Fixing the joints

Arthroscopic surgery revolutionizes approach to repairing damaged joints

By Tracy Sutherland
Special to The Washington Post
Tuesday, March 16, 2010

Olie Kolzig knows all about pushing the body to its limits: During a 19-year hockey career, most of it as a goalie for the Washington Capitals, he dislocated his right kneecap twice and damaged his hip, elbow, shoulder and finger -- and required a total of nine surgeries.

Luckily for Kolzig, 39, his career coincided with the rise of arthroscopy, in which a surgeon makes tiny incisions and uses a high-definition mini-camera and minuscule surgical instruments to detect and treat damaged joints. The result is a reduction in postoperative pain and recovery times, as well as greater precision in surgery.

Kolzig had six of his operations through arthroscopy, saving him months of rehab and recovery. "Without it, I probably wouldn't have had a career," the now-retired player says.

Arthroscopy -- from the Greek "arthros" (joint) and "scopos" (to look) -- has been used in the United States since the 1960s, but it is only in the past few decades that the technology has become widespread, revolutionizing the field of orthopedics. A 2006 study by the National Center for Health Statistics found that 1.48 million knee, shoulder and wrist arthroscopies were performed that year; the tally did not include the less common hip, elbow and ankle procedures.

"Sometimes in medicine, a new procedure comes along that fundamentally changes the way we see and understand illness and disease, with a direct impact on how we provide care for our patients. Arthroscopy is such a procedure," said Washington orthopedist Benjamin Shaffer, who performed three of Kolzig's arthroscopies as head team physician for the Capitals.

"I do think that to describe it as revolutionary is not an overstatement," he said.

A Japanese professor, Kenji Takagi, is generally credited with having pioneered the technology when he used a cystoscope -- a telescopic instrument normally used to examine the bladder -- in 1918 to examine the tubercular knees of some patients.

One of his former students, Masaki Watanabe, enlisted Japan's newly emerging optics and electronics companies to produce the Watanabe No. 14 scope in 1955, which provided the first color photographs of the inside of a knee joint. That year Watanabe used an arthroscope to remove a patient's knee tumor.

It took some time for the technology to catch on.

J. Whit Ewing, executive vice president of the Arthroscopy Association of North America, says a Canadian surgeon embraced the technology in the 1960s and began offering courses on using arthroscopes. But it took a while to attract interest. Ewing, who finished his orthopedic residency in 1971 before arthroscopy really developed in the United States, recalls having to solicit advice from the few practitioners he could find and then practicing on cadavers before operating on his first patient, a 16-year-old boy who presented with torn knee cartilage in 1972.

Certain the problem was on the inner side of the boy's knee ("medial meniscus"), Ewing inserted the arthroscope, only to discover that the tear was actually on the outside of the knee ("lateral meniscus"). Without an arthroscope, Ewing said, he would have used open-cut surgery, which reveals only part of the joint and can lead to misdiagnosis.

"It was exhilarating, and I knew at that moment that I would never operate on a knee without looking into it" first, said Ewing.

By 1985, Ewing said, "anybody who was opening a knee [using open-cut surgery] would be frowned upon."

Today, the technology is routinely used on shoulders and knees as well as elbows, ankles and wrists. It tends not to be used in small joints, such as fingers, which are closer to the skin and challenging for even tiny instruments. In the past 10 years, the hip has joined the list of joints that are scoped to repair damaged tissue and cartilage, and preliminary work is being done on arthroscopy for the spine.

Diving in

Developments in optics, instruments and implants have elevated arthroscopy to a new level with clearer images, better techniques with instruments such as shavers and scissors, and new tools, such as "anchors" that secure repaired tendons to the bone.

When Shaffer floods the interior of a joint with sterile saline solution to distend it, inserts a tiny camera and operates the instruments while watching his progress on a monitor, he says he gets a "Jacques Cousteau" experience, a reference to the famous French undersea explorer and filmmaker.

To the untrained eye, the scene is strangely oceanic, exposing an internal landscape of pinks and creams with odd formations and feathery white tissue undulating in a saline current -- all projected in crystal clarity onto a screen above the operating table.

On one recent morning, Shaffer operates on a man with a cartilage tear in his shoulder. He uses a tiny scalpel to make a 0.2-inch incision in the back of the shoulder and inserts a thin, strawlike tube called a cannula into the joint. The high-definition camera, sitting at the end of a narrow, six-inch metal probe, is inserted through the cannula into the joint. Shaffer manipulates it by holding onto a handle, similar to a screwdriver handle, outside the patient's body.

Shaffer inflates the joint using saline solution pumped down the same cannula. He makes another small incision on the side of the shoulder and inserts a second cannula. Through that one, Shaffer inserts a shaver to clean up the torn and frayed tissue inside. All the while he watches the images of the joint interior on the screen in front of him. Once the joint has been cleaned, Shaffer uses a tiny drill to bore holes into the edge of the shoulder socket, and then inserts three minute absorbable anchors to secure the newly cleaned cartilage to the bone using sutures.

When all this is done, Shaffer carefully checks his work, scanning everything with the camera, and then withdraws all his mini-tools. The two incisions in the patient's skin get two small stitches each. The entire operation takes about two hours. And some three hours later, the patient goes home.

"You can see better arthroscopically in some joints than you can see through an open incision; it's really revealed a whole new world," said Shaffer. In rotator cuff surgery, for instance, he said, the open-cut method required "vigorous traction on the deltoid muscle for exposure, and still afforded a limited view of the extent of the tear."

Patients who have experienced joint surgery via both the open-cut and arthroscopic methods have no doubts about which they prefer. Sorell Schwartz, a Georgetown University emeritus professor of pharmacology, has been operated on twice for torn rotator cuffs, the muscles and tendons that stabilize the shoulder.

In 1996, when shoulder arthroscopy was still being perfected, Schwartz's left shoulder was operated on using the open-cut method; last April, the right one was done using an arthroscope. Both operations were performed by Shaffer.

The first operation involved five hours of surgery, a two-inch cut, an overnight stay in the hospital and "severe" postoperative pain, Schwartz said. He regained full range of motion in six months.

Last year's operation took two hours, left only quarter-inch incisions, involved no overnight stay and "no post-surgical discomfort" from the incisions, although the joint was tender. Schwartz regained full range of motion after 17 weeks. Scars from the first operation are still visible; Schwartz has a hard time finding the scars from his second one.

"The right shoulder experience was much less traumatic," he said.

For retired goalie Kolzig, meanwhile, arthroscopy was literally a game-changer, saving him months of time off the ice over the years, which could have damaged his career. In fact, he says, were it not for arthroscopy he might not have been drafted by the Capitals in 1989. His first surgery was in 1988, for a torn meniscus in his knee. He was up and skating soon after.

"The timing was right for me," said Kolzig.

Sutherland is a Washington-based freelance writer.

© 2010 The Washington Post Company