Knee Arthroscopy

Arthroscopy is a procedure in which the inside of a joint is visualised using advance camera and lighting equipment. Technology has allowed both the camera and the light source to be incorporated in a thin tube. This tube can be introduced inside the joint through a very small incision or cut. The name key-hole surgery has been coined for arthroscopy as it is minimally invasive. Knee arthroscopy has many advantages. The interior of the joint can be completely visualised by this procedure. As it doesn't require a lot of skin and tissue cutting, it can be used as a diagnostic tool. Because the arthroscope tube is thin, we can visualise areas at the back of the knee which are difficult to see in open surgery.  As the surgery is done through small holes, postoperative pain is minimal and recovery is very quick.

Knee arthroscopy has revolutionised treatment of certain problems. A classic example is synovitis or thickening of the lining of the knee. Synovitis can happen due to various reasons. Sometimes it is necessary to remove a part of the synovium (or lining) as a biopsy. In other cases it is required to remove the entire lining as treatment. Formal open synovectomy (or removal of lining) was a major surgery that led to postoperative pain and knee stiffness. Besides some synovium would remain behind at the back of the knee due to difficult access. With arthroscopy, total synovectomy can be achieved with minimal pain and stiffness.
 
Another area where arthroscopy has made tremendous progress is in the field of ligament and meniscal injury. The commonest ligament which gets injured during a sport or road traffic accident is called the anterior cruciate ligament (ACL). Once this ligament is injured, it leads to instability. The patients knee buckles every now and then and he/she loses balance and may fall. The patients describe the problem as a 'wobbly knee' and get a typical 'giving way' sensation in the knee. These repeated instability episodes eventually wear out the knee and patients end up with knee arthritis in a few years. In earlier times there was no good solution for this problem. Open ligament reconstruction procedures were fought with failure. All this changed with the advent of arthroscopy. Nowadays arthroscopic ligament reconstruction has become an extremely successful procedure. The patients own hamstring muscle tendon is harvested and a new ligament is made by folding the tendon on itself. This new ligament is then fixed into pre-drilled tunnels in the patients thigh and leg bone to become the new ACL ligament. This eliminates instability so efficiently that patients can start playing contact sports like football after the procedure. The patients knee is restored to its original state and any further wear and tear is arrested. It has now been proved beyond doubt, in multiple studies done internationally that results of ACL reconstruction are much better than non surgical treatment.

The meniscus is a thick structure found inside the knee joint which acts like a shock absorber. Just like the ligaments, the meniscus can also tear due to injury. A meniscal tear classically causes pain and locking of the knee. The locking occurs because the torn meniscal fragment gets stuck between the two bones. Repeated locking episodes lead to pain and swelling. Before the advent of arthroscopy, it was very difficult to treat meniscal tears. Surgeons ended up removing the entire meniscus which was not only unnecessary but also harmful as it lead to early degeneration of the knee. With arthroscopy it is now possible to tackle only the torn fragment. Either the torn part is removed and the rest of the meniscus is left behind or the torn fragment is repaired. Again arthroscopy allows the knee to be restored to its original state.

Arthroscopy is a major advance in orthopaedics and it is now being successfully utilised in solving problems of other joints as well like the shoulder. Patients should be aware of the benefits of arthroscopy and must take advantage of this science when required.

Frozen Shoulder

Few disorders in Orthopedics affect a patient as dramatically as frozen shoulder does. Most often the pain starts suddenly without any warning. And what puzzles the patient is that the pain starts without any fall or trauma. The pain is severe and is aggravated by any sudden movement of the shoulder. At times the pain is unbearable. The pain worsens at night and patients are unable to fall asleep. They cannot lie down sideways because of pain. The pain is accompanied by increasing stiffness of the shoulder. The patient becomes very anxious because of this catastrophic onset of pain and inability to move the shoulder. 

Frozen shoulder comes with good news and bad news. The good news is that the disorder is self limiting. This means that it is notan ongoing problem like arthritis which ends up with complete destruction of the joint. On the contrary frozen shoulder undergoes a typical evolution from stage to stage and then completely resolves. Therefore almost all patients of frozen shoulder will eventually be completely cured of their illness. Sofrozen shoulder is not a bad disease to have. What then is the bad news? The bad news is that it takes awfully long for the shoulder to get better. Typically a patient suffers for one year to 18 months before the pain goes away. 18 months is a long time for someone to suffer severe pain and sleepless nights!

What is frozen shoulder? In order to understand frozen shoulder we need to understand some simple facts about the shoulder joint. The shoulder is a ball and socket type of joint. Like all other joints the shoulder is strengthened by ligaments and moved by muscles. Similarly the shoulder also has a covering or lining called the capsule. The capsule makes and keeps the lubricating fluid within the joint. In frozen shoulder the capsule gets inflamed and contracted. This inflammation causes severe pain with the slightest movement of the shoulder. The contracture of the capsule causes the shoulder to become stiff. Frozen shoulder in medical terms is also called 'adhesive capsulitis'. We are still not sure why frozen shoulder occurs. However we do know some definite risk factors. It is more common in diabetic patients. It also is more likely to occur in patients who have not moved their shoulder for a long time due to some other reason like an arm fracture or stroke. Frozen shoulder is generally seen in adults above 40 and is slightly more common in women. There are three stages through which the disease progresses before it finally resolves. First is the stage of inflammation. It lasts for approximately 6 to 12 weeks. It is characterised by severe often unbearable pain. In this stage, pain is more prominent than stiffness. The second stage is of stiffness. In this stage the shoulder is very stiff with almost no movement occurring in some patients. The pain reduces in intensity in this stage. This stage lasts for another 12 weeks. The last stage is of thawing. In this stage the disorder resolves. Movements of the shoulder begin to improve and eventually the patient is cured. This stage lasts for 6 to 12 months. 

Are frozen shoulder patients destined to suffer? Is there any treatment for this disease or can these patients help themselves? There is no medicine to cure frozen shoulder. However the disability from frozen shoulder can definitely be reduced. The aim of treatment is to bring back the movements of the shoulder with range of motion exercise. A physiotherapist helps guide the patient through the exercise routine. Once the patients learn the exercises, they continue doing them at home. Those who try to regain movements by exercise are able to reduce pain and shorten the duration of illness. However exercise is many a times extremely difficult because it worsens the pain. Many patients are just not able to do any exercise. We as doctors help patients reduce pain so as to enable patients to do exercise.Initial pain management is with medicines. Tablets are given only with the intention to decrease pain so that patient can do exercise. Exercise remains the mainstay of treatment. If tablets do not work, local injection of steroid medicine is given to reduce the inflammation and pain. One or two injections of steroids do not harm the joint. Repeated injections should be avoided. Sometimes the patients are able to exercise, but are not able to overcome the severe stiffness. For such cases we do a manipulation under anesthesia. As the name suggests, the patient is given anesthesia so that they do not experience any pain. Then the surgeon forcibly moves the shoulder in all directions to loosen the joint. After the manipulation, the patient needs to continue exercise to gain the movements and benefit from manipulation. In very resistant cases, arthroscopic surgery is done to cut the adhesions and allow shoulder movements. 

To conclude, frozen shoulder patients should not be worried about the pain as the problem is self limiting and will get better in time. All attempts must be made to exercise and gain movements with the help of your doctor. Patients who exercise are able to shorten the period of their disability and achieve a cure quickly!