The death of teenage footballer Priya R, who succumbed to post-surgical complications following arthroscopic knee ligament repair, has raised many questions about the safety of arthroscopic procedures in general. Considering that a lot of corrective procedures on the knee are done through this method, should we worry? “The girl’s death has been an unusually rare case but this is by and large a safe procedure with a 90 per cent success rate. Sometimes complications do take place but if arrested and controlled in time, there is no room for worry,” says Dr Gaurav Prakash Bhardwaj, Director, Sports Injury, Joint Preservation and Replacement Surgery at PSRI, New Delhi.
WHAT IS KNEE ARTHROSCOPY?
Knee arthroscopy is a minimally invasive surgery. The procedure involves making a small incision into the knee to insert a tiny camera known as an arthroscope to view the insides of the joint. The arthroscope sends back HD images on to a screen where the surgeon can see the insides and make a diagnosis, and if needed, correct the issue at hand using instruments that go along with the arthroscope. “It is a keyhole technique to understand what needs to be done inside the joint. But at times, we do fairly complex procedures and do get closer to the vital structures behind our knees. Small cuts are made to insert the tiny camera and small surgical tools into your knee. There is minimal bleeding and the delicacy and flexibility it allows helps us to fix problems like torn meniscus, misaligned patella or damaged ligaments. The recovery time depends on the complexity of the procedure as well as the rest and rehabilitation regime that could differ from patient to patient,” says Dr Bhardwaj.
WHAT IS THE POSSIBILITY OF DAMAGE? WHAT DID HAPPEN TO PRIYA?
In the case of Priya, her ligament was injured and she needed intervention. “Sometimes, during repair, though aided by the arthroscope, we do get very close to vital blood vessels and nerve clusters that crowd around the knee. For example, there’s the peroneal nerve, which is small but has major functionality as it runs from the back across the side of the knee. Since it is responsible for helping muscles move the ankle and foot, damage to this nerve can affect your mobility. A wrong nick could affect nerve systems relating to sensation and movement. And it could damage blood vessels and cause blood loss while cutting of blood supply to the knee muscles. This blood loss has to be stopped immediately and cannot be delayed. If the blood leaks longer than the window that the knee allows, there can be irreversible damage to the tissue. That’s why very intense scrutiny and monitoring of post-operative pain, discomfort or bleeding around the area of intervention becomes very important. I am guessing this is what might have happened to the girl,” says Dr Bhardwaj.
If the blood loss is prolonged, then it could lead to compartment syndrome, where the muscles, denied blood flow, can choke on themselves, and, therefore, need to be relieved instantaneously. “It usually occurs in the legs, feet, arms or hands, but can occur wherever there’s an enclosed compartment inside the body that can confine muscle tissue. When the pressure within a compartment increases, it restricts the blood flow to the area and potentially damages the muscles and nearby nerves. The first priority should be to tie up the blood channels. This has to be done at the earliest because the damage is irreversible if delayed. Later interventions won’t work then,” says Dr Bhardwaj. Clinically, the patient will give you enough indications. According to symptoms reported in such cases, patients complain of sharp, incisive pain, more intense than the original pain itself. This is probably that Priya’s family was alluding to.
As to what might have happened in Priya’s case, Dr Bhardwaj says, “When muscles choke and degenerate, they release toxins. That’s the reason why her leg was amputated as it generated toxins. But it seems toxins had spread way too much by then. I read that one of the doctors said that the muscle breakdown spiked a protein called myoglobin in the urine. That led to a spike in creatinine levels and multi-organ failure. That’s why I said that timely identification of an aberration and swift intervention is required should such rarities happen.”
WHAT IS THE RISK OF INFECTION?
Data shows that the risk of infection from arthroscopic knee surgery is very small, ranging from 0.009 to 0.4 per cent. “I repeat this is one of the safest procedures that are around but a very small prorportion of people can react to it in a manner they are not supposed to. That’s when swift intervention is required. Nerve damage can happen during meniscus suturing. Blood clots can happen in patients with blood disorders or genetic conditions that make them prone to clotting. For patients with no blood disorders, the risk is very low. If an infection happens in the bone, it needs immediate attention,” says Dr Bhardwaj.
WHAT’S THE SAFETY CHECKLIST?
Dr Bhardwaj recommends that choosing the right surgeon while performing arthroscopy is important. “Always rely on a surgeon who has a vast experience and knows what a fraction of a nick here and there can do. Doctors should follow protocol and prevent blood loss on the outside chance that the surgery does go awry. They should monitor patients post-procedure very carefully. A surgeon should do a risk-benefit analysis on a case-by-case basis and a full medical assessment because patients with pre-existing medical conditions such as heart and kidney disease can develop serious and fatal complications and inflammation,” he adds.