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Introduction ⬇

Arthroscopy is the direct visual examination of the interior of a joint by means of a specially designed fiberoptic endoscope and is frequently associated with a surgical procedure. It is most commonly done for the diagnosis of athletic injuries (meniscus, patella, condyle, extrasynovial area, and synovium) and for the differential diagnosis of acute or chronic joint disorders. For example, degenerative processes can be accurately differentiated from injuries. Postoperative rehabilitation programs can be initiated to shorten recovery periods. Arthroscopy can also assess response to treatment or identify whether other corrective procedures are indicated.

Although the knee is the joint most frequently examined, the shoulder, ankle, hip, elbow, wrist, and metacarpophalangeal joints can also be explored. Calcium deposits, biopsy specimens, loose bodies, bone spurs, torn meniscus or cartilage, and scar tissue can be removed during the procedure. These procedures are often performed in an ambulatory surgical setting.

Procedure ⬆ ⬇

  1. The examination is usually performed under general or spinal anesthesia for the following reasons:

    1. The joint is very painful.

    2. Definitive treatment or surgical intervention can be done at the same time if within the realm of arthroscopic surgery.

    3. An inflated tourniquet may be used during part of the procedure to minimize bleeding at the site.

    4. Complete muscle relaxation permits a thorough examination and eliminates the risk for inadvertent patient movement while the arthroscope is in the joint.

  2. Start an IV line for the administration of medications.

  3. Drape and prep the surgical site according to institutional protocols. Attach proper monitoring equipment to the patient.

  4. Apply a tourniquet to the appropriate area (by use of an elastic bandage or elevation) and then insert an arthroscope into the joint through a small insertion. Some surgeons choose not to inflate the tourniquet unless bleeding cannot be controlled by irrigation.

  5. Aspirate the joint and subsequently perform continuous irrigation and flushing throughout the procedure.

  6. Collect joint washings and examine for loose bodies or cartilage fragments.

  7. Examine all parts of the joint carefully. Take photographs or video record of the procedure. The healthcare provider may choose to perform surgical interventions for problems that can be corrected using arthroscopy.

  8. As the arthroscope is slowly withdrawn, compress the joint to squeeze out excess irrigation fluid.

  9. Inject steroids or local anesthetics into the joint for postoperative pain control and reduction of inflammation. Close the wounds with sutures or adhesive strips and apply small dressings to the wound or wounds (e.g., two to three small incisions for the knee joint). Apply compressive dressings and splints or immobilizers.

  10. Follow guidelines in Chapter 1 for safe, effective, informed intratest care.

Clinical Implications ⬆ ⬇

Abnormal results may reveal the following conditions:

  1. Torn or displaced meniscus or cartilage (symptoms relate to clicking, locking, and swelling of the joint)

  2. Trapped synovium

  3. Loose fragments of joint contents

  4. Torn or ruptured ligaments

  5. Necrosis

  6. Nerve entrapment

  7. Fractures or nonunion of fractures

  8. Ganglions

  9. Infections

  10. Degenerative disease

  11. Osteochondritis dissecans

  12. Chronic inflammatory arthritis

  13. Secondary osteoarthritis caused by injury, metabolic disorders, and wearing away of weight-bearing joints

  14. Chondromalacia of femoral condyle

Interventions ⬆ ⬇

Pretest Patient Care

  1. Ensure that the history and physical examination, requisite laboratory work, x-ray films, and other preoperative requirements are completed, reviewed, and documented in the patient’s record.

  2. Explain the purpose and procedure of the test. Confirm that the patient fasted from midnight before the examination unless otherwise ordered (e.g., if scheduled late in the day, a liquid breakfast may be permitted).

  3. Ensure that a properly signed and witnessed consent form is in the patient’s medical record (see Chapter 1).

  4. Teach crutch walking before the procedure if its necessity is anticipated postoperatively.

  5. Follow guidelines in Chapter 1 for safe, effective, informed pretest care.

Clinical Alert

  1. Arthroscopy is usually contraindicated if ankylosis or fibrosis is present because it is very difficult to maneuver the examining instrument in this type of joint.

  2. For knee arthroscopy, the posterior approach is not used because of the neurovascular structures present in that area.

  3. Do not place pillows under the knee; flexion contractures can occur as a result. If the patient’s leg is ordered to be elevated, make sure the entire leg is elevated in a straight position. The knee is not flexed because a flexion contracture may result. Pad pressure points such as the heel.

  4. If there is risk for sepsis or if sepsis is present in any part of the body, the procedure should not be done.

  5. Arthroscopy is usually not done less than 7–10 days after arthrography because chemical synovitis caused by a contrast medium can adversely affect the visual examination. However, it may be necessary to perform arthroscopy if the patient is experiencing severe pain. In this case, the joint must be thoroughly irrigated to remove contrast medium.

Posttest Patient Care

  1. Assess vital signs, bleeding, neurologic status, and circulatory status of the affected extremity (e.g., color, pulse, temperature, capillary refill times, sensation, and motion).

  2. Apply cold pack and, if ordered, elevate the extremity to minimize swelling and pain. Notify the healthcare provider of unusual bleeding or swelling.

  3. Administer appropriate pain medication and assess its effectiveness.

  4. Explain that the patient can usually be ambulatory after recovery from the anesthetic. Crutches may be used. Degree of weight bearing and joint motion is at the discretion of the healthcare provider; however, caution the patient to avoid excessive joint use for at least 24–48 hours.

  5. Explain any exercise and physical therapy that is ordered postoperatively to strengthen and maximize use of the joint.

  6. Advise the patient to consume no alcohol for 24 hours after the procedure. Progress diet from fluid to solid foods as tolerated.

  7. Instruct the patient to report fever, altered sensation, numbness, tingling, coldness, duskiness (i.e., bluish color), swelling, bleeding, or abnormal pain to the healthcare provider immediately. Mild soreness and a mild grinding sensation for a few days are normal.

  8. Review test results; report and record findings. Modify the nursing care plan as needed. Counsel the patient appropriately.

  9. Follow guidelines in Chapter 1 for safe, effective, informed posttest care. Provide written discharge instructions.

Clinical Alert

  1. Watch for signs of thrombophlebitis postoperatively. Instruct patient to watch for calf tenderness, pain, and heat and to report these symptoms to the healthcare provider immediately. Warn the patient not to massage the affected area.

  2. Other complications may include hemarthrosis, adhesions, neurovascular injury, pulmonary embolus, effusion, scarring, and compartmental syndrome as a result of swelling. Compartmental syndrome is a musculoskeletal complication that occurs most commonly in the forearm or leg. The compartment of fascia surrounding muscles does not expand when bleeding or edema occurs. Consequently, the neurovascular status of the extremity may be severely compromised. This presents an emergency situation that usually requires surgical intervention to release pressure. Assess the neurovascular status of an affected extremity frequently for 24 hours after the procedure.

Interfering Factors ⬆ ⬇

Ankylosis, fibrosis, sepsis, or presence of contrast agent from previous arthrogram may affect results.

Reference Values ⬆

Normal