The field of arthroscopic surgery has experienced a number of incredible advances in the last few years. Through the latest techniques, it is now possible for surgeons to make smaller incisions; with less tissue dissection, surgeries now have a higher success rate, and patients enjoy a faster recovery time. In order to fully appreciate the latest advances in this form of surgery, we first need to explain what it is and look back at its history. Once this has been covered, this article examines the most common types of arthroscopic surgery and discusses the impact of new technology and techniques.
What Is Arthroscopy?
It is essentially a surgical procedure used by orthopaedic surgeons to see, diagnose, and treat any problems found inside a joint. The word comes from the Greek “arthro” (which means joint) and “skopein” (which means to look). During an examination of this nature, a surgeon will create a tiny incision into a patient’s skin before inserting miniature instruments containing a lighting system and a small lens. This makes it easier to see inside the joint since its structures are both magnified and illuminated.
Light is transmitted through fiber optics to the end of the arthroscope. As it is attached to a television camera, the surgeon can see the interior of the joint through the tiny incision. The surgeon can inspect the cartilage and ligaments and can even see beneath the kneecap, for example. This makes it easy for an experienced surgeon to accurately diagnose problems and work on fixing them. The small incision means less damage and a substantially faster recovery time.
How Is It Performed?
Though arthroscopic surgery is easier on the body than “open” surgery, patients still need some form of anesthetic, which depends on where the surgical site is. A tiny incision will be made so the arthroscope can be inserted. It is possible there will be several other incisions made in order to see other areas of the joint or to insert further instruments.
At one time, an arthroscope was only used as a diagnostic tool for the planning of open surgery. With the improvement in surgical techniques and instrumentation, an increasing number of conditions can be treated via arthroscopic surgery. For example, it is increasingly common to treat the majority of meniscal tears using arthroscopic surgery.
Once the procedure has been completed, a dressing will be used to cover the incision(s). Patients will then be taken to a recovery room, but many people don’t require any form of pain medication. Prior to being discharged, your surgeon will provide you with details of how to care for the incisions and also give you a list of exercises to perform in order to speed up recovery. There will be a follow-up appointment where the surgeon inspects the incisions and removes any sutures before discussing your rehabilitation program.
In most cases, the tiny puncture wounds only take a few days to heal. The dressing is normally removed the day after the procedure, and adhesive strips are placed over the wounds. Though there is little pain felt in the aftermath of the surgery and the wounds heal very quickly, the joint may still take some time to recover 100 percent.
The aforementioned rehabilitation program that patients are prescribed is designed to speed up this process. Although arthroscopic surgery is producing incredible results, there is still no accounting for individual recovery time. Those who are already in good physical condition will recover much faster than individuals who do not partake in athletic activity.
History of Arthroscopy
Few orthopaedic advances in the last 100 years can match the impression arthroscopic surgery has made on the medical landscape. The first instance of this kind of surgery occurred in 1918 when Professor Kenji Takagi performed an arthroscopy on a cadaver knee using a cystoscope. In the 1950s, a student of Takagi’s by the name of Dr. Masaki Watanabe helped to improve the field of arthroscopy.
He helped develop arthroscopes so they could be used to examine joints and published the “Atlas of Arthroscopy” along with several colleagues. At around the same time, Dr. Eugene Bircher began using arthroscopes on live patients in the United States and published the results of these surgeries. By the 1980s, it was possible to use arthroscopes for surgery, and a host of new techniques and implements were developed on the back of it. To date, shoulder and knee joints have gained the most benefit. With greater experience and improved simulation training models, the learning curve for arthroscopic surgery has also decreased, and this can only be good news for the future.
Advances in Arthroscopy
Recent improvements in 3D imaging, surgical techniques, and instrumentation mean surgeons can now perform what were once “open surgeries” through arthroscopy. Now it is possible to perform surgery for hip problems without making large incisions or dislocating the hip.
Hip arthroscopy is demanding due to the large complex of muscles crossing the joint, but new technological advances are making it easier than ever to reduce the level of difficulty involved. Here is a look at some hip arthroscopy advances.
Internal Snapping Hip Syndrome
Patients suffering from this problem experience a nasty sensation of pain due to the iliopsoas tendon slipping once it crosses the anterior femoral head or iliopectineal eminence. Thanks to advanced techniques in the field of hip arthroscopy, the surgeon is able to pass through the hip’s central compartment during surgery and make a tiny window to locate and release the tendon.
Treatment of the Capsule
Previously, surgeons had to cut through the capsule and remove significant amounts of it in order to reach the hip. With the new advances in arthroscopic operations, surgeons are able to close the capsule once it has been cut. The result is the minimization of capsule that has to be cut out, so the patient enjoys better stabilization of the hip.
The Hana Table
This has been marketed as a “surgeon’s assistant” because of its ability to reduce the recovery times of patients. It is a rotating table that enables surgeons to perform minimally invasive surgery. It is specifically designed for hip and knee arthroscopy and allows external rotation and hyperextension during hip replacement.
Thanks to the Hana table, surgeons can position patients to ensure no muscles are cut, which means an incision of 5 inches or less is now possible. Before this innovation, incisions of at least 10 inches were required. Surgeons can reach the hip joint from the front instead of the back or from the side, so this minimizes trauma under the skin. By going between the muscles, surgeons leave the back and side tissues alone, thus improving stability after surgery and decreasing the patient’s stay in the hospital. It is not unusual for patients to be allowed to leave a medical facility within 48 hours of having the surgery.
The da Vinci Surgical System
This is undoubtedly one of the most spoken-about advances in the field of arthroscopy. It is a robot platform that allows surgeons to perform procedures in more comfort and with an extraordinary degree of accuracy. It was approved by the Food and Drug Administration (FDA) in 2000, and to date an estimated 1.5 million procedures have been performed using the da Vinci Surgical System. Only a few thousand systems have been sold, and with a price tag of around $2 million for the Si version of the system, this is hardly a surprise. Yet it would appear that this is money well spent, because the results it produces are amazing.
The console is located in the same room as the patient, and there is a cart beside the patient with four robotic arms. The surgeon controls the arms from the console; three of the arms are designed to hold instruments such as scalpels and scissors. The joint-wristed design of the robotic hands greatly exceeds a human’s natural range of motion, thus ensuring a higher degree of accuracy. The surgeon takes up a seated position at the console, and his or her eyes and hands remain in line with the instruments; the surgeon also only needs to move his or her hands to move the instruments. The result is greater accuracy, smaller incisions, less blood loss in the patient, and improved recovery time.
Mazor Robotics Renaissance System
This is another technological advance designed to reduce recovery time by making surgeons more accurate during procedures. It is specifically designed for spinal surgery, and to date the system has been used successfully in tens of thousands of cases all over the world. It utilizes image-based planning and guided instrumentation to ensure spinal surgeries are accurate to an astonishing 1.5 mm!
The Renaissance model has a guidance system with six legs, a workstation, and 3D pre-planning software, which can run on a workstation or even a personal computer. Typically, a procedure using the Renaissance model looks something like this:
- Planning: Each patient has different needs, so a unique blueprint is laid out in a virtual 3D environment.
- Mounting: Due to the rigid attachment to each patient, you can be sure there will be maximum accuracy during the procedure.
- Syncing: The mounting system is instantly synchronized with the surgical blueprint as two fluoroscopy images are shown.
- Operating: All implants and tools are used to operate on the site to an incredible level of accuracy.
Given the incredible innovations we have already seen, it almost feels greedy to be considering the future, since we should be enjoying the advances we already have. However, the medical field must continue to march forward and push the boundaries of modern science.
Clearly, the future of arthroscopic surgery depends on further advances in both biology and technology. We’re already seeing the implementation of tissue engineering, as it is being used in surgery. It is likely we will see tendon and muscle tissue engineering in the near future since there are numerous studies and tests already taking place. We would expect arthroscopy to involve the insertion of these tissues when they become available.
We are already seeing needle arthroscopes that are roughly the size of an 18-gauge needle. Soon it will be possible to perform certain procedures in a doctor’s office under local anesthetic.
Imagine having surgery without the need for any scarring whatsoever. You would be forgiven for thinking this is the stuff of science fiction, but it could be possible by combining the technologies already in place. Perhaps one day we will be able to inject nanobots into the shoulder joint, for example. Nanobots are carbon-based robots that are less than 100 nanometers in size (hence the name); they are so small it is impossible to see them with the naked eye.
Theoretically, it could be possible to have nanobots equipped with cameras, which would allow us to watch and control them. The injected ethylene monomer molecules could be manipulated and placed in the joint’s damaged regions. The monomer then would be irradiated by a small gamma emitter found inside the nanobot. The result would be free-radical polymerization that causes the monomers to combine and form a substance that is strong and flexible enough to patch up the damaged area. The body’s lymph system could then remove the nanobots within a few days.
Obviously, this is a long way into the future and probably seems far-fetched. Then again, few people would have thought we would be using robots to complete complex surgeries just 20 years ago.
The possibilities with arthroscopic surgery seem to be almost endless. We have already entered a golden age, and who knows what the future holds? Even if the aforementioned nanobot technology doesn’t materialize in the scenario outlined above, further advances are inevitable. As things stand, arthroscopic surgery is in a great place and has the ability to repair a damaged body with minimal muscle tissue damage and reduced recovery time.