CONSULTANT, KNEE AND SHOULDER SURGERY
Mr Nitin Kumar Jha,
"I'm extremely satisfied by the treatment given by Dr Shekhar Srivastav...
Dr Rajeev Gupta, Dental Surgeon
"I had problem of repeated dislocation & Pain of my Rt. Shoulder following trauma....
I would like to thank u and ur entire team for my speedy recovery. The way u and ur staff handled my knee...
We offer a wide assortment of video patient education for surgical specialties.
Knee Education
HOW NORMAL KNEE WORKS?
The knee is the largest joint in the body, and one of the most easily injured. It is made up of the lower end of the thigh bone (femur), the upper end of the shin bone (tibia), and the knee cap (patella), which slides in a groove on the end of the femur. Four bands of tissue, the anterior and posterior cruciate ligaments, and the medial and lateral collateral ligaments connect the femur and the tibia and provide joint stability. Strong thigh muscles give the knee strength and mobility.

The surfaces where the femur, tibia and patella touch are covered with articular cartilage, a smooth substance that cushions the bones and enables them to glide freely. Semicircular rings of tough fibrous-cartilage tissue called the lateral and medial menisci act as shock absorbers and stabilizers.

The bones of the knee are surrounded by a thin, smooth capsule which is lined by a thin synovial membrane which releases a special fluid that lubricates the knee, reducing friction to nearly zero in a healthy knee.
WHAT IS ARTHROSCOPY
Arthroscopy is a procedure by which various joints in the body (Knee, Shoulder, Ankle, Hip & Wrist) can be inspected and treatment given by a small pencil shaped instrument called arthroscope (Telescope). This is a keyhole incision surgery where two single stitch incisions (Pic. 2). are usually enough to treat any problem which would have normally required a large incision ( Pic.3). This has been made possible by technological advancement in Bio-engineering field. The small instruments (biters, shaver, probes, scissors etc.) also measuring 2 to 5 millimeters, are placed into the joint through separate incisions to remove torn cartilage, trim torn structures, or do other procedures.
               
WHO NEEDS ARTHROSCOPIC SURGERY ?
Arthroscopy is frequently required in young patients having knee problems following injury during sports, road accidents or fall in day to day activities. In older persons it may be helpful in arthritic patients having torn meniscus, loose cartilage or loose bone pieces.

Signs that you may be a candidate for this procedure include swelling, persistent pain, catching, giving-way, and loss of confidence in your knee. When other treatments such as the regular use of medications, knee supports, and physical therapy have provided minimal or no improvement, you may benefit from arthroscopy.

IN WHICH CONDITIONS CAN ARTHROSCOPY BE HELPFUL?
Common conditions which can be treated by knee arthroscopy include:-
  Removal or repair of torn meniscal cartilage
  Reconstruction of torn cruciate ligament
  Trimming of torn pieces of articular cartilage
  Removal of loose fragments of bone or cartilage
  Removal of inflamed synovial tissue.

HOW IS ARTHROSCOPY PERFORMED ?
Arthroscopic surgery, although much easier in terms of recovery than "open" surgery, still requires the use of anaesthetics and the special equipment in a hospital operating room. After arrival, you will be evaluated by a member of the anesthesia team. Arthroscopy can be performed under local, regional, or general anesthesia. Local anesthesia numbs your knee, regional anesthesia numbs you below your waist, and general anesthesia puts you to sleep. The anesthesiologist will help you determine which would be the best for you. The orthopaedic surgeon will make a few small incisions in your knee. A sterile solution will be used to fill the knee joint and rinse away any cloudy fluid, providing a clear view of your knee. The surgeon will then insert the arthroscope (telescope) to properly diagnose your problem, using the TV image to guide the arthroscope. If surgical treatment is needed, the surgeon can use a variety of small surgical instruments (e.g., scissors, biters, motorized shavers, or lasers) through another small incision(pic.5,6).After arthroscopic surgery, the small incisions will be covered with a dressing. You will be moved from the operating room to a recovery room. Many patients need little or no pain medications.

WHAT WILL BE THE DURATION OF HOSPITAL STAY ?
Most of the arthroscopic procedures are performed on day care basis and the patients are usually ready to go home same evening. In cases where ligament reconstructions are performed the patient is discharged within two to three days.

WHAT IS A MENISCUS TEAR?
The meniscus is a specialized structure that is thicker where it attaches to the lining of the joint and thinner toward the middle of the joint. If you made a cut across it, the meniscus would be triangular or pie shaped.

The meniscus can tear in a number of ways. Tears can result from a sudden twisting-type injury or can occur gradually with age. The tear can be through either the outer thick part or inner thin part. Some tears involve only a small portion of the meniscus, while in others nearly the entire meniscus can be involved.

Meniscus tears can cause symptoms from portions of the torn fragments getting stuck or pulled in between the bones as the knee moves. This can cause snapping or popping, locking, pain, and swelling. Not all meniscus tears cause problems, but when they do the arthroscope can be used to trim out the piece which is torn. Only the portion which is torn is removed(pic.7,8).

CAN THE MENISCUS BE FIXED?
The ability of a meniscus tear to heal depends primarily on its blood supply. The outer or thicker part of the meniscus receives a fairly good blood supply from the lining of the joint, whereas the inner or thin part has a poor blood supply. Thus, tears at the outer margin of the meniscus are more amenable to successful repair which can be done by placing sutures across the tear by arthroscopic techniques. If the tear is in the thin part, the cartilage will not heal and the torn fragment is typically excised. Old or chronic tears also tend to have a poorer success rate with repair and are typically trimmed out as well.

WHAT IS LIGAMENT RECONSTRUCTION ( ACL ) ?
Ligament reconstruction involves replacing the torn ligament with a tendon (graft) from your knee or a synthetic material, and attaching the graft in place with screws. This procedure is performed with the use of the arthroscope. The anterior cruciate ligament (ACL) is the most common ligament requiring reconstruction procedures. The torn ligament is excised arthroscopically and new ligament is prepared by ligament grafts taken from your own body. Bony tunnels are prepared in femur and tibia using specialized instruments through which the new ligament is passed and fixed with special screws. This procedure requires relative rest or leave from your work or studies for about 3 weeks after which you will be allowed normal day to day activities.

CAN OTHER LIGAMENTS OF KNEE BE ALSO RECONSTRUCTED?
Yes. Though ACL is the most common ligament to be reconstructed in knee, but other ligaments such as PCL or collateral ligaments if torn and causing symptoms in a patient can also be reconstructed. Most of them can be reconstructed arthroscopically but reconstruction of collateral ligaments is usually done by open procedure. Multiple ligament injuries can be treated by combined procedures (both arthroscopic and open). The post op protocol and rehabilitation varies according to the type of injury.

WHAT IF THERE IS ARTHRITIS ?
Arthroscopic surgery is very successful in relieving the pain and swelling from a torn meniscal cartilage. However, the results of arthroscopic surgery for arthritis alone are somewhat unpredictable. While it is relatively easy to excise or repair a torn meniscus, not much can be done if the articular cartilage is significantly frayed or worn from the ends of the bones (arthritis). Current technology does not allow surgical repair or regeneration of the surface cartilage. In some select cases where only a small area (around one centimeter) of cartilage is missing from the ends of the bones, the bone can be drilled to stimulate a scar to form on the end of the bone. This scar may reduce the pain but it is not as good as normal cartilage. Overall, the results of arthroscopy in arthritic knee is unpredictable and is helpful in only those cases where there are mechanical symptoms due to torn meniscus or loose bodies.

WHAT HAPPENS WHEN I GO HOME ?
Recovery from arthroscopy is much faster than recovery from traditional 'open' joint surgeries. Still it is important to follow instructions carefully after you return home.

Swelling : keep the operated limb elevated as much as possible for first few days. Apply ice as recommended by your doctor to relieve swelling and pain.

Wound care : Keep your wound and dressing clean and dry. Your wound should not come in contact with water. Change any bandage immediately if it becomes wet or bloody.

Activity : After most arthroscopic surgeries you can walk unassisted, but your surgeon may advise you to use a brace, crutches, a cane or a walker for a limited period of time after surgery. You can gradually put more weight on your leg as your discomfort subsides.

Medications : You may require pain medications for first few days. Antibiotics may be prescribed in major reconstructions surgeries.

Complications : Potential post operative problems with arthroscopy surgery include infections, blood clots in the legs and an accumulation of blood in the joint. These complications occur infrequently and are minor and easily treatable.

Warning signs : If you notice any of the following, call the concerned orthopaedic surgeon or orthopaedic duty doctor at Sant Parmanand Hospital
. Fever
. Chills
. Persistent warmth or redness around the operated joint
. Persistent or increased pain
. Excessive bleeding
. Tingling or numbness

Rehabilitation programme :Hospital physical therapist will instruct you for ambulation, range of motion and muscle strengthening exercises. Your doctor will specify when you should begin an exercise programme to gain motion and to strengthen muscles around the joint e.g. two commonly used exercises to strengthen the muscles above your knee are : quadriceps setting and straight leg raising exercises.

WHAT ARE THE ADVANTAGES OF ARTHROSCOPIC SURGERY OVER OPEN SURGERY ?
Arthroscopy is a blood less surgery. It has very less morbidity compared to 'open' joint surgery. This has resulted in less pain and stiffness, fewer complications, decreased length (if any) of hospitalization as most of the arthroscopic procedures are done as "Day care surgery'. The small incisions are closed by single stitch and most of patients are discharged walking same evening of surgery and has faster recovery times.

WHAT ARE THE POSSIBLE COMPLICATIONS ?
Although uncommon, complications do occur occasionally during or following arthroscopy. Infection, phlebitis (blood clots of a vein), excessive swelling or bleeding, damage to blood vessels or nerves and instrument breakage are the possible complications but occur in far less than 1 percent of all arthroscopic procedures.

WHEN DO I COME FOR FOLLOW-UP?
Follow up visits are necessary for your doctor to chart progress, change bandages, check for any complications and evaluate your rehabilitation. Your first follow-up would be within a week of arthroscopy when we change the dressing, aspirate the joint, if any effusion is present. Second follow-up will be after 2 weeks of surgery, when we will remove the stiches and see the progress of joint movement and teach other exercises. Thereafter you will be called as per requirement of surgery performed.

WHAT ARE THE REASONABLE EXPECTATIONS AFTER ARTHROSCOPIC SURGERY?
Although arthroscopy can be used to treat many problems, the outcome of your surgery will often be determined by the degree of injury or damage found in the your joint. For example surgery done for meniscal tear or loose bodies when the patient has no other problem (like arthritis) is usually uncomplicated and most patient can expect full recovery. Arthroscopic removal of synovium can be of great benefit to patients with rheumatoid arthritis. Arthroscopic reconstruction of ligament and repair of meniscus in the knee is much more complicated with prolonged recovery and more variable results.

Remember, that people who have arthroscopy can have many different diagnosis and pre- existing conditions. So each patient's arthroscopic surgery is unique to that person. Recovery time will reflect that individuality.

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