim is to regain range of motion, reduce swelling and achieve full weight bearing.
The remaining rehabilitation will be supervised by a physiotherapist and will involve activities such as exercise bike riding, swimming, proprioceptive exercises and muscle strengthening. Cycling can begin at 2 months, jogging can generally begin at around 3 months. The graft is strong enough to allow sport at around 6 months however other factors come into play such as confidence, fitness and adequate fitness and training.
Professional sportsmen often return at 6 months but recreational athletes may take 10 -12 months depending on motivation and time put into rehabilitation.
The rehabilitation and overall success of the procedure can be affected by associated injuries to the knee such as damage to meniscus, articular cartilage or other ligaments.
Videos
Informative Video about the arthroscopic surgeries
ACL
Duration : 4 mins 17 seconds
Medial Meniscus Tear
Duration : 1 mins 06 seconds
Meniscus Repair
The surgeon sews torn pieces of cartilage back together so they can heal on their own. However, because of tear type and blood supply, less than 10%of tears are actually repairable.
Partial meniscectomy: The surgeon trims and removes the damaged cartilage and leaves healthy meniscus tissue in place.
Synovectomy
Synovectomy refers to the destruction or surgical removal of the membrane (synovium) that lines a joint.
As the largest articulation and the one most frequently affected by chronic inflammation, the knee is the joint most often selected for synovectomy.
PCL Tear
Your posterior cruciate ligament (PCL) runs along the back of your knee and connects your thighbone to the top of your lower leg bone.
This ligament keeps your bones in place and helps your knee move smoothly. When the PCL is sprained or torn, it’s called a posterior cruciate ligament injury.
Platelet-Rich Plasma (PRP Treatment Knee)
Platelet-rich plasma (PRP) is a concentrate of autologous blood growth factors. PRP has been shown to provide some symptomatic relief in knee osteoarthritis.
To date, this intervention has been largely delivered in hospital settings. This study has shown that it is feasible to deliver PRP therapy in primary care.