Neurological complications due to arthroscopy.

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Abstract
Arthroscopy has become a widely used procedure for the diagnosis and treatment of a growing list of disorders of the joints. Such procedures are now commonly performed on the knee, shoulder, elbow, ankle, wrist, and hip. The American Academy of Orthopaedic Surgeons, at a recent symposium on the uses and abuses of arthroscopy, estimated that 1.4 million arthroscopic procedures were performed in the United States in 1990 [31]. Despite the growing literature on arthroscopic procedures and results, there have been few reports on the complications of arthroscopy. In this paper, we review the prevalence and etiology of specific neurological complications that have been reported after arthroscopy of the knee, shoulder, elbow, ankle, wrist, and hip. We discuss the treatment of these complications and the use of methods to decrease the risk of neurological injury during arthroscopy. In retrospective studies, the over-all rates of complications after arthroscopy have ranged from less than 1 to 8 per cent [10,12,46,48]. The reported rates of neurological injuries in a number of large series have ranged from less than 0.1 to 2 per cent [12,46,48,49]. In the largest known survey of the results of arthroscopy, Small identified 234 nerve injuries in association with 395,566 joint procedures--a prevalence of less than 0.1 per cent [48]. In a retrospective study of procedures performed by members of the Arthroscopy Association of North America, representing ten geographical locations in the United States, sixty-three neurological complications were reported in association with 118,590 arthroscopic procedures on the knee--a prevalence of less than 0.1 per cent [12]. At The Hospital for Special Surgery in New York City, 8254 arthroscopic procedures were performed during the five-year period from 1988 to 1992. A survey of surgeons at our institution revealed three neurological complications--a prevalence of less than 0.1 per cent--during this period. Because the survey relied on the surgeon's memory, this rate probably represents the minimum number of complications; the actual rate is probably somewhat greater. The four general types of neurological injury that may occur secondary to arthroscopy are direct injury to a nerve, compression secondary to compartment syndrome, tourniquet-related neurapraxia, and reflex sympathetic dystrophy. Because direct injury to a nerve can be caused by incorrect placement of the portals, correct placement is the major way to decrease the rate of neurological injury. When the surgeon is making the portal, the scalpel should penetrate only skin; a blunt trocar should then be used to enter the joint. Extravasation of fluid used for distension of the joint can increase compartment pressures, with potential nerve compression. The risk of compartment syndrome due to extravasation of fluid can be reduced by minimization of the pressure caused by distension of the joint and by limitation of the over-all duration of the procedure. A physiological solution, such as saline or lactated Ringer solution, rather than a non-physiological solution, such as glycine, should be used for distension of the joint, as the former type of solution will be absorbed rapidly by clysis [52]. The risk of extravasation of fluid into the interstitium can also be decreased by limitation of the number of capsular punctures. Frequent palpation of the extremity and examination at the end of the procedure will aid in the early detection and prevention of compartment syndrome. Tourniquet compression may be used in arthroscopy on the knee, ankle, elbow, and wrist. The three principal factors related to the damage that may occur secondary to use of a tourniquet are the duration of use, the inflation pressure, and the size of the cuff.

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