Knee and Shoulder Arthroscopy

Knee and shoulder arthroscopy has moved from cutting out damaged tissue to repairing, reinforcing and regenerating it. The newest advances include all-inside ACL reconstruction with fibre tape bracing, meniscus repair and transplant, cartilage regeneration, patch-augmented rotator cuff repair and instability surgery chosen by bone loss. Most of these operations are day-care procedures, and the joint is seen better through the arthroscope than through an open incision.

Dr. Vipin Maheshwari, Sr. Consultant - Orthopaedics, Artemis Hospitals, Gurugram, India, is an orthopaedic surgeon who specialises in sports injuries, joint replacement and joint preservation surgery. He framed the newer advances in arthroscopic surgery of the knee and shoulder around one question: how to restore the anatomy, the biomechanics and, above all, the biology the patient was born with.

This guide sets out that framework, the safety case for arthroscopy, what recovery looks like, the gym and sports injuries that bring patients to surgery, when a referring doctor should seek a specialist opinion, and the costs and success rates Dr. Maheshwari gave for international patients. Three companion articles go deeper: all-inside ACL reconstruction, internal bracing and lateral extra-articular tenodesis; meniscus repair, meniscal transplant and cartilage restoration; and shoulder arthroscopy for rotator cuff tears and instability.

What is arthroscopic surgery, and how has it evolved?

Arthroscopy is keyhole surgery inside a joint: a camera (the arthroscope) and slim instruments pass through small portals, short incisions placed at known safe points, so the surgeon can see and repair the joint from within.

Dr. Maheshwari traces the field through six stages, each built on the one before:

1. Repair. The meniscus and the anterior cruciate ligament (ACL) were once stitched through open surgery.
2. Reconstruction. Surgeons then replaced torn ligaments with grafts harvested from elsewhere in the body.
3. Reinforcement. The next step was to protect those grafts with synthetic augmentation while they heal.
4. Preservation. Attention turned to saving both the graft and the patient's own native tissue.
5. Regeneration. Orthobiologics and tissue engineering now aim to regrow damaged tissue.
6. Personalisation. The operation is increasingly tailored to the individual patient's anatomy and demands.

The current goal, in his words, is to recreate anatomy with fixation secure enough to mobilise the patient on day one, to protect the graft, to restore rotational stability and to reduce failures.

The newer advances in knee arthroscopy

The main advances in knee arthroscopy concern three structures: the ACL, the meniscus and the cartilage.

The ACL. Reconstruction has moved from full-length bone tunnels to the all-inside technique, in which short sockets are drilled only as deep as the graft needs and fixation sits on the outer bone surface. A fibre tape internal brace, tensioned tighter than the graft, takes the first load while the graft incorporates into bone. Synthetic grafts help patients with multiligament injuries or limited graft sources, and lateral extra-articular tenodesis (LET) adds the rotational control a central ACL graft does not fully provide. Dr. Maheshwari applies the same evolution in implants and grafts to the posterior cruciate ligament (PCL). The detail, including why ACL reconstructions fail, is in the ACL reconstruction article.

The meniscus. The meniscus, the C-shaped cushion between thigh bone and shin bone, was once simply cut out. Modern practice repairs bucket handle tears, reattaches torn roots, hunts for hidden ramp lesions and, in young patients who have already lost a meniscus, transplants a donor meniscus arthroscopically. Dr. Maheshwari is unequivocal on the stakes: a patient can do well without an ACL, but without a meniscus arthritis cannot be stopped.

Cartilage. Every knee operation is ultimately done to protect cartilage for the future. Treatment now scales with the size of the defect, from microfracture for small lesions to osteochondral autograft transfer (OATS) for larger ones and autologous chondrocyte implantation (ACI), in which the patient's own cartilage cells are grown in a laboratory, for the largest. Both are covered in the meniscus and cartilage article.

The newer advances in shoulder arthroscopy

Rotator cuff repair has progressed from single-row to double-row and suture bridge repairs, rip-stop constructs and, for poor-quality or retracted tendons, patch augmentation with a synthetic patch placed arthroscopically over the repair. For tendons that cannot be repaired, the options run from superior capsular reconstruction and tendon transfer to reverse shoulder arthroplasty once arthritis has set in.

Shoulder instability is no longer treated with a single operation. Dr. Maheshwari chooses between a Bankart repair, a Bankart repair with remplissage and the Latarjet procedure according to glenoid bone loss (bone lost from the front of the shoulder socket), the size of the Hill-Sachs lesion (a dent in the back of the ball of the shoulder left by dislocation) and whether that lesion engages, with 17% glenoid bone loss as his threshold for the Latarjet. The algorithm is set out in the shoulder arthroscopy article.

How safe is arthroscopic surgery?

Arthroscopy of the knee and shoulder is one of the safest operations a surgeon can offer, Dr. Maheshwari explained, because of how the joints are built: every important blood vessel and nerve lies outside the joint, and none runs inside it. In his view, a surgeon who knows the anatomy and plans well is working in a space with no major structure to damage. Some of those structures lie close behind the joint capsule, however, and complications such as infection, deep vein thrombosis and, rarely, nerve or vessel injury, for example during repairs at the back of the meniscus, do occur.

He is candid that every operation on earth carries risk, and that the aim of surgery is to make the patient better, not worse. When patients ask him about risk, he compares it to buying a car: buyers weigh comfort, air conditioning and mileage, and rarely dwell on the fact that cars can have accidents. Arthroscopy carries that order of risk.

Two practical facts follow:

• Most arthroscopies are day-care procedures. Patients are admitted in the morning and go home the same evening or night.
• In his experience, conversion to open surgery does not arise. Minimally invasive spine and brain surgery are a different situation, and in gynaecological laparoscopy a surgeon may find a tumour stuck to the omentum or intestines, with no plane between them, and have to open. Arthroscopy works the other way round: the joint is seen far better through the scope than through an open approach. Even with the knee fully opened, a surgeon cannot see an ACL reconstruction as well or reach the posterior horn of the medial meniscus for a repair. Dr. Maheshwari does not recall converting a planned arthroscopy to open surgery in the last 20 years.

Hip arthroscopy

The hip is different because it is a deep joint rather than one lying just under the skin. It is reached through designated portals, designed by surgeons who studied the anatomy for years before introducing a scope, and Dr. Maheshwari considers hip arthroscopy very safe for a surgeon who knows the landmarks. His team performs labral repairs, loose body removals and cartilage procedures through the hip arthroscope. For surgeons starting out, he recommends a mini-open approach: a small skin incision, careful dissection towards the joint and introduction of the scope once close to the hip. Where a hip joint is already beyond preservation, replacement is a separate pathway, discussed in Dr. Rakesh Mahajan's guide to complex total hip arthroplasty.

Recovery after arthroscopic surgery

Recovery starts sooner than most patients expect. After an all-inside ACL reconstruction with fibre tape augmentation, Dr. Maheshwari's patients bear weight and walk from day one, using a stick for three to four days until the pain settles. He is equally clear that walking is not the end of treatment: rehabilitation with physiotherapy continues, and every case differs. The full ACL timeline, including the six weeks the graft needs to incorporate into bone, the start of running at about three months and the later return to pivoting sport, is in the ACL article. Rehabilitation costs are set out on the physiotherapy and rehabilitation cost page.

His rule for recovery is a simple one: every surgery demands respect. Respect the surgery and it will respect the anatomy; ignore it and it fails.

Can orthobiologics replace surgery?

For a defined group of patients, they increasingly can. Orthobiologics are treatments prepared from the patient's own tissue, chiefly platelet-rich plasma (PRP), a platelet concentrate made from the patient's blood, and bone marrow aspirate concentrate (BMAC), a concentrate of cells drawn from the bone marrow.

Dr. Maheshwari now offers orthobiologics without surgery for small cartilage defects, partial ACL tears and small meniscal tears that are mildly symptomatic in patients who do not want an operation, and reports that these patients do symptomatically very well. His team has also had very good results with PRP and BMAC in avascular necrosis of the hip, in which bone dies from loss of its blood supply.

The choice is personal. A young, very active patient in contact sport who wants to return quickly is a poor fit, because orthobiologics take time and the field is still at a nascent stage. A low-demand patient who is frightened of surgery is a good one: his advice to such patients is to try it. The main obstacles are availability, acceptability and patience. A PRP course needs at least three to four injections, and some patients lose patience and want to get back to their lives. He expects much to change within two to three years, and many operations to be avoided once patients understand they have that option.

Technology and the future of arthroscopy

Dr. Maheshwari groups the future into three themes: biology, technology and personalisation.

• Biology: orthobiologics, tissue engineering, scaffolds and cell-based therapy. Laboratory-grown tissue for grafts is not yet freely available in India, and he expects that to change.
• Technology: 3D visualisation, navigation, artificial intelligence and patient-specific planning, borrowing the patient-specific instruments and planning already used in robotic joint replacement.
• Robotics: robotic systems are established in joint replacement but had not yet reached arthroscopy at the time of the session; he expected them within about six months, while noting that arthroscopy needs robotics less, because the camera already shows the joint.
• Personalisation: every patient's MRI and CT scans should drive the plan. Not every patient needs the most aggressive stabilisation: most patients with a dislocating shoulder who come to his clinic are not athletes who have dislocated many times, and the operation should match the patient's demands.

Gym and sports injuries: who gets hurt, and how to avoid it

Over the past 10 to 15 years, sport has become part of daily life rather than a weekly games period, and running, trekking, cycling and high-impact sports such as tennis, table tennis, cricket and football all load the knee. Dr. Maheshwari sees the upside: active patients arrive better informed about their injury, the procedure and the rehabilitation. Ankle ligament injuries, once wrapped in a crepe bandage and left alone, are now diagnosed and operated on.

In the gym, he sees heavy weight training produce knee cartilage degeneration and ligament injuries, partly because effort goes into building the upper body rather than the leg muscles. In the shoulder, rotator cuff tears are mainly degenerative, while dislocations are rising with contact sports such as boxing and taekwondo.

The exercises he considers most dangerous:

• Heavy squats, especially with a large weight across the shoulders: number one on his list.
• Fast treadmill running on a steep incline, set to four or five, which can easily twist the knee.
• Twister machines, where a slight slip of the foot can cause a major ligament injury.
• Ever-heavier quadriceps extensions, which can rupture the ACL, the quadriceps tendon or the patellar tendon.
• Fly exercises taken too far back, particularly with a history of shoulder subluxation or pain.

His advice is not to stop exercising but to warm up, know one's limits and stop comparing with others. Above all, pain is a signal, not an obstacle. If a 5 kg biceps curl hurts, stop, give the tissue a few weeks to heal, then restart with a smaller weight and build up. In his words, the answer to pain is never more exercise.

When to refer a knee or shoulder injury for a specialist opinion

For a referring doctor, the decision rests on the history. Dr. Maheshwari's approach:

1. Take a careful history of the mechanism. A woman in her twenties with mild pain at the front of the knee after an ordinary walk needs rest and painkillers, not an MRI. A footballer who felt the knee pop and fell to the ground in pain should be treated as having a ligament injury. Ligaments are very strong and do not tear without real force.
2. Investigate when suspicion is high. If the knee functions normally, moves through a full range and the ligaments feel intact, no investigation is needed. After an accident, heavy sport or a blow from behind with severe pain, never hesitate to order an MRI.
3. Do not lose time. Torn ligaments are increasingly stitched back rather than replaced. A patient seen within two to three weeks of injury can have the ACL repaired and keep their own ligament. Primary ACL repair is generally suited to tears close to the ligament's attachment on the femur with good tissue quality; reconstruction remains the standard treatment for most ACL tears.
4. Listen to the returning patient. A patient who keeps coming back with pain is not simply short of vitamins or failing to rest; something is being missed, and clinical examination does not always reveal a ligament injury. Order an MRI.
5. Seek a second opinion when unsure. If the MRI report leaves doubt, a specialist opinion settles whether surgery is needed. Cases that do not need surgery can be treated locally; where surgery is needed, the referring doctor and patient decide whether it is done in their own country or abroad.

His closing message to doctors was to listen to the patient. Most of the answers lie in the history and a careful examination, not in a rush to surgery on the strength of an MRI.

Arthroscopic surgery cost in India for international patients

Dr. Maheshwari gave the following approximate all-inclusive figures for international patients at Artemis Hospitals, covering admission to discharge: surgery, implants, medicines, anaesthesia, operating theatre and ward. The hospital issues an individual quotation for each patient.

In his summary, most single procedures, such as one ligament or one meniscus, fall between USD 4,000 and 5,000. PRP itself is inexpensive; the larger consideration is time, because injections are given at least two weeks apart and a patient stays about six weeks for a course. Benchmarks for the ligament operation are on the ACL reconstruction cost page, and for other arthroscopic procedures on the orthopaedic treatment cost page.

Success rates of knee and shoulder arthroscopy

Dr. Maheshwari defines success as returning the patient to the condition they were in before the injury. On that definition, the rates he gave were:

• ACL or PCL reconstruction: about 98 to 99%; he rarely sees failures in his ligament reconstructions.
• Meniscal repair: about 90 to 95%, even where a long-standing tear has to be trimmed and the remnant repaired; results depend on how much meniscus is torn and how soon the patient presents.
• Surgery for a dislocating shoulder, well planned: about 95 to 98%.
• Rotator cuff repair: about 90 to 95%.

He attributes these figures to two things: recreating the biology of the joint, and advances in implants. Published series set a more conservative benchmark: about two in three patients return to their pre-injury level of sport after ACL reconstruction, around one meniscal repair in four to five fails within five years, recurrence after arthroscopic Bankart repair is commonly about 10 to 20%, and around one rotator cuff repair in four re-tears, more often in large tears, although most patients still gain good pain relief and function.

The principles behind modern arthroscopy

Dr. Maheshwari closed his lecture with a sequence that summarises the whole field:

• Preserve what is normal, because nothing a surgeon builds matches the original.
• Repair whenever repair is possible, including a fresh ACL.
• Reinforce what is at risk, for example with fibre tape in an athlete likely to return to sport early.
• Restore what is lost.
• Regenerate wherever biology allows.
• Personalise every plan, because patients cannot be treated by the book.

The questions doctors asked during the session, from meniscal healing zones to conversion rates, are answered in the Live Discussion. For the wider spectrum of bone and joint conditions, see Dr. Rohit Lamba's guide to orthopaedic disorders and Dr. Ramkinkar Jha's guide to hip and knee replacement, or browse the orthopaedics specialty hub.