Diagnostic Arthroscopy

A diagnostic knee arthroscopy is a procedure to look inside your knee joint. An arthroscope is a flexible tube with a light and camera on the end. Diagnostic arthroscopy is usually done to check for disease or damage inside your knee.

Ligament reconstruction

Ligaments are bands of tough, elastic connective tissue that surround a joint to give support and limit the joint's movement.

When ligaments are damaged, the knee joint may become unstable. Ligament damage often happens from a sports injury. A torn ligament severely limits knee movement. This results in the inability to pivot, turn, or twist the leg. Surgery is a choice to repair a torn ligament if other medical treatment is not effective.

Anterior cruciate ligament (ACL)

Anterior Cruciate Ligament Reconstruction or simply ACL Reconstruction is a surgical procedure where the torn ACL ligament is removed and replaced with a graft sourced from the same patient. Usually, the grafts are sourced from the same patient’s hamstring tendon. The surgery is done using minimally invasive arthroscopic techniques. People with the injury to the anterior cruciate ligament get ACL reconstruction surgery.


How does ACL injury occur?

Most ACL injury happens during sports. When the sportsmen move sharply while running, jumping or hitting another sportsman, and if the impact area is the knee, then an ACL injury might occur. In non-sports person, the injury to ACL is caused due to sudden abrupt fall or trauma to knees where the knee is stretched or strained badly. Very commonly a fall from the two-wheeler.

Do all ACL injuries require ACL Reconstruction Surgery?

If the injury to the ACL is a slight tear or just a strain, ACL reconstruction surgery may not be required. There are three grades of ACL injuries.

  • The first grade of ACL injury is where the ligament is slightly strained and stretched and there is no tear. There might be slight swelling and pain, but the knee does not have any instability.
  • The second grade of ACL injury is where the ligament is partially torn. There might be swelling, and the knee may give way and show instability.
  • The third grade of ACL injury is where the ligament is completely torn into two parts. There are tenderness and swelling. The knee is completely unstable and can show signs of giving away at times when there is activity

Who gets ACL Reconstruction Surgery?

A person who has got a badly injured Anterior Cruciate Ligament (ACL) are candidates for ACL Reconstruction surgery. When the anterior cruciate ligament is completely torn, the knee becomes unstable and such patients require ACL reconstruction surgery. Usually, people with third-degree ACL injuries are ideal candidates for ACL Reconstruction Surgery. If the person with second degree ACL injury has pain with unstable knee and is younger in age, then ACL reconstruction surgery can be recommended.

Generally, people with a first degree and second degree ACL injuries are given physical therapy or physiotherapy. The therapy is aimed at managing the pain and strengthening the muscles around the knee so that instability to the knee is addressed.

ACL Reconstruction Surgery Procedures
  • The patient is administered anesthesia and then taken to surgical theatre.- Slightly below the knee a small incision is made. The incision is made to harvest the graft needed from the hamstring. The semitendinosus and gracilis tendons are harvested through this incision. The incision is usually just 1 inch in length.- The harvested graft is prepared separately. Usually the tendon so harvested is folded and sutured and made into one solid string. The preparation of the graft happens side-by-side as the orthopedic surgeon prepares the knee to take in the graft.
  • The surgeon then proceeds to drill two tiny holes on either side of the patella. This incision is required to remove the torn ACL and also to drill tiny hole on the thigh bones that will attach the graft.
  • The surgeon then removes the torn ACL from the site. This removal clears the way to place the graft accurately inside the femoral and tibial tunnel.
  • Femoral and tibial tunnels are small drills of appropriate depth that are created on the femur (thigh bone) and the tibia (shin bone) by the ortho surgeon. These two drills are required to place the grafts firmly in place.
  • The prepared hamstring graft is then pulled inside the intended position and one end of it is placed inside the femoral tunnel and the other end is placed inside the tibial tunnel.
  • Bioabsorbable screws are then used to tighten the graft to the tibia bone. These screws do not warrant removal as they fuse naturally with the bones eventually offering stability. On the femoral side, the graft is stabilized and fixed with a small suspensory device with a small button made of titanium.
  • After this all the incisions are sutured and closed. The patient is then discharged from the surgical theatre and lodged in the recovery room.

What is Anterior Cruciate Ligament Reconstruction using Transportal Technique?
  • It refers to the same ACL Reconstruction surgery only. Traditionally the femoral (thigh bone) tunnel is prepared aiming through the tibial tunnel referred as Trans-tibial position (referred as TT). Because the aiming device goes through the tibial tunnel which is usually between 6-8 mm, the selection of the femoral tunnel may not be accurate all the times.In the new Transportal Technique, the position of the drill is lowered to a more anatomic position which can be done independently and freely. This newer technique is said to be superior to the traditional trans-tibial position. The advantages they offer is more control of rotational instability post surgery and less incidence of meniscal tear and cartilage tear post surgery.
Posterior cruciate ligament (PCL)

Posterior Cruciate Ligament Reconstruction or simply PCL Reconstruction is a surgical procedure where the torn PCL ligament is removed and replaced with a graft. The graft sourced from the same patient’s hamstring tendon is used in the PCL reconstruction.

How does PCL injury occur?

Most PCL injury happens during sports. The injury to PCL alone can happen when there is a direct blow to the front of the knee when it is in bent position or when it is in a flexed position. In non-sports person the injury to PCL can be caused by trauma or accidents to or when there is a hard landing to the knee. Accidents involving two wheelers are common.

Generally speaking, given the strength of the PCL, an isolated injury to the PCL alone is rare. So a PCL injury is mostly accompanied by injury to the surrounding hard and soft tissues. It also needs to be emphasized that ACL injury is more rampant than the PCL injury.

Do all PCL injuries require PCL Reconstruction Surgery?

If the injury to the PCL is partial and is more of a sprain, PCL reconstruction surgery may not be required. There are three grades of PCL injuries.

  • The first grade of PCL injury is where the ligament is sprained there is only a partial tear. There might be slight swelling and pain but the knee does not have any instability.
  • The second grade of PCL injury is where the ligament suffers near complete tear. There might be swelling and the knee may give way and show instability.
  • The third grade of PCL injury is where the ligament has a complete tear. There are tenderness and swelling. The knee is completely unstable and the ligament has lost functionality. The knee gives away when there is activity and it is extremely painful.

Who gets PCL Reconstruction Surgery?

A person with grade three PCL injuries is a candidate for PCL Reconstruction surgery. If the person with second degree PCL injury has pain and shows instability of the knee, then PCL reconstruction surgery is widely recommended given the importance of PCL in functionality of the knee.

Generally people with first degree and second degree PCL injuries are given physio-therapy. The therapy is aimed at managing the pain and strengthening the muscles around the knee so that instability to the knee is addressed.

PCL Reconstruction Surgery Procedures
  • The patient is administered anesthesia and then taken to surgical theatre.
  • Slightly below the knee, a small incision is made. The incision is made to harvest the graft needed from the hamstring. The semitendinosus and gracilis tendons are harvested through this incision. The incision is usually just 1 inch in length.
  • The harvested graft is prepared separately. Usually, the tendon so harvested is folded and sutured and made into one solid string. The preparation of the graft happens side-by-side as the orthopedic surgeon prepares the knee to take in the graft.
  • The surgeon then proceeds to create a posteromedial portal and introduces a service cannula. Through this cannula, a guiding wire is inserted through which the graft will be pulled inside.
  • The surgeon then removes the torn PCL from the site. This removal clears the way to place the graft accurately inside.
  • The anatomical position of PCL is more interior and is more complex than the ACL. Hence the drills made for PCL reconstruction are more complex and different in positions.
  • Then femoral (thigh bone) and tibial (shin bone) tunnels are created separately. PCL jigs are used to assist in the drilling.
  • Femoral and tibial tunnels are small drills of appropriate depth that are created on the femur (thigh bone) and the tibia (shin bone) by the ortho surgeon. These two drills are required to place the grafts firmly in place.
  • The prepared graft is then pulled inside the intended position and one end of it is placed inside the femoral tunnel and the other end is placed inside the tibial tunnel. The pulling of the graft inside and placing in the intended position itself is a complex two-step procedure going through the complex drills created.
  • Bioabsorbable screws are then used to tighten the graft to the tibia bone. These screws do not warrant removal as they fuse naturally with the bones eventually offering stability
  • On the femoral side, the graft is stabilized and fixed with a small suspensory device which has a small button made of titanium.
  • Once the surgery is over, the orthopedic surgeon then proceeds to do a Lachman’s test. This is done to test the stability of the knee. Once the surgeon is convinced that the grafts have been perfectly placed and the knee is stable he proceeds to close the incisions by suturing them.
  • The patient is then discharged from the surgical theatre and lodged in the recovery room.
Meniscus Repair

Meniscectomy is a surgical procedure where the meniscus is removed either partially or fully. Meniscus is a fibrous cartilage that runs connecting the tibia (shin bone) and the femur (thigh bone). There are two menisci inside each of our knee, namely the lateral meniscus and the medial meniscus.

How does Meniscus tear occur?

A sudden twist to the knee or wearing off can cause meniscus to tear. Most ACL and PCL injuries are accompanied by tearing of meniscus. However meniscus tear can also happen in isolation. In the young age group, the tear happens predominantly while they play any sport. In the higher age group, beyond the age of 40, isolated meniscal tear can happen due to wear and tear of the menisci. The twist, the kneeling, the squatting and all the pressure so created passes on to the menisci of the knee and they slowly degenerate leading to tear as they wear. That is why the knee pain that has manifested over years may be because of the tear the meniscus has suffered.

Can the torn menisci not heal by itself?

Certain tissues in our body are not regenerative like skin. Unfortunately, the menisci are non-regenerative and hence any tear to them cannot heal itself. The meniscus has a two-third outer portion which is supplied with blood and a one-third inner portion which does not have any blood supply. This outer portion, in turn, has a portion that is fully supplied with blood called the red-red region and a portion inside that is partially supplied with blood called the red-white region. The deep inner portion with no blood supply is called the white-white region. Any tear to the outer portion (Red-red region) can heal because of the presence of the blood supply where a tear that has proceeded deep inside (white-white) cannot heal at all. The red-white region can heal with Meniscal Repair Surgeries.

Do all Meniscal Tear require Meniscectomy?

Not really. Meniscectomy is done when the meniscus tear is too large and it has “locked” the knee. The locked knee is referred as bucket handle meniscus tear. The locked knee is also characterized by persistent swelling. If the two conditions have prevented the patient from carrying on with the normal daily activities, then Meniscectomy is required. Meniscectomy can be either partial or complete depending on the situation.

Meniscectomy Surgery Procedures
  • The patient is administered general anesthesia most of the time and then taken to surgical theatre. Sometimes the patient may also be given a spinal anesthesia
  • Three small incisions are made to the knee for inserting the camera and special arthroscopic surgical instruments that will be used to remove the torn part of the meniscus.
  • With these arthroscopic instruments, the rough edges of the meniscus are trimmed and made smooth.
  • A drain is placed which assists in draining the fluid accumulated in the surgical area. This assists in the healing process.
  • The incisions are closed with sutures and the patient is discharged from the surgical theatre to the recovery room.

Risks involved in Meniscectomy

Complete or Total Meniscectomies are often thought to cause degenerative arthritis in the long run. Since the meniscus provides cushion and also helps in load bearing, the absence of it caused by total meniscectomy can lead to this risk. Generally, the orthopedic surgeon informs the patient about this risk. Hence Complete Meniscectomy surgeries are performed keeping in mind this impending risk. This surgery is done only after careful consideration and taking into account the locked condition of the knee where the patient gives consent to perform Complete Meniscectomy.

Cartilage surgeries

Cartilage surgery is performed arthroscopically or an incision is made in the front of the knee. Arthroscopy consists in making two small 5-mm incisions in the front of the knee. An arthroscope, or small camera, is inserted through one of the incisions to view the joint, and in particular the damaged cartilage. Small instruments are inserted through the other incision to carry out the surgery.

Arthroscopic surgery is often used for cartilage reattachment as well as the microfracture technique.

Diagnostic

Diagnostic shoulder arthroscopy is frequently used to evaluate and treat several shoulder conditions including rotator cuff tears, labral tears, adhesive capsulitis, and subacromial impingement.

Subacromial Decompression

During subacromial decompression the surgeon removes or shaves down part the shoulder blade’s acromion. By removing bone tissue, the surgeon creates more space for the shoulder’s soft tissues, including the rotator cuff, tendons, and the subacromial bursa. Removing bone does not typically affect the shoulder joint’s long-term function. This surgery is most likely to be recommended if the acromion is curved or hook-shaped (as opposed to flat), as experts believe these shapes increase the likelihood for impingement.

Rotator Cuff Repair

Rotator cuff repair is surgery to repair a torn tendon in the shoulder. The procedure can be done with a large (open) incision or with shoulder arthroscopy, which uses smaller incisions

Bankart repair

A Bankart Shoulder Repair procedure is a surgical technique for the repair of recurrent shoulder joint dislocations. Within the procedure, the worn out ligaments are re-attached to the proper place in the shoulder joint, using the objective of rebuilding normal function.

Recurrent Dislocation

Recurrent dislocation implies having repeated dislocations of the shoulder. Patients with a tendency for recurrent (repeated) dislocation or subluxation are said to have an unstable shoulder or shoulder instability (unstable shoulder). Shoulder instability may follow after a traumatic dislocation (after a fall or injury to the shoulder), due a generalized laxity of ligaments, or due to gradual stretching of the joint capsule due to a repetitive injury as in a throwing athlete.

Capsular release for frozen shoulder

Capsular release is a minimally invasive surgical procedure to treat frozen shoulder (adhesive capsulitis). This is a condition that develops when the capsule of connective tissues surrounding the shoulder thickens and tightens, causing pain and restricted movement.

Cartilage Surgeries

In the shoulder, cartilage protects the end of the upper arm bone (the humerus) as well as the internal surface of the joint, called the glenoid cavity. These two structures comprise a ball-and-socket joint that can move in many different directions. When the protective cartilage inside the joint begins to wear away and break down, it can result in significant pain when reaching upward or behind your back, lifting objects, reaching across your body, or moving your arm in an arcing motion.

There are several minimally invasive techniques that can be used to restore damaged joint cartilage including shoulder surgery and arthroscopy. The technique that’s used in your case will depend on several factors, including the cause and extent of the joint damage, your overall health, your lifestyle, and other factors.

Diagnostic

Diagnostic elbow arthroscopy can evaluate the elbow and provide a detailed diagnosi.

Cartilage

Arthroscopic techniques are used to restore damaged elbow cartilage.

Diagnostic

During diagnostic hip arthroscopy, a small and flexible tube with a camera is inserted within the small incisions made. The procedure is performed to determine the condition of the cartilage, ligaments, whether there is loose cartilage material, inflammation, or bone spurs.

Lateral Repair

Surgery to repair a hip labral tear is usually done arthroscopically. This is a minimally invasive surgery in which the doctor makes small incisions (cuts) in the hip and uses miniature instruments to make the following repairs: Refixation or repair (stitching the torn tissue back together)

FAI (Femoroacetabular Impingement)

Femoroacetabular impingement (FAI) is a condition in which extra bone grows along one or both bones that form the hip joint — giving the bones an irregular shape. Because they do not fit together perfectly, the bones rub against each other during movement. Over time this friction can damage the joint, causing pain and limiting activity.

Many FAI problems can be treated with arthroscopic surgery. Arthroscopic procedures are done with small incisions and thin instruments. We clean out any damage to the labrum and articular cartilage.

Diagnostic

Diagnostic Ankle Arthroscopy can evaluate the ankle and provide a detailed diagnosis. Ankle arthroscopy allows the orthopaedic surgeon to see the current status of the ligaments, cartilage, synovia and bones forming the complex ankle joint.

Cartilage

Arthroscopic techniques are used to restore damaged ankle cartilage.

Diagnostic

Diagnostic wrist arthroscopy can evaluate the writst and provide a detailed diagnosis

TFCC Repair

This is a minimally invasive procedure in which 2 to 3 small incisions of 5 mm each are made in the wrist. A slender viewing instrument called an arthroscope and other surgical instruments are inserted as needed. Repair is based on the damage caused to the ligament and cartilage.

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