Arthroscopy, or Minimally Invasive “keyhole” surgery, allows the surgeon to look into the knee joint, make an exact diagnosis, and treat the condition with an operation that requires very small skin cuts. We use specially made instruments that fit through the small skin incisions and we visualise the knee using a camera. Because this technique disturbs the knee joint less than open surgery, the hospital stay is shorter and the recovery smoother than with “open surgery”.
There are several conditions that can be treated with knee arthroscopic surgery
- 1. Cartilage tears
- 2. Meniscus (shock absorber) tears
- 3. Ligament injuries – ACL, PCL, MCL, PLC, MPFL
- 4. Knee cap pain (patellar maltracking)
- 5. Knee cap dislocation
- 6. Early arthritis
- 7. Loose particles in the joint
- 8. Knee stiffness
- 9. Infections
You will require some preoperative tests, to ensure you are fit for a general or spinal anaesthetic. We will ask you to fill in some questionnaires prior to surgery. We are part of an international group who study outcomes of different operations to ensure that surgical outcomes are satisfactory. We get you to fill out similar questionnaires at the conclusion of your treatment. You will be admitted to the hospital a day prior to surgery or in the morning of surgery. You must remove all rings from your hands and feet prior to surgery. There usually will be 2 or 3 very small puncture wounds about the knee. There could be a 2 cm incision on the shin if we have to take tendon graft from the leg (eg: when doing ACL reconstructions). In some cases, knee arthroscopy is performed under local anaesthesia, making it a “walk in and walk out” procedure. Patients are usually discharged home the same day or the day following surgery
Knee arthroscopy can be performed in local anaesthesia
We will discuss this option during consultation with you. In this technique, patients walk up to the operation table where the surgeon gives injections of anaesthetic medicines inside the knee joint. This numbs the knee joint. No Spinal anesthesia (anaesthesia by injection in the back) or general anaesthesia (making patient unconscious) is required. As patients are awake, they can follow their surgery on screen. After the surgery, patients can walk out of the operation theatre by themselves, go up or down stairs and even go home after an hour. The whole procedure is much like going to a dentist !!
Who needs knee arthroscopy?
People with injury to ligaments, meniscus, or cartilage which often occurs in sports injuries and road accidents, often require knee arthroscopy to repair the damage. Similarly, people suffering from osteoarthritis sometimes benefit from knee arthroscopy to remove loose fragments or cartilage flaps.
Anterior Cruciate Ligament (ACL) Reconstruction:
Anterior Cruciate Ligament (ACL) is an important ligament which holds together the thigh bone and shin bone at the centre of the knee joint. It is often torn during sports injuries, road accidents, or other twisting knee injuries. People suffering from torn ACL feel instability and insecurity in the knee while running. This causes secondary damage to other structures of the knee (meniscus, cartilage, etc.), eventually leading to permanent joint damage or arthritis. This ligament is surgically reconstructed by minimally invasive technique using arthroscopic surgery. The damaged ligament is replaced by a graft taken from the patient’s own body (autograft) which is slotted into the two bones at the exact location of the original ligament and fixed using special devices (implants). After reconstruction, the knee regains enough strength and stability to run and play sports after an adequate recovery period and physiotherapy rehabilitation. At The Joint Clinic, our surgeons are pioneers in performing ANATOMIC ACL RECONSTRUCTIONS in India. This restores your ligament with high accuracy helping patients return to sports
Meniscus repair or removal:
Meniscus is a special cartilage cushion, present only in the knee, which helps in uniform load distribution in the joint. This can tear during any minor or major twisting injury to the knee. Some meniscal tears, particularly in young people, are capable of healing. Such tears are repaired by applying stitches with arthroscopic surgery, so that the meniscal cushion is preserved in later life. Other tears which are not capable of healing need arthroscopic removal of the loose flap fragments to prevent further damage and ensure smooth painless knee function.
Posterior Cruciate Ligament (PCL) Reconstruction:
Similar to the ACL, the PCL is a strong and important ligament holding the bones in the knee together. When this tears and causes instability of the knee, it is reconstructed by minimally invasive arthroscopic surgery just like the ACL.
Articular cartilage repair
Articular cartilage is the smooth slippery layer covering the portion of bones inside the joint. Localised defects of this cartilage can be repaired by arthroscopic techniques like microfracture, mosaic-plasty, osteochondral transfer (OATS), or by two-stage procedure using cartilage cell culture techniques (ACI). In OATS or mosaic-plasty, healthy cartilage plugs from unimportant areas in the knee are used as “spare parts” to replace lost cartilage in important weight bearing areas.
In ACI, a small sample of healthy cartilage is harvested through arthroscopic surgery, and sent to the lab where it is processed and incubated to get a huge number of healthy cartilage cells in 6 to 8 weeks’ time. The knee is then opened and these cells are implanted using a gel matrix to cover the cartilage defect at the second stage operation.
Stiffness or restricted movements in the knee can occur after injury, after surgery, or due to arthritis or congenital conditions. If the stiffness is because of scarring inside the joint, then the tough scar tissue is removed through arthroscopic surgery. This is called arthroscopic adhesiolysis, where all the empty pockets in the joint cavity (supra-patellar and para-patellar gutters, intercondylar notch, etc.) are cleared of scar tissue to restore the pliability and flexibility of the joint. If the tight tissues are outside the joint (extra-articular), then they are released by open surgery to restore flexibility.
MCL & PLC Reconstruction
Peripheral ligaments of the knee are often damaged either singly, or in combination with other ligaments during knee injuries. The Medial Collateral Ligament (MCL), or the Postero Lateral Corner (PLC) are commonly involved. If treated early, it is possible to repair the ligaments by stitching the torn ends together. However, in neglected cases and badly damaged ligaments, it is necessary to reconstruct using grafts with open surgery.
Multi Ligament Reconstruction
Multiple ligaments of the knee are damaged in cases of knee dislocation. The ACL, PCL, MCL, and PLC are the four main ligamentous structures which form a framework to stabilise the knee. Of these, three or even all four structures can be damaged during a knee dislocation, apart from possible damage to blood vessels and nerves. Such injuries present unique challenges for ligament reconstruction, since it may not be possible to harvest sufficient number of autografts to reconstruct all ligaments. This problem can be solved using cadaveric donor allografts if available. Also, multiple ligament surgery can be very long and extensive, which increases the risk of post-operative stiffness. To reduce this risk, we often do it in two stages. The repair/reconstruction of the peripheral ligaments (MCL, PLC) is done first by open surgery, and when the knee regains good range of motion after a few weeks of the first surgery, the central ligaments (ACL, PCL) are reconstructed by arthroscopic technique.
Surgery for Dislocating Patella (Knee-cap)
The Knee-cap (Patella) can dislocate during an injury, particularly in children and adolescents. In 50% of cases, it then starts to dislocate repeatedly without any injury, a condition called as “Recurrent Dislocation of Patella”. The primary cause of this is a tear in the Medial Patello-Femoral Ligament (MPFL) which is an important stabilising ligament of the patella. This ligament needs to be surgically reconstructed by a graft. Before such a surgery, the knee is thoroughly investigated by MRI scan and CT scan to identify underlying bony deformities or cartilage fragments, which need to be corrected at the same time.
High Tibial Osteotomy (HTO)
This is a joint conserving surgery for young and active people with unicompartmental knee osteoarthritis (affecting only one compartment or half the joint) with varus deformity or bowed legs, who cannot comply with the restrictions of a knee replacement. Here, the bowed leg is straightened after making a cut in the shin bone (tibia) near the knee, and fixed by plate and screws or external frame. Sometimes, the external frame is used to correct the deformity gradually over a few weeks. This surgery can give significant pain relief and allows unrestricted activity afterwards. However, the relief usually lasts only for a few years, and when the pain returns, we need to do a knee replacement surgery. Thus this surgery is used for “buying time” before a knee replacement in young patients.
Unicompartmental Knee Replacement
Older and less active patients who have severe unicompartmental knee osteoarthritis (affecting only one compartment or half the joint) may be suitable for unicompartmental or half knee replacement, as an alternative to total or full knee replacement. In this surgery, because only half of the knee is replaced, all the original ligaments are left intact (ACL & PCL, which are otherwise removed during total knee replacement). This allows almost full knee bending after the surgery, and quicker recovery as compared with total knee replacement.
What is Knee Joint Replacement Surgery?
Rough and damaged cartilage surfaces in cases of knee arthritis are replaced with smooth artificial components, while most of the original knee ligaments are left intact. External appearance of the knee remains unchanged, except for the surgical scar. This surgery needs a large clean operation theatre with modern equipment and infrastructure.
Who needs Knee Replacement Surgery?
Patients suffering from painful, disabling arthritis in the knee need to undergo knee joint replacement surgery. Limited walking distance, night pain, severe deformity, difficulty in performing daily activities, are indications for this surgery.
What to expect after knee replacement surgery?
Most of our patients start walking 1 or 2 days after surgery, and feel comfortable to go home in 3 days. Almost everybody can bend the knee to 120 deg and slimmer people can bend even better.
They can sit cross-legged if required, though we do not encourage this. The knee deformity gets corrected, the leg becomes straight, and all patients find tremendous improvement in walking and daily activities because of the operation.
Most patients stop using walking stick within a month. Knee function continues to improve for a year after surgery.
How successful is knee replacement surgery?
Overall, this has been a very successful and rewarding surgery in our experience. We do not recommend this operation for every patient of osteoarthritis. We offer this surgery only to select patients when our experts feel sure that the knee is badly damaged and the patient will benefit significantly from the surgery. Once they recover from the operation and experience its benefits, all our patients feel happy that they underwent the surgery.
In the long term, more than 90% of patients do well for 15 to 20 years without the need for any further surgery. Hence, the chance of requiring a second operation after knee replacement in reality is very low.
The Economics of Knee Replacement
Once considered a luxury for the elite, it is now well within the reach of the common man. The overall approximate expense for a single knee replacement ranges from 1.5 to 1.8 lac rupees in the economy class of most hospitals, including high quality imported implants and medicines. That for both-sided simultaneous knee replacement ranges from 2.6 to 3.2 lac rupees.
Although many patients recover well on their own, some may need 5 to 8 sessions of physiotherapy. Simple inexpensive tablets are required for 3 to 6 months. Working patients can return to work in 4 to 6 weeks.