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Acute and Subacute Complications of Pediatric and Adolescent Knee Arthroscopy
Acute and Subacute Complications of Pediatric and Adolescent Knee Arthroscopy Ali Ashraf, M.D., T. David Luo, B.S., Christy Christophersen, B.S., Lindsay R. Hunter, B.S., Diane L. Dahm, M.D., and Amy L. McIntosh, M.D.
Purpose: The purposes of this study were to determine the frequency of acute and subacute complications (within 6 months) of arthroscopic knee procedures in patients aged 17 years or younger and to determine associated risk factors. Methods: We identified all patients aged 17 years or younger who underwent arthroscopic knee procedures at our institution from 1997 to 2009. Patient demographic and surgical data were collected from the medical and surgical records, with specific focus on intraoperative and postoperative complications. Results: During the study period, 1,002 knee arthroscopies were reviewed. The overall complication rate was 14.7%. Major complications occurred in 21 surgeries (2.1%) and included the following: septic arthritis (n ¼ 3, 0.3%), wound complication requiring operative revision (n ¼ 9, 0.9%), arthrofibrosis requiring manipulation (n ¼ 4, 0.4%), other unplanned subsequent surgery (n ¼ 4, 0.4%), and death (n ¼ 1, 0.1%). Surgeries with an anesthesia time of 265 minutes or greater (P ¼ .026), operative time of 220 minutes or greater (P ¼ .013), or tourniquet time of 114 minutes or greater (P < .001) and surgeries with 3 or more Current Procedural Terminology codes (P ¼ .003) had a statistically significant increase in risk of major complications. The incidence of minor complications was 12.6%, which included persistent effusion/hemarthrosis requiring arthrocentesis (n ¼ 59, 5.9%) and superficial wound infection (n ¼ 18, 1.8%). Conclusions: Major complications after knee arthroscopy in children and adolescents are rare, but minor complications are more common. If possible, surgeons should avoid prolonged anesthesia, surgery, and tourniquet times. The pediatric patient’s medical and family history should be reviewed to identify important risk factors. Level of Evidence: Level IV, therapeutic case series.
A
rthroscopy has become 1 of the most common orthopaedic procedures performed in both adults and children.1-3 Previous data from a large series showed that only 3.4% of knee arthroscopies were performed in patients aged younger than 16 years.4 As more children participate in competitive athletics at younger ages, knee injuries that require arthroscopic treatment are expected to increase dramatically.5,6 Knee arthroscopy is generally considered a safe procedure.7-11 Reported complication rates in all patients after knee arthroscopy are low, ranging from 0.56% to 8.2% in the existing literature, whereas patient satisfaction rates are high.8,9,12-18
From the Department of Orthopaedic Surgery (A.A., T.D.L., D.L.D., A.L.M.) and College of Medicine (L.R.H.), Mayo Clinic, Rochester; and University of Minnesota Medical School (C.C.), Duluth, Minnesota, U.S.A. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received October 23, 2013; accepted February 19, 2014. Address correspondence to Amy L. McIntosh, M.D., Department of Orthopedic Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905, U.S.A. E-mail: [email protected] Ó 2014 by the Arthroscopy Association of North America 0749-8063/13757/$36.00 http://dx.doi.org/10.1016/j.arthro.2014.02.028
Most of the studies of knee arthroscopy complications have focused primarily on adult patients or included small numbers of pediatric patients in the study cohort.2,8,9 Previous studies involving the pediatric and adolescent populations have focused primarily on diagnostic findings of knee pathology and the indications for treatment, with very limited data on complications or adverse outcomes.4,11,19-22 Identifying risk factors for complications in this population may allow physicians to develop strategies for prevention. The purposes of this study were to determine the incidence of acute and subacute complications (within 6 months) of knee arthroscopy in patients aged 17 years or younger and to identify potential associated risk factors. We hypothesize that the complication rate will be low and that risk factors can be identified to help optimize surgical outcomes.
Methods Patient Selection This study was a retrospective review of arthroscopic knee surgeries performed at our institution between January 1, 1997, and May 31, 2009, in patients aged
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17 years or younger. Institutional review board approval was obtained for all aspects of the study. Patients were excluded if they underwent a primarily open procedure (n ¼ 3), did not provide authorization for research (n ¼ 12), or were lost to follow-up (n ¼ 9) or if the surgery involved the use of a hand arthroscope (n ¼ 1). Patients who did not return to the clinic were assumed to be lost to follow-up and thus were excluded from the study. Arthroscopic surgeries that involved the use of a hand arthroscope were excluded because it was only used in the knee joints of smaller patients for diagnostic purposes when other means of visualization were not possible. Patients’ medical and surgical records were reviewed to gather information on patient demographic data, including height, weight, body mass index (BMI), preoperative medications, and medical conditions, and surgical data, including surgical procedure, type of anesthesia used, dose and strength of intraoperative local anesthetic, and postoperative pain pump use, as well as total length of time for tourniquet use, surgery, and anesthesia. Arthroscopic Procedures With the help of Current Procedural Terminology (CPT) codes, we divided the arthroscopic procedures into 8 groups based on the type of surgery. The groups were as follows: 1. Ligament reconstruction involving the anterior cruciate ligament (ACL), posterior cruciate ligament, collateral ligament, or medial patellofemoral ligament 2. Meniscal surgery including meniscectomy and meniscus repair 3. Combined treatment of ligament and meniscus 4. Chondroplasty 5. Synovectomy and/or lateral release 6. Treatment of osteochondral defect with or without loose body removal 7. Tibial eminence fracture treatment 8. Diagnostic arthroscopy Complications Specific data were gathered from hospital records and outpatient clinic notes to review intraoperative and postoperative complications within 6 months of the arthroscopic knee surgery. Postoperative outcomes were recorded and divided into 2 categories: major complications and minor complications. The grouping of complications was based on previously published methods from knee arthroscopy complication studies.8 The complete list is shown in Table 1. In general, major complications were defined as events that were either life or limb threatening, required additional surgery, or had potentially detrimental effects on the patient’s long-term outcome. Minor complications were
Table 1. Complications in 1,002 Pediatric Knee Arthroscopy Cases Type of Complication Major Septic arthritis requiring irrigation and debridement Wound complication requiring repeat closure Arthrofibrosis requiring manipulation under anesthesia Unplanned revision surgery Death Total No. of major complications Total No. of patients with major complications Minor Hemarthrosis/effusion Superficial wound infection, treated with antibiotics only Minor medical problems Postoperative pain pump complication Failed regional anesthetic Sensory nerve paresthesia Arthrofibrosis without manipulation Intra-articular instrument breakage Total No. of minor complications Total No. of patients with minor complications Any Total No. of complications Total No. of patients
No. of % (Per 1,002 Cases Cases) 3
0.3
9
0.9
4
0.4
4 1 21 21
0.4 0.1 2.1 2.1
59 18
5.9 1.8
17 15 10 5 1 1 126 122
1.7 1.5 1.0 0.5 0.1 0.1 12.6 12.2
147 143
14.7 14.3
defined as events that either were localized to the surgical site, did not require additional surgery, or posed only a temporary problem to the recovery process of the patient. Statistical Analysis Statistical comparison of patient factors and surgery and anesthesia variables with complication rates were conducted by univariate analysis. We used the c2 test and Fisher exact test for categorical data and the Student t test for continuous data. The significance level was set at P < .05. Descriptive statistics were reported as numbers (percentage, mean, range).
Results A search of our institutional registry identified 1,002 arthroscopic knee surgeries in patients aged 17 years or younger during the study period. The patients had a mean age of 15.4 years (range, 4 to 17 years). The overall complication rate was 14.7% in 1,002 procedures. Major complications occurred in 21 surgeries (2.1%). The most common major complication was a wound complication that required a return to the operating room (0.9%). Two patients (0.2%) had concomitant medical complications, both of which required readmission to the hospital: 1 had disseminated intravascular coagulation (DIC) and 1 had new-onset atrial fibrillation. The patient with DIC had underlying Klippel-Trénaunay syndrome
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COMPLICATIONS OF PEDIATRIC KNEE ARTHROSCOPY
that prolonged the postoperative course, although the patient eventually went on to have a full recovery. The patient with atrial fibrillation had septic arthritis after arthroscopic ACL reconstruction that required irrigation, debridement, and removal of the ligament graft. There were no incidences of deep vein thrombosis (DVT), pulmonary emboli, lower-extremity neurologic injuries, or vascular injuries. No patients had compartment syndrome or complex regional pain syndrome develop. There was 1 death (0.1%), in a previously healthy 16-year-old boy, that occurred due to previously undiagnosed dilated cardiomyopathy resulting in left middle cerebral artery infarct 3 days after ACL reconstruction. The incidence of minor complications was 12.6% (126 complications in 122 surgeries). The 2 most common minor complications were persistent effusion/ hemarthrosis that required arthrocentesis (n ¼ 59, 5.9%) and superficial wound infection treated with antibiotics (n ¼ 18, 1.8%) (Table 1). There was no significant difference in the incidence of overall complication rates, major complications, or minor complications among the surgery types (P ¼ .134, P ¼ .499, and P ¼ .114, respectively). The procedure with the highest incidence of overall complications was combined ligament and meniscus repair (8.8%). For major complications, the highest incidence occurred in tibial eminence fracture repairs (5.3%). For minor complications, the highest incidence occurred in ligament reconstructions (15.5%) (Table 2). In our series, there were 548 male patients (54.7%) and 454 female patients (45.3%). BMI data were available for 965 patients, of whom 666 (69%) had a BMI less than 25 kg/m2 and 299 (31%) had a BMI greater than or equal to 25 kg/m2 at the time of surgery. There was no significant difference between patient sex and BMI and the incidence of major complications (P ¼ .376 and P ¼ .119, respectively) or the incidence of minor complications (P ¼ .846 and P ¼ .398, respectively). Anesthesia data were available for 998 surgeries. Of those, 668 (66.9%) were performed with patients under general anesthesia, 107 (10.7%) with patients under spinal anesthesia, 89 (8.9%) with an epidural, and 134 (13.4%) with regional anesthesia.
Table 3. Anesthesia, Surgery, and Tourniquet Times and Number of CPT Codes Patient Group Anesthesia time 265 min <265 min Surgery time 220 min <220 min Tourniquet time 114 min <114 min No. of CPT codes 3 <3
Major Complication Rate [No. (%)]
Odds Ratio 3.556
P Value .026
5 of 84 (5.95) 16 of 915 (1.75) 3.766
.013
8.561
<.001
4.609
.003
6 of 100 (6) 15 of 900 (1.67) 7 of 94 (7.45) 5 of 537 (0.93) 7 of 103 (6.80) 14 of 899 (1.56)
Regional anesthesia had the highest rate of major complications, at 5.2%, but there were otherwise no significant differences among the types of anesthesia in relation to the rate of major (P ¼ .101) or minor (P ¼ .984) complications. The surgery records showed a mean operative time of 133.8 minutes (range, 14 to 520 minutes) for 1,000 surgeries. The mean anesthesia time was 173.9 minutes (range, 20 to 547 minutes) for 999 surgeries. A tourniquet was used in 643 surgeries (64.2%), with a mean tourniquet time of 78.4 minutes (range, 11 to 264 minutes). There were 899 procedures (89.7%) with fewer than 3 CPT codes, whereas 103 procedures (10.3%) had 3 or more codes, with a maximum of 6 codes. Statistical analysis identified that an anesthesia time of 265 minutes or greater (P ¼ .026), operative time of 220 minutes or greater (P ¼ .013), or tourniquet time of 114 minutes or greater (P < .001) and surgeries with 3 or more CPT codes (P ¼ .003) had a statistically significant increase in risk of major complications (Table 3).
Discussion In our series the overall complication rate (14.7%) was higher than the reported values from previous studies in the general patient population. Early large-scale retrospective studies by the Arthroscopy Association of North
Table 2. Types of Arthroscopic Knee Surgery and Incidences of Complications Surgery Type Ligament reconstruction Meniscus surgery Combined ligament and meniscus surgery Chondroplasty Synovectomy and/or lateral release Osteochondral defect treatment with or without loose body removal Diagnostic arthroscopy Tibial eminence fracture treatment
No. (%) (out of 1,002) 291 (29) 208 (20.8) 222 (22.2) 63 (6.3) 53 (5.3) 103 (10.3)
Major Complications [No. (%)] 5 (1.7) 2 (1.0) 8 (3.6) 1 (1.6) 2 (3.8) 1 (1.0)
Minor Complications [No. (%)] 45 (15.5) 24 (11.5) 31 (14.0) 8 (12.7) 4 (7.6) 6 (5.8)
Overall Complications [No. (%)] 50 (17.2) 26 (12.5) 39 (17.6) 9 (14.3) 6 (11.3) 7 (6.8)
43 (4.3) 19 (1.9)
1 (2.3) 1 (5.3)
4 (9.3) 0 (0.0)
5 (11.6) 1 (5.3)
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America showed overall rates of 0.56% and 0.8%.16,17 More recently, a population-based study in Australia by Bohensky et al.23 showed that the frequency of adverse outcomes after knee arthroscopy in patients aged older than 20 years was 0.64%. In choosing the complications we reviewed, we followed the study method of Sherman et al.8 by designating major complications as those events that may be life or limb threatening or have detrimental effects on the patient’s long-term outcome. Most of the reported complications in our study were designated as minor complications (events localized to the surgical site), which we deemed to only pose a temporary problem to the recovery process of the patient. Many of these complications were not included by authors of other studies (pain pump complication, failed regional anesthetic), but we viewed them as potentially contributing to the patient’s overall outcome and satisfaction.9,23 This information can also be helpful when obtaining consent and educating young patients and their families on the risks of knee arthroscopy. It should be noted that the complication rate in the general population reported by Sherman et al. (8.2%) was more consistent with our findings. If we focus only on major complications, the complication rate of 2.1% in our study is consistent with rates reported in adult patients,8,9,12-18 which confirms our hypothesis. Few previous studies have quantified variables, such as operative time, that may be under the surgeon’s control. Our findings with respect to prolonged anesthesia, surgery, and tourniquet times (265 minutes, 220 minutes, and 114 minutes, respectively) showed a significant increase in the frequency of major complications and may reflect the complexity of the surgery. It was necessary to report these times separately because a tourniquet was not used in approximately one-third of the procedures. This is consistent with results in adults reported by Sherman et al.,8 showing that patients with a tourniquet time greater than 60 minutes, regardless of age, had a predicted complication rate of 28.6%. Conversely, patients aged younger than 30 years with a tourniquet time under 40 minutes had a predicted complication rate of 3.2%. Kieser24 reported that tourniquet use could cause sciatic nerve ischemia and transient lower-extremity neurologic damage, although this was not seen in our series. The complexity of a surgery may be further shown by the number of CPT codes, given that our findings suggest that surgeries with 3 or more CPT codes had a significantly higher complication rate than those with fewer than 3 codes. Patient factors, such as sex and BMI, did not significantly affect the overall morbidity and mortality rates. To our knowledge, no such comparisons in children have been made in previous studies. Harrison et al.13 reviewed subjective patientcentered outcomes of knee arthroscopy in women aged between 30 and 55 years and concluded that the obese
group (BMI 27 kg/m2) had significantly poorer outcomes than the normal-weight group (BMI <27 kg/m2). In addition to surgical complications, we reported 3 adverse events (0.3%) from medical complications: Two required readmission and subsequently recovered, including DIC in a patient with Klippel-Trénaunay syndrome and a case of atrial fibrillation in association with septic arthritis. One patient died due to acute left middle cerebral artery infarct in the setting of previously undiagnosed dilated cardiomyopathy 3 days after surgery. The patient was a previously healthy 16-yearold boy with a benign medical history and negative family history for dilated cardiomyopathy, a hypercoagulable state, or any other cardiac manifestations. In this setting of an otherwise healthy pediatric patient, an extensive preoperative workup was not performed. Careful attention must be given to the medical history and family history in pediatric patients regarding any underlying medical conditions that may increase the risk of adverse outcomes after knee arthroscopy. Surgeons must also take caution to identify congenital or syndromic factors that may predispose the pediatric patient to medical complications. Studies in adults have shown similarly low rates of medical complications after knee arthroscopy. Bohensky et al.23 reported rates lower than 0.02% for acute renal failure, myocardial infarction, and stroke within 30 days of surgery. Jameson et al.7 reported low rates of renal failure (0.01%), respiratory infection (0.02%), and DVT (0.12%). Martin et al.9 similarly reported a low incidence of DVT (0.46%). Many of these comorbidities and risk factors may be age related and therefore may not be typically encountered in otherwise healthy pediatric patients. Limitations Our data are limited by the retrospective nature of the study, which relies on the accuracy and completeness of chart documentation. Thus there may be certain minor complications that were under-reported in our data. In addition, because our study was performed at a tertiary referral center, the complexity of patients and procedures may be somewhat higher than what might be seen in a community practice, and thus the numbers (procedure types and complication rates) might not be entirely generalizable. Anesthesia and surgical times may also be expected to be different at an academic center heavily focused on the training of residents and fellows. Unfortunately, data on the proportion of each surgery performed by residents or fellows are not readily available in our surgical database. We focused primarily on shortterm complications because nearly all patients return to knee-related activity within 6 months.2 Long-term follow-up to measure knee motion, pain, and patientcentered outcomes may be helpful to further quantify the impact of knee arthroscopy complications in children.
COMPLICATIONS OF PEDIATRIC KNEE ARTHROSCOPY
Conclusions Major complications after knee arthroscopy in children and adolescents are rare, but minor complications are more common. If possible, surgeons should avoid prolonged anesthesia, surgery, and tourniquet times. The pediatric patient’s medical and family history should be reviewed to identify important risk factors.
References 1. Tait GR, Maginn P, Macey AC, Beverland DE, Mollan RA. Unnecessary arthroscopies. Injury 1992;23:555-556. 2. Lubowitz JH, Ayala M, Appleby D. Return to activity after knee arthroscopy. Arthroscopy 2008;24:58-61.e4. 3. Kim S, Bosque J, Meehan JP, Jamali A, Marder R. Increase in outpatient knee arthroscopy in the United States: A comparison of National Surveys of Ambulatory Surgery, 1996 and 2006. J Bone Joint Surg Am 2011;93: 994-1000. 4. Bergstrom R, Gillquist J, Lysholm J, Hamberg P. Arthroscopy of the knee in children. J Pediatr Orthop 1984;4:542-545. 5. Cook PC, Leit ME. Issues in the pediatric athlete. Orthop Clin North Am 1995;26:453-464. 6. Kraus T, Heidari N, Svehlik M, Schneider F, Sperl M, Linhart W. Outcome of repaired unstable meniscal tears in children and adolescents. Acta Orthop 2012;83: 261-266. 7. Jameson SS, Dowen D, James P, Serrano-Pedraza I, Reed MR, Deehan DJ. The burden of arthroscopy of the knee: A contemporary analysis of data from the English NHS. J Bone Joint Surg Br 2011;93:1327-1333. 8. Sherman OH, Fox JM, Snyder SJ, et al. Arthroscopyd “No-problem surgery.” An analysis of complications in two thousand six hundred and forty cases. J Bone Joint Surg Am 1986;68:256-265. 9. Martin CT, Pugely AJ, Gao Y, Wolf BR. Risk factors for thirty-day morbidity and mortality following knee arthroscopy: A review of 12,271 patients from the national surgical quality improvement program database. J Bone Joint Surg Am 2013;95:e98:1-10. 10. Allum R. Complications of arthroscopy of the knee. J Bone Joint Surg Br 2002;84:937-945.
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11. Angel KR, Hall DJ. The role of arthroscopy in children and adolescents. Arthroscopy 1989;5:192-196. 12. Cardosa M, Rudkin GE, Osborne GA. Outcome from daycase knee arthroscopy in a major teaching hospital. Arthroscopy 1994;10:624-629. 13. Harrison MM, Morrell J, Hopman WM. Influence of obesity on outcome after knee arthroscopy. Arthroscopy 2004;20:691-695. 14. Schippinger G, Wirnsberger GH, Obernosterer A, Babinski K. Thromboembolic complications after arthroscopic knee surgery. Incidence and risk factors in 101 patients. Acta Orthop Scand 1998;69:144-146. 15. Lamo-Espinosa JM, Llombart Blanco R, Valenti JR. Inferior lateral genicular artery injury during anterior cruciate ligament reconstruction surgery. Case Rep Surg 2012;2012: 457198. 16. DeLee J. Complications of arthroscopy and arthroscopic surgery: Results of a national survey. Committee on Complications of Arthroscopy Association of North America. Arthroscopy 1985;1:214-220. 17. Small NC. Complications in arthroscopy: The knee and other joints. Committee on Complications of the Arthroscopy Association of North America. Arthroscopy 1986;2:253-258. 18. Small NC. Complications in arthroscopic surgery performed by experienced arthroscopists. Arthroscopy 1988;4: 215-221. 19. Maffulli N, Chan KM, Bundoc RC, Cheng JC. Knee arthroscopy in Chinese children and adolescents: An eight-year prospective study. Arthroscopy 1997;13:18-23. 20. Morrissy RT, Eubanks RG, Park JP, Thompson SB Jr. Arthroscopy of the knee in children. Clin Orthop Relat Res 1982;162:103-107. 21. Saciri V, Pavlovcic V, Zupanc O, Baebler B. Knee arthroscopy in children and adolescents. J Pediatr Orthop B 2001;10:311-314. 22. Ziv I, Carroll NC. The role of arthroscopy in children. J Pediatr Orthop 1982;2:243-247. 23. Bohensky MA, Desteiger R, Kondogiannis C, et al. Adverse outcomes associated with elective knee arthroscopy: A population-based cohort study. Arthroscopy 2013;29: 716-725. 24. Kieser C. A review of the complications of arthroscopic knee surgery. Arthroscopy 1992;8:79-83.
Purpose: The purposes of this study were to determine the frequency of acute and subacute complications (within 6 months) of arthroscopic knee procedures in patients aged 17 years or younger and to determine associated risk factors. Methods: We identified all patients aged 17 years or younger who underwent arthroscopic knee procedures at our institution from 1997 to 2009. Patient demographic and surgical data were collected from the medical and surgical records, with specific focus on intraoperative and postoperative complications. Results: During the study period, 1,002 knee arthroscopies were reviewed. The overall complication rate was 14.7%. Major complications occurred in 21 surgeries (2.1%) and included the following: septic arthritis (n ¼ 3, 0.3%), wound complication requiring operative revision (n ¼ 9, 0.9%), arthrofibrosis requiring manipulation (n ¼ 4, 0.4%), other unplanned subsequent surgery (n ¼ 4, 0.4%), and death (n ¼ 1, 0.1%). Surgeries with an anesthesia time of 265 minutes or greater (P ¼ .026), operative time of 220 minutes or greater (P ¼ .013), or tourniquet time of 114 minutes or greater (P < .001) and surgeries with 3 or more Current Procedural Terminology codes (P ¼ .003) had a statistically significant increase in risk of major complications. The incidence of minor complications was 12.6%, which included persistent effusion/hemarthrosis requiring arthrocentesis (n ¼ 59, 5.9%) and superficial wound infection (n ¼ 18, 1.8%). Conclusions: Major complications after knee arthroscopy in children and adolescents are rare, but minor complications are more common. If possible, surgeons should avoid prolonged anesthesia, surgery, and tourniquet times. The pediatric patient’s medical and family history should be reviewed to identify important risk factors. Level of Evidence: Level IV, therapeutic case series.
A
rthroscopy has become 1 of the most common orthopaedic procedures performed in both adults and children.1-3 Previous data from a large series showed that only 3.4% of knee arthroscopies were performed in patients aged younger than 16 years.4 As more children participate in competitive athletics at younger ages, knee injuries that require arthroscopic treatment are expected to increase dramatically.5,6 Knee arthroscopy is generally considered a safe procedure.7-11 Reported complication rates in all patients after knee arthroscopy are low, ranging from 0.56% to 8.2% in the existing literature, whereas patient satisfaction rates are high.8,9,12-18
From the Department of Orthopaedic Surgery (A.A., T.D.L., D.L.D., A.L.M.) and College of Medicine (L.R.H.), Mayo Clinic, Rochester; and University of Minnesota Medical School (C.C.), Duluth, Minnesota, U.S.A. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received October 23, 2013; accepted February 19, 2014. Address correspondence to Amy L. McIntosh, M.D., Department of Orthopedic Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905, U.S.A. E-mail: [email protected] Ó 2014 by the Arthroscopy Association of North America 0749-8063/13757/$36.00 http://dx.doi.org/10.1016/j.arthro.2014.02.028
Most of the studies of knee arthroscopy complications have focused primarily on adult patients or included small numbers of pediatric patients in the study cohort.2,8,9 Previous studies involving the pediatric and adolescent populations have focused primarily on diagnostic findings of knee pathology and the indications for treatment, with very limited data on complications or adverse outcomes.4,11,19-22 Identifying risk factors for complications in this population may allow physicians to develop strategies for prevention. The purposes of this study were to determine the incidence of acute and subacute complications (within 6 months) of knee arthroscopy in patients aged 17 years or younger and to identify potential associated risk factors. We hypothesize that the complication rate will be low and that risk factors can be identified to help optimize surgical outcomes.
Methods Patient Selection This study was a retrospective review of arthroscopic knee surgeries performed at our institution between January 1, 1997, and May 31, 2009, in patients aged
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17 years or younger. Institutional review board approval was obtained for all aspects of the study. Patients were excluded if they underwent a primarily open procedure (n ¼ 3), did not provide authorization for research (n ¼ 12), or were lost to follow-up (n ¼ 9) or if the surgery involved the use of a hand arthroscope (n ¼ 1). Patients who did not return to the clinic were assumed to be lost to follow-up and thus were excluded from the study. Arthroscopic surgeries that involved the use of a hand arthroscope were excluded because it was only used in the knee joints of smaller patients for diagnostic purposes when other means of visualization were not possible. Patients’ medical and surgical records were reviewed to gather information on patient demographic data, including height, weight, body mass index (BMI), preoperative medications, and medical conditions, and surgical data, including surgical procedure, type of anesthesia used, dose and strength of intraoperative local anesthetic, and postoperative pain pump use, as well as total length of time for tourniquet use, surgery, and anesthesia. Arthroscopic Procedures With the help of Current Procedural Terminology (CPT) codes, we divided the arthroscopic procedures into 8 groups based on the type of surgery. The groups were as follows: 1. Ligament reconstruction involving the anterior cruciate ligament (ACL), posterior cruciate ligament, collateral ligament, or medial patellofemoral ligament 2. Meniscal surgery including meniscectomy and meniscus repair 3. Combined treatment of ligament and meniscus 4. Chondroplasty 5. Synovectomy and/or lateral release 6. Treatment of osteochondral defect with or without loose body removal 7. Tibial eminence fracture treatment 8. Diagnostic arthroscopy Complications Specific data were gathered from hospital records and outpatient clinic notes to review intraoperative and postoperative complications within 6 months of the arthroscopic knee surgery. Postoperative outcomes were recorded and divided into 2 categories: major complications and minor complications. The grouping of complications was based on previously published methods from knee arthroscopy complication studies.8 The complete list is shown in Table 1. In general, major complications were defined as events that were either life or limb threatening, required additional surgery, or had potentially detrimental effects on the patient’s long-term outcome. Minor complications were
Table 1. Complications in 1,002 Pediatric Knee Arthroscopy Cases Type of Complication Major Septic arthritis requiring irrigation and debridement Wound complication requiring repeat closure Arthrofibrosis requiring manipulation under anesthesia Unplanned revision surgery Death Total No. of major complications Total No. of patients with major complications Minor Hemarthrosis/effusion Superficial wound infection, treated with antibiotics only Minor medical problems Postoperative pain pump complication Failed regional anesthetic Sensory nerve paresthesia Arthrofibrosis without manipulation Intra-articular instrument breakage Total No. of minor complications Total No. of patients with minor complications Any Total No. of complications Total No. of patients
No. of % (Per 1,002 Cases Cases) 3
0.3
9
0.9
4
0.4
4 1 21 21
0.4 0.1 2.1 2.1
59 18
5.9 1.8
17 15 10 5 1 1 126 122
1.7 1.5 1.0 0.5 0.1 0.1 12.6 12.2
147 143
14.7 14.3
defined as events that either were localized to the surgical site, did not require additional surgery, or posed only a temporary problem to the recovery process of the patient. Statistical Analysis Statistical comparison of patient factors and surgery and anesthesia variables with complication rates were conducted by univariate analysis. We used the c2 test and Fisher exact test for categorical data and the Student t test for continuous data. The significance level was set at P < .05. Descriptive statistics were reported as numbers (percentage, mean, range).
Results A search of our institutional registry identified 1,002 arthroscopic knee surgeries in patients aged 17 years or younger during the study period. The patients had a mean age of 15.4 years (range, 4 to 17 years). The overall complication rate was 14.7% in 1,002 procedures. Major complications occurred in 21 surgeries (2.1%). The most common major complication was a wound complication that required a return to the operating room (0.9%). Two patients (0.2%) had concomitant medical complications, both of which required readmission to the hospital: 1 had disseminated intravascular coagulation (DIC) and 1 had new-onset atrial fibrillation. The patient with DIC had underlying Klippel-Trénaunay syndrome
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COMPLICATIONS OF PEDIATRIC KNEE ARTHROSCOPY
that prolonged the postoperative course, although the patient eventually went on to have a full recovery. The patient with atrial fibrillation had septic arthritis after arthroscopic ACL reconstruction that required irrigation, debridement, and removal of the ligament graft. There were no incidences of deep vein thrombosis (DVT), pulmonary emboli, lower-extremity neurologic injuries, or vascular injuries. No patients had compartment syndrome or complex regional pain syndrome develop. There was 1 death (0.1%), in a previously healthy 16-year-old boy, that occurred due to previously undiagnosed dilated cardiomyopathy resulting in left middle cerebral artery infarct 3 days after ACL reconstruction. The incidence of minor complications was 12.6% (126 complications in 122 surgeries). The 2 most common minor complications were persistent effusion/ hemarthrosis that required arthrocentesis (n ¼ 59, 5.9%) and superficial wound infection treated with antibiotics (n ¼ 18, 1.8%) (Table 1). There was no significant difference in the incidence of overall complication rates, major complications, or minor complications among the surgery types (P ¼ .134, P ¼ .499, and P ¼ .114, respectively). The procedure with the highest incidence of overall complications was combined ligament and meniscus repair (8.8%). For major complications, the highest incidence occurred in tibial eminence fracture repairs (5.3%). For minor complications, the highest incidence occurred in ligament reconstructions (15.5%) (Table 2). In our series, there were 548 male patients (54.7%) and 454 female patients (45.3%). BMI data were available for 965 patients, of whom 666 (69%) had a BMI less than 25 kg/m2 and 299 (31%) had a BMI greater than or equal to 25 kg/m2 at the time of surgery. There was no significant difference between patient sex and BMI and the incidence of major complications (P ¼ .376 and P ¼ .119, respectively) or the incidence of minor complications (P ¼ .846 and P ¼ .398, respectively). Anesthesia data were available for 998 surgeries. Of those, 668 (66.9%) were performed with patients under general anesthesia, 107 (10.7%) with patients under spinal anesthesia, 89 (8.9%) with an epidural, and 134 (13.4%) with regional anesthesia.
Table 3. Anesthesia, Surgery, and Tourniquet Times and Number of CPT Codes Patient Group Anesthesia time 265 min <265 min Surgery time 220 min <220 min Tourniquet time 114 min <114 min No. of CPT codes 3 <3
Major Complication Rate [No. (%)]
Odds Ratio 3.556
P Value .026
5 of 84 (5.95) 16 of 915 (1.75) 3.766
.013
8.561
<.001
4.609
.003
6 of 100 (6) 15 of 900 (1.67) 7 of 94 (7.45) 5 of 537 (0.93) 7 of 103 (6.80) 14 of 899 (1.56)
Regional anesthesia had the highest rate of major complications, at 5.2%, but there were otherwise no significant differences among the types of anesthesia in relation to the rate of major (P ¼ .101) or minor (P ¼ .984) complications. The surgery records showed a mean operative time of 133.8 minutes (range, 14 to 520 minutes) for 1,000 surgeries. The mean anesthesia time was 173.9 minutes (range, 20 to 547 minutes) for 999 surgeries. A tourniquet was used in 643 surgeries (64.2%), with a mean tourniquet time of 78.4 minutes (range, 11 to 264 minutes). There were 899 procedures (89.7%) with fewer than 3 CPT codes, whereas 103 procedures (10.3%) had 3 or more codes, with a maximum of 6 codes. Statistical analysis identified that an anesthesia time of 265 minutes or greater (P ¼ .026), operative time of 220 minutes or greater (P ¼ .013), or tourniquet time of 114 minutes or greater (P < .001) and surgeries with 3 or more CPT codes (P ¼ .003) had a statistically significant increase in risk of major complications (Table 3).
Discussion In our series the overall complication rate (14.7%) was higher than the reported values from previous studies in the general patient population. Early large-scale retrospective studies by the Arthroscopy Association of North
Table 2. Types of Arthroscopic Knee Surgery and Incidences of Complications Surgery Type Ligament reconstruction Meniscus surgery Combined ligament and meniscus surgery Chondroplasty Synovectomy and/or lateral release Osteochondral defect treatment with or without loose body removal Diagnostic arthroscopy Tibial eminence fracture treatment
No. (%) (out of 1,002) 291 (29) 208 (20.8) 222 (22.2) 63 (6.3) 53 (5.3) 103 (10.3)
Major Complications [No. (%)] 5 (1.7) 2 (1.0) 8 (3.6) 1 (1.6) 2 (3.8) 1 (1.0)
Minor Complications [No. (%)] 45 (15.5) 24 (11.5) 31 (14.0) 8 (12.7) 4 (7.6) 6 (5.8)
Overall Complications [No. (%)] 50 (17.2) 26 (12.5) 39 (17.6) 9 (14.3) 6 (11.3) 7 (6.8)
43 (4.3) 19 (1.9)
1 (2.3) 1 (5.3)
4 (9.3) 0 (0.0)
5 (11.6) 1 (5.3)
4
A. ASHRAF ET AL.
America showed overall rates of 0.56% and 0.8%.16,17 More recently, a population-based study in Australia by Bohensky et al.23 showed that the frequency of adverse outcomes after knee arthroscopy in patients aged older than 20 years was 0.64%. In choosing the complications we reviewed, we followed the study method of Sherman et al.8 by designating major complications as those events that may be life or limb threatening or have detrimental effects on the patient’s long-term outcome. Most of the reported complications in our study were designated as minor complications (events localized to the surgical site), which we deemed to only pose a temporary problem to the recovery process of the patient. Many of these complications were not included by authors of other studies (pain pump complication, failed regional anesthetic), but we viewed them as potentially contributing to the patient’s overall outcome and satisfaction.9,23 This information can also be helpful when obtaining consent and educating young patients and their families on the risks of knee arthroscopy. It should be noted that the complication rate in the general population reported by Sherman et al. (8.2%) was more consistent with our findings. If we focus only on major complications, the complication rate of 2.1% in our study is consistent with rates reported in adult patients,8,9,12-18 which confirms our hypothesis. Few previous studies have quantified variables, such as operative time, that may be under the surgeon’s control. Our findings with respect to prolonged anesthesia, surgery, and tourniquet times (265 minutes, 220 minutes, and 114 minutes, respectively) showed a significant increase in the frequency of major complications and may reflect the complexity of the surgery. It was necessary to report these times separately because a tourniquet was not used in approximately one-third of the procedures. This is consistent with results in adults reported by Sherman et al.,8 showing that patients with a tourniquet time greater than 60 minutes, regardless of age, had a predicted complication rate of 28.6%. Conversely, patients aged younger than 30 years with a tourniquet time under 40 minutes had a predicted complication rate of 3.2%. Kieser24 reported that tourniquet use could cause sciatic nerve ischemia and transient lower-extremity neurologic damage, although this was not seen in our series. The complexity of a surgery may be further shown by the number of CPT codes, given that our findings suggest that surgeries with 3 or more CPT codes had a significantly higher complication rate than those with fewer than 3 codes. Patient factors, such as sex and BMI, did not significantly affect the overall morbidity and mortality rates. To our knowledge, no such comparisons in children have been made in previous studies. Harrison et al.13 reviewed subjective patientcentered outcomes of knee arthroscopy in women aged between 30 and 55 years and concluded that the obese
group (BMI 27 kg/m2) had significantly poorer outcomes than the normal-weight group (BMI <27 kg/m2). In addition to surgical complications, we reported 3 adverse events (0.3%) from medical complications: Two required readmission and subsequently recovered, including DIC in a patient with Klippel-Trénaunay syndrome and a case of atrial fibrillation in association with septic arthritis. One patient died due to acute left middle cerebral artery infarct in the setting of previously undiagnosed dilated cardiomyopathy 3 days after surgery. The patient was a previously healthy 16-yearold boy with a benign medical history and negative family history for dilated cardiomyopathy, a hypercoagulable state, or any other cardiac manifestations. In this setting of an otherwise healthy pediatric patient, an extensive preoperative workup was not performed. Careful attention must be given to the medical history and family history in pediatric patients regarding any underlying medical conditions that may increase the risk of adverse outcomes after knee arthroscopy. Surgeons must also take caution to identify congenital or syndromic factors that may predispose the pediatric patient to medical complications. Studies in adults have shown similarly low rates of medical complications after knee arthroscopy. Bohensky et al.23 reported rates lower than 0.02% for acute renal failure, myocardial infarction, and stroke within 30 days of surgery. Jameson et al.7 reported low rates of renal failure (0.01%), respiratory infection (0.02%), and DVT (0.12%). Martin et al.9 similarly reported a low incidence of DVT (0.46%). Many of these comorbidities and risk factors may be age related and therefore may not be typically encountered in otherwise healthy pediatric patients. Limitations Our data are limited by the retrospective nature of the study, which relies on the accuracy and completeness of chart documentation. Thus there may be certain minor complications that were under-reported in our data. In addition, because our study was performed at a tertiary referral center, the complexity of patients and procedures may be somewhat higher than what might be seen in a community practice, and thus the numbers (procedure types and complication rates) might not be entirely generalizable. Anesthesia and surgical times may also be expected to be different at an academic center heavily focused on the training of residents and fellows. Unfortunately, data on the proportion of each surgery performed by residents or fellows are not readily available in our surgical database. We focused primarily on shortterm complications because nearly all patients return to knee-related activity within 6 months.2 Long-term follow-up to measure knee motion, pain, and patientcentered outcomes may be helpful to further quantify the impact of knee arthroscopy complications in children.
COMPLICATIONS OF PEDIATRIC KNEE ARTHROSCOPY
Conclusions Major complications after knee arthroscopy in children and adolescents are rare, but minor complications are more common. If possible, surgeons should avoid prolonged anesthesia, surgery, and tourniquet times. The pediatric patient’s medical and family history should be reviewed to identify important risk factors.
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