Arch Orthop Trauma Surg
DOI 10.1007/s00402-014-2054-0
ARTHROSCOPY AND SPORTS MEDICINE
Complications after arthroscopic knee surgery
Tetsuo Hagino • Satoshi Ochiai • Yoshiyuki Watanabe
Shinya Senga • Masanori Wako • Takashi Ando •
Eiichi Sato • Hirotaka Haro
Received: 10 February 2014
Ó Springer-Verlag Berlin Heidelberg 2014
Abstract
Purpose To examine the complications of arthroscopic
knee surgeries conducted in the Sports Medicine and Knee
Center of our hospital.
Subjects and methods In this prospective study, a total of
2,623 patients (1,396 men and 1,227 women) who under-
went arthroscopic knee surgeries in our center between
January 2006 and March 2013 (7 years and 3 months) were
studied. The ages at surgery ranged 7–96 years (mean
33.5 years). Arthroscopy was conducted because of sports
injuries in 1,653 patients (63.0 %). The main diagnoses
included meniscal injury in 920 patients, discoid meniscus
in 64 patients, anterior cruciate ligament injury in 580
knees, posterior cruciate ligament injury in 30 knees, loose
body in 61 knees, and intraarticular fracture in 33 knees.
Arthroscopic procedures included meniscectomy in 987
knees, meniscal suture repair in 262 knees, and anterior
cruciate ligament reconstruction in 508 knees. Intraopera-
tive and postoperative complications in these cases were
investigated.
Results The rate of complication was 7 in 2,623 cases
(0.27 %). Intraoperative complications comprised three
cases of intraarticular instrument breakage and one case of
meniscal injury. Postoperative complications consisted of
two cases of septic arthritis and one case of superficial
infection, and reoperation was necessary in the two cases of
septic arthritis. There were no neural, vascular and
T. Hagino (&)
S. Ochiai
Y. Watanabe
S. Senga
The Sports Medicine and Knee Center, Kofu National Hospital,
11-35 Tenjin-cho, Kofu, Yamanashi 400-8533, Japan
e-mail: tmhagino@amber.plala.or.jp
M. Wako
T. Ando
E. Sato
H. Haro
Department of Orthopaedic Surgery, Faculty of Medicine,
University of Yamanashi, Yamanashi, Japan
•
ligament injuries during surgery, and no complex regional
pain syndrome, symptomatic deep vein thrombosis, and
pulmonary embolism were observed.
Conclusion Arthroscopic knee surgeries are considered to
be minimally invasive, and are conducted relatively safe
with low complication rates. In this series, however, seven
cases of complications occurred, including two cases
(0.08 %) of septic arthritis. Furthermore, symptomatic
thromboembolism has been reported to occur also in
arthroscopic surgery. The risk of severe complications has
to be acknowledged.
Keywords Complication
Arthroscopy
Knee
Introduction
Arthroscopic knee surgeries are one of the most common
orthopaedic procedures performed worldwide. They
account for 3 of the 10 most common orthopaedic proce-
dures in the United States [3]. However, the associated
complication rates are not clearly defined. Much of the
information regarding arthroscopic knee surgical compli-
cation rates dates back to the 1980s, with rates ranging
0.8–8.2 % [2, 11–13]. A review of literature found few
recent reports on the complications of arthroscopic knee
surgery [6, 8, 9], and the complications in Japan have not
been reported. With the recent advances in equipment for
arthroscopic surgeries, evolution of techniques, and
increased frequency of arthroscopic surgeries, it is possible
that the occurrence of complications has also changed
greatly. Accurate analysis of the complications is important
for improving the outcome of arthroscopic surgeries and
for providing prognostic information to patients while
obtaining informed consent.
123

Table 1 Main diagnoses based on arthroscopic findings (multiple
diagnoses in some cases)
Diagnosis Number
of knees
Meniscal injury
Medial 411
Lateral 372
Medial and lateral 137
Discoid meniscus 64
Anterior cruciate ligament injury 580
Posterior cruciate ligament injury 30
Loose body 61
Intraarticular fracture 33
Synovitis 204
Osteoarthritis 38
In the present study, we examined the complications of
arthroscopic knee surgeries conducted in the Sports Med-
icine and Knee Center of our hospital during recent years.
Subjects and methods
A total of 2,623 patients (1,396 men and 1,227 women)
who underwent arthroscopic knee surgeries in our center
between January 2006 and March 2013 (a period of 7 years
and 3 months) were enrolled in this prospective study. The
ages at surgery ranged 7–96 years (mean ± standard
deviation, 33.5 ± 17.2 years), and the majority were
young persons in their teens and twenties. Arthroscopy was
conducted because of sports injuries in 1,653 patients
(63.0 %), no triggering factor in 361 patients (13.8 %),
traffic accident in 108 patients (4.1 %), falls in 69 patients
(2.6 %), and staircase injury in 54 patients (2.1 %). The
main types of sports injuries included soccer in 296
patients (11.3 %), basketball in 289 patients (11.0 %),
volley ball in 269 patients (10.3 %), skiing in 136 patients
(5.2 %), and rugby in 96 patients (3.7 %). The main
diagnoses based on arthroscopic findings included meniscal
injury in 920 knees (medial in 411 knees, lateral in 372
knees, and both medial and lateral in 137 knees), discoid
meniscus in 64 knees, anterior cruciate ligament (ACL)
injury in 580 knees, posterior cruciate ligament (PCL)
injury in 30 knees, loose body in 61 knees, intraarticular
fracture in 33 knees, and synovitis in 204 knees (Table 1).
The arthroscopic procedures conducted included men-
iscectomy in 987 knees, meniscal suture repair in 262
knees, ACL reconstruction in 508 knees, PCL reconstruc-
tion in 30 knees, synovectomy in 846 knees, removal of
loose body in 91 knees, bone drilling in 47 knees, and
arthroscopic osteosynthesis in 34 knees (Table 2). All
patients except emergency were admitted 1 day before the
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Arch Orthop Trauma Surg
Table 2 Arthroscopic procedures conducted (multiple procedures in
some cases)
Procedure Number
of knees
Meniscectomy 987
Meniscal suture repair 262
Anterior cruciate ligament reconstruction 508
Posterior cruciate ligament reconstruction 30
Synovectomy 846
Removal of loose body 91
Microfracture or drilling 47
Arthroscopic osteosynthesis 34
Second look 181
Medial plica resection 282
scheduled date for surgery. All the surgeries were con-
ducted by a team of four orthopaedic surgeons. In princi-
ple, tourniquet was not used in all the surgical procedures
including ligament reconstruction and arthroscopic osteo-
synthesis. However, in rare occasions, a tourniquet was
used briefly for controlling bleeding during surgery. To
prevent postoperative surgical site infection, a first gener-
ation cephalosporin cefazolin (CEF), or a wide-spectrum
penicillin piperacillin (PIPC) was administered at the start
of surgery, after completion of surgery and during 2 days
after surgery, for a total of six times. In addition, after
completion of surgical procedures, the interior of the joint
was irrigated with at least 2 L of lactated Ringer’ solution
(ArthromaticÒ; Baxter Ltd., Tokyo).
One day after surgery, patients were allowed to leave
bed and rehabilitation was started. They were discharged
after regaining walking ability. With a very few exceptions,
all patients were hospitalized for at least 1 week. In all
patients, anticoagulant was not used pre- or post-opera-
tively. All patients wore compression stocking after sur-
gery, and lower limb exercises were conducted early after
surgery. In all 2,623 patients, intraoperative and postop-
erative complications as well as reoperations in these cases
were investigated prospectively. Symptomatic deep vein
thrombosis was assessed based on clinical observation of
swelling, pain and colour change in lower extremities,
hardening of crural muscle, and tenderness. Pulmonary
embolism was assessed based on subjective symptoms of
shortness of breath on exertion or dyspnoea, or clinical
observation of circulatory collapse or cardiopulmonary
arrest.
Results
The rate of complication was 7 in 2,623 cases (0.27 %).
Intraoperative complications comprised three cases of
Arch Orthop Trauma Surg
Table 3 Complications and reoperation
Complication No. of patients Reoperation
(%) no. of patients
Intra-articular instrument breakage 3 (0.11) -
Meniscal injury 1 (0.04) - tion rate, and 0.40 % 30-day reoperation rate. Furthermore,
Septic arthritis 2 (0.08) 2 Salzler et al. [9] reported 4,305 complications out of
Superficial infection 1 (0.04) - 92,565 knee arthroscopic procedures obtained from the
Symptomatic DVT or PE - -
Neural, vascular, or ligament injury - -
Complex regional pain syndrome - -
Total 7 (0.27) 2 procedure, and patients should be aware of the risk of
DVT deep-vein thrombosis, PE pulmonary embolism
intraarticular instrument breakage and one case of meniscal
injury. Postoperative complications consisted of two cases
of septic arthritis and one case of superficial infection.
Reoperation was necessary only in the two cases of septic
arthritis (Table 3). There were no neural, vascular and
ligament injuries during surgery, and no complex regional
pain syndrome, symptomatic deep vein thrombosis, and
pulmonary embolism were observed. In the two cases of
septic arthritis that were reoperated, inflammation was
controlled by arthroscopic washout and debridement.
Discussion
In 1985, the Committee on Complications of the Arthros-
copy Association of North America (AANA) conducted a
retrospective review of 118,590 arthroscopies and reported
930 complications (0.8 %) [2]. In 1986, the same com-
mittee carried out a retrospective review of 395,566 ar-
throscopies, and reported an overall complication rate of
0.56 % [11]. The complication rate was higher in more
complex procedures; 2.4 % in meniscal repair and 1.8 % in
reconstruction of the ACL. In 1988, Small [12] reported a
prospective study in which 10,262 procedures were regis-
tered, and reported an overall complication rate of 1.68 %.
The most common complications in that study were
haemarthrosis (60.1 %), infection (12.1 %), thromboem-
bolic disease (6.9 %), anaesthetic complications (6.4 %),
instrument failure (2.9 %), complex regional pain syn-
drome (CRPS) 1 (2.3 %), ligament injury (1.2 %) and
fracture or neurological injury (0.6 % each). In 1986,
Sherman et al. [10] retrospectively reviewed 2,640 ar-
throscopies performed by four surgeons. Overall, there
were 216 complications (8.2 %) of which 126 were des-
ignated as major and 97 as minor. The major complications
were infection, haemarthrosis, adhesions, effusions, car-
diovascular and neurological problems, CRPS 1 and
instrument breakage.
In recent reports, Jameson et al. [6] evaluated 30-day
reoperation and readmission rates based on 301,701 knee
arthroscopies performed from 2005 to 2010, utilizing the
English National Health Service data. They found a 0.64 %
30-day readmission rate, 0.26 % 30-day wound complica-
American Board of Orthopaedic Surgery database, or an
overall candidate-reported complication rate of 4.7 %.
They concluded that knee arthroscopy is not a benign
complications. Martin et al. [7] reviewed 12,271 cases of
elective knee arthroscopy from the National Surgical
Quality Improvement Program Database, and reported an
overall incidence of any complication of 1.6 % (199
patients). Even for arthroscopic procedures, pulmonary
embolism occurred at a rate of 0.05 % (6 patients), and
death at a rate of 0.008 % (1 patient) in their series. In the
study of Jameson et al. [6] also, even in arthroscopic sur-
geries, deep vein thrombosis occurred at a rate of 0.12 %,
pulmonary embolism at 0.08 %, and death at 0.02 %. The
rate of pulmonary embolism has recently been reported to
be 2.8 per 10 000 knee arthroscopies in a large cohort of
patients in the United States [5]. In our present single-
centre study, our complication rate was low; 7 of 2,623
cases (0.27 %), and we encountered no deep vein throm-
bosis and no pulmonary embolism in our series. However,
since we did not perform ultrasonographic examination in
all our patients, the possibility of asymptomatic thrombosis
among our cases cannot be excluded.
Martin et al. [7] identified black race, prior operation
within 30 days, operative time longer than 1.5 h, and age of
40–65 years as the risk factors of any complication fol-
lowing knee arthroscopy. Bohensky et al. [1] reported that
risk factors for adverse outcomes after knee arthroscopy
included chronic kidney disease, myocardial infarction,
cerebrovascular accident, and cancer. We did not analyse
the risk factors of the development of complications, which
is a weakness of the present study. Further studies of risk
factors in Japanese patients are necessary.
The present result showed a low complication rate of
0.27 % following arthroscopic knee procedures in our
institute. Although arthroscopic knee surgery is considered
minimally invasive and can be conducted relatively safely,
reports have indicated that symptomatic thromboembolism
or death may occur in patients with risk factors. The risk of
severe complications in arthroscopic knee procedures has
to be acknowledged. Septic arthritis occurred as severe
local complication in two of our cases, and both were
successfully treated by early arthroscopic washout [4],
arthroscopic debridement and antibiotics. Septic arthritis
can be cured without sequel by early detection and early
123

appropriate treatment. Therefore careful postoperative
observation is important.
Acknowledgments No benefits in any form have been received or
will be received from a commercial party related directly or indirectly
to the subject of this article.
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