Arthroscopic surgery

"Career-ending injury." "His season is over." "Out from four to six months." "Placed on Injured Reserve.'

Not too long ago, when an athlete was felled by a serious knee injury, he most likely could kiss the season, and possibly his career, goodbye. Invasive operations followed by months of exhaustive and painful rehabilitation were the norm. How things have changed.

With the advent of technological breakthroughs in the fields of medicine and fiber optics, athletes of all levels can be back on the playing field in as little as six weeks. One of the primary advances making these quick recoveries possible has been arthroscopic surgery. "The arthroscope allows for much smaller incisions, which has a tremendous effect for our patients because they are able to get back to playing and working much faster," says Dr. Jan Fronek, head team physician for the San Diego Padres and a member of the Association of Professional Team Physicians (PTP). We asked Dr. Fronek to explain the basics of the surgery and to give us his insight into how this procedure has revolutionized sports medicine and rehabilitation.

What is arthroscopic surgery exactly?

Dr. Fronek: Arthroscopy describes a surgical procedure where a joint is evaluated with the help of an arthroscope. The arthroscope is a telescope, approximately the size of a pen, which is introduced into the joint (usually the knee) to visualize the critical structures of the joint. The surgeon can evaluate the healthy, as well as the injured, tissues and then introduce instruments to remove or repair the injured structures. Therefore, the procedure is an incredibly valuable diagnostic as well as treatment-oriented tool.

How has arthroscopy evolved over the years?

Dr. Fronek: In terms of history, the first people to experiment with arthroscopy were physicians in the 1930s. At that time, they had limited tools to work with. Instrumentation was poor, the optics was poor and sometimes the light bulb would break off inside the knee, which was obviously a disaster. It remained a relatively underutilized procedure until the late 1970s and early 1980s when three events occurred, independently and at the same time, that brought the concept into practical use.

One was the explosion of interest in sports and fitness around the world. Another was the advent of fiber optics. The third was the invention of new surgical instrumentation. They all met at the juncture that is arthroscopic surgery. Today, new applications for arthroscopic surgery are developed almost monthly. Now, 98 percent of all knee surgeries are done this way, even ACL (anterior cruciate ligament) injuries. Similarly, shoulder stabilization and instablity issues are two areas where arthroscopy has become very commonplace. The procedure has evolved from a tool of assessment that gave us insight into the workings of a joint into a specific, highly specialized diagnostic and operative technique.

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Q: For the past two years I have been having quite a bit of lower back pain from weightlifting and marathon running. My doctor contends the pain is centered around the sacroiliac joint area. I have tried rest, anti-inflammatories, accupuncture and chiropractic treatments. Yet, after a hard workout the pain will re-emerge and while sitting the pain can become unbearable. What treatment alternatives are available to rehab this type of injury to the lower back area? -- Leon Feltham, Gander, Newfoundland, Canada A: From Dr. Timothy Hosea, PTP member physician: "If you have been having pain in your sacroiliac area for two years, and it hasn't responded, there is a good chance that the primary problem is elsewhere, and that the pain is referred. Depending on your age, I would consider the possibility that your symptoms are more indicative of sciatica and related to a problem with the lumbar disc. Sciatica can be related to a degenerative disc or herniation. While this doesn't necessarily mean that you would need surgery, it would help focus your rehab and exercise program. "I recently have seen a number of athletes with the diagnosis of SI joint dysfunction, and they all turned out of have either a small herniated lumbar disc, or degeneration of a lumbar disc. The diagnosis is easily made with an MRI of the lumbar spine. If possible, I would be seen by a spine expert, and obtain the further work-up, including an MRI. Good luck." Do you have a question for a team physician? Click here to ask. And check out more "Ask the Pro Doc" answers to users' questions.

What does this mean for the athlete that gets "scoped"?

Dr. Fronek: Twenty years ago, when we used to perform open menisectomies on torn knee cartilage, we would make a two- to three-inch incision and remove the entire cartilage. Those patients would stay in the hospital for 4 or 5 days. They would then be immobilized in a splint, be on crutches for three weeks and then start a rehabilitation program. They would be really fortunate to be running in three to six months after surgery.

Today, the same type of surgery would be done arthroscopically on an outpatient basis with three small, one-fourth-inch incisions. We haven't had to admit anyone overnight for years. These patient stay on crutches for three or four days and in two to three weeks they are out there starting to run, pivot, twist and do agility drills. Less invasive procedures equals shorter rehabilitation schedules.

What specific types of sports injuries are treated with arthroscopic surgery?

Dr. Fronek: In a nutshell, almost everything. In the knee joint, cartilage injuries, ACL tears, synovial injuries involving the inner lining of the joint, loose bodies that may be inside the joint and even certain problems that deal with patellar instability are all managed with arthroscopic techniques. In the shoulder, one can address a huge number of problems with the arthroscope. Loose bodies, calcium deposits and certain types of rotator cuff injuries can be addressed arthroscopically. If the patient has a significant tear of the rotator cuff, it's still a little controversial to use arthroscopy exclusively, so at this point the injury is probably better taken care of through open surgery. Yet if there is a partial tear or impingement where the rotator cuff is inflamed or compressed, then the arthroscope is very valuable.

For almost any operation that we perform, we'll use the arthroscope as a diagnostic tool, regardless of the type of surgery needed. We'll often see changes or certain things that were not seen in the pre-operative phase through plain X-rays or even MRIs. Neither of these is as sensitive as the arthroscope. Once in a while, we find a significant tear or injury that we wouldn't have seen without the arthroscope that we were going to repair arthroscopically but because of what we've found, open surgery seems to be the best option.

What are the advantages of arthroscopy as opposed to open incision surgery?

Dr. Fronek: In any operation, the length of the incision is directly related to the amount of pain that the patient is going to experience after surgery because a greater amount of healing needs to take place inside the joint to recover from the trauma of the operation. The arthroscope allows you to make much smaller incisions. The patient has a faster, less painful recovery period.

The diagnostic application of the arthroscope has tremendous value in that it cuts down on the invasiveness and increases the accuracy of the operation, also decreasing recovery time. In addition, because the procedure is done on an outpatient basis, it benefits the entire health care industry. Patients no longer spend nights in the hospital and it is less expensive for the entire community.

Dr. Jan Fronek, a member of the Association of Team Physicians (PTP), serves as head team physician for the San Diego Padres and is also a team physician for the U.S. Pro Ski Tour. He is head of the Section of Sports Medicine and an attending surgeon in the Division of Orthopaedic Surgery at the Scripps Clinic in La Jolla, Calif. Dr. Fronek received his undergraduate degree from the University of California, San Diego and his medical degree from the University of Rochester School of Medicine, and he completed a fellowship in shoulder and knee surgery in the Sports Medicine Department at the Hospital for Special Surgery in New York City.

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