Orthopaedic Surgery - Arthroscopy

Basics

Arthroscopy is a minimally invasive surgical technique that allows direct visualization and treatment of structures within a joint through small portal incisions.

The procedure should be performed only after a complete clinical history, thorough physical examination, and appropriate imaging studies have been obtained.

Most arthroscopic procedures can be performed on an outpatient basis, although the postoperative course depends on the joint involved and the complexity of the procedure.

General Principles

Arthroscopy uses a small camera, or arthroscope, inserted through one portal while surgical instruments are introduced through one or more additional portals.

The technique allows the surgeon to inspect articular cartilage, ligaments, tendons, menisci, labral structures, synovium, and other intra-articular tissues.

In addition to diagnostic evaluation, many abnormalities can be treated during the same procedure.

Knee Arthroscopy

Indications

Common indications for knee arthroscopy include meniscal repair or debridement, treatment of meniscal cysts, management of osteochondral lesions, and reconstruction or debridement of anterior or posterior cruciate ligament injuries.

It may also be performed for synovial biopsy, synovectomy, evaluation of unexplained knee pain or instability, and selected cases of degenerative joint disease requiring debridement.

Procedure

Knee arthroscopy is usually performed through two or more small portal incisions, each measuring approximately 0.5 cm.

One portal is used for the arthroscope, while the remaining portals permit insertion of surgical instruments.

The technique allows systematic visualization of all three major compartments of the knee: the patellofemoral, medial, and lateral compartments.

Articular Cartilage Assessment

The articular cartilage of the femur, tibia, and patella can be directly inspected.

The surgeon can evaluate cartilage for degeneration, fissuring, osteochondral defects, loose fragments, or traumatic injury.

Selected cartilage lesions may be treated arthroscopically during the same procedure.

Meniscal Assessment

Both the medial and lateral menisci can be visualized and probed.

Probing helps determine the location, configuration, stability, and extent of a meniscal tear.

Depending on the tear pattern and vascularity, treatment may involve meniscal repair or selective debridement.

Cruciate Ligament Assessment

The anterior cruciate ligament and posterior cruciate ligament can also be visualized and probed arthroscopically.

Their integrity, tension, attachment sites, and associated injuries can be assessed.

ACL and PCL reconstruction can be performed with arthroscopic assistance.

Postoperative Weight-Bearing

After uncomplicated knee arthroscopy, many patients can begin partial or full weight-bearing with crutch assistance soon after surgery.

The exact amount of permitted weight-bearing depends on the procedure performed.

For example, rehabilitation after simple debridement may progress more rapidly than after meniscal repair, cartilage restoration, or ligament reconstruction.

Rehabilitation After Knee Arthroscopy

The duration of rehabilitation varies according to the underlying injury and surgical procedure.

Physical therapy commonly focuses on restoring range of motion, gait, core stability, quadriceps strength, and hamstring strength.

The rehabilitation protocol should be individualized rather than based solely on the fact that arthroscopy was performed.

Shoulder Arthroscopy

Indications

Shoulder arthroscopy may be performed for a wide variety of conditions.

Common indications include shoulder instability, synovial or tissue biopsy, removal of loose bodies, subacromial impingement, rotator cuff tears, and superior labral anterior-posterior (SLAP) lesions.

It can provide both diagnostic assessment and definitive surgical treatment.

Procedure

Shoulder arthroscopy typically requires two or more portals, generally measuring approximately 0.8 cm.

The arthroscope is introduced into the glenohumeral joint to inspect the articular surfaces and surrounding soft tissues.

Additional portals provide access for probing, debridement, repair, and fixation.

Articular Cartilage Assessment

The articular surfaces of the glenoid and humeral head can be inspected directly.

Arthroscopy may identify abnormalities such as osteoarthritis, cartilage defects, osteochondral fragments, or loose bodies.

The severity and distribution of cartilage damage can therefore be assessed accurately.

Glenohumeral Ligament Assessment

The major soft-tissue stabilizers of the shoulder can be examined arthroscopically.

These include the inferior, middle, and superior glenohumeral ligament complexes.

Their integrity is particularly important when evaluating recurrent instability or previous dislocation.

Labral Assessment

The glenoid labrum can be inspected throughout its circumference.

Arthroscopy can identify Bankart lesions, SLAP tears, degenerative labral changes, and other labral injuries.

The stability of the labrum can also be assessed with a probe.

Subacromial Assessment

When rotator cuff or impingement symptoms are present, arthroscopy can be extended into the subacromial space.

The rotator cuff, bursa, undersurface of the acromion, and surrounding structures are examined for causes of mechanical impingement or tendon injury.

Arthroscopic Stabilization

Recurrent shoulder instability can often be treated arthroscopically.

Procedures may include Bankart repair or capsulolabral stabilization, in which the detached labrum and capsule are restored to the glenoid rim.

These procedures aim to restore stability while preserving shoulder motion.

Acromioplasty

Arthroscopic acromioplasty may be performed in selected cases of mechanical subacromial impingement.

The procedure involves reshaping part of the acromion and removing impinging tissue to increase the available space for the rotator cuff.

Rotator Cuff Repair

Many rotator cuff tears can be repaired arthroscopically.

The torn tendon is mobilized and reattached to its insertion on the greater tuberosity, commonly using suture anchors.

Arthroscopic repair allows treatment through small portals while minimizing disruption of the surrounding deltoid muscle.

SLAP Lesions

SLAP lesions may be treated with arthroscopic repair or debridement, depending on the tear pattern, patient age, activity level, and associated pathology.

Direct visualization allows accurate evaluation of the superior labrum and biceps anchor.

Rehabilitation After Shoulder Arthroscopy

Physical therapy is an essential component of recovery after shoulder arthroscopy.

Early rehabilitation usually emphasizes restoring appropriate motion while protecting repaired tissues.

Later stages focus on strengthening the rotator cuff, scapular stabilizers, and other dynamic stabilizers of the shoulder.

The duration and progression of rehabilitation depend on the operation performed.

Hip Arthroscopy

Indications

Hip arthroscopy may be used for synovial biopsy, synovectomy, removal of loose bodies, and treatment of labral tears.

Because the hip is a deep, constrained joint, specialized traction and instrumentation are generally required.

Labral Treatment

Hip arthroscopy allows direct inspection of the acetabular labrum.

Symptomatic labral tears may be treated with repair, selective debridement, or other arthroscopic techniques, depending on the pattern and quality of the tissue.

Loose-Body Removal

Intra-articular loose bodies can produce pain, locking, catching, and restricted motion.

Arthroscopy permits their removal without requiring a large open surgical exposure.

Ankle Arthroscopy

Indications

Ankle arthroscopy may be performed for synovial biopsy or synovectomy, removal of loose bodies, excision of bone spurs, and treatment of osteochondral lesions.

It is particularly useful for disorders causing mechanical impingement, locking, or persistent intra-articular pain.

Osteochondral Lesions

Osteochondral lesions of the talus can be evaluated directly during ankle arthroscopy.

Depending on the size and characteristics of the lesion, treatment may include debridement, stabilization of unstable cartilage, or marrow-stimulation techniques.

Bone-Spur Removal

Anterior or posterior ankle osteophytes can produce painful impingement during motion.

Arthroscopic excision of selected osteophytes can improve movement and relieve mechanical symptoms.

Elbow Arthroscopy

Indications

Elbow arthroscopy may be used for synovial biopsy, synovectomy, loose-body removal, and debridement of cartilage lesions or osteophytes.

It can be especially useful in patients with mechanical locking, restricted motion, or symptomatic intra-articular pathology.

Cartilage and Osteophyte Debridement

Degenerative cartilage fragments and osteophytes may restrict elbow motion and cause pain.

Arthroscopic debridement can remove these structures while minimizing soft-tissue disruption compared with some open procedures.

Wrist Arthroscopy

Indications

Wrist arthroscopy may be performed for synovial biopsy, synovectomy, removal of loose bodies, and diagnosis or treatment of triangular fibrocartilage complex (TFCC) injuries.

It provides detailed visualization of small intra-articular structures that may be difficult to assess using imaging alone.

TFCC Assessment

The triangular fibrocartilage complex can be directly inspected and probed arthroscopically.

Tears may be assessed according to their location, stability, and tissue quality.

Depending on the lesion, treatment may involve debridement or repair.

Advantages of Arthroscopy

Arthroscopy generally requires smaller incisions than traditional open surgery.

Potential benefits include less disruption of surrounding soft tissues, improved visualization of intra-articular structures, and the ability to diagnose and treat several abnormalities during the same procedure.

Many procedures can also be performed without overnight hospitalization.

Limitations

Arthroscopy is not appropriate for every joint disorder.

The decision to operate should be based on the patient’s symptoms, physical examination, imaging, functional impairment, and likelihood that the identified pathology is responsible for the symptoms.

Abnormal imaging alone does not necessarily justify arthroscopic surgery.

Postoperative Rehabilitation

Rehabilitation should always be tailored to the specific procedure performed.

Simple diagnostic arthroscopy or debridement may allow rapid progression of activity.

Procedures involving meniscal repair, ligament reconstruction, labral repair, rotator cuff repair, or cartilage treatment generally require more prolonged protection and structured rehabilitation.

Patient Monitoring

Postoperative follow-up should assess wound healing, pain, swelling, joint range of motion, strength, and functional recovery.

Patients should also be monitored for complications such as infection, stiffness, neurovascular symptoms, or persistent mechanical complaints.

Progression of weight-bearing, strengthening, and return to sport should follow the requirements of the specific arthroscopic procedure rather than a single universal protocol.