Tension
pneumarthrosis complicating arthroscopy of the knee JEFFREY FERNYHOUGH,* MD, AND BRUCE E. RAZZA, MD From the Elmwood Medical Center, New Orleans, Louisiana
Arthroscopic surgery of the knee appears to be associated with a relatively low rate of complication, less than 2%. 1,3,6,8 There
have, however, been
a
nearly unrestricted, painless
range of motion from 120° of flexion to 0° of extension. There was a minimal, nontender joint effusion. The other two portal wounds were dry and healing well, so the sutures were removed. She was placed on doxycycline hyclate, since she was allergic to penicillin. She returned 4 days later with a 1-day history of &dquo;bubbling&dquo; at the portal wound site and a painless pressure sensation within the knee. There was an audible sucking sound associated with flexion or extension of the knees, and at times with applied pressure some air could be expelled. The range of motion was still painless and nearly full, limited only by the distension of the knee with air. There was also subcutaneous air, palpable as crepitus, within the lower quadriceps musculature. There were still no systemic signs of infection. She was afebrile and the white blood count was only 8.4 mm’, with a normal differential. The patient was admitted for arthroscopic irrigation of the knee joint through the same portal where the air was expelled, deep wound cultures, and intravenous antibiotics. The cultures again were negative and she recovered uneventfully, with the addition of splinting of the knee to reduce tension on the portal wound.
wide variety of infrequent
complications reported, including hemarthrosis, adhesions, nerve and vascular injuries, fistula formation, extravasation of gases,5,6 pneumoscrotum,~and others.1-5 We are reporting the first described case of tension pneumarthrosis of the knee after arthroscopy. This most unusual clinical entity was treated with surgical exploration and irrigation and resulted in
an
uneventful recovery.
CASE REPORT
Arthroscopic debridement and partial meniscectomy of a degenerative lateral meniscal tear was performed on the left knee of a 47-year-old female patient under general anesthesia. A tourniquet was applied, but not inflated. The patient’s past surgical history included two arthroscopic procedures, including partial lateral meniscectomy and lateral retinacular release, as well as two arthrotomies, using the same lateral parapatellar incision. Left knee arthroscopy was uneventfully performed through the same standard anterolateral parapatellar portal previously used. An inferior anteromedial parapatellar tendon portal was also used, in addition to a superolateral irrigation portal. Lactated Ringer’s solution was introduced into the knee under gravitational pressure alone. After completion of arthroscopy, the residual intraarticular irrigation fluid was removed by suction through the anterolateral portal, and each portal was closed with a single 4-0 nylon simple suture. Vaseline gauze and sterile cast padding were applied and the knee was wrapped in an Ace bandage. Six days after surgery she was seen for a routine followup, had no complaints, and was able to bear full weight on the knee. The inferior anterolateral portal wound was noted to be draining a small amount of serous fluid, which was cultured and found to be negative. She was afebrile and had *
Address correspondence and reprnt requests to 900 Glades Road, Suite 2A, Boca Raton, FL 33431
DISCUSSION We report a most unusual complication of arthroscopy of the knee, which we have termed &dquo;tension pneumarthrosis.&dquo; The pathogenesis of this appears to involve the development of a communication from the knee joint space through the anterolateral parapatellar tendon portal to the outside environment. Notably, this portal had been used two times previously for arthroscopy and twice for arthrotomy, with the incision made at the same portal wound. Preoperatively, the skin was obviously puckered at this portal scar, with the superficial tissues adherent to the deeper ones. On palpation, there was an absence of subcutaneous fat within the scar tissue. We have postulated both a mechanical and a biological basis for the development of this tract and the poor healing response of the local tissue.
Jeffrey Fernyhough, MD, 479
480
there was dense scar tissue present in the of this portal wound caused by the number of surgical violations that eliminated the normally mobile anatomic tissue planes. This may have impeded the normal mechanical &dquo;sealing&dquo; of portal wounds by the overlapping mobile tissue planes and subcutaneous fat. Hence, the local environment was rendered more susceptible to the development of a tract through the surgical path of the portal. This may have also been facilitated by the early mobilization and consequent increased shear forces across the wound, as well as a wound-spreading force associated with knee flexion. Biologically, it is well known that wounds in dense scar tissue do not heal as well as those in primary surgical wounds. These mechanical factors, along with the poor healing response of dense scar tissue, probably account for the development of this tract from the knee joint to the skin through the portal wound.
Undoubtedly,
REFERENCES
area
1. Ansalem Y, Lin E, Salai
M, et al Extensive subcutaneous emphysema complicating arthroscopy of the knee Br J Sports Med 19. 167, 1985 2 DeLee JC: Complications of arthroscopy and arthroscopic surgery. Results of a national survey Arthroscopy 1: 214-220, 1985 3. Henderson CE, Hopson CN Pneumoscrotom as a complication of arthroscopy J Bone Joint Surg 64A. 1238-1240, 1982 4 Lindenbaum BL: Complications of knee joint arthroscopy Clin Orthop 160 158, 1981 5 Sherman OH, Fox JM, Snyder SJ, et al. Arthroscopy—"No problem surgery." An analysis of complications in two thousand six hundred and forty cases J Bone Joint Surg 68A. 256-265, 1986 6 Small NC: Complications in arthroscopic surgery performed by expenmental arthroscopists Arthroscopy 4 215-221, 1988 7. Small NC: Complications in arthroscopy The knee and other joints Ar: 253-258, 1986 throscopy 2 8. Williamson DM, Copeland SA. Suturing arthroscopy wounds Brief report J Bone Joint Surg 70B 146, 1988
pneumarthrosis complicating arthroscopy of the knee JEFFREY FERNYHOUGH,* MD, AND BRUCE E. RAZZA, MD From the Elmwood Medical Center, New Orleans, Louisiana
Arthroscopic surgery of the knee appears to be associated with a relatively low rate of complication, less than 2%. 1,3,6,8 There
have, however, been
a
nearly unrestricted, painless
range of motion from 120° of flexion to 0° of extension. There was a minimal, nontender joint effusion. The other two portal wounds were dry and healing well, so the sutures were removed. She was placed on doxycycline hyclate, since she was allergic to penicillin. She returned 4 days later with a 1-day history of &dquo;bubbling&dquo; at the portal wound site and a painless pressure sensation within the knee. There was an audible sucking sound associated with flexion or extension of the knees, and at times with applied pressure some air could be expelled. The range of motion was still painless and nearly full, limited only by the distension of the knee with air. There was also subcutaneous air, palpable as crepitus, within the lower quadriceps musculature. There were still no systemic signs of infection. She was afebrile and the white blood count was only 8.4 mm’, with a normal differential. The patient was admitted for arthroscopic irrigation of the knee joint through the same portal where the air was expelled, deep wound cultures, and intravenous antibiotics. The cultures again were negative and she recovered uneventfully, with the addition of splinting of the knee to reduce tension on the portal wound.
wide variety of infrequent
complications reported, including hemarthrosis, adhesions, nerve and vascular injuries, fistula formation, extravasation of gases,5,6 pneumoscrotum,~and others.1-5 We are reporting the first described case of tension pneumarthrosis of the knee after arthroscopy. This most unusual clinical entity was treated with surgical exploration and irrigation and resulted in
an
uneventful recovery.
CASE REPORT
Arthroscopic debridement and partial meniscectomy of a degenerative lateral meniscal tear was performed on the left knee of a 47-year-old female patient under general anesthesia. A tourniquet was applied, but not inflated. The patient’s past surgical history included two arthroscopic procedures, including partial lateral meniscectomy and lateral retinacular release, as well as two arthrotomies, using the same lateral parapatellar incision. Left knee arthroscopy was uneventfully performed through the same standard anterolateral parapatellar portal previously used. An inferior anteromedial parapatellar tendon portal was also used, in addition to a superolateral irrigation portal. Lactated Ringer’s solution was introduced into the knee under gravitational pressure alone. After completion of arthroscopy, the residual intraarticular irrigation fluid was removed by suction through the anterolateral portal, and each portal was closed with a single 4-0 nylon simple suture. Vaseline gauze and sterile cast padding were applied and the knee was wrapped in an Ace bandage. Six days after surgery she was seen for a routine followup, had no complaints, and was able to bear full weight on the knee. The inferior anterolateral portal wound was noted to be draining a small amount of serous fluid, which was cultured and found to be negative. She was afebrile and had *
Address correspondence and reprnt requests to 900 Glades Road, Suite 2A, Boca Raton, FL 33431
DISCUSSION We report a most unusual complication of arthroscopy of the knee, which we have termed &dquo;tension pneumarthrosis.&dquo; The pathogenesis of this appears to involve the development of a communication from the knee joint space through the anterolateral parapatellar tendon portal to the outside environment. Notably, this portal had been used two times previously for arthroscopy and twice for arthrotomy, with the incision made at the same portal wound. Preoperatively, the skin was obviously puckered at this portal scar, with the superficial tissues adherent to the deeper ones. On palpation, there was an absence of subcutaneous fat within the scar tissue. We have postulated both a mechanical and a biological basis for the development of this tract and the poor healing response of the local tissue.
Jeffrey Fernyhough, MD, 479
480
there was dense scar tissue present in the of this portal wound caused by the number of surgical violations that eliminated the normally mobile anatomic tissue planes. This may have impeded the normal mechanical &dquo;sealing&dquo; of portal wounds by the overlapping mobile tissue planes and subcutaneous fat. Hence, the local environment was rendered more susceptible to the development of a tract through the surgical path of the portal. This may have also been facilitated by the early mobilization and consequent increased shear forces across the wound, as well as a wound-spreading force associated with knee flexion. Biologically, it is well known that wounds in dense scar tissue do not heal as well as those in primary surgical wounds. These mechanical factors, along with the poor healing response of dense scar tissue, probably account for the development of this tract from the knee joint to the skin through the portal wound.
Undoubtedly,
REFERENCES
area
1. Ansalem Y, Lin E, Salai
M, et al Extensive subcutaneous emphysema complicating arthroscopy of the knee Br J Sports Med 19. 167, 1985 2 DeLee JC: Complications of arthroscopy and arthroscopic surgery. Results of a national survey Arthroscopy 1: 214-220, 1985 3. Henderson CE, Hopson CN Pneumoscrotom as a complication of arthroscopy J Bone Joint Surg 64A. 1238-1240, 1982 4 Lindenbaum BL: Complications of knee joint arthroscopy Clin Orthop 160 158, 1981 5 Sherman OH, Fox JM, Snyder SJ, et al. Arthroscopy—"No problem surgery." An analysis of complications in two thousand six hundred and forty cases J Bone Joint Surg 68A. 256-265, 1986 6 Small NC: Complications in arthroscopic surgery performed by expenmental arthroscopists Arthroscopy 4 215-221, 1988 7. Small NC: Complications in arthroscopy The knee and other joints Ar: 253-258, 1986 throscopy 2 8. Williamson DM, Copeland SA. Suturing arthroscopy wounds Brief report J Bone Joint Surg 70B 146, 1988
