The effect of lower limb position on anterior cruciate ligament reconstruction on uncommon complications after surgery
Hamidreza Aslani1, Sona Bonakdar2, Farzad Amoozade2, Mona Gorji3, Amir H Gholami2, Katayoun Tajic2, Morteza Gholipour2
1 Sport Medicine and Knee Research Center, Milad Hospital, Tehran, Iran
2 Clinical Research Development Unit of Akhtar Hospital, Shahid Beheshti University of Medical Science, Tehran, Iran
3 Skin Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
|Date of Submission||29-Jan-2022|
|Date of Acceptance||29-May-2022|
|Date of Web Publication||31-Jul-2023|
Dr. Morteza Gholipour
Clinical Research Development Unit of Akhtar Hospital, Shahid Beheshti University of Medical Science, Tehran
Source of Support: None, Conflict of Interest: None
Background: To reduce the complications of orthopedic surgery, the desire for less invasive procedures, such as, knee arthroscopy to repair the anterior cruciate ligament, has increased. There are, currently, two common positions for limbs that are used during surgery depending on the surgeon's experience. Therefore, our aim was to investigate the effect of limb position on complications after anterior cruciate ligament reconstruction surgery.
Materials and Methods: From April 2016 to July 2020 at our orthopedic-sports trauma center, 688 patients between the ages of 18 and 50 with anterior cruciate ligament rupture underwent reconstruction surgery with a hamstring graft. Patients were divided into two groups in terms of limb position at the time of surgery. For three months, patients were evaluated for surgical complications, basic demographic information, and information during surgery.
Results: There was no statistically significant difference between the two groups in terms of demographic information, side of injury, preparation time, tourniquet time, operation time, and duration of hospitalization. At quarterly follow-up, there was no significant difference between the two groups in terms of postoperative complications (P = 0.976).
Conclusions: There is no difference between compartment syndrome and deep vein thrombosis in different situations, therefore, the surgeon should operate in any position he is skilled in. Also, surgeons should always pay special attention to these complications and provide necessary training to patients in order to prevent them.
Keywords: Anterior cruciate ligament, arthroscopy, compartment syndrome, lower extremity, venous thrombosis
|How to cite this article:|
Aslani H, Bonakdar S, Amoozade F, Gorji M, Gholami AH, Tajic K, Gholipour M. The effect of lower limb position on anterior cruciate ligament reconstruction on uncommon complications after surgery. Adv Biomed Res 2023;12:204
|How to cite this URL:|
Aslani H, Bonakdar S, Amoozade F, Gorji M, Gholami AH, Tajic K, Gholipour M. The effect of lower limb position on anterior cruciate ligament reconstruction on uncommon complications after surgery. Adv Biomed Res [serial online] 2023 [cited 2023 Sep 28];12:204. Available from: https://www.advbiores.net/text.asp?2023/12/1/204/382552
| Introduction|| |
Anterior cruciate ligament reconstruction is a gold standard treatment because its success rate is about 95-97%.,, Anterior cruciate ligament tear is common between the ages of 15-34 years.,, Complications after surgery have been reported between 1-15%, which mainly include deep vein thrombosis, bleeding, and infection. Compartment syndrome is a very rare complication following the reconstruction of the anterior cruciate ligament, it may be because of fluid extravasation to the compartments due to joint capsule damage or may be a result of anterior tibial artery injury during tunnel preparation.,,,,, Deep vein thrombosis and pulmonary embolism following anterior cruciate ligament reconstruction are relatively rare because the prevalence has been reported between 0.2-14%.,, It may be clinically symptomatic or asymptomatic.,, There are currently two common positions for limbs during operation depending on the surgeon's preference; the first one involves limb on the bed in the supine position and the second one involves limb in a hanging position. In addition to the known risk factor for DVT and compartment syndrome, such as surgical technique, non-ambulatory, obesity, and previous DVT the question arises as to whether a limb condition may be causing these complications. To date, no study has been conducted to evaluate the effect of limb positions on these complications in patients undergoing ACL reconstruction. This is a retrospective cohort study in two groups of patients with different limb position for answering this question.
| Materials and Methods|| |
This is a retrospective cohort study on 765 patients between 18 and 50 years, from April 2016 until July 2020, with a definitive diagnosis of anterior cruciate ligament rupture. Eighty-one patients were excluded from the study due to general anesthesia, multiple ligament injuries, affected limb fractures, operated limb burns, history of malignancy, coagulation disorders, peripheral vascular diseases, as well as incomplete electronic records. Finally, 688 patients were included in the study. Demographic information and surgical results of patients were collected from patients' electronic records and patients' operating room records. Ethical approval was obtained from the Ethics Committee of the University of Medical Sciences. The patients underwent reconstruction with hamstring autograft by a single surgeon. All patients had spinal anesthesia. Patients were divided into two groups. The first group placed a limb on the bed in the supine position [Figure 1] and the second group placed a limb in the hanging position (using a well leg holder with the contralateral hip abducted and flexion, and placed in a well-padded leg holder) [Figure 2]. All patients had varicose vein stockings on the opposite leg before surgery. After the surgery, the operate limb was also covered with varicose socks. The patients were encouraged with an ankle pump and range of motion early postoperative period. They received anticoagulant treatment for 2 weeks. The patients were followed up in five periods (first day, 7th and 14th day, sixth week, and third month after operation, for compartment syndrome and deep vein thrombosis mainly. The compartments pressures were measured by the Needle manometers method in anterior, lateral, and all posterior leg compartments. The values below 10-12 mm Hg were considered normal, between 12-30 mm Hg were considered intermediate, and above 30-45 mm Hg were considered abnormal. Patients with progressive pain in the limb and difference in leg diameter of more than 10 cm below the tibia tuberosity underwent arterial and venous Color Doppler Ultrasound, for confirmation. Patients with suspected pulmonary embolism (PE) were hospitalized and screened for pulmonary perfusion and computed tomography angiography.
|Figure 1: A 32-year-old patient with a tear of anterior cruciate ligament who underwent surgery with a supine (on bed) position|
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|Figure 2: A 40-year-old patient with tear of anterior cruciate ligament and medial meniscus who underwent surgery with a hanging position|
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After data collection, Chi-square test and student t-test were used to correlate the qualitative variables and quantitative variables. Data were analyzed by IBM SPSS 16.0 software (SPSS Inc., Chicago, IL, USA) with a significance level of 5% and a 95% confidence interval.
| Results|| |
688 patients were enrolled in this study, 332 patients underwent surgery with a hanging limb position and 352 patients underwent surgery with a supine limb position. The patients were similar in terms of basic characteristics including demographic information, side of injury, preparation time, tourniquet time, and duration of hospitalization, based on [Table 1]. Postoperative complications in patients with hanging vs. supine position were deep vein thrombosis (4.2% vs. 3.4%), compartment syndrome (1.2% vs. 1%), surgical site infection (3% vs. 3.4%), surgical site hematoma (4.5% vs. 3.7%), lower back pain (20.4% vs. 21.2%), headache (4.2% vs. 4.5%) and skin lesions (3.9% vs. 4.2%) respectively, based on [Table 2]. None of the patients in the two groups had pulmonary thromboembolism or neurovascular damage. There were no statistical differences in postoperative complications between the two groups at different follow-up times. (P = 0.976). Patients with compartment syndrome were treated conservatively and did not require fasciotomy. Patients with deep thrombosis were treated with anticoagulants.
|Table 1: Demographic information and Clinical results of patients based on lower limb position in surgery (n=688)|
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| Discussion|| |
Anterior cruciate ligament reconstruction is one of the most common knee injuries, due to sports, which involves surgery today. The main finding of this study is the lack of difference between limb supine and lime hanging position in the incidence of compartment syndrome and deep vein thrombosis. There are many known risk factors and complications following ACL reconstruction. Adala et al., reported 1.78% rate of DVT after ACL reconstruction. Cullison et al. also reported only one case in 67 patients with venous thrombosis. Williams et al. reported 3.5% of DVT and Schippinger et al. reported 8% of venous thrombosis. All of the above studies didn't evaluate the effect of limb position as a risk factor in DVT. The incidence of compartment syndrome after knee arthroscopy was reported to range from 0.0043% (13 of 301,701 cases) to 0.04% (four of 8,500 cases). Rare cases of compartment syndrome following arthroscopic anterior cruciate ligament reconstruction have been reported mainly due to technical errors in literature.,, Yalçin et al. showed during arthroscopic removal of an intra-articular bullet that the joint capsule may rupture and that fluid leakage into surrounding tissues leads to compartment syndrome.
Bomberg et al. reported four cases of compartment syndrome secondary to fluid extravasation when using infusion pump during arthroscopy. Two of the four cases needed fasciotomy. Different limb position was a known risk factor of compartment syndrome in ACL reconstruction. One of the most common risk factors is the lithotomy position.,, The difference between diastolic blood and muscle pressure significantly declined due to external compression in the cuffin lithotomy position, so an increased perfusion pressure was needed. Halliwill et al., in a study of the effect of different lithotomy positions on lower limb blood pressure, found the predicted systolic pressure in the lithotomy position was lower than measured one. Therefore, to reduce blood pressure in the lower extremities, the lithotomy position should be used intermittently. Limb position is a concern during ACL reconstruction, so a suitable position is important to reduce the complications. There are two limb positions during ACL reconstruction, limb hanging and limb on the bed. We could not find any study that has been conducted to evaluate the effect of limb positions in patients undergoing ACL surgery up to now. Our main question was whether limb position has an effect on compartment syndrome and DVT in ACL reconstruction. The incidence of deep vein thrombosis in limb hanging position was 4.2% and in limb supine position was 3.4%. The incidence of compartment syndrome in limb hanging position was 1.2% and in limb supine position was 1%. There is no significant difference in the incidence of deep vein thrombosis and compartment syndrome in limb positions based on this study. These findings show that the two positions. supine and hanging, do not change the blood flow status of the lower extremities, which is consistent with the results of other studies related to surgical complications. Limitations of this study were: 1) Patients were operated on by 2 orthopedic surgeons. The surgeon's experience was involved in choosing the surgical position, which may cause problems in the results. 2) Due to changes in the patient's hemodynamic status, the supine position was inevitably used in some patients.
| Conclusions|| |
The risk of compartment syndrome and deep vein thrombosis following knee arthroscopy is slightly related to limb condition during surgery. It may cause these rare complications and is associated with high morbidity. Hence, surgeons should always pay attention to this issue and keep it at the back of their minds. Surgeons must carefully monitor patients and provide pat them with necessary training such as the use of ankle pumps, isometric quadriceps exercises, and the use of compression stockings.
Declaration of patient consent
The authors declare that they have obtained consent from patients. Patients have given their consent for their images and other clinical information to be reported in the journal. Patients understand that their names will not be published and due efforts will be made to conceal their identity but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Stewart BA, Momaya AM, Silverstein MD, Lintner D. The cost-effectiveness of anterior cruciate ligament reconstruction in competitive athletes. AmJSports Med 2017;45:23-33.
Gunderson T. Orthopedic Overview. US Bancorp Piper Jaffray Equity Research; 1999.
Renstrom P, Ljungqvist A, Arendt E, Beynnon B, Fukubayashi T, Garrett W, et al
. Non-contact ACL injuries in female athletes: An International Olympic Committee current concepts statement. BrJSports Med 2008;42:394-412.
Baer GS, Harner CD. Clinical outcomes of allograft versus autograft in anterior cruciate ligament reconstruction. ClinSports Med 2007;26:661-81.
McCullough KA, Phelps KD, Spindler KP, Matava MJ, Dunn WR, Parker RD, et al
. Return to high school–and college-level football after anterior cruciate ligament reconstruction: A multicenter orthopaedic outcomes network (MOON) cohort study. AmJSports Med 2012;40:2523-9.
Tay KS, Tan AHC. Clinical outcomes, return to sports, and patient satisfaction after anterior cruciate ligament reconstruction in young and middle-aged patients in an asian population—A2-year follow-up study. Arthroscopy 2018;34:1054-9.
Cinque ME, Chahla J, Moatshe G, DePhillipo NN, Kennedy NI, Godin JA, et al
. Outcomes and complication rates after primary anterior cruciate ligament reconstruction are similar in younger and older patients. Orthopaedic JSports Med 2017;5:2325967117729659.
Mayr H, Stoehr A. Komplikationen arthroskopischer Eingriffe am Kniegelenk. Der Orthopäde 2016;45:4-12.
Marti CB, Jakob RP. Case report accumulation of irrigation fluid in the calf as a complication during high tibial osteotomy combined with simultaneous arthroscopic anterior cruciate ligament reconstruction. Arthroscopy 1999;15:864-6.
Kaper BP, Carr CF, Shirreffs TG. Compartment syndrome after arthroscopic surgery of knee: A report of two cases managed nonoperatively. AmJSports Med 1997;25:123-5.
Fruensgaard S, Holm A. Compartment syndrome complicating arthroscopic surgery: Brief report. JBone Joint SurgBr1988;70:146-7.
Nillius A, Rööser B. Acute compartment syndrome in knee arthroscopy. Lakartidningen 1983;80:590.
Peek RD, Haynes DW. Compartment syndrome as a complication of arthroscopy: A case report and a study of interstitial pressures. Am J Sports Med 1984;12:464-8.
Yalçin S, Oltulu İ, Erdil ME, Örmeci T. Compartment syndrome following arthroscopic removal of a bullet in the knee joint after a low-velocity gunshot injury. Clin Orthop Surg 2016;8:115-8.
Janssen RPA, Reijman M, Janssen DM, Van Mourik JBA. Arterial complications, venous thromboembolism and deep venous thrombosis prophylaxis after anterior cruciate ligament reconstruction: A systematic review. World JOrthop 2016;7:604-17.
Kibler W, Chandler TJ, Uhl T, Maddux RE. A musculoskeletal approach to the preparticipation physical examination: Preventing injury and improving performance. Am J Sports Med 1989;17:525-31.
Gaskill T, Pullen M, Bryant B, Sicignano N, Evans AM, DeMaio M. The prevalence of symptomatic deep venous thrombosis and pulmonary embolism after anterior cruciate ligament reconstruction. Am J Sports Med 2015;43:2714-9.
Ye S, Dongyang C, Zhihong X, Dongquan S, Jin D, Jianghui Q, et al
. The incidence of deep venous thrombosis after arthroscopically assisted anterior cruciate ligament reconstruction. Arthroscopy 2013;29:742-7.
Büyükyılmaz F, Şendir M, Autar R, Yazgan İ. Risk level analysis for deep vein thrombosis (DVT): A study of Turkish patients undergoing major orthopedic surgery. J Vasc Nurs 2015;33:100-5.
Saikia K, Bhattacharya T, Agarwala V. Anterior compartment pressure measurement in closed fractures of leg. Indian JOrthop 2008;42:217-21.
Paschos NK, Howell SM. Anterior cruciate ligament reconstruction: Principles of treatment. EFORT Open Rev 2016;1:398-408.
Adala R, Anand A, Kodikal G. Deep vein thrombosis and thromboprophylaxis in arthroscopic anterior cruciate ligament reconstruction. Indian J Orthop 2011;45:450-3.
] [Full text]
Cullison TR, Muldoon MP, Gorman JD, Goff WB. The incidence of deep venous thrombosis in anterior cruciate ligament reconstruction. Arthroscopy 1996;12:657-9.
Williams JS Jr, Hulstyn MJ, Fadale PD, Lindy PB, Ehrlich MG, Cronan J, et al
. Incidence of deep vein thrombosis after arthroscopic knee surgery: A prospective study. Arthroscopy 199511:701-5.
Schippinger G, Wirnsberger GH, Obernosterer A, Babinski K. Thromboembolic complications after arthroscopic knee surgery. Incidence and risk factors in 101 patients. Acta Orthop Scand 1998;69:144-6.
Bamford DJ, Paul AS, Noble J, Davies DR. Avoidable complications of arthroscopic surgery. J R Coll Surg Edinb 1993;38:92-5.
Siegel MG. Compartment syndrome after arthroscopic surgery of the knee. A report of two cases managed nonoperatively. Am J Sports Med 1997;25:589-90.
Mendel T, Wohlrab D, Hofmann GO. [Acute compartment syndrome of the lower leg due to knee arthroscopy]. Orthopade 2011;40:925-8.
Bomberg BC, Hurley PE, Clark CA, McLaughlin CS. Complications associated with the use of an infusion pump during knee arthroscopy. Arthroscopy 1992;8:224-8.
Meyer RS, White KK, Smith JM, Groppo ER, Mubarak SJ, Hargens AR. Intramuscular and blood pressures in legs positioned in the hemilithotomy position: Clarification of risk factors for well-leg acute compartment syndrome. J Bone Joint Surg Am 2002;84:1829-35.
Lydon JC, Spielman FJ. Bilateral compartment syndrome following prolonged surgery in the lithotomy position. Anesthesiology 1984;60:236-8.
MacIntosh EL, Blanchard RJ. Compartment syndrome after surgery in the lithotomy position. Can J Surg 1991;34:359-62.
Halliwill JR, Hewitt SA, Joyner MJ, Warner MA. Effect of various lithotomy positions on lower-extremity blood pressure. Anesthesiology 1998;89:1373-6.
Abdul W, Hickey B, Wilson C. Case report: Lower extremity compartment syndrome in the setting of iliofemoral deep vein thrombosis, phlegmasia cerulea dolens and factor VII deficiency. BMJ Case Rep 2016;2016:bcr-2016-215078.
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[Table 1], [Table 2]