Keyhole knee surgery

Overview

If you're experiencing persistent joint pain, swelling, or stiffness and scans haven't shown the source, you may require an arthroscopy. Arthroscopy, often known as keyhole surgery, is a minimally invasive surgical procedure that allows the surgeon to view the interior of the knee. It's commonly done with two tiny puncture holes on either side of the knee-cap tendon.

What is Keyhole knee surgery?

Keyhole knee surgery is also referred to as knee arthroscopy or arthroscopic. It’s a minimally invasive surgical procedure to treat and repair various joint conditions. This technique uses a small camera that is usually inserted via the incision made on the skin. It enables the surgeon to visualize the inside part of the knee joint. 

Keyhole knee surgery is also an effective treatment option for patients with symptoms associated with obstructive lesions in the knee. It can include torn meniscus or cartilage shock absorbers. However, it’s less helpful for patients with minor knee ache associated with arthritis. 

Anatomy

Your knee is the biggest and most complicated joint in your body. The lower end of the femur (thighbone), the upper end of the tibia (shinbone), and the patella (kneecap) are the bones that make up the knee (kneecap).

Other important structures that make up the knee joint include:

• Articular cartilage. Articular cartilage covers the extremities of the femur and tibia, as well as the rear of the patella. As you bend or straighten your leg, this slick material helps your knee bones move easily across one other.
• Synovium. Synovium is a thin lining that surrounds the knee joint. This lining secretes a lubricant that coats the cartilage and decreases friction during movement.
• Meniscus. Shock absorbers are two wedge-shaped portions of meniscal cartilage located between the femur and tibia. The meniscus, unlike articular cartilage, is strong and springy and serves to cushion and support the joint.
• Ligaments. Ligaments link the bones to one another. The four major ligaments in your knee work together like strong ropes to keep your knee stable.
• • On either side of your knee are the two collateral ligaments.
  • Inside your knee joint are the two cruciate ligaments. The anterior cruciate ligament in front and the posterior cruciate ligament in rear cross each other to form an X.

Why Keyhole Knee Surgery is done?

Not all knee-related conditions and pain are addressed using knee arthroscopic surgical procedures. However, the surgeon can perform the surgery for various reasons, including; 

• Meniscus surgery (torn cartilage)

This is a procedure to remove a section of the meniscus cartilage from the knee joint. Alternatively, the surgeons can perform meniscus surgery to trim small meniscus tears. This can be an effective way of relieving pain and associated symptoms of a torn meniscus. Meniscus refers to the piece of cartilage that acts as a cushion between the tibia and the thighbone. 

• Meniscus repair 

This is a surgical procedure to repair the damaged or torn meniscus. It also helps restore the standard knee anatomy and gives an enhanced long-term prognosis if the procedure is successful. However, the recovery duration of meniscus repair can take long since it’s associated with limited blood flow towards the meniscus. 

• Excision of plica

A plica refers to the tissue remnant that usually remains following fetal development. During early development, the knee usually comprises separate compartments. With time, the compartments are gradually lost while some remnants are left behind. The prominent remnant tissue thus forms the plica. 

Sometimes, the plica gets irritated, resulting in a condition known as plica syndrome. In such a case, the surgeon can perform a plica resection to remove the irritating tissue. 

• Anterior cruciate ligament (ACL) reconstruction

ACL forms one of the vital knee ligaments that facilitate knee stability. Patients with damaged or injured ACL often experience a feeling of instability or giving away. Therefore, a surgical procedure is essential to reconstruct ACL injury or tear. 

• Microfracture 

This is a treatment that surgeons use to stimulate the body to produce new cartilage, especially if it is damaged. The microfracture procedure involves penetrating the firm outer layer of bone. This is done to expose the inside layers, including the marrow cells region. This allows the cells to access the damaged part of the bone, filling in the cartilage gap. 

• Cartilage transfer 

Cartilage transfer is the procedure to move the cartilage from the healthy joint part towards the damaged region. This involves removing small plugs of cartilage, including a section of the underlying bone, and moving them to the damaged area. After that, the plugs will be removed from the joint part, where the cartilage transfer is unnecessary.

• Anaesthetic examination of the knee
• If the knee has been significantly wounded, a full examination may be impossible. The surgeon can check the knee in depth under a general anaesthetic and find any anomalies that are limiting movement or tears that are difficult to detect while you are awake and in pain.
• Scar tissue may form inside the knee after an accident or surgery, making it harder to bend or completely straighten the knee. This might make it difficult for you to walk. The doctor may be able to modify the knee under anaesthesia if non-surgical treatment, such as focused physiotherapy, does not help and the knee is still stiff. This entails gradually bending and straightening the knee while sleeping in order to increase the range of motion of the knee.

How to Prepare for Keyhole Knee Surgery?

You'll visit with the surgeon before your knee arthroscopy to discuss your procedure. Because your procedure will be tailored to your specific needs, it may differ from what is detailed here. Your surgeon will tell you how to prepare for your procedure ahead of time.

You will be asked to cease smoking if you do. Smoking increases your chances of getting an infection after surgery, which can delay your recovery. It can also make your operation less likely to succeed and increase the risk of complications. Knee arthroscopy is often performed under general anesthesia, however it may be possible to have it done under local anesthesia.

Your knee will be numbed by a local anesthetic, and you will remain awake during the procedure. You'll be sleeping during the operation if you get a general anaesthetic. Because general anaesthesia might make you nauseous, it's vital to fast for a certain length of time before your arthroscopy. Your healthcare team will provide you with specific instructions.

On your other (unaffected) leg, you may be advised to wear a compression stocking. This can assist to prevent blood clots from developing in your leg veins, which can lead to DVT (deep vein thrombosis). You could require an anti-clotting drug injection (or pills) as well.

You may generally have your knee arthroscopy and leave the hospital the same day. You may need to remain overnight if you've received a regional anesthesia (a local anaesthetic that numbs a larger portion of your leg). Once you're able to walk normally again, you'll be able to leave the hospital.

Your surgeon will go over what to expect before, during, and after your operation with you. If you have any questions, don't be hesitant to ask. No inquiry is too insignificant. It's critical that you be completely informed before giving your consent for the procedure to proceed. You may be requested to sign a permission form to do so. 

The Procedure 

Before the surgeon begins operating on your knee, they will first administer anesthesia. The appropriate type of anesthesia to use usually varies depending on the procedure. It can be one of the following; 

Local anesthesia: This is a common alternative that surgeons often use when performing keyhole knee surgery. It only numbs the surgical area by blocking the sensation. This means that you will be awake and conscious during the procedure but won’t feel any pain. 

Regional anesthesia: This anesthetic drug is usually administered via a small needle injected between the two lumbar vertebrae in the spine. It numbs the entire region below the waist, but you will be awake during the procedure. 

General anesthesia: Depending on the type and complexity of the procedure, the surgeon can recommend general anesthesia. This is to make you completely unconscious during the surgery. General anesthesia is usually administered intravenously through the vein. 

After administration of anesthesia, the surgeon will ask you to lie in a particular position. It can be on your side or back. A positioning device is then used to stabilize the knee. The surgeon can also use a tourniquet to prevent blood flow towards the wound, hence enhancing visibility. 

The surgeon can start by creating a few minute incisions in the knee. After that, sterile salt water, or saline, is pumped in so as to enlarge the knee. This generally makes it much easier for the surgeon to visualize the inner joint parts. 

The surgeon will then insert an arthroscope device attached to a small camera through one of the incisions. This enables him or her to view the joint and the surrounding areas. An arthroscope is usually connected to a computer. Hence the surgeon can see and analyze the images produced on the screen. 

Once the surgeon identifies the knee problem, they can insert small operating tools via the incisions to treat and correct it. As soon as the procedure is complete, the surgeon immediately drains the sterile saltwater from the joint and sutures the incision. They can close the incisions with a stitch or small band-aids and cover the area with a bandage. 

What should I expect before and after keyhole surgery?

The procedure for keyhole surgery is simple and low-risk. The procedure is normally performed under general anaesthesia. You'll then be transferred to the recovery ward before being returned to your accommodation. The majority of patients are able to return home the same day.

In the operating room, a bandage is put that may be removed the next day. After surgery, you should be able to walk without crutches in the majority of situations. You won't require a knee brace, and you'll be urged to exercise your knee as much as possible as quickly as feasible. Paper strips or a single stitch are used to seal the minor incisions, which are removed after 10 days.

Around two weeks following surgery, you'll be offered a follow-up visit to review the results of any tests in further detail, utilizing photos or video recorded during the treatment.

After surgery, you'll be encouraged to rest your knee for around 48 hours before gradually returning to typical activities like walking and driving. Most patients are able to return to work after approximately a week, while some discomfort may persist for 4-6 weeks following surgery, depending on the cause for the treatment.

Recovery 

Knee arthroscopy affects everyone differently. The length of your recovery will be determined by a variety of factors, including whether you had any therapy during your knee surgery. Most people require two to six weeks to fully recover. You could feel more weary than normal, so don't overwork yourself. Request assistance from friends, relatives, and neighbors with practical activities such as grocery shopping and moving heavy goods.

Your knee will most likely be uncomfortable and swollen after surgery. Keep your leg elevated and use a cold compress, such as ice or a frozen pea bag. This may assist in the reduction of swelling and bruising. Ice should not be applied directly to the skin; instead, cover it in a towel.

You may be able to remove the dressing and expose your cuts after the first 48 hours. Around this time, you might be able to get them wet. When you can have a bath or shower, your surgeon or nurse will let you know.

You can get pain relief with over-the-counter pain relievers like paracetamol or ibuprofen. Always read the patient information that comes with your prescription medication. Ask your pharmacist for help if you're worried about anything or have any queries. A general anesthesia can have a variety of side effects. You may notice that you're less coordinated or that thinking clearly is tough. Within 24 hours, this should be over. In the meanwhile, avoid driving, drinking alcohol, operating machinery, and signing vital documents. Always follow the advice of your surgeon.

After your operation, you may be able to walk practically straight. However, this will depend on the reason for your operation as well as the sort of surgery you have. Some doctors prescribe rest for a week or two, then light activity and sports afterwards.

You should be able to undertake some more demanding exercises after two to three weeks. As long as you're comfortable, stick to walking, swimming, easy cycling, and light exercise. Breaststroke may be tough to master when swimming. For at least six weeks, avoid impact sports and always see your surgeon first. Some sports may be unavailable for the first six months. You may usually follow your surgeon's post-surgery exercise plan.

Post-operative recovery exercise therapy

Exercises:

1. Ankle pumps

To increase circulation and reduce swelling, the foot and ankle should be regularly "pumped" up and down 10-20 times each hour.

2. Range of Motion

• Flexion – Bend your knee by moving your heel towards your buttocks while lying down. As required, you can use your other leg to assist you. Repeat up to 20 times a day, two to three times a day.

• Extension - Place a roll beneath your ankle while lying down to extend your knee into extension. Begin with 2 minutes and gradually increase to 5 minutes as tolerated. Perform two or three times every day. It is critical to concentrate on straightening your knee during this time.

3. Strengthening

• Quadriceps Contraction – Tighten your thigh muscle by pressing your leg downwards while sitting with your knee straight and leg supported. Avoid elevating your leg from the hip and concentrate on tightening the muscle. Perform the exercise 5-10 times, with each contraction lasting 5 seconds.

• Straight Leg Raises – Tighten your thigh muscle while maintaining your knee straight and pull your leg up 2 inches in the posture illustrated. Perform the exercise 5-10 times, with each contraction lasting 5 seconds.

• Hip Adduction – Squeeze a soft ball or a cushion between your knees while lying with your knees bent as illustrated. Perform the exercise 5-10 times, with each contraction lasting 5 seconds.

Managing Pain 

Most patients often experience some pain after surgery. Although this can be part of the recovering process, the surgeon can help you ease and manage the pain. This is to ensure a quick, successful recovery. 

They can thus recommend the following; 

Medications: This helps relieve short term pain after the procedure. Examples of pain-relieving medicines include non-steroidal anti-inflammatory drugs (NSAIDs), local anesthetics, and sometimes opioids. The doctor can also recommend aspirin drugs to help minimize the risk of blot clotting. 

Dressing care: The purpose of dressing the knee is to prevent infections and avoid several other risks. Therefore, it’s essential to keep it clean and dry at all times. Ask your surgeon how you can shower without interfering with the dressing and when to change it. 

Preventing swelling: Try as much as possible to keep your leg elevated for at least 2 to 3 days after the procedure. You can as well apply ice to ease pain and swelling. 

Rehabilitation exercise: In most cases, the doctor can recommend rehabilitation exercise and physical therapy. This is to help strengthen the joint muscles and enhance functionality. 

Results 

Most patients can resume their normal daily activities after a few days of the surgery. However, the recovery can vary among patients depending on the initial knee damage and procedure. 

In case you had a ligament reconstruction, then the recovery period might take some time. You may also return to your usual activities after six or eight weeks, or sometimes sooner, depending on your health state. You should, however, avoid vigorous activities for a much longer period. 

For instance, if your job entails heavy tasks, it might take longer before you are physically fit to continue working. It would also be helpful if you discuss with the surgeon when you can safely resume work. 

Sometimes, lifestyle changes can add a significant impact on the knee condition. For instance, you can limit vigorous exercises like running and opt for low impact activities such as cycling and swimming. 

Complications of Keyhole Knee Surgery 

There are a few complications that can arise during or after the keyhole knee surgery. Besides, these complications are usually minor and are manageable. They include; 

• Infection of the surgical site 
• Excess bleeding during the surgery 
• Allergic reactions to anesthesia and other drugs administered during the procedure
• Breathing problems triggered by anesthesia 
• Formation of blood clots 
• Knee stiffness 
• Damage or injury to the ligament, cartilage, meniscus, nerves, or blood vessels. 

Conclusion 

Keyhole knee surgery is a surgical procedure designed to diagnose and address a range of knee joint problems. It enables the surgeons to view the inside of the joint, identify the underlying problem and effectively correct it. Furthermore, the keyhole knee procedure is a reliable and safe method associated with few to no complications.