The use of an infusion pump in arthroscopy

The use of an infusion pump is an effective method of irrigating the joint in arthroscopy. A Sarns roller blood pump is used to pump fluid into the joint through the arthroscope with outflow by gravity drainage through a plastic cannula. Flow and pressure can be adjusted independently. Measurements were made of calf, knee, and thigh swelling after arthroscopy in 42 patients; the average swelling of each was less than 1 cm. In 45 patients, the average rate of flow through the joint was 45 mm/min, with a measured outflow of 40 mm/min. Intraarticular pressure greater than 200 mm Hg can be obtained with the pump, compared with maximum pressures only slightly greater than 100 mm Hg with gravity inflow alone. The operator must carefully monitor the system; retention of excessive fluid can lead to postoperative swelling and morbidity.     

Complications associated with traction on the hip during arthroscopy

We studied 16 hips (eight cadaver specimens) using arthrography, arthroscopy and anatomical dissection, under incremental traction of up to a maximum of 64 kg, to determine the relationship of the portals to nearby neurovascular structures. The distance of each arthroscopic portal (anterior, anterolateral, and posterolateral) to the associated neurovascular structures was measured after the application of 23 kg of traction. Traction of up to 64 kg on the lower limb failed to produce evidence of labral or capsular injury. Furthermore, traction of 23 kg resulted in little change in the position of adjacent neurovascular structures relative to the standard arthroscopic portals.     

Complications of continuous intraperitoneal insulin infusion with an implantable pump

AIM: To monitor the course of continuous intraperitoneal insulin infusion (CIPII) and to gain more insight into possible complications. METHODS: A retrospective, longitudinal observational cohort study in patients with type 1 diabetes mellitus (T1DM) was performed. Only patients with "brittle" T1DM who started CIPII between January 1, 2000 and June 1, 2011, and were treated in the only centre inThe Netherlands providing CIPII treatment (Isala clinics, Zwolle) were eligible for inclusion. Outcomes were defined as operation-free period (OFP), rate and type of complications. Subanalyses were made between patients starting CIPII from 2000 to 2007 and from 2007 onwards in order to study possible changes over time in complications and/or OFP. The OFP was calculated as the time from initial implantation to the date of first documented re-operation. If patients had not experi- enced an operation, their data were recorded at the date of last follow up or death. Kaplan-Meier curves were constructed to visualize the OFP. A (two-sided) P value of less than 0.05 was considered statistically significant. RESULTS: Fifty-seven patients were treated with CIPII, although one patient was excluded from analyses because of self-induced complications. In the remaining 56 patients, 70 complications occurred during 283 patient years. Catheter occlusion (32.9%), pump dysfunction (17.1%), pain at the pump site (15.7%) and infections (10.0%) were the most frequent complications. This resulted in a median OFP of 4.5 years (95% confidence interval 4.1-4.8 years) without any difference between the time periods. Fifty re-operations were performed because of complications, one per 5.6 patient years, with a decrease in pump dysfunction (P = 0.04) and pump explantations (P = 0.02) after 2007. In total, 9 episodes of ketoacidosis occurred during follow up and there were 69 hospital re-admissions, with a median duration of 6 d. CIPII was ceased in five patients due to recurrent infections (n = 2), pain (n = 1), inadequate glycaemic control (n = 1) or by own choice (n = 1). No CIPII related mortality was reported. CONCLUSION: The OFP has been stable over the last decade. No CIPII related mortality was reported. A significant decrease in pump dysfunction and explantation was seen after 2007 compared to the period 2000-2007. CIPII remains a safe treatment modality for specific patient groups.     

Complications associated with foot and ankle arthroscopy

Despite a late start within the realm of arthroscopy, foot and ankle arthroscopy proves to be an important diagnostic and treatment tool for the foot and ankle specialist. As indication for arthroscopy increases, complications associated with foot and ankle arthroscopy must be revisited. We reviewed 405 foot and ankle arthroscopic procedures performed on 390 patients in 4 different facilities over a 3-year period extending from January 2005 to August 2008. Two-hundred-sixty foot and ankle arthroscopic procedures on 251 patients met our inclusion criteria. A total of 246 ankle and 14 posterior subtalar arthroscopic procedures were performed with a mean follow-up of 10.7 ± 3.5 months. Patient demographics, preoperative findings, intraoperative technique, and postoperative course were reviewed. We failed to identify statistically significant predictive factors for complications. Arthroscopy performed in combination with adjunctive procedures showed a trend toward higher complication rate, although statistical significance was not noted. Overall, 20 cases (7.69%) experienced arthroscopy-related complications, and this finding was comparable with previously published results. The most common complication was cutaneous nerve injury, which involved 9 cases (3.46%), and localized superficial infection, which involved 8 cases (3.08%). Injury to the superficial peroneal nerve accounted for 5 of the cutaneous nerve injuries. There were no cases of arthroscopy-related vascular injury. All cases of superficial postoperative infection resolved with antibiotic therapy, and none of the cases required return to the operating room. These results were also similar to published data.     

Complications associated with the use of the gamma nail.

At Kingston Hospital, the Gamma nail has only been used for the fixation of unstable intertrochanteric and subtrochanteric fractures of the femur. There have been 28 cases; 21 required distal locking. Of these, there were intraoperative difficulties in nine.     

Complications of arthroscopy of the hip.

Although arthroscopy of the hip is being carried out increasingly, little is known about the rate of associated complications. We describe a prospective study of 640 consecutive procedures in which a consistent technique was used. The overall complication rate was 1.6%. Complications, none of which was major or long-term, included transient palsy of the sciatic and femoral nerves, perineal injury, bleeding from the portal wounds, trochanteric bursitis and intra-articular breakage of the instrument. We believe that it is possible to undertake this operation safely using the technique described.     

The use of arthroscopy for follow-up in knee joint surgery.

Fifty-three joints in 48 patients were examined arthroscopically after surgery in order to evaluate postoperative results and particularly to reveal the causes of poor results. The chief arthroscopic findings in unsatisfactory cases were the following: recurrence of synovitis or osteoarthritic changes after synovectomy for rheumatoid arthritis, residual meniscal or osteoarthritic changes after meniscectomy, loose ligamentous or meniscal lesions after ligamentous repair or reconstruction, and poor regeneration of cartilage after high tibial osteotomy.     

Intra-articular pressure in the knee during routine arthroscopy

The intra-articular pressure in 19 knees was studied during routine knee arthroscopy with saline insufflation. Filling pressures of up to 300 mm Hg were noted. The average range of intra-articular pressure during the procedure was found to be 40-70 mm Hg. Higher pressures were usually needed to keep good distension while performing arthroscopic surgery in the suprapatellar pouch, whereas the pressure could be as low as 20 mm Hg and still enable good vision in the tibio-femoral compartments.     

The use of a volumetric infusion pump for the intra-arterial infusion of drugs.

Volumetric infusion pumps are widely used for intravenous infusions. We have extended their use to the intra-arterial infusion of drugs. An in vitro evaluation of the performance of such devices, under experimental conditions comparable to an intra-arterial infusion, was carried out. The results obtained confirmed the accuracy of volumetric infusion pumps for intra-arterial infusions. The system was found to be safe, reliable and simple in clinical practice.     

Complications associated with the use of the Esophageal-Tracheal Combitube

Purpose

To report four cases of subcutaneous emphysema, pneumomediastinum and pneumoperitoneum associated with the use of the Esophageal-Tracheal Combitube® (ETC) during prehospital management of cardiac arrest.

Clinical features

Between September 1994 and April 1996, 1139 patients were resuscitated with the ETC and the semiautomated external defibrillator as part of the CPR protocol for prehospital management of cardiac arrest by basic emergency medical technicians. Eight of these patients presented with subcutaneous emphysema. Four of them, declared dead after arrival in the emergency room (ER), had autopsy studies. In two, autopsy revealed large (6 and 6.5 cm respectively) longitudinal transparietal lacerations of the anterior wall of the oesophagus. Multiple superficial lacerations of the oesophagus were also present in another patient, while no lesion of the airway or the oesophagus was found in the last patient.

Conclusion

These cases suggest that subcutaneous emphysema, pneumomediastinum and pneumoperitoneum might be complications associated with the use of the ETC. At least in two cases, oesophageal laceration appears to be the mechanism by which these complications occurred.

Objectif

Rapporter quatre cas d’emphysème sous-cutané, de pneumothorax et de pneumopéritoine associés à l’usage du Combitube® durant la réanimation pré-hospitalière de l’arrêt cardiaque.

Aspects cliniques

Entre septembre 1994 et avril 1996, 1139 patients ont été réanimés en utilisant le Combitube® et un défibrillateur externe semi-automatique dans le cadre d’un protocole de RCR pour la prise en charge des arrêts cardiaques par des techniciens médicaux d’urgence ayant une formation de base. Huit de ces patients ont présenté de l’emphysème sous-cutané. Quatre d’entre eux, décédés après leur arrivée à la salle d’urgence, eurent des autopsies. Chez deux, l’autopsie a montré d’importantes lacérations longitudinales transpariétales (6 et 6,5 cm respectivement) de la paroi antérieure de l’?sophage. Des lacérations superficielles multiples étaient aussi présentes chez le troisième patient, alors qu’aucune lésion ni des voies aériennes ni de l’?sophage ne fut retrouvée chez le dernier patient.

Conclusion

Ces cas suggèrent une association entre l’emphysème sous-cutané, le pneumo-médiastin et le pneumopéritoine comme complications de l’utilisation du Combitube®. Au moins chez deux patients, des lacérations oesophagiennes semblent être le mécanisme de ces complications.     

Simultaneous live video presentation during knee arthroscopy

To improve patient understanding, we evaluated prospectively the effect of patient-observed simultaneous surgeon-explained live video during knee arthroscopy. Patient satisfaction, understanding, and tolerance of the tenderness and pain were measured by a questionnaire completed immediately after the procedure. There were 72 patients (41 men, 31 women) with a mean age of 47 years; 76 joints were treated among them. All but one were comfortably able to watch the live video of the procedure, and 89% of the patients reported a good understanding of and satisfaction with the procedure. Moreover, if the patients ever had to have another arthroscopy, 66% answered that they certainly wanted a live video presentation, and 25% somewhat desired it. Live video-presented outpatient arthroscopic knee surgery could be considered a method for improving patient understanding of knee pathology.     

Complications associated with warfarin prophylaxis in total knee arthroplasty

Systemic and local complications associated with the use of warfarin for deep vein thrombosis prophylaxis in total knee arthroplasty (TKA) are significant. Forty-seven patients with primary TKAs considered at high risk for developing thromboembolic disease were treated with a regimen of preoperative and postoperative warfarin. The incidence (n = 2) of systemic complications was 4%. The incidence (n = 6) of wound complications requiring specific treatment or discontinuing physiotherapy was 12%. In this series, wound complications did not jeopardize the end results of TKA. However, such wound complications as may have delayed recovery occurred with a frequency similar to that reported in other series of TKA using different antithromboembolic modalities.