After receiving training at the Frank País García International Orthopedic Scientific Complex in Havana on general knee arthroscopy. The young orthopedic and trauma specialist introduced this new therapeutic tool at the Octavio de la Concepción de la Pedraja Pediatric Hospital in Holguin in July of this year.
To date, three of these procedures have been performed in the northeast region on two patients, ages 15 and eight, respectively, with complete success, following favorable outcomes.
Regarding how this approach has been achieved and minimally invasive surgery, which positively impacts the quality of life of patients undergoing surgery, has been a reality. The orthopedist shares some interesting points in an interview with Radio Angulo Digital.
What are the objectives of implementing arthroscopy in the treatment of knee pathologies in the pediatric population?
“First and foremost, we are based on the premise of beneficence. Pediatric specialties assume the moral responsibility to comply with the principle of beneficence, especially when a procedure is required. To achieve this, it is essential to report a low rate of complications in patients. Since the mid-1980s, pioneers in this field in our country, such as Dr. Dolores Cantera, began to define the guidelines that the rest of minimally invasive surgeons would later use as a premise for safely performing procedures on pediatric patients.
«Therefore, pediatric specialists responsible for treating the musculoskeletal system, particularly orthopedic specialists and rheumatologists, still find it difficult to classify pain and the functional impairment of the knee joints, despite the use of pathological anatomy, conventional laboratory diagnostic tools, and imaging. Among the latter, X-rays, soft tissue ultrasound, computed tomography, and magnetic resonance imaging stand out. This demonstrates the inadequacy of these recognized tools when applied in isolation or in combination, with their respective costs for the country, society, and the patient, for a group of diagnoses of joint problems that are common in daily clinical and pediatric practice.
«Precisely, having arthroscopy is a tool that supports the study and defines treatments to resolve the different conditions that some children present and restore their health.»
What are the most common indications for this procedure?
This therapeutic procedure on the knee joint in children and adolescents is primarily indicated in cases of persistent joint effusion with pain not classified by conventional procedures, with a history of more than six months. It may also be due to persistent functional limitation, unresponsive to established conservative therapies for more than three months, or intermittent pain with joint effusion that limits joint function and has a history of more than a year. Therefore, it can be used in virtually the entire pediatric population, given its undeniable benefits and low morbidity.
“However, it has certain contraindications, such as local sepsis, uncontrolled systemic diseases, or the arthroscopist’s lack of experience due to lack of training in this type of procedure in pediatric patients.”
What training or qualifications have the medical or surgical staff received to perform this procedure? “Our pediatric university hospital has extensive experience in the anesthetic management of these patients, a fundamental pillar for performing this procedure. Added to this is the professionalism of the operating room staff and the highly trained nurses who work in the wards, with years of experience and ongoing training.
“For our part, in the surgical area, in the Orthopedics Service, we have received training at the Frank País García International Orthopedic Scientific Complex in Havana on general knee arthroscopy, based not only on adults but also on pediatric patients, so that we can perform it in our province and in our hospital. With this, we offer the possibility of a new therapeutic tool to our patients, our children in Holguin.”
Are there significant differences in the arthroscopy technique compared to adult patients?
“There are significant differences in the arthroscopy technique between adults and pediatric patients. The arthroscopic approach technique—the anatomy is there from birth, right? And when we reach adulthood, it’s the same. What happens? Its characteristics change; the elements within the knee joint are not the same in a three-year-old patient as in an 11-year-old patient. In an adolescent or in an adult at an advanced stage of life, where there has been wear and tear. All these elements change; the characteristics of the cartilage are different, as are those of the synovium and the menisci, so the approach is very varied, the management depends on the patient’s age, but the procedure is described in a similar way.
“An author, one of the professors of arthroscopy, says that it involves manipulating very delicate instruments in a very small space. We distend it with liquid, with sodium chloride to increase that space, and the instruments are specifically designed for that purpose. It also requires significant skill and expertise. And since we’re talking about a patient, the smaller the patient, the smaller the space, and the more delicate the instruments to be manipulated.
We must maneuver in a way that doesn’t damage the knee, but also doesn’t damage the instruments because instrument breakage can lead to a very serious complication, and we never want that to happen.” Technically, when the technique is evaluated in adults and children, they are similar, but in pediatric cases, they require much more concentration and preparation to be able to perform it in this smaller space.
What postoperative follow-up is provided to patients undergoing this procedure?
“After the procedure, patients are instilled or administered a portion of local anesthetic medication during the same surgical procedure to make the postoperative period less painful. With the help of the vast knowledge of our anesthesiology colleagues, we aim to ensure that this procedure, followed by immediate recovery, is painless and painless. Upon awakening, they are instructed to perform quadriceps complex contractions, instructed to raise their extended leg 80 degrees off the bed several times, to demonstrate that the analgesia applied was effective and to give them confidence to subsequently begin walking.
“When the anesthetic recovery process is over, they are taken to our room and are observed for a final time. Some procedures are slightly more extensive than others, but this is an outpatient surgery; For those requiring more extensive manipulation, we prefer to leave them until the next day, observe them, and prescribe a longer analgesic treatment. After explaining the situation, parents perform physical therapy and apply compresses over the bandage, without moistening it, with the knees extended. They can be washed with plenty of water and follow all the hygiene precautions the wounds require.
“Between seven and 10 days later, the stitches are removed and active and passive movements begin, including measured knee extension. A program is guided toward gradually extended walking time, combined with isometric exercises for muscle groups, knee joint extensors with varied repetitions and movements performed three or four times a day. Returning to the classroom and other routine activities is even authorized, without significant loads, which are subsequently increased over the days as patients and family members verify the restoration of normal joint mechanics.”
How will this procedure be integrated into the overall approach to pediatric orthopedic treatment?
“We must acknowledge and be grateful for the support our hospital’s management has given us. From the moment we proposed this project and explained the benefits and possibilities we have provided to our patients, they gave us the green light and supported us. We have that support to continue with the process, which is being fully integrated.
I’m referring to all the procedures so that the different specialties in the different locations can interact with us and we can conduct multidisciplinary consultations to provide this comprehensive care alongside our colleagues, the Rheumatology professors, who also have patients who may be candidates for this type of procedure.
“We also have a close relationship with the Physiotherapy professors in the rehabilitation of these patients who need early rehabilitation, with high-quality analgesia and postoperative care. The procedure is being implemented appropriately, with steady, firm steps, and above all, providing great satisfaction to patients and families.
Future projections related to this approach…
“Future projections related to the procedure are to continue its development and add more techniques. Currently, we only perform simple arthroscopy, diagnosis, and treatment at a very basic level. That’s why we want to make it more complex, and to do so, we must improve our training. We are in this process, which also includes the staff who support us and the instrumentation. We remain optimistic; we plan to continue with this type of surgery and offer more surgical options to our patients.
“Later, we want to involve other joints, such as the shoulder and hip. This will resolve a large number of health problems and situations our patients face in these joints, which are quite common today.”
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