Arthroscopic Procedures
Arthroscopy is a surgical procedure in which an arthroscope is inserted into a joint. Arthroscopy is a term that comes from two Greek words, arthro-, meaning joint, and -skopein, meaning to examine.
The benefits of arthroscopy involve smaller incisions, faster healing, a more rapid recovery, and less scarring. Arthroscopic surgical procedures are often performed on an outpatient basis and the patient is able to return home on the same day.
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Hip Arthroscopy
Indications for a Hip Arthroscopy:
Hip pain resulting from tears of the acetabular labrum or impingement on the femoral (Cam) or acetabular (Pincer) sides.
Discussion:
The acetabular labrum is a horseshoe-shaped cartilaginous structure attached to the peripheral rim of the acetabulum (socket) that adds depth to the hip joint. It is a different type of cartilage than that which lines the hip joint. Its function is to provide additional stability to the hip when moving the hip to the extremes of motion.
The labrum can tear suddenly as a result of a stumble or fall or by moving the hip to the extremes of motion or it can be torn gradually from repetitive stress. The patient may experience catching or clicking associated with discomfort on the front of the hip. Pain may worsen with long periods of sitting. Only 1/3 of patients recall trauma to the hip joint.
A labral tear can often occur if the hip socket is shallow or as a result of impingement. In this condition, the labrum is trying to compensate for insufficient bone covering the femoral head and it is bearing the majority of the load. In this type of “hip dysplasia”, repairing the labral tear is not indicated as it will not solve the underlying cause (i.e., shallow socket) and an osteotomy needs to be considered. It should be noted that pure labral tears with no underlying hip malformation are rare in comparison to other conditions that necessitate hip reconstruction.
Diagnosis:
On physical exam, a labral tear manifests itself when the range of motion is more than normal and there is pain either with hip flexion, internal rotation and adduction or extension in external rotation. General radiographs are initially reviewed to rule out hip dysplasia followed by an MRI with contrast injection (gadolinium enhancement). The MRI cannot detect all labral tears and, in fact, a “false-negative” result occurs in about 10% of cases.
Treatment and Post-Operative Recovery:
If the MRI is positive and the hip joint is properly formed then a hip arthroscopy is the procedure of choice. A hip arthroscopy can address the labral tear resulting in pain relief and a return to near normal function. Some patients (5%) do not experience full pain relief because of damage to the cartilage lining. The procedure is performed on an outpatient basis. The recovery is relatively simple in that the patient is on crutches for 1-2 weeks and they are able to bear full weight on the operated leg. 70%-90% of patients with labral tears who undergo hip arthroscopy report good to excellent results at three years.
If the MRI is negative yet hip pain persists, the hip is injected with a local anesthetic (marcaine) to confirm that the hip is the source of the pain. If the pain relief is complete, then an arthroscopy is still indicated since the MRI may not have detected the tear.
Exercises following hip arthroscopy
Stage I – Protected weight bearing
This should be followed whilst the patient is using walking aids, and may last 2 – 6 weeks depending on the level of surgical intervention. These exercises are aimed at restoring range of movement and maintaining muscle function whilst allowing tissue healing and pain to settle.
Stage II – Intermediate exercises
Once fully weight bearing and experiencing minimal levels of discomfort, these exercises e.g. squats and step-ups may be commenced with the guidance of the physiotherapists. Ideally range of movement in the involved
hip should be at least 80% of the uninvolved side. Exercises taught in this stage are aimed at restoring and maintaining movement, promoting normal walking patterns, strengthening muscle and improving balance reactions. There is a strong focus on core stability work at this stage.
Stage III – Advanced exercises
These exercises e.g. lunges should only be commenced when range of movement is full, walking is normal and pain free and muscle strength is greater than 70% of the uninvolved side in all directions. The goals of this stage are the restoration of muscular and cardiovascular endurance, and the improvement of balance reactions. Return to social sport should be possible at this stage.
Stage IV – Sports specific training
Not all patients require rehabilitation to this level. Those who take part in competitive sport will certainly benefit from further strengthening and more sports specific exercise. Training regimes for this stage should be developed in conjunction with sports club physiotherapists or personal trainers.
Knee Arthroscopy
Knee arthroscopy allows surgeons to look inside your knee, repair torn ligaments and remove damaged parts. Two small (~5mm) incisions are made on the front of the knee. A fiber optic camera is inserted in through one incision, and an instrument is inserted in through the other incision. The surgeon can then examine and repair the knee in ways that previously required large incisions and longer rehab. A knee scope is the most commonly performed orthopedic surgery today because of it relative ease and speed of surgery, quick return to function, and multitude of knee problems that can be addressed with a knee scope.
Most patients go home after a knee scope. The knee will likely be swollen for 3-5 days and patients may or may not require crutches for a few days. Most patients will not have restrictions after surgery. Patients can usually resume normal activities and return to work within 2-3 weeks. Pain medicine is usually prescribed for about 3-4 weeks as needed.
The most common indication for a knee scope is a meniscal tear. A meniscal tear is often referred to as a torn piece of cartilage. Typically, older patients have degenerative tears that are cleaned up (debrided), and younger patients have traumatic sports related injuries that may be either cleaned up or repaired. A meniscal tear that is treated without surgery will not likely injure the knee any further or cause arthritis, but may cause chronic pain in the knee. Surgery (knee scope) is therefore an option, but not a requirement.
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