ED90 of spinal 2-chloroprocaine 1% in ambulatory knee arthroscopy up to 45 min: a randomized biased-coin- up-and-down sequential allocation trial

BackgroundA short acting spinal anesthetic facilitates smooth flow since quick recovery of motor function will facilitate unassisted ambulation. The aim of this study was to estimate the effective dose (ED90) of intrathecal 2-chloroprocaine 1% in outpatient knee arthroscopy.MethodsTwo cohorts were included in two different hospitals. In cohort I, a randomized biased-coin up-and-down design with 40 patients was used to find the ED90. Four dose-levels of plain 2-chloroprocaine 1% were used: 25, 30, 35 and 40 mg. The identified primary outcome, the ED90, was validated in 50 patients in cohort II with an open label design. Secondary outcomes included time to complete recovery from motor and sensory block with spinal injection as time zero, peak sensory block level, urine retention and time until hospital discharge.ResultsForty patients were included in the final analysis in cohort I. The ED90 was estimated at 27.8 mg, successful spinal anesthesia was obtained in 38 patients (95%). Fifty patients were included in the final analysis in cohort II, 49 patients had successful anesthesia with a fixed round dose of 28 mg. In this Cohort, peak sensory block was T10/T11 (range: (L4–T4)). The median time to full recovery of the motor block was 60 min (45–60) and 90 min (75–105) for the sensory block. The mean time to hospital discharge was 2.9 hours (0.7).ConclusionThe ED90 of 2-chloroprocaine 1% in knee arthroscopy was estimated to be 27.8 mg. In an external population, the ED90 resulted in successful anesthesia in 98% of the patients (95% CI 89% to 100%).Trial registration numberNetherlands Trial Registry (NL6769).

Total Knee Arthroplasty following Knee Arthroscopy in Patients over 50

The purpose of this study was to evaluate the conversion rate of knee arthroscopy to ipsilateral total knee arthroplasty (TKA) within 2 years in patients aged 50 or older at the time of arthroscopy. The administrative database from a large, physician-owned orthopaedic practice (>100 surgeons) was queried to identify patients over the age of 50 who had undergone arthroscopic knee surgery between January 1, 2006 and January 2, 2015. The subset of patients who converted to TKA within 2 years after knee arthroscopy was identified and matched by age and sex to a control population that did not convert to TKA. Rates of conversion to TKA were calculated. Prearthroscopic digital radiographs were reviewed and Kellgren–Lawrence (KL) grades were compared among case and control populations. Univariable analyses and multivariable regression analysis were performed. Eight hundred seven of 16,061 (5.02%) patients aged 50 or older were converted to TKA within 2 years following ipsilateral knee arthroscopy. In univariable analysis, the rate of conversion to TKA in patients aged between 50 and 54 was 2.94%, compared with 4.44% in patients aged between 55 and 64, and 8.32% in patients 65 or older (p < 0.0001). Female sex was associated with a higher rate of conversion to TKA in univariable analysis (5.93 vs. 4.02% in males, p < 0.0001). KL grades were higher among patients who converted to TKA compared with those who did not (p < 0.0001). In a multivariable regression model controlling for age, sex, and KL grade, only increased KL grade was associated with increased odds of conversion to TKA. In the appropriately selected older patient, the risk of conversion to TKA within 2 years of knee arthroscopy is low (∼5%). Patients with KL grade 2 or higher at the time of arthroscopy should be counseled on the increased odds of early conversion to TKA.

EFFECTIVE USE OF VISCOSUPPLEMENTATION AFTER KNEE ARTHROSCOPY: EXPERIENCE FROM A WORKING GROUP

The aim of this work was to assess the efficacy of viscosupplementation after knee arthroscopy in a series of cases and to propose an adequate dosage regimen.The cases studied corresponded to patients undergoing arthroscopic surgery presenting meniscal injury and/or free bodies and where osteoarthritis could be present. Viscosupplementation started 3 weeks after arthroscopy and one set of patients received one shot of 5 ml of hyaluronic acid and the other set received three injections of 2.5 ml with weekly intervals. Patients were followed at 3 and 6 months. Improvements in pain and function as well as patient satisfaction were assessed and the appearance of adverse events was monitored. The groups studied were homogeneous with no differences in the type of surgery, associated gestures or other procedures performed during the intervention. Considering the patients as a whole, significant improvements were observed at 3 weeks post-arthroscopy (prior to intra-articular treatment) and at 3 and 6 months compared to pre-arthroscopy scores. Pain reductions were of 39.8%, 63.4% and 80.9% respectively and function improvement was of 20.9%, 58.8% and 77.9% respectively. There were no differences between the two groups in any of the parameters analysed. The treatment was rated by the patients as excellent. The group concluded that viscosupplementation inpost-arthroscopy achieves significant pain reduction and function improvement; moreover, one shot of hyaluronic acidis a safe and effective option as an adjuvant treatment in arthroscopic surgery favouring a better recovery with a lower cost for both the patient and the Healthcare System.

The aspiration test reveals an instability of the posterior horn of the lateral meniscus in almost one-third of ACL-injured patients

Purpose Anterior cruciate ligament (ACL) injuries often lead to associated injuries of the posterior horn of the lateral meniscus (PHLM). Arthroscopic, assessment of PHLM instability may be difficult in the absence of a visible meniscus damage. The main objective of this prospective multi-center study was to compare the ability of the probing and aspiration tests to identify PHLM instability in a population of patients undergoing ACL reconstruction (ACLR) and a control group of patients with an intact ACL undergoing knee arthroscopy. Methods A prospective case–control analysis was performed in three sports medicine centers. One-hundred and three consecutive patients operated for a primary isolated ACLR without structural lateral meniscus damage other than a root tear were included. They were compared to a control group of 29 consecutive patients who had a knee arthroscopy with an intact ACL and no structural lateral meniscus lesion. The probing and aspiration tests were consecutively executed according to previously published methods. Results In the control group, no lateral meniscus lesions were visualized during arthroscopy, and both probing and aspiration tests were negative in all patients. In the group of ACL-injured patients, a Forkel type I–III posterolateral meniscus root tear (PLMRT) was found in 12 patients (12%). In this subgroup, the probing test was positive in 4/12 patients (33%) and the aspiration test in 5 additional patients (75%). In 15 patients (15%), an elongation of the posterior root of the lateral meniscus (defined as type IV PLMRT as an addendum to the Forkel classification) could be observed during arthroscopy. In this subgroup, only 1 patient displayed a PHLM instability with the probing test (7%), whereas the aspiration test was positive in 13/15 patients (87%). In the remaining 76 patients (74%), no structural lesion of the PHLM could be identified. Nevertheless, an instability of the PHLM could be identified in 8 of them (11%) with the probing test, and the aspiration test was positive in 2 additional knees (13%) of this apparently normal subgroup. Altogether, in the entire ACL injury cohort, a positive probing test was observed in 13/103 patients (13%) and a positive aspiration test in 32/103 knees (31%) (p < 0.01). Conclusion Careful observation and examination of the PHLM with the aspiration test revealed a substantial amount of previously undiagnosed lateral meniscus instabilities in ACL-injured knees. The prevalence of PHLM instability as evaluated by the aspiration test was high (31%). The aspiration test was superior to the probing test in detecting an instability of the PHLM in a population of ACL-injured patients. Level of evidence II.

Impact of dexamethasone added to intra-articular morphine and bupivacaine for postoperative analgesia after knee arthroscopy

Background Pain relief after knee arthroscopy is very important for early recovery and rehabilitation. The study was conducted to evaluate the effects of adding dexamethasone (8 mg) to intra-articular morphine (10 mg) and bupivacaine (25 mg) combination on postoperative pain after knee arthroscopy. Results We enrolled 40 patients, 18–65 years-old of both sexes, ASA I and II scheduled for minor arthroscopic knee surgeries. The study group showed a lower visual analog score at rest and movement, prolonged postoperative analgesia, and decreased total analgesic consumption compared with the control group (P value < 0.05). Conclusions Adding dexamethasone to intra-articular combination of morphine and bupivacaine after knee arthroscopy prolongs the duration of analgesia, lowers pain scores, and decreases total analgesic consumption with no detected adverse effects.