Minimally Invasive Orthopedic Surgery: Arthroscopy Robert Treuting, MD Department of Surgery, Ochsner Clinic and Alton Ochsner Medical Foundation, New Orleans, LA Arthroscopy,aminimallyinvasivealternativetostandardopensurgicaltechniquesandnowthemostcommonly performedorthopedicsurgicalprocedure,wasoneofthegreatestadvancesinorthopedicsurgeryofthe20 th century.Minimallyinvasivesurgeriesresultinlesspostoperativeswellingthanopentechniquesandreduce pain,riskofcomplications,andrecoverytimes.Arthroscopyhasevolvedfromadiagnostictooltoatherapeutic toolcapableoftreatingawiderangeofinjuriesanddisorders.Manyinjuries,particularlythosethatatonetime wouldhavebeencareerendingforathletes,cannowbeaddressedwitharthroscopyallowingaquickerreturnto fullfunction.Whilearthroscopyhasresultedinanoveralldecreaseinmorbiditycomparedwithopentechniques, itisstillaninvasiveprocedureandinherentlyinvolvesrisks.Almostallarthroscopicprocedurescanbeperformed inanoutpatientsetting.In1999,211arthroscopicprocedureswereperformedatOchsner. TreutingR.Minimallyinvasiveorthopedicsurgery:arthroscopy.TheOchsnerJournal2000;2:158-163. rthopedicsurgery,likeallfieldsofmedicine,experienced outbreakofWorldWarII.In1921,Bircher(1882-1956)useda tremendousprogressinthe20thcentury.Alongwithan modifiedJacobaeuslaparoscopetovisualizetheinteriorofthe O improvedunderstandingofbasicmolecular,cellular, kneein18patientsinSwitzerlandandlaterpublishedhisfindings genetic,andbiomechanicalfactorsofthemusculoskeletalsystem, onposttraumaticarthritisandthediagnosisofmeniscalpathology jointreplacementsurgeryandarthroscopicsurgerywerethetwo (1).Kneuscher(1884-1943)publishedthefirstarticleon mostimportantinnovationsinorthopedicsurgeryinthelast100 arthroscopyintheUnitedStatesin1925butfailedtopursuehis years.Theseinnovations,madepossiblebyadvancesin studiesfurther(3).In1930,Burman(1901-1975)oftheHospital technology,willcontinuetoimproveoutcomesoftreatmentand forJointDiseaseinNewYorkcarriedoutextensivestudiesin expandtheindicationsforusageastechnologyadvances. cadaversusingthearthroscopetoexamineeveryjointinthebody (4).Burmanpublishedhisfindingsin1931,butclinicaltrialsof History hismethodsweremetwithskepticismandfailedtocreateinterest Theoriginsofarthroscopyreachbacktothe19 thcentury inthemethod.Takagi’sstudentWatanabe(1921-1994)continued when,in1879,Nitze(1848-1706)devisedthefirstmodern Takagi’sworkinthedevelopmentofthearthroscopeafterWorld cystoscopeanddemonstratedthatitwaspossibletoperform WarII.In1957,heintroducedoperativetechniquesusing operationsthroughthisinstrument(1).Jacobaeus(1879-1937) arthroscopicvisionwiththepublicationoftheAtlasofArthroscopy adaptedthecystoscopefortheexaminationofthepleuraland (5).Ayearlater,WatanabereleasedtheWatanabe#21,thefirst peritonealcavitiesin1910(1).Eightyearslater,Takagi(1888- trulysuccessfularthroscope,signalingthecomingofagefor 1963)ofTokyoUniversitybecamethefirsttoapplytheprinciples modernarthroscopy. ofendoscopytoakneejointwhenheintroducedacystoscope In1964,Dr.RobertJacksonwenttoTokyoonfellowshipto intoacadaverknee(2).ProfessorTakagicontinuedtodevelop studytissueculturetechnique.Aftermeetingandobserving thearthroscopeinJapanuntilhisstudiesweredisruptedbythe Watanabe,Jacksonwasconvincedthatarthroscopyofferedamajor 158 TheOchsnerJournal TreutingR contributioninthediagnosisandtreatmentofjointdisorders. outpatientsetting.Somearthroscopistsevenhavethefacilities ReturningtoTorontoGeneralHospitalin1965withaWatanabe toperformproceduresinanofficesetting,furtherreducing #21arthroscope,JacksonbegantopracticearthroscopyinNorth costs.Arthroscopycanbeperformedundermanyoptionsof AmericaandpublishedthefirstEnglishtextonthesubjectin1976 anesthesiarangingfromlocaltogeneral.Choiceofanesthesia (6).TheUniversityofPennsylvaniahadofferedthefirstmajor variesdependingonthenatureoftheprocedureand educationalcourseonarthroscopytheyearbefore.The preferencesofthepatientandphysician. introductionoffiberopticsandminiaturetelevisioncamerasin 1972wasthemajortechnologicaldevelopmentthatledtothe Complications currentwidespreaduseofarthroscopy,andcontinuedtechnologic Aswithanyinvasiveprocedure,complicationscanoccur development(ofinstruments,fiberoptics,electronics,lasers,etc.) witharthroscopy,nowthemostcommonlyperformed hasexpandedtherangeofavailabletechniquesandindications. orthopedicprocedure.A1983nationalsurveyof118,590 proceduresreported930complications—anincidenceof0.8% Benefits (7).Inthissurvey,equipmentfailureaccountedfor17%of Priortothewidespreadclinicaluseofarthroscopyandits complicationsreportedwhilevascularinjuriesaccountedfor specializedinstrumentation,jointsurgeryrequiredextended 1%.Arthroscopyisatechnicalprocedurerequiringawiderange incisionsandarthrotomiesforexposureandtreatmentofjoint ofequipment(cameraandmonitor,surgicalequipment,pump, pathology.Arthroscopyoffersseveraladvantagesoversuch tourniquet,etc.)thatcanmalfunctionorbreakduringa extendedopenarthrotomies.Comparedwithminimallyinvasive procedure.Thesurgeonshouldbefamiliarwiththeequipment arthroscopicprocedures,theextendedexposureofjointsprolongs anduseitonlyforitsintendedpurposes.Anesthesiaproblems recoveryandincreasespainandriskofcomplications,suchas canalsooccur,butthisisnotuniquetoarthroscopicsurgery. infectionandarthrofibrosis.Minimallyinvasivesurgeries,in Whenarthroscopicsurgeryisperformedinanofficesetting, general,resultinlesspainandpostoperativeswellingthanopen thesurgeonmustbepreparedforanypotentialanesthesia techniques.Asaresult,arthroscopicallytreatedpatientstendto problemsthatmightarise. healfasterandbeginrehabilitationearlierand,subsequently, Othercomplicationsincludehemarthrosis, returntonormalactivityandworksooner. thrombophlebitis,arterialinjury,nerveinjury,compartment Astechniquesandindicationsfortreatmenthaveexpanded, syndrome,andinfectionandmetaboliccomplicationsinpatients injuries,particularlythoseinathletesthatatonetimewouldhave withmetabolicdiseases(diabetes,gout)orthoseusingsteroids. beencareerending,cannowbeaddressedwitharthroscopy Whilearthroscopyhasresultedinanoveralldecreasein allowingpatientstoreturntofullfunction.Examplesinclude morbiditycomparedwithopentechniques,itisstillaninvasive anteriorcruciatekneeligamentinjuriesinrunningathletesand procedureandinherentlyinvolvesrisks. intra-articularshoulderpathologyinthrowingathletes.While theseproblemscanbeaddressedwith extendedopentechniques,the comorbidityassociatedwithopen proceduresoftenpreventssuchpatients fromreturningtotheirpre-injury functionalstatus.Forprofessionalathletes, thesetypesofinjuriesmoreoftenledto theendoftheirpayingcareers. Anothersocioeconomicbenefitof Figure 1. Dr. Lock Ochsner performs a arthroscopyisthatalmostallarthroscopic knee arthroscopy. procedurescanbeperformedinan Volume2,Number3,July2000 159 MinimallyInvasiveOrthopedicSurgery Clinical Applications necessary.Asequipmentandtechniquesimproved,arthroscopy Thekneewasthemodeljointforthedevelopmentof becameasurgicaltoolinitsownright(Figure1),reducingthe arthroscopy,andtheevolutionofthearthroscopefrom comorbidityofjointsurgery. diagnostictooltotherapeutictooliscommontoitsapplication tootherjoints.Thearthroscopewasinitiallyusedtoclearly The Knee identifyspecificintra-articularpathology,therebyassisting Themeniscioftheknee,thesemi-lunarshockabsorbing treatmentmanagement.Iftreatmentrequiredsurgerytoaddress cartilagebetweenthefemurandtibia,werethefocusofmostearly pathologysuchasmeniscaltears,openarthrotomieswere kneearthroscopists(3).Priortoarthroscopy,totalmenisectomy wasadvocatedformeniscaltears,anditwasfeltthatanew meniscuswouldregeneratesimilartotheoriginal(8). Subsequently,theuseofarthroscopyhasshownthatpartial meniscectomiesforamenabletearsprovidebettershort-andlong- termfunctionalresultsandlessarthriticchangesthantotal meniscectomies(9).Currently,meniscalsurgeryoftheknee (Figure2)isthemostcommonlyperformedarthroscopic procedure.Peripheraltearsofthemeniscimaybeamenableto repairandtodaycanbeperformedcompletelyarthroscopically byexperiencedorthopedicsurgeons. Withthepopularityofathletics,theadventofarthroscopy Figure 2a. Knee arthroscopy demonstrating degenerative meniscus tear. hasbroughtthetreatmentoftheanteriorcruciateligament(ACL) ofthekneetotheforefrontofmodernorthopedics.Atonetime, anACLinjurycouldbecareerendingforaprofessionalathlete. TodayboththeACLandtheposteriorcruciateligamentcanbe reconstructedthroughanarthroscope.Suchproceduresnow allowallathletes,fromprofessionalstoweekendwarriors,toreturn topre-injurylevelsofactivitywithappropriaterehabilitation. Theindicationsforkneearthroscopyarenumerousand continuetoexpand.Arthroscopyhasproventobeabeneficial, temporizing,andtherapeuticprocedureforthetreatmentof osteoarthritis(10).Kneearthroscopyforosteoarthritisoffersan Figure 2b. Partial meniscectomy. alternativepainreliefoptionforpatientswhoarenotreadyorare unwillingtoundergoamajorsurgicalproceduresuchasknee replacementsurgery.Arthroscopicsynovectomyofthekneesin patientswithrheumatoidarthritisandotherhypertrophicsynovial- producingsyndromeshassignificantlyreducedcomplicationsand improvedoutcomescomparedwithopensynovectomiesofthe knee(11).Osteochondralinjuriesandosteochondritisdessicans lesionsofthekneecanberepairedanddrilled(Figure3)to stimulatefibrocartilaginoushealing,anddissociatedloosebodies (Figure4)caneasilyberemovedbyarthroscopy. Kneearthroscopycanalsobeusedasanadjunctinassessing Figure 2c. Postmeniscectomy. theintra-articularreductionoftibialplateaufracturesandintra- 160 TheOchsnerJournal TreutingR Figure 3. Drilling Figure 5a. osteochondral Noninvasive defect to ankle distraction stimulate system allowing fibrocartilaginous improved access healing. in ankle arthroscopy.