Problems and Complications


9
Problems and Complications


Significant complications are very uncommon with arthroscopy in small animals. Arthroscopy in over 2600 joints performed by the author has produced three cases of suspected nerve irritation. These three cases experienced excessive postoperative pain for approximately six weeks. None exhibited any functional nerve deficits. All three resolved completely with time. There were no detectable cases of joint contamination or septic arthritis caused by arthroscopy in this series of patients. One patient chewed out all the sutures from an arthroscopically assisted UAP removal to create an open joint with a resultant septic arthritis that resolved with joint irrigation and antibiotics.


There is extensive literature on the complications of arthroscopy in people but much of this does not apply to our small animal patients. Many of the listed complications are related to thromboembolism, cosmetic deformities, and synovial fistulas. Nerve damage is a common complication and probably has the closest relationship to our patients but the comparisons do not fit. A comprehensive comparison of the complications in human and veterinary medicine is beyond the scope of this book.


9.1 Actual and Potential Complications of Arthroscopy


9.1.1 Failure to Enter the Joint


Inability to establish telescope or operative portals prevents performing the procedure. This is a common complication for beginners and becomes much less common with experience. This really is not a complication but is simply part of the learning curve.


9.1.2 Articular Cartilage Damage


This is common in early cases for the beginner and decreases with experience. Cartilage damage occurs with needle placement for the telescope portal as linear cuts (Figure 9.1) or as focal lesions (Figure 9.2) and during operative portal placement (Figure 9.3). Needles used for arthrocentesis and portal placement are easily burred when bone is contacted during placement (Figure 9.4) greatly increasing the potential for and severity of cartilage damage. Telescope trocar placement is another source of potential cartilage damage also producing linear cuts (Figure 9.5) or focal lesions with partial‐ (Figure 9.6) or full‐thickness (Figure 9.7) injuries. Operative hand instruments can damage cartilage by applying excessive pressure to crush the cartilage (Figure 9.8) or removing cartilage by cutting or chewing. Power instruments such as the arthroscopy shaver have the potential to cause extensive cartilage damage very quickly at one location (Figure 9.9) or over an extensive area of the joint (Figure 9.10). Because of this, their use is recommended for experienced surgeons. Proper shaver blade positioning is critical to preventing cartilage damage with the cutting portion of the blade. The cutting portion of the blade must be visible whenever power is applied, and it is not directed toward any structure that is not planned for removal (Figure 9.11). Radiofrequency devices are also potential sources for cartilage damage (Figure 9.12) when not used properly.


Most articular cartilage damage is of limited significance and is difficult to find without the magnification of the arthroscope. Minimizing articular cartilage damage is important but the small amount of cartilage damage seen with arthroscopy is much less than damage that occurs with an open arthrotomy. Articular cartilage damage from arthroscopy in dogs has been documented but its significance has not been determined (Klein and Kurze 1986; Rogatko et al. 2018).

Photo depicts linear cartilage damage in the shoulder joint caused by initial needle placement prior to telescope portal placement. The needle cut a full thickness transverse groove in the humeral head articular cartilage. Pink coloration in the base of the groove is exposed subchondral bone. The telescope is looking medially from a lateral portal with proximal up and cranial is to the left. The humeral head fills the bottom of the image with the glenoid articular surface across the top and the medial joint capsule is seen in the background.

Figure 9.1 Linear cartilage damage in the shoulder joint caused by initial needle placement prior to telescope portal placement. The needle cut a full thickness transverse groove in the humeral head articular cartilage. Pink coloration in the base of the groove is exposed subchondral bone. The telescope is looking medially from a lateral portal with proximal up and cranial is to the left. The humeral head fills the bottom of the image with the glenoid articular surface across the top and the medial joint capsule is seen in the background.


Source: Timothy C. McCarthy. © John Wiley & Sons Inc.

Photo depicts focal cartilage damage in the elbow joint caused by initial needle placement prior to telescope portal placement. This injury is irregular with multiple areas of cartilage penetration and loose flaps of variable thickness cartilage in both the humeral and ulnar cartilage. The telescope is looking laterally from a medial portal with proximal to the upper left and cranial to the lower left. The articular cartilage of the ulnar semilunar notch is seen curving around the lower right of the image with the medial surface of the lateral ridge of the humeral condyle filling the upper left.

Figure 9.2 Focal cartilage damage in the elbow joint caused by initial needle placement prior to telescope portal placement. This injury is irregular with multiple areas of cartilage penetration and loose flaps of variable thickness cartilage in both the humeral and ulnar cartilage. The telescope is looking laterally from a medial portal with proximal to the upper left and cranial to the lower left. The articular cartilage of the ulnar semilunar notch is seen curving around the lower right of the image with the medial surface of the lateral ridge of the humeral condyle filling the upper left.


Source: Timothy C. McCarthy. © John Wiley & Sons Inc.

Photo depicts a 20 gauge hypodermic needle placed to establish position for a craniomedial elbow operative portal causing cartilage damage. The tip of the needle cut a linear free flap of cartilage in the ulnar articular surface. The telescope is looking laterally from a medial portal with proximal to the upper left and cranial to the upper right. The ulnar articular surface of the semilunar notch fills the image with exposed bone in the bed of the cartilage cut at the bottom, the free cartilage curving up from the lower left, and the needle coming into the picture from the far left side.

Figure 9.3 A 20 gauge hypodermic needle placed to establish position for a craniomedial elbow operative portal causing cartilage damage. The tip of the needle cut a linear free flap of cartilage in the ulnar articular surface. The telescope is looking laterally from a medial portal with proximal to the upper left and cranial to the upper right. The ulnar articular surface of the semilunar notch fills the image with exposed bone in the bed of the cartilage cut at the bottom, the free cartilage curving up from the lower left, and the needle coming into the picture from the far left side.


Source: Timothy C. McCarthy. © John Wiley & Sons Inc.

Photo depicts a burred needle created when bone was contacted during placement. Burred needles greatly increase the potential for cartilage damage and the severity of damage when it does occur. The image is of a shoulder joint with the telescope looking medially from a lateral portal, proximal or dorsal up, and caudal is to the left. The glenoid is seen in the top of the picture and the humeral head is at the bottom.

Figure 9.4 A burred needle created when bone was contacted during placement. Burred needles greatly increase the potential for cartilage damage and the severity of damage when it does occur. The image is of a shoulder joint with the telescope looking medially from a lateral portal, proximal or dorsal up, and caudal is to the left. The glenoid is seen in the top of the picture and the humeral head is at the bottom.


Source: Timothy C. McCarthy. © John Wiley & Sons Inc.

Photo depicts linear cartilage damage in the glenoid articular surface in a shoulder joint caused by a telescope trocar during telescope portal placement. The groove is close to full thickness but bone is not visible in the lesion. The telescope is looking medially from a lateral portal with the glenoid filling the top of the figure, the humeral head at the bottom, and medial joint capsule is visible across the center in the background.

Figure 9.5 Linear cartilage damage in the glenoid articular surface in a shoulder joint caused by a telescope trocar during telescope portal placement. The groove is close to full thickness but bone is not visible in the lesion. The telescope is looking medially from a lateral portal with the glenoid filling the top of the figure, the humeral head at the bottom, and medial joint capsule is visible across the center in the background.


Source: Timothy C. McCarthy. © John Wiley & Sons Inc.

Photo depicts mild partial thickness focal ulnar cartilage damage caused by telescope trocar placement in an elbow joint. The telescope is looking laterally from a medial portal with humeral condyle to the upper left and ulnar semilunar notch articular cartilage filling the lower right of the image. A flap of free cartilage elevated by the trocar cannula is visible in the center of the picture with the cartilage defect below it at the lower right.

Figure 9.6 Mild partial thickness focal ulnar cartilage damage caused by telescope trocar placement in an elbow joint. The telescope is looking laterally from a medial portal with humeral condyle to the upper left and ulnar semilunar notch articular cartilage filling the lower right of the image. A flap of free cartilage elevated by the trocar cannula is visible in the center of the picture with the cartilage defect below it at the lower right.


Source: Timothy C. McCarthy. © John Wiley & Sons Inc.

Photo depicts full thickness focal ulnar cartilage damage produced during telescope trocar placement in the elbow joint. The telescope is looking laterally from a medial portal with proximal up to the left and cranial down to the left. The undamaged humeral condyle is to the upper left with the damaged ulnar cartilage to the lower right. Multiple free cartilage fragments have been created, a large full thickness defect is present in the lower left of the image, and an area of partial thickness injury extends to the right.

Figure 9.7 Full thickness focal ulnar cartilage damage produced during telescope trocar placement in the elbow joint. The telescope is looking laterally from a medial portal with proximal up to the left and cranial down to the left. The undamaged humeral condyle is to the upper left with the damaged ulnar cartilage to the lower right. Multiple free cartilage fragments have been created, a large full thickness defect is present in the lower left of the image, and an area of partial thickness injury extends to the right.


Source: Timothy C. McCarthy. © John Wiley & Sons Inc.

Photo depicts crushed cartilage on the humoral condyle caused by excessive pressure with an operative hand instrument. The telescope is looking craniolaterally from a medial portal with the medial ridge of the humeral condyle filling the top of the image, the articular surface of the medial coronoid process in the lower right background, the radial head to the left, and the radio-ulnar articulation as a fine curving line extending obliquely across the lower left.

Figure 9.8 Crushed cartilage on the humoral condyle caused by excessive pressure with an operative hand instrument. The telescope is looking craniolaterally from a medial portal with the medial ridge of the humeral condyle filling the top of the image, the articular surface of the medial coronoid process in the lower right background, the radial head to the left, and the radio‐ulnar articulation as a fine curving line extending obliquely across the lower left.


Source: Timothy C. McCarthy. © John Wiley & Sons Inc.

Photo depicts inappropriate focal full thickness cartilage damage on the humoral head caused with a power shaver. The telescope is looking medially from a lateral portal with proximal to the right in the image, the humeral head to the left, the glenoid articular surface to the right, the cartilage defect with exposed bone in the center, and a loose cartilage fragment displaced by the shaver blade.

Figure 9.9 Inappropriate focal full thickness cartilage damage on the humoral head caused with a power shaver. The telescope is looking medially from a lateral portal with proximal to the right in the image, the humeral head to the left, the glenoid articular surface to the right, the cartilage defect with exposed bone in the center, and a loose cartilage fragment displaced by the shaver blade.


Source: Timothy C. McCarthy. © John Wiley & Sons Inc.

Photo depicts widespread cartilage damage on the humeral head caused with a power shaver by accidental activation of the shaver prior to proper positioning and without adequate control of the shaver handpiece. The telescope is looking medially from a lateral portal with proximal up and cranial to the left. The humeral head with multiple semilunar cartilage cuts is to the lower left with the undamaged glenoid articular cartilage to the upper right. The shaver burr walked across the cartilage surface producing multiple deep cartilage cuts and displaced multiple free cartilage fragments.

Figure 9.10 Widespread cartilage damage on the humeral head caused with a power shaver by accidental activation of the shaver prior to proper positioning and without adequate control of the shaver handpiece. The telescope is looking medially from a lateral portal with proximal up and cranial to the left. The humeral head with multiple semilunar cartilage cuts is to the lower left with the undamaged glenoid articular cartilage to the upper right. The shaver burr walked across the cartilage surface producing multiple deep cartilage cuts and displaced multiple free cartilage fragments.


Source: Timothy C. McCarthy. © John Wiley & Sons Inc.

Photo depicts improper placement of a shaver blade with the cutting surface placed against normal cartilage that is not planned for removal. This image is in the stifle joint and the blade is positioned against normal femoral condyle cartilage in the upper left. The tissue for removal is the cut end of the meniscus that is visible in the lower left of the image. The blade was repositioned prior to activation. The cutting blade of the shaver is visible as a verry narrow line of metal to the left of the fixed outer sheath of the blade seen as a flat surface in the upper center and the back side of the fixed outer sheath is seen in the upper right of the picture. Proximal is up on the image.

Figure 9.11 Improper placement of a shaver blade with the cutting surface placed against normal cartilage that is not planned for removal. This image is in the stifle joint and the blade is positioned against normal femoral condyle cartilage in the upper left. The tissue for removal is the cut end of the meniscus that is visible in the lower left of the image. The blade was repositioned prior to activation. The cutting blade of the shaver is visible as a verry narrow line of metal to the left of the fixed outer sheath of the blade seen as a flat surface in the upper center and the back side of the fixed outer sheath is seen in the upper right of the picture. Proximal is up on the image.


Source: Timothy C. McCarthy. © John Wiley & Sons Inc.

Photo depicts damage to the medial aspect of the lateral femoral condyle cartilage caused by a radiofrequency (VAPR) handpiece used to complete removal of the origin of the cranial cruciate ligament. Proximal is up with lateral to the right and the telescope is looking caudolaterally from a craniomedial portal. The vertical white structure on the left is the caudal cruciate ligament and the medial aspect of the lateral femoral condyle is to the right.  The origin of the cranial cruciate ligament is the flat area of soft tissue in the upper center of the image between the caudal cruciate and the medial articular cartilage of the lateral femoral condyle.

Figure 9.12

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Nov 28, 2021 | Posted by in SMALL ANIMAL | Comments Off on Problems and Complications
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