Arthroscopy

Arthroscopy is currently the most effective method for diagnosing damage to intra-articular structures. Arthroscopy is used to diagnose joint damage in cases where non-invasive research methods are ineffective.

The importance of arthroscopy is determined by a number of factors:

• diagnostic accuracy of the method;
• the possibility of replacing arthrotomy with closed surgery:
• improvement of arthroscopic equipment, variety of instruments, the ability to perform operations on various joints;
• the possibility of performing the procedure on an outpatient basis;
• short period of rehabilitation.

The advantages of the arthroscopy method include minimal damage to joint tissues, diagnostic accuracy, the ability to fully visualize all joint structures, and improved planning of further therapeutic and surgical treatment tactics. In addition, the undoubted advantages of the method are a small number of postoperative complications and a short rehabilitation period.

During diagnostic arthroscopy, it is possible to record pathological changes in the joint on external media, which allows for dynamic monitoring of the subject.

During diagnostic arthroscopy, if intra-articular changes are detected that can be corrected immediately during surgery, diagnostic arthroscopy becomes therapeutic.

In degenerative joint diseases, arthroscopy is most often performed on intra-articular structures and articular cartilage. In inflammatory joint diseases, the synovial membrane is most often the target.

In general, operations for degenerative joint diseases can be divided into three groups;

• arthroscopic lavage and joint debridement;
• operations aimed at stimulating the restoration of the integumentary cartilage;
• cartilage transplant operations.

The therapeutic effect of arthroscopic sanitation and lavage is based on the removal of damaged structures during surgery, evacuation with a flow of water of free intra-articular bodies, particles of cartilage tissue, and inflammatory agents.

The second group of operations is based on the activation of reparative processes during nitration of the subchondral bone, which allows mesenchymal cells from the bone marrow to penetrate into the area of the cartilaginous defect and replace it with fibrous cartilage, consisting mainly of type 1 collagen. Operations in this group include abrasive chondroplasty, subchondral tunneling, and the creation of microfractures of the subchondral bone.

In recent years, methods for restoring true hyaline cartilage have become increasingly common. These methods are based on transplanting autogenous or allogeneic cartilage tissue into the damaged area.

[ 1 ], [ 2 ], [ 3 ], [ 4 ]

Why is arthroscopy performed?

The main goal is to remove pathological tissue from the joint and improve the mechanical function of the inflamed joint. Even though complete healing is impossible, synovectomy returns normal function to the joint due to the removal of pathological inflammatory tissues and the elimination of synovitis.

Indications for arthroscopy

Arthroscopic synovectomy is indicated for chronic synovitis that is resistant to drug treatment for 6 months or more. A number of studies have shown that by eliminating an extensive focus of inflammation, the progression of joint erosion and cartilage destruction is slowed. Due to the potential ability of synovectomy to prevent changes in the joint, some authors suggest that synovectomy be performed earlier in young patients with radiographic changes.

Contraindications to arthroscopy

Any damage to the skin in the area of arthroscopic access, skin infection. Infectious arthritis is not considered a contraindication to arthroscopy. On the contrary, joint infection is currently an indication for arthroscopic sanitation. Relative contraindications to arthroscopy include the final stages of deforming arthrosis, when the operation may be technically difficult. In addition, it has been shown that in patients with severe joint damage (stage IV destruction), synovectomy yields an unacceptably high percentage of unsuccessful results.

[ 5 ], [ 6 ], [ 7 ]

How to prepare for arthroscopy?

Arthroscopy, despite its minimally invasive nature, is still an operation, therefore, in the preoperative period, the patient is examined to assess the general somatic condition, and the surgical and anesthetic risks are assessed.

How is arthroscopy performed?

Arthroscopy surgery is performed under local, regional or general anesthesia. The choice of anesthesia method depends on the somatic and psychological state of the patient, on the scope of the surgical intervention. During surgery on the joints of the lower extremities, spinal anesthesia is often used, which provides good muscle relaxation and eliminates discomfort when using a tourniquet; this effect cannot be achieved with local anesthesia.

Arthroscopy is performed using a pneumatic tourniquet with the patient lying on the ground. The operated limb can be placed in a special fixator and bent at an angle of 90°. Diagnostic arthroscopy is most often performed from standard anterolateral and anterolateral approaches located 1 cm above the joint space and 1 cm lateral to the medial edge of the patellar ligament. When performing therapeutic arthroscopy, depending on the location of the pathological changes, additional arthroscopic portals can be used, such as posteromedial, posterolateral, superomedial, superolateral and others.

Arthroscopic synovectomy allows to solve some of the problems that surgeons face with open synovectomy, the radicality of resection and postoperative complications. Using additional portals and optics with different angles of view, it is possible to work in any part of the joint under direct visual control. As with the open method, the removal of synovium is facilitated by separating the inner synovial layer from the underlying one. This can be done with a motorized bur.

Isometric exercises and active movements in the operated joint are allowed immediately after arthroscopy. Since arthroscopic approaches do not disrupt normal muscle function, the limb quickly returns to its original state. Full activity is allowed after wound healing, in the absence of pain, swelling, and restoration of the full range of motion and strength of the limb. In some cases, physiotherapy is prescribed. Most authors note that the refusal of crutches and restoration of the preoperative range of motion is achieved by the 7th to 10th day after arthroscopic synovectomy of the knee joint.

Operating characteristics

The effectiveness of arthroscopic synovectomy has been demonstrated in many studies to date. A study involving 84 patients with rheumatoid arthritis showed that by the end of the 5th year of observation, arthroscopic synovectomy resulted in a significant reduction in pain, improved joint function, and no signs of local inflammation. Another study found 90% good results after 3 years of observation, but by the end of the 5th year, the percentage of positive outcomes had dropped to 75%. Despite the variability of clinical data, in general, most studies report clinical remission 2 years after surgery. Given the low trauma and low percentage of complications, arthroscopic synovectomy can be considered the method of choice for treating persistent recurrent synovitis of the knee joint that is not amenable to conservative treatment.

Alternative methods

Arthrotomy, open synovectomy.

[ 8 ], [ 9 ], [ 10 ], [ 11 ]

What are the complications of arthroscopy?

Postoperative complications of open synovectomy are one of the main factors limiting its use in the early stages of the disease. When performing arthroscopy, surgical trauma is significantly less, and, as a result, the intensity of the pain syndrome decreases, the duration of drug treatment, rehabilitation and hospitalization is reduced. Due to the decrease in the intensity of the postoperative pain syndrome, the risk of developing contractures and the need to use physiotherapy and exercise therapy are reduced.

But according to various studies conducted in different countries, the incidence of complications after arthroscopy ranges from 1 to 2%. Thus, in one study, the risk of complications was less than 1%, and in a study that assessed the results of 8791 operations, the incidence of complications was 1.85%. The most common complication is hemarthrosis, the second most common complication is infection. One multicenter prospective study showed that the incidence of infectious complications reached 0.2% (one in 500 operations). Thromboembolism and anesthetic problems are also relatively common complications. Their incidence is on average 0.1% (one in 1000 operations). Other complications include damage to blood vessels and nerves, thrombophlebitis, stiffness and loss of range of motion in the joint, and damage from compression by a tourniquet. The patient must be informed of possible complications before surgery.

It is important to understand that only with the right approach can arthroscopy be a safe and effective operation.