Indications: Trauma (including Meniscal injury, Chondral damage, Ligament rupture, joint line fractures) Osteoarthritis, Rheumatoid Arthritis
Patients are seen in this specific clinic approximately 2-3 weeks prior to surgery. Here they under a thorough assessment by both medical and nursing staff. This includes simple blood and urine tests as well as the taking of swabs which identify patients carrying certain bacteria including MRSA. Mr Hartwright sees patients at this point in order to explain the nature of the surgery and possible risks, identify any possible problems, obtain the patient’s consent to surgery and, of course, to answer any outstanding questions the patient may have.
Patients normally receive a General Anaesthetic (GA).
If a patient is thought to have any anaesthetic risk factors which may cause problems during, or after surgery, they are seen in pre-assessment clinic or given an appointment to see an Anaesthetist well before the day of surgery.
Once positioned on the operating table a tourniquet is applied and an Examination Under Anaesthesia (EUA) is performed. This allows a more thorough assessment of the knee than is possible in the clinic setting.
Mr Hartwright performs the operation through two small stab incisions (approximately 0.5cm) on either side of the knee (the so called anterolateral and antermedial ports). These allow him to pass the arthroscope and instruments into the knee joint.
Initially the knee is examined both by directly visualising and probing all parts of the joint: including the lining of the joint (synovium), the joint surfaces, menisci and ligaments. It is at this point that the diagnosis is made and a decision made regarding treatment.
The Menisci are rubbery, crescentic shaped pieces of fibrocartilage that lie on either side of the joint. They have a number of different functions including to act as shock absorbers to the knee. In twisting injuries, the menisci can be torn and subsequently cause symptoms eg locking, clicking, pain. There are several different types of tear (horizontal, radial, bucket-handle etc.). Treatment depends upon the pattern of the tear but tends to be either repair or excision of the affected part of the meniscus.
Meniscal repair involves roughening of the torn surfaces and suturing of the tear. This is all performed within the knee and so no further incisions are (usually) necessary. Only certain types of meniscal tear are amenable to this type of treatment and this is can only be assessed during the procedure. Post operatively, the repair needs to be protected and so a period of gentle rehabilitation and occasionally bracing is required.
Partial menisectomy: This is where the torn part of the meniscus is removed. As much of the normal meniscus is preserved in order to retain the functions of the tissue and decrease the potential for late Osteoarthritis.
The part of the bones that make up the knee joint i.e. those parts of the bone articulating with one another (femur, tibia and patella) are covered in a thin layer of specialised tissue called Hyaline (or articular) cartilage. This tissue facilitates the fluid movement of the joint. In certain conditions (e.g. Osteochondritis Dissecans, Chondromalacia) and trauma, this surface can be damaged. Treatment of this damage depends upon several factors but ranges from conservative management to Autologous Chondrocyte Implantation.
It is the articular cartilage that is significantly affected in Osteoarthritis (wear and tear arthritis). The cartilage becomes thin, losing it’s smooth surface and is eventually worn away completely exposing the underlying bone.
In any of the above conditions, if part of the articular cartilage (+/- an area of the attached bone) breaks off, this becomes a loose body. This can interfere with the normal function of the knee causing pain, locking and can sometimes actually be felt by the patient
Arthroscopy of the knee is a day-case procedure i.e. the patient can return home on the same day. It does require a general anaesthetic so patients are advised to have a friend/relative to collect them from hospital and to look after them for the first 12-24 hours.
Mr Hartwright encourages patients to start mobilising as soon as comfort allows. This is done under the supervision of either the physiotherapists or nursing staff. Most patients start to walk within an hour or so of the operation albeit with crutches surgery.
Patients are provided with instructions as to the exercises that they should perform once discharged. It is vital that they do these exercises in order to optimize the results of surgery.
Mr Hartwright uses steristrips to close the skin. These are covered by a simple dressing and the knee is bandaged with wool and crepe. The bandage can be removed at 48-72 hrs but the dressings should remain intact for 7-10 days post-operatively. This is normally performed by the patient’s district or practice nurse. The wounds should be kept dry for the same period of time.
Patients are allowed to drive as soon as they feel safe (and are able to perform emergency manoeuvres).
Patients normally require 2 weeks off work (depending upon their type of employment i.e. desk job or manual labour).
Potential Risks
There are many other potential risks but the above probably represent the most important and certainly most asked about.