New advances in arthroscopic procedures
Simon Moyes gives an overview of arthroscopy and looks at new research and advances in the field that could revolutionise the procedure
Arthroscopy overview
Arthroscopy is a treatment which is used to look inside almost any joint and treat injuries or problems within it. Arthroscopic techniques are highly sophisticated and minimally invasive so that patients spend less time in hospital and are more likely to have a quick recovery. An arthroscope is a fibre optic tube which is inserted into the relevant joint to allow the treating doctor performing the surgery to visual the interior of that joint. I have been using this technique as a consultant since 1994.
The technique is used for the treatment of a range of intra-articular problems within joints, from injuries to degenerative conditions to inflammatory conditions. The most common joints, arthroscoped, are the knee, hip, ankle and shoulder, but small joints too can be accessed including the elbow and wrist.
Arthroscopy is ideal for many orthopaedic procedures in joints, such as removing torn cartilage, ligament and tendon reconstruction and smoothing out bone defects. Due to the nature of the surgery – since the joint does not have to be opened fully – there is lower risk of infection, healing can be quicker, scarring is minimal and there is less trauma to the connective tissue in the joint.
Arthroscopy is usually performed under general anaesthesia but can be performed under regional blocks or spinal anaesthesia if necessary.
A number of small stab wounds are made around the joint – the number varies from joint to joint; for example, in the knee it is normally only two but in the shoulder it can be up to four or five. In the knee the incisions are made on either side of the patellar tendon, one for visualisation and the other for instrumentation. Where more complex surgery is required, more incisions/portals are used – often two operating portals and one visualisation portal for reconstruction of a shoulder joint, for example.
Small incisions are made to insert the arthroscope with the attached camera into the joint. The image is shown on a large high-definition TV screen, enabling the surgeon to make a thorough diagnostic examination of the area following which other small incisions are made to allow small surgical instruments to be inserted. This advent of modern technology means that virtually all procedures apart from joint replacement surgery can now be performed arthroscopically rather than with open surgery.
The overwhelming majority of arthroscopic procedures are performed as day cases. The post-operative regime will depend on how complex the surgery has been but for most routine knee arthroscopies, such as removal of loose bodies and trimming of torn cartilages, no splints or crutches are required. I normally advise patients to rest and ice the knee for 48 hours, before returning to most activities within 72 hours.
For more extensive operations, such as anterior cruciate ligament reconstructions, braces and crutches may be required and longer periods away from work. For most routine shoulder arthroscopies, such as subacromial decompressions and ACJ arthroplasties, patients can mobilise their arms almost immediately and they are back at work within two or three days; however, for more complex procedures such as shoulder stabilisations and cuff repairs, slings are normally required for four weeks, followed by an out-patient physiotherapy programme.
Stem cell research
I am particularly inter-ested in this area from both a professional and personal perspective. Hailed as revolutionary to medicine, stem cell research and treatment is moving at a fast and exciting pace.
I’ve undertaken my own research into current developments in stem cell technology for cartilage regeneration over the last two years. In the past 12 months I’ve specifically looked at Arthrex, a manufacturing company specialising in orthopaedic products, which has developed an Angel system that utilises stem cells taken from bone marrow. I’ve also looked at Regeneus, a Sydney-based regenerative medicine company, which uses adipose-derived stem cells for cartilage repair and regenerative techniques. In addition, since the autumn of 2015, I have been in contact with a company called Neurotechnics, which also uses bone-marrow-derived stem cells to augment cartilage repair techniques. I’m working with these companies to assess the efficacy of new regenerative orthopaedic treatments. Sadly, Regeneus failed to get this treatment licensed in the UK recently.
All three companies have been going through regulatory proceedings in Europe and the USA. Historically, patients have had to travel to countries where regulations were less rigorous to have these treatments performed. The Arthrex and Neurotechnics systems are now licensed in the UK.
BST-CarGel is a development by Piramal Technology, which enhances cartilage regeneration. This is used in my practice to promote repair of cartilage defects and has already shown great promise in patients with cartilage damage and deterioration.
PRP for osteoarthrosis
Autologous blood products like platelet-rich plasma (PRP) have created a growing interest for use in a number of orthopaedic therapies. The healing effects of this are supported by growth factors released by platelets. There is now an autologous conditioned plasma (ACP) double syringe system, which will shortly be available for use for treatment for a number of conditions, including the cartilage damage of osteoarthrosis in addition to other conditions such as tendinopathy. The major effect of these growth factors is to induce proliferation in differentiation of various cell types, such as osteoblasts and chondroblasts, and also to help improve production of matrix such as collagen. This PRP/ACP injection is performed under local anaesthetic as an outpatient procedure and it is an attractive alternative to hyaluronic acid analogue injections for the treatment of osteoarthrosis.
Natural Biosciences – a personal experience
I was introduced to Natural Biosciences by colleagues here in the UK and eventually travelled to Zurich in 2013 as part of a trial for Natural Biosciences, a company specialising in the production of stem-cell-derived microvesicles.
The treatment involves harvesting fat-derived stem cells then expanding them in a laboratory, stressing them to release microvesicles and then injecting them either focally or intravenously depending upon the need. Natural Biosciences treatments aim to use these microvesicles for multiple uses, including the treatment of arthritis, but also to optimise organ function. I have a number of friends and patients who have also travelled to Switzerland for similar treatments. My own experience of the treatment was that pain from united rib fractures healed within about six weeks of the injection, and for approximately six months following the injection my back pain improved. I also felt generally re-energised for a similar period of time. My testament alone cannot be of empirical value but as a consultant involved professionally with these types of techniques, it is relatively unique to be involved personally as well.
Simon Moyes is a consultant orthopaedic surgeon with a special interest in the treatment of knee, shoulder, foot and ankle problems. He was one of the first to introduce arthroscopic/keyhole surgery to the foot and ankle into the UK. He has a particular interest in developing cartilage regeneration and repair techniques and is one of the few international members of the Arthroscopy Association of North America.
t: 0207 323 0040; e: simonmoyes@simonmoyes.com
