Knee Arthroscopy in Perth

Knee arthroscopy is keyhole surgery: a small telescope with a camera is passed into the joint through an incision a few millimetres wide, projecting the inside of the knee onto a monitor, with instruments passed through one or two more.

It is a genuinely useful operation for a specific set of problems. It is also one of the most over-performed operations in orthopaedic history, and the honest version of this page has to cover both.

What it does not fix

Start here, because it saves a lot of people a lot of trouble.

Arthroscopy does not help an arthritic knee. Washing the joint out, trimming frayed tissue and smoothing worn cartilage — sometimes offered as a “clean out” — has been tested against exercise therapy and against placebo surgery, where patients had the incisions and the anaesthetic but nothing was done inside the joint. The results did not favour the real operation.

The Australian clinical guideline for knee and hip osteoarthritis does not recommend offering arthroscopic lavage and debridement for knee osteoarthritis.

This matters because arthritis and mechanical knee problems produce overlapping symptoms, and an MRI of an older knee almost always shows a meniscal tear whether or not it is causing anything. It is very easy to find something on a scan, operate on it, and change nothing — while the arthritis that was actually causing the pain carries on.

If arthritis is the problem, the non-surgical options are where the evidence is, and knee replacement is where the answer lies if those stop working.

What it genuinely fixes

Now the other half, because arthroscopy being wrong for arthritis does not make it a bad operation.

It is the right operation when there is a mechanical problem — something physically wrong inside the joint that an instrument can correct:

• A locked knee, or one blocked from fully straightening, usually from a displaced bucket-handle meniscal tear where a torn fragment has flipped into the joint
• Loose bodies — fragments of bone or cartilage floating in the knee, catching and jamming
• An acute traumatic meniscal tear, particularly in a younger patient, where the tear pattern and blood supply make repair possible
• Meniscal tears causing true mechanical symptoms that have not settled with time and rehabilitation
• Infection within the joint requiring urgent washout
• As part of ACL reconstruction, where the new graft is placed arthroscopically

The distinction running through that list is between a joint that is jamming and a joint that is worn. Arthroscopy is good at the first and does nothing for the second.

How the decision is actually made

Three things separate the patients who benefit from the ones who do not.

The story. Mechanical symptoms have a particular character — the knee catching, locking, giving way, or refusing to straighten, often traceable to a specific incident. Arthritic pain is more diffuse, worse with activity and after rest, and comes on over months to years rather than in a moment.

The examination. A knee that will not fully straighten, or that has joint-line tenderness with a positive provocation test, points differently from one that is diffusely stiff with crepitus and deformity.

The imaging. X-ray first, to see how much arthritis is there — this is the single most useful discriminator, and skipping to MRI is a common way to end up operating on the wrong problem. MRI where a repairable tear or ligament injury is suspected.

If your knee X-ray shows significant arthritis, a meniscal tear seen on MRI is very likely incidental. Operating on it usually disappoints.

What the operation involves

Two or three incisions of a few millimetres each. One takes the arthroscope; the others take the instruments.

Diagnosis and treatment happen in the same sitting — if a tear is found that warrants treating, it is treated there and then rather than requiring a second operation. Arthroscopy is rarely done for a look alone.

The procedure takes roughly fifteen to thirty minutes depending on what is found. It is usually a day case: most patients go home four to six hours afterwards, though you will need someone to drive you and, ideally, to stay with you overnight.

Recovery, honestly

Faster than open surgery. Not instant.

Expect swelling and discomfort for a week or two, and use crutches for a few days if you need them. Most people return to desk-based work within about a week. Physically demanding work and sport take longer.

The important variable is what was done inside:

• Trimming a torn meniscus (partial meniscectomy) allows a relatively quick return, because nothing needs to heal.
• Repairing a meniscus — stitching the tear so it can heal rather than removing it — carries considerably more restriction, often limited weight-bearing and limited bend for several weeks. Repair preserves the meniscus, which matters a great deal for the long-term health of the knee, and the price is a slower, more protected recovery.

Where repair is possible it is usually worth the extra restriction, because a meniscus you keep is a meniscus still protecting the joint surface. That trade-off is discussed before surgery rather than decided afterwards.

Where this fits

Arthroscopy is a precise tool for structural problems. Used for the right knee it solves something quickly and with little disruption; used for a worn joint it is an anaesthetic and a fortnight of recovery in exchange for very little.

Meniscus tear covers the commonest reason arthroscopy is considered, including which tears are worth operating on. Knee arthritis and treating knee arthritis without surgery cover the problem arthroscopy is not the answer to.

To have a knee assessed, book a consultation, phone the rooms on (08) 6332 6365 or email info@rhysclark.com.au. Dr Clark consults at Murdoch and Mandurah.