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Fig. 1 Typical portals used for hip arthroscopy (left hip shown) include the midanterior portal (MA), the anterolateral portal (AL), and the posterolateral portal (PL). Reproduced from Larson CM: Arthroscopic Management of Hip Pathomorphology. Instr Course Lect 2012;61:287-293.

AAOS Now

Published 9/1/2012
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Elliott H. Leitman, MD; Thomas B. Fleeter, MD

Avoiding Complications in Arthroscopic Surgery

Not all medical complications result in litigation. According to an AAOS member survey, postoperative complications that resulted in litigation included deep vein thrombosis (DVT), infection, or persistent pain following knee arthroscopy. Technical errors, including implant failures and nerve injury, were also common causes of litigation.

Consumer demand for arthroscopic solutions to orthopaedic ailments has increased, due to the public’s perception of arthroscopic surgery as having minimal risk and the increase in the range of problems that can be treated arthroscopically. Although surgical expertise has minimized complications and improved outcomes, arthroscopic surgery is not without risk.

Problems can also arise postoperatively. For example, after a procedure, surgeons often see patients briefly in the postanesthesia care unit before the anesthetic has fully resolved, and complications such as nerve injury or impending compartment syndrome may be masked in an anesthetized limb. Alternatively, the doctor on call may respond to the initial postoperative complaint without a full understanding of the problem

As arthroscopic procedures increase in complexity, surgeons must take care not to underestimate their difficulty. Awareness of the pertinent anatomy and potential complications is key in avoiding complications.

Anatomic considerations
Shoulder—
Stiffness is a common complication following arthroscopic shoulder surgery, affecting between 2.7 percent and 15 percent of patients. Preoperative counseling and patient education are important in managing patient expectations, and proper rehabilitation is needed to avoid stiffness.

Vascular injury is rare, and neurologic injuries are usually temporary neurapraxia as opposed to nerve lacerations. Superficial radial nerve injuries can occur from the compressive wrap associated with traction devices.

The use of implants also may result in complications. Guide wires, drill bits, and insertion devices may break in the joint. Suture anchors can loosen or be prominent in the joint, resulting in cartilage damage and early arthritis. Loose or broken implants should be removed.

Thermal burns can occur as the result of heated arthroscopic fluid associated with the use of radiofrequency (RF) devices. Temperatures of 45 degrees C or higher can occur in a low-flow environment. Excess heat can result in chondral injury. In addition, although several RF devices have outflow cannulas to prevent overheating, the egress fluid can burn the skin.

Postoperatively, improper use of cryotherapy can result in cold injury to the skin. Surgeons should exercise caution when using cryotherapy in patients with prolonged, postoperative regional blocks.

Elbow and Wrist—Nerve injuries are the most common complications that occur following elbow arthroscopy. In a review of 473 cases, the most common injuries were to the ulnar and superficial radial nerves. All reported injuries in this study were transient. Rheumatoid arthritis was an important independent risk factor, largely due to the altered bony anatomy. Similarly, transient nerve palsy can occur following wrist arthroscopy.

Hip—Despite its steep learning curve, hip arthroscopy has become increasingly common (Fig. 1). Surgeons must be aware of the possibility of pudendal nerve palsy from excessive or prolonged traction. A dedicated hip arthroscopy table with an extra padded post can reduce this risk, and the administration of anesthesia with a muscle relaxant can minimize the necessary traction force. In addition, efforts should be made to minimize traction time.

Injuries to the lateral femoral cutaneous nerve can be avoided through awareness of the pertinent anatomy and proper portal placement. Injuries to the femoral vessels as well as compartment syndrome and DVT have been reported following hip arthroscopy.

Knee—The sheer volume of knee arthroscopy procedures performed make this the most likely arthroscopic procedure to result in a medical liability claim. Although intraoperative complications are rare, postoperative DVT rates of up to 9.9 percent (2.1 percent for proximal clots) have been reported. Although no definite criteria for chemoprophylaxis have been established, DVT risk factors include age older than 40 years, obesity, smoking, prolonged surgical time, tourniquet use, family history, and history of previous DVT.

Neurovascular injury is more likely in surgeries involving the posterior portion of the knee. Compressive neuropathy from tourniquet use has occurred with tourniquet times of as little as 20 minutes. Proper pump pressure and the use of cautery can reduce the need for a tourniquet in many knee procedures, including anterior cruciate ligament reconstruction.

Compartment syndrome can result from fluid extravasation combined with compressive wrapping of the leg. Surgeons should keep pump pressure at the minimum setting needed for hemostasis.

Efforts should be made to avoid prominent interference screw placement during cruciate ligament reconstruction. In addition, meniscal repair devices can result in cyst formation or pain.

Ankle—Surgeons should properly close portals to minimize infection. The superficial branch of the peroneal nerve is in proximity to the anterolateral portal. Extensor tendons are immediately anterior to the ankle joint and can be injured in the process of performing a synovectomy. Instances of DVT have not been reported, but could certainly occur.

General considerations
Although surgical complications during arthroscopy may occur, maximizing doctor–patient communication can minimize the risk of litigation. For example, thorough preoperative education helps manage patient expectations and enable patients to fully participate in their care by making them aware of potential complications. The surgeon should also encourage communication among team members and promote awareness of potential complications. Complacency and failure to maintain proficiency can lead to medical errors.

Arthroscopic surgery can be a safe, minimally invasive way to address joint pathology. Despite its efficacy, however, complications may occur.

Proper training and care are required to minimize complications. When complications do occur, it is vital that the surgeon maximize communication with the patient to explain what occurred, how it will be handled, and what the impact might be on the expected outcome.

Elliott H. Leitman, MD, and Thomas B. Fleeter, MD, are members of the AAOS Medical Liability Committee.

References

  1. Wong DW, Herndon JH. Medical Errors in Orthopaedics: Results of an AAOS Member Survey. J Bone Joint Surg Am 2009:91(3):547–557
  2. Weber SC, Abrams JA, Nottage WM. Complications Associated with Arthroscopic Shoulder Surgery. Arthroscopy 2002:18(2):88–95
  3. Good C, Shindle MK,Effect of Radiofrequency Energy on Glenohumeral Fluid Temperature During Shoulder Arthroscopy. J Bone Joint Surg Am 2009:91(2):428–431
  4. Troxell CR,Morgan CD, Leitman, EH. Dermal Burns Associated With Bipolar Radiofrequency Ablation in the Subacromial Space. Arthroscopy 2011:27(1):136–141
  5. Kelly EW, Morrey BF, O’Driscoll SW. Complications of Elbow Arthroscopy.J Bone Joint Surg Am 2001:83(1):25-35
  6. Sujith K, Shin-Jae R: Hip Arthroscopy: Analysis of a Single Surgeon’s Learning Experience. J Bone Joint Surg Am 2011:93:52–56.
  7. Bushnell BD, Anz AW, Bert JM. Venous Thromboembolism in Lower Extremity Arthroscopy. Arthroscopy 2008:24(5):604–611.