Advanced Arthroscopic Joint Surgery

Understanding Arthroscopy in the Indian Context

Sports injuries, road accidents, and workplace trauma frequently damage knee and shoulder joints. At Ajuda Hospitals, our arthroscopy program offers minimally invasive solutions—repairing torn menisci, reconstructing ligaments, and fixing rotator cuffs through 5mm incisions with same-day discharge.

Arthroscopy involves inserting a pencil-thin camera (arthroscope) through tiny portals, projecting HD images onto monitors while specialized instruments repair tissues. Compared to traditional open surgery, benefits include:

• 90% same-day discharge (vs 3-5 day hospital stays)
• Faster recovery: Return to work in 1-2 weeks vs 6-8 weeks
• Minimal scarring: 5mm punctures vs 10-15 cm incisions
• Lower infection risk: <0.5% vs 2-3% with open surgery
• Better visualization: HD cameras magnify structures; see inside joint spaces impossible with naked eye

Hyderabad's growing cricket, badminton, and gym culture drives demand for sports medicine expertise. Our fellowship-trained arthroscopic surgeons—trained at top centers in Germany, UK, and USA—deliver outcomes matching international standards for ACL reconstruction, meniscal preservation, and rotator cuff repair.

When to Consult Our Arthroscopy Specialists

Athletes should seek evaluation within 2-4 weeks of injury. Delayed ACL reconstruction (>6 months) increases risk of irreparable meniscal tears and cartilage damage, compromising long-term outcomes.

Our Diagnostic Approach

Clinical Examination & Provocative Tests

Knee Assessment:

• McMurray Test: Flexion-rotation maneuver reproduces meniscal tear pain/click
• Lachman Test: Anterior tibial translation >5mm indicates ACL rupture
• Pivot Shift: Subluxation-reduction with knee extension confirms ACL insufficiency
• Patellofemoral Tracking: Lateral patellar tilt or J-sign indicates instability

Shoulder Assessment:

• Neer/Hawkins Signs: Positive indicates subacromial impingement
• Jobe's Test (Empty Can): Weakness suggests supraspinatus rotator cuff tear
• O'Brien's Test: Pain with resisted forward flexion indicates SLAP labral tear
• Apprehension/Relocation: Positive suggests anterior instability from Bankart lesion

Advanced MRI Imaging

High-Resolution 3T MRI (preferred over 1.5T for better cartilage detail):

• Meniscal Tears: Classify location (red-red/red-white/white-white zones determine repair vs debridement), pattern (horizontal, radial, bucket-handle)
• Ligament Injuries: Complete vs partial ACL/PCL tears. MCL/LCL grading (Grade 1-3)
• Rotator Cuff: Tear size (small <1cm, medium 1-3cm, large 3-5cm, massive >5cm), retraction, fatty infiltration (Goutallier grading predicts healing)
• Cartilage Defects: ICRS grading (0-4) determines if microfracture, OATS, or observation needed

MR Arthrogram: Contrast injection delineates subtle labral tears, partial rotator cuff tears missed on standard MRI.

Functional & Strength Testing

Isokinetic Dynamometry: Measures quadriceps/hamstring strength ratio. Pre-operative weakness (>20% deficit vs opposite leg) predicts poor outcomes—delay surgery for "prehabilitation."

Sport-Specific Assessment: Single-leg hop test, Y-balance, agility drills identify deficits requiring pre-op physiotherapy.

Surgical Planning & Consent

Graft Selection for ACL: Hamstring (less donor-site pain, 2% kneeling discomfort) vs patellar tendon (gold standard, 5% anterior knee pain, theoretical higher strength). Allograft (cadaver) for revisions or multi-ligament injuries.

Meniscal Repair vs Debridement: Repair if tear in red-red or red-white vascular zones, age <40, stable rim >3mm. Debride if white-white avascular zone, degenerative flap, age >50 with arthritis.

Treatment Pathways

Our arthroscopic techniques follow ISAKOS (International Society of Arthroscopy, Knee Surgery & Orthopaedic Sports Medicine) and AOSSM (American Orthopaedic Society for Sports Medicine) protocols:

Knee Arthroscopy

Meniscal Repair

Indications: Vertical longitudinal tears in red-red or red-white zones (vascular region), acute tears (<6 months), stable rim >3mm, age <40.

Techniques:

• Inside-Out: Sutures passed from joint to outside; tied over capsule. Gold standard for posterior horn tears. Risk: 1-2% neurovascular injury (requires posteromedial/posterolateral safety incisions).
• All-Inside: Implantable anchors (darts, arrows) deployed entirely arthroscopically. Faster, lower nerve risk. Concern: implant prominence causing pain (rare with modern devices).
• Outside-In: For anterior horn tears. Spinal needles guide suture placement.

Rehabilitation: Non-weight-bearing 4-6 weeks to allow healing. Return to sport 4-6 months. 80-90% healing rate if red-red zone; 60-70% if red-white.

Meniscal Debridement

Indications: Degenerative flap tears in white-white avascular zone, age >50, irreparable bucket-handle tears with early arthritis.

Technique: Motorized shaver removes unstable flap to stable rim. Preserve maximum tissue. Radiofrequency probe smooths edges.

Rehabilitation: Immediate full weight-bearing. Return to activities 2-4 weeks. Does NOT prevent future arthritis but relieves mechanical symptoms.

ACL Reconstruction

Indications: Complete ACL rupture in athletes, young patients, or those with instability (giving-way) during daily activities. Non-operative if sedentary, elderly, partial tears.

Procedure (Hamstring Autograft):

1. Harvest semitendinosus/gracilis tendons via 3cm anteromedial incision
2. Prepare 4-strand graft (8-9mm diameter) on graft station
3. Debride ACL remnant; identify anatomical femoral/tibial footprints
4. Drill tibial tunnel via anteromedial portal (avoids roof impingement)
5. Drill femoral tunnel at 2 o'clock (right knee) or 10 o'clock (left knee) position
6. Pass graft through tunnels; fix with interference screws or cortical suspensory devices
7. Tension graft at 20-30° flexion to match native ACL

Rehabilitation:

• Weeks 0-2: Brace unlocked; ROM 0-90°; quad sets, SLR, ankle pumps
• Weeks 2-6: Progress to full ROM; closed-chain exercises (leg press, mini squats); proprioception
• Weeks 6-12: Single-leg balance; eccentric hamstring work; stationary cycling; pool running
• Months 3-6: Jogging progression; agility drills; isokinetic strength ≥70% opposite leg
• Months 6-9: Sport-specific training; non-contact practice
• Months 9-12: Return to full contact sport if strength ≥85%, hop tests ≥90%, psychological readiness

Outcomes: 90% return to sport. 5-10% graft rupture risk (higher if return <9 months or family history of hyperlaxity).

Shoulder Arthroscopy

Rotator Cuff Repair

Indications: Full-thickness tears causing pain/weakness, acute tears in active patients, chronic tears without advanced fatty infiltration (Goutallier <3).

Procedure (Arthroscopic Double-Row Repair):

1. Beach-chair or lateral decubitus positioning
2. Posterior portal for camera; anterior/lateral portals for instruments
3. Subacromial decompression: Burr removes anterior acromion spur (if impingement present)
4. Mobilize torn tendon edges from footprint to bursal surface
5. Debride footprint to bleeding bone (enhances healing)
6. Insert medial-row suture anchors at articular margin of footprint
7. Pass sutures through tendon; tie down (medial row fixation)
8. Insert lateral-row anchors 1cm lateral; create "suture bridge" compression
9. Close portals; apply immobilizer sling

Rehabilitation:

• Weeks 0-6: Sling immobilization; pendulum exercises; passive ROM by therapist only
• Weeks 6-12: Active-assisted ROM; begin gentle strengthening (scapular stabilizers first)
• Months 3-6: Progressive resistance training; return to swimming, golf
• Months 6-12: Return to overhead sports, manual labor (if MRI confirms healing)

Outcomes: 85-95% healing for small-medium tears. Large/massive tears: 60-70% healing but 90% pain relief even if re-tear occurs (scar tissue fills gap).

Bankart Repair (Shoulder Instability)

Indications: Recurrent anterior dislocations (2+ episodes), young athletes at high risk of re-dislocation (90% risk if first dislocation <20 years old).

Procedure:

1. Identify torn anteroinferior labrum (Bankart lesion) from 3-6 o'clock position
2. Debride glenoid neck to bleeding bone
3. Insert 3-4 suture anchors along glenoid rim (5:30, 4:30, 3:30 positions)
4. Pass sutures through labrum; tie sequentially to restore "bumper" effect
5. Capsular plication tightens redundant tissues

Rehabilitation: Sling 4 weeks; ROM 6-12 weeks; strengthening 3-6 months; return to contact sport 6 months.

Outcomes: Reduces re-dislocation from 90% to <10%. Failure risks: large bone loss (>20% glenoid), Hill-Sachs lesion "engaging" glenoid rim (requires remplissage or bone graft).

Hip Arthroscopy

Femoroacetabular Impingement (FAI) Treatment

Indications: Hip/groin pain in young adults during flexion activities (sitting, squatting), positive impingement test, MRI shows labral tear + cam/pincer morphology.

Procedure:

1. Traction applied to distract hip joint (perineal post; monitor pudendal nerve)
2. Central compartment access: Repair acetabular labral tear with suture anchors
3. Peripheral compartment: Burr reshapes femoral head-neck junction (cam resection) or acetabular rim (pincer trimming)
4. Release traction; assess impingement-free ROM

Rehabilitation: Crutches 2 weeks (protected weight-bearing); avoid hip flexion >90° for 6 weeks; return to sport 4-6 months.

Outcomes: 75-85% good-excellent results at 5 years if no pre-existing arthritis (Tönnis grade 0-1). Failure if advanced cartilage loss (consider hip replacement).

Technology & Innovation

4K Ultra-HD Arthroscopy Systems

Stryker/Arthrex 4K Cameras: 3840x2160 pixel resolution (4x clarity of 1080p) reveals:

• Subtle partial-thickness rotator cuff tears (articular-side fraying)
• Early cartilage softening (chondromalacia) before visible defects
• Small meniscal root tears preventing extrusion detection

LED Light Sources: Adjustable intensity prevents tissue photodamage while maintaining brightness throughout fluid-filled joint.

Radiofrequency Ablation & Coagulation

ArthroCare/Coblation Wands: Bipolar radiofrequency (40-100°C) precisely removes damaged tissue (meniscal flaps, synovial inflammation) while sealing bleeding vessels. Advantages over mechanical shavers:

• Hemostatic effect maintains clear visualization
• Smooth tissue edges (vs ragged shaver cuts)
• Reduced inflammatory response (lower post-op pain)

Biological Augmentation

PRP (Platelet-Rich Plasma): Concentrated growth factors from patient's blood injected into repair sites (rotator cuff, meniscus, ACL graft). Evidence mixed; most benefit for partial rotator cuff tears and tendinopathy.

Bone Marrow Aspirate Concentrate (BMAC): Mesenchymal stem cells enhance cartilage healing in microfracture procedures. Increases fibrocartilage fill by 20-30%.

What to Expect: Your Care Journey

Pre-Operative Phase (1-2 Weeks Before)

• Physiotherapy "prehabilitation": Strengthen muscles, improve ROM—speeds post-op recovery by 30%
• Stop NSAIDs, aspirin 5 days pre-op (bleeding risk)
• Arrange ride home (cannot drive after general anesthesia)
• Obtain crutches, ice machine, sling (depending on procedure)

Day of Surgery

• Admission 1 hour before; IV placement, antibiotic prophylaxis
• General anesthesia + regional nerve block (femoral block for knee, interscalene for shoulder—provides 12-24 hours post-op pain control)
• 30-120 min surgery depending on complexity
• Recovery room 1-2 hours; discharge once awake, able to urinate, pain controlled on oral meds

Post-Operative Week 1

• Ice 20 min every 2 hours; elevate limb above heart
• Pain meds: Tramadol/acetaminophen (avoid NSAIDs first 6 weeks—impair tendon/ligament healing)
• Start passive ROM exercises (pendulums for shoulder, heel slides for knee)
• Wound care: Keep portals dry 48 hours; shower after 3 days (no soaking/swimming 2 weeks)

Weeks 2-6: Protected Motion Phase

• Suture removal at 10-14 days
• Physiotherapy 2-3x/week: Gentle ROM, isometrics, proprioception
• Crutches/sling weaning per protocol (immediate for meniscal debridement; 4-6 weeks for repairs)

Months 2-6: Strengthening & Return-to-Function

• Progressive resistance exercises; closed-chain then open-chain
• Aquatic therapy (buoyancy reduces joint stress)
• Sport-specific drills; plyometrics for athletes
• Isokinetic testing confirms strength thresholds before clearance

Preventing Complications

Arthroscopy complications are rare (<2%) but include:

Infection (<0.5%)

Risk Factors: Diabetes, immunosuppression, steroid injections <3 months before surgery.

Prevention: IV cefazolin pre-op; sterile technique; minimize operative time.

Symptoms: Fever, increasing pain/swelling, purulent drainage after Day 3. Requires urgent washout and IV antibiotics.

Stiffness/Arthrofibrosis (2-5%)

Risk Factors: Prolonged immobilization, poor physiotherapy compliance, genetic predisposition (Dupuytren's disease, frozen shoulder).

Prevention: Early ROM exercises (even if painful); CPM machines for knee; avoid over-aggressive repairs (excessive sutures restrict motion).

Treatment: Manipulation under anesthesia if plateau at <90° knee flexion or <120° shoulder elevation at 3 months.

Nerve Injury (<1%)

At-Risk Nerves: Peroneal nerve (lateral knee portals), axillary nerve (anterior shoulder portals), pudendal nerve (hip traction).

Prevention: Anatomical landmarks; safe zones; limit traction time <2 hours for hip.

Symptoms: Numbness, weakness, foot drop. Most resolve spontaneously 3-6 months; nerve conduction studies if persistent.

Why Ajuda for Arthroscopic Surgery?

Take the First Step

If knee locking, shoulder pain, or sports injury is limiting your life, arthroscopy offers minimally invasive solutions with faster recovery than open surgery. Early treatment prevents secondary damage—ACL tears lead to meniscal tears; rotator cuff tears enlarge over time.

Schedule Your Consultation: Call 9010550550 or WhatsApp to book an MRI review and surgical evaluation. Bring recent imaging and prior treatment records.

Restore your active lifestyle with Ajuda's advanced arthroscopy program.