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Arthroscopic Surgery

  • Introduction
  • Specialized Imaging for Joints
  • Planning for Arthroscopic or Keyhole surgery
  • Hospital documentation procedures
  • Pre-operative preparation
  • Operation
  • Post-operative Care
  • First Post-operative day
  • Common complications following arthroscopic surgery
  • Return to activity following arthroscopic surgery




  • Introduction
    Arthroscopic surgery or keyhole surgery, involves the examination and treatment of joint disorders by means of small incisions, the use of a variety of telescopic lenses and specialized micro-instruments.

    Arthroscopic surgery, which is usually performed as a day procedure, minimizes time off work and hastens return to pre-injury activity in a majority of patients. The risk of complication is also lower with arthroscopic surgery than with open or conventional surgery. However, some conditions cannot be fully treated by arthroscopic surgery alone and may require concomitant open surgical procedures to solve the problem, for example, cartilage transplants.

    Only after a thorough review of a patient’s history and a detailed physical examination, will the surgeon consider surgery as an option. Often X-rays and Magnetic Resonance Scans (MRI) are necessary to identify and plan the surgery. MRI scans use magnetic rays to image the body structures and distinguish diseased entities from healthy structures. Sometimes Bone Scans and Computed Tomography Scans (CT Scan) may be necessary to establish a diagnosis. The details of the different investigational modalities are detailed below.

    The information provided here is readily available from other sources and websites. Some of the information has been collated from other available public and educational websites.


    Specialized Imaging for Joints
    • X-ray (radiography) - An X-ray beam is passed through the joint to produce a two-dimensional picture of the bones.
    • Computerized axial tomography (CAT) scan - X rays lasting a fraction of a second are passed through the joints at different angles, detected by a scanner, and analyzed by a computer. This produces a series of clear cross-sectional images ("slices") of the tissues on a computer screen. CAT scan images show soft tissues such as ligaments or muscles more clearly than conventional X-rays. The computer can combine individual images to give a three-dimensional view of the joint.
    • Bone scan (radionuclide scanning) - A very small amount of radioactive material is injected into the patient's bloodstream and detected by a scanner. This test detects blood flow to the bone and cell activity within the bone and can show abnormalities in these processes that may aid diagnosis.
    • Magnetic resonance imaging (MRI) - Energy from a powerful magnet stimulates the tissues to produce signals that are detected by a scanner and analyzed by a computer. This creates a series of cross-sectional images of a specific part of the anatomy. An MRI is particularly useful for detecting soft tissue damage or disease.

    Planning for Arthroscopic or Keyhole surgery
    Once you have decided to undergo surgery, your pre-operative preparation is important. The surgeon will explain the benefits, risks and complications of the procedure that you are to undergo. Do not hesitate to ask the surgeon to explain any part of the procedure. the results vary from patient to patient and it is advisable not compare your progress with other patients who may appear to have had a similar procedure, as the incisions for different procedures are similar.

    Hospital documentation procedures

    The practice will assist you in the documentation and admission procedures to the hospital.

    The hospital requires a deposit to be paid on the day of admission and prior to surgery. Alternatively the hospital will accept letters of guarantee from your insurance company, provided pre-certification has been approved.

    The admission room for day surgery at Mt Elizabeth Hospital is at Level 3 of the main hospital building. The day surgery ward, to which you will be admitted, is at the same level. There are individual safes available for patient use at the day surgery ward. It is advisable not to bring any valuables when you come for surgery.

    For inpatient admission, the admission office is on the second floor.

    Prior to surgery you will be required to sign an informed consent form, which states the nature of the surgery and provides consent for additional procedures, which your surgeon may deem warranted during the course of surgery, should complications arise.

    You will be required to come to the clinic at 9a.m. on the day of surgery.


    Pre-operative preparation

    Pre-Op Dos and Don’ts

    DO avoid alcohol the day before surgery

    DO stop smoking for a few days before and after surgery

    DO abstain from food and water from midnight before the day of surgery

    DO wear lose clothing in order to accommodate post-operative dressings and braces which may be required following surgery

    DO inform your doctor of any pre-existing ailments, diseases and drug allergy

    DO let your doctor know all medications that you currently take, such as aspirin, vitamins or herbal supplements, as they may affect your surgery. If you are taking aspirin or anti-coagulants, you may have to stop the medication 5 days before surgery

    DO ask your doctor when to take any of your usual medications (e.g. for diabetes, hypertension or heart problems) and how much to take before your surgery

    DO notify your surgeon immediately if you develop a cold, fever, sore throat or infection prior to surgery

    DO take pre-medication on the day of surgery, which will be prescribed, to reduce the incidence of post-operative pain and complications

    DO NOT wear any jewelry and make-up and remove all body piercings and nail polish

    Do NOT drive to the hospital on the day of surgery

    You may consume small amounts of clear liquids up to six hours before you arrive for surgery. This will reduce your chances of nausea and vomiting after surgery.

    Depending on risk factors, you may require some pre-operative blood test, ECG test and X-ray assessment.


    Operation
    Arthroscopic surgery is carried out under general or regional anesthesia. Most of these surgeries are performed at Mt. Elizabeth Hospital, which has the state of the art voice activated computer controlled minimally invasive surgery suite. Latest technology is used where possible to expedite surgery and minimize complication and recovery time.

    In this practice we regularly use a motorized cryotherapy machine with a pad to reduce post-op pain and swelling. You will be prescribed this device following surgery. Patient controlled analgesia (PCA) is also regularly used following major surgeries to reduce pain and initiate early joint function.


    Post-operative Care
    Rehabilitation and recovery periods vary from patient to patient and sometimes your recovery may be somewhat different from other patients with apparently similar problems. Post-operative rehabilitation is an essential part of the treatment and should be followed strictly.

    You will generally be discharged from hospital four to six hours after surgery, and pain medication and antibiotics will be prescribed to you before you leave. You will have a bulky dressing around the operated joint to prevent formation of haematoma or the accumulation of blood in the joint. This will slowly resolve after a few days. A cryocuff cold therapy pad will be in place circulating cold water at a temperature between 3-50 Celsius. You will be instructed on the use of this machine and further information is available in this website regarding its operation.

    You must turn off the cryocuff machine when you sleep, as excessive cold therapy can compromise circulation to your limbs. It is generally recommended that you use it for 1 hour at any one time, followed by a rest interval of an hour. Alternatively you can use the cryocuff for 15-20 minutes every hour. It should never be turned on when you are asleep. To prevent circulatory problems in the limbs, it is advisable to keep the operated limb elevated as much as possible in the first few days following surgery.

    The leg and foot often swell because of pausity of muscle contraction and pain following surgery. Post-operative swelling significantly reduces the return of rapid function to the operated limb. To reduce swelling of the limbs the following exercises are helpful:


    Exercises for the lower limb to decrease post-operative swelling


    • Foot pumping exercise, that is moving your foot up and down, 10 times every hour. This will encourage return of venous blood and fluids back to the circulation. The incidence of deep vein thrombosis or blood clot in the leg will also be minimized.
    • Straight leg exercises, that is lifting your leg off the bed, 4-5 times every hour. This will also prevent wasting and stimulate the leg muscles.
    • Knee extension exercises, that is gently pushing the knee into a straight leg position allowing the back of the knee to touch the surface your leg is resting on. This will prevent a flexed knee position, which may compromise your walking ability.
    • Ambulation or movement is generally encouraged following arthroscopic surgery of the lower limbs to aid circulation and return of normal function, within the limits of pain. Excessive stair-climbing or prolonged walking is not encouraged in the first few days after arthroscopic surgery of the lower limb.
    • Elevate the legs as much as possible with the help of pillows under the heel.
    • Cryotherapy will also help reduce pain and swelling.

    Exercises for the upper limb to decrease post-operative swelling


    • Perform opening and closing of the hand or make a clenched fist 10 times every hour
    • Gentle movement of the elbows and shoulder s to encourage venous return.
    • Pendular movements of the shoulder may be advisable following certain types of arthroscopic shoulder surgery.
    • Elevate the limb as much as possible when in a recumbent position.


    Complete the course of antibiotics that has been prescribed according to the instructions. Anti-inflammatory medication (Vioxx or Arcoxia) and pain-killers ( Tramadol or Toradol) should be taken to reduce pain especially in the first 48 hours. Subsequently these tablets can be taken as and when required.

    Medication Dosage Instructions:

    Ciprobay - 1 tablet twice a day

    Arcoxia (120mg) - 1 tablet once a day

    Ultracet - 2 tablets three times a day

    Panadeine - 2 tablets three times a day 

     

    Common side effects of these medication include:

    Arcoxia - Fluid retention stomach upset, nausea, vomiting, drowsiness, metallic taste, constipation, flatulence, blurred vision.

    Ultracet -Nausea, dizziness, headache, constipation, anxiety, confusion, insomnia,rash, increased sweating, dry mouth

    Panadeine - light headedness, dizziness, nausea, vomiting, skin reaction

    Ciprobay - Nausea, diarrhea, insomnia, agitation, tachycardia, migraine, hallucinations, nightmares, impaired smell, hot flushes

     

    Use the water-proof shield when you take shower so as to avoid getting the dressings wet for the first few days till the wounds dry.

    If the lower limbs were operated on, use the crutches to aid your ambulation. Partial to full weight bearing may be allowed depending on the type of surgery.


    First Post-operative day
    Following a day surgery procedure you will be generally reviewed in the clinic the following morning. The detailed nature of your surgery would be explained to you and the dressings will be changed. A lighter compression bandage in the form of a tubigrip would be prescribed for the next few days. Sometimes a brace may be indicated. The purpose of compression is to prevent further accumulation of blood or fluid in the joint following surgery. However, this swelling will subside over the following few days.

    You will be reviewed regularly following your initial visit and physiotherapy would be arranged. For a speedier recovery it is imperative that you follow the advice of the physiotherapist. The surgeon would usually discuss the management protocol with the therapist prior to your visit.


    Common complications following arthroscopic surgery
    • Swelling or haemarthrosis. This is usually common and will subside fairly soon. In some patients the swelling may accumulate and cause pain in which case an aspiration of the joint may be indicated.
    • Infection. This can occur following any surgery but it is less common following arthroscopic surgery. Nevertheless, it should not be taken lightly. The signs of infection are pain not relived with usual doses of painkillers, redness and discharge from the surgical wound. If there is excessive staining or discharge from the wound you should contact your surgeon immediately.
    • Deep vein thrombosis. In this condition the leg tends to swell and calf pain may be present. It is common in the certain population groups and high-risk patients include those with a past history of thrombosis, pulmonary embolism, strongly family history, clotting disorders, contraceptive medication and prior venous disorders amongst other causes. If you are concerned you should contact your surgeon and a Duplex scan or a venogram may be necessary to confirm the diagnosis prior to treatment. The best way to prevent this complication is to move the limbs as soon as possible following surgery and the exercises suggested to prevent swelling of the lower limbs would also be helpful in decreasing the incidence of this condition. This can be fatal in a small percentage of patients.
    • Muscle wasting. Pain and the effects of surgery may prevent the muscles from functioning normally and hence weakness and wasting of the muscles may set in. To prevent this it is important that within the limits of pain you should constantly move the operated limb. Physiotherapy can also help minimize decrease of muscle function.
    • Numbness and sensory disturbances. The joints are richly supplied with nerve endings and sometimes it is inevitable that during surgery there may some damage to these nerves, despite adequate precautions. This may result in patchy numbness around the operated area and these will generally recover fully but in some patients the numbness may take a long time to resolve or remain permanent. This is particularly common following ligament reconstruction and meniscal repair surgery.
    • Keloid formation. Some patients are prone to develop keloid or excessive scar tissue formation following surgery. Prevention is usually not possible but the small size of the arthroscopic incision may not cause a significant cosmetic blemish.
    • Effusion. This accumulation of fluid in the joints is a little different from the initial post-operative swelling that is seen commonly, which is due to accumulation of blood. This is secondary or as a result of the healing process and may take a few weeks sometimes a month or two to resolve fully. Anti-inflammatory medication and rehabilitation helps in reducing this effusion.
    • Residual pain and symptom. Sometimes following surgery your symptoms may not resolve completely. this is especially so if there rae structural or antomical changes which are not amenable to surgical correction. this is particularly true if you have any articular cartilage defects or osteoarthritic changes, in which case your symptoms can be improved to a certain degree but it may not be possible to alleviate the symptoms. You may also need to modify your activities in line with severity of the symptoms.

    Do let your doctor know if the limbs are persistently swollen and painful, or if you have any chest problems or breathing difficulties.


    Return to activity following arthroscopic surgery
    It is generally advisable to delay return to sports activity till the primary pathology has been treated or resolved completely. Premature return to strenuous activity may precipitate effusion and irritation of the joints. It is generally advisable to undergo adequate rehabilitation and strength training prior to resuming sports activity. Icing and stretching regularly will decrease the incidence of spasm and recurrence of pain following arthroscopic surgery of the upper or lower limbs.

    The time frame for actual return to sports depends on a number of factors including age, activity level, type of pathology and expectation of individual patients.

    However, do not wait until your injury is healed to get back into shape. To aid speedier return to activity, follow the RICE formula: Rest, Ice, Compression and Elevation, along with a limitation of activities. Do stay fit while injured, and keep a positive, upbeat attitude.

     
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