Arthroscopic Surgery

Arthroscopy has fast become one of the least invasive exploratory and surgical procedures available for many upper extremity injuries and conditions that exist today. The slender instruments require only a small incision, where a narrow, surgical telescope (arthroscope) attached to a special camera within the operating room travels unobtrusively around the inside of the joint – allowing a three-dimensional view of the affected area with magnified clarity on a nearby monitor.

Arthroscopic surgery is performed in an environment in which the joint is inflated with pressurized water. The arthroscope traveling through the joint has a small lens and fiber optic lighting system that enlarges and illuminates the area – for a complete assessment of the injury with minimal contact.

Arthroscopy is used in both diagnosing a problem, as well as repairing some minor injuries non responsive to conservative treatment such as cartilage and tendon tears. It is also used in treating some larger rotator cuff tears and in treating other shoulder instability, elbow and wrist conditions formerly requiring more invasive surgical procedures and incisions.

The small surgical area and incision (generally smaller than a dime) involved in an arthroscopy dramatically reduces the risk of infection and overall recovery time. Involving either a general or regional anesthetic, most arthroscopic procedures are done on an outpatient basis.

Wrist Arthroscopy is performed when wrist pain persists despite conservative treatment options.

The small cameras and instruments in arthroscopy today make it the ideal procedure for addressing conditions within the wrist. This complex joint comprised of eight small bones, many connecting ligaments and a triangular fibrocartilage complex (TFCC) in a small, confined space is seen with greater clarity through the arthroscope projection amplified on a large screen monitor – allowing a more accurate diagnosis.

The Procedure
Before the arthroscopy is performed, a physical examination of the hand and wrist is conducted. Dr. Collins then observes, through a series of exercises, the manner in which the hand moves when pain is experienced. He may order one or more imaging studies such as an X-ray, an MRI (magnetic resonance imaging) or an arthrogram, in order to assess the area of pain.

Generally, a regional anesthesia is used during this type of arthroscopic procedure. Other sedative medication may be used to relax patients. Two or more small incisions, or portals, are made to the back of the wrist and the arthroscope and instruments are inserted.

For Wrist Fractures, small bone fragments and fracture debris is removed, and the bone pieces are realigned and stabilized with a fixation device such as pins, screws, or wires.

For Ganglion Cysts, a stalk found between two of the wrist bones and on which these cysts commonly grow, is arthroscopically removed. This procedure may also be called an arthrosocopic ganglionectomy.

For Chronic Wrist Pain, arthroscopy is used to first identify the cause of pain or inflammation and then address possible damage by removing torn cartilage, loose bony bodies or inflamed synovium tissue.

For Ligament Damage such as Triangular Fibrocartilage Complex (TFCC) tears and the torn edges of damaged ligament or cartilage – often occurring from breaking a fall on an outstretched hand – arthroscopy is used to trim or remove frayed edges and repair damage.

Recovery and Rehabilitation
Following surgery, patients are instructed to keep their wrist elevated for the first couple of days and to keep clean, dry bandages on the surgical area. Swelling is reduced with cold compressions. And analgesic medications may be prescribed to help minimize postoperative pain.

Range of motion exercises generally begin the day following the arthroscopic procedure, but may vary on the patient and condition of the wrist following surgery.

Advances in arthroscopy over the years make it a valuable tool in both the diagnosis and treatment of many elbow disorders. Arthroscopic surgery of the elbow requires special skill because of the anatomy of the elbow joint. The bones lie close together and the nerves and blood vessels are located very close to the joint.

While very useful in the evaluation of patients with chronic elbow pain, elbow arthroscopy is also instrumental in the removal of osteophytes as a result of impingement or osteoarthritis, as well as adhesions and capsular release in patients with contractures. It is used in the removal of loose bodies and for synovectomy of patients suffering from inflammatory arthritis.

Loose Body Removal
Elbow arthroscopy in the removal of loose bodies resulting from a fracture or degenerative condition is frequently used and yields a 90 percent or better success rate. The loose bodies are removed with various sized graspers with “teeth,” and the assistance of the sheath of the arthroscope.

Synovectomy
The capsular release of the joint capsule of the synovial membrane (removal of excessive synovial fluid causing the synovial membrane to become inflamed) is generally required to restore motion and eliminate pain during motion in those suffering from rheumatoid arthritis. During a synovectomy (surgical removal of the joint lining that has become inflamed), careful attention is paid to the radial and ulnar nerves, which lie very near the capsule. During this procedure, any visible scar tissue from previous joint damage is removed – as are osteophytes (bone spurs) that may be present.

Capsular Release
A capsular release is performed after a synovectomy has failed to restore sufficient motion. Once all synovium is cleared from the joint capsule and the nerves are arthroscopically visualized and determined to be a safe distance from the cutter, the soft tissue behind the capsule is dissected away in order to create a safe plane for incision of the capsule. The capsule is then removed in stages.

Recovery and Rehabilitation
Following elbow arthroscopy, a compressive dressing is wrapped around the elbow and movement is encouraged as tolerated. Initially the elbow is elevated when not in use, in order to reduce swelling, and a catheter may be inserted for brachial plexus block anesthetic, in order to begin range of motion exercises.

Recovery following arthroscopic treatment of an elbow injury or condition is generally more rapid than after traditional open surgery.

Arthroscopic rotator cuff repair is done in cases lending themselves well to the precise instruments and technique of the arthroscopic procedure – which is generally a tear with no other associated injury. In such procedures preoperative planning is key. The procedure is outlined carefully, a health assessment is performed and rehabilitation expectations are discussed before the procedure is scheduled.

Patients then meet with the anesthesiologist to review their health history and discuss the type of anesthesia to be used during the procedure.

The Procedure
Placed either lying on their side or in a comfortable sitting position, the procedure is performed under a general anesthesia. Small incisions, or portals, are made in the back, side and front of the shoulder. Initially a complete diagnostic arthroscopy is performed. The arthroscope is inserted and a complete inspection of the bursa, as well as the biceps tendon, labrum and surrounding ligaments, tendons and cartilage surfaces are carefully inspected. When it is determined that no other injury exists, the repair and/or decompression of the supraspinatus or rotator cuff tendon of the shoulder is begun.

Upon completion, the area of the incision is not sutured, in order to allow for egress (drainage) of the fluid used in the arthroscopic procedure – minimizing swelling and bruising.

Recovery and Rehabilitation
The recovery and rehabilitation of an arthroscopic procedure is much easier than that which is experienced following traditional surgery with a large incision.

Following a period of rest and stabilization of the arm by keeping the elbow beneath shoulder level, the doctor will determine which series of resistive shoulder strengthening exercises should begin. When patients are advised to proceed, they will be instructed to perform a series of exercises using a latex exercise band in order to provide both positive and negative force for muscle strengthening. The exercises improve range of motion and encourage involvement of surrounding muscle groups.

The emphasis during this phase of recovery is also on strengthening the shoulder in flexion, abduction, internal rotation and external rotation – as well as helping stretch the shoulder into internal rotation and strengthening the scapula rotators.

Debridement is the process of removing dead (necrotic) tissue, bone fragments or foreign material from and around an injury in order to “clean” the impacted area and expose healthy tissue. While no different in “theory” than the maggots once used in early medicine to “clean” a wound, the “practice” has changed quite a bit.

Today a range of injuries and degenerative conditions can indicate a need for arthroscopic debridement. Once done a number of different ways including surgically with a scalpel and scissors, today arthroscopic debridement has made the procedure far less invasive than it once was.

Debridement enhances conditions for healing by – removing dead tissue prone to bacteria growth and infection, bone fragments disrupting other soft tissue and joint function, and foreign matter that the body will fight to reject (such as that which is present in gun shot wounds). Debridement may also be used to treat pockets of pus called abscesses, which could develop into a general infection that has the potential to invade the bloodstream (sepsis) and lead to severe conditions. Tissue that is burned or exposed to corrosive substances tends to form a black crust called eschar, which also requires debridement because it can inhibit wound healing.