Artroscopy of the Knee
What is knee arthroscopy?
Arthroscopy is a Minimally Invasive Surgery (MSI) technique, which gives the Surgeon the ability to examine the joint in detail and then deal with various problems and pathologies in the area. It is performed with the use of special rigid endoscope, called arthroscope, which enters the joint through small-sized incisions -about half a centimeter.
What are the advantages?
This surgical technique allows the specialized Orthopaedic Surgeon to precisely confirm the diagnosis and directly intervene therapeutically, in an increasing range of joint problems.
Moreover, during the last years, arthroscopy is used increasingly in the shoulder joint. In the hands of skilled Orthopaedic Surgeons, almost all the problems and pathologies of the knee joint are treated with arthroscopy, with very low morbidity, minimal hospitalization and rapid postoperative recovery.
What pathologies of the knee can be treated?
The most common pathologies of the knee joint are:
- The Cartilage damage, which is connected with acute or chronic, persistent pain, and most usually with effusion –fluid around the knee joint.
- The anterior Cruciate Ligament (ACL) torn, which may lead to knee destabilization.
- The tear of the meniscus, where the broken part of the meniscus is removed with arthroscopy -meniscectomy.
Arthroscopic Surgery For Cartilage Damage
What is the cartilage damage?
Cartilage is a resilient and smooth elastic tissue, with rubber-like padding that covers and protects the ends of long bones at the joints. This tissue ensures smooth movement of the knee, while at the same time reduces the vibrations, which can prove extremely dangerous. Although it has a complex structure, cartilage does not contain blood vessels or nerves, which means that it is directly “fed” from the synovial fluid –the fluid that exists within all joints of the human body. As a result, when this tissue is injured, cannot be healed.
The chondral or osteochondral lesions usually appear after a significant trauma or repetitive minor injuries, though they can also appear as a consequence of degeneration-aging tissues. However, the most extensive and serious injuries are likely to result in arthritis, if not treated on time. Chondral lesions occur most frequently in the knee and less frequently in the ankle, hip and shoulder.
What are the symptoms?
Cartilage damage causes acute or chronic persistent pain, and most usually effusion –fluid around the knee joint. Moreover, it is likely to cause joint locking. The diagnosis includes clinical examination, confirmed by Magnetic Resonance Imaging (MRI).
What is the right treatment?
At the first stage of treatment, conservative measurements are proposed, moreover:
- Reduction of the “burden” in the area of the affected joint, targeting the reduction of the effusion and the avoidance of damage’ worsening. Simply, that means decreasing the level of activities, increasing rest or even using crutches for less strain.
- Medication, basically analgesics and anti-inflammatory drugs.
- Physiotherapy, which includes exercises for empowerment and stretching.
- In special cases, injections can be applied with hyaluronic acid.
If all the above mentioned prove to be unsuccessful, surgical treatment is necessary.
What is the most appropriate surgical treatment?
The most modern surgical treatment of cartilage damage –as accepted worldwide- is arthroscopy, which gives to the Orthopaedic Surgeon the ability to confirm the diagnosis and interfere therapeutically at the same time.
Based on the clinical examination, the sort and extension of the damage, the arthroscopic surgical procedures that can be performed are the following:
- “Removal” of the cartilage damage, Arthroscopic Chondroplasty,
- Cartilage regeneration, “Microfracture” Procedure,
- Implantation of osteochondral cylinders – “Mosaicplasty”, or implantation of chondrocytes.
What is arthroscopic chondroplasty?
This outpatient procedure is used to repair a small area of damaged cartilage in the knee by removing the damaged tissue and replacing it with biological materials. Arthroscopic chondroplasty treatment is completed with arthroscopy -inserting thin surgical instruments in small incisions around your knee, with the aid of a small video camera called an arthroscope.
What is cartilage regeneration or “Microfracture” Procedure?
Microfracture is a surgical technique that has been developed to treat chondral defects, which are damaged areas of articular cartilage of the knee. The Orthopaedic Surgeon uses the arthroscope to assess the defect and to perform the procedure using special instruments that are inserted through three small incisions on the knee. After assessing the cartilage damage, any unstable cartilage is removed from the exposed bone.
Multiple holes, or microfractures, are then made in the exposed bone about 3 to 4mm apart. Bone marrow cells and blood from the holes combine to form a «super clot» that completely covers the damaged area. This marrow-rich clot is the basis for the new tissue formation. The microfracture technique produces a rough bone surface that the clot adheres to more easily.
What is the osteochondral cylinders implantation –“Mosaicplasty”- or what the osteocytes implantation?
Mosaicplasty is a technique in which chondral and osteochondral lesions are repaired by harvesting and transplanting cylindrical plugs of bone and cartilage. In the knee, these plugs are taken from less weight-bearing areas, termed “donor sites”, and inserted into drilled tunnels in the defective section of the cartilage.
The transplanted hyaline cartilage is capable of surviving and produces a more durable surface than the fibrous repair tissue that would have formed if the defective cartilage had been left to heal on its own. Repair of the donor site occurs via natural healing processes. The tunnels become filled with cancellous bone and the surface is covered with fibrocartilage built by marrow-derived cells.
Mosaicplasty ensures good results in most cases, and the findings of experimental arthroscopies and laboratory assessments confirm what have been seen clinically in patients undergoing the procedure.
What happens after surgery?
All the above procedures, when performed by experienced and specialized Orthopaedic Surgeons, even though are technically demanding, are operations of low morbidity, with particularly high success rates, that allows the patient to leave the hospital the same day it is performed. Additionally, the postoperative recovery is rapid.
Arthroscopic Surgery For Anterior Cruciate Ligament Rupture
What is the anterior cruciate ligament and how does it tear?
The anterior cruciate ligament (ACL) is one of the four main ligaments within the knee that connect the femur to the tibia. The ACL runs diagonally in the middle of the knee, preventing the tibia from sliding out in front of the femur, as well as providing rotational stability to the knee.
ACL tear is usually associated with extreme violence during sports, with a severe accident or a fall from important height. The injury causes acute and persistent pain, as well as haemarthrosis –an amount of blood within the knee-, while in some cases joint locking may even occur. After an ACL tear, the knee is notably destabilized and becomes unstable, especially in anteroposterior and twisting movements. The diagnosis is easy, because the symptoms are very characteristic, and it is usually confirmed with Magnetic Resonance Imaging (MRI).
How is it treated?
The significant destabilization caused by ACL tear demands surgical treatment, for most cases. According to worldwide standards, the most appropriate procedure for these cases is arthroscopy, a Minimally Invasive Surgery technique, during which tendon graft for the patient is used in order to replace the injured muscle.
Most Orthopaedic Surgeons perform this operation using an arthroscope, a small camera with optical fibers that gives the Surgeon the ability to have visual access of the injured area and interfere therapeutically inside the joint. Two small incisions are needed, called gates, in order the arthroscopy to be performed. These gates allow entrance to the arthroscope and the rest of surgical instruments inside the knee joint, though special attention to avoid injuries around the nerves or the vessels.
What happens after surgery?
The above procedure, when performed by experienced and specialized Orthopaedic Surgeons, even though is technically demanding, is an operation of low morbidity, with particularly high success rates, that allows the patient to leave the hospital within 48 hours –patient can walk, using crutches after 24 hours.
Postoperative rehabilitation includes physiotherapy and muscle strengthening. Everyday activities and return to work can be managed after a few weeks, while mild sports activities are possible after 3 months.
Arthroscopic Treatment of Meniscal Tear
What is meniscus and how does it tear?
Menisci –two in each knee, the medial and the lateral-, are two pads of fibrocartilaginous tissue, made basically of collagen and proteoglycans. They go around the knee joint in a crescent-shaped path and they are located between the medial condyles of the shin and the femur, or thighbone, increasing the stability of the knee. Additionally, they absorb and soften daily pressures on the articular surfaces of the knee, helping the rotation of the leg during the bending and stretching of the joint.
Meniscus injuries are always connected with violent rotation of the joint, meaning that meniscus tear can happen not only when a person is exercising, but also with a simple misstep or other everyday activity. Meniscus tears are sudden and they can occur to people regardless of age or other factors, however obesity is a serious aggravating factor.
What are the symptoms?
Meniscus tear can cause acute and persistent pain, as well as effusion –amount of water in the joint-, while joint locking is also possible. In many cases, the broken part of the meniscus might act as an “alien” within the knee, causing more damages. The diagnosis is made with clinical examination and confirmed with Magnetic Resonance Imaging (MRI).
How it can be treated?
For most cases, conservative treatment proves to be ineffective -the symptoms are worsening over time. The only appropriate treatment is surgery, moreover the arthroscopic removal of the meniscus’ broken part, widely known as arthroscopic meniscectomy. During this Minimally Invasive Surgery (MIS) procedure, the Orthopaedic Surgeon is able to remove the minimum of the damages meniscus, so the healthy part remains untouched in order to protect the joint. This procedure lasts 8-10 minutes.
In which cases the suture-based arthroscopy is appropriate;
The suture-based arthroscopic repair of the meniscus is possible only for specific cases, for example when the lateral meniscus is injured, in the position where connected with the synovial bursa. This portion of the meniscus is not highly vascularized, making the healing process impossible. Besides this case, the procedure is also highly recommended for elongated tears, when ACL tear co-exists, as well for in younger patients.
What happens after surgery?
Arthroscopic treatment for meniscus tear, when performed by experienced and specialized Orthopaedic Surgeons, even though is technically demanding, is an operation of low morbidity, with particularly high success rates, that allows the patient to leave the hospital the same day walking, usually without the need of clutches.
Everyday activities and return to work can be managed after a few weeks.