Arthroscopy

Arthroscopy is currently the most dense method of diagnosing lesions of intraarticular structures. Arthroscopy is used to diagnose joint damage in cases where non-invasive methods of research are ineffective.

The value of arthroscopy is due to a number of factors:

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

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

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

During the diagnostic arthroscopy, when there are intra-articular changes that are amenable to a one-stage correction during an operation, diagnostic arthroscopy goes to the treatment arthroscopy.

In degenerative joint diseases, arthroscopy is performed most often on intraarticular structures and articular cartilage. In inflammatory diseases of joints, the object of exposure is usually the synovium.

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

• arthroscopic lavage and joint sanation;
• operations aimed at stimulating the restoration of the integumentary cartilage;
• operations on cartilage transplantation.

The therapeutic effect of arthroscopic sanitation and lavage is based on removal during the operation of damaged structures, evacuation of free intraarticular bodies, particles of cartilaginous tissue, inflammatory agents with water.

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

In recent years, methods for restoring true hyaline cartilage have been increasingly used. These methods are based on transplantation of autologous or allogeneic cartilage tissue into the damaged area.

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

What is arthroscopy for?

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

Indications for arthroscopy

Arthroscopic synovectomy is indicated for chronic synovitis, not susceptible to drug treatment for 6 months or more. In a number of works, it has been shown that, by eliminating a large inflammation focus, slow the progression of articular erosion and cartilage destruction. Due to the potential ability of synovectomy to prevent joint changes, some authors suggest that younger patients with x-ray changes perform synovectomy at an earlier time.

Contraindications to arthroscopy

Any damage to the skin in the field of arthroscopic access, infection of the skin. Infectious arthritis is not considered a contraindication to arthroscopy. On the contrary, at present, articular infection is an indication for arthroscopic sanitation. Relative contraindication to arthroscopy can be considered the final stages of deforming arthrosis, when the operation can be technically difficult. In addition, it was shown that in patients with severe joint damage (stage IV destruction) synovectomy gives an unacceptably high percentage of unsuccessful results.

[5], [6], [7]

How to prepare for arthroscopy?

Arthroscopy, despite the low invasiveness, is still an operation, therefore, in the preoperative period, a patient is examined to assess the overall somatic condition, and operational and anesthetic risks are assessed.

How is arthroscopy performed?

The operation of arthroscopy is performed under local, regional or general anesthesia. The choice of the method of anesthesia depends on the patient's physical and psychological state, on the amount of surgical intervention. When operating on the joints of the lower extremities, spinal anesthesia is often used, which provides good muscle relaxation and eliminates discomfort when using a tourniquet, with local anesthesia this effect can not be achieved.

Arthroscopy is performed using a pneumatic turnstile in the position of the patient lying on the blue. The operated limb can be placed in a special fixator and bent at an angle of 90 °. Diagnostic arthroscopy is most often performed from the standard anterior and antero-internal approaches located 1 cm above the joint gap and 1 cm lateral to the medial edge of the patellar ligament. When performing therapeutic arthroscopy, depending on the location of pathological changes, additional arthroscopic portals can be used, such as posteromedial, posterolateral, supermedial, topolateral, and others.

Arthroscopic synovectomy allows solving some problems that surgeons face with open synovectomy, radical resection and postoperative complications. If you use additional portals and optics with different angles of view, you can work in any part of the joint under direct visual control. As with the open procedure, the removal of synovia is facilitated by the separation of the internal synovial layer from the subject. This can be done with a motorized boron.

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

Operational characteristics

The effectiveness of arthroscopic synovectomy for today is shown in many works. In a study conducted in 84 patients with rheumatoid arthritis, it was shown that after arthroscopic synovectomy, by the end of the fifth year of observation, there was a significant reduction in pain syndrome, improved joint function, and no signs of local inflammation. In another work, after 3 years of observation, 90% of good results were noted, but by the end of the fifth year the percentage of positive outcomes decreased to 75%. Despite the variability of clinical data, in general, in most studies 2 years after surgery, clinical remission is noted. Taking into account the low traumatism and low percentage of complications, arthroscopic synovectomy can be considered a method of choice in the treatment of persistent recurrent synovitis of the knee joint. 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 much less, and as a consequence, the intensity of the pain syndrome decreases, the duration of drug treatment, rehabilitation and hospitalization is reduced. In connection with the decrease in the intensity of postoperative pain syndrome, the risk of developing contractures and the need to use physiotherapy and physiotherapy exercises.

But according to various studies conducted in different countries, the number of complications after arthroscopy is 1 to 2%. Thus, in one study the risk of complications was less than 1%, and in the work evaluating the results of 8791 operations, the complication rate was 1.85%. The purest complication is hemarthrosis, the second purest complication of infection. In one of the multicenter prospective studies, it was shown that the incidence of infectious complications reached 0.2% (one for 500 operations). Thromboembolism and anesthesia are also relatively common complications. Their frequency is on average 0.1% (one per 1000 operations). Of the other complications, damage to blood vessels and nerves, thrombophlebitis, stiffness and loss of movement in the joint, damage from compression by the turnstile are noted. About possible complications, the patient must be informed before the operation.

It is necessary to understand that arthroscopy alone is a safe and effective operation only with a competent approach.