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TYPE OF OPERATION
Day case procedure, meaning most patients will not need to stay the night and can go home later in the day after the operation.
‘Keyhole’ operation, meaning that the operation within the knee is carried out through small incisions with special instruments, avoiding making a large incision and opening into the knee.
Arthroscopy means ‘looking inside the joint’. As well as inspection, some treatments can be administered at the same time via the ‘keyhole’ approach.
INDICATIONS (REASONS FOR HAVING THE OPERATION)
The decision to have any kind of operation is made case by case and in discussion with the patient in clinic. Individual circumstances vary. The following is a brief summary of what is generally possible:
Arthritis of the knee:
Inspection of the condition of the knee in the course of planning further treatment.
Removal of detached cartilage. Loose, detached cartilage can occur with arthritis and can aggravate the condition. Removal of the loose cartilage (debridement) will not restore normality to the knee but can make the arthritis more manageable for up to one year, avoiding more complex surgery.
(Also known as cartilage tear, occurring in an otherwise healthy or only minimally arthritic knee), often in sporting accidents. The torn and loose portion of meniscus (the soft cartilage rings of the knee) can cause locking or giving way and pain. It can be removed to resolve those symptoms with surgery. In a few circumstances and only in patients under the age of 30, the meniscus has some healing potential and it is possible to repair the meniscus instead of removing the detached portion. If this is performed, the knee needs to be in a brace and crutches used to offload for 6 weeks, therefore, return to activity takes longer.
Joint surface cartilage injury:
The articular cartilage (the hard surface cartilage of the knee) can be similarly chipped in an accident. The loose fragment can also cause locking or giving way and there may be pain from the location that has lost the fragment of surface cartilage. It may be helpful to remove the detached fragment and sometimes to carry out ‘microfracture’ which is a procedure to stimulate some substitute scar tissue to grow in the defect and fill it in, improving the symptoms. Microfracture also necessitates bracing and crutches for 6 weeks.
There are also several other less common situations in which an arthroscopy may be helpful. These include ligament release for some types of dislocating patella, synovectomy or removal of the lining of the knee for some types of inflammatory arthritis (eg: rheumatoid arthritis) and biopsy.
ARRANGEMENTS ON THE DAY OF SURGERY
Full details will be provided if you are booked in for surgery. The following is a brief summary of what you can generally expect.
You will be asked to attend hospital, having fasted that day either early in the morning (for a morning operating list) or late morning (for an afternoon operating list). You will be waiting before and after the operation for a few hours altogether, so please bring reading material.
The anaesthetic is usually a general anaesthetic (fully unconscious) but it is also possible to use a spinal anaesthetic and remain awake. We will discuss this at the time.
Following the operation, we will keep you for around 2 or 3 hours for observation. Almost all patients can then be discharged home, as long as there is someone to accompany you home and supervise for the next 24 hours. You will not be able to drive home yourself.
Arthroscopic synovectomy for inflammatory arthritis is a more extensive procedure and together with bilateral arthroscopy (both knees at the same time) may require a one night stay.
Patients are routinely discharged later on the day of surgery.
The knee will have a bandage and the patient will be walking with two crutches, weight bearing as tolerated to full weight bearing. Physiotherapy exercises will be instructed.
A few patients (eg: who have had microfracture treatment or meniscal repair) may be instructed to partially weight bear for 6 weeks and wear a brace that is provided. This will delay return to activity or work and we will discuss with you before the operation if you would therefore wish to have these procedures, depending on your schedule and work demands.
We will ask the nurse at your GP practice to remove the bandage after 48 hours and remove the stitches (sutures) after 10-12 days.
The pace of recovery varies greatly between patients and situations. The following is a brief guide to what one can generally expect. Sometimes it is possible to return to function much sooner but similarly recovery can also take longer on occasions and it is advisable to allow for this.
Patients will ordinarily spend about 1 week resting at home and carrying out physiotherapy exercises. Walking will be with two crutches for the first few days then one crutch for another few days. It is possible to use stairs with crutches. Patients are encouraged to walk outside the house by two weeks and can usually return to driving by 2 or 3 weeks. Some patients may find that they need crutches for up to 6 weeks.
Recovery from the operation takes about 6 weeks but the actual clinical outcome is variable and is dependent on the pathology being treated.
You will have an appointment for a review in clinic at 6 weeks following the surgery.
Fit patients with isolated meniscal tears in an otherwise healthy knee undergoing arthroscopy and removal of loose cartilage would be ready to commence exercise and normal activities after 6 weeks and can expect an improvement and return to sport by by 3 to 6 months. Physiotherapy may also be recommended in order to achieve a satisfactory result. If there is a co-existing ligament injury, you may need further treatment which will be discussed at the review clinic appointment.
Patients with arthritic knees undergoing inspection and removal of loose cartilage will have a variable outcome depending on the severity of arthritis. Symptoms may be improved for up to about one year in two thirds of cases. However, there may well be no improvement in symptoms or potentially a slight deterioration in about one third, requiring further treatment. The latter situation arises if the arthritis is found to be more advanced than was apparent form x-rays. In this situation, even if the arthroscopy may not have improved symptoms, it will still have provided the necessary information to be able to plan further treatment.
Knee arthroscopy carries a low risk of significant complications, however, as with any operation, there can be adverse outcomes and therefore an operation should only be carried out if the symptoms are sufficiently troublesome in the first place to justify the risks. We can reach a sensible decision on the requirement for surgery following a discussion in clinic.
The common complications which are not serious but can delay recovery include:
- Discharge or fluid leak from the small incisions in the first few days. This may require re-bandaging.
- Excessive swelling of the knee and/or leg. This can delay progress but not necessarily alter the eventual outcome.
- Persisting pain or slow recovery is common, especially with arthritic knees and may improve with an injection that will be administered at the 6 week clinic appointment if necessary.
Uncommon complications include:
- superficial scar inflammation or minor infection. If this is suspected please contact the relevant secretary and we will arrange a prompt review. If confirmed, would respond to simple antibiotics.
- A ‘Deep Vein Thrombosis’ (DVT) or blood clot in the deep veins of the leg. This can occur in approximately 5% of cases and causes tight swelling, redness, discomfort and tenderness of the calf. If suspected, please seek a same day appointment with your GP to be assessed. Simple swelling that goes down with lying down at night and elevation is not a sign of DVT. Most legs will swell after surgery and is normal and does not require a review.
- Sensitivity of the scar may prevent kneeling but should resolve over a few months.
Rare complications include:
- Internal infection in the knee itself. This occurs in about 0.5% of cases, despite the sterile precautions of the operation. This may occur In the first two weeks following surgery; the knee would become strikingly swollen and painful and be impossible to bend or straighten without much pain. If suspected, you should attend A&E immediately for assessment. A simple test in A&E will determine if the cause is infection or just plain swelling which is of no concern. An actual infection in the joint (septic arthritis) will require admission to hospital, further surgery and antibiotics for several weeks. It may also cause some long term damage, however, it is rare.
- Pulmonary Embolus (blood clot extension to the lungs). This is rare but can occur after any operation, including knee arthroscopy. Symptoms typically include feeling breathless, pain in the chest with breathing and sometimes coughing with some blood. If suspected, please attend A&E immediately for assessment.
There are many other potential complications and adverse outcomes of any operation but which are uncommon. If you have any particular concerns, please discuss with Mr Sehat in clinic.
Complications of surgery are kept to the minimum that the present knowledge and technology allows, nevertheless can still occur. This means that surgery should only be considered in situations in which the actual condition being treated is sufficiently problematic to justify the risks of adverse outcomes and complications. This is ultimately a decision for each patient to make, having been informed of the options for treatment and the potential risks. Mr Sehat will help you to reach a reasonable decision on whether surgery is the right course of action in any particular situation and if you would like to discuss further, please request an appointment.