Arthroscopy (Encyclopedia of Nursing & Allied Health)

Definition

Arthroscopy is the examination of a joint, specifically, the inside structures. The procedure is performed by inserting a specifically designed illuminated device, called an arthroscope, into the joint through a small incision. Arthroscopy may be used to diagnose, as well as treat, conditions. When a repair is performed, the procedure is called arthroscopic surgery.

Purpose

Arthroscopy is used primarily by physicians who specialize in treating disorders of the bones and related structures (orthopedics) to help diagnose joint problems. Once described as essential for those who primarily care for athletic injuries, arthroscopy is now a technique commonly used by orthopedic surgeons for the treatment of patients of all ages. The six joints most frequently examined are:

• knee
• shoulder
• elbow
• ankle
• hip
• wrist

Arthroscopy is primarily used to help diagnose joint problems. This procedure, most commonly associated with knee and shoulder problems, allows accurate examination and diagnosis of damaged joint ligaments, surfaces, and other related joint structures. The illustration above indicates the most common entry sites, or portals, in knee arthroscopy. (Illustration by Electronic Illustrators Group.)

A joint is a complex system. Within a joint, ligaments attach bones to other bones, tendons attach muscles to bones, cartilage lines and helps protect the ends of bones, and a special fluid (synovial fluid) cushions and lubricates the structures. Direct visualization of the joint allows the doctor to see exactly which structures are damaged. Arthroscopy also permits earlier diagnosis of many types of joint problems, including those that had been difficult to detect in previous years.

Precautions

Arthroscopy is contraindicated for patients with ankylosis, due to the stiffness of the joint involved. Arthroscopy is also contraindicated in patients with an existing local infection, due to the potential for sepsis. Because of inflammation after the use of contrast dye, arthroscopy is contraindicated in patients who have recently undergone an arthrogram. Most arthroscopic procedures are performed as same-day surgery and do not require hospital admission. A few hours following the procedure, the patient is allowed to return home, although usually someone else must drive. Depending on the type of anesthesia used, the patient may need to remain NPO (nil per os, nothing by mouth) for several hours prior to the arthroscopy. Before the procedure, the anesthesiologist will ask if the patient has any known

allergies to local or general anesthetics. Airway obstruction is always possible in any patient who receives a general anesthesia. Because of this, oxygen, suction, and monitoring equipment must be available. Cardiac status should be monitored in the event that any abnormalities arise during the procedure.

Description

The arthroscope is an instrument used to directly examine the joint. It contains magnifying lenses and glass-coated fibers that send concentrated light into the joint. A camera attached to the arthroscope allows the surgeon to view a clear image of the joint. This image is then transferred to a monitor. By attaching the arthroscope to a monitor, the surgeon is able to view the interior of the joint. This video technology is also important for documentation of the arthroscopic procedure. For example, if the surgeon decides after the arthroscopic examination that a conventional approach to surgically expose or "open" the joint (arthrotomy) must be used, a good photographic record will be useful when the surgeon returns to execute the final surgical plan.

The procedure requires the surgeon to make several small incisions (portals) through the skin's surface into the joint. Through one or two of the portals, the pencil-sized instruments that contain a lens and lighting system to magnify and illuminate the joint structures are inserted. The joint is inflated with a sterile saline solution to expand the joint for viewing. Often, following a recent traumatic injury to a joint, the synovial fluid may be cloudy, making interior viewing of the joint difficult. Therefore, a constant flow of the saline solution may be necessary. In other cases, a tourniquet may be applied in order to distend the joint, rather than use an infusion. The arthroscope is placed through one of the portals to view and evaluate the condition of the joint.

Preparation

The patient should be kept NPO after midnight the day of the procedure. Follow facility procedure for shaving the skin area around the joint, if needed.

Before the arthroscopy, the surgeon completes a thorough medical history and evaluation, which may reveal other disorders of the joint or body parts. Anatomical models and pictures are useful aids to explain to the patient the proposed arthroscopy and what the surgeon may be looking at specifically.

Proper draping of the body part is important to prevent contamination from instruments used in arthroscopy. Draping packs used in arthroscopy usually include disposable paper gowns and drapes with adhesive backing.

General or local anesthesia may be used during arthroscopy. Local anesthesia is preferred because it reduces the risk of lung and heart complications. The local anesthetic may be injected in small amounts in multiple locations in skin and joint tissues in a process called infiltration. In other cases, the anesthetic is injected into the spinal cord or a main nerve supplying the area. This process is called a "block," as it blocks all sensation below the main trunk of the nerve. For example, a femoral block anesthetizes the leg from the thigh down. Most patients are comfortable once the skin, muscles, and other tissues around the joint are numbed by the anesthetic; however, some patients may be given a sedative if they express anxiety about the procedure. It is important for the patient to remain still during the arthroscopic examination.

General anesthesia may be used if the procedure is unusually complicated or painful, or extensive surgery is planned. For example, people who have relatively "tight" joints may be candidates for general anesthesia because the procedure may take longer and cause more discomfort.

Aftercare

The portals are closed by small tape strips or sutures and covered with sterile dressings and a pressure bandage. The patient spends a short amount of time in the recovery room after arthroscopy. Most patients can go home after about an hour in the recovery room. A routine arthroscopy may take from 30 minutes to two hours.

Following the surgical procedure, the patient needs to be aware of the signs of infection, which include redness, warmth, excessive pain, and swelling. The risk of infection increases if the incisions become wet too early following surgery. Patients can cover the joint with plastic (for example, a plastic bag) while showering after arthroscopy. If a knee arthroscopy was performed, the patient should be instructed to elevate the knee while sitting, and to avoid twisting the joint. Ice may be applied to relieve pain and swelling.

The use of crutches is common after arthroscopy of the knee or hip, with progression to independent walking on an "as tolerated" basis by the patient. Generally, a rehabilitation program, supervised by a physical therapist, follows shortly after the arthroscopy to help the patient regain mobility and strength of the affected joint and limb.

Alternative procedures

Alternatives to arthroscopy depend upon the condition, and have limitations. X rays only examine bones, they will not show ligaments or torn cartilages. Magnetic resonance imaging (MRI) will reveal ligaments and cartilages but does not treat the condition. If a torn cartilage were discovered with MRI, an arthroscopy would be performed to correct the problem. Lateral ligament reconstruction for the treatment of ankle injuries is preferred over arthroscopy.

Complications

The incidence of complications is low compared to the number of arthroscopic procedures performed every year. Possible complications include infection, swelling, damage to the tissues in the joint, thrombophlebitis (blood clots in the leg veins), hemarthrosis (leakage of blood into the joint), pulmonary embolus (blood clots that move to the lung), and injury to the nerves around the joint. Low molecular weight heparin has been found to achieve effective prophylaxis for arthroscopy.

Results

Arthroscopy may show normal ligaments, menisci, and articular surfaces. Findings that require further treatment include spur formation, torn meniscus, and torn ligaments. Another finding that may require further treatment include adhesive capsulitis. In this condition, the joint capsule that naturally forms around the joint becomes thickened, forming adhesions, which results in a stiff and less mobile joint. This problem may be corrected by manipulation and mobilization of the joint with the patient placed under general anesthesia.

Arthroscopic examination is often followed by arthroscopic surgery performed to repair the problem with appropriate arthroscopic tools. The optimal result is decreased pain, increased joint mobility, and improved quality of the patient's activities of daily living (ADL).

Health care team roles

Arthroscopy is usually performed on an outpatient basis by a physician, but surgical repair may require hospitalization. In addition to providing assistance during the procedure, nurses monitor vital signs in the recovery room, including blood pressure, pulse, and respiration. They may also monitor circulation and sensation in the area that has been examined and/or operated on. Following arthroscopic surgery, a physical therapist guides the patient in rehabilitation to ensure that the patient regains full functioning in the targeted joint.

KEY TERMS

Ankylosis stiff or fixed joint due to disease or surgery.

Hemarthrosis condition of blood within a joint.

Pulmonary emboluslockage of an artery of the lung by foreign matter such as fat, tumor, tissue, or a clot originating from a vein.

Sepsis toxic condition resulting from the spreading of bacteria due to infection.

Synovial fluid naturally occurring fluid that lubricates the joints.

Thrombophlebitisnflammation of a vein with the formation of a thrombus or clot.

Tourniquetomething used to stop the flow of blood by pressure applied with an encircling device, such as a bandage twisted with a stick to apply pressure.

Maggie Boleyn, RN, BSN