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Complications in arthroscopic surgery performed by experienced arthroscopists
Arthroscopy: The Journal of Arthroscopic and Related Surgery 4(3):215-221
Published by Raven Press, Ltd. © 1988 Arthroscopy Association of North America
Complications in Arthroscopic Surgery Performed by Experienced Arthroscopists Neal C. Small, M.D.
Summary: Twenty-one experienced arthroscopists participated in a prospective, 19-month study to analyze complications in arthroscopic surgery of the knee and other joints. Participants responded to a monthly questionnaire that provided information on a case-by-case basis for the duration of the study. A total of 63 specific procedures were studied. A total of 10,262 procedures were recorded. Procedures performed on the knee joint were most prevalent in the study (8,741 or 86%). Complications were placed in one of 11 descriptive categories for analysis; 173 complications occurred and the overall complication rate was 1.68%. The types of complications recorded in order of frequency were hemarthrosis, 60.1%; infection, 12.1%; thromboembolic disease, 6.9%; anesthetic complications, 6.4%; instrument failure, 2.9%; reflex sympathetic dystrophy, 2.3%; ligament injury, 1.2%; and fracture and neurologic injuries, 0.6% each. The remainder were miscellaneous complications, 6.9%. No vascular injuries were reported. The two most frequent procedures reported were medial meniscectomy (2,468) with a complication rate of 1.78%, and lateral meniscectomy (1,149) with a complication rate of 1.48%. Overall, there was a lower incidence of complications in meniscal repair (1.29%), including both inside-out and outside-in techniques, than in meniscectomy (1.69%). In-depth information was gathered on each complication. In addition, profiles on surgical techniques and surgical equipment were obtained from each of the contributing surgeons. The complication rate in arthroscopic surgery was found to be higher than had been previously found in retrospective surveys. With further analysis of the complication data and profiles of the surgeons, protective techniques can be further identified to help reduce the incidence of complications in arthroscopic surgery. Key Words: Survey--Hemarthrosis--Surgery, complications--Shoulder--Knee.
cations o f these various surgical procedures performed by the many thousand orthopaedic surgeons in the United States. Serious neurovascular complications do occur at a rate not yet known, and which perhaps never will be known. This survey, however, reports no such complications among this select group o f arthroscopic surgeons. This article is being published not with the idea o f setting standards, but to establish a goal towards which the majority o f arthroscopic surgeons in the United States and elsewhere can aspire.
Editor's comments: This is a careful and welldocumented study o f a very large number o f arthroscopic procedures performed by 21 of the most experienced arthroscopic surgeons in the United States. The statistics report the complication rate o f these 21 surgeons, but the study itself does not purport to shed any light on the number o f compli-
From Associated Orthopedics and Sports Medicine, Piano; and Orthopedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas. Address correspondence and reprint requests to Neal C. Smith, M.D., 3801 West 15th Street, Building II, Suite 350, Plano, TX 75075, U.S.A.
A r t h r o s c o p y and a r t h r o s c o p i c surgery h a v e virtually exploded onto the o r t h o p a e d i c scene since
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the early 1970s. Many orthopaedists now use arthroscopy as a routine part of their practice and most will use it occasionally. The diagnostic value of arthroscopy is well established. Surgical arthroscopy, which evolved initially from work in the knee joint in the later half of the 1970s, is being increasingly utilized to correct knee pathology and is being heavily utilized in other joints as well. The future utilization of arthroscopic techniques seems almost limitless when consideration is given to the exponential advancements of the past 15 years. As with many newly developed procedures, the initial excitement of being technically able to perform a procedure in a new and seemingly less invasive manner creates a substantial increase in the number of these procedures being performed. The initial excitement often turns to surprise and then disappointment when the surgeon realizes that the same complications and failures can occur with arthroscopy and new arthroscopic techniques as with the older techniques. The first attempt to determine the rate of complications in arthroscopy and arthroscopic surgery was a survey taken among the faculty of a course chaired by Dr. Richard O'Connor in Los Angeles in June 1980. This informal survey was taken by Dr. James Mulhollan (1). The participants surveyed were doing basically diagnostic arthroscopy and other so-called first-generation arthroscopic procedures. Complications were mentioned only sporadically in the literature for the next few years (2-8). In 1983, the Arthroscopy Association of North American (AANA)sponsored a survey of complications in arthroscopy (9). This was in the form of a questionnaire sent to members of AANA and others who were known to be doing a substantial amount of arthroscopic surgery. This survey also was targeted toward diagnostic arthroscopy and the firstgeneration arthroscopic surgical procedures such as arthroscopic meniscectomy and lateral retinacular release. The overall complication rate was found to be quite low (0.6%). Despite the low overall rate of complications, several notable conclusions were drawn from this study. Of particular note was the potential occurrence of injury to the popliteal artery and vein and to the tibial and peroneal nerves. At that point, arthroscopists were presented the first documentation of these catastrophic complications. The survey's limitations included its retrospective and recollective nature. There appeared to be an
Arthroscopy, Vol. 4, No. 3, 1988
inherent tendency for survey respondents to exaggerate the numbers of procedures performed and minimize the number of complications. In 1986, AANA sponsored a more extensive survey of complications (10). This survey was designed to determine whether the incidence of various complications noted in the survey tabulated 3 years earlier was remaining constant. In addition, newer procedures were surveyed for the first time. These included more advanced arthroscopic procedures in the knee such as meniscal repairs and anterior cruciate ligament (ACL) repairs and reconstructions. Complications resulting from arthroscopic procedures on the shoulder, subacromial space, elbow, wrist, and ankle were surveyed for the first time as well. Pertinent conclusions were reached in this 1986 survey, including that there was a high incidence of thromboembolic disease and an increased incidence of infection when meniscal repair sutures were tied externally over buttons or bolsters. The overall complication rate in this retrospective survey was again 0.6%. However, when the more advanced knee procedures were analyzed separately, it was apparent that the complication rate in each of these newer procedures was > 1%. Several newer procedures in other joints also showed complication rates of >1%. Most notable was anterior staple capsulorrhaphy of the shoulder with a complication rate of 5.3%. When this somewhat disturbing trend toward a higher incidence of complications was noted in the second retrospective survey published in 1986, AANA commissioned the Complications Committee to design a prospective and contemporaneous registry of cases from various centers around the country (11). With this accurate means of compiling a database, the complication rate for most of the commonly performed procedures could be accurately determined.
MATERIALS AND METHODS The Complications Committee of AANA formulated a registry to further investigate complications in arthroscopy. A comprehensive form was completed each month by 21 arthroscopists for a period of 19 months beginning in August 1986 and concluding in February 1988. A total of 63 specific procedures and 11 descriptive complication classifica-
COMPLICATIONS IN ARTHROSCOPIC SURGERY tions were included in the survey. The range of procedures that were recorded in the registry included commonly performed procedures in the ankle, knee, hip, wrist, elbow, and shoulder. Many newer procedures were also recorded. Included in shoulder arthroscopy were procedures involving the subacromial space and the acromioclavicular joint. Participating surgeons recorded the number of arthroscopic procedures that they performed each month and the number and type of complications that resulted. A detailed analysis of each complication was also provided. Each month, upon completion of the monthly survey form, the surgeons returned their forms to a central office for tabulation and analysis of the data. Data were recorded in a computer database on a continuous basis as the surveys were returned each month. Statistical analysis was applied to the final tabulations to determine the validity of conclusions that might be drawn. A confidence interval of 95% was assigned to each procedure for analysis. A confidence interval provides an estimate of the range of reasonable values for the " t r u e " (or population) complication rate. The sample rate (or proportion) provides a point estimate. The 95% confidence intervals are constructed in such a way that, if the study was repeated many times and confidence intervals were constructed for each, 95% Of such intervals should bracket the true value of the complication rate. Since only one such interval is usually calculated, the interpretation of limits is that there should be 95% confidence that the true rate (proportion) is contained within the stated limits. For example: Overall there were 10,282 procedures with 173 complications. The complication rate is 0.0168 or 1.68% or 168 per 10,000 procedures. The confidence limits are 0.0144-0.0195. Based on the results of this study, the overall complication rate could be as low as 144 per 10,000 or as high as 195 per 10,000 procedures. This statement can be made with 95% confidence (Joan S. Reisch, Ph.D., Academic Computing, University of Texas Southwestern Medical Center: correspondence on confidence intervals, 19 March 1988; Table 1). Unlike the 1983 or 1985 retrospective surveys, this survey did not rely on the memory of the surgeon. Tabulations of procedures and complications were recorded month by month as they took place. In addition, the participating surgeons were some of the most active and experienced arthroscopists in the country (Table 2).
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RESULTS In the 19-month period from August 1986 through February 1988, a total of 10,282 procedures were recorded by 21 a r t h r o s c o p i c surgeons: 8,791 (85.5%) of the procedures were in the knee joint; 1,184 (11.51%) were in the shoulder or subacromial space; 146 (1.42%) were in the ankle; 79 (0.77%) were in the elbow; 68 (0.66%) were in the wrist; and 14 (0.14%) were in the hip. The total number of complications recorded was 173:162 complications were recorded in the knee, nine in the shoulder and subacromial space, one in the ankle, and one in the hip (Table 3). The overall complication rate was 1.68% for arthroscopic surgery. Types of complications The most frequent complication noted was hemarthrosis (Table 4). In this registry, hemarthrosis must require aspiration or surgical evacuation to be classified as a true complication. There were 104 hemarthroses reported, comprising >60% of all the complications. The incidence of hemarthrosis was just over 1% in knee arthroscopy. Only three hemarthroses have occurred in a joint other than the knee. The second most frequently reported complication was infection. This was reported in 21 cases: 19 of these occurred in knee procedures, one in an ankle procedure, and one in a hip procedure. In the cases where the organism was identified, seven of these infections were Staphylococcus aureus, three were Staphylococcus epidermidis, and two were Streptococcus. The average interval between the procedure and discovery of the infection was 11.7 days. Prophylactic antibiotics were used in four of these procedures. There were 11 anesthetic complications reported. This represents 6.4% of all complications, compared with 3.7% of the anesthetic complications recorded in the previous study. Six of the complications occurred intraoperatively and five were postoperative. There were eight complications with general anesthesia. In the 1983 and the 1986 retrospective surveys, thromboembolic disease was found to be the most common complication, with the exception of hemarthrosis. Its frequency continued to be quite significant in this study although the incidence was somewhat less than the incidence of hemarthrosis and infection. There was 12 cases of thromboem-
Arthroscopy, Vol. 4, No. 3, 1988
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N . C. S M A L L
T A B L E 1. Confidence intervals Procedures
Number of procedures
Number of complications
Rate
95% Confidence range
Diagnostic arthroscopy Medial meniscectomy Lateral meniscectomy Medial meniscal repair Lateral meniscal repair Outside repairs Abrasion arthroplasty Lateral retinacular release Excision plica Synovectomy ACL staple repair ACL reconstruction autogenous tissue ACL reconstruction allograft ACL reconstruction synthetic Osteochondritis dissecans Excision loose bodies Shaving chondroplasty Lysis of adhesions Posterior cruciate reconstruction Fracture fixation Extraarticular restraint autogenous tissue Debridement degenerative joint disease
643 2468 1149 197 60 53 318 446 410 385 45 469 151 27 112 470 1128 135 8 10 54 3
3 44 17 3 0 1 6 32 7 12 0 8 5 1 1 2 18 1 0 0 1 0
0.0047 0.0178 0.0148 0.0152 0 0.0189 0.0189 0.0717 0.0171 0.0312 0 0.0171 0.0331 0.0370 0.0089 0.0043 0.0160 0.0074 0 0 0.0185 0
0.0012-0.0148 0.0131-0.0240 0.0089-0.0241 0.0039-0.0474 0.0015-0.0750 0.0009-0.1130 0.0077-0.0427 0.0503-0.1008 0.0075-0.0365 0.0170-0.0553 0.0020--0.0980 0.0080-0.0347 0.0122-0.0796 0.0019-0.2088 0.0005-0.0559 0.0008-0.0171 0.0098-0.0257 0.0004--0.0467 0.0116-0.4023 0.0092-0.3445 0.0010-0.1118 0.0318-0.6900
204 91 4 206 35 138 18 59 51 2
1 3 0 1 0 0 0 1 0 0
0.0049 0.0330 0 0.0049 0 0 0 0.0169 0 0
0.0003-0.0312 0.0086--0.1002 0.0235-0.6042 0.0003-0.0310 0.0026--0.1232 0.0007-0.338 0.0051-0.2188 0.0009-0.1029 0.0018-0.0873
28 22
0 0
0 0
0.0033-0.1502 0.0042-0.1850
65 45 9 175 82
0 0 1 2 0
0 0 0.1111 0.0114 0
0.0014-O.0695 0.0020-0.0980 0.0058-0.4933 0.0020--0.0450 0.0011-0.0558
26 31 2 5 15 0
0 0 0 0 0 0
0 0 0 0 0 0
0.0035-0.1602 0.0029-0.1373
39 5 6 17
0 0 0 0
0 0 0 0
1
0
0
KNEE
SHOULDER
Diagnostic arthroscopy Anterior staple capsulorrhaphy Extraarticular capsular staple Debridement of labrum tear Reconstruction AIGL with facia latae graft Intraarticular debridement of cuffBankhart repair Excision loose bodies Synovectomy Fracture fixation AC JOINT PROCEDURES
Debridement Mumford-type decompression SUBACROMIAL SPACE Diagnostic arthroscopy Debridement of rotator cuff Arthroscopic repair rotator cuff Anterior acromioplasty Coracoacromial ligament resection ELBOW
Diagnostic arthroscopy Excision loose bodies Spur removal Abrasion or drill, articular cartilage Synovectomy Fracture fixation
0.0187-0.5371 0.0061-0.2535
WRIST
Diagnostic arthroscopy Excision loose bodies Articular cartilage debridement Fracture fixation SL pinning
Arthroscopy, Vol. 4, No. 3, 1988
0.0023-0.1117 0.0187-0.5371 0.0155-0.4832 0.0054-0.2292
COMPLICATIONS IN ARTHROSCOPIC SURGERY
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TABLE 1--(Continued) Procedures
Number of procedures
ANKLE Diagnostic arthroscopy Excision loose bodies Osteochondritic lesion Lysis adhesions Synovectomy Staple repair AFT ligament Ankle arthrodesis Distraction pins Fracture fixation
Number of complications
26 31 40 10 34 0 3 1 1
HIP Diagnostic arthroscopy
Excision loose bodies Abrasion arthroplasty Fracture fixation
Rate
95% Confidencerange
0 0 0 1 0 0 0 0 0
0 0 0 0.10 0 0 0 0 0
0.0035-0.1602 0.0029-0.1373 0.0023-0.1091 0.0052-0.4589 0.0027-0.1264
9
1
0.1111
0.0058-0.4933
2 0 3
0 0 0
0 0 0
0.0318-0.6900
ACL, anterior cruciate ligament; AIGL, anterior inferior glenohumeral ligament; SL, scapho-lunate; AFT, anterior fibulo-talar.
bolic disease reported. The diagnosis was made by venogram in five cases. In eight of the 12 cases, a tourniquet was used. The average tourniquet time was 50 min. The average tourniquet pressure was 350 mm Hg. There were four pulmonary emboli documented. None were fatal. Five instrument failures have been reported in this study. This incidence of 0.05% was substantially less than the incidence of 0.1% reported in the 1986 retrospective study. Other complications were less frequent. There were two medial collateral ligament ruptures reported. Both occurred during medial meniscal procedures. This incidence was also significantly less than previously noted. There were four reflex sympathetic dystrophies recorded. Two followed knee procedures and two followed shoulder procedures. One fracture was reported in a knee procedure. A lateral leg holder was utilized during this procedure. Only one neurologic injury was recorded in this
study. This was a saphenous nerve injury following a medial meniscal repair. The incidence is this study was substantially less than previously reported. No vascular injuries were reported. The dramatically lowered incidence of neurologic and vascular injuries in this registry probably reflects the experience level of the surgeons, as well as relatively recent anatomical studies and refinements in surgical techniques that allow better protection of nerves and vessels, particularly during meniscal repair. As to the individual procedures and their respective complication rates, some interesting trends were noted (Table 5). As mentioned previously the overall complication rate in this study was 1.68%. Lateral retinacular release had the highest complication rate (7%) of any of the commonly performed procedures. Sixty-five percent of these complications were hemarthroses. The complication rate for medial meniscectomy TABLE 3. Total number of procedures and complications reported: overall rate 1.68% or 168 per 10,000
TABLE 2. Experience level o f participating surgeons
Knee Shoulder~ Elbow ~ Ankle ~ Wrist ~ Hip a a
Average number of years diagnostic arthroscopy
Average number of years surgicalarthroscopy
14.5 7.2 7.2 7.1 9.6 7.8
11.0 6.1 6.6 6.6 9.3 7.8
Not all respondents performed arthroscopy on these joints.
Knee Shoulder Ankle Elbow Wrist Hip Total
Number of procedures
%
Number of complications
%
8,791 1,184 146 79 68 14
85.5 11.51 1.42 0.77 0.66 0.14
162 9 1 0 0 1
93.64 5.2 0.58 0 0 0.58
10,282
100
173
100
Arthroscopy, Vol. 4, No. 3, 1988
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N. C. S M A L L TABLE 4. Types of complications (173 complications) Complications
%
Number of complications
Hemarthrosis/hematoma Infection Thromboembolic disease Anesthetic Instrument failure Reflex sympathetic dystrophy Ligament injury Fracture Neurologic injury Miscellaneous Vascular injury
60.1 12.1 6.9 6.4 2.9 2.3 1.2 .6 .6 6.9 0
104 21 12 11 5 4 2 1 1 12 0
Total
100
173
was slightly higher than for medial meniscal repair. The rate was 1.78% for medial meniscectomy and 1.52% for medial meniscal repair. The complication rate for lateral meniscectomy was 1.48%. No complications were reported in lateral meniscal repair. Thus, there does not appear to be a significantly higher incidence of complications for meniscal repair than for arthroscopic partial meniscectomy among this very experienced group of arthroscopic surgeons. The complication rates in the newer and more complicated arthroscopic procedures were observed closely. Specifically regarding ACL procedures, the highest complication rate was seen in ACL reconstruction using synthetic materials. The complication rate for this procedure was 3.7% although only 27 procedures were recorded. The complication rate for allograft ACL reconstructions was 3.3% (five complications, in 151 procedures).
For autogenous ACL reconstructions, the complication rate was 1.7% (eight complications in 469 procedures). No complications were noted in 45 ACL staple repairs. Among shoulder procedures, the anterior staple capsulorrhaphy once again had the highest complications rate (3.3%). Two of the three complications noted for this procedure were staple impingements against the humeral head. The other was a hemarthrosis. In rotator cuff repairs performed arthroscopically, one complication of staple impingment occurred in nine procedures. In two other subacromial space procedures, a reflex sympathetic dystrophy developed in the involved extremity. No complications were noted in 79 elbow procedures and 61 wrist procedures. One case of spontaneous drainage was reported in 10 diagnostic hip arthroscopies. One complication, an infection, occurred in 146 ankle arthroscopies.
TABLE 5. Incidence of complications for specific
DISCUSSION
procedures (in decreasing order of frequency) Complication
Incidence
Lateral retinacular release ACL synthetic reconstruction ACL allograft reconstruction Shoulder staple capsulorrhaphy Arthroscopic synovectomy Abrasion arthroplasty Outside-in meniscal repairs Medial meniscectomy Plica excision ACL autogenous reconstruction Shaving chondroplasty Medial meniscal repair Lateral meniscectomy Anterior acromioplasty Debridement of glenoid labrum tear Lateral meniscal repair
7.17% 3.7% 3.3% 3.3% 3.12% 1.89% 1.89% 1.78% 1.71% 1.71% 1.6% 1.52% 1.48% 1.1%
Arthroscopy, Vol.4, No. 3, 1988
O.5% 0
This controlled study confirms the fears that the complication rate in arthroscopy is greater than the incidence previously reported of < 1%. The arthroscopists who participated in this study are some of the most experienced in the country. The average participant in this study has been performing diagnostic knee arthroscopy for 141/2 years and surgical knee arthroscopy for 11 years. Of particular interest in this series was the occurrence of two cases of adult respiratory distress syndrome that were both associated with ACL procedures. Both were manifested by fulminant pulmonary edema and significantly altered blood gases. Both required treatment with a diuretic and sub-
COMPLICATIONS IN ARTHROSCOPIC S U R G E R Y
stantial pulmonary support, but resolved by the following day. This particular complication of arthroscopy and ACL procedures has not been previously reported. No explanation is available at this time as to the exact etiology. In analyzing the voluminous data tabulated, it is apparent that this group of experienced arthroscopic surgeons experienced a complication rate significantly higher than previously found in retrospective surveys. Despite this overall increase, certain major complications such as neurologic and vascular injuries were reported less frequently. This is probably the result of the experience level of the study participants and recent advances in techniques for meniscal repair and ACL procedures. These important protective techniques include accessory posterior incisions for posterior horn tears, deflecting retractors, and proper knee positioning for needle insertions during meniscal repair procedures. In addition, sutures are no longer tied over buttons or bolsters, thus diminishing the incidence of infection in meniscal repair. CONCLUSIONS In conclusion, one can no longer state that the complication rate in arthroscopy is <1%. In this controlled multicenter study with 10,282 procedures recorded, the complication rate was 1.68%. Hemarthrosis was the most frequent complication. The procedure with the highest complication rate (7%) was lateral retinacular release. Among this very experienced group of arthroscopic surgeons, there was a slightly higher complication rate in meniscectomy (1.78%) than in meniscal repair (1.52%). The statistical data and the profiles on each surgeon will be further analyzed to obtain correlations between various arthroscopic techniques and complications.
221
Acknowledgment: The author acknowledges and thanks the participants in the multicenter study. They are, in alphabetical order: Jack Andrish, M.D., Cleveland, OH; Bruce Baker, M.D., Syracuse, NY; John Bergfeld, M.D., Cleveland, OH; Richard Caspari, M.D., Richmond, VA; Kenneth DeHaven, M.D., Rochester, NY; David Drez, Jr., M.D., Lake Charles, LA; Robert Eilert, M.D., Denver, CO; Lanny Johnson, M.D., East Lansing, MI; J. Lee Leonard, M.D., Lafayette, LA; Richard Levitt, M.D., Miami, FL; Ralph Lidge, M.D., Arlington Heights, IL; George Mauerman, M.D., Tulsa, OK; James Mauerman, M.D., Tulsa, OK; James Mulhollan, M.D., Little Rock, AR; Serge Parisien, M.D., New York, NY; Dinesh Patel, M.D., Boston, MA; Neal Small, M.D., Piano, TX; Robert Stone, M.D., Dallas, TX; Robert Vandermeer, M.D., Dallas, TX; Garron Weiker, M.D., Cleveland, OH; Terry Whipple, M.D., F.A.C.S., Richmond, VA; Paul Yerys, M.D., East Meadow, NY. The author also thanks the Arthroscopy Association of North America for funding and Ms. Kim Merholtz for her assistance in coordinating this study and in preparing the manuscript. REFERENCES 1. Mulhollan JS. Symposium: arthroscopic knee surgery. Can Orthop 1982;5:79-112. 2. Fiddian N J, Poirier H. The morbidity of arthroscopy of the knee. J Bone Joint Surg [Br] 1981;63:630. 3. Hershman E, Nisonson B. Arthroscopic meniscectomy: a follow-up report. Am J Sports Med 1983;11:253-7. 4. Gillquist J, Oretorp N. Arthroscopic partial meniscectomy: technique and long term results. Clin Orthop 1982;167:2933. 5. Walker RH, Dillingham M. Thrombophlebitis following arthroscopic surgery of the knee. Conternp Orthop 1983;6:2933. 6. Jackson RW. Current concepts review: arthroscopic surgery. J Bone Joint Surg [Am] 1983;65:416-20. 7. Lindenbaum BL. Complications of knee joint arthroscopy. Clin Orthop 1981;160:158. 8. Rorabeck CH, Kennedy JC. Tourniquet-induced nerve ischemia complicating knee ligament surgery. Am J Sports Med t980;8:98-102. 9. DeLee J. Complications of arthroscopy and arthroscopic surgery: results of a national survey. Arthroscopy 1985; 1:214-20. 10. Small NC. Complications in arthroscopy: the knee and other joints. Arthroscopy 1986;4:253-8. 11. Small NC. Complications in arthroscopy. Presented at the AANA annual meeting, Washington, DC, 25-27 March 1988.
Arthroscopy, Vol. 4, No. 3, 1988
Published by Raven Press, Ltd. © 1988 Arthroscopy Association of North America
Complications in Arthroscopic Surgery Performed by Experienced Arthroscopists Neal C. Small, M.D.
Summary: Twenty-one experienced arthroscopists participated in a prospective, 19-month study to analyze complications in arthroscopic surgery of the knee and other joints. Participants responded to a monthly questionnaire that provided information on a case-by-case basis for the duration of the study. A total of 63 specific procedures were studied. A total of 10,262 procedures were recorded. Procedures performed on the knee joint were most prevalent in the study (8,741 or 86%). Complications were placed in one of 11 descriptive categories for analysis; 173 complications occurred and the overall complication rate was 1.68%. The types of complications recorded in order of frequency were hemarthrosis, 60.1%; infection, 12.1%; thromboembolic disease, 6.9%; anesthetic complications, 6.4%; instrument failure, 2.9%; reflex sympathetic dystrophy, 2.3%; ligament injury, 1.2%; and fracture and neurologic injuries, 0.6% each. The remainder were miscellaneous complications, 6.9%. No vascular injuries were reported. The two most frequent procedures reported were medial meniscectomy (2,468) with a complication rate of 1.78%, and lateral meniscectomy (1,149) with a complication rate of 1.48%. Overall, there was a lower incidence of complications in meniscal repair (1.29%), including both inside-out and outside-in techniques, than in meniscectomy (1.69%). In-depth information was gathered on each complication. In addition, profiles on surgical techniques and surgical equipment were obtained from each of the contributing surgeons. The complication rate in arthroscopic surgery was found to be higher than had been previously found in retrospective surveys. With further analysis of the complication data and profiles of the surgeons, protective techniques can be further identified to help reduce the incidence of complications in arthroscopic surgery. Key Words: Survey--Hemarthrosis--Surgery, complications--Shoulder--Knee.
cations o f these various surgical procedures performed by the many thousand orthopaedic surgeons in the United States. Serious neurovascular complications do occur at a rate not yet known, and which perhaps never will be known. This survey, however, reports no such complications among this select group o f arthroscopic surgeons. This article is being published not with the idea o f setting standards, but to establish a goal towards which the majority o f arthroscopic surgeons in the United States and elsewhere can aspire.
Editor's comments: This is a careful and welldocumented study o f a very large number o f arthroscopic procedures performed by 21 of the most experienced arthroscopic surgeons in the United States. The statistics report the complication rate o f these 21 surgeons, but the study itself does not purport to shed any light on the number o f compli-
From Associated Orthopedics and Sports Medicine, Piano; and Orthopedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas. Address correspondence and reprint requests to Neal C. Smith, M.D., 3801 West 15th Street, Building II, Suite 350, Plano, TX 75075, U.S.A.
A r t h r o s c o p y and a r t h r o s c o p i c surgery h a v e virtually exploded onto the o r t h o p a e d i c scene since
215
216
N. C. S M A L L
the early 1970s. Many orthopaedists now use arthroscopy as a routine part of their practice and most will use it occasionally. The diagnostic value of arthroscopy is well established. Surgical arthroscopy, which evolved initially from work in the knee joint in the later half of the 1970s, is being increasingly utilized to correct knee pathology and is being heavily utilized in other joints as well. The future utilization of arthroscopic techniques seems almost limitless when consideration is given to the exponential advancements of the past 15 years. As with many newly developed procedures, the initial excitement of being technically able to perform a procedure in a new and seemingly less invasive manner creates a substantial increase in the number of these procedures being performed. The initial excitement often turns to surprise and then disappointment when the surgeon realizes that the same complications and failures can occur with arthroscopy and new arthroscopic techniques as with the older techniques. The first attempt to determine the rate of complications in arthroscopy and arthroscopic surgery was a survey taken among the faculty of a course chaired by Dr. Richard O'Connor in Los Angeles in June 1980. This informal survey was taken by Dr. James Mulhollan (1). The participants surveyed were doing basically diagnostic arthroscopy and other so-called first-generation arthroscopic procedures. Complications were mentioned only sporadically in the literature for the next few years (2-8). In 1983, the Arthroscopy Association of North American (AANA)sponsored a survey of complications in arthroscopy (9). This was in the form of a questionnaire sent to members of AANA and others who were known to be doing a substantial amount of arthroscopic surgery. This survey also was targeted toward diagnostic arthroscopy and the firstgeneration arthroscopic surgical procedures such as arthroscopic meniscectomy and lateral retinacular release. The overall complication rate was found to be quite low (0.6%). Despite the low overall rate of complications, several notable conclusions were drawn from this study. Of particular note was the potential occurrence of injury to the popliteal artery and vein and to the tibial and peroneal nerves. At that point, arthroscopists were presented the first documentation of these catastrophic complications. The survey's limitations included its retrospective and recollective nature. There appeared to be an
Arthroscopy, Vol. 4, No. 3, 1988
inherent tendency for survey respondents to exaggerate the numbers of procedures performed and minimize the number of complications. In 1986, AANA sponsored a more extensive survey of complications (10). This survey was designed to determine whether the incidence of various complications noted in the survey tabulated 3 years earlier was remaining constant. In addition, newer procedures were surveyed for the first time. These included more advanced arthroscopic procedures in the knee such as meniscal repairs and anterior cruciate ligament (ACL) repairs and reconstructions. Complications resulting from arthroscopic procedures on the shoulder, subacromial space, elbow, wrist, and ankle were surveyed for the first time as well. Pertinent conclusions were reached in this 1986 survey, including that there was a high incidence of thromboembolic disease and an increased incidence of infection when meniscal repair sutures were tied externally over buttons or bolsters. The overall complication rate in this retrospective survey was again 0.6%. However, when the more advanced knee procedures were analyzed separately, it was apparent that the complication rate in each of these newer procedures was > 1%. Several newer procedures in other joints also showed complication rates of >1%. Most notable was anterior staple capsulorrhaphy of the shoulder with a complication rate of 5.3%. When this somewhat disturbing trend toward a higher incidence of complications was noted in the second retrospective survey published in 1986, AANA commissioned the Complications Committee to design a prospective and contemporaneous registry of cases from various centers around the country (11). With this accurate means of compiling a database, the complication rate for most of the commonly performed procedures could be accurately determined.
MATERIALS AND METHODS The Complications Committee of AANA formulated a registry to further investigate complications in arthroscopy. A comprehensive form was completed each month by 21 arthroscopists for a period of 19 months beginning in August 1986 and concluding in February 1988. A total of 63 specific procedures and 11 descriptive complication classifica-
COMPLICATIONS IN ARTHROSCOPIC SURGERY tions were included in the survey. The range of procedures that were recorded in the registry included commonly performed procedures in the ankle, knee, hip, wrist, elbow, and shoulder. Many newer procedures were also recorded. Included in shoulder arthroscopy were procedures involving the subacromial space and the acromioclavicular joint. Participating surgeons recorded the number of arthroscopic procedures that they performed each month and the number and type of complications that resulted. A detailed analysis of each complication was also provided. Each month, upon completion of the monthly survey form, the surgeons returned their forms to a central office for tabulation and analysis of the data. Data were recorded in a computer database on a continuous basis as the surveys were returned each month. Statistical analysis was applied to the final tabulations to determine the validity of conclusions that might be drawn. A confidence interval of 95% was assigned to each procedure for analysis. A confidence interval provides an estimate of the range of reasonable values for the " t r u e " (or population) complication rate. The sample rate (or proportion) provides a point estimate. The 95% confidence intervals are constructed in such a way that, if the study was repeated many times and confidence intervals were constructed for each, 95% Of such intervals should bracket the true value of the complication rate. Since only one such interval is usually calculated, the interpretation of limits is that there should be 95% confidence that the true rate (proportion) is contained within the stated limits. For example: Overall there were 10,282 procedures with 173 complications. The complication rate is 0.0168 or 1.68% or 168 per 10,000 procedures. The confidence limits are 0.0144-0.0195. Based on the results of this study, the overall complication rate could be as low as 144 per 10,000 or as high as 195 per 10,000 procedures. This statement can be made with 95% confidence (Joan S. Reisch, Ph.D., Academic Computing, University of Texas Southwestern Medical Center: correspondence on confidence intervals, 19 March 1988; Table 1). Unlike the 1983 or 1985 retrospective surveys, this survey did not rely on the memory of the surgeon. Tabulations of procedures and complications were recorded month by month as they took place. In addition, the participating surgeons were some of the most active and experienced arthroscopists in the country (Table 2).
217
RESULTS In the 19-month period from August 1986 through February 1988, a total of 10,282 procedures were recorded by 21 a r t h r o s c o p i c surgeons: 8,791 (85.5%) of the procedures were in the knee joint; 1,184 (11.51%) were in the shoulder or subacromial space; 146 (1.42%) were in the ankle; 79 (0.77%) were in the elbow; 68 (0.66%) were in the wrist; and 14 (0.14%) were in the hip. The total number of complications recorded was 173:162 complications were recorded in the knee, nine in the shoulder and subacromial space, one in the ankle, and one in the hip (Table 3). The overall complication rate was 1.68% for arthroscopic surgery. Types of complications The most frequent complication noted was hemarthrosis (Table 4). In this registry, hemarthrosis must require aspiration or surgical evacuation to be classified as a true complication. There were 104 hemarthroses reported, comprising >60% of all the complications. The incidence of hemarthrosis was just over 1% in knee arthroscopy. Only three hemarthroses have occurred in a joint other than the knee. The second most frequently reported complication was infection. This was reported in 21 cases: 19 of these occurred in knee procedures, one in an ankle procedure, and one in a hip procedure. In the cases where the organism was identified, seven of these infections were Staphylococcus aureus, three were Staphylococcus epidermidis, and two were Streptococcus. The average interval between the procedure and discovery of the infection was 11.7 days. Prophylactic antibiotics were used in four of these procedures. There were 11 anesthetic complications reported. This represents 6.4% of all complications, compared with 3.7% of the anesthetic complications recorded in the previous study. Six of the complications occurred intraoperatively and five were postoperative. There were eight complications with general anesthesia. In the 1983 and the 1986 retrospective surveys, thromboembolic disease was found to be the most common complication, with the exception of hemarthrosis. Its frequency continued to be quite significant in this study although the incidence was somewhat less than the incidence of hemarthrosis and infection. There was 12 cases of thromboem-
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N . C. S M A L L
T A B L E 1. Confidence intervals Procedures
Number of procedures
Number of complications
Rate
95% Confidence range
Diagnostic arthroscopy Medial meniscectomy Lateral meniscectomy Medial meniscal repair Lateral meniscal repair Outside repairs Abrasion arthroplasty Lateral retinacular release Excision plica Synovectomy ACL staple repair ACL reconstruction autogenous tissue ACL reconstruction allograft ACL reconstruction synthetic Osteochondritis dissecans Excision loose bodies Shaving chondroplasty Lysis of adhesions Posterior cruciate reconstruction Fracture fixation Extraarticular restraint autogenous tissue Debridement degenerative joint disease
643 2468 1149 197 60 53 318 446 410 385 45 469 151 27 112 470 1128 135 8 10 54 3
3 44 17 3 0 1 6 32 7 12 0 8 5 1 1 2 18 1 0 0 1 0
0.0047 0.0178 0.0148 0.0152 0 0.0189 0.0189 0.0717 0.0171 0.0312 0 0.0171 0.0331 0.0370 0.0089 0.0043 0.0160 0.0074 0 0 0.0185 0
0.0012-0.0148 0.0131-0.0240 0.0089-0.0241 0.0039-0.0474 0.0015-0.0750 0.0009-0.1130 0.0077-0.0427 0.0503-0.1008 0.0075-0.0365 0.0170-0.0553 0.0020--0.0980 0.0080-0.0347 0.0122-0.0796 0.0019-0.2088 0.0005-0.0559 0.0008-0.0171 0.0098-0.0257 0.0004--0.0467 0.0116-0.4023 0.0092-0.3445 0.0010-0.1118 0.0318-0.6900
204 91 4 206 35 138 18 59 51 2
1 3 0 1 0 0 0 1 0 0
0.0049 0.0330 0 0.0049 0 0 0 0.0169 0 0
0.0003-0.0312 0.0086--0.1002 0.0235-0.6042 0.0003-0.0310 0.0026--0.1232 0.0007-0.338 0.0051-0.2188 0.0009-0.1029 0.0018-0.0873
28 22
0 0
0 0
0.0033-0.1502 0.0042-0.1850
65 45 9 175 82
0 0 1 2 0
0 0 0.1111 0.0114 0
0.0014-O.0695 0.0020-0.0980 0.0058-0.4933 0.0020--0.0450 0.0011-0.0558
26 31 2 5 15 0
0 0 0 0 0 0
0 0 0 0 0 0
0.0035-0.1602 0.0029-0.1373
39 5 6 17
0 0 0 0
0 0 0 0
1
0
0
KNEE
SHOULDER
Diagnostic arthroscopy Anterior staple capsulorrhaphy Extraarticular capsular staple Debridement of labrum tear Reconstruction AIGL with facia latae graft Intraarticular debridement of cuffBankhart repair Excision loose bodies Synovectomy Fracture fixation AC JOINT PROCEDURES
Debridement Mumford-type decompression SUBACROMIAL SPACE Diagnostic arthroscopy Debridement of rotator cuff Arthroscopic repair rotator cuff Anterior acromioplasty Coracoacromial ligament resection ELBOW
Diagnostic arthroscopy Excision loose bodies Spur removal Abrasion or drill, articular cartilage Synovectomy Fracture fixation
0.0187-0.5371 0.0061-0.2535
WRIST
Diagnostic arthroscopy Excision loose bodies Articular cartilage debridement Fracture fixation SL pinning
Arthroscopy, Vol. 4, No. 3, 1988
0.0023-0.1117 0.0187-0.5371 0.0155-0.4832 0.0054-0.2292
COMPLICATIONS IN ARTHROSCOPIC SURGERY
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TABLE 1--(Continued) Procedures
Number of procedures
ANKLE Diagnostic arthroscopy Excision loose bodies Osteochondritic lesion Lysis adhesions Synovectomy Staple repair AFT ligament Ankle arthrodesis Distraction pins Fracture fixation
Number of complications
26 31 40 10 34 0 3 1 1
HIP Diagnostic arthroscopy
Excision loose bodies Abrasion arthroplasty Fracture fixation
Rate
95% Confidencerange
0 0 0 1 0 0 0 0 0
0 0 0 0.10 0 0 0 0 0
0.0035-0.1602 0.0029-0.1373 0.0023-0.1091 0.0052-0.4589 0.0027-0.1264
9
1
0.1111
0.0058-0.4933
2 0 3
0 0 0
0 0 0
0.0318-0.6900
ACL, anterior cruciate ligament; AIGL, anterior inferior glenohumeral ligament; SL, scapho-lunate; AFT, anterior fibulo-talar.
bolic disease reported. The diagnosis was made by venogram in five cases. In eight of the 12 cases, a tourniquet was used. The average tourniquet time was 50 min. The average tourniquet pressure was 350 mm Hg. There were four pulmonary emboli documented. None were fatal. Five instrument failures have been reported in this study. This incidence of 0.05% was substantially less than the incidence of 0.1% reported in the 1986 retrospective study. Other complications were less frequent. There were two medial collateral ligament ruptures reported. Both occurred during medial meniscal procedures. This incidence was also significantly less than previously noted. There were four reflex sympathetic dystrophies recorded. Two followed knee procedures and two followed shoulder procedures. One fracture was reported in a knee procedure. A lateral leg holder was utilized during this procedure. Only one neurologic injury was recorded in this
study. This was a saphenous nerve injury following a medial meniscal repair. The incidence is this study was substantially less than previously reported. No vascular injuries were reported. The dramatically lowered incidence of neurologic and vascular injuries in this registry probably reflects the experience level of the surgeons, as well as relatively recent anatomical studies and refinements in surgical techniques that allow better protection of nerves and vessels, particularly during meniscal repair. As to the individual procedures and their respective complication rates, some interesting trends were noted (Table 5). As mentioned previously the overall complication rate in this study was 1.68%. Lateral retinacular release had the highest complication rate (7%) of any of the commonly performed procedures. Sixty-five percent of these complications were hemarthroses. The complication rate for medial meniscectomy TABLE 3. Total number of procedures and complications reported: overall rate 1.68% or 168 per 10,000
TABLE 2. Experience level o f participating surgeons
Knee Shoulder~ Elbow ~ Ankle ~ Wrist ~ Hip a a
Average number of years diagnostic arthroscopy
Average number of years surgicalarthroscopy
14.5 7.2 7.2 7.1 9.6 7.8
11.0 6.1 6.6 6.6 9.3 7.8
Not all respondents performed arthroscopy on these joints.
Knee Shoulder Ankle Elbow Wrist Hip Total
Number of procedures
%
Number of complications
%
8,791 1,184 146 79 68 14
85.5 11.51 1.42 0.77 0.66 0.14
162 9 1 0 0 1
93.64 5.2 0.58 0 0 0.58
10,282
100
173
100
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N. C. S M A L L TABLE 4. Types of complications (173 complications) Complications
%
Number of complications
Hemarthrosis/hematoma Infection Thromboembolic disease Anesthetic Instrument failure Reflex sympathetic dystrophy Ligament injury Fracture Neurologic injury Miscellaneous Vascular injury
60.1 12.1 6.9 6.4 2.9 2.3 1.2 .6 .6 6.9 0
104 21 12 11 5 4 2 1 1 12 0
Total
100
173
was slightly higher than for medial meniscal repair. The rate was 1.78% for medial meniscectomy and 1.52% for medial meniscal repair. The complication rate for lateral meniscectomy was 1.48%. No complications were reported in lateral meniscal repair. Thus, there does not appear to be a significantly higher incidence of complications for meniscal repair than for arthroscopic partial meniscectomy among this very experienced group of arthroscopic surgeons. The complication rates in the newer and more complicated arthroscopic procedures were observed closely. Specifically regarding ACL procedures, the highest complication rate was seen in ACL reconstruction using synthetic materials. The complication rate for this procedure was 3.7% although only 27 procedures were recorded. The complication rate for allograft ACL reconstructions was 3.3% (five complications, in 151 procedures).
For autogenous ACL reconstructions, the complication rate was 1.7% (eight complications in 469 procedures). No complications were noted in 45 ACL staple repairs. Among shoulder procedures, the anterior staple capsulorrhaphy once again had the highest complications rate (3.3%). Two of the three complications noted for this procedure were staple impingements against the humeral head. The other was a hemarthrosis. In rotator cuff repairs performed arthroscopically, one complication of staple impingment occurred in nine procedures. In two other subacromial space procedures, a reflex sympathetic dystrophy developed in the involved extremity. No complications were noted in 79 elbow procedures and 61 wrist procedures. One case of spontaneous drainage was reported in 10 diagnostic hip arthroscopies. One complication, an infection, occurred in 146 ankle arthroscopies.
TABLE 5. Incidence of complications for specific
DISCUSSION
procedures (in decreasing order of frequency) Complication
Incidence
Lateral retinacular release ACL synthetic reconstruction ACL allograft reconstruction Shoulder staple capsulorrhaphy Arthroscopic synovectomy Abrasion arthroplasty Outside-in meniscal repairs Medial meniscectomy Plica excision ACL autogenous reconstruction Shaving chondroplasty Medial meniscal repair Lateral meniscectomy Anterior acromioplasty Debridement of glenoid labrum tear Lateral meniscal repair
7.17% 3.7% 3.3% 3.3% 3.12% 1.89% 1.89% 1.78% 1.71% 1.71% 1.6% 1.52% 1.48% 1.1%
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O.5% 0
This controlled study confirms the fears that the complication rate in arthroscopy is greater than the incidence previously reported of < 1%. The arthroscopists who participated in this study are some of the most experienced in the country. The average participant in this study has been performing diagnostic knee arthroscopy for 141/2 years and surgical knee arthroscopy for 11 years. Of particular interest in this series was the occurrence of two cases of adult respiratory distress syndrome that were both associated with ACL procedures. Both were manifested by fulminant pulmonary edema and significantly altered blood gases. Both required treatment with a diuretic and sub-
COMPLICATIONS IN ARTHROSCOPIC S U R G E R Y
stantial pulmonary support, but resolved by the following day. This particular complication of arthroscopy and ACL procedures has not been previously reported. No explanation is available at this time as to the exact etiology. In analyzing the voluminous data tabulated, it is apparent that this group of experienced arthroscopic surgeons experienced a complication rate significantly higher than previously found in retrospective surveys. Despite this overall increase, certain major complications such as neurologic and vascular injuries were reported less frequently. This is probably the result of the experience level of the study participants and recent advances in techniques for meniscal repair and ACL procedures. These important protective techniques include accessory posterior incisions for posterior horn tears, deflecting retractors, and proper knee positioning for needle insertions during meniscal repair procedures. In addition, sutures are no longer tied over buttons or bolsters, thus diminishing the incidence of infection in meniscal repair. CONCLUSIONS In conclusion, one can no longer state that the complication rate in arthroscopy is <1%. In this controlled multicenter study with 10,282 procedures recorded, the complication rate was 1.68%. Hemarthrosis was the most frequent complication. The procedure with the highest complication rate (7%) was lateral retinacular release. Among this very experienced group of arthroscopic surgeons, there was a slightly higher complication rate in meniscectomy (1.78%) than in meniscal repair (1.52%). The statistical data and the profiles on each surgeon will be further analyzed to obtain correlations between various arthroscopic techniques and complications.
221
Acknowledgment: The author acknowledges and thanks the participants in the multicenter study. They are, in alphabetical order: Jack Andrish, M.D., Cleveland, OH; Bruce Baker, M.D., Syracuse, NY; John Bergfeld, M.D., Cleveland, OH; Richard Caspari, M.D., Richmond, VA; Kenneth DeHaven, M.D., Rochester, NY; David Drez, Jr., M.D., Lake Charles, LA; Robert Eilert, M.D., Denver, CO; Lanny Johnson, M.D., East Lansing, MI; J. Lee Leonard, M.D., Lafayette, LA; Richard Levitt, M.D., Miami, FL; Ralph Lidge, M.D., Arlington Heights, IL; George Mauerman, M.D., Tulsa, OK; James Mauerman, M.D., Tulsa, OK; James Mulhollan, M.D., Little Rock, AR; Serge Parisien, M.D., New York, NY; Dinesh Patel, M.D., Boston, MA; Neal Small, M.D., Piano, TX; Robert Stone, M.D., Dallas, TX; Robert Vandermeer, M.D., Dallas, TX; Garron Weiker, M.D., Cleveland, OH; Terry Whipple, M.D., F.A.C.S., Richmond, VA; Paul Yerys, M.D., East Meadow, NY. The author also thanks the Arthroscopy Association of North America for funding and Ms. Kim Merholtz for her assistance in coordinating this study and in preparing the manuscript. REFERENCES 1. Mulhollan JS. Symposium: arthroscopic knee surgery. Can Orthop 1982;5:79-112. 2. Fiddian N J, Poirier H. The morbidity of arthroscopy of the knee. J Bone Joint Surg [Br] 1981;63:630. 3. Hershman E, Nisonson B. Arthroscopic meniscectomy: a follow-up report. Am J Sports Med 1983;11:253-7. 4. Gillquist J, Oretorp N. Arthroscopic partial meniscectomy: technique and long term results. Clin Orthop 1982;167:2933. 5. Walker RH, Dillingham M. Thrombophlebitis following arthroscopic surgery of the knee. Conternp Orthop 1983;6:2933. 6. Jackson RW. Current concepts review: arthroscopic surgery. J Bone Joint Surg [Am] 1983;65:416-20. 7. Lindenbaum BL. Complications of knee joint arthroscopy. Clin Orthop 1981;160:158. 8. Rorabeck CH, Kennedy JC. Tourniquet-induced nerve ischemia complicating knee ligament surgery. Am J Sports Med t980;8:98-102. 9. DeLee J. Complications of arthroscopy and arthroscopic surgery: results of a national survey. Arthroscopy 1985; 1:214-20. 10. Small NC. Complications in arthroscopy: the knee and other joints. Arthroscopy 1986;4:253-8. 11. Small NC. Complications in arthroscopy. Presented at the AANA annual meeting, Washington, DC, 25-27 March 1988.
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