Therapeutic knee arthroscopy with partial meniscus removal is one of the most common surgical procedures in the United States and Europe. In Germany, around 100,000 such operations are performed on patients with degenerative joint diseases every year.
Mostly, arthroscopy is not only used for diagnosis, but also therapeutically. For this purpose, fine instruments such as scissors or milling are inserted into the joint via a second cut.
There are two options for therapeutic arthroscopy:
- Lavage (joint irrigation): The joint is rinsed with a saline solution. The flushing is intended to remove particles floating in the synovial fluid, such as cartilage and tissue fibers, and to calm an existing inflammatory reaction in the joint.
- Debridement: In debridement (English = wound restoration), rough cartilage surfaces are smoothed with various instruments and detached cartilage parts are removed. The joint is then rinsed.
Arthroscopic Knee Surgery
Before this surgery a patient signs an informed consent statement for operative treatment and anesthesia. These documents define what kind of anesthesia will be applied during the arthroscopic knee surgery. Small incisions are made on skin, in the area of the knee joint. Microsurgical instruments and microscopic digital camera are inserted via these incisions inside. The surgeon tracks all actions during the surgery or diagnostic procedure on the screen. The image can be magnified up to 60x that gives a surgeon maximally precise picture. Due to the arthroscopic knee surgery it is possible to avoid knee joint replacement. One more advantage is the ability to leave bed in a few hours instead of a few days as it was before.
At the beginning, arthroscopy was only a convenient diagnostic method. However, the rapid progress of medical technologies made it possible to switch from diagnostic arthroscopy to therapeutic.
If at the very beginning arthroscopic surgery was limited to the simplest purposes – for example, removing of a damaged part of the ligament and fragments of the meniscus, later on, in the 70s and 80s of the last century, arthroscopy had reached such a level, that the majority of surgical interventions became possible without opening a joint.
Using special micro-tools increases the accuracy of surgery and makes it minimally traumatic, enabling, at the same time,preservationof healthy tissues. To accurately remove damaged areas and, at the same time, to keep healthy parts of the joint as much as possible, a surgeon needs high skilland a lot of experience.
Indications for Arthroscopic Knee Surgery
- Anterior cruciate ligament rupture or injury
- Meniscus injury
- Debride in the knee joint cavity
- Rheumatoid arthritis
- The existence of unidentified loose bodies in the cavity (cartilage flaps, loose meniscus fragments).
- Knee arthrosis deformans
- Liquid accumulation
- Failed surgeries performed before
- Joint fractures
- Chronic fat pad hyperplasia
- Arthropathy deformans
Contraindications to Arthroscopy
Absolute contraindications (conditions in which a surgeon rejects surgery without doubts):
- Poor general health of the patient whenany surgical interventions are contraindicated.
- Purulent inflammation in the tissues around the joint, as infection can get into the joint.
- Infected wounds.
- Bony or fibrous ankylosis, a condition in which the articular cleftis filled with bone or dense connective tissue causing immobilization of the joint. You can see this on anX-ray picture.
Types of Arthroscopy
This method is used both as a surgical intervention and as a diagnostic procedure. If it is used for both purposes at the same time, we speak about therapeutic and diagnostic arthroscopy.
The knee joint mobility is provided by the ligamentous apparatus - the anterior and posterior cruciate, medial, and lateral ligaments (these ligaments are located on the outside).
Ligament damages often occur in case of injuries (falling, bruises). As a result of trauma the patient experiences strong pain sensations and cannot make full movements, bending a leg in a knee. Therefore, in such cases, the plastic of cruciate ligament is prescribed.
The anterior ligament of the knee joint length is approximately 40 mm, the posterior ligament is 30 mm. Each of them is actively involved in the stabilization of the joint, so if damaged, the patient cannot bend the leg at the knee fully. Arthroscopy procedure allows a physician to diagnose a specific injury area, remove inflammatory processes products and restore ligament tissue.
Knee ligaments arthroscopy is carried out to restore their anatomical mobility, and is performed using live biological tissues (popliteal muscles tendons or patellar tendons) or neutral artificial materials, called transplants.
A bioresorbable element, which is a self-absorbable implant that restores the natural stabilization of the joint, is installed as a fixative.
The anterior cruciate ligament is the most vulnerable to traumatic effects, therefore, injuries of this department are recorded in surgery most often. When talking about the knee stabilization surgery, first of all, the plastic of the anterior ligament is meant.
During arthroscopy procedure damaged tissues are removed through a perforated hole (all doctor's actions are visible on the monitor with 40-60-fold zoom) and replaced with a transplant.
The surgeon must create the anatomical structure as close as possible to the natural one, providing a normal ligaments tension and the natural amplitude of movements. The fact that athletes after surgical arthroscopy show high results in international competitions, without experiencing any pain, excessive fatigue or discomfort during movement is the best evidence of this technique's high efficiency.
The posterior cruciate ligament damage is a severe trauma and, fortunately, not a common one. Causes - a fall from a height, an accident, gunshot and knife wounds. Arthroscopy of the posterior cruciate ligament plastic is classified as a complex operation, and is performed under general anesthesia.
Arthroscopic meniscus resection
Meniscus rupture occurs as a result of a strong mechanical effect (blows, falls). Professional athletes, circus performers, dancers are at the greatest risk. Trauma is accompanied by severe pain and limb mobility loss.
Arthroscopic meniscus resection is a minimally invasive surgery, with the purpose of the removal of the damaged fragments of the articular part. Meniscus rupture can be:
- Total (full);
- Fragmentation (when crushing the knee);
In this case, the operation is prescribed to restore after a meniscus rupture. The main surgery purpose is to remove ruptured parts, as well as products of inflammatory processes, and suppurations.
The damaged part of the meniscus is subjected to resection (cut off), after making a small incision (0.5 cm in diameter). One day after, the patient can already stand on the injured leg, and after 2 weeks he can withstand simple loads. Due to the complete removal of the damaged parts, it is possible to do sports and make heavy loads after 1-2 months using special sports knee pads.
Since the trauma is accompanied by the strongest pain syndrome, the patients do not hesitate visiting the specialist, and this fact increases the chances of a complete cure. After surgical arthroscopy for partial or complete resection of the meniscus, the patient can stand up several hours after operation has been performed, and D/C occurs after 1-2 days if there are no signs of complications.
Sanation of the articular cavity
The efficiency of the knee joint's sanational arthroscopy, prescribed to patients with rheumatoid arthritis, is proven over time. The use of an irrigation device with an outflow system, through which medicinal solutions are injected, allows the removal of pathological formations fragments (urate crystals, cartilage detritus, fibrin flakes, cytokines) from the articular cavity. Anti-inflammatory drugs injection is the final stage of the arthroscopic procedure.
Within a few hours after arthroscopy, a positive therapeutic effect is observed, which is expressed in the cessation of pain, reduction of swelling and hyperemia in the knee area, and expansion of the movements amplitude. This surgical procedure is also valuable thanks to the fact that after it is carried out, the need for taking painkillers and anti-inflammatory drugs that increase the load on the liver is reduced.
As a diagnostic method, this procedure is used to analyze such diseases and disorders:
- Blood in the knee (hemarthrosis);
- peculiarities of the synovial membrane condition – presence/absence of inflammations;
- the presence / absence of chondromic bodies in the joint;
- peculiarities of articular cartilage condition (uniformity of tissue, dimensions and forms of damage, smoothness and elasticity of cartilage surface are checked);
- condition of ligaments (their general condition, density, tone, features of damages);
- joint dynamic characteristics analysis (slipping, displacement);
- condition of the tendons.
Diagnostic knee joint arthroscopy is performed to confirm the diagnosis, especially in cases where the clinical picture remains unclear.
This is a modern method of examination, which allows to determine the cause of the violation with maximum precision and choose the appropriate treatment methods correctly. The diagnostician in the clinic inserts an arthroscope to study the patient's condition and analyze the complications based on the pictures received - this is the essence of the technique. The procedure is not expensive,most patients can afford it.
Skin and soft tissues perforation is performed at the knee joint, in the area of the joint space, (incision length does not exceed 6 mm). An arthroscope with a light source turned on is inserted into the holes, illuminating the area of the intra-articular space.
Joint examination during arthroscopy is carried out in the following sequence:
- Synovial membrane's state examination (color, vascular pattern, folds presence and their state).
- Femoropatellar area examination. The cartilaginous patella tissue is examined for the presence of cracks, necrotic areas, and pathological growths. The density of the cartilage is determined using a probe inserted into the anterior medial part. The condition of the wing folds is assessed.
- Lateral, and medial pockets examination. Pathological hemorrhage sites, as well as pathological intra-articular bodies, ruptures of the synovium in the sites of the lateral ligaments attachment are revealed.
- Medial meniscus examination. The knee is bent at 150 degreesangle, the device is transferred to the plane of the medial joint space. This perspective helps to examine the body of the meniscus, and the articular cartilage of the tibia, with much more precision.
- Detailed examination of the medial joint space. To inspect the back of the lower leg, it should be bent at 100 degreesangle.
- Investigation of the intercondylar hole and adipoid joint area. The joint is bent at 160 degrees, the arthroscope is transferred to the femoropatellar department area and moved along the vertical axis to the point of "the gap".
- Anterior cruciate ligament condition examination. Tension degree, and the state of the synovial membrane are determined.
- Examination of posterior cruciate connection (bending at 90 degrees with internal rotation of the lower leg).
During the examination, the doctor is using the probe, which allows to assess the tissues density.
For better visibility and accuracyduring arthroscopy, the operating field is exsanguinated. For this purpose, a pneumatic tourniquet is applied to the thigh to prevent bleeding, which is attained by inflating the cuff of the tourniquet.
Since using tourniquetsincreases probability of side effects (severe pain, circulatory disorders in the operated limb, thromboembolism, etc.), before it is applied, the limb is tightly wrapped with an elastic bandage to ensure safer exsanguination.
Important! Simultaneous application of the tourniquets on the both legs causes an increase in intracranial and arterial pressure, which can lead to serious complications if a patient has cardiovascular diseases (coronary heart disease or left ventricular hypertrophy). The duration of the surgery should not exceed two hours, as adult patients may develop irreversible damage to the peripheral nerve, whilst in children, a critical increase in body temperature may occur.
Pain derived from squeezing thelimbwith the tourniquet is called a “tourniquet pain”. It is characterized by a gradual increase and resistance to pain management with local anesthetics. This fact is takeninto accountwhen surgery is planned to set a proper duration and type of anesthesia.
Anesthesia for the Knee Joint Arthroscopy
Since arthroscopy involves minimally invasive incision of the knee, the anesthesiologist conducts a number of diagnostic activities and pre-selects an effective anesthetic. Besides, when choosing anesthesia, it is important to consider the surgery duration. Here's what you need to learn about anesthesia before the procedure:
- Local anesthesia. It is commonly used when carrying out a diagnostic method for determining the pathology, it has a short-time effect, and provides a mediocre effect.
- Conductive anesthesia. Requires an intra-articular injection of lidocaine, the analgesic effect is maintained for 1-2 hours at most.
- Epidural anesthesia. It's the most common modern anesthesia method with minimum contraindications, which allows the patient to remain conscious and to control the process of the operation.
- General anesthesia. Such an “obsolete” method of anesthesia is used extremely rarely, because it has a lot of medical contraindications and damages health considerably.
Knee Arthroscopy Performing Technique
The surgery is performed under general anesthesia. Epidural (spinal) anesthesia is possible only in case of serious comorbidity or minor defects requiring minimal correction.
A tourniquet is applied to the middle part of the thigh to stop the blood supply and minimize the intensity of bleeding. For arthroscopy above and below the knee, three small incisions are made: a central one and two lateral ones. Incisions length does not exceed 3-5 cm. Then three specially designed devices, arthroscopes, are inserted into the articular cavity. One of them is a light source that has a camera element attached to the end. The surgeon receives an enlarged, high-resolution image on the screen. All the necessary manipulations inside the knee joint are carried out through the third device. The cavity is filled with a transparent aseptic solution, increasing the pressure in it. For greater convenience and to increase the review,
The main arthroscopy therapy measures include the meniscus removal, ligament stitching, transplant implantation, blood clots aspirations, fibrin, fragments and damaged structures, patella stabilization, etc. At the final stage of arthroscopic surgery, the joint cavity is examined one more time, washed with a sterile liquid, antibiotics, then solutions are completely pumped out. Bleeding vessels are coagulated. The total surgery duration ranges from 40 minutes to 1.5 hours.
The incisions are stitched in layers with several sutures and covered with sterile gauze or plaster. On top of the knee joint a pressure bandage is applied, which is changed as and when necessary. The stitches are removed on the 7th to 10th day after arthroscopic surgery. At the doctor's discretion, drains can be left in the postoperative wound, which are removed the next day.
The main advantage of arthroscopy is no need for almost complete knee joint cavity opening, as well as less affection of the surrounding structures and tissues, significantly reduced healing time, rapid recovery of the patient's function and working ability.
Rehabilitation After Arthroscopic Knee Surgery
Hospital stay: Knee arthroscopy is usually performed on an outpatient basis or in case of previous illnesses and/or lack of home care. The patient has to be under the doctor's supervision, he receives painkillers (nonsteroidal anti-inflammatory drugs, analgesics). In some cases, there's a possibility of short-term gypsum splints application to immobilize the knee joint. In case of persistent intense pain, the patient stays in the unit for a little while.
To prevent vascular disorders and edema, 7–9 days of hypodermic anticoagulants injections (heparins) are prescribed. To prevent the joint infection development during and after surgery, treatment with a broad-spectrum antibacterial drug is necessary.
During the rest, the leg is fixed in an elevated position, it is allowed to attach a heating pad with ice to the joint for a short time (up to 7-10 minutes several times a day).
A good thromboembolic complications prevention measure after arthroscopy is wearing an elastic tissue bandage made of class 2 compression for the first 10-14 days, which is applied on the operated lower limb from the toes to the middle of the thigh.
The patient is allowed to get up and gradually expand his motions range right from the first day. The use of crutches is not required, except severe cases, elderly patients, and complications. The resumption of the usual knee joint load and flexion movements are allowed a week after the operation. As an additional measure, gymnastics is prescribed 2-3 times a week to prevent the development of muscle weakness, and atrophy. One week after arthroscopy, it is recommended to conduct a stationary bike low resistance training.
Each case requires an individual exercise intensity and time calculation with a gradual increase in loads on the knee joint.
In the early postoperative period, it is advisable to avoid thermal, warming, and water procedures. Visiting the pool, bath, sauna, or solarium is prohibited.
During the year after arthroscopy, it is not recommended to engage in sports such as jogging on a hard surface, jumping, exercises associated with the shuttle movements and maximum knee joint extension with additional load.
Arthroscopic surgery in crucial ligament injury
Anterior cruciate ligament is the main stabilizer of the knee. Injuries give the feel of instability and uncertainty of moves. Instability and problems in joint mechanics lead to further damage of medial and lateral meniscus and cartilage.
Arthroscopic cruciate ligament surgery provides much less load on the joint compared to the open surgery. The key of success is precise location of bone canals in the initial cruciate ligament structure.
Comparing with other surgery techniques, arthroscopy has a number of advantages:
- Low traumatism. It does not involvecutting a 10-20 cm long incisionto open the joint cavity, sothe tissues surrounding the joint get minimal damage. To introduce an arthroscope and surgical instruments, a cut of 0.3-0.5 cm is sufficient. In most cases, the incision is not even sutured: itsuccessfully heals without suturing.
- Withjoint arthroscopy, the patient,as a rule, can be discharged on the same day as surgery, but after open interventions– only after 10-14 days.
- Aarthroscopy is well tolerated by patients as it produces fewer pain, swelling, and joint exudate.
- Postoperative complications, such as cicatricial contracture of the joint, infections of the joint cavity, and excessive bleeding, develop very rarely.
- Prolonged immobilization of the joint with a plaster cast is not required as after open arthrotomy.
- Minimal rehabilitation period:the patient recovers quickly and can return to normal activities soon. After open surgery, workability is restored on average in 4-6 weeks, whilst after arthroscopy in 2-3 weeks.
- The scar left after surgery is small and unobtrusive.
- Some procedures became possible only with the implementation of arthroscopy. For example, removing chondromas that block the joint and cause pain, as well as treating chondromalacia of the joints.
The Cost of Arthroscopic Knee Surgery in Germany
Arthroscopic knee surgery costs approximately 5.600 €. You should plan at least two days of inpatient stay. Complex arthroscopic surgery aimed at fixing meniscal tears costs slightly more: 7.000-8.000 €. Arthroscopic therapy in cartilaginous tissue or cruciate ligament injuries costs 3.500-6.000 €, depending on the amount of damage. Additional diagnostic services such as MRI or CT will cost up to 800 €.
Orthopedic centers provide ability for an accompanying person to stay in one room with a patient, it would cost 55-100 € a night. Our specialists will answer all your questions regarding arthroscopic knee surgery.