Arthroscopic surgery is a procedure that allows surgeons to visualize, diagnose, and treat joint problems. The name is derived from the Greek words arthron, joint, and skopein, to look at. Arthroscopy is performed using an arthroscope, a small fiber-optic instrument that enables a close look at the inside of a joint through a small incision.
Arthroscopic surgery is used to diagnose, treat, and monitor joint injuries and diseases that affect the joints. Diagnostic arthroscopic surgery is performed when the medical history, physical exam, x rays, and bone scanning examinations, such as MRI or CT, do not provide a definitive diagnosis. Corrective arthroscopic surgery is used primarily to remove bone or cartilage or repair tendons or ligaments.
Diagnostic arthroscopic surgery is not recommended unless non-surgical treatment does not fix the problem.
Arthroscopic surgery is performed most commonly on the knees, and also on ankles, shoulders, wrists, elbows, and hips. Knee joints are large enough to allow free movement of arthroscopic instruments and therefore are ideal for the benefits of this type of examination and treatment. The technique is valued because it allows surgeons to see inside the joint through incisions as tiny as a quarter of an inch (about 1 cm) rather than the large incisions that open surgery procedures require. The accuracy of arthroscopy is said to be 100% for diagnosis compared to diagnostic imaging such as MRI. Arthroscopic surgery may be used to relieve mechanical joint problems, such as buckling, stiffness, or locking, and can preclude or delay the need for more aggressive surgery such as a joint replacement.
In arthroscopic surgery, an orthopedic surgeon uses a pencil-sized arthroscope—a fiber-optic instrument fitted with a lens, a light source, and a miniature video camera—to see inside a joint. Advanced fiber optics allow even more detail to be seen than in open surgery, often identifying problems that may have been difficult to diagnose with other methods. The arthroscope transmits highlighted images of the structures to a television monitor in the operating room . The surgeon is able to view the entire examination, getting a full view of the joint, its cartilage, and surrounding tissue. The type and extent of the injury can be determined and repair or correction can be performed if necessary. Some of the most common joint problems diagnosed and treated with arthroscopic surgery are:
- synovitis (inflamed joint lining) of the knee, shoulder, elbow, wrist, or ankle
- injuries to the shoulder, such as rotator cuff tendon tears, impingement syndrome, and dislocations
- injuries to the knee, such as meniscal (cartilage) tears, wearing down of or injury to the cartilage cushion, and anterior cruciate ligament tears with instability
- injuries to the wrist, such as carpal tunnel syndrome
- loose bodies of bone and/or cartilage in the knee, shoulder, elbow, ankle, or wrist
- joint damage caused by rheumatoid arthritis or osteoarthritis
Arthroscopic procedures are performed in a hospital or outpatient surgical facility by an orthopedic surgeon. The type of anesthesia used (local, spinal, or general) varies, as does the length of the procedure; both depend on the joint that will be operated on, the type and extent of the suspected joint injury, and/or the complexity of the anticipated repair. Arthroscopic surgery rarely takes more than an hour. Most patients who have arthroscopic surgery, whether diagnostic or corrective, are discharged within the same day; some patients, depending on the complexity of the surgery or their post-operative condition, may stay in the hospital one or two days.
Considered the most important orthopedic development in the twentieth century, arthroscopic surgery is widely used. The American Association of Orthopedic Surgeons reports that it is performed by 80% of all orthopedic surgeons. The use of arthroscopic surgery on famous athletes has been well publicized. Although arthroscopic surgery was initially only a diagnostic tool used prior to open surgery, the availability of better instruments and techniques has encouraged its use to actually treat a variety of joint problems, often avoiding more complicated surgeries with longer recovery times. New techniques under development are likely to lead to other joints being treated with arthroscopic surgery in the future. Laser technology has been introduced as a treatment option in arthroscopic surgery and other advanced technologies are being explored.
After making two small incisions about the size of a buttonhole in the skin near the joint, the surgeon injects sterile sodium chloride solution through one incision into the joint to expand it for better viewing and movement of the instruments. The surgeon will also use this access to irrigate (flood with fluid) the joint area during surgery and to suction blood and debris away from the joint. This irrigation, or "washing" part of the procedure, is believed to be of value in itself, improving joint function. The arthroscope is then inserted into the second incision. While looking at the interior of the joint on the television monitor, the surgeon can determine the extent or type of injury and, if necessary, take a biopsy specimen or repair or treat the problem. A third tiny incision may be made in order to see other parts of the joint or to insert additional instruments, such as laser or tiny scalpels, when repairs or corrections need to be made. Arthroscopic surgery can be used to remove floating bits of cartilage, to debride (clean by removing tissue or bone), and to treat minor tears and other disorders. When the procedure is finished, the arthroscope is removed and the joint is once again irrigated. The site of the incision is dressed with compression bandages (ace bandages).
Prior to arthroscopy, the patient's medical history will be reviewed and the patient will have a complete physical examination . Standard pre-operative blood and urine tests will be done as well as scans of the affected joint, such as MRI (magnetic resonance imaging ), CT (computed tomography), and arthrogram (an x ray using dye). In some cases, an exercise regimen or muscle stimulation treatment (TENS) may be recommended to strengthen muscles around the joint prior to surgery. Surgeons may recommend pre-operative guidelines, such as:
- Discontinue aspirin and anti-inflammatory medications two weeks before surgery.
- Stop smoking to encourage post-operative healing.
- Inform the surgeon if any fever or other illness occurs, or if cuts, scratches, or bruises appear near the surgical site before the scheduled surgery.
- Do not eat, drink, or chew gum for 12 hours prior to surgery.
- Bring crutches or a walker if hip, knee, or ankle arthroscopy is being performed.
- Wear loose fitting clothing to allow for bulky dressings over the surgical site.
Immediately after the procedure, the patient will spend up to two hours in a recovery area before being discharged. Some patients may be transferred to a hospital room if the surgeon determines overnight care is necessary. The surgical site will be dressed with a compression bandage (ace bandage) or a tightly fitting stocking (support hose). An ice pack will be placed on the joint that was examined or treated by arthroscopy. This treatment may continue for up to 72 hours after surgery to keep swelling down and help prevent the formation of clots. Pain medication will be administered if needed, although most patients require little or no medicine for pain. Dressings can usually be removed on the morning after surgery and replaced by adhesive strips. The surgeon should be notified if the patient experiences any increase in pain, swelling, redness, drainage or bleeding at the site of the surgery, signs of infection (headache, muscle aches, dizziness, fever), and nausea or vomiting.
It takes several days for the puncture wounds to heal and several weeks for the joint to fully recover. Many patients can resume their daily activities, including going back to work, within a few days of the procedure. Muscle strength must be regained as soon as possible after surgery to help support the affected joint. A rehabilitation program, including physical therapy, may be suggested to speed recovery and improve the functioning of the joint. The surgeon's recommendations for recovery may include:
- Keep the surgical site and the dressings clean and dry.
- Use ice packs for up to 72 hours to reduce pain and swelling.
- Elevate the affected joint (wrist, elbow, ankle, knee) on pillows; exercise gently to encourage circulation.
- Use a knee brace or shoulder sling temporarily.
- Allow weight-bearing exercise as able.
Few complications are to be expected with arthroscopy. Those that may occur occasionally (fewer than 1% of all arthroscopies, according to the American Academy of Orthopedic Surgeons) are infection, blood clot formation, swelling or bleeding, or damage to blood vessels or nerves. Rare instrument breakage during procedures has also been reported.
Most patients undergo arthroscopic surgery as an outpatient and are home with hours or at most a day or two. Pain and complications are rare and most patients will enjoy improved mobility as they recover over a period of days, possibly with the aid of physical therapy and gentle exercise.
Some people undergoing arthroscopy may have preexisting conditions and diseases that will affect the surgical result. Recovery times will vary depending on each patient's overall condition. Certain problems may need to be treated with a combination of arthroscopic and open surgical procedures.
Alternatives to arthroscopic surgery include:
- changing activities to those less strenuous or demanding
- anti-inflammatory medications
- physical therapy and appropriate, gentle exercise such as yoga
- wearing a brace or using a walking aid
- glucosamine sulfate and chondroiten to reduce pain and stiffness
- therapeutic massage, acupuncture, or other body work
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American Academy of Orthopedic Surgeons(AAOS). 6300 North River Road, Rosemont, IL 60018. (800) 346-AAOS. <http://www.aaos.org>.
Institute for Bone and Joint Disorders. 2222 East Highland Avenue, Phoenix, AZ 85016; 602-553-3113. <http://www.ibjd.com>.
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The Arthritis Foundation. About Arthroscopic Surgery. [cited April 2003]. <http://www.arthritis.org>.
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Lori De Milto L. Lee Culvert
WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?
Arthroscopic surgery is performed in a hospital operating room or an outpatient surgical facility by an orthopedic surgeon.
QUESTIONS TO ASK THE DOCTOR
- Why is arthroscopy necessary for me?
- What kind of anesthesia will I have?
- How often do you perform this procedure? What results are typical?
- How much discomfort can I expect short term? Long term?
- Will physical therapy be necessary after the surgery?
- Will this procedure correct my joint problem?
"Arthroscopic Surgery." Gale Encyclopedia of Surgery: A Guide for Patients and Caregivers. . Encyclopedia.com. (July 22, 2017). http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/arthroscopic-surgery-0
"Arthroscopic Surgery." Gale Encyclopedia of Surgery: A Guide for Patients and Caregivers. . Retrieved July 22, 2017 from Encyclopedia.com: http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/arthroscopic-surgery-0
Arthroscopy is the examination of a joint, specifically, the inside structures. The procedure is performed by inserting a specifically designed illuminated device into the joint through a small incision. This instrument is called an arthroscope. The procedure of arthroscopy is primarily associated with the process of diagnosis. However, when actual repair is performed, the procedure is called arthroscopic surgery.
Arthroscopy is used primarily by doctors who specialize in treating disorders of the bones and related structures (orthopedics) to help diagnose joint problems. Once described as essential for those who primarily care for athletic injuries, arthroscopy is now a technique commonly used by orthopedic surgeons for the treatment of patients of all ages. This procedure is most commonly used to diagnose knee and shoulder problems, although the elbow, hip, wrist, and ankle may also be examined with an arthroscope.
A joint is a complex system. Within a joint, ligaments attach bones to other bones, tendons attach muscles to bones, cartilage lines and helps protect the ends of bones, and a special fluid (synovial fluid) cushions and lubricates the structures. Looking inside the joint allows the doctors to see exactly which structures are damaged. Arthroscopy also permits earlier diagnosis of many types of joint problems which had been difficult to detect in previous years.
Most arthroscopic procedures today are performed in same-day surgery centers where the patient is admitted just before surgery. A few hours following the procedure, the patient is allowed to return home, although usually someone else must drive. Depending on the type of anesthesia used, the patient may be told not to eat for several hours before arriving. Before the procedure, the anesthesiologist will ask if the patient has any known allergies to local or general anesthetics. Airway obstruction is always possible in any patient who receives a general anesthesia. Because of this, oxygen, suction, and monitoring equipment must be available. The patient's cardiac status should always be monitored in the event that any cardiac abnormalities arise during the arthroscopy.
The arthroscope is an instrument used to look directly into the joint. It contains magnifying lenses and glass-coated fibers that send concentrated light into the joint. A camera attached to the arthroscope allows the surgeon to see a clear image of the joint. This image is then transferred to a monitor located in the operating room at the time of the arthroscopy. This video technology is also important for documentation of the arthroscopic procedure. For example, if the surgeon decides after the arthroscopic examination that a conventional approach to surgically expose or "open" the joint (arthrotomy) must be used, a good photographic record will be useful when the surgeon returns to execute the final surgical plan.
The procedure requires the surgeon to make several small incisions (portals) through the skin's surface into the joint. Through one or two of the portals, a large-bore needle, called a cannula, is attached to tubing and inserted into the joint. The joint is inflated with a sterile saline solution to expand the joint and ensure clear arthroscopic viewing. Often, following a recent traumatic injury to a joint, the joint's natural fluid may be cloudy, making interior viewing of the joint difficult. In this condition, a constant flow of the saline solution is necessary. This inflow of saline solution may be through the cannula with the outflow through the arthroscope, or the positions may be reversed. The arthroscope is placed through one of the portals to view and evaluate the condition of the joint.
Before an arthroscopy can take place, the surgeon completes a thorough medical history and evaluation. Important for the accuracy of this diagnostic procedure, a medical history and evaluation may discover other disorders of the joint or body parts, proving the procedure unnecessary. This is always an important preliminary step, because pain can often be referred to a joint from another area of the body. Anatomical models and pictures are useful aids to explain to the patient the proposed arthroscopy and what the surgeon may be looking at specifically.
Proper draping of the body part is important to prevent contamination from instruments used in arthroscopy, such as the camera, light cords, and inflow and outflow drains placed in the portals. Draping packs used in arthroscopy include disposable paper gowns and drapes with adhesive backing. The surgeon may also place a tourniquet above the joint to temporarily block blood flow to the area during the arthroscopic exam.
General or local anesthesia may be used during arthroscopy. Local anesthesia is usually used because it reduces the risk of lung and heart complications and allows the patient to go home sooner. The local anesthetic may be injected in small amounts in multiple locations in skin and joint tissues in a process called infiltration. In other cases, the anesthetic is injected into the spinal cord or a main nerve supplying the area. This process is called a "block," and it blocks all sensation below the main trunk of the nerve. For example, a femoral block anesthetizes the leg from the thigh down (its name comes from femur, the thighbone). Most patients are comfortable once the skin, muscles, and other tissues around the joint are numbed by the anesthetic; however, some patients are also given a sedative if they express anxiety about the procedure. (It's important for the patient to remain still during the arthroscopic examination.)
Hemarthrosis— A condition of blood within a joint.
Pulmonary embolus— Blockage of an artery of the lung by foreign matter such as fat, tumor, tissue, or a clot originating from a vein.
Thrombophlebitis— Inflamation of a vein with the formation of a thrombus or clot.
General anesthesia, in which the patient becomes unconcious, may be used if the procedure may be unusually complicated or painful. For example, people who have relatively "tight" joints may be candidates for general anesthesia because the procedure may take longer and cause more discomfort.
The portals are closed by small tape strips or stitches and covered with dressings and a bandage. The patient spends a short amount of time in the recovery room after arthroscopy. Most patients can go home after about an hour in the recovery room. Pain medication may be prescribed for a short period; however, many patients find various over-the-counter pain relievers sufficient.
Following the surgical procedure, the patient needs to be aware of the signs of infection, which include redness, warmth, excessive pain, and swelling. The risk of infection increases if the incisions become wet too early following surgery. Because of this, it is good practice to cover the joint with plastic (for example, a plastic bag) while showering after arthroscopy.
The use of crutches is commonplace after arthroscopy, with progression to independent walking on an "as tolerated" basis by the patient. Generally, a rehabilitation program, supervised by a physical therapist, follows shortly after the arthroscopy to help the patient regain mobility and strength of the affected joint and limb.
The incidence of complications is low compared to the high number of arthroscopic procedures performed every year. Possible complications include infection, swelling, damage to the tissues in the joint, blood clots in the leg veins (thrombophlebitis ), leakage of blood into the joint (hemarthrosis), blood clots that move to the lung (pulmonary embolus), and injury to the nerves around the joint.
The goal of arthroscopy is to diagnose a joint problem causing pain and/or restrictions in normal joint function. For example, arthroscopy can be a useful tool in locating a tear in the joint surface of the knee or locating a torn ligament of the shoulder. Arthroscopic examination is often followed by arthroscopic surgery performed to repair the problem with appropriate arthroscopic tools. The final result is to decrease pain, increase joint mobility, and thereby improve the overall quality of the patient's activities of daily living.
Less optimal results that may require further treatment include adhesive capsulitis. In this condition, the joint capsule that naturally forms around the joint becomes thickened, forming adhesions. This results in a stiff and less mobile joint. This problem is frequently corrected by manipulation and mobilization of the joint with the patient placed under general anesthesia.
Glassman, Scott. "Advances in Treating Shoulder Injuries." Advanced Magazine for Physical Therapists (December 1997): 10-12.
"Arthroscopy." Gale Encyclopedia of Medicine, 3rd ed.. . Encyclopedia.com. (July 22, 2017). http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/arthroscopy
"Arthroscopy." Gale Encyclopedia of Medicine, 3rd ed.. . Retrieved July 22, 2017 from Encyclopedia.com: http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/arthroscopy
Arthroscopic surgery is a procedure to visualize, diagnose, and treat joint problems. The name is derived from the Greek words arthron, which means joint, and skopein, which means to look at.
Arthroscopic surgery is used to identify, monitor, and diagnose joint injuries and disease; or to remove bone or cartilage or repair tendons or ligaments. Diagnostic arthroscopic surgery is performed when medical history, physical exam, x rays, and other tests such as MRIs or CTs don't provide a definitive diagnosis.
Diagnostic arthroscopic surgery should not be performed unless conservative treatment does not fix the problem.
In arthroscopic surgery, an orthopedic surgeon uses an arthroscope, a fiber-optic instrument, to see the inside of a joint. After making an incision about the size of a buttonhole in the patient's skin, a sterile sodium chloride solution is injected to distend the joint. The arthroscope, an instrument the size of a pencil, is then inserted into the joint. The arthroscope has a lens and a lighting system through which the structures inside the joint are transmitted to a miniature television camera attached to the end of the arthroscope. The surgeon uses irrigation and suction to remove blood and debris from the joint before examining it. Other incisions may be made in order to see other parts of the joint or to insert additional instruments. Looking at the interior of the joint on the television screen, the surgeon can then determine the amount or type of injury and, if necessary, take a biopsy specimen or repair or correct the problem. Arthroscopic surgery can be used to remove floating bits of cartilage and treat minor tears and other disorders. When the procedure is finished, the arthroscope is removed and the joint is irrigated. The site of the incision is bandaged.
Arthroscopic surgery is used to diagnose and treat joint problems, most commonly in the knee, but also in the shoulder, elbow, ankle, wrist, and hip. Some of the most common joint problems seen with an arthroscope are:
- inflammation in the knee, shoulder, elbow, wrist, or ankle
- injuries to the shoulder (rotator cuff tendon tears, impingement syndrome, and recurrent dislocations), knee (cartilage tears, wearing down of or injury to the cartilage cushion, and anterior cruciate ligament tears with instability), and wrist (carpal tunnel syndrome)
- loose bodies of bone and/or cartilage in the knee, shoulder, elbow, ankle, or wrist
Corrective arthroscopic surgery is performed with instruments that are inserted through additional incisions. Arthritis can sometimes be treated with arthroscopic surgery. Some problems are treated with a combination of arthroscopic and standard surgery.
Also called arthroscopy, the procedure is performed in a hospital or outpatient surgical facility. The type of anesthesia (local, spinal, or general) and the length of the procedure depends on the joint operated on and the complexity of the suspected problem. Arthroscopic surgery rarely takes more than an hour. Most patients who have arthroscopic surgery are released that same day; some patients stay in the hospital overnight.
Considered the most important orthopedic development in the 20th century, arthroscopic surgery is widely used. The use of arthroscopic surgery on famous athletes has been well publicized. It is estimated that 80% of orthopedic surgeons practice arthroscopic surgery. Arthroscopic surgery was initially a diagnostic tool used prior to open surgery, but as better instruments and techniques were developed, it began to be used to actually treat a variety of joint problems. New techniques currently under development are likely to lead to other joints being treated with arthroscopic surgery in the future. Recently, lasers were introduced in arthroscopic surgery and other new energy sources are being explored. Lasers and electromagnetic radiation can repair rather than resect injuries and may be more cost effective than instruments.
Before the procedure, blood and urine studies and x rays of the joint will be conducted.
Immediately after the procedure, the patient will spend several hours in the recovery room. An ice pack will be put on the joint that was operated on for up to 48 hours after the procedure. Pain medicine, prescription or non-prescription, will be given. The morning after the surgery, the dressing can be removed and replaced by adhesive strips. The patient should call his/her doctor upon experiencing an increase in pain, swelling, redness, drainage or bleeding at the site of the surgery, signs of infection (headache, muscle aches, dizziness, fever ), or nausea or vomiting.
It takes several days for the puncture wounds to heal, and several weeks for the joint to fully recover. Many patients can resume their daily activities, including going back to work, within a few days of the procedure. A rehabilitation program, including physical therapy, may be suggested to speed recovery and improve the future functioning of the joint.
Complications are rare in arthroscopic surgery, occurring in less than 1% of patients. These include infection and inflammation, blood vessel clots, damage to blood vessels or nerves, and instrument breakage.
Wilkinson, Todd. "Pop, Crackle, Snap." Women's Sports & Fitness (April 1998): 68.
Joint— The point where bones meet. Arthroscopic surgery is used on joint problems.
Laser— A device that concentrates electromagnetic radiation into a narrow beam and treats tissue quickly without heating surrounding areas.
Orthopedics— The medical specialty that deals with preserving, restoring, and developing form and function in the extremities, spine, and other structures using medical, surgical, and physical methods. Arthroscopic surgery is performed by orthopedic surgeons.
"Arthroscopic Surgery." Gale Encyclopedia of Medicine, 3rd ed.. . Encyclopedia.com. (July 22, 2017). http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/arthroscopic-surgery
"Arthroscopic Surgery." Gale Encyclopedia of Medicine, 3rd ed.. . Retrieved July 22, 2017 from Encyclopedia.com: http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/arthroscopic-surgery
The arthroscope is an optical (pertaining to the eye) instrument that allows doctors to view the inner workings of a moveable joint without having to perform surgery. The instrument is a flexible narrow tube containing several bundles of hair-thin glass fibers that are covered with a reflective coating. A highly intense light source, usually a halogen lamp, is used to transmit light along one bundle of fibers toward the target area inside the joint (a place where two bones are joined, usually so that they can move). Another bundle of fibers carries an image of the target area back up the tube where it is viewed through an eyepiece.
Crude versions of the arthroscope were used as early as the nineteenth century and included long, rigid tubes illuminated by candles. The first efforts to develop the kind of glass fibers that would eventually be used in arthroscopes were made by the Atomic Energy Authority and the Rank Organization in England. By 1965, a 25-micron (a micron is one-thousandth of a millimeter) fiber had been produced which was quickly followed by the development of a 15-micron (a much finer) fiber. When the American Cytoscopic Company succeeded in sterilizing glass fibers, the possibilities for medical uses of the arthroscope increased greatly.
The modern arthroscope contains additional features in the form of air and water channels for flushing water through or inflating targeted areas. Miniature instruments can be placed at the tip of the arthroscope to perform simple operations. Used with a laser beam, the instrument can control localized bleeding. Because the size of the incision (cut) needed to insert the arthroscope is small, surgery within a joint is less traumatic for patients. With less damage to the surrounding tissue, patients heal faster and regain use of their joints with less pain and in less time.
[See also Endoscope ]
"Arthroscope." Medical Discoveries. . Encyclopedia.com. (July 22, 2017). http://www.encyclopedia.com/medicine/medical-journals/arthroscope
"Arthroscope." Medical Discoveries. . Retrieved July 22, 2017 from Encyclopedia.com: http://www.encyclopedia.com/medicine/medical-journals/arthroscope
ar·thro·scope / ˈär[unvoicedth]rəˌskōp/ • n. Med. an instrument through which the interior of a joint may be inspected or operated on. DERIVATIVES: ar·thro·scop·ic / ˌär[unvoicedth]rəˈskäpik/ adj. ar·thros·co·py / ärˈ[unvoicedth]räskəpē/ n.
"arthroscope." The Oxford Pocket Dictionary of Current English. . Encyclopedia.com. (July 22, 2017). http://www.encyclopedia.com/humanities/dictionaries-thesauruses-pictures-and-press-releases/arthroscope
"arthroscope." The Oxford Pocket Dictionary of Current English. . Retrieved July 22, 2017 from Encyclopedia.com: http://www.encyclopedia.com/humanities/dictionaries-thesauruses-pictures-and-press-releases/arthroscope
"arthroscopy." A Dictionary of Nursing. . Encyclopedia.com. (July 22, 2017). http://www.encyclopedia.com/caregiving/dictionaries-thesauruses-pictures-and-press-releases/arthroscopy
"arthroscopy." A Dictionary of Nursing. . Retrieved July 22, 2017 from Encyclopedia.com: http://www.encyclopedia.com/caregiving/dictionaries-thesauruses-pictures-and-press-releases/arthroscopy