Arthroscopic Surgery: An Answer To Sports Injuries & Other Joint Problems 

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By Dr. Arvind K. Derhgawen, MS Orth. (Pat)
Consultant, Sports Medicine & Arthroscopic Surgery
Sports Medicine Center, MH Stadium
Rajendra Nagar, Patna 800016 India

Science and Technology has made tremendous progress in recent times, but the pace of development of Medical Sciences leaves other disciplines far behind. This science is taking full advantage of the latest scientific inventions and discoveries. Latest diagnostic and therapeutic treatment options are being made available for the common people almost everyday. Notable examples are: Cardiac Surgery, Cardiac Pacemaker, Lithotripsy (to break kidney stones without surgery), CT Scanning, MRI Scanning, Organ Transplantation, Replantation of severed body parts with the help of Microsurgery, Endoscopic Surgery, Joint Replacement and many more. Arthroscopic Surgery is a new addition to this growing list. The word "Arthroscope" comes from Greek root,  arthro for joint and scope, meaning to view. The Arthroscope consists of a tube, an optical system of magnifying lenses, and a fiberoptic light source. Other instruments required for this surgery are Motorized Shaver, a special Video Camera with Monitor, Flexible Fiberoptic Light Source, Fluid Irrigation Pump and various Hand Instruments. The surgery itself is least invasive and usually minor, and therefore, the surgery done with the help of the Arthroscope is considered a "Minimally Invasive Surgery". 

Prevalence of knee problems in Indian setting: 

The number of two-wheelers in modern India is increasing very rapidly. These vehicles are equipped with very advanced and powerful engines to provide a peppy pickup adored by the youngsters. Fast two wheelers, dilapidated roads and violation of traffic rules provide a ready mix for the road accidents to happen. Fractures are treated effectively after the road traffic accident, but more subtle injuries to the joint usually remain undetected or ineffectively treated, resulting in continuing problems of the involved joint affecting the quality of life substantially. This problem is not resolved by the conventional treatment usually. Repeated "kick starting" of the two wheelers may end up with joint problems. According to our Indian culture and traditions many of our daily chores and prayers are performed in a squatting position, this may affect the knee joint in association with other aggravating factors. Climbing up and down on the flight of stairs in the multistoried buildings is also contributory to the joint problems. These factors coupled with lack of exercise in the Indian life style; sedentary work and obesity damage the joints. 

Presently, traditional open procedures available for these conditions require prolonged hospital stay and painfully protracted physiotherapy. There is unsightly scarring of the skin as the incision is bigger. Other minor conditions are usually dealt traditionally with the help of Intra-articular steroid injections. This injection suppresses signs of malfunction only for short while, and does not heal the deformity or malfunction at all. Not only that, the injected steroid has a proven destructive effect on the cartilage pad and this deleterious effect may lead to early arthritis of the involved joint. Nevertheless, we have to keep in mind that arthroscopic surgery was not available in the past and therefore steroid injection was the only treatment option available to the surgeon to alleviate pain in all such conditions. 

The history: 

The development of Arthroscopic Surgery has taken place in the last two decades mainly. Dr. Watanabe of Japan developed first practical arthroscope named "Watanabe No. 21". Many surgeons of North America used this arthroscope shortly thereafter. There was a flood of experiments and publications based on this revolutionary instrument, instantly. Other accessory equipment for this surgical modality like Motorized Cartilage Shaver, special Video Camera, Flexible Fiber-optic Light Source and special Hand Instruments were developed thereafter. Dr. O’Connor (Developer of Arthroscopic Surgery), Dr. Lanny Johnson and internationally acclaimed surgeon of Indian origin, Dr. Dinesh Patel (Chief, Dept. of Arthroscopic Surgery, Harvard Medical School, Boston) helped in the development of these specialized instruments in United States. 

A magnified view of the interior of the joint is obtained by the use of a Video Camera and the monitor. This magnification helps in carrying out microsurgery with utmost precision. A video recording of the procedure is done and made available to the patient so that other surgeons may know about the condition of the joint and the details of the procedure performed. 

Motorized Shaver helps in speedy and accurate repair of the torn or diseased cartilage (padding or cushion for the joint) or meniscus (a "C" shaped, pad like structure inside the knee joint). 

The indications: 

The arthroscopic surgery is indicated for the following conditions: 

• Meniscus Repair or Meniscectomy: Meniscus is a "C" shaped pad like structure inside the knee joint which gets torn after a twist or a jerk on the knee or a direct injury close to the knee joint. The knee gets swollen and painful. Recurrent episodes of swelling and locking (inability to straighten the knee fully) take place and the patient is apprehensive of falling down while walking downstairs. The arthroscopic method to treat this condition is very successful and conventional techniques lead to arthritis and joint instability later. 
• Clearing of degenerated and torn tissues in Degenerative Arthritis (Arthritis affecting older people).
• Synovectomy: (removal of inflamed inner lining of the joint) for patients of Rheumatoid Arthritis who suffer from swelling and pain of knee unresponsive to usual medications. 
• Removal of Loose Bodies: which could be fleshy or bony 
• Removal of Foreign Bodies: pieces of glass, iron or wood in the joint 
• Reconstruction of the Cruciate Ligament of the knee: this ligament is a very powerful restraint of the knee joint which keeps the knee from abnormal and dangerous mobility. Arthroscopic Reconstruction is the gold standard for this problem and improper treatment could lead to early arthritis of the knee joint with devastating effects on the patients life style. This ligament is torn when too much twisting strain is put on the knee joint and within few hours, the joint is all swollen as blood accumulates quickly within the joint. The patient usually feels a "Pop or Cracking" sound too in the joint, when this ligament gives way. The patient feels insecure while walking and feels that his/her knee joint may "give way". It is imperative that this condition is diagnosed and treated urgently and effectively. 
• Diagnostic Procedure to document joint status before planning any major open surgery on the joint. 
•   Besides knee joint many diseases affecting other joints like shoulder, ankle, wrist, elbow and hip, could also be taken care of with the help of Arthroscopic Surgery very effectively. 

Although some problems still require larger incisions, most joint injuries can now be treated with the help of the arthroscopic surgery. An exciting and revolutionary new area in which research work is going on is "Autogenous Chondrocyte Transplantation" which may prove to be a blessing for the patients of Arthritis. In this technique normal cartilage cells are taken from a site and arthroscopically transplanted on the diseased joint surface, which is deficient in the cartilage cells. This process may potentially reverse the aging effects on the joint. Laser Knife is also being used to tackle some problems at select centers. 

The Procedure: 

Let me now give a little more information about the procedure itself. Too expensive or detailed investigations are not needed before the procedure and regular blood work and X-ray of the joint is sufficient to proceed with this procedure. This procedure can be performed under local anesthesia (making the joint numb with the help of some injections before the surgery) and various surgical procedures may be accomplished without any problem. The patient may watch the procedure on a video monitor, while the surgery is being performed. The procedure is performed under General Anesthesia (unconscious state) or under sedation (semi-conscious or in sleep), if the procedure is difficult or if the patient so desires. The procedure may be performed by using "Spinal Anesthesia" too, which numbs both legs. After anesthesia, a small pencil size hole is made into the skin and the arthroscope is introduced into the joint through this hole. A Fiberoptic Light Source is attached to the Arthroscope with the help of a Flexible Fiberoptic Light Cable. A small video camera is attached to one end of the arthroscope and the video pictures (movie), of interior of the joint, starts coming on the video monitor. A constant flow of sterile irrigation fluid is maintained through the joint space with an irrigation pump to enlarge the joint space and enhance the visibility. This continuous irrigation of the joint space flushes the joint and reduces the risk of infection to one of the lowest among orthropaedic surgery procedures. Other accessory surgical instruments like Motorized Shaver and Specialized Hand Instruments are then introduced into the joint through another pencil size hole made into the skin of the knee joint. 

The Options: 

Once inside the joint, the arthroscope offers a unique opportunity not only to examine the tissues but also, through the use of various attachments, to take biopsy specimen or to perform various surgical procedures with the help of the Motorized or Hand Instruments. These instruments are precision engineered for going into the most inaccessible spaces with tremendous control and safety. These instruments provide ability to perform difficult surgeries with millimeter precision inside the joint. Knee joint is vital for weight bearing and surgical procedures need to be highly accurate if long term good results are required. Traditional open procedures do not provide this accuracy and can leave irregularities on the joint surface leading to early development of arthritic changes with disastrous results on the life style of the patient. Magnified and sharp pictures on the video monitor help in performing microsurgical procedures efficiently. The surgical procedure usually takes about thirty minutes but the total duration for this surgery could be about two hours. There is no need to put stitches on the small skin holes and the patient does not have to return for the removal of stitches. 

The Recuperation: 

Unlike traditional procedures in which the joint itself is opened, very little time is needed for the joint to heal after the arthroscopic procedure. The procedure rarely takes more than an hour, and the individual usually can return home shortly thereafter. Physiotherapy, if needed, is shorter than traditional open procedures resulting in reduced expenditure and an early return to activity. Although the joint should not be subjected to vigorous physical activity, pressure or shocks for several days, most normal activities can be resumed immediately. 

It is noteworthy that arthroscopic procedures of the knee are among the most common surgical procedures performed in the United States. Approximately 1.2 million procedures are done in the United States each year. The reasons behind this popularity are safety, reliability and a unique ability to provide quick and definite results. 

Present status of this procedure in India: 

The credit to bring this revolutionary technique to India goes to Dr. Dinesh Patel. Later, his talented disciple Dr. Anant Joshi enriched this field through his valuable contributions. The Indian metropolitan cities started having arthroscopic surgeons from 90’s onward. Top Indian players like Kapildeo and Srinath took advantage of this surgical technique to stay fit in a competitive sport like cricket. International celebrities like Andre Agassi, Diego Maradona and Monica Seles benefited from this revolutionary technique. It is not an overstatement to say that Arthroscopic Surgery has played a key role in the area of competitive sports by making a sports person physically fit, very soon after an injury. This technique which was developed and available only for the top athletes is now available to the whole community. 

Financial aspects: 

Arthroscopic Surgery is comparatively cheaper in comparison to the traditional open surgery, as the patient is discharged and can return to work almost immediately, and, precious man-hours are not lost. The individual as well as the society in general, benefits from this save. Moreover, the cost of investigations and medications is also lower. In metropolitan cities of India, arthroscopic procedure costs between Rs. Eight Thousands to Eighteen Thousands, depending upon the severity and complexity of the procedure undertaken. Until recently, this technique was available in a few metropolitan cities only but the situation is changing rapidly and specialists trained in this area are getting available even in other cities. 

Conclusion: 

There is now a need to instill awareness in the community towards this novel technique, so that more people may derive benefit for their joint problems by consulting a specialist trained in the area of Sports Medicine & Arthroscopic Surgery.