Role of Arthroscopy - Primary care appro

Role of Arthroscopy : 

Role of Arthroscopy A Primary Care Approach

Clinical Questions : 

Clinical Questions What is Arthroscopy What Are there Indications ? Which are the guidelines for diagnosis and management of such conditions ? How such surgery done ? Postoperative care ? Can TKR( Total knee replacement ) be post-poned by Arthroscopy ?

What is Arthroscopy ? : 

What is Arthroscopy ? The word arthroscopy comes from two Greek words, "arthro" (joint) and "skopein" (to look). The term literally means "to look within the joint Simply ---as if you see a building ….

How Arthroscopy done : ?? : 

How Arthroscopy done : ?? ." A small incision is made in the patient's skin and the arthroscope, an instrument like a small telescope, is inserted into the joint. Light is transmitted through fiber optic cables to the end of the arthroscope, and the instrument is attached to a video monitor.

What Surgical procedures done arthroscpically ? : 

What Surgical procedures done arthroscpically ? Torn cartilage smoothen Damaged ligaments can be reconstructed Loose bodies removed Joint swelling reduced Biopsy can be taken Fracture can be fixed Sports Related Injuries

Sports Related Injury : 

Sports Related Injury

Cricket too …..!!!! : 

Cricket too …..!!!! Knee injuries Throwing – shoulder injuries

Cricketer and Arthroscopic surgery : 

Cricketer and Arthroscopic surgery Sachin – Shoulder A’scopy for Biceps tendon pathology Kapildev - Knee A’scopy for Meniscus

What joints are being scoped ? : 

What joints are being scoped ? + MAJOR – Knee & Shoulder + MINOR – Wrist ,Ankle & Hip…, But not that much of Elbow

KNEE ARTHROSCOPY : 

KNEE ARTHROSCOPY

Knee Anatomy : 

Knee Anatomy

Slide 12: 

Knee Arthroscopy - Common Indications Meniscal tears Ligaments injuries – ACL.PCL –cruciates Sports related Injuries – but not always…routine house hold work too…. Early Osteoarthritis - loose body and synovectomy

Shoulder Arthroscopy : 

Shoulder Arthroscopy

Shoulder Anatomy of Rotator cuff tear : 

Shoulder Anatomy of Rotator cuff tear

Shoulder – common indications : 

Shoulder – common indications Recurrent Dislocation Persistent painful shoulder Restricted range of movement Persistent night pain – Abduction weaknessRotator cuff tear Sports/Gym. related shoulder problems

Which anesthesia used for Arthroscopy ? : 

Which anesthesia used for Arthroscopy ? Arthroscopies can be performed under general, local or regional-spinal anesthesia. Spinal anesthesia preferred

What are the advantages of Arthroscopy? : 

What are the advantages of Arthroscopy? No major surgery Short hospital stay Early return to activity Very few- almost no complications Tiny scar – no scar related problems Overall cost reduced

What are the possible complications of Arthroscopy ? : 

What are the possible complications of Arthroscopy ? infection – as for any surgery but very less – around 10- 15 % with conventional open surgery , while its <1% for Arthroscopy Complications related to anesthesia

CLINICAL PRESENTATIONSCASE – 1 : 

CLINICAL PRESENTATIONSCASE – 1 Male - 34, VINODBHAI History of twisting injury at work place Complains : - persistent pain - swelling + - locking ++ - catching ++ - restricted move. Examination : - point tenderness

What is Locking – then cant move himself but has to take leg with hand – Typical for displaced Meniscal injury. : 

What is Locking – then cant move himself but has to take leg with hand – Typical for displaced Meniscal injury.

ARTHROSCOPIC FINDINGS : 

ARTHROSCOPIC FINDINGS Meniscal tear - “Kapildev”., & recently “Big – B” also..did same

Arthroscopic procedure :Excised or repaired : 

Arthroscopic procedure :Excised or repaired

Post operative : 

Post operative Three small incisions next day discharge One followup only for removal of stitch Done regular physiotherapy at home Return to work after one week

CASE – 2. : 

CASE – 2. Male – 40 ,Channabhai History of fall from wall Clinical diagnosis ACL ( Anterior Cruciate Ligament tear ) COMPLAINS : - Instability - inability to balance and frequent fall during walking Examination : - laxity

Arthroscopic finding : : 

Arthroscopic finding : Torn ACL

Economic Alternative Procedure: : 

Economic Alternative Procedure: Extra articular ITB tenodesis – an alterative Arthroscopic meniscectomy and open tenodesis

ACL- ligaments reconstructed : 

ACL- ligaments reconstructed With Autologus hamstring tendon graft – which are gods given gift- extra tendons of no use Semitendinosus or grascilis

Case – 3 , Early Osteoarthritis Knee : 

Case – 3 , Early Osteoarthritis Knee Female – 48 Complains : - persistent knee pain with mechanical symptoms - Advised elsewhere joint Replacement Arthroscopic procedure to delay TKR- “microfrature” done

Many other knee loading sports - Microfracture : 

Many other knee loading sports - Microfracture Base ball – Fred Robbins Bascketball – Andrew Buynum

Case 4 : Shoulder Female – 45, : 

Case 4 : Shoulder Female – 45, Complains : persitent – night pain abduction weakness Examination : -Tenderness - no active , but passive move. Possible ---Tried enough conservative trial of 6 weeks. Clinical Diagnosis : Rotator cuff tear

Rotator cuff surgery : 

Rotator cuff surgery “ SRK” – had same Problem and underwent Arthroscopic procedure

Arthroscopic procedure :preparation of bed : 

Arthroscopic procedure :preparation of bed Mini open repair

Recurrent dislocation shoulder : 

Recurrent dislocation shoulder Presentation : frequent shoulder disloaction with abduction activity Treatment : * Arthroscopic Procedure -Ant. Instability – Bankart * Mutidirectional Instability –capsular plication

Small Joint Arthroscopy : 

Small Joint Arthroscopy Indicatons: Chronic synovitis OCD talus Pesistant ankle pain Ankle

Hip Joint : 

Hip Joint Indications -Labral tears( persistant pain with normal x-rays -Impingement syndrome

Labral Tear : 

Labral Tear

Wrist Joint : 

Wrist Joint Common Indications TFCC tear ( persistent ulnar side pain) Synovitis ( require special traction and positioning device) Mini – open Repair

MYTHS – regarding TKR : 

MYTHS – regarding TKR TKR-Total knee replacement (only solution for Degenerative arthritis arthroscopic procedure not useful

FACTS : : 

FACTS : Developed western Countries are in the era of Revision and Re-revision of TKR surgery ------!!!!! We in Gujarat have not yet faced problem of Revision TKR Soon, we too will be facing …..

Can Arthroscopy delay TKR ?- YES., : 

Can Arthroscopy delay TKR ?- YES., As Life expectancy increase upto 75-80 yrs Atleast first Joint replacement should at age of 60 or more then can be manage with one Revision As 2nd revision is very cumbersome……!!! So western people started doing 1st A’scope, 2nd A’scope and even 3rd A’scope but not Replacement till age of 65-70 even if needed…….!!!!

So, Arthorscopy can Delay but not Replace TKR…… : 

So, Arthorscopy can Delay but not Replace TKR…… TKR has its own place..

How it delays TKR ?? : 

How it delays TKR ?? Arthroscopic removal of torn cartilage and meniscus remove mechanical pain ---that will allow more active physiotherapy and that indirectly delay ageing ……. Method - 1. Arthroscopic Debridement and lavage 2. Arthroscopic Microfracture.

1.Joint surfaces smoothened : 

1.Joint surfaces smoothened : for early arthritis with mechanical symptoms with good alignment give excellent result – almost 70-80 % people do not require future major surgery like : TKR

Loose bodies removed : 

Loose bodies removed Clinical Presentation - some thing moving inside joint Arthroscopic procedure : removal

Take Home message : 

Take Home message All young patient with chronic knee pain – Definite Role of Arthroscopy Middle age patient with chronic knee pain with …..

2.Patient of early OA knee who can benefited with A’Scopy and can Delay TKR are…… : 

2.Patient of early OA knee who can benefited with A’Scopy and can Delay TKR are…… a. Patient with mechnical sympotms e.g.. Loose bodies., locking., catching. b. with Normal or near normal alignment- no significant deformity c. with atleast 50 % joint space preserve on x-rays.

3.Shoulder problems : 

3.Shoulder problems Most shoulder problems can be deal with Physiotherapy in contrast to knee where there is definite role of A' copy…. Still there are specific and rewarding indications for Shoulder Arthroscopic Procedure in Chronic shoulder problems….such as Recurrent Shoulder dislocation and Rototor cuff tear.

Thanks for Your Attention -Dr.Ujjval H. Deliwala- Orthopedic and Arthroscopic Surgeon, Govt.Medical College and Sir.T.Hospital, Bhavnagar, Gujarat, India – 364002. : 

Thanks for Your Attention -Dr.Ujjval H. Deliwala- Orthopedic and Arthroscopic Surgeon, Govt.Medical College and Sir.T.Hospital, Bhavnagar, Gujarat, India – 364002. Specialty Interest Arthroscopic Surgery Fellow Arthroscopy and Sports Medicine : Narverkar’s Clinic,Mahim , Mumbai., NYU Hospital for Joint Disease, NY, USA., Sunnybrook Health Science, Toronto,Canada.