Arthroscopic Surgery: Everything You Need to Know

Arthroscopic surgery, also known simply as arthroscopy, is a minimally invasive orthopedic procedure used to diagnose and treat joint problems. It involves the use of a narrow scope, called an arthroscope, and specialized surgical tools to access a joint through tiny "keyhole" incisions. Because arthroscopic surgery requires smaller incisions than open surgery, recovery times tend to be shorter.

Arthroscopy has become an increasingly attractive alternative to traditional procedures, but may not be appropriate in all cases.

What Is Arthroscopic Surgery?

Arthroscopy is not one procedure, but rather a surgical approach that can be used for many different procedures used to diagnose a joint problem or treat acute and chronic joint conditions. (Arthro- meaning "joint" and -scopy meaning to "study or examination.")

These procedures have been performed as early as 1912, but it was only in 1959 that the first production arthroscope (named the Watanabe 2 after its inventor, Dr. Masaki Watanabe) was introduced.

Today, arthroscopic surgery is considered both commonplace and indispensable, enabling outpatient treatment where hospitalization was once needed. In fact, arthroscopic surgery is considered a fundamental part of orthopedic resident training and the standard of care for many joint problems.

The arthroscope that is used transmits live visuals to a monitor so that the surgeon can view the area to be operated on without actually seeing it directly. This only requires an incision about the size of a buttonhole, meaning arthroscopic procedures are not as complicated or risky as open procedures.

The tools used to perform arthroscopic procedures are also smaller and narrower than the scalpels and surgical equipment used in open surgery.

Contraindications

There are few absolute contraindications to arthroscopic surgery other than those related to surgery in general.

Arthroscopic surgery should be delayed if there is local soft-tissue infection around the joint. Arthroscopic procedures are also often avoided if there is poor blood circulation that may impede healing (particularly in the lower extremities).

One absolute contraindication for arthroscopy is a severe degenerative joint disease, such as advanced osteoarthritis, in which the joint cartilage is fully denuded (stripped). The use of arthroscopy may cause more harm than good in such cases compared to open surgery.

Similar concerns are warranted if the joint space has narrowed excessively beyond expected limits. The appropriateness of arthroscopic versus open surgery needs to be weighed on a case-by-case basis.

Potential Risks

Arthroscopic surgery is generally considered safe with relatively few complications. With that said, arthroscopy is an indirect way of visualizing joints, and there is a potential for tissue and nerve injury as instruments are placed and moved within the joint space.

According to a 2018 review from the American Academy of Orthopedic Surgeons (AAOS), 7.9% of arthroscopic shoulder procedures end up with medical complications, ranging from mild nerve injury to frozen shoulder. Of these, 1% require revision surgery.

However, physician experience plays a large part in the risk of such injuries. The same research review found that orthopedists who obtained AAOS board-certification for shoulder arthroscopy conducted procedures that resulted in far fewer surgical complications than those who chose not to seek this certification.

Purpose of Arthroscopic Surgery

According to the AAOS, the six most commonly performed arthroscopic surgeries are:

Such procedures may be done to help diagnose or treat a variety of conditions, the most common of which are:

Knee and shoulder arthroscopy are, by far, the most common arthroscopic procedures. The spaces within these joints are large enough to accommodate the surgical instruments. Recent advances in arthroscopic technology (including miniaturized cameras and needle-sized probes) have allowed for more delicate arthroscopic surgeries in articulated joints of the wrist and ankles.

Technically speaking, any joint can have arthroscopic surgery performed on it. An orthopedist's ability and/or willingness to use arthroscopy in every joint, however, is limited by available instrumentation, the practicality of the procedure, and the potential outcomes it can provide in a given case.

For example, while people with small- to medium-sized tears of tendons or ligaments tend to respond well to arthroscopic surgery, the rate of recovery is often higher in people with large tears and ruptures when open surgery is used.

There are pros and cons to both arthroscopic and open surgical approaches, and the best choice depends not only on prescribed treatment guidelines but physician experience.

Arthroscopic Surgery
  • Smaller incision and scar

  • Less loss of blood

  • Generally faster recovery

  • Less risk of infection

  • Minimizes pain/need for pain medications

  • About to be performed in outpatient settings

Open Surgery
  • More room to perform surgically

  • Easier access to large or complex joint injuries

  • Better suited for small, delicate, or complex joints

  • Generally better suited for joint prothetic placement

  • Higher recovery rates for major tears and injuries

Pre-Operative Evaluation

To decide whether arthroscopic surgery is appropriate and/or to map out a surgical plan, orthopedists will perform a number of preoperative tests. The diagnostic workup may include such imaging tests as:

  • X-ray, which uses ionizing radiation to create plain film images of bones and joints
  • Computed tomography (CT), which composites multiple X-ray images on a computer to create three-dimensional "slices" of a joint or joint space
  • Ultrasound, which uses high-frequency sound waves to generate images of soft tissues that may be missed on an X-ray
  • Magnetic resonance imaging (MRI), which uses powerful magnetic and radio waves to generate high-definition images, particularly of soft tissues

The doctor may also order blood tests to check for inflammation, infection, or evidence of autoimmune disease. These may include:

The doctor may also perform arthrocentesis, a procedure in which joint fluid is removed with a needle and syringe for examination under the microscope. In addition to spotting abnormalities, such as crystallization, the fluid can be cultured to determine if a bacterial infection is involved.

How to Prepare

If arthroscopic surgery is recommended, you will meet in advance with your orthopedist (also known as an orthopedic surgeon) to review the pre-operative test results and discuss the procedure in detail, including preparations and recovery.

Location

Depending on the condition being treated, arthroscopic surgery may be performed in the operating room of a hospital or a specialized orthopedic surgical center. Less complicated procedures can be performed in the orthopedist's office using local anesthesia.

Regardless, the procedure room will be equipped with a flexible or rigid arthroscope that has a light and a camera built in. Live images are fed to a video monitor via a cable. Specialized surgical tools—such as scissors, mallets, retractors, forceps, cutters, and punches—will also be available to the surgeon. Some of these are fed through the neck of the scope, while others are used separately.

What to Wear

Depending on the joint being treated, you may need to undress partially or completely. Dress in casual clothes that are easy to remove. A hospital gown will be provided if needed.

Food and Drink

If undergoing regional or general anesthesia, you will need to stop eating at midnight the night before the procedure. The same applies to monitored anesthesia care (MAC), a form of intravenous sedation used to relax you and induce "twilight sleep."

There are no food or drink restrictions if only local anesthesia is used. With that said, MAC is sometimes used with local anesthesia and would require the same restrictions as regional or general anesthesia.

If you are unsure about any food/drink restrictions, ask your doctor.

Medications

To prepare for surgery, the surgeon will review the list of medications that you take. Some of these may need to be temporarily stopped before and after surgery. These include drugs that promote bleeding, most especially nonsteroidal anti-inflammatory drugs (NSAIDs) like aspirin, Aleve (naproxen), and Celebrex (celecoxib), or blood thinners such Coumadin (warfarin) and Plavix (clopidogrel).

These restrictions vary by the type of surgery being performed. To avoid complications, let your doctor know about any drugs or supplements you take, whether they are prescription, non-prescription, herbal, nutritional or recreational.

What to Bring

To register at the hospital or clinic, bring your driver's license (or other form of government ID), your insurance card, and an approved form of payment if copay or coinsurance costs are expected upfront. Leave all valuables at home.

While you should never drive or operate heavy machinery after undergoing general anesthesia, regional anesthesia, or MAC, it is best to err on the side of caution and have a friend or family member with you to drive you home no matter what type of anesthesia you receive. Even if carpal tunnel surgery is performed under local anesthesia, the restriction of movement of your wrist can make driving hazardous.

Pre-Operative Lifestyle Changes

There are many different reasons for arthroscopic surgery, some of which may require lifestyle changes to ensure a full recovery. Joint problems in the lower extremities, for example, are often compounded by obesity and can benefit from weight loss prior to and after the surgery.

The same applies to injuries caused by repetitive stress, which often require prolonged immobilization of the joint and an adjustment in the behaviors that contributed to the injury. This may include the cessation of certain sports or a change of responsibilities if the injury is work-related.

What to Expect on the Day of Surgery

On the morning of the procedure, you may need to wash and scrub with an antibacterial cleanser before leaving home.

Upon arrival, you will need to register, complete a medical information sheet, and sign a consent form stating that you understand the aims and risks of the procedure. You are then led to the back to undress and change into a hospital gown.

In addition to the orthopedic surgeon, the surgical team may include a surgical nurse, anesthesiologist, medical technician, and circulating nurse. In-office procedures may only require an orthopedist and assistant.

Before the Surgery

Once you are changed, your height, weight, and vital signs (including temperature, blood pressure, and heart rate) are taken by the nurse. A blood sample may also be taken to check your blood chemistry.

For procedures involving general anesthesia, regional anesthesia, or MAC, an intravenous (IV) line is inserted into a vein in your arm to deliver medications and fluids. Adhesive probes are then placed on the chest to monitor your heart rate on an electrocardiogram (ECG) machine, while a pulse oximeter is clamped to a finger to monitor your blood oxygen saturation.

During the Surgery

After you are prepped for surgery, the appropriate anesthesia is administered, be it a local injection or intravenous.

You are then placed in the best position for the procedure you are having. This may be supine (upward-facing), prone (downward-facing), or lateral decubitus (sideway-facing). For elbow and wrist surgery, the joint is typically placed on an elevated platform called an arm table.

There are different types of instruments used in arthroscopic surgery, each of which are designed for a specific joint or joint condition. The tools used for wrist arthroscopy, for example, would be different than those used for hip arthroscopy.

There are arthroscopes that are larger or smaller; some have cameras that are angled or have special filters or attachment. Others, called needle arthroscopes, are equipped with retractable tools that can cut, shave, anchor, and suture damaged tissues. (An increasing number of rotator cuff injuries are repaired in this way.)

Your doctor will choose the appropriate tools for your surgery, but the incisions used to access the area are similar regardless of the procedure being done. By definition, arthroscopy involves incisions of less than 3 centimeters (roughly 1 inch). Many procedures can be performed with incisions as small as 0.25 centimeters (1/4 inch) or even less.

A primary incision is made to insert the arthroscope to help guide the placement of tools. Sometimes, this incision is the only one that is needed.

In other cases, additional incisions are made to accommodate the various tools needed to repair, resect (cut out), release (sever), reduce (make smaller), or debride (remove damaged tissue) the joint or joint space.

The total number of incisions depends on the joint and the aim of the surgery.

If the joint space is especially narrow, the surgeon may prep the site with an injection of saline fluid. This helps widen the space and provides a clearer view within the joint.

Next steps differ depending on the exact procedure being done. For example, where a surgeon would remove swollen tissue to treat impingement syndrome, they might work to surgically repair damaged tissue when performing an ankle arthroscopy.

Once the surgery is complete, the incisions are closed with either sutures or adhesive strips (called Steri-strips), and the joint is bandaged. A support—such as a splint, brace, walking boot, or cast—may be used to immobilize the joint and allow it to heal properly.

After Surgery

If general or regional anesthesia was used, you are taken to a recovery room and monitored until you are fully awake. This can take anywhere from 10 to 45 minutes. When steady enough to change into your clothes, you can leave. Pain medications may be provided along with detailed wound care instructions.

People who have undergone in-office arthroscopy under local anesthesia can usually leave immediately after the procedure. Even so, arthroscopy is still considered surgery, and precautions may need to be taken. These may include joint immobilization, pain medications, and the use of crutches or other mobility devices.

Recovery

Recovery from arthroscopic surgery can vary by the type of procedure used. Typically, pain and inflammation are treated with R.I.C.E. (rest, ice application, compression, and elevation of the joint).

Less extensive surgeries may only require over-the-counter Tylenol (acetaminophen) to alleviate pain. More extensive procedures or those involving larger joints may require a short course of prescription opioid painkillers (usually for no more than three to five days).

In addition to pain management, consistent wound care is needed to avoid infection and wound dehiscence (an opening of the incision). This requires the daily changing of the dressing, during which you should check for signs of infection.

When to Call a Doctor

Call your surgeon if you experience any of the following after arthroscopic surgery:

  • Uncontrolled bleeding
  • Increasing pain, redness, swelling, and heat at the surgical site
  • High fever (over 100.5 degrees F) and chills
  • A greenish-yellow discharge from the wound
  • Broken sutures with a visibly open wound

Healing

One of the main advantages of arthroscopic surgery is that it limits damage to the soft-tissues surrounding the joint. Not only are bleeding, swelling, and inflammation minimized, but recovery tends to be shorter than with open surgery.

Once the joint no longer requires immobilization, range-of-motion and strengthening exercises can usually begin to restore flexibility and strength in the joint. It often helps to work with a physical therapist who can provide in-office therapies (like hydrotherapy and soft tissue mobilization) and design an exercise and rehabilitation program you can perform at home.

You should also ensure regular follow-up visits with your orthopedist to monitor for any new or unexpected complications and ensure that your condition is improving as expected.

Coping With Recovery

Even though you can usually return to normal activity faster with arthroscopic surgery, it can take many months before you are fully recovered and symptom-free. During this time, there are limitations to how much activity you should do.

Type of Arthroscopic Surgery Time to Recovery
Chondromalacia repair 4 to 5 months
Rotator cuff tear 3 to 6 months
Shoulder impingement syndrome 3 to 6 months
Meniscus repair 3 to 8 months
ACL repair 6 to 9 months
Carpal tunnel surgery  Up to 10 months

In the end, arthroscopy is traumatic to the body and can cause increased pain, stiffness, and risk of re-injury if not treated appropriately. Gradually increasing your activity levels can help to ensure these problems do not occur.

A Word From Verywell

Arthroscopic surgery has gone from being an attractive alternative to open surgery to the standard of care for many types of joint problems. Even so, arthroscopic surgery is not a one-size-fits-all solution.

If your doctor advises against arthroscopic surgery for whatever reason, try to keep an open mind and ask as many questions as you need to understand why. If you remain in doubt, do not hesitate to seek a second opinion from an orthopedic surgeon specializing in your condition.

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