Thanks Dr Rey, I agree with you

Regards

If you could make Arthroscopic surgery a basic learning objective for the master programme in Orthopaedics, it can become like trauma surgery, but it needs set up and training facilties to all.

Dear Ravi

I believe there are two fundamental qualifications for the orthopedic surgeon performing arthroscopy: 1) Domain use the arthroscopes , 2) Knowledge of each anatomical joint. The orthopedic surgeon receives this distinction after completing the course of post graduation, and this qualifies the orthopedist to work in any area, since he feels able

I agree Dr Nelson

Thanks and

Regards

Dr Ravi,

This question is so Indian since i found that there are surgeons who only do arthroscopic work here. the training in the west is region based and the surgeon who does arthroscopy is also trained to replace the joint. the point is that the knowledge of anatomy and the pathology is excellent. Regional subspecialsation is increasingly becoming necessary to provide all round care of the joint. like for eg arthroscopic to HTO to UKR to TKR in the knee and from ascopic stabilisation to Copeland to TSR to Reverse SR

Srikant,

I disagree that the training in west is universally region based. There are huge no of sports medicine experts at the global level who practice arthroscopy of more than one joint. Shoulder and Knee is extremely common.

If you look at the history of arthroscopy of individual joints, the development and standardization of the surgical techniques of all the joints did not emerge all at once. It was only the experts of one joint that they developed and standardized the technique of the other joint.

Our limited exposures to some centers may not be sufficient to universalize the situations, In US, Japan and europe there are huge number of surgeons who practice only arthroscopy (of multiple joints).

In this debate, the other participants have endorsed the view of not restricting the arthroscopy to one anatomical region. So this is a global question and not an Indian question as perceived by you.

I am attaching the website of one randomly selected hospital of UK where the profile of consultants shows that they are not limited to one anatomical region:

http://www.roh.nhs.uk/meet-the-team/consultants/arthroplasty-knee-shoulder

The thought of practice based on anatomical region have its own merits and demerits because when we say anatomical region that means arthrosocpy, arthroplasty, tumours, trauma and congenital malformations. The skills of each one of them are different although the anatomy of the region is same.

So ultimately it depends upon one's training whether he is more expert in the technical skills of one procedure applicable on many joints; or if one is more meticulous with the anatomy of one region and is able to apply all other procedures on that joint only.

I think arthroscopy should be restrictive for specific are because lack of skills due to imposes large costs and side effects.

Dr Gupta,

That is quite an argument there!!

I agree with you that surgeons seem to be very fond of Knee and Shoulder(myself included). Shoulder surgeons do tend to do elbows and wrist arthroscopists migrate as far up as the elbows.

But i am yet to see someone who does knee, shoulder, ankle and elbow and wrist!!!

The main problem of such practice is medicolegal. Even in the UK for those who are doing two region specialisations, they need to back it up in court with expertise.

I must declare that i have hardly met any sports specialists who are mutiple joint arthroscopists- they seem very fond of sports hernias and tendonitis and tendinopathies or end up stabilising ankles or knees.

Dear All,

Thanks for all the inputs in the debate.

After the views of all of you and an extensive search in the literature,I learnt that there are two schools of thoughts.

Some top experts in the world tend to confine themselves to one or two joints while the fellowship programs of sports medicine in many centers in North America provide exposure to the fellow to multiple joints so that he has basic training of arthroscopy.

In my humble opinion we should distinguish what we consider basic arthroscopic surgery and arthroscopic surgery with high specialization , for many years as head of a Department of Orthopaedic Surgery and Traumatology of a University Hospital , with specialized sections in different pathologies , my opinion is that during training as a specialist, the medical trainee should know the basic techniques of arthroscopic of knee surgery ( meniscectomy , biopsy, synovectomy ) and to know shoulder entrance gates and have the knowledge to make an acromioplasty . After the period of specialization a time of special training and a long learning curve is absolutely necessary to perform more complex techniques in knee and shoulder , or be able to perform arthroscopic surgery of ankle , hip or wrist

I believe that to perform these techniques with a high degree of efficacy and safety , it is necessary take into acount , the category of the hospital, its technical possibilities and the demand for care prior to making the decision to initiate these

Dear Dr Herrera,

Thanks for making the topic crystal clear!

Regards!

Dear Mr. Gupta,

I have the same opinion as Dr. Herrera.

In Germany for example after the specialization we usually concentrate on one or two joints (lower (hip and knee) or upper extremity (shoulder/elbow))- ankle by foot and ankle surgeons, wrist by hand-surgeons.

But it is improtant to have basic knowledge on basic arthroscopic skills on all joint (access portals, anatomy) to deal with complication on a 24-hour call (e.g infection).

As a hip arthroscopist I think it is necessary to concentrate on one or two joints due to the complexity of some reconstructive surgery techniques. On this way, a high level of operative results and a good clinical outcome for the patient can be expected.

Regards

Medical School Hannover

Thanks Dr Exechieli,

I learnt high end arthroscopy from a german speaking country - Austria when I worked with Dr Benedetto in 1998.

At that time it was mainly only knee being practiced there. Ankle team was using occasionally arthroscopy for treating distal tibial fractures.

Thanks for your answer!

I feel that the persons doing arthroscopy should continue to evolve and work on all the joints......

Thanks Dr Biraris for your input!

Dear Dr. Gupta, thanks for your nice and clear question.

I think all is matter of training and number of procedure the surgeon does. I should be no restriction, but a continuous training and eduction should be the goal.

Kind regrads K

Thanks Dr Kabir for your answer,

Regards

Dear Dr Gupta :

I agree with Dr Kabir , the techniques of shouder arthroscopy need a very imortant training

Thanks Dr Herrera. I agree with you and Dr Kabir!

Regards

when arthroscopy began worldwide in the seventies, it was a developing ART. Now it is just another skill that is needed to practise surgery. I believe that it is just another instrument and the time for "Arthroscopic Societies" has now passed. we may just as well have an "international society of the scalpel". I believe in major centres the time has come for expert regional specialisation. I have practised knee surgery from the Womb to the Tomb for 30 years. in our clinic we have regional specialties all doing arthroscopy of their particular joints. I believe that arthroplasties should be done by those surgeons qualified in their region. Knee arthroplasty should be done by Knee surgeons who know how to arthroscope, not by Hip surgeons.

Mervyn Cross

Of course arthroscopy should be a separate subspecialty of orthopaedic surgery. The problem is to set reasonable borders for its application. I have the feeling that arthroscopists widen their domain to regions where conventional surgical procedures could be more efficient with better outcomes.

Thanks Dr Tanchev

Regards

I am a foot and ankle surgeon and do ankle arthroscopy front and back and subtalar arthroscopy. I strongly feel this should not be performed by general arthroscopists. The techniques are difficult and training and experience are required to get best outcomes.

Define please the level of arthroscopy practice. Also define the level of experties expected by the arthroscopist. Do you think that because the arthroscopist knows how to used the instruments would be familiar with the anatomy and technicalities for all joints? And as I want to act as a "devil's advocate", do you think that as the instruments of laparoscopy are similar, the arthroscopists would be safe to perform laparoscopic work? Any sub-speciality of our great Orthopaedic art would be much better to perform the arthroscopies of their own trade as any arthroscopy may fail and has the chance to be converted to an open surgery and repair. Are we questioning the sub-specialty existance? Are we moving back to General Orthopaedic?

Thanks all!

I think this issue needs to be looked at from the patient's perspective. The patient with a clinical problem is seeking a solution for their problem. The role of a clinician is to identify the pathology causing the clinical problem and treat it it in the most appropriate way, be it without surgery or with open surgery or arthroscopy. It is the clinicians' responsibility to keep their skills - both diagnostic and operating, up to date. Though arthroscopy offers numerous advantages and is undoubtedly the preferred option for treating certain conditions, there are others where an open operation may be better. I think it is a folly for any surgeon to be a slave to a particular technique. Given the choice between a reliable open operation with a predictable outcome but which may leave a bigger scar versus a less reliable arthroscopic operation with an unpredictable outcome, most patients would choose the former. The real skill of a surgeon lies in picking the "winners" both in terms of patients as well as operations and this is a skill which only comes with experience.

Some (but not all) arthroscopic skills are transferable - between certain joints eg the knee and shoulder, or the shoulder and hip. However the skills required for arthroscopic surgery on smaller joints eg the elbow, ankle and wrist are different and not necessarily easy to acquire or transfer. The learning curve for arthroscopic surgery is longer than open surgery and so the number of patients being seen and surgeries carried out is very relevant to acquiring competency.

Very apt answer Dr Patel! I agree with you!

Regards,

As an open orthopedic surgeon was operating all joints some years ago and now there is a specialization , the same thing and for the same reasons there joint specific arthroscopic surgery is emerging.

For a specialized surgeon it is logical to improuve the skills by arthroscopy in a special surgery. A general arthroscopist surgeon can not be a leader. An arthroscopist specialized to a domain knee, shoulder ...can develop it skil and practice. So it is difficult to affirm a general roule .

It looks like the questioned is "bitten around and not on the head". The question as I could understand it and please correct me if I am wrong is: Can we have an arthroscopist that can do all joints or a specialised by area surgeon for different joints who also can perform arthroscopies of the relevant joints?

The answer to it, considering also the learning curve, is that a specialised per joint surgeon has the grip of the anatomy of the joint and because of this will be better than the "holistic" arthroscopist. Also he will have the skills to open and put everything right in case of a failed arthroscopy, due to his full understanding of the anatomy. So generalised arthroscopist will be a handicapped person who will ask for help of a specialist in case of difficulties. This is the only way to have winner patients.