Complications in Orthopaedics: Sports Medicine E-Book

Stephen R. Thompson, Matthew Schmitz

• Publisher: Elsevier
• Year: 2020
• ISBN:
  9780323545990
• Topic: Medicina
• Subtopic: Medicina dello sport

One of the hallmarks of a master surgeon is the ability to navigate a wide variety of inevitable difficult situations in surgery, whether errors in judgment, technical mistakes, or unavoidable outcomes. Complications in Orthopaedic Surgery is a new series designed to provide real-world guidance on recognizing and avoiding errors, as well as how to "course-correct" during surgery. In this inaugural volume dedicated to sports medicine surgery, series editor Dr. Stephen R. Thompson and Dr. Matthew Schmitz describe and demonstrate practical solutions that are integral to improving patient outcomes.

• Covers a wide variety of procedures, including meniscus repair and transplantation, revision ACL reconstruction, pediatric ACL surgery, cartilage surgery in adults and children, knee osteotomies, acromioclavicular surgery, hip arthroscopy, and much more.
• Describes and offers solutions to the most common or most devastating errors and complications in the practice of sports medicine surgery, combining the breadth of knowledge of academic
• surgeons with the in-the-trenches skills of community surgeons.
• Uses an easy-to-follow, standardized chapter format that covers preoperative errors, intraoperative issues, and postoperative complications.
• Includes procedural video clips to reinforce discussions in the text.
• Features a full-color design with numerous photographs, radiographs, and illustrations.

Part I

The Meniscus

Outline

1. Partial Meniscectomy

2. Meniscus Repair

3. Meniscus Transplantation

1: Partial Meniscectomy

Michelle E. Kew, and Brian C. Werner

Abstract

Knee arthroscopy is one of the most commonly performed procedures in the United States, with partial meniscectomy reported as the most often performed arthroscopic procedure. Arthroscopy is a minimally invasive procedure with low morbidity; however, complication rates have been reported to range from 1% to 8%. These complications vary in severity and can lead to significant alterations in a patient’s postoperative course and rehabilitation. The most common complications among experienced arthroscopists are hemarthrosis, infection, venous thromboembolic disease, and instrument failure, with an overall meniscectomy complication rate of 1.48% to 1.78%. Preoperative planning is a critical part of a surgical procedure and helps to identify potential intraoperative difficulties and strategies to navigate unexpected intraarticular pathology. Intraoperative and postoperative complications can be divided into minor and major categories based on the morbidity experienced by the patient, and can include complications because of technique or patient-specific factors.

Keywords

complications; knee arthroscopy; meniscectomy

Chapter outline

1. Introduction,
   1. Preoperative Complications,
   2. Intraoperative Complications,
   3. Postoperative Complications,
   4. Conclusions,

Introduction

Knee arthroscopy is one of the most commonly performed procedures in the United States, with partial meniscectomy reported as the most frequently performed arthroscopic procedure. ¹ Arthroscopy is a minimally invasive procedure with low morbidity; however, complication rates have been reported to range from 1% to 8%. ^{2 , 3} These complications vary in severity and can lead to significant alterations in a patient’s postoperative course and rehabilitation. Small et al. analyzed the complications of 21 experienced arthroscopists and noted that the most common complications were hemarthrosis, infection, venous thromboembolic disease, and instrument failure, with an overall meniscectomy complication rate of 1.48% to 1.78%. ⁴

Preoperative planning is a critical part of a surgical procedure and helps to identify potential intraoperative difficulties and strategies to navigate unexpected intraarticular pathology. Intraoperative and postoperative complications can be divided into minor and major categories based on the morbidity experienced by the patient, and can include complications attributed to technique or patient-specific factors.

Preoperative Complications

Patients undergoing arthroscopic partial meniscectomy should undergo a thorough preoperative workup, including appropriate imaging and physical examination evaluation. Radiographs and magnetic resonance imaging (MRI) are critically evaluated to identify the morphology of meniscus tear, associated ligamentous or chondral injuries, as well as the presence of osteoarthritic changes. Imaging findings should be correlated to physical examination because patients may not be symptomatic from meniscal pathology, and further investigation should be performed to identify the root cause of the symptoms. ⁵ Knee pain can be referred from the lumbar spine or sacroiliac joint pathology or can be caused by a crystalline or inflammatory arthropathy; ⁵ therefore, physical examination should be used to confirm that presenting symptoms are the result of meniscus tear. Marzetti et al. found that a positive McMurray test had an 86.4% specificity for meniscus tear, whereas joint line tenderness was of little clinical utility. ⁶ AV Van der Post, et al. demonstrated that the duck walk was 71% sensitive and 39% specific for medial and lateral meniscus tears (67% and 76%, respectively). ⁷ Osteoarthritis is a significant contributor to knee pain and is commonly associated with meniscal tears; however, studies have not demonstrated consistent, prolonged symptom improvement with arthroscopic debridement, ⁸ and most of these patients should be managed initially, and perhaps permanently, with conservative measures. ⁵ Patients experiencing acute catching or locking symptoms or those with no more than early radiographic changes of degenerative disease can be considered for operative intervention after failing conservative therapies; ⁸ however, Kirkley et al. reported no improvement in outcomes after arthroscopic intervention in this patient population. Patients with larger meniscal flaps were excluded from the aforementioned study and do benefit from an arthroscopic procedure to address the acute pathology. Additionally, younger patients with symptoms of less than 6 months’ duration and those with normal lower extremity alignment can be considered for operative intervention after failing an appropriate conservative treatment regimen. ⁹

Patient expectations can influence postoperative outcomes; therefore, a preoperative discussion should be had to ensure patient understanding of a standard postoperative course and the patient-specific goals for postoperative functional outcomes. ¹⁰ Specifically, patients undergoing arthroscopic knee surgery in the setting of osteoarthritis have been shown to have a modest improvement of symptoms and functional outcomes in the immediate postoperative period (<3 months); however, these results become equivalent to conservative management (physical therapy, injections, oral medications) at long-term evaluation. ¹¹ Additionally, patients who receive surgical treatment have a 2- to 6-week recovery with an increased risk of venous thromboembolism (VTE) and postoperative infection. ¹¹ Patients should understand the small likelihood of long-term improvement, as well as the associated risks of surgical intervention. Recent evidence-based clinical guidelines from the American Academy of Orthopaedic Surgeons cannot recommend for or against the use of arthroscopic surgery for patients with knee osteoarthritis; ¹² therefore, the surgeon should perform a detailed evaluation of the patient and have a thorough discussion with the patient about his or her treatment goals and desired clinical outcomes, particularly in the setting of meniscal pathology with osteoarthritis.

Intraoperative Complications

Technical Complications

Partial meniscectomy is a...

Table of contents

• Cover image
• Title page
• Table of Contents
• Copyright
• Dedications
• Preface
• Contributors
• Part I. The Meniscus
• Part II. Complications in Anterior Cruciate Ligament Surgery
• Part III. Pediatric Anterior Cruciate Ligament
• Part IV. Other Knee Surgery
• Part V. The Shoulder
• Part VI. The Elbow
• Part VII. The Hip
• Index