A study of role of arthroscopy in diagnosis and therapeutic intervention at tertiary health care centre

 

Rajkumar Indrasen Suryawanshi^1*, Amol Khairnar², Vikas Kamble³

 

 

Abstract               Background: Arthroscopy (also called arthroscopic or keyhole surgery) is a minimally invasive surgical procedure on a joint in which an examination and sometimes treatment of damage is performed using an arthroscope. Aims and Objectives: To Study role of arthroscopy in diagnosis and therapeutic intervention at tertiary health care centre. Methodology: After approval from institutional Ethical committee this longitudinal study was carried out in the Orthopedic patients at tertiary health centre who were associated with various joint related pathology during the one year period i.e. January 2017 to January 2018. In the one year there were 50 patients. The statistical analysis was done by Chi-square test and analyzed by SPSS 19 version software. Results: In our study we have seen that The majority of the patients were in the age group 50-60 i.e. 30% followed by 30-40 were18%, >60-16%. 40-50-10%, 20-30 were 4%. The majority of the patients were Male i.e. 58% and Female were 42%. MRI Detected 35 patients as TP, 7 as TN, 3 as FP and hence Sensitivity was 87.50% and Specificity was 70.00%, Accuracy of Diagnosis was 84%, Where as Arthroscopy detected 37 patients as TP,9 as TN, 3 as FN and 1 as FP and hence the Sensitivity was 92.50%, Specificity was 90% and Accuracy was 92.00%. The majority of the patients who undergone Arthroscopic surgeries were having Excellent and Satisfactory results i.e. 63.15% and 63.64% as compared to Non Arthroscopic Surgery i.e. 36.85% and 36.36% this observed difference was statistically significant(χ² = 8.534, df=3,p<0.03) Conclusion: It can be concluded from our study that the diagnostic efficacy of Arthroscopy was superior to MRI and the therapeutic results were superior to conventional non arthroscopic surgical management, so with the minimal complication, arthroscopy should be preferred for conventional diagnostic and therapeutic intervention.

Key Words: Arthroscopy, MRI (Magnetic Resonance Imaging).

 

 

INTRODUCTION

Arthroscopy (also called arthroscopic or keyhole surgery) is a minimally invasive surgical procedure on a joint in which an examination and sometimes treatment of damage is performed using an arthroscope, an endoscope that is inserted into the joint through a small incision. Arthroscopic procedures can be performed during ACL reconstruction. The advantage over traditional open surgery is that the joint does not have to be opened up fully. For knee arthroscopy only two small incisions are made, one for the arthroscope and one for the surgical instruments to be used in the knee cavity. This reduces recovery time and may increase the rate of success due to less trauma to the connective tissue. It has gained popularity due to evidence of faster recovery times with less scarring, because of the smaller incisions.¹ Irrigation fluid (most commonly 'normal' saline) is used to distend the joint and make a surgical space. The surgical instruments are smaller than traditional instruments. Surgeons view the joint area on a video monitor, and can diagnose and repair torn joint tissue, such as ligaments. It is technically possible to do an arthroscopic examination of almost every joint, but is most commonly used for the knee, shoulder, elbow, wrist, ankle, foot, and hip.

 

MATERIAL AND METHODS

After approval from institutional Ethical committee this longitudinal study was carried out in the Orthopedic patients at tertiary health centre who were associated with various joint related pathology during the one year period i.e. January 2017 to January 2018. In the one year there were 50 patients with their written consent, who were having various joint related pathology confirmed by Orthopedic Expert, Radiologist were included into the study. The variety of Diagnosis initially done by MRI, then Arthroscopy, necessary histopathology and clinical expert opinion was taken, finally the TP-True Positive, TN-True Negative, FP-False Positive, S-Sensitivity, Sp-Specificity, Ac-Accuracy etc. value of each diagnostic test i.e. AS-Arthroscopy, MRI-Magnetic Resonance Imaging was calculated by MEDCAL* software, out these 50 patients who requires surgical interventions was assessed, there were 40 patients who need various surgeries out of these 40 ;20 undergone the routine non arthroscopic surgical intervention and 20 undergone arthroscopic intervention. At the End of 6 weeks the results of both the groups was assessed as Excellent Satisfactory, Not Satisfactory as perceived by the patients. The statistical analysis was done by Chi-square test and analyzed by SPSS 19 version software.

 

RESULT

 

Table 1: Distribution of the patients as per the Age

The majority of the patients were in the age group 50-60 i.e. 30% followed by 30-40 were18%, >60-16%. 40-50-10%, 20-30 were 4%.

 

Table 2: Distribution of the patients as per the sex

The majority of the patients were Male i.e. 58% and Female were 42%.

 

Table 3: Diagnostic performance of Arthroscopy versus MRI

(TP-True Positive, TN-True Negative, FP-False Positive, S-Sensitivity, Sp-Specificity, Ac-Accuracy, AS-Artoscopy, MRI-Magnetic Resonance Imaging) MRI Detected 35 patients as TP, 7 as TN, 3 as FP and hence Sensitivity was 87.50% and Specificity was 70.00%, Accuracy of Diagnosis was 84%, Where as Arthroscopy detected 37 patients as TP,9 as TN, 3 as FN and 1 as FP and hence the Sensitivity was 92.50%, Specificity was 90% and Accuracy was 92.00%.

 

Table 4: Distribution of the patients with respect to results of surgery

(χ² = 8.534, df=3,p<0.03)

The majority of the patients who undergone Arthroscopic surgeries were having Excellent and Satisfactory results i.e. 63.15% and 63.64% as compared to Non Arthroscopic Surgery i.e. 36.85% and 36.36% this observed difference was statistically significant(χ² = 8.534, df=3,p<0.03)

 

DISCUSSION

Knee: Knee arthroscopy has, in many cases, replaced the classic open surgery (arthrotomy) that was performed in the past. Arthroscopic knee surgery is one of the most common orthopaedic procedures, performed approximately 2 million times worldwide each year.² The procedures are more commonly performed to treat meniscus injury and to perform anterior cruciate ligament reconstruction.³ While knee arthroscopy is commonly used for partial meniscectomy (trimming a torn meniscus) on middle aged to older adults with knee pain, the claimed positive results seem to lack scientific evidence.⁴ During an average knee arthroscopy, a small fiberoptic camera (the arthroscope) is inserted into the joint through a small incision, about 4 mm (1/8 inch) long. More incisions might be performed in order to visually check other parts of the knee and to insert the miniature instruments that are used to perform surgical procedures.

Osteoarthritis: The BMJ Rapid Recommendations group makes a strong recommendation against arthroscopy for osteoarthritis on the basis that there is high quality evidence that there is no lasting benefit and less than 15% of people have a small short-term benefit.⁵ There are rare but serious adverse effects that can occur, including venous thromboembolism, infections, and nerve damage^5,6 The BMJ Rapid Recommendation includes infographics and shared decision making tools to facilitate a conversation between doctors and patients about the risks and benefits of arthroscopic surgery.⁵ Two major trials of arthroscopic surgery for osteoarthritis of the knee found no benefit for these surgeries.^7,8 Many medical insurance providers are now reluctant to reimburse surgeons and hospitals for what can be considered a procedure which seems to create the risks of surgery with questionable or no demonstrable benefit. However this is still a widely adopted treatment for a range of conditions associated with osteoarthritis, including labral tears, femoroacetabular impingement, osteochondritis dissecans.⁹ A 2017 meta-analysis confirmed that there is only a very small and usually unimportant reduction in pain and improvement in function at 3 months (e.g. an average pain reduction of approximately 5 on a scale from 0 to 100).⁶ A separate review found that most people would consider a reduction in pain of approximately 12 on the same 0 to 100 scale important-suggesting that for most people, the pain reduction at 3 months is not important.¹⁰ Arthroscopy did not reduce pain or improve function or quality of life at one year.⁶ There are important adverse effects.⁶

Meniscal tears: One of the primary reasons for performing arthroscopies is to repair or trim a painful and torn or damaged meniscus.¹¹ The technical terms for the surgery is arthroscopic partial meniscectomy (APM). Arthroscopic surgery, however, does not appear to result in benefits to adults when performed for knee pain in patients with osteoarthritis who have a meniscal tear.^12,13,16 This may be due to the fact that a torn meniscus may often not cause pain and symptoms, which may be caused by the osteoarthritis alone.¹⁴ Some groups have made a strong recommendation against arthroscopic partial meniscectomy in nearly all patients, stating that the only group of patients who may - or may not - benefit are those with a true locked knee.² Professional knee societies, however, highlight other symptoms and related factors they believe are important, and continue to support limited use of arthroscopic partial meniscectomy in carefully selected patients.^15,16

Hip: Hip arthroscopy was initially used for the diagnosis of unexplained hip pain, but is now widely used in the treatment of conditions both in and outside the hip joint. The most common indication currently is for the treatment of femoroacetabular impingement (FAI) and its associated pathologies. Hip conditions that may be treated arthroscopically also includes labral tears, loose / foreign body removal, hip washout (for infection) or biopsy, chondral (cartilage) lesions, osteochondritis dissecans, ligamentum teres injuries (and reconstruction), Iliopsoas tendinopathy (or ‘snapping psoas’), trochanteric pain syndrome, snapping iliotibial band, osteoarthritis (controversial), sciatic nerve compression (piriformis syndrome), ischiofemoral impingement and direct assessment of hip replacement.

Shoulder: Arthroscopy is commonly used for treatment of diseases of the shoulder including subacromial impingement, acromioclavicular osteoarthritis, rotator cuff tears, frozen shoulder(adhesive capsulitis), chronic tendonitis, removal of loose bodies and partial tears of the long biceps tendon, SLAP lesions and shoulder instability. The most common indications include subacromial decompression, bankarts lesion repair and rotator cuff repair. All these procedures were done by opening the joint through big incisions before the advent of arthroscopy. Arthroscopic shoulder surgeries have gained momentum in the past decade. "Keyhole surgery" of the shoulder as it is popularly known has reduced inpatient time and rehabilitation requirements and is often a daycare procedure.

Wrist: Arthroscopic view showing two of the wrist bones. Arthroscopy of the wrist is used to investigate and treat symptoms of repetitive strain injury, fractures of the wrist and torn or damaged ligaments. It can also be used to ascertain joint damage caused by wrist osteoarthritis.

Spine: Many invasive spine procedures involve the removal of bone, muscle, and ligaments to access and treat problematic areas. In some cases, thoracic (mid-spine) conditions require a surgeon to access the problem area through the rib cage, dramatically lengthening recovery time. Arthroscopic procedures (also endoscopic spinal procedures) allow access to and treatment of spinal conditions with minimal damage to surrounding tissues. Recovery times are greatly reduced due to the relatively small size of incision(s), and many patients are treated as outpatients.¹⁷ Recovery rates and times vary according to condition severity and the patient's overall health. Arthroscopic procedures treat : Spinal disc herniation and degenerative discs, spinal deformity, tumors, general spine trauma

Temporomandibular joint: Arthroscopy of the temporomandibular joint is sometimes used as either a diagnostic procedure for symptoms and signs related to these joints, or as a therapeutic measure in conditions like temporomandibular joint dysfunction. TMJ arthroscopy can be a purely diagnostic procedure,¹⁸ or it can have its own beneficial effects which may result from washing out of the joint during the procedure, thought to remove debris and inflammatory mediators, and may enable a displaced disc to return to its correct position. Arthroscopy is also used to visualize the inside of the joint during certain surgical procedures involving the articular disc or the articular surfaces, similar to laparoscopy.¹⁹ Examples include release of adhesions (e.g., by blunt dissection or with a laser) or release of the disc.20 Biopsies or disc reduction can also be carried out during arthroscopy.¹⁸ It is carried out under general anesthetic.²¹ In our study we have seen that The majority of the patients were in the age group 50-60 i.e. 30% followed by 30-40 were18%, >60-16%. 40-50-10%, 20-30 were 4%. The majority of the patients were Male i.e. 58% and Female were 42%. MRI Detected 35 patients as TP, 7 as TN, 3 as FP and hence Sensitivity was 87.50% and Specificity was 70.00%, Accuracy of Diagnosis was 84%, Where as Arthroscopy detected 37 patients as TP,9 as TN, 3 as FN and 1 as FP and hence the Sensitivity was 92.50%, Specificity was 90% and Accuracy was 92.00%. The majority of the patients who undergone Arthroscopic surgeries were having Excellent and Satisfactory results i.e. 63.15% and 63.64% as compared to Non Arthroscopic Surgery i.e. 36.85% and 36.36% this observed difference was statistically significant (χ² = 8.534, df=3,p<0.03).

 

CONCLUSION

It can be concluded from our study that the diagnostic efficacy of Arthroscopy was superior to MRI and the therapeutic results were superior to conventional non arthroscopic surgical management, so with the minimal complication, arthroscopy should be preferred for conventional diagnostic and therapeutic intervention.

 

REFERENCES

1. Millar, Neal L.; Wu, Xiao; Tantau, Robyn; Silverstone, Elizabeth; Murrell, George A. C. (2009-04-01). "Open versus Two Forms of Arthroscopic Rotator Cuff Repair". Clinical Orthopaedics and Related Research. 467 (4): 966–978.
2. Siemieniuk RA, Harris IA, Agoritsas T, Poolman RW, Brignardello-Petersen R, Van de Velde S, Buchbinder R, Englund M, Lytvyn L, Quinlan C, Helsingen L, Knutsen G, Olsen NR, Macdonald H, Hailey L, Wilson HM, Lydiatt A, Kristiansen A, et al. (May 2017). "Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline". BMJ. 357: j1982. doi:10.1136/bmj.j1982. PMC 5426368 . PMID 28490431.
3. Jameson, S. S.; Dowen, D.; James, P.; Serrano-Pedraza, I.; Serrano-Pedraza, Deehan; Reed, M. R.; Deehan, D. J. (October 2011). "The burden of arthroscopy of the knee: a contemporary analysis of data from the English NHS". The Journal of Bone and Joint Surgery. British Volume. 93 (10): 1327–1333. doi:10.1302/0301-620X.93B10.27078. ISSN 2044-5377. PMID 21969430.
4. Järvinen, Teppo L N; Guyatt, Gordon H (20 July 2016). "Arthroscopic surgery for knee pain". BMJ: i3934. doi:10.1136/bmj.i3934.
5. Siemieniuk RA, Harris IA, Agoritsas T, Poolman RW, Brignardello-Petersen R, Van de Velde S, Buchbinder R, Englund M, Lytvyn L, Quinlan C, Helsingen L, Knutsen G, Olsen NR, Macdonald H, Hailey L, Wilson HM, Lydiatt A, Kristiansen A, et al. (May 2017). "Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline". BMJ. 357: j1982. doi:10.1136/bmj.j1982. PMC 5426368 . PMID 28490431.
6. Brignardello-Petersen R, Guyatt GH, Buchbinder R, Poolman RW, Schandelmaier S, Chang Y, Sadeghirad B, Evaniew N, Vandvik PO, et al. (May 2017). "Knee arthroscopy versus conservative management in patients with degenerative knee disease: a systematic review". BMJ Open. 7 (5): e016114. doi:10.1136/bmjopen-2017-016114. PMC 5541494 . PMID 28495819.
7. Kirkley, Alexandra; Birmingham, Trevor B.; Litchfield, Robert B.; Giffin, J. Robert; Willits, Kevin R.; Wong, Cindy J.; Feagan, Brian G.; Donner, Allan; Griffin, Sharon H. (2008-09-11). "A Randomized Trial of Arthroscopic Surgery for Osteoarthritis of the Knee". New England Journal of Medicine. 359 (11): 1097–1107. doi:10.1056/nejmoa0708333. ISSN 0028-4793. PMID 18784099.
8. Moseley JB, O'Malley K, Petersen NJ, et al. (July 2002). "A controlled trial of arthroscopic surgery for osteoarthritis of the knee". N. Engl. J. Med. 347 (2): 81–8. doi:10.1056/NEJMoa013259. PMID 12110735.
9. "Hip Arthroscopy Surgery in Sydney — From Dr. Sunny Randhawa (June 2015)". Retrieved 2008-01-14.
10. Devji T, Guyatt GH, Lytvyn L, Brignardello-Petersen R, Foroutan F, Sadeghirad B, Buchbinder R, Poolman RW, Harris IA, Carrasco-Labra A, Siemieniuk RA, Vandvik PO, et al. (May 2017). "Application of minimal important differences in degenerative knee disease outcomes: a systematic review and case study to inform BMJ Rapid Recommendations". BMJ Open. 7 (5): e015587. doi:10.1136/bmjopen-2016-015587. PMID 28495818.
11. Available at: www. Orthoinfo.com / www.wikipedia.com
12. Thorlund, J. B.; Juhl, C. B.; Roos, E. M.; Lohmander, L. S. (2015-06-16). "Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms". BMJ. 350: h2747. doi:10.1136/bmj.h2747. ISSN 1756-1833. PMC 4469973. PMID 26080045.
13. Khan, M; Evaniew, N; Bedi, A; Ayeni, OR; Bhandari, M (7 October 2014). "Arthroscopic surgery for degenerative tears of the meniscus: a systematic review and meta-analysis". CMAJ : Canadian Medical Association Journal. 186 (14): 1057–64. doi:10.1503/cmaj.140433. PMC 4188648  . PMID 25157057.
14. Englund M, Guermazi A, Gale D, et al. (September 2008). "Incidental meniscal findings on knee MRI in middle-aged and elderly persons". N. Engl. J. Med. 359 (11): 1108–15. doi:10.1056/NEJMoa0800777. PMC 2897006  . PMID 18784100.
15. Stone, Jonathan A.; Salzler, Matthew J.; Parker, David A.; Becker, Roland; Harner, Christopher D. (2017-04-21). "Degenerative meniscus tears - assimilation of evidence and consensus statements across three continents: state of the art". Journal of ISAKOS: Joint Disorders and Orthopaedic Sports Medicine. 2 (2): 108–119. doi:10.1136/jisakos-2015-000003.
16. Beaufils, Ph; Becker, R.; Kopf, S.; Englund, M.; Verdonk, R.; Ollivier, M.; Seil, R. (2017-02-01). "Surgical management of degenerative meniscus lesions: the 2016 ESSKA meniscus consensus". Knee Surgery, Sports Traumatology, Arthroscopy. 25 (2): 335–346. doi:10.1007/s00167-016-4407-4. ISSN 0942-2056.
17. "Minimally Invasive Endoscopic Spinal Surgery". June 20, 2005. Cleveland Clinic contribution to SpineUniverse.com
18. Wray D, Stenhouse D, Lee D, Clark AJ (2003). Textbook of general and oral surgery. Edinburgh [etc.]: Churchill Livingstone. pp. 173–178. ISBN 0443070830.
19. Kalantzis A, Scully C (2005). Oxford handbook of dental patient care, the essential guide to hospital dentistry (2nd ed.). New York: Oxford University Press. pp. 116, 117. ISBN 9780198566236.
20. Guo, C; Shi, Z; Revington, P (October 7, 2009). "Arthrocentesis and lavage for treating temporomandibular joint disorders". Cochrane Database of Systematic Reviews (4): CD004973. doi:10.1002/14651858.CD004973.pub2. PMID 19821335.
21. Kerawala C, Newlands C, eds. (2010). Oral and maxillofacial surgery. Oxford: Oxford University Press. pp. 342–351.