PROCEDURE ON

KNEE ARTHROSCOPY
SUBJECT: ADVANCED NURSING PRACTICE

SUBMITTED TO:
Mrs. ELAIYARASI
PRINCIPAL and
PROFESSOR
KTG COLLEGE OF NURSING
BENGALURU

SUBMITTED BY:
Mr. LOKESHA P S
1ST YEAR MSc NURSING
KTG COLLEGE OF NURSING
BENGALURU

Date of submission:

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INTRODUCTION
Arthroscopy is a minimally invasive surgical procedure that allows orthopedic surgeons
to diagnose and treat various joint-related issues with a high degree of precision. It
involves the use of a specialized instrument called an arthroscope to visualize the
inside of a joint without the need for large incisions. Instead, small incisions, typically
less than half an inch in size, are made to insert the arthroscope and other instruments
into the joint.

Definition
The arthroscope is a thin, flexible tube with a camera and light source at its tip, which
allows the surgeon to view the joint's interior on a monitor in real-time. Arthroscopy
can be performed on various joints in the body, with knee and shoulder arthroscopy
being the most common procedures.

Purpose of Arthroscopy
1. Diagnostic Assessment: Arthroscopy is commonly used to diagnose the cause of
unexplained joint pain, swelling, or limited joint mobility. It provides a direct
visualization of the joint's interior, allowing the surgeon to identify and assess various
joint conditions, such as:

 Tears or damage to ligaments (e.g., ACL or PCL tears in the knee).

 Tears in the cartilage (e.g., meniscus tears in the knee).

 Inflammation or synovitis.

 Loose bodies (e.g., bone or cartilage fragments) within the joint.

 Arthritis or degenerative joint diseases.

2. Treatment of Joint Conditions: Arthroscopy can be used for therapeutic purposes to

address and treat joint issues, including:

 Repairing Torn Tissues: Surgeons can use arthroscopy to repair torn ligaments,
tendons, or cartilage within the joint. For example, in the knee, they can
perform procedures like anterior cruciate ligament (ACL) reconstruction or
meniscus repair.

 Synovectomy: The removal of inflamed or damaged synovium (lining of the

joint) to alleviate pain and inflammation.

 Removal of Loose Bodies: Surgeons can remove loose bone or cartilage

fragments that can cause pain, catching, or locking of the joint.

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  Microfracture: In cases of cartilage defects, surgeons can perform
microfracture procedures to stimulate the growth of new cartilage.

 Debridement: Removal of damaged or degenerated tissues within the joint.

3. Recovery and Rehabilitation: Arthroscopy is minimally invasive, leading to smaller

incisions, less tissue damage, and generally faster recovery times compared to open
surgery. This allows patients to return to their daily activities and sports more quickly,
with reduced pain and a smaller risk of complications.

4. Reduced Scarring: Arthroscopy leaves smaller scars, which are cosmetically more
appealing than larger incisions used in open surgery.

5. Early Intervention: Arthroscopy can often identify joint issues at an earlier stage,
potentially preventing the progression of joint damage and reducing the need for
more invasive surgeries later on.

6. Joint Preservation: Arthroscopy can be a part of joint preservation strategies for

conditions like osteoarthritis, where the aim is to delay the need for joint replacement
surgery.

Contraindications of Arthroscopy
1. Severe Infection: Arthroscopy is not advisable in the presence of an active joint
infection. The procedure can introduce bacteria into the joint, worsening the infection
and potentially leading to septic arthritis.

2. Coagulopathy or Bleeding Disorders: Patients with coagulation disorders, such as

hemophilia or those taking blood-thinning medications, may be at an increased risk of
bleeding complications during arthroscopy. Special precautions may be needed in such
cases.

3. Severe Osteoarthritis: Arthroscopy is generally less effective in cases of advanced

osteoarthritis, as it primarily addresses soft tissue and cartilage issues. In severe
osteoarthritis, joint replacement surgery may be more appropriate.

4. Joint Fusion: Arthroscopy is not suitable for joints that have been previously fused or
immobilized. The procedure relies on joint mobility, which is limited to fused joints.

5. Severe Joint Deformity: Joint deformities, such as significant joint contractures or

anatomical abnormalities, may limit the effectiveness and safety of arthroscopy.
Surgical access may be challenging in such cases.

6. Joint Replacement: In cases where a joint has already been replaced with a prosthetic
implant, arthroscopy may not be recommended, as it may damage the implant or
interfere with its function.

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 7. Inadequate Informed Consent: A patient's informed consent is essential before any
surgical procedure, including arthroscopy. If a patient is unable or unwilling to provide
informed consent, the procedure should not be performed.

8. Medical Comorbidities: Patients with severe medical comorbidities, such as

uncontrolled diabetes, heart disease, or severe respiratory conditions, may not be
good candidates for arthroscopy. These conditions can increase the risk of
complications during and after the procedure.

9. Allergy or Hypersensitivity to Anesthetics or Surgical Materials: Patients with known

allergies or hypersensitivity to anesthesia agents, surgical instruments, or materials
used in arthroscopy should be evaluated carefully, and alternative approaches may be
considered.

10. Lack of Surgical Expertise: Arthroscopy is a specialized procedure that requires the
skills and experience of a trained orthopedic surgeon. If a facility lacks the necessary
expertise, the procedure should not be attempted.

PRE REQUSITE-KNOWLEDGE AND SKILLS

1. Anatomy and Physiology Knowledge:

 Understanding the anatomy and physiology of the joint being operated on is essential.
Nurses should be familiar with the specific joint structures and their functions.

2. Infection Control:

 Aseptic techniques and infection control practices are critical to prevent surgical site
infections. Nurses should be well-versed in maintaining a sterile field, handling
instruments, and following proper hand hygiene protocols.

3. Surgical Instrumentation:

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  Familiarity with the instruments used in arthroscopy is essential. Nurses should know
how to handle, prepare, and maintain surgical instruments, including arthroscopic
equipment.

4. Anesthesia Management:

 Nurses should have knowledge of anesthesia techniques and be able to assist the
anesthesiologist in administering and monitoring anesthesia during the procedure.
This includes understanding the potential complications and interventions related to
anesthesia.

5. Patient Assessment:

 Nurses should be skilled in pre-operative and intra-operative patient assessment,

including monitoring vital signs and recognizing signs of distress or complications. They
should also understand the patient's medical history and any potential risks.

6. Medication Administration:

 Proficiency in administering medications, including analgesics and antibiotics, is crucial.

Nurses should be able to calculate and administer doses accurately.

7. Emergency Response:

 Nurses should be trained in basic life support (BLS) and advanced cardiac life support
(ACLS) in case of emergency situations during surgery.

8. Documentation and Charting:

 Accurate and thorough documentation of patient information, vital signs, medications,

and any event’s during surgery is essential for patient care and legal purposes.

9. Communication Skills:

 Effective communication within the surgical team is vital. Nurses should be able to
relay information between the surgeon, anesthesia team, and other personnel. They
should also communicate effectively with the patient before and after the procedure.

10. Patient Advocacy:

 Nurses need to advocate for the patient's safety and comfort. This includes ensuring
that the surgical site is properly marked, verifying informed consent, and addressing
the patient's questions or concerns.

11. Postoperative Care:

 Nurses must be prepared to provide postoperative care, including monitoring the

patient in the recovery room, managing pain, assessing for complications, and
educating the patient on postoperative care instructions.

12. Knowledge of Equipment:

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  Nurses should be familiar with the arthroscopy equipment and systems used in the
procedure, including the arthroscopy tower, camera systems, and surgical
instruments.

13. Informed Consent:

 Understanding the process of obtaining informed consent is crucial, and nurses should
ensure that the patient's consent has been properly obtained before the procedure.

14. Sterile Technique:

 Proficiency in maintaining a sterile field and adhering to strict aseptic techniques is

essential for preventing infections.

NORMAL VALUES OF SYNOVIAL FLUID

i. Appearance: Normal synovial fluid is clear and colorless, similar to egg white. Cloudy
or turbid synovial fluid may indicate an underlying issue, such as inflammation or
infection.

ii. Volume: The normal volume of synovial fluid in a joint is typically small, and it may
vary between joints. For example, the knee joint can hold around 3 to 4 mL of synovial
fluid. An abnormally increased volume of synovial fluid is known as joint effusion and
can be indicative of various joint conditions.

iii. Viscosity: Healthy synovial fluid is viscous, and it helps to lubricate and cushion the
joint. Reduced viscosity can be associated with joint diseases.

iv. Cell Count: The total nucleated cell count (white blood cells) in normal synovial fluid is
usually low, typically less than 200-300 cells per microliter. Elevated white blood cell
counts can indicate inflammation or infection.

v. Differential Cell Count: The types of white blood cells present in synovial fluid are
primarily mononuclear cells (monocytes and lymphocytes) with a small percentage of
polymorphonuclear cells (neutrophils). An elevated neutrophil count may indicate
acute inflammation, such as in septic arthritis.

vi. Protein Concentration: The normal protein concentration in synovial fluid is typically
less than 3.5 g/dL. Elevated protein levels can be seen in various joint conditions,
including inflammatory and degenerative diseases.

vii. Glucose Concentration: The glucose concentration in synovial fluid is usually similar to
blood glucose levels, which is around 60-80 mg/dL. Decreased glucose levels can be a
sign of septic arthritis.

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viii. Lactate Dehydrogenase (LDH): Normal synovial fluid LDH levels are typically less than
250 IU/L. Elevated LDH levels may indicate inflammation, infection, or other joint
diseases.

ARTICLES USED IN ARTHROSCOPY

1. Arthroscope:

 A slender, tube-like instrument equipped with a light source and a camera that
allows visualization of the joint's interior on a monitor.

2. Cannulas:

 Tubes that provide access to the joint space for the arthroscope and other
instruments.

3. Trocars:

 Sharp-pointed instruments are used to puncture the joint capsule, providing

an entry point for the cannulas.

4. Arthroscopic Instruments:

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  Various specialized instruments designed for specific tasks within the joint,
such as:

 Graspers: Used to hold and manipulate tissues.

 Scissors: Used for cutting tissues.

 Probes: Used to assess the integrity of cartilage and other structures.

 Shavers: Devices equipped with rotating blades for removing damaged

tissues or debris.

 Punches: Used for creating holes or removing small areas of damaged

tissue.

 Suture Passers: Instruments for passing sutures through tissues.

 Raspatories: Used for smoothing or reshaping bone surfaces.

5. Fluid Management System:

 A system for irrigating and distending the joint with saline solution during the
procedure, providing a clearer view of the surgical site.

6. Pumps and Shavers:

 High-pressure fluid pumps to control irrigation, and motorized shaver systems

for efficient removal of tissue and debris.

7. Electrocautery Devices:

 Instruments that use electrical current to cut or coagulate tissues, controlling

bleeding during the procedure.

8. Suction/Irrigation Devices:

 Instruments are used to remove excess fluid and debris from the joint space.

9. Light Source and Camera System:

 Provides illumination for the arthroscope and transmits images from the joint
to a monitor.

10. C-Arm Fluoroscopy (if used):

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  Imaging equipment that provides real-time X-ray images to assist in the
precise placement of instruments or confirm the reduction of fractures or
dislocations.

11. Sterile Drapes and Gowns:

 Ensures a sterile field and minimizes the risk of infection.

12. Patient Positioning Devices:

 Equipment to support and position the patient appropriately for the specific
joint being treated.

PREPARATION OF ARTICLES

Before the Procedure:

1. Patient Assessment: Review the patient's medical history, including allergies, current
medications, and any special requirements. Ensure that the patient has provided
informed consent for the procedure.

2. Preoperative Instructions: Provide the patient with preoperative instructions, such as

fasting guidelines, medication instructions, and dressing requirements.

3. Preparation of the Surgical Suite: Ensure that the arthroscopy procedure room is
properly set up, as described in the SOP mentioned earlier.

4. Preoperative Checklist: Collaborate with the surgical team to verify that all required
equipment, instruments, and supplies are ready for the procedure.

5. Patient Preparation: Assist the patient in changing into a surgical gown and ensure
that the patient's vital signs (blood pressure, heart rate, etc.) are stable.

6. Intravenous (IV) Line Insertion: Start an IV line if required for administering anesthesia
or medications.

7. Preoperative Skin Preparation: Help sterilize the surgical site with an antiseptic
solution, following aseptic techniques.

8. Positioning Assistance: Assist in positioning the patient on the surgical table in the
appropriate manner, which is usually determined by the surgeon's preference.

During the Procedure:

1. Monitoring: Continuously monitor the patient's vital signs and alert the surgical team
to any irregularities.

2. Anesthesia Support: Assist the anesthesiologist in administering anesthesia and

ensuring the patient's comfort and safety throughout the procedure.

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 3. Instrument Handling: Hand sterile instruments to the surgeon and surgical team as
needed during the procedure.

4. Suction and Irrigation: Operate the suction and irrigation devices as directed by the
surgeon to maintain a clear surgical field.

5. Communication: Maintain effective communication within the surgical team, ensuring

that everyone is informed about the progress of the procedure.

6. Documenting: Accurately document the procedure, including the time it began,

specific instruments used, any medications administered, and any unexpected events
or complications.

After the Procedure:

1. Postoperative Care: Assist with the postoperative care of the patient, including
monitoring vital signs and ensuring the patient's comfort as they recover from
anesthesia.

2. Wound Care: Help dress and care for the surgical incisions, ensuring that they remain
clean and free from infection.

3. Transportation: Arrange for the patient's transportation to the recovery area or their
room once they are stable and ready to be moved.

4. Equipment Management: Assist in cleaning, sterilizing, and restocking the surgical

suite and instruments for future use.

5. Handover and Documentation: Provide a detailed handover to the nursing team

taking over the patient's care and ensure that all essential documentation is complete
and accurate.

6. Patient Education: Provide postoperative instructions to the patient and their family,
including information on wound care, pain management, and any necessary follow-up
appointments.

PREPARATION OF THE PATIENT

1. Preoperative Assessment:

 Review the patient's medical history, including allergies, current medications, and any
existing medical conditions.

 Assess the patient's overall health and suitability for arthroscopy.

2. Informed Consent:

 Ensure that the patient has been fully informed about the procedure, its risks,
benefits, and alternative treatments.

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  Obtain the patient's written consent for the arthroscopy.

3. Preoperative Instructions:

 Provide the patient with clear preoperative instructions, including:

 Fasting guidelines (usually nothing to eat or drink for a specified period before
the procedure).

 Medication instructions (whether to continue or discontinue certain

medications).

 Showering instructions, emphasizing the use of a specific antiseptic soap.

4. Preoperative Testing:

 Conduct any necessary preoperative tests, such as blood tests, imaging studies, or
electrocardiograms, based on the patient's medical history and the surgeon's
requirements.

5. Anesthesia Consultation:

 If the patient undergoes general anesthesia or sedation, ensure a preoperative

consultation with the anesthesiologist to assess the patient's fitness for anesthesia.

6. Dressing and Changing:

 Instruct the patient to change into a surgical gown, ensuring that all personal items are
safely stored.

7. IV Line Insertion:

 Start an intravenous (IV) line for the administration of anesthesia and other
medications as needed during the procedure.

8. Preoperative Skin Preparation:

 Assist with the preoperative skin preparation by cleaning the surgical site with an
antiseptic solution. This helps reduce the risk of infection.

9. Positioning:

 Position the patient on the surgical table in the appropriate manner, which may vary
depending on the joint undergoing arthroscopy (e.g., supine, lateral, or beach chair
position).

10. Monitoring:

 Attach monitoring devices, such as electrocardiogram (ECG) leads and a blood pressure
cuff, to continuously monitor the patient's vital signs throughout the procedure.

11. Preoperative Time-Out:

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  Conduct a preoperative time-out just before the procedure, during which the surgical
team verifies the patient's identity, the surgical site, and the planned procedure.

12. Communication:

 Establish clear communication with the patient, explaining what to expect before,
during, and after the procedure. Address any concerns or questions they may have.

13. Warming Blankets:

 Provide warming blankets to maintain the patient's body temperature during the
procedure, as operating rooms can be cool.

14. Documentation:

 Document the preoperative care provided, including vital signs, medications

administered, and any relevant information for the patient's medical record.

15. Emotional Support:

 Offer emotional support and reassurance to alleviate any anxiety the patient may be
experiencing.

PERFORMANCE PHASE

The performance phase in arthroscopy involves the actual execution of the surgical procedure
after all the preparatory steps have been completed. This phase is critical, requiring precision,
coordination, and communication among the surgical team members.

1. Joint Access and Visualization:

 The surgeon and the team use trocars to access the joint space, and the
arthroscope is inserted through a cannula to visualize the interior of the joint.

2. Instrumentation:

 Specialized arthroscopic instruments, such as graspers, scissors, probes,

shavers, and electrocautery devices, are used to address the specific pathology
within the joint.

3. Tissue Examination and Treatment:

 The surgeon systematically examines the joint structures, including cartilage,

ligaments, tendons, and synovium, using arthroscopic instruments.
Pathological conditions, such as tears, lesions, or abnormalities, are identified
and addressed.

4. Debridement and Resection:

 Damaged or diseased tissues may be debrided or resected using arthroscopic

shavers, scissors, or other cutting instruments.

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 5. Cartilage Repair and Reconstruction:

 Techniques such as microfracture, chondroplasty, or autologous chondrocyte

implantation may be employed for cartilage repair and reconstruction.

6. Ligament Reconstruction:

 In cases of ligamentous injuries, the surgeon may perform arthroscopic

ligament reconstruction using autografts or allografts.

7. Suturing and Closure:

 Suturing of tissues may be necessary for repairing tears or reattaching

structures. Suture passers and knot-tying instruments are used for this
purpose.

8. Hemostasis:

 Hemostasis is maintained using electrocautery or other hemostatic techniques

to control bleeding during the procedure.

9. Fluoroscopy (if used):

 If C-arm fluoroscopy is employed, real-time X-ray images may be utilized to

confirm the reduction of fractures, assess implant placement, or verify the
accuracy of surgical steps.

10. Communication and Coordination:

 Effective communication among the surgical team members is crucial

throughout the performance phase. The team coordinates instrument
exchanges, communicates findings, and responds to the surgeon's directives.

11. Adaptability:

 The surgical team must be adaptable, responding to unexpected findings or

complications that may arise during the procedure.

12. Patient Monitoring:

 Continuous monitoring of the patient's vital signs is maintained to ensure their

safety and well-being throughout the surgery.

COMPLICATIONS IN ORTHROSCOPE

1. Infection:

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  Although arthroscopy is a minimally invasive procedure, there is still a risk of
infection. Strict adherence to sterile techniques and antibiotic prophylaxis
helps mitigate this risk.

2. Bleeding:

 Some bleeding is expected during arthroscopy, but excessive bleeding may

occur, especially in patients with bleeding disorders or those taking blood-
thinning medications.

3. Blood Clot Formation (Thrombosis):

 Prolonged immobility during the procedure can increase the risk of blood clot
formation, especially in the lower extremities.

4. Nerve or Blood Vessel Damage:

 In rare cases, nerves or blood vessels near the surgical site may be damaged,
leading to sensory or motor deficits or vascular complications.

5. Complications Related to Anesthesia:

 Adverse reactions to anesthesia, respiratory issues, or other anesthesia-

related complications may occur.

6. Joint Stiffness or Instability:

 Manipulation and instrumentation within the joint can sometimes lead to

postoperative joint stiffness or instability.

7. Persistent Pain:

 Some patients may experience persistent pain after arthroscopy, which may
be related to the underlying joint condition or the surgical procedure itself.

8. Deep Vein Thrombosis (DVT):

 Prolonged immobility during and after surgery may increase the risk of DVT,
particularly in patients with pre-existing risk factors.

9. Allergic Reactions:

 Some patients may experience allergic reactions to anesthesia medications,

contrast agents, or materials used during the procedure.

10. Incomplete Resolution of Symptoms:

 In some cases, arthroscopy may not fully resolve the patient's symptoms, and
additional treatment may be required.

11. Instrument Breakage or Malfunction:

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  Breakage or malfunction of arthroscopic instruments during the procedure can
occur, requiring prompt resolution to avoid complications.

12. Inadequate Surgical Access:

 In certain cases, the surgeon may encounter challenges in

CONCLUSION

Arthroscopy is widely used in orthopedic practice and has revolutionized the approach to joint
surgery. Its benefits include minimal scarring, reduced postoperative pain, shorter hospital
stays, and quicker recovery times. However, not all joint conditions are suitable for
arthroscopy, and the decision to undergo the procedure depends on the specific diagnosis and
the surgeon's assessment.

BIBLIOGRAPHY

1. Sandra MN. The Lippincott manual of nursing practice. 7 th ed. Jaypee

brothers: Lippincott; 2003. P. 441-45.
2. Rochele LB, Maribeth. American association of critical care nurses,
procedure manual of critical care. Philadelphia: WB Saunders company;
1993. P.505-11.
3. Lewis, Heitkemper, Dirsken, O’Brien, Bucheri. Medical surgical
nursing. 7th ed. New Delhi: Elsevier publishers; 2008. P. 1461-62.

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