Venous thromboembolism prophylaxis after ambulatory arthroscopic knee surgery: a systematic review and meta-analysis of incidence and risk factors (109)

Objectives: Over 100,000 anterior cruciate ligament (ACL) reconstructions are performed in the United States annually, yet the reported incidence of venous thromboembolism (VTE) and the use of VTE thromboprophylaxis after ACL reconstruction and other arthroscopic knee surgeries still varies widely. Current VTE risk assessment scores, for example the Caprini score, incorporate arthroscopic surgery as a known risk factor but were not developed for stratification of an outpatient ambulatory surgical patient population. There is no current consensus to guide the orthopedic surgeon in prescribing chemoprophylactic agents after arthroscopic knee surgery. The objectives of this study were to determine the incidence, efficacy, and risk factors for VTE specifically following knee arthroscopic procedures. The null hypotheses of this study was that previously defined risk factors for VTE after ambulatory knee arthroscopy (age over 60 years, BMI greater than 30 kg/m2, tobacco use, prior VTE, malignancy, coagulopathy, oral contraceptive use, family history of coagulopathy, and prolonged tourniquet time greater than 90 minutes) would not reach statistical significance when compared across multiple cohorts. Our hypothesis is that a systematic review and meta-analysis of these variables will reject the null hypotheses with a significance of level of p < .05. Methods: A systematic review and meta-analysis was performed using data collected from 30 cohort and therapeutic trials (721,005 patients) published between January 2000 and April 2020 to compare both the incidence of deep vein thrombosis (DVT) and/or pulmonary embolism (PE) and associated risk factors after knee arthroscopy with or without thromboprophylaxis in adults. Ultrasound, venography, and International Classification of Diseases, 10th Revision (ICD-10) diagnosis codes were deemed acceptable detection methods for VTE. We also performed a meta-analysis of published patient characteristics and risk factors in developing VTE after arthroscopic knee procedures. Individual studies were not evaluated for symptomatic versus asymptomatic VTE detection criteria or methods. Results: Of 331 eligible articles, 6 therapeutic RCTs and 24 cohort studies met the inclusion criteria. Overall incidence of DVT and PE was found to be 0.97% and 0.03% respectively. Analysis of the RCTs was found to support the use of prophylactic anticoagulation in preventing DVTs (relative risk: 0.24, 95% confidence interval [CI]: 0.13-0.44). After analysis of the cohort studies, age greater than 60 years was found to be a statistically significant risk factor for VTE (OR: 1.84, 95% CI: 1.03 – 3.29; p=.04) while a history of malignancy (OR: 2.61, 95% CI: 0.97 – 7.00; p=.06), and history of previous VTE (OR: 4.14, 95% CI: 0.90 – 19.14, p=.07) trended toward significance. Other factors such as BMI greater than 30 kg/m2, tobacco use, tourniquet time, personal or family history of coagulopathy, and oral contraceptive use were not found to be statistically significant risk factors for VTE after knee arthroscopy, however there were limited studies (one to three studies per risk factor) available to distinguish of a majority of these variables. Conclusions: Our results show that the overall incidence of DVT in adults after arthroscopic knee surgery is approaching 1% and that of PE is exceedingly rare, however this may be underestimated if asymptomatic VTE is not identified. Despite a low incidence of VTE after knee arthroscopy, thromboprophylaxis is effective in preventing VTE and trends in risk factors exist in ambulatory sports medicine patients diagnosed with VTE post-operatively. The risk for adverse bleeding events while taking chemoprophylaxis and requires further research. Only rejection of the null hypothesis on age over 60 years was statistically significant, however other defined risk factors may be clinically significant. With these results, we conclude that a preoperative assessment may be warranted in identifying at-risk, high risk, or multi-risk patients for which prophylactic anticoagulation postoperatively after knee arthroscopic procedures may be beneficial. A modified version of the Caprini score specifically stratifying these risk factors in an ambulatory sports medicine population may be valuable to the practicing orthopedic arthroscopic surgeon. More research is warranted for identifying risk factors to better stratify this unique patient population.

Comparison of the effects of combined neuraxial anesthesia and multicomponent low-flow inhalation anesthesia in the structure of perioperative anesthesia management in arthroscopic knee surgeries

Background. Arthroscopic knee surgery is one of the most common types of surgeries in the world. But the optimal anesthesia management for this type of orthopedic surgery is still debatable. The purpose of the study was to improve the quality of anesthesia management for arthroscopic interventions on the knee joint by introducing a personalized perioperative anesthesia management. Materials and methods. One hundred and forty-two patients aged 18–78 years, who underwent arthroscopic knee surgery, took part in the study. They were randomized into 2 groups according to the type of anesthesia chosen by the patient. In the first group (n1 = 82), individuals underwent neuraxial anesthesia in combination with intravenous administration of dexmedetomidine, in the second group (n2 = 60) — multicomponent low-flow inhalation anesthesia with sevoflurane combined with multimodal analgesia. Before the operation, the level of preoperative stress was assessed. During the first 24 hours after surgery, we have evaluated the level of postoperative pain by the visual analogue scale, the incidence of postoperative nausea and vomiting, and overall patient’s satisfaction with the surgery. Results. The level of pain according to the visual analogue scale, the incidence of postoperative nausea and vomiting, the level of satisfaction in the study groups did not differ significantly. The level of preoperative stress had a significant impact on the patient’s choice regarding the type of anesthesia. Conclusions. Neuraxial and general anesthesia for arthroscopic knee surgery has advantages and disadvantages. Decision-making on the method of anesthesia should be based on the patient’s wishes and possible previous surgical experience.

High incidence of acute self-reported sleep disturbances in patients following arthroscopic-assisted knee surgery

ObjectivesTo evaluate the self-reported incidence of sleep disturbances, defined as ≤7 hours of sleep per 24-hour period, in patients undergoing arthroscopic-assisted knee surgery.MethodsPatients who underwent arthroscopic knee surgery over the course of a 4-month period were prospectively included. Patients were excluded if a history of insomnia or other sleep altering medical history was reported. Self-reported sleep metrics included average number of hours of sleep per night, average number of awakenings during sleep per night, perceived quality of sleep, average pain level during sleep and number of hours of physical activity/therapy per week. Data were collected at weeks 1, 3, and 6 postoperatively. Joint circumference was measured on postoperative day 1 and served as an indicator of a knee effusion. Paired t-tests were used to compare preoperative to postoperative hours of sleep. Simple and multiple linear regression were used to evaluate relationships between surgical variables and postoperative sleep metrics.ResultsThere were 123 patients who underwent arthroscopic knee surgery during the prospective enrolment period; 83 patients were included in the final analysis. The overall incidence of preoperative sleep disturbances was 20% (n=17). The overall incidence of self-reported postoperative sleep disturbances was 99%, 96% and 90% at weeks 1, 3 and 6, respectively. The average number of hours slept was significantly reduced at 1, 3 and 6 weeks postoperatively compared with the preinjury state (p<0.001). Knee joint circumference had a significantly negative correlation with average number of hours of sleep in the first 6 weeks postoperatively (R=−0.704; p=0.001). Surgical variables including severity of surgery, weekly postoperative pain level and weekly hours of postoperative physical therapy were not significant independent predictors of acute postoperative sleep disturbances (p>0.05).ConclusionSleep disturbances were commonly reported in patients following arthroscopic knee surgery without correction of sleep metrics by 6 weeks postoperatively. The majority of sleep disturbances in this cohort correlated with an increased knee effusion. A multidisciplinary team approach is recommended to counsel patients regarding the potential for and problems with acute sleep disturbances following arthroscopic knee surgery.Level of evidence: 3.

Earlier Is Better? Timing of Adductor Canal Block for Arthroscopic Knee Surgery under General Anesthesia: A Retrospective Cohort Study

The adductor canal block (ACB) is effective for treating postoperative pain during arthroscopic knee surgery, but its impact on anesthesia course and the optimal administration timing are unknown. This retrospective study addressed these questions. The aim of this study was to compare the effects of preoperative ACB and postoperative ACB on anesthesia course and postoperative recovery. We allocated 215 adult patients who underwent arthroscopic knee surgery under sevoflurane anesthesia between January 2019 and December 2019 to three groups. Group A received general anesthesia without ACB, Group B received ACB before general anesthesia induction, and Group C received ACB in the post-anesthesia recovery unit (PACU). Group B consumed significantly less sevoflurane (0.19 mL/kg/h) and milligram morphine equivalents (0.08 MME) intraoperatively than Groups A (0.22 mL/kg/h; 0.10 MME, respectively) and C (0.22 mL/kg/h; 0.09 MME, respectively). Groups B and C had lower visual analogue scale (VAS) scores upon PACU discharge than Group A. Dynamic, but not at-rest VAS scores, were significantly higher in Group A. Opioid consumption was similar in the ward, but Group A requested more intravenous parecoxib for pain relief. Length of hospital stay was similar. Thus, preoperative ACB reduced the amount of volatile anesthetic required and maintained stable hemodynamics intraoperatively. Preoperative or postoperative ACB improved postoperative pain control. Consequently, preoperative ACB is optimal for intraoperative stress suppression and postoperative pain control.

COMPARISON OF THE EFFECTS OF COMBINED NEURAXIAL ANESTHESIA AND MULTICOMPONENT LOW-FLOW INHALATION ANESTHESIA IN THE STRUCTURE OF PERIOPERATIVE ANESTHETIC MANAGEMENT IN PATIENTS UNDERGOING ARTHROSCOPIC INTERVENTIONS ON THE KNEE JOINT

Arthroscopic knee surgery (AKS) is one of the most common types of surgery in the world. But there is still a debate about the optimal type of anesthetic management for this type of orthopedic surgery. The purpose of the study was to improve the quality of anesthetic management of arthroscopic interventions on the knee joint by introducing personalized perioperative anesthesia management. Materials and methods: 142 patients, aged 18-78 years, who were planned for AKS, took part in the study. The patients were randomized into 2 groups according to the type of anesthesia chosen by the patient. In the first group (n1 = 82) patients underwent neuraxial anesthesia in combination with intravenous administration of dexmedetomidine, in the second group (n2 = 60) – multicomponent low-flow inhalation anesthesia with sevoflurane in combination with multimodal analgesia. Before the operation, the level of preoperative stress was assessed. During the first 24 hours after surgery, the level of postoperative pain was assessed by the VAS, the incidence of PONV, and overall patient satisfaction with the surgery. Results: the level of pain according to the VAS, the incidence of PONV, the level of satisfaction in the study groups did not differ significantly. Conclusions: Neuraxial and general anesthesia for arthroscopic knee surgery has advantages and disadvantages. The patient’s choice of one or another type of anesthetic aid was significantly influenced by the level of preoperative stress. Decision-making on the method of anesthesia should be based on the patient’s wishes and possible previous surgical experience.

Efficiency of gravitational therapy in complex rehabilitation of patients after arthroscopic knee operations

An analysis of the effectiveness of the complex of medical rehabilitation of patients with minimally invasive knee operations in the early and late postoperative periods, which provides for the use of gravity therapy with dosed muscle work of the lower extremities. To assess the effectiveness of the rehabilitation complex, patients of the studied groups were subjected to knee joint goniometry, rheovasography and electrothermometry of the lower extremities, as well as evaluation by the visual-analog pain scale and the total algofunctional Leken index. The result of the study shows that earlier inclusion of the gravitational factor in combination with dosed physical activity in the rehabilitation complex increases its effectiveness and can significantly reduce negative manifestations due to pathogenetic action in patients who have undergone arthroscopic knee surgery.

Intra-articular magnesium to alleviate postoperative pain after arthroscopic knee surgery: a meta-analysis of randomized controlled trials

Objective We aimed to evaluate the safety and efficacy of intra-articular (IA) magnesium (Mg) for postoperative pain relief after arthroscopic knee surgery. Methods We searched PubMed, Embase, Medline, Cochrane library, and Web of Science to identify randomized controlled trials that compared postoperative pain outcomes with or without IA Mg after knee arthroscopy. The primary outcomes were pain intensity at rest and with movement at different postoperative time points and cumulative opioid consumption within 24 h after surgery. Secondary outcomes included the time to first analgesic request and side effects. Results In total, 11 studies involving 677 participants met the eligibility criteria. Pain scores at rest and with movement 2, 4, 12, and 24 h after surgery were significantly lower, doses of supplementary opioid consumption were smaller, and the time to first analgesic requirement was longer in the IA Mg group compared with the control group. No significant difference was detected regarding adverse reactions between the groups. Conclusions Intra-articular magnesium is an effective and safe coadjuvant treatment for relieving postoperative pain intensity after arthroscopic knee surgery. Protocol registration at PROSPERO: CRD42020156403.

Intra-articular Magnesium to Alleviate Postoperative Pain After Arthroscopic Knee Surgery: A Meta-analysis of Randomized Controlled Trials

Objective: We aimed to evaluate the safety and efficacy of intra-articular (IA) magnesium (Mg) for postoperative pain relief after arthroscopic knee surgery. Methods. We searched PubMed, Embase, Medline, Cochrane library, and Web of Science to identify randomized controlled trials that compared postoperative pain outcomes with or without IA Mg after knee arthroscopy. The primary outcomes were pain intensity at rest and with movement at different postoperative time points and cumulative opioid consumption within 24 hours after surgery. Secondary outcomes included the time to first analgesic request and side effects. Results. In total, 11 studies involving 677 participants met the eligibility criteria. Pain scores at rest and with movement 2, 4, 12, and 24 h after surgery were significantly lower, doses of supplementary opioid consumption were smaller, and the time to first analgesic requirement was longer in the IA Mg group compared with the control group. No significant difference was detected regarding adverse reactions between the groups. Conclusions. Intra-articular magnesium is an effective and safe coadjuvant treatment for relieving postoperative pain intensity after arthroscopic knee surgery.Protocol registration at Prospero: CRD42020156403.