Pain and complications of knee arthroscopy: causes, symptoms and treatment

Among all orthopedic surgeries, arthroscopy is considered the least invasive. However, its implementation is associated with certain risks. According to statistics, arthroscopic interventions are accompanied by the development of complications in 0.6-1.7% of cases. The likelihood of undesirable consequences directly depends on the complexity of the operation. They occur most rarely during diagnostic arthroscopy, and most often during incomplete medial meniscectomy.

Soon after the operation.

Curious! The risk of complications does not depend on the experience of the surgeon or the gender of the patient. However, the age of the patient plays a certain role. It is known that in people over 50 years of age, undesirable consequences occur much more often than in younger people.

Table 1. Incidence of various complications of arthroscopy.

Fact! In terms of the development of complications, operations on the meniscus, synovium, and anterior and posterior cruciate ligaments are considered the most dangerous. During these surgical interventions, patients most often experience hemarthrosis, infectious and thrombotic complications.

Ligament damage

To gain access to the medial meniscus, surgeons artificially widen the joint space before arthroscopy. To do this, they use special leg holders and power traction. Carrying out such manipulations can lead to damage to the ligaments of the knee joint (0.04% of all arthroscopy). Note that most patients suffer from the medial collateral ligament, which is located on the inside of the knee.

Meniscus suturing.

Mild sprains or tears of the ligaments cause knee pain and may be accompanied by ligamentitis. Painkillers (Diclofenac, Ibuprofen) and temporary immobilization of the knee help get rid of unpleasant symptoms.

Massage after a knee fracture

Massage after a knee fracture
Massage is done for the following purposes:

• prevention of hip muscle atrophy during the period of immobilization;
• strengthening regenerative processes;
• reducing pain and eliminating swelling.

If a plaster splint is applied, massage begins on the third or fourth day. It helps to quickly get rid of hematoma and swelling. After removing the plaster, a gentle massage of the knee is indicated. The main attention should be paid to the quadriceps femoris, as it is most susceptible to atrophic changes.

Ischemia of the muscles of the lower limb

To prevent bleeding during arthroscopy, doctors apply a tourniquet to the patient's leg. Unfortunately, long-term exposure can cause temporary paralysis of the lower limb. The pathology is characterized by a short-term impairment of muscle contractility and motor functions of the leg.

The leg is bandaged.

Table 2. The risk of developing paresis depending on the age of the patients and the time of application of the tourniquet.

Thus, the likelihood of temporary paresis is much higher among older people. Those patients who have undergone complex long-term operations are also at greater risk. Undesirable complications can be avoided by reducing the time of application of the tourniquet.

Fact! Temporary paresis is usually harmless and responds well to treatment. To combat them, physical therapy, massage and physiotherapeutic procedures are used.

Compartment syndrome

Occurs due to leakage of irrigation fluid in the presence of a defect in the joint capsule. The development of pathology is facilitated by an increase in irrigation pressure and blockage of drainage. Compartment syndrome is accompanied by soft tissue swelling and a sharp increase in intrafascial pressure. As a rule, it leads to necrosis of muscle tissue and the appearance of contractures in the postoperative period.

Compartment syndrome is treated conservatively. Patients are prescribed analgesics (Tramadol, Ketorolac), decongestants (Furosemide) and anti-ischemic drugs. They are also administered drugs that improve the rheological properties of the blood and relieve vascular spasm. If conservative therapy is ineffective, patients undergo surgery - decompressive fasciotomy.

Arthroscopy

Registration for arthroscopic surgery is made only after visiting a traumatologist and undergoing an appropriate examination. At the SportClinic, the doctor usually prescribes an MRI; computed tomography or x-rays may be added. Only after the final collection of data and thorough consultation is the issue of surgical treatment decided.

Arthroscopy for arthrosis is carried out in the following order:

• After anesthesia, the doctor makes two small skin incisions to insert an arthroscope and other necessary instruments into the joint cavity. The image from the arthroscope camera is transmitted to the monitor.
• After which it inspects the cavity, removes damaged tissue and polishes irregularities on the surface of the articular cartilage.
• If osteophytes are present, they are eliminated.
• Deformed areas of the synovial membrane are removed (synovectomy).
• At the end of the surgical procedures, the intra-articular cavity is sanitized.

The effectiveness of the arthroscopic method for arthrosis is achieved due to the ability to determine the degree of deformation within one intervention and immediately carry out the necessary manipulations. Another obvious advantage is the fast and relatively easy postoperative recovery period. Of course, with strict adherence to all recommendations of the attending physician and rehabilitator.

Damage to intra-articular structures

During arthroscopic surgery, the surgeon can damage any structure of the knee joint. Most often this occurs when a sharp trocar is used, insufficient expansion of the joint space, poor visibility, or the doctor attempts to perform “blind” manipulations.

During arthroscopy the following may be affected:

• menisci;
• articular cartilage;
• cruciate ligaments;
• joint capsule.

Damage to intrasynovial structures is very dangerous and can have serious consequences. It can provoke leakage of irrigation fluid, deformation of the menisci or intra-articular ligaments, the development of deforming osteoarthritis in the postoperative period, etc. Naturally, in the future all this will lead to impairment of the functions of the knee joint.

If the surgeon notices an injury to the ligaments, menisci or joint capsule in time, he can immediately eliminate it. Unfortunately, this is not always possible.

Causes of arthrosis

Deforming osteoarthritis is very common among older people, as well as among those who devote their lives to sports. Most often, the disease appears after an injury (especially if there is no treatment after it).

In addition, the following factors influence the occurrence of arthrosis:

• Age from 50 years.
• Overweight.
• Frequent loads on the lower limbs.
• Intensive workouts in the gym (working with heavy weights).
• Old injuries.
• Joint diseases (rheumatism, gout, arthritis).
• Genetic predisposition.
• Joint instability.
• Various metabolic disorders.
• Alcohol abuse, smoking, systematic use of drugs, potent medications.

Doctors note that one of the main reasons for the increasing number of cases of the disease is associated, oddly enough, with the increase in life expectancy of the population. Most likely, in the future this problem will become even more pressing than it is today.

Tool failure

In recent years, it has become less common due to the improvement of arthroscopic equipment. If an instrument breaks down, doctors immediately stop irrigation and aspiration. They then carefully remove the broken fragment using special equipment. If the piece is small and difficult to access, it may be left in the synovial cavity.

Tools.

Damage to nerves and blood vessels

They occur very rarely, in only 0.06-0.08% of cases. Neurological disorders may develop due to the use of a tourniquet or against the background of compartment syndrome. The cause of vascular damage is most often the careless handling of instruments by the surgeon. As you know, the popliteal artery is located very close to the posterior capsule of the knee joint. Consequently, dissection of the latter is often accompanied by a violation of the integrity of the vessel.

The structure of damage to various nerves during arthroscopy:

• subcutaneous – 84%;
• fibular – 10%;
• femoral – 6%;
• sciatic – 6%.

Fact! Ischemic and traction nerve injuries respond well to treatment. But if their anatomical integrity is violated, it is almost impossible to eliminate neurological disorders.

To do or not to do?

Before the advent of the arthroscope, all operations on the knee joint were performed in an open manner. Of course, this was accompanied by damage to surrounding tissues and an increased risk of complications. Other advantages of arthroscopy include:

• absence of large scars and cicatrices;
• fast recovery;
• the opportunity to solve a huge number of problems related to the diagnosis and treatment of the joint.

This operation is often performed on professional athletes, for whom knee joint injuries are a common occurrence, but there is very little time for recovery.

Pain after knee arthroscopy

A pronounced pain syndrome occurs after synovectomy, intra-articular ligament reconstruction and meniscal surgery. In the early postoperative period, pain is relieved with opioid analgesics or intramuscular injections of nonsteroidal anti-inflammatory drugs (Ketorolac, Diclofenac). In the future, NSAIDs may be prescribed in tablet form.

3rd day after surgery.

Some patients may experience knee pain several days after arthroscopy. This symptom often indicates the development of deforming osteoarthritis. The reason for this is intraoperative damage to the articular cartilage.

Advice! If after arthroscopy you have been bothered by knee pain for a long time, do an ultrasound or MRI. The study will help identify pathological changes in the knee joint and make a diagnosis.

Operation

If you type “knee arthroscopy surgery” into a search engine, you can see that the operation takes place in several stages and, despite its low morbidity, requires careful preparation.

• Collection of information. Before surgery, the patient must:
• Donate blood.
• Get an ECG.
• To make an X-ray.
• He should also visit an orthopedist and an anesthesiologist. The latter will determine how ready the patient is for anesthesia and which method will be optimal for him. As a rule, local anesthesia is used during arthroscopy.
• Direct preparation. When all the tests have been completed and the doctors have determined that the operation will not harm the patient, he must prepare: acquire crutches that will be needed while the leg is being restored; buy painkillers that will be used during treatment; refrain from drinking and eating twelve hours before surgery.
• Operation. Knee arthroscopy is performed on the same day the patient arrives at the hospital. He is placed in a sterile room, and the leg is tied at hip level with a tourniquet so that the blood does not flow into the joint cavity in full. After this, anesthesia is administered and three incisions are made, seven millimeters each. Through them the following are introduced into the joint:
• A light source and camera that allows the doctor performing the operation to see his own actions.
• Hollow Fluid Tube - A sterile solution allows the joint to be flushed and inflated, providing better visibility and more room for instruments.
• An arthroscope, with the help of which all necessary procedures are performed.

When the tears are stitched up, the fracture is reduced, the joint is no longer in danger and the operation, arthroscopy of the knee joint, is completed, the instruments are removed, the sterile liquid is pumped out. The cavity, if necessary, is filled with medications: antibiotics, which fight possible infection, and anti-inflammatory drugs, which will prevent fever. The incisions are covered with a sterile cloth and the knee is bandaged to form a pressure bandage. After this, the patient is escorted to the ward, where:

• After a period of time, the bandage is replaced with an elastic one, which reduces pain and prevents swelling.
• An ice pack is applied to the knee, which also reduces pain and prevents swelling.

The patient is discharged as soon as he can move independently on crutches - usually this happens on the day of the operation, but sometimes it is necessary to stay for a couple of days so that doctors can observe the dynamics.

Hemarthrosis - accumulation of blood in the knee

Usually develops due to damage to the ascending lateral femoral circumflex artery. Hemarthrosis is treated by arthroscopic lavage of the synovial cavity and intra-articular injection of a local anesthetic (Lidocaine, Novocaine) with adrenaline. After this, a pressure bandage must be applied to the patient’s knee.

Accumulation of blood in the capsule.

Infection

Infectious complications are rare, occurring in only 0.1-0.42% of patients. The causative agent of septic arthritis is most often Staphylococcus aureus. The disease is acute and usually does not cause difficulties in diagnosis. In rare cases, it may have a subacute, more “insidious” course.

Classic signs of septic arthritis:

• acute pain;
• severe swelling;
• skin redness;
• fever;
• increased ESR and neutrophilic leukocytosis in the blood.

Infectious inflammation.

Note that the absence of typical symptoms of arthritis does not mean the patient is completely healthy. Infection can be excluded only through bacteriological examination of the synovial fluid. The analysis should be done at the slightest suspicion of septic arthritis.

During arthroscopic procedures, doctors may not prescribe prophylactic antibiotics to patients. This, like intra-articular corticosteroids during arthroscopy, increases the risk of infectious complications.

Treatment for septic arthritis can take anywhere from a few days to 6 weeks. In some cases, parenteral administration of antibiotics is sufficient for patients. Sometimes patients require lavage and drainage of the joint cavity. The choice of treatment usually depends on the severity of the arthritis.

Complex regional pain syndrome

It can occur with any injury to the knee, including after arthroscopic surgery. It is assumed that the syndrome is of a reflex nature and occurs due to damage to the autonomic nerve fibers of the saphenous nerve. The syndrome can develop at any age in both sexes, but most often it affects women over 40 years of age.

The clinical manifestations of this pathology are very variable. Most often, the syndrome goes through three phases of development (vasodilation, vasoconstriction, atrophy) and leads to arthromatic changes in the skin, muscles, and periarticular tissues. Almost all patients with CRPS eventually develop knee contractures. Note that X-ray changes in patients are detected 2-8 weeks after the onset of the first symptoms.

The leg does not fully extend.

Signs of CRPS:

• chronic pain in the lower limb;
• pronounced swelling of soft tissues;
• change in skin color;
• increased sensitivity of the skin in the knee area;
• osteoporosis, which is detected using radiography.

Complex regional pain syndrome is treated conservatively with psychotherapy and medications. Patients are prescribed anticonvulsants, antidepressants, muscle relaxants, NSAIDs, bisphosphonates, calcitonin, B vitamins and drugs that improve venous outflow. Patients often undergo a stellate ganglion block or lumbar sympathetic block.

Treatment for CRPS is only effective if it is started within the first 3 months after the first symptoms appear. If this does not happen, the patient experiences irreversible changes in nerves, muscles and bones.

Symptoms

You should contact a specialist if you notice at least one of the following symptoms:

1. Pain syndrome.
   In the early stages it occurs periodically, usually after intense exercise. The danger is that often the pain is not too strong, passes after a while, and many people simply do not pay attention to it.
2. Swelling.
   As a rule, it accompanies a period of exacerbation of pain.
3. Crunch.
   Due to the gradual thinning of the cartilage layer and the decrease in the amount of synovial fluid, the bones begin to collide with each other, which is why a characteristic rough crunching sound becomes heard.
4. Limited movement.
   Dysfunction and stiffness are observed. The more advanced the disease, the less ability to move.
5. External changes.
   The appearance of the limb gradually changes.