Among all orthopedic surgeries, arthroscopy is considered the least invasive. Nevertheless, its implementation is associated with a certain risk. According to statistics, arthroscopic interventions are accompanied by the development of complications in 0.6-1.7% of cases. The likelihood of occurrence of undesirable consequences directly depends on the complexity of the operation. They occur less often with diagnostic arthroscopy, most often with incomplete medial meniscectomy
Curious!The risk of developing complications does not depend on the experience of the surgeon and the gender of the patient.However, the patient’s age plays a role.It is known that people over 50 years of age have undesirable consequences much more often than young people.
Table 1. The incidence of various complications of arthroscopy.
|A place||Pathology||% among all complications|
|3||Deep vein thrombosis of the lower extremities||7|
|4||Complications of anesthesia||6.5|
|6||Complex regional pain syndrome (CRPS)||2,3|
|8||Fractures and nerve damage||0.6|
Fact! In terms of the development of complications, the most dangerous are operations on the menisci, synovium, anterior and posterior cruciate ligaments. With these surgical interventions, patients most often have hemarthrosis, infectious and thrombotic complications.
To gain access to the medial meniscus, surgeons artificially dilate the joint space before arthroscopy. To do this, they use special leg holders and power traction. Carrying out such manipulations can lead to damage to the ligaments of the knee joint (0.04% of all arthroscopies). Note that most patients suffer from the medial collateral ligament, which is located on the inner side of the knee.
Light sprains or tears of the ligaments cause knee pain and may be accompanied by ligamentitis. Pain relievers (Diclofenac, Ibuprofen) and temporary knee immobilization help to get rid of unpleasant symptoms.
Ischemia of the muscles of the lower limb
To prevent bleeding during arthroscopy, doctors place a tourniquet on the patient’s leg. Unfortunately, prolonged exposure can cause temporary paralysis of the lower limb. The pathology is characterized by a short-term violation of the contractility of the muscles and the motor functions of the leg.
Table 2. The risk of developing paresis depending on the age of the patients and the time of application of the tourniquet.
|Low||It is seen in patients younger than 50 years old who have a tourniquet applied for less than 40 minutes. The predicted complication rate in these patients is 7.6%.|
|Middle||It is typical for persons under 50 years of age with an exposure time of 40-60 minutes and for persons over 50 years of age with an exposure time of less than 40 minutes. Among this group of patients, paresis develops in 10-16% of cases.|
|Tall||Equals 28% or more. It is typical for all patients who had a tourniquet applied for more than 60 minutes.|
Thus, the likelihood of temporary paresis is much higher among older people. Patients who have undergone complex long-term operations are also more at risk. It is possible to avoid the appearance of unwanted complications by reducing the time of applying the tourniquet.
Fact! Temporary paresis is usually harmless and responds well to treatment. To combat them, exercise therapy, massage and physiotherapy procedures are used.
It occurs due to leakage of irrigation fluid in the presence of a defect in the joint capsule. The development of pathology is facilitated by an increase in irrigation pressure and blockage of drainage. Compartment syndrome is accompanied by soft tissue edema and a sharp increase in intrafascial pressure. As a rule, it leads to necrosis of muscle tissue and the appearance of contractures in the postoperative period.
Compartment syndrome is treated conservatively. Patients are prescribed analgesics (Tramadol, Ketorolac), decongestants (Furosemide) and anti-ischemic agents. They are also injected with drugs that improve the rheological properties of blood and relieve vascular spasm. If conservative therapy is ineffective, patients undergo an operation – decompression fasciotomy.
Damage to intra-articular structures
During arthroscopic intervention, the surgeon can damage any structure of the knee joint. Most often this occurs when using a sharp trocar, insufficient expansion of the joint space, poor visibility, or attempts by the doctor to perform “blind” manipulations.
During arthroscopy, you may suffer:
- articular cartilage;
- cruciate ligaments;
- joint capsule.
Damage to intrasynovial structures is very dangerous and can have serious consequences. It can provoke irrigation fluid leakage, deformation of the menisci or intra-articular ligaments, the development of deforming osteoarthritis in the postoperative period, etc. Naturally, in the future, all this will lead to the identification of the functions of the knee joint.
If the surgeon noticed an injury to the ligaments, menisci or joint capsule in time, he can immediately eliminate it. Unfortunately, this is not always possible.
In recent years, it happens less and less due to the improvement of arthroscopic equipment. If the instrument breaks down, doctors immediately stop irrigation and aspiration. Then they carefully remove the broken-off piece using special equipment. If the piece is small and difficult to access, it may be left in the synovial cavity.
Damage to nerves and blood vessels
They occur very rarely, only in 0.06-0.08% of cases. Neurological disorders can develop due to the use of a tourniquet or against the background of compartment syndrome. The cause of vascular damage is most often the careless handling of the surgeon with instruments. As you know, the popliteal artery is located very close to the posterior capsule of the knee joint. Consequently, the dissection of the latter is often accompanied by a violation of the integrity of the vessel.
The structure of damage to various nerves during arthroscopy:
- subcutaneous – 84%;
- peroneal – 10%;
- femoral – 6%;
- sciatic – 6%.
Fact! Ischemic and traction nerve injuries respond well to treatment. But if their anatomical integrity is violated, it is almost impossible to eliminate neurological disorders.
Pain after knee arthroscopy
A pronounced pain syndrome occurs after synovectomy, intra-articular reconstruction of the ligaments and operations on the menisci. In the early postoperative period, pain is relieved with opioid analgesics or intramuscular injections of nonsteroidal anti-inflammatory drugs (Ketorolac, Diclofenac). In the future, NSAIDs can be prescribed in the form of tablets.
Advice! If after arthroscopy you are worried about knee pain for a long time, do an ultrasound or MRI. The study will help identify pathological changes in the knee joint and make a diagnosis.
Hemarthrosis – accumulation of blood in the knee
It usually develops due to damage to the ascending lateral artery that surrounds the femur. Hemarthrosis is treated by arthroscopic lavage of the synovial cavity and intra-articular injection of a local anesthetic (Lidocaine, Novocaine) with adrenaline. After that, a pressure bandage is imposed on the patient’s knee.
They are rare due to the low invasiveness of the procedure and the short-term immobilization of the patient. It is noteworthy that persons over 40 are more susceptible to deep vein thrombosis of the lower extremities. Prevention and treatment of pathology is carried out according to standard medical protocols.
Infectious complications are rare, only in 0.1-0.42% of patients. The causative agent of septic arthritis is most often Staphylococcus aureus. The disease is acute and usually does not cause difficulties in diagnosis. In rare cases, it can have a subacute, more “insidious” course.
The classic signs of septic arthritis are:
- sharp pain;
- severe edema;
- redness of the skin;
- increased ESR and neutrophilic leukocytosis in the blood.
Note that the absence of typical symptoms of arthritis does not mean the patient’s full health. The only way to exclude infection is by bacteriological examination of the synovial fluid. The analysis should be done at the slightest suspicion of septic arthritis.
For arthroscopic procedures, doctors may not prescribe antibiotic prophylaxis to patients. This, like the intra-articular administration of corticosteroids during arthroscopy, increases the risk of infectious complications.
Treatment for septic arthritis can take anywhere from a few days to 6 weeks. In some cases, parenteral administration of antibiotics is sufficient for patients. Sometimes patients need to flush and drain the joint cavity. The choice of treatment will usually depend on the severity of the arthritis.
Effusion and synovitis
The accumulation of effusion in the synovial cavity is a common occurrence and rarely turns into a problem. According to various sources, a non-infectious inflammatory process in the joint develops in 2-15% of cases. It is treated conservatively, with temporary immobilization of the limb, pressure bandages and non-steroidal anti-inflammatory drugs.
It is a pathological hole in the joint capsule at the site of its puncture during arthroscopy. According to statistics, it is formed on the third or sixth day after the operation. Does not require special treatment. All the patient needs when a fistula develops is to temporarily immobilize the knee before closing it.
Complex regional pain syndrome
It can occur with any knee injury, including after arthroscopic surgery. It is assumed that the syndrome is of a reflex nature and arises from damage to the autonomic nerve fibers of the saphenous nerve. The syndrome can develop at any age in both sexes, but most often women in their 40s suffer from it.
The clinical manifestations of this pathology are very variable. Most often, the syndrome goes through three phases of development (vasodilation, vasoconstriction, atrophy) and leads to arthrophic changes in the skin, muscles, paraarticular tissues. Almost all patients with CRPS eventually develop contractures of the knee joint. Note that X-ray changes in patients are detected 2-8 weeks after the onset of the first symptoms.
Signs of CRPS:
- chronic pain in the lower limb;
- pronounced swelling of soft tissues;
- discoloration of the skin;
- increased skin sensitivity in the knee area;
- osteoporosis, which is detected by radiography.
Complex regional pain syndrome is treated conservatively, with the help of psychotherapy and medication. Patients are prescribed anticonvulsants, antidepressants, muscle relaxants, NSAIDs, bisphosphonates, calcitonin, B vitamins and drugs that improve venous outflow. Patients often undergo a stellate ganglion block or sympathetic lumbar block.
CRPS treatment is effective only if started within the first 3 months after the first symptoms appear. If this does not happen, the patient has irreversible changes in the nerves, muscles and bones.
Infrapatellar contracture syndrome
It usually develops after complex reconstructive operations. It is characterized by a significant violation of the mobility of the patella. The reason is the pathological proliferation of connective tissue in the area of the patellofemoral junction. The disease is treated conservatively, with the help of physiotherapy exercises and non-steroidal anti-inflammatory drugs. If this does not help, the formed adhesions are dissected surgically.