Keyhole surgery, or minimally invasive surgery using a camera and very small surgical incisions, has revolutionised the way surgery is conducted. When this technique is used to manage a joint problem, then it is called arthroscopy – ‘arthro’ meaning joint and ‘scopy’ meaning vision. In fact, we can use this technique both to determine what the problem is in a joint (diagnostic) and to treat the problem in the joint (therapeutic).
Until a few decades ago, all surgery to the joints in the body was carried out using open techniques requiring large incisions.
Today, the advancement in optic technology has allowed us to view a joint through an incision less than a centimetre in size. A special camera attached to a tube the size of a pencil with a lens at the tip is used. Through another portal, special equipment is inserted and used to carry out any necessary work required in the joint. This equipment may include a burr, a hot burning stick, suction, a grabber or cutter, etc. To aid in vision, water is normally pumped into the joint under pressure to decrease bleeding.
Most joints in the body may be treated surgically in this way. The equipment also allows for the procedure to be recorded or photos taken during the operation. These may be used to help explain the surgical findings in the post-operative period and thus aid in the recovery.
The most common joint treated arthroscopically is by far the knee joint, to remove loose bodies, excise a torn cartilage (meniscus) or clean out debris in arthritis, for example. The shoulder joint probably runs a close second. However, in my practice, I arthroscope wrist joints, elbow joints, ankle joints and even the joint of the big toe.
Although patients very commonly present with hip pain, interestingly enough, hip arthroscopy is rarely performed. This is because the hip joint is deep and hip arthroscopy is technically very difficult.
Arthroscopy is generally more demanding technically for the surgeon and requires specialist training and occasionally expensive equipment. But it has huge advantages for the patient when compared with open surgery.
Arthroscopic surgery allows the surgeon to visualise areas in the joint that are hard or impossible to see if the procedure is done with the open technique.
Keyhole surgery is less traumatic to the soft tissues as small incisions are made. Complications, including bleeding, infection and thrombosis, are thus decreased. The surgical scar is normally very small and mostly inconspicuous. The operations are mostly done as a day case.
Due to the fact that there is less trauma to surrounding tissues, the pain levels are decreased and thus patients would require significantly less painkillers after the operation. The patient can move the joint or ambulate quicker. As a consequence, their post-operative experience is much more positive. Studies have also shown that the recovery for the patient to go back to work or sport is 50 per cent faster when compared to open techniques.
Alistair Pace is a consultant orthopaedic surgeon at St James Hospital, Sliema and Żejtun, Da Vinci Hospital, Birkirkara, and St Thomas Hospital, Qormi.