The Future of Arthroscopy: Biology, Technology and Personalisation

Blood supply to the meniscus runs from outside to inside, dividing it into three zones. The outer red-red zone near the capsule has decent blood supply, which is why peripheral tears heal well. The middle red-white zone has moderate blood supply and can still be repaired if augmented with orthobiologics. The innermost white-white zone has very poor blood supply, and a peripheral rim tear there is better debrided than repaired with multiple anchors into non-vascular tissue.

The meniscus is the only shock absorber between the femur and the tibia, taking on all the compressive and shear stress of walking, running and sport, and preventing the two bones' cartilage from grinding directly against each other. Once it is removed, that cartilage-on-cartilage contact leads to arthritis within a few years. A patient can function without an ACL, but without a meniscus, arthritis is inevitable.

Not at all, this is a different situation from minimally invasive spine or brain surgery. Arthroscopy actually gives a clearer view of the joint than open surgery would; even opening the knee completely to repair the posterior horn of the meniscus does not give as clear a view as the arthroscope does. In twenty years of practice, an arthroscopy has never needed conversion to an open procedure, provided the surgeon is patient and knows the anatomy well.

All surgery carries some residual risk, similar to how buying a car involves a small residual risk of a road accident that is rarely front of mind. The reassuring fact is that all the major blood vessels and nerves sit outside the knee and shoulder joint capsule, so as long as the anatomy is well understood and the surgery carefully planned, arthroscopy is one of the safest procedures available. Most arthroscopies are done as day-care procedures, with patients going home the same day.

Hip arthroscopy is a little different because the hip is a deeper joint, but designated portals developed over many years of anatomical study make it safe as long as a surgeon sticks to those landmarks. Labral repairs, loose body removal and cartilage surgery can all be done through the hip arthroscope. Surgeons early in their hip arthroscopy experience can use a safer mini-open approach, a small skin incision leading to the joint before introducing the scope.

Biology (orthobiologics, tissue engineering, PRP and BMAC), technology (3D visualisation, navigation, AI-assisted planning and patient-specific instrumentation, including emerging robotic arthroscopy), and personalisation of treatment to each patient's anatomy and demands.

Preserve what is normal, repair whenever possible, reinforce what is addressed for patients at higher risk of graft failure, and restore whatever is lost while keeping regeneration in mind.