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Arthroscopic Surgery
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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
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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. |
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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.
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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. |
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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. |
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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.
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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. |
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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
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- 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.
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Exercises for the upper limb to decrease post-operative swelling
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- 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.
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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. |
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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. |
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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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