THE PAIN CAME only when he ran-a nagging ache that got worse as the year wore on. But it wasn’t until spring training, when he began having trouble pitching, that Texas Ranger Charlie Hough accepted the fact that he had a knee problem and that something would have to be done about it. An ar-throgram X-ray revealed cartilage damage (one of the most common knee afflictions), which requires surgery. Not too long ago, the cutting away of torn cartilage or the smoothing of abraded cartilage would have involved open surgery, an expensive hospital stay and perhaps months of recovery time. For a professional athlete like Hough, months away from the game could have been devastating.
But Hough didn’t have to spend months in recovery. He underwent arthroscopic knee surgery, a technique in which a tiny fiberoptic telescope is inserted into the knee joint through a small incision as a second incision allows thin surgical instruments to enter the joint. By looking through an eyepiece at the end of the arthroscope or by watching a TV monitor connected to the arthroscope, the surgeon can repair the knee without exposing the joint. Standard arthroscopic surgical procedures take less than an hour. A patient arriving for surgery in the early morning can plan to return home early that afternoon.
Two days after his surgery, Hough could move his knee. After three days, he was walking. And in one month, he was pitching again. “My recovery was pretty good,” says Hough, who, because of the arthroscope, missed only several games instead of the whole season. “I was surprised by how simple it all was.”
Hough’s case is dramatic, but it’s not unusual. Speedy recoveries are the norm with arthroscopic surgery. “I think arthroscopic knee surgery is one of the most important advances in orthopedic surgery in the last 20 years,” says Dr. Carl Highgen-boten, an orthopedic surgeon on staff at Medical City Dallas. “Instead of being on crutches for anywhere from two to six weeks -which used to be very common for a patient with a torn cartilage-we’ve found that the average crutch time (until they quit limping) is about three and a half days.”
Back in 1975, Highgenboten was one of a handful of orthopedic surgeons who practiced arthroscopy in Dallas. He estimates that now more than 50 percent of the city’s orthopedic specialists use arthroscopic surgery techniques and that, eventually, arthroscopic surgery will be the standard procedure whenever possible. The reasons: It’s faster, cheaper and less painful and the recovery time is brief.
This is great news for professional athletes and very good news for the rest of us. (By the way, “the rest of us” undergo arthroscopic surgery more often than professional athletes, even though they’re the ones we hear about.) At present, arthroscopy is mainly confined to knee work, and anyone can have a knee ailment. The procedure can be performed on other joints, such as the shoulder, elbow and ankle, but just a few arthroscopic surgeons use these techniques. Arthroscopic surgery is not a feasible way to repair torn ligaments or to treat arthritis, but it is an excellent way to trim or remove torn cartilage or to remove “loose bodies” of cartilage that float in the joint. Cartilage tears, which account for more than 60 percent of all knee dysfunctions requiring surgery, can occur because of a sudden blow or fall, by twisting the knee or simply from overuse. So, although arthroscopy may sound sophisticated and elite, its applications are very common, and it is an increasingly available service.
The concept of working on a joint by way of simple punctures was introduced at the turn of the century by the Japanese, who used crude instruments and worked blindly. By the end of the Sixties, the Japanese had developed arthroscopy as it is known today. Later, the use of newly developed fiber optics (super-thin glass strands of light) refined the technique. Several Eastern and Canadian doctors experimented with arthroscopy during the early Seventies. By the end of the decade, the practice was widely accepted as a proven medical method, but not all doctors had access to the equipment or the necessary training. This is still the case today, but to a lesser degree. Many orthopedic specialists don’t practice arthroscopy and a few don’t even believe in it, but if arthroscopic surgery is right for you and you want it, you can have it done in Dallas.
The arthroscope, the device that allows a doctor to see into the joint, is about 8 inches long and only 4 to 5 millimeters wide, resembling a thin telescope. It consists of a hollow tube (called a canula) with light fibers inside. Separate lens tubes, each set at a different angle, are inserted into the larger tube, which is attached to either an eyepiece or to a small camera. With the eyepiece, the doctor can look directly into the arthroscope and see, magnified, the inside of the knee joint. With the camera attachment, the image of the joint can be viewed on a TV monitor. This second method of looking into the joint is more common when surgery is being performed because the screen image is amazingly clear and the monitor keeps everyone in the operating room involved. The cost of the basic equipment is about $25,000, but most arthro-scopic surgeons have much more invested in other small instruments and motorized equipment that shave and trim cartilage within the joint.
During surgical proceedings, a separate canula is inserted into the knee, and various thin instruments for cutting, scraping, grasping and suturing enter the knee through the tube. The doctor controls the instruments while watching the screen. The damage to the knee is minimal, the 3/8-inch incisions are negligible and the chance of infection is slight. For the patient, it can mean a quicker operation, usually no overnight hospital stay, less pain and a fester recovery. It also means little or no scarring.
As important as the arthroscope’s surgical application is its diagnostic function- its use as a tool to help doctors diagnose a knee problem. “The diagnostic ability is far more superior to anything we had before,” says Dr. Mike Mycoskie, orthopedic consultant to the Texas Rangers. “I consider the diagnostic use the real advance.” Previously, orthopedic specialists determined the nature of an injury by looking at the knee and studying X-rays to analyze pain and swelling, which often gives a limited view of the problem. Arthrogram X-rays, in which a dye is injected into the joint to make cartilage visible, makes things clearer, but not always clear enough. In the past, open surgery was sometimes necessary just to make a thorough diagnosis.
An arthroscopic evaluation, which takes less than 30 minutes, usually can reveal the nature of an injury. Arthroscopic surgery then may be possible, or open surgery may be necessary, or perhaps the problem-if there really is one-may not require surgery at all. In any case, the doctor and the patient know immediately, so there’s no waiting in the dark for a month or a year, with the patient being either pointlessly cautious or foolishly making the knee worse.
Last April, Hough’s teammate, Mike Richardt, hurt his knee during the last play of a game against Baltimore. After three days of consideration, Richardt opted for an arthroscopic look-see. Mycoskie, his surgeon, diagnosed a severely stretched medial collateral ligament. Surgery would not have been effective. Instead, Richardt rested with a full leg cast for one month, a hinge cast for two weeks, then continued therapy. He missed most of the season. “The alternative to going in with the arthroscope,” says Richardt, “would have been resting six or seven weeks and taking a chance that nothing was wrong. I would’ve been waiting for a disaster. It cost me a part of a good season, but it also may have saved the rest of the year.”
Recovery time from arthroscopy is relatively quick compared to open surgery. “For certain types of knee injuries,” says Dr. Neal Small of the Piano Orthopedic and Sports Medicine Center, “arthroscopic surgery is very effective and certainly allows the most rapid recovery.” Of course, the amount of time needed for full rehabilitation depends upon the individual, his age, the kind of surgery done and the person’s goals. In general, though, a businessman might go back to work the next day, spending a day or two on crutches. A patient may be swimming in three to four days, biking in a week and running in three to six weeks. Four to seven days after arthroscopic surgery, a patient may begin seeing a physical therapist, if recommended by the doctor, and may continue supervised therapy for two to four weeks. Since putting the thigh muscles to use after surgery is vital for preventing-atrophy, some patients have an electronic muscle stimulator attached to their legs. Strength measurement testing on thigh musculature will often be used to determine when a patient can run and return to full sports activity.
It is wrong, however, to expect an instant recovery. Says Highgenboten: “You take a high-priced athlete whose income depends upon his performance and you take torn cartilage out of his knee, then you may have him back playing in three weeks. Everyone thinks someone has worked a miracle. Well, you have to remember that that guy’s motivation is 10 or 100 times higher than yours or mine.”
While arthroscopic surgery can sometimes be performed using only local anesthesia, general anesthesia is preferred, so the patient is asleep during the surgery. The chance of infection is very low; the chance of complications, even lower. My-coskie says that arthroscopy is “a relatively benign procedure with few possible side effects.” When the patient awakens, he or she will feel little or no pain because Novocaine is used after the surgery. The doctor may recommend pain pills, but most patients report very little discomfort. Unless the specific knee injury requires it, no cast is applied, just a large pressure dressing. Usually, crutches are needed for the first few days. All in all, arthroscopic surgery involves considerably less trauma than open surgery.
It also involves less money. In most cases, the cost of hospitalization is unnecessary and the patient can return to work sooner, so he can save between $1,500 and $2,500 on the operation. And faster operations mean that the doctors can do more of them. Dr. Small performs six or seven operations a week, and many area hospitals service more than 50 in a week. There is some concern that arthroscopy could encourage unnecessary surgery; some doctors may be tempted to do it earlier than necessary simply because patients ask for it. Regardless, arthroscopy will surely be standardized by the end of the decade and will probably open up still better surgical and diagnostic techniques.
But for now, it’s still somewhat new. SaysHighgenboten: A lot of patients still don’tknow it’s available.