Arthroscopic surgery provides minimally invasive option for joint injuries
Hardly a week goes by without a report that a professional athlete’s season is in jeopardy because of a torn ACL or rotator cuff. But these joint injuries are not just for athletes; they can occur in laborers or weekend warriors who push themselves too hard.
Since the early 1990s, the primary treatment for these and many other joint ailments has been arthroscopic surgery. “It’s a minimally invasive method of evaluating, diagnosing and treating problems in almost all joints,” says Gordon Nuber, MD, clinical professor of orthopedic surgery at Northwestern University Feinberg School of Medicine.
Minimally invasive surgery
Orthopedic surgeons who practice the procedure use an arthroscope, a pencil-thin scope equipped with a camera. “It’s a fiber-optic viewing device that goes into the joint … so that you can visualize inside of the joint,” Nuber says.
To perform the procedure, surgeons make quarter-inch incisions — one for the arthroscope and usually two more for the instruments. With such small incisions, patients have faster recovery and rehabilitation periods. “Minimally invasive means less pain and more functionality immediately after the surgery,” Nuber says. Arthroscopic surgery is also less expensive than open surgery.
Arthroscopic surgery can be used to repair damage to the tissues found in joints, such as the tendons that connect the bones within a joint and the cartilage that covers the outside of a joint.
Like other minimally invasive procedures, arthroscopic surgery offers several advantages over open surgery, such as avoiding an overnight hospital stay. “Virtually all of these operations are done as outpatient procedures,” says Preston Wolin, MD, director of sports medicine at the Chicago Center for Orthopedics at Weiss Memorial Hospital.
Not just for athletes
Nuber and Wolin practice sports medicine (Nuber was the Chicago Bears team physician for 25 years; Wolin has been physician to many Chicago-area high school, collegiate and professional teams, including the Chicago Fire), so the joints they treat most often are the shoulder, knee and elbow. But arthroscopy can be used for almost every joint, they say, including the hip, wrist and ankle.
Injuries they often see are a tear of the rotator cuff at the shoulder or a tear of the meniscus, which Wolin describes as “the washer between the two bones of the knee.”
These injuries do not only afflict athletes. Laborers such as construction workers and agriculture workers are also prone to joint problems, Wolin says. “There is a lot of bending or kneeling in these occupations, which is hard on the knee.”
Wolin also sees shoulder injuries for people in sedentary jobs — office workerswho spend all day at a computer, often with bad posture. “It’s not at all uncommon to see people with shoulder problems who sit at their computers a lot,” he says.
Weekend warriors are also susceptible to joint injuries. “A lot of meniscal injuries can occur over time,” Wolin says. “We see that all the time in runners.”
Joint tissues may get torn in a sudden injury, such as a bad twist at the knee or a fall, or they may wear out gradually. “Many people tear their meniscus just walking down the street,” Nuber says.
Jamal Seale, a 37-year-old Chicago resident, believes his knee problems were a result of gradual wear from 20 years of playing soccer, combined with a sudden injury while playing basketball five years ago. After two arthroscopic procedures to repair tears to his meniscus, doctors noticed a more significant articular cartilage injury, Seale says.
Articular cartilage is the smooth tissue that covers the ends of bones where they come together at the joint. Seale spent the next two years consulting with orthopedic surgeons who told him he would need an invasive procedure that would require harvesting cartilage from elsewhere in his knee.
Then Wolin informed him of a new procedure where an articular cartilage transplant could be done arthroscopically. “Basically,” Wolin says, “you take out an area where the articular cartilage has been damaged [and] fill in with what’s called a plug, which eventually will become the patient’s articular cartilage.” It is part of a new frontier of treatments known as regenerative medicine.
In the three years since his surgery, Seale has not needed any more treatment for his knee. He now keeps active by running. “I’ve been able to do what
I want to do on a day-to-day basis,” he says. “To this point in time, I’ve been very pleased with the outcome.”
When to turn to arthroscopy
There are voices in the medical community that say arthroscopy might be overused. In a May 2017 article in The BMJ, an international panel of health experts strongly recommended against arthroscopy for patients with degenerative knee disease, primarily osteoarthritis.
For these patients, arthroscopic surgery seldom results in better outcomes compared with conservative treatments like physical therapy and medication anddoes not typically result in improvement in pain or function, the panel states.
Nuber agrees with the article’s findings for the most part, noting that osteoarthritis should be treated differently from a knee injury. “I think that most orthopedists, including arthroscopists, treat osteoarthritis very conservatively,” he says.
However, Nuber believes arthroscopy has a role in osteoarthritis treatment, such as when symptoms include a mechanical locking of the knee. It’s less invasive than a knee replacement, he says.
“I would say, though, that a majority of patients who don’t respond to conservative treatment would prefer to have an arthroscopy for mechanical symptoms long before jumping into having a total knee replacement, which is obviously a much more invasive procedure with much greater morbidity,” Nuber says.
Arthroscopic surgery continues to advance. Complete joint replacement requires open surgery, but short of that, most joint ailments can be treated with minimally invasive surgery, Wolin says. “There’s a huge number of reconstructive procedures we can do arthroscopically,” he says.
The higher the definition gets, the better we see. And the smaller the equipment gets, the more we can get into the recesses of the joints.
One of the newest procedures is the arthroscopic reconstruction of the four tendons that form the rotator cuff. For patients whose tendons are too severely damaged for repair, this spares them from needing a shoulder replacement. “The results so far have been very, very encouraging,” Wolin says.
A minimally invasive meniscus transplant may be a treatment option for tears in the knee. “It is a technically demanding procedure that replaces the missing meniscus with donor tissue, enabling athletes to stay active at least another 10 years,” Wolin says.
The technology continues to improve as arthroscopes get smaller and the cameras’ definition gets higher. “The higher the definition gets, the better we see,” Nuber says, “and the smaller the equipment gets, the more we can get into the recesses of the joints that we might not have been able to do years ago.”