Newspaper coverage of a recent talk in Max Pitam pura

Video of arthroscopic bankart repair (recurrent shoulder dislocation surgery)

Recurrent shoulder dislocations produce the so called bankart lesion i.e. detatchment of the capsule labrum complex from the anterioinferior glenoid. The standard of care for this injury is to repair this lesion. It is now done arthroscopically as is shown in the video. Latest arthroscopic instrumentation & state of the art bone anchors as shown here help the surgeon to do a consistent, predictable soft tissue reattachment. The same operation can be done through an open incision, but inadvertently some motion, especially external rotation is lost after the open surgery & hence recovery is also proportionately delayed.

Ligament injuries of the knee

1) What are the ligaments of the knee?

The knee joint has 4 main ligaments. The ligaments are rope like structures, made out of a protein called collagen. They are designed to stabilize the joint against excessive movements in one particular direction. They include the following:

a)      Anterior cruciate ligament (ACL)

b)      Posterior cruciate ligament (PCL)

c)      Medial collateral ligament (MCL)

d)      Lateral collateral ligament (LCL)

 Each of the above ligaments has a specific function in the knee & tear of any one of these or a combination makes the knee unstable for day to day living & active sport.

2) How does the injury happen?

Ligaments require a lot of force to get injured & hence only a high velocity trauma, like that sustained during road traffic accidents & competitive sports can injure them. One or several ligaments may be injured in the process. Generally if the ligament is injured, the bone is spared from fracture, but severe trauma can fracture the bone & rupture the ligament. Sometimes, especially in children & adolescents, the ligament can be torn off with a small piece of bone.

3) What are the symptoms of ligament injury?

Apart from causing a lot of knee pain, an acute injury is always accompanied by a joint hematoma (swelling due to blood accumulation). It is not possible to fully straighten the knee due to this & the patient keeps the knee bent 5-10 degrees. Walking is very difficult & painful.

In a chronic ligament injury, the patient feels that the knee is unstable, both during straight-line walking & particularly on changing direction, descending stairs & walking on uneven surfaces. The knee may also swell up, off & on. The direction of instability depends on which ligament/ set of ligaments is torn.

4) How is acute injury of ligaments treated?

An X ray of the knee is always taken to rule out fractures or avulsion injuries (when the ligament tears off with a small piece of bone). Acute injuries are rested in a brace or a plaster. Ice is applied & anti-inflammatory medicines are prescribed. A pair of crutches needs to be used temporarily, till the ligament heals fully. Once healing has taken place, physiotherapy allows you to gradually return to your pre-injury level of activities. Note that each ligament of the knee has its own specialized & individualized treatment protocol & if more than one ligament is injured, the treatment may take a totally different direction.

5) What is the treatment of chronic ligament injury?

A ligament injury is called chronic if 6 weeks or more have elapsed since the injury. God has bestowed good healing power to the medial collateral ligament (MCL). To a certain extent an isolated posterior cruciate ligament (PCL) injury can also heal with good physiotherapy & proper splintage. ACL & LCL injuries usually do not heal themselves & require reconstructive surgery, if symptoms of instability are present. ACL & PCL reconstruction can be done arthroscopically. LCL & MCL are located outside the knee capsule & require a mini open surgery for reconstruction.

6) What is the usual hospitalization & recovery period after a ligament reconstruction?

One day hospitalization is required for most ligament reconstructions. A graft needs to be taken, either from the front of the knee (bone patella graft) or from the hamstrings. Screws & other implants need to be used to fix the ligament in the bones till they heal. Healing times vary from one ligament to the other, but generally it takes 6 weeks to 3 months to heal fully. Your mobility is not hampered after surgery. Infact in most instances you are out of bed & moving about, the very next day after the surgery.

On the day of the surgery

Arthroscopy is mostly done as a day care procedure. You are admitted to the hospital on the morning of the procedure & sent home in the evening. One is required to be fully fasting on the day of the procedure (not even a drop of water after previous night's dinner). The nurse will administer some antibiotics & sedatives on admission. The lower limb surgeries are done under spinal anesthesia (prick in the back) & the upper limb surgeries are done under general anesthesia. A pain pump is usually inserted after the procedure & tablets consisting of pain killers & antibiotics are prescribed for a short duration after the discharge. Patients with diabetes & other illnesses need special pre-operative evaluation, which can be personally discussed with your physician.

The physics behind the arthroscope

An Arthroscope is essentially a long miniature lens system. It has a set of complex optics built in.

There are three main parts o this assembly:

1)      Objective lens

2)      Transmission system

3)      Eyepiece

The objective lens is located at the tip of the arthroscope & is the first point of contact with the interior of the joint. Joints are tight spaces & in order to increase the field of view, prisms are used to bend the light so that the surgeon can easily look around the corners by simply rotating the lens, without having to physically move the arthroscope back & forth. Normally a 30 degree prism is used, but for more field of view 70 degree scopes are also available.

The transmission system consists of a series of rod shaped lenses within the shaft of the arthroscope, joined together by cement glue. They relay an inverted image of the object to the eyepiece. The rod lens system is known for its high light transmission efficiency compared to conventional lenses, because the air gaps between the lens is kept to a minimum.

The eyepiece serves to magnify & invert the inverted image relayed to it by the transmission system, thereby giving a natural view of the joint to the surgeon.

The history of arthroscopy

The first use of the arthroscope is credited to the Japanese. Dr Kengi Takagi of Tokyo first used it in cadaveric knees (experimental work on dead bodies), as early as 1918! In 1920, he performed the first operation on the knee of a patient with tuberculosis.

World wars 1& 2 slowed down further research & development in this field, till Dr Masaki Watanabe of Tokyo revived it again, by making the prototype of the modern day arthroscope in 1951. He later developed the ability to take black & white photographs & produced the first atlas of arthroscopy in 1957. With the advent of color photography, this atlas was revised in 1969 & served as a good reference material for surgeons of that era & continues to be consulted even today.

The initial arthroscopic surgeries were limited to inspecting the joint’s interior & taking out a small portion of tissue for microscopic analysis (biopsy). Japan pioneered in the first arthroscopic surgery as well, when in 1955, a knee tumor was removed & later in 1962, a 17 year old basketball player was treated for knee injury & returned to playing in 6 weeks time.

The surgeons from America & Europe visited the Tokyo Teishin hospital to learn these techniques from Dr Watanabe. They later modified & improved upon the instruments & made arthroscopy the art & science that it is today. The biggest revolution in arthroscopy came in 1975 when an American surgeon Mc Ginty introduced a television system, which could relay the images to a TV screen or a medical grade monitor.

Arthroscopy hit Indian shores in the late 80’s & early 90’s when pioneers like Dr Anant Joshi (BCCI doctor) & several others returned back to the country after training from USA & developed their practice. In Delhi, the Central Institute of Orthopedics (Safdarjang Hospital) is credited with the earliest arthroscopic surgeries. Now Safdarjang has a busy sports medicine center & is one of the centers of excellence for learning arthroscopy. I was fortunate to be the first thesis student of the director of this institute, Dr Deepak Chaudhary. My thesis on arthroscopic ACL reconstructions was later published as a paper in the Journal of Orthopedic Surgery, Hong Kong. 

Introduction

Hi Everyone

I am Dr Raju Easwaran, an Orthopedic Surgeon from New Delhi, India. I have a special interest in treating diseases of the knee & shoulder with keyhole surgery or Arthroscopy. This is a small effort on my part to educate people about this powerful tool that we have with us i.e. Arthroscopy. I will start posting from scratch on the evolution of Arthroscopy from it's inception in the 70's to its present role as an indispensable clinical tool of the modern Orthopedic practice. My blog aims to provide education about common orthopedic diseases & their treatment, so that patients can make intelligent & informed choices. Please post comments in the subsequent posts to enable me to post articles of relevance & clinical interest. I want this blog to bridge the gap that exists to a certain extent in a direct doctor-patient interaction. I also hope to interact with like minded colleagues so that we can improve our understanding of this science & translate it into better patient care.