Complications of arthroscopic meniscectomy in the hands of third world beginners

Introduction The purpose of this study was to evaluate the complications of arthroscopic partial meniscectomy, especially in the early stages of experience with a review of literature. Materials and methods About 170 patients in the age group of 18–50 years, who underwent arthroscopic partial meniscectomy for isolated meniscal tears volunteered for the study. Results The intraoperative complications were malpositioning of portals (n = 7), difficulty in identifying the components of the tear (n = 11), damage to the articular cartilage (n = 12), excessive resection of the meniscus (n = 8), breakage of blade during portal making (n = 2), breakage of the punch forceps (n = 1), and prolonged surgical time (n = 30). The postoperative complications were haemarthrosis (n = 1), persistent swelling (n = 22), portal site tenderness (n = 12), deep venous thrombosis (n = 2), saphenous nerve injury (n = 1). However, we did not observe any infections (superficial or deep). Most of the intraoperative complications were observed during the initial surgeries. Conclusion Arthroscopic partial meniscectomy is a minimally invasive procedure which, in well-selected patients, is a method of choice for treatment of meniscal injuries when repair techniques are not a viable option. It has low morbidity, fast rehabilitation, and low cost of care. However, even this procedure is not without complications, especially for surgeons who have just started doing the procedure. Since arthroscopy has a steep learning curve, the incidence of complications decreases with the experience of the surgeon. Introduction The wheel has turned full cycle for the menisci, contrary to the previously described ‘functionless’ structure within the knee to the view that they are, indeed, crucial components of the normal biomechanics and functioning of the knee.1 The menisci participate in many important functions, including tibio– femoral load transmission, shock absorption, lubrication, and passive stabilization of the knee joint.2–8 The advent of arthroscopy in the 1970s and a greater understanding of the natural history and long term sequelae of open meniscectomy resulted in a greater emphasis on meniscal preservation by partial meniscectomy/ repair.9 The surgical indications for arthroscopic treatment of meniscal pathology include symptoms of meniscal injury that affect activities of daily living, work, and/or sports; positive physical findings of joint line tenderness, joint effusion, limitation of motion, and provocative signs, such as pain with squatting or a positive McMurray or Apley grind test; failure to respond to non-surgical treatment, including activity modification, medication, a rehabilitation programme; and absence of other causes of knee pain identified on plain radiographs or other imaging studies. Arthroscopic partial meniscectomy, where only damaged or unstable parts of the meniscus are removed leaving the remainder of the meniscus intact, has become an almost routine treatment of the menisci, thus providing early relief from pain, eliminating mechanical symptoms caused by unstable meniscal fragments and allowing early weight bearing, return of the function, significantly reduced morbidity, and reduction of the cost of care.9 Arthroscopy is not an entirely safe procedure. Arthroscopic surgery can be, in some cases, life-threatening and may cause unusual complications. A good preoperative and intraoperative planning and attention to the details of the basic techniques can prevent most of the complications. Familiarity with new techniques through learning centres, operating with colleagues, videos, and staying current with speciality journals allows the surgeon to gain valuable information from the experiences of other colleagues. The present study was carried out to document the complications during arthroscopic partial meniscectomies surgeries and review the literature regarding these complications. Materials and methods This work conforms to the values laid down in the Declaration of Helsinki (1964). The protocol of this study has been approved by the relevant ethical committee related to our institution in which it was performed. All subjects gave full informed consent to participate in this study. * Corresponding author Email: drnasir@in.com Department of Orthopaedics, Hospital for Bone and Joint Surgery, Barzalla, Srinagar, Kashmir, India. A rt hr os co py


Introduction
3][4][5][6][7][8] The advent of arthroscopy in the 1970s and a greater understanding of the natural history and long term sequelae of open meniscectomy resulted in a greater emphasis on meniscal preservation by partial meniscectomy/ repair. 9he surgical indications for arthroscopic treatment of meniscal pathology include symptoms of meniscal injury that affect activities of daily living, work, and/or sports; positive physical findings of joint line tenderness, joint effusion, limitation of motion, and provocative signs, such as pain with squatting or a positive Mc-Murray or Apley grind test; failure to respond to non-surgical treatment, including activity modification, medication, a rehabilitation programme; and absence of other causes of knee pain identified on plain radiographs or other imaging studies.
Arthroscopic partial meniscectomy, where only damaged or unstable parts of the meniscus are removed leaving the remainder of the meniscus intact, has become an almost routine treatment of the menisci, thus providing early relief from pain, eliminating mechanical symptoms caused by unstable meniscal fragments and allowing early weight bearing, return of the function, significantly reduced morbidity, and reduction of the cost of care. 9rthroscopy is not an entirely safe procedure.Arthroscopic surgery can be, in some cases, life-threatening and may cause unusual complications.A good preoperative and intraoperative planning and attention to the details of the basic techniques can prevent most of the complications.Familiarity with new techniques through learning centres, operating with colleagues, videos, and staying current with speciality journals allows the surgeon to gain valuable information from the experiences of other colleagues.
The present study was carried out to document the complications during arthroscopic partial meniscectomies surgeries and review the literature regarding these complications.

Materials and methods
This work conforms to the values laid down in the Declaration of Helsinki (1964).The protocol of this study has been approved by the relevant ethical committee related to our institution in which it was performed.All subjects gave full informed consent to participate in this study.2).We also made separate observations on the percentage of the complications initially in half of the patients, that is, the first 85 patients and compared with the rest of the 85 patients who had been operated on later (Tables 3, 4).As shown in Tables 3 and 4, there is a significant decrease in the complications in the latter half of the patients.

Discussion
Arthroscopic partial meniscectomy is the most common orthopaedic surgery performed for meniscal tears which are not amenable for repair.This procedure is performed for both traumatic as well as degenerative tears.Arthroscopic management of meniscal tears, though a relatively down weight bearing using crutches and a range of motions (0-90) was started.
Observations related to the complications, both during the procedure (intraoperative) and in the follow-up (postoperative), were recorded.

Results
In our study of the complications related to the arthroscopically treated meniscal tears, 170 patients met the inclusion criteria.We noted both intraoperative as well as postoperative complications.The intraoperative complications were malpositioning of portals (n = 7), difficulty in identifying the components of the tear (n = 11), damage to the articular cartilage (n = 12), excessive resection of the meniscus (n = 8), breakage of blade during portal making (n = 2), breakage of the punch forceps (n = 1), and prolonged surgical time (n = 30) (Table 1).The postoperative complica-The present hospital based prospective study was conducted on 170 patients in the age group of 18-50 years, including both male and females who gave consent for participating in the study.Associated ligamentous injuries, bony injuries around the knee or severe grades of osteoarthritis (SFA grade 3, 4) were excluded from the study.
All patients received a single dose of prophylactic antibiotic (Cefazolin 1 gm) 1 hour before surgery.The procedure was performed under spinal anaesthesia.A tourniquet was applied to the thigh.The patients were placed supine on a standard operating table with the knee joint positioned slightly past the distal breakpoint of the table.The opposite limb was well-padded to prevent potential pressure problems.Identification of the correct limb was done before surgical preparation.A sandbag was placed under the ipsilateral distal thigh.The limb was draped using a standard arthroscopy drape.
Gravity flow of normal saline into the knee was used.Portal sites were marked, using the standard portals, that is, anterolateral and anteromedial, with the accessory portals, whenever required.After introducing the arthroscope through the anterolateral (viewing portal), diagnostic arthroscopy of all the compartments was done.Once the diagnosis of the meniscal tear was established, anteromedial (working portal) was used for carrying out the procedure.At the end of the procedure, thorough irrigation of the joint was done.The portal sites were closed with a single suture.A sterile compressive dressing was applied and the tourniquet was released.Vascular status was checked.Patients were shifted to the postoperative ward.The limb was kept elevated.Patients' vital signs were monitored in the immediate postoperative period.Patients were shifted to the general ward on the first postoperative day, where they were made ambulatory with touch- instrument breakage, and minor difficulties were wound healing and ecchymoses.A number of predisposing factors were recognized.There was a higher incidence of neurological complications and CRPS 1 in patients with an industrial injury.As would be expected, the lowest complication rate occurred with diagnostic arthroscopy.A higher overall complication rate occurred with partial medial meniscectomy and the incidence of haemarthrosis was highest in this procedure.Instrument breakage occurred most frequently during partial lateral meniscectomy.Rodeo, Forster, and Weiland 8 reported four mechanisms by which neurological damage can occur during arthroscopy.They are: 1) direct trauma, 2) pressure secondary to a compartment syndrome occurring as a result of extravasation of fluid, 3) damage related to the use of a tourniquet, and 4) dysfunction due to ill-understood condition of CRPS 1. Injury to a nerve is rare.In Small's initial series, 11 there were 229 nerve injuries in 375,069 knee arthroscopies, an incidence of 0.06%.The saphenous nerve was the most commonly involved (42%).The peroneal nerve was damaged in 5%, the femoral nerve in 3%, and the sciatic nerve in 3%.In the remaining 47%, the details of the involved nerve were not specified.In DeLee's study, 12 there were 63 neurological complications in 118,590 arthroscopies, an incidence of 0.05% out of which 25 involved the peroneal nerve, 23 comprised the saphenous nerve, seven the femoral nerve, four the tibial nerve, and four the sciatic nerve.On the medial side of the knee, the saphenous nerve is potentially vulnerable posteromedially.The nerve lies deep to the sartorius and is protected to a certain extent when the knee is flexed.If there is any doubt, the nerve can be exposed directly or may be visualized by transillumination.Injury to a superficial nerve is not uncommon.The infragenicular copies performed by four surgeons.Overall, there were 216 complications (8.2%) of which 126 were designated as major and 97 as minor.The major complications were infection, haemarthrosis, adhesions, effusions, and cardiovascular and neurological problems, CRPS 1 and safe procedure, is still associated with complications, especially at the hands of the less-experienced surgeons and with inadequate preoperative and intraoperative planning and attention to details of the basic techniques.Sherman et al. 10 retrospectively reviewed 2640 arthros- Control of pain after operation is of utmost importance.It is rarely a problem after diagnostic or simple operative arthroscopy, but may occur after more prolonged surgery and complex surgery.There are a number of options for the management of pain.Opiates and other potent analgesics can be given as an intermittent fixed dose, into the epidural space, or as an intra-articular injection. 23Local anaesthetics can also be given by the intra-articular route. 24Non-steroidal anti-inflammatory drugs (NSAIDs) are effective orally, by injection, or rectally.6][27][28][29][30][31] All these methods have disadvantages and none are ideal.As for the important factor of the comfort of the patient, the level of pain experienced on coming round from the anaesthetic in the recovery room may well determine progress in the early stages after operation.A minimal level of pain has a very positive effect on the morale of the patient, which may help the early programme of rehabilitation, partic-that a relatively minor nerve injury can lead to CRPS 1.
Jackson 18 reported the occurrence of injury to the popliteal artery leading to amputation.In the AANA review there were six cases of penetrating injury of the popliteal artery.Four of these patients required amputation.There were 12 vascular injuries in Small's report, 11 but no vascular complications were listed in his later study. 19Beck, Robison, and Hallett 20 described a case of pseudoaneurysm of the popliteal artery after arthroscopy and, in 1987, Jeffries et al. 21presented two cases of injury to this vessel occurring during arthroscopic lateral meniscectomy using power tools.Both lesions required repair.The popliteal neurovascular bundle is in close proximity to the posterior capsule of the knee and is clearly potentially vulnerable.It is important that the tip of any surgical instrument must be seen clearly at the back of the knee.Particular care needs to be taken with power tools and it is imperative that the operative field is clear at all times with adequate irrigation.If a vascular injury is suspected because of either excessive bleeding at the site of operation or compromise of the distal circulation, it is imperative that an urgent vascular opinion is sought followed by prompt arteriography and appropriate surgery when indicated.Any delay may result in the need for amputation.Fasciotomy may also have to be considered after any period of ischaemia.The risk of bleeding can be minimized by the use of electrocautery.
Arthroscopy is an invasive procedure and it is not a substitute for other methods of diagnosis.It is vital that a careful evaluation of the patient is carried out by standard clinical means with a history, examination, and appropriate investigations.Often the history alone will provide the diagnosis.A careful systematic examination is essential.Plain radiographs should always be taken.MRI branch of the saphenous nerve (IG-BSN) runs a variable course and at times damage by anterior portals may be unavoidable.Injury to the IGBSN has been reported after knee arthroscopy. 10,13In the study of Sherman et al., 10 there was an incidence of 22.2% of sensory change in the distribution of the IGBSN after standard portals had been used.Although 'safe zones' have been advocated, the wide variability in the course of the nerve precludes the absolute avoidance of damage. 14,15Mochida and Kikuchi 16 recommended that arthroscopic portals should be positioned close to both the patella and the patellar tendon, if injury to the IGBSN is to be avoided.On the lateral side, the common peroneal nerve is vulnerable and the effects of injury to this structure are significant.There has been one report of injury to the common peroneal nerve during lateral meniscectomy. 17Proximally, above the level of the knee, the nerve lies medial to the biceps tendon, between the biceps and the lateral head of gastrocnemius.At the level of the joint, it passes posterior to the biceps to wind around the neck of the fibula.Flexion of the knee will allow the nerve to drop back posteriorly making it less vulnerable.The safe area is between the posterior edge of the iliotibial band and the biceps, preferably deep to the lateral head of gastrocnemius.To aid identification of the correct site for placement of a portal, the joint can be transilluminated from within or a needle can be passed into the posterolateral joint and its position checked with the arthroscope.The interval between the iliotibial band and the biceps is developed.To confirm the position, a probe can be passed across the joint from the anteromedial portal to tent the posterolateral capsule from within.The lateral head of gastrocnemius can be identified and its lateral border freed by blunt dissection.Occasionally, formation of a neuroma can be troublesome and it is possible consensus in literature regarding the management of established septic arthritis after arthroscopy.There is a general agreement that intravenous antibiotics are indicated initially based on the sensitivities from the synovial Gram stain or culture.The duration of treatment recommended varies from a few days to six weeks.It would seem wise to continue with intravenous antibiotics until the patient is clearly responding and the systemic signs are resolving.Any pus or infected synovial fluid in the knee should be removed.Adequate removal of all infected material can only be achieved by an arthroscopic washout using copious lavage with several litres of fluid.After this, a drain may be inserted for 24 to 36 hours.An irrigation-suction system can be set up, but these are difficult to manage and there is no definite evidence that there is any advantage over lavage itself.This may have to be repeated after 48 to 72 hours.The joint should be rested initially, but as soon as the infection is under control, a graduated programme of rehabilitation needs to be instituted concentrating on the return of movement.Continuous passive motion (CPM) may be useful in the early stages of recovery.
An effusion is not uncommon after arthroscopy, but rarely causes a problem.The reported incidence varies between 0% and 15%. 40It may persist after arthroscopic surgery, particularly for degenerative joint disease.The knee will remain painful, irritable, and swollen because of postoperative synovitis.This can be a difficult and recalcitrant condition.Treatment is essentially conservative with rest, ice, compression, and elevation, together with NSAIDs and physiotherapy.If symptoms continue, further investigation may be indicated.A full blood count, ESR, and CRP should be undertaken to exclude infection, and also plain radiography.An isotope bone scan can be useful to determine the extent of the inflammatory response.MRI may be neces-postoperative mobilization should be as rapid as possible.Some form of prophylaxis should be considered for patients in the risk groups mentioned above, particularly those with a previous thromboembolism.
Infection after arthroscopy is uncommon.The knee is the largest synovial cavity in the body and septic arthritis is therefore a very serious complication.DeLee 12 reported an incidence of 0.08%; Sherman et al. 10 0.1%; D' Angelo and Ogilvie-Harris 37 0.23%; and Armstrong, Bolding, and Joseph 38 0.42%.Diagnosis is not always straightforward.In classical septic arthritis, there is acute pain, swelling, warmth, and erythema accompanied by the systemic signs of fever and malaise, together with leucocytosis, with a raised ESR and an increased level of C-reactive protein (CRP).Staphylococcus aureus is the most common infecting organism under these circumstances.The presentation, however, can be more insidious with a subacute onset of pain, swelling, mild fever, and minimal or no leucocytosis, which may be associated with a coagulase-negative staphylococcus.Under these circumstances, a Gram stain of the synovial fluid may be negative and a culture is required to confirm the diagnosis.Infection is more common among patients with longer operating times, an increased number of procedures during surgery and prior. 38A number of authors have also reported an increased incidence of septic arthritis after the administration of intra-articular corticosteroids at the time of arthroscopy.There is almost certainly impairment of local and systemic immune defence mechanisms. 38,39Prophylactic antibiotics are not routinely used for arthroscopic surgery, apart from more complex procedures such as reconstruction of the ACL.D' Angelo and Ogilvie-Harris, 37 however, have suggested that there may be a case for their use from the point of view of cost benefit.There is no definite ularly in the recovery of movement.Severe pain will impede this.
The incidence of haemarthrosis is approximately 1%. 32 It is more common after lateral release because of damage to the superior lateral geniculate artery, and between 5% and 42% incidence has been reported after this procedure. 33If a painful, tense haemarthrosis develops, the knee should be washed out arthroscopically, local anaesthetic with adrenaline should be infiltrated into the joint, and a pressure bandage applied.Consideration should be given to introducing a suction drain for 24 hours.
The risk of thromboembolic disease after arthroscopy is clearly low, since the procedure is relatively short and mobilization is quick.The incidence in the AANA study1 was 0.1% and in Small's studies, 11,19 0.17% and 0.13%, respectively.In the AANA study1, 23% of patients with deep vein thrombosis (DVT) developed pulmonary embolism (PE) and there were four deaths.The figures for DVT were probably underestimated, since the reviews were based on clinical symptoms.The overall reported incidence of DVT after arthroscopy of the knee ranges from 0% to 7.3% and PE from 0% to 0.32%. 34In a study using venography, 35 the incidence of DVT was 4.2%.There are a number of factors which are associated with an increased risk of thromboembolism.Patients over the age of 40 years are more likely to develop postoperative thrombosis.A prolonged operating or tourniquet time is also a risk factor, but there is no definite evidence that the tourniquet itself increases the risk.When there is a previous history of thrombosis or embolism, the risk of thromboembolic complications increases significantly.Kakkar et al. 36 reported an incidence of DVT of 100% in a group of patients with a history of previous PE.There is no indication for routine thromboprophylaxis in arthroscopic surgery, but the operating and tourniquet times should be kept to a minimum and sary to exclude a continuing mechanical problem.A further arthroscopic procedure with a washout should be considered if the joint does not respond to conservative measures, but there is no guarantee that this will lead to resolution of the symptoms of a postoperative inflammatory synovitis.
There have been isolated reports of a compartment syndrome in association with arthroscopic surgery. 41,42ncreased irrigation pressure or blockage of the drainage will increase the risk.Noyes and Spievack 43 demonstrated in a cadaver study that fluid can extravasate into the thigh from a rupture of the suprapatellar pouch and into the calf from a rupture of the semimembranosus bursa.In the cases reported by Peek and Haynes 41 and Fruensgaard and Holm, 42 fasciotomies were carried out Any intra-articular structure can be damaged in an invasive procedure.It is important not to use a sharp trocar to introduce the arthroscope into the knee.A portal of adequate size should be made so that a blunt obturator can be used.The anterior horns of the menisci are vulnerable when the incisions for the anteromedial and anterolateral portals are being made, and it is wise to cut upwards with the knife away from the meniscus rather than downwards.Apart from the first portal, the knife blade should be observed from within the joint.

Conclusion
No invasive procedure will be entirely free from risk, and arthroscopy of the knee is no exception.Patients should be made aware of this fact.Complications are relatively rare, but can have serious and significant consequences when they occur.Not all are unavoidable and it is important to exercise due care in all phases of the surgical process, including preoperative assessment, the surgery itself, and aftercare.

Table 1 Intraoperative complications S.No. Type of complication
Licensee OA Publishing London 2013.Creative Commons Attribution License (CC-BY) For citation purposes: Muzaffar N, Shah N. Complications of arthroscopic meniscectomy in the hands of third world beginners.OA Orthopaedics 2013 Sep 09;1(2):17.Competing interests: none declared.Conflict of interests: none declared.All authors contributed to conception and design, manuscript preparation, read and approved the final manuscript.All authors abide by the Association for Medical Ethics (AME) ethical rules of disclosure.

Table 3 Complications in the initial 85 patients Types of complications Number of patients
Licensee OA Publishing London 2013.Creative Commons Attribution License (CC-BY) For citation purposes: Muzaffar N, Shah N. Complications of arthroscopic meniscectomy in the hands of third world beginners.OA Orthopaedics 2013 Sep 09;1(2):17.Competing interests: none declared.Conflict of interests: none declared.All authors contributed to conception and design, manuscript preparation, read and approved the final manuscript.All authors abide by the Association for Medical Ethics (AME) ethical rules of disclosure. is a very effective non-invasive method of diagnosis and rarely should the arthroscope now be used solely for this purpose.Its function is predominantly to enable appropriate intraarticular surgery to be carried out after a definitive diagnosis has been made.Joyce and Mankin 22 described 12 cases in which significant diagnostic errors were made because of inadequate preoperative evaluation.Six patients had a significant neoplastic lesion visible on plain radiographs.During the procedure itself, an inexperienced surgeon may have problems with visualization because of poor technique.It is important that adequate supervision is given in the early stages of the learning curve so that the important technical aspects of the operation are addressed.These include placement of the portals, positioning of the knee, triangulation, and adequate irrigation.