Suggested Guidelines for the Practice of Arthroscopic Surgery

Abstract Background Opioids continue to be the analgesic of choice for postoperative pain control following arthroscopic knee and shoulder surgery. Despite their widespread use, there are limited evidence-based clinical practice guidelines for postoperative opioid prescribing. The Non-Opioid Prescriptions after Arthroscopic Surgery in Canada (NO PAin) Trial is a randomized controlled trial (RCT) designed to determine whether a non-opioid analgesia approach to postoperative pain, compared to usual care, reduces oral morphine equivalents (OME) consumed in patients undergoing outpatient knee and shoulder arthroscopy. Methods This is a multi-centre, RCT with a target sample size of 200 patients. Adult (18+ years of age) patients undergoing outpatient knee and shoulder arthroscopy will be randomized to a non-opioid postoperative protocol (intervention) or the current standard of care (control). The intervention will consist of a standardized non-opioid analgesic prescription, a limited rescue opioid prescription, and a patient education infographic. The control is defined as the treating surgeons’ pre-trial postoperative analgesic regimen. Exclusion criteria include chronic opioid use, concomitant open surgery, contraindications to the prescribed analgesics or ongoing workers compensation/litigation. The primary outcome is OMEs consumed at 6 weeks postoperatively. Secondary outcomes will include patient-reported pain and satisfaction, quantity of OMEs prescribed, number of opioid refills, and any adverse events up to 6 weeks postoperatively. Utilizing the intention to treat principle for all analyses, independent samples t-test and presented with a p-value as well as a mean difference (MD) with 95% confidence intervals (CIs) will be performed for primary and secondary outcomes. Discussion The ongoing opioid epidemic and overprescribing of opioids in orthopaedics serve as the rationale for this trial. There is a lack of evidence upon which to develop post-operative pain management guidelines for patients undergoing arthroscopic surgery. A prospective evaluation of this relatively inexpensive intervention will demonstrate whether an explicit effort to reduce the number of opioids prescribed results in a reduction in the amount of opioids consumed and help to inform future studies and guidelines. Trial registration The NO PAin trial has been prospectively registered with clinicaltrials.gov (NCT04566250).

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Comment on “Comparison of open arthrotomy versus arthroscopic surgery for the treatment of septic arthritis in adults: a systematic review and meta-analysis”

International Orthopaedics ◽

10.1007/s00264-021-05158-3 ◽

2021 ◽

Author(s):

Yuquan Wang ◽

Lingjun Kong ◽

Haixia Ding

Keyword(s):

Systematic Review ◽

Septic Arthritis ◽

Meta Analysis ◽

Arthroscopic Surgery ◽

Open Arthrotomy

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The ‘wave sign’ in hip arthroscopy: a systematic review of epidemiological factors, current diagnostic methods and treatment options

Journal of Hip Preservation Surgery ◽

10.1093/jhps/hnaa058 ◽

2020 ◽

Author(s):

Jason Derry Onggo ◽

James Randolph Onggo ◽

Mithun Nambiar ◽

Andrew Duong ◽

Olufemi R Ayeni ◽

...

Keyword(s):

Risk Factors ◽

Systematic Review ◽

Protective Factor ◽

Treatment Options ◽

Arthroscopic Surgery ◽

Classification Systems ◽

Diagnostic Methods ◽

Suture Repair ◽

Significant Heterogeneity ◽

Epidemiological Factors

ABSTRACT This study aims to present a systematic review and synthesized evidence on the epidemiological factors, diagnostic methods and treatment options available for this phenomenon. A multi-database search (OVID Medline, EMBASE and PubMed) was performed according to PRISMA guidelines on 18 June 2019. All studies of any study design discussing on the epidemiological factors, diagnostic methods, classification systems and treatment options of the wave sign were included. The Newcastle–Ottawa quality assessment tool was used to appraise articles. No quantitative analysis could be performed due to heterogeneous data reported; 11 studies with a total of 501 patients with the wave sign were included. Three studies examined risk factors for wave sign and concluded that cam lesions were most common. Other risk factors include alpha angle >65° (OR=4.00, 95% CI: 1.26–12.71, P=0.02), male gender (OR 2.24, 95% CI: 1.09–4.62, P=0.03) and older age (OR=1.04, 95% CI: 1.01–1.07, P=0.03). Increased acetabular coverage in setting of concurrent cam lesions may be a protective factor. Wave signs most commonly occur at the anterior, superior and anterosuperior acetabulum. In terms of staging accuracy, the Haddad classification had the highest coefficients in intraclass correlation (k=0.81, 95% CI: 0.23–0.95, P=0.011), inter-observer reliability (k=0.88, 95% CI: 0.72–0.97, P<0.001) and internal validity (k=0.89). One study investigated the utility of quantitative magnetic imaging for wave sign, concluding that significant heterogeneity in T1ρ and T2 values (P<0.05) of acetabular cartilage is indicative of acetabular debonding. Four studies reported treatment techniques, including bridging suture repair, reverse microfracture with bubble decompression and microfracture with fibrin adhesive glue, with the latter reporting statistically significant improvements in modified Harris hip scores at 6-months (MD=19.2, P<0.05), 12-months (MD=22.0, P<0.05) and 28-months (MD=17.5, P<0.001). No clinical studies were available for other treatment options. There is a scarcity of literature on the wave sign. Identifying at risk symptomatic patients is important to provide prompt diagnosis and treatment. Diagnostic techniques and operative options are still in early developmental stages. More research is needed to understand the natural history of wave sign lesions after arthroscopic surgery and whether intervention can improve long-term outcomes. Level IV, Systematic review of non-homogeneous studies.

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Multivariate ordered logistic regression analysis of the postoperative effect of symptomatic discoid lateral meniscus

Archives of Orthopaedic and Trauma Surgery ◽

10.1007/s00402-021-03821-3 ◽

2021 ◽

Author(s):

Shun-Jie Yang ◽

Jian Li ◽

Yang Xue ◽

Zhong Zhang ◽

Gang Chen

Keyword(s):

Logistic Regression ◽

Age Of Onset ◽

Univariate Analysis ◽

Arthroscopic Surgery ◽

Lateral Meniscus ◽

Postoperative Outcomes ◽

Discoid Lateral Meniscus ◽

Work Intensity ◽

Duration Of Symptoms ◽

Ordered Logistic Regression

Abstract Introduction The postoperative effect of arthroscopy in the treatment of symptomatic discoid lateral meniscus (DLM) varies greatly among individuals. Therefore, this study aims to investigate the factors affecting the postoperative outcomes of symptomatic DLM. Materials and methods According to the inclusion and exclusion criteria, patients with symptomatic single-knee DLM who underwent arthroscopic surgery at our hospital from 9/2008 to 9/2015 were included. Retrospectively collected 16 factors probably affecting postoperative outcomes. The Ikeuchi grade system was used to evaluate the knee joint function. Univariate analysis was performed by Kruskal–Wallis rank-sum test or Mann–Whitney U test, and multivariate analysis by ordered logistic regression. P < 0.05 was considered statistically significant. Results A sum of 502 patients was included, including 353 females (70.3%) and 149 males (29.7%). Difference between preoperative and postoperative Ikeuchi grade was statistically significant (P < 0.001). Female was bad to obtain a good Ikeuchi grade (P = 0.009, OR 0.458). Outerbridge grade (P = 0.018, OR 0.638) was negatively correlated with Ikeuchi grade. BMI (P = 0.001, OR 0.875) and work intensity (P = 0.020, OR 0.611) were inversely correlated with Ikeuchi grade. Age of onset (P < 0.001, OR 0.956) and symptoms duration (P < 0.001, OR 0.988) were negatively correlated with Ikeuchi grade. Besides, compared to total meniscectomy, meniscoplasty with a repair was an unfavourable factor for Ikeuchi grade (P = 0.044, OR 0.245). Conclusions With the increase of BMI, work intensity, age of onset, duration of symptoms, and the severity of cartilage lesion, the postoperative results become worse. Moreover, female and meniscoplasty with repair are risk factors for the postoperative outcomes.

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Pre-Planned and Non-Planned Agility in Patients Ongoing Rehabilitation after Knee Surgery: Design, Reliability and Validity of the Newly Developed Testing Protocols

Diagnostics ◽

10.3390/diagnostics11010146 ◽

2021 ◽

Vol 11 (1) ◽

pp. 146

Author(s):

Ivan Peric ◽

Miodrag Spasic ◽

Dario Novak ◽

Sergej Ostojic ◽

Damir Sekulic

Keyword(s):

Total Knee Arthroplasty ◽

Body Mass ◽

Knee Arthroplasty ◽

Arthroscopic Surgery ◽

The Body ◽

Clinical Population ◽

Pearson's R ◽

Total Knee ◽

Type Of Surgery ◽

Pearson’S R

Background: Due to its association with the risk of falling and consequent injury, the importance of agility is widely recognized, but no study so far has examined the different facets of agility in an untrained/clinical population. The aim of this study was to evaluate the reliability, validity, and correlates of newly developed tests of non-planned agility (NPA) and pre-planned agility (PPA) in an untrained/clinical sample. Methods: The sample comprised 38 participants older than 40 years (22 females, age: 56.1 ± 17.3 years, height: 170.4 ± 10.8 cm, mass: 82.54 ± 14.79 kg) who were involved in a rehabilitation program following total knee arthroplasty and knee arthroscopy. Variables included age, gender, type of surgery, history of fall, anthropometrics/body composition, and newly developed tests of NPA and PPA. Results: The results showed the high inter-testing- (ICC > 0.95, CV < 9%), and intra-testing-reliability (ICC > 0.96, CV < 9) of the newly developed tests. PPA and NPA were found to be valid in differentiation between age groups (>50 yrs. vs. <50 yrs.), and genders, with better performance in younger participants and males. Only NPA differentiated participants according to type of surgery, with better performance in those who had arthroscopic surgery, than those who had total knee arthroplasty. No differences in NPA and PPA were established between groups based on fall-history. In females, the body mass (Pearson’s r = 0.58 and 0.59, p < 0.001) and body fatness (Pearson’s r = 0.64 and 0.66, p < 0.001) were negatively correlated, while the lean body mass (Pearson’s r = 0.70 and 0.68, p < 0.001) was positively correlated with PPA and NPA. The NPA and PPA were highly correlated (Pearson’s r = 0.98, p < 0.001). Conclusions: We found that the proposed tests are reliable when evaluating agility characteristics in an untrained/clinical population after knee arthroplasty/arthroscopy. Further evaluation of the specific validity of the proposed tests in other specific subsamples is warranted.

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Influence of Femoral Version on the Outcomes of Hip Arthroscopic Surgery for Femoroacetabular Impingement or Labral Tears: A Systematic Review and Meta-analysis

Orthopaedic Journal of Sports Medicine ◽

10.1177/23259671211009192 ◽

2021 ◽

Vol 9 (6) ◽

pp. 232596712110091

Author(s):

Chenghui Wang ◽

Yaying Sun ◽

Zheci Ding ◽

Jinrong Lin ◽

Zhiwen Luo ◽

...

Keyword(s):

Systematic Review ◽

Patient Satisfaction ◽

Femoroacetabular Impingement ◽

Arthroscopic Surgery ◽

Harris Hip Score ◽

Cochrane Library ◽

Femoral Version ◽

Labral Tears ◽

Significant Difference ◽

Secondary Outcomes

Background: It remains controversial whether abnormal femoral version (FV) affects the outcomes of hip arthroscopic surgery for femoroacetabular impingement (FAI) or labral tears. Purpose: To review the outcomes of hip arthroscopic surgery for FAI or labral tears in patients with normal versus abnormal FV. Study Design: Systematic review; Level of evidence, 4. Methods: Embase, PubMed, and the Cochrane Library were searched in July 2020 for studies reporting the outcomes after primary hip arthroscopic surgery for FAI or labral tears in patients with femoral retroversion (<5°), femoral anteversion (>20°), or normal FV (5°-20°). The primary outcome was the modified Harris Hip Score (mHHS), and secondary outcomes were the visual analog scale (VAS) for pain, Hip Outcome Score–Sport-Specific Subscale (HOS-SSS), Non-Arthritic Hip Score (NAHS), failure rate, and patient satisfaction. The difference in preoperative and postoperative scores (Δ) was also calculated when applicable. Results: Included in this review were 5 studies with 822 patients who underwent hip arthroscopic surgery for FAI or labral tears; there were 166 patients with retroversion, 512 patients with normal version, and 144 patients with anteversion. Patients with retroversion and normal version had similar postoperative mHHS scores (mean difference [MD], 2.42 [95% confidence interval (CI), –3.42 to 8.26]; P = .42) and ΔmHHS scores (MD, –0.70 [96% CI, –8.56 to 7.15]; P = .86). Likewise, the patients with anteversion and normal version had similar postoperative mHHS scores (MD, –3.09 [95% CI, –7.66 to 1.48]; P = .18) and ΔmHHS scores (MD, –1.92 [95% CI, –6.18 to 2.34]; P = .38). Regarding secondary outcomes, patients with retroversion and anteversion had similar ΔNAHS scores, ΔHOS-SSS scores, ΔVAS scores, patient satisfaction, and failure rates to those with normal version, although a significant difference was found between the patients with retroversion and normal version regarding postoperative NAHS scores (MD, 5.96 [95% CI, 1.66-10.26]; P = .007) and postoperative HOS-SSS scores (MD, 7.32 [95% CI, 0.19-14.44]; P = .04). Conclusion: The results of this review indicated that abnormal FV did not significantly influence outcomes after hip arthroscopic surgery for FAI or labral tears.

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