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To see inside joints using a small scope is something that first was done around 100 years ago. The first arthroscopes were both large and clumsy and for many decades only diagnostic evaluations were possible. It is only during the last 20–30 years that therapeutic arthroscopy has seen the light of day. Today, diagnostic arthroscopy alone is hardly performed. In the beginning, arthroscopy was almost only related to the knee and other joints were rarely considered—and in fact technically more or less impossible. The knee is still the joint where the most progress is made, but nowadays the arthroscope is an universal tool and more or less all joints of the body are evaluated and treated using the arthroscope, even the smallest joints.
In this issue of the journal we find two important and updated state of the art papers about arthroscopy of the ankle1 and the elbow.2 After arthroscopy of the knee had become widespread around the world, other joints followed, first the shoulder, and thereafter joints like the ankle and elbow. In the last 10 years, arthroscopy of the hip has become an important tool in the diagnostic and therapeutic evaluation of hip pain. However, it is not only about looking inside a joint, but much more about performing surgery—often detailed and complicated—in the joints.
In the year 2017, we can clearly differentiate between the anterior and posterior parts of the ankle, as can be read in the state of the art paper on posterior ankle arthroscopy. There are different techniques in different areas of the joint. Detailed and evidence-based descriptions of techniques are available and are constantly being refined. In addition, it is obvious that there are areas in the body, like the posterior aspect of the ankle joint, that would be more or less unaccessible without the arthroscope. This is also by and large a question about surgical morbidity. Posterior ankle arthroscopy does not only mean to remove an os trigonum, which is probably one of the easiest arthroscopic interventions, but also detailed and thorough investigation of the posterior compartment of the ankle joint, the subtalar joint, the Achilles tendon, and the posterior tendons, like the flexor hallucis longus (FHL) and peroneal tendons. Even disorders of the posterior tibial tendon can be treated using the arthroscope. This has been shown to be beneficial and future expansion of indications can be expected. No one really can foresee where it will end. Complications are few and contraindications almost none (only ongoing septic arthritis is a definitive contraindication). There is another important issue; arthroscopy, for instance of the ankle, is today not only a technique, it is scientifically proven and based on evidence.
The second paper is related to state of the art of elbow arthroscopy. Elbow arthroscopy was mentioned in the literature as early as 1931, although not successful at that date. It was first in the 1970s and 1980s that new understanding of elbow anatomy—sometimes called arthroscopic anatomy—allowed new techniques that made elbow arthroscopy possible on a wider scale. In the same manner as the ankle, elbow arthroscopy is currently well established, progressing from simple free body removal to much more complicated surgery. Moreover, as with the ankle, the number and complexity of surgical indications has exploded. For instance, using the arthroscope, several intra-articular fractures of the elbow as well as rotatory laxity due to ligament injuries can be successfully treated. These are not only technical advancements, but—as with the ankle—are treatments based on good anatomic knowledge and scientific evidence.
Of course, we need to be careful and understand the limits, which probably cannot be stretched much further. On the other hand, the same thing was said 10–20 years ago. And the current status of arthroscopy use in the ankle and elbow is related to good surgical technique that will not hurt the patient—due to low risk of complications and low morbidity—based on sound anatomical knowledge and well done patient studies.
There is no doubt that arthroscopy is here to stay. Much has happened during the last 100 years since the very first arthroscopies were done, and much more has happened during the last 10–20 years. When it comes to the future, the use of the arthroscope—and other mini-invasive techniques—will probably be a central part of orthopedic reserach.
The JISAKOS is today a leading source of systematic reviews and state of the art articles. It has grown quickly and it will grow more as the journal begins pubishing original research of all sorts beginning of 2018.
We are looking forward!
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.
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