PHYSICAL THERAPY COMPLICATION OF PNEUMARTHROSIS AND SUBCUTANEOUS EMPHYSEMA FOLLOWING KNEE ARTHROSCOPY

Hull Auditorium

Introduction. Physical Therapy is often utilized for the post-operative rehabilitation of patients who have undergone arthroscopic knee surgery. The number of knee arthroscopic procedures performed in 2006 had increased 49% since 1996 to 984,607. Nearly 500,000 arthroscopic procedures were performed for medial or lateral meniscal tears. (Kim, Bosque, Meehan, Jamali, & Marder, 2011)Complications of arthroscopic surgery have been identified including laceration of popliteal artery, personal and saphenous nerve palsies, deep infection, instrumental breakage, deep vein thrombosis and multiple other complications.(Austin & Sherman, 1993) The purpose of this case study is to describe the treatment of a patient who developed subcutaneous emphysema and knee pneumarthrosis of the right knee region following an arthroscopic medial meniscal repair and debridement of osteoarthritis. Few case studies have been published which identify this condition. This specific case contains video of the conditions as it presented on the first day of symptoms. Case presentation. Case description: The patient is a 69 year old female with a 12 preoperative diagnosis of a medial meniscal tear and arthritis of the right knee. The patient reported that she had knee pain with a history of arthritis for many months and underwent conservative physical therapy treatment without success. The patient underwent a right knee arthroscopy, partial meniscectomy and debridement on January 25, 2012. The finding reported by the surgeon indicated a marked arthrosis consisted with a prior MRI. The surgery revealed a degenerative, significant flap, displaced flap tear, posterior horn medial meniscus with degeneration. Marked articular cartilage loss in the tibia and the femur, medial compartment as well as moderate loss in lateral compartment and moderate loss patellofemoral compartment were apparent during surgery. Minor fraying of the lateral meniscus was noted. The surgical procedure involved the patient positioned supine with successful induction of anesthesia and prepped and draped in the usual fashion. The arthroscope was inserted in the usual fashion through a standard portal distal and lateral to the patella. The unstable portion of the medial meniscus was identified and resected, preserving as much meniscus as possible. Debridement was performed and the rest of the knee reevaluated and no lose bodies were found. Lavage took place and the instruments were removed and the portals closed with interrupted 4-0 nylon. A sterile compressive dressing was applied. The patient was ordered physical therapy and was scheduled in Florida on 1/30/2012. Prior to traveling from New York on a follow up visit on 1/30/2012 the sutures were removed from the portal sites. Upon evaluation, the patient ambulated with a cane independently and performed all transfers without pain or limitation. The patient reported actively ascending and descending steps and curb. Strength limitations to the knee were 4-/5 and Range of motion to the knee was within normal limits. Deviation From the Expected. The patient underwent 3 visits of physical therapy when upon her 4th visits she stated that she noticed a “swishing sound” when she flexed her knee and painless pressure was reported in the midrange of motion. The portal site were producing exudate and palpable and the patient was referred to her local physician who ordered oral antibiotics. Discussion. Following the MD visit, the patient underwent treatment to address the subcutaneous emphysema and pneumarthrosis which was produced by a communication from the knee joint and surrounding tissue through the portal sites and the environment. Treatment involved two manual techniques to address the edema and the emphysema. Primary treatment required the use of deep “milking” manual technique to migrate the trapped air to the portal sites for evacuation. This technique was followed by complex decongestive therapy with manual lymphatic drainage and compression therapy using short stretch bandages. The patient wore the bandages continuously until she returned for the next visit at which time the treatment was repeated. After 3 weeks of treatment with a frequency of 3 times a week, the pneumarthrosis and subcutaneous emphysema had resolved. Conclusion. It is postulated that the combination of the removal of sutures and a local infection produced and environment in which the portal site dehisced allowing a tunneling to occur and infiltration of ambient air which became trapped within and surrounding the joint. Grants. To be added