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.

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.

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.

Femur-tibia Angle and Patella-tibia Angle: New Indicators for Diagnosing Anterior Cruciate Ligament Tears in Magnetic Resonance Imaging

Background: Torn anterior cruciate ligament (ACL) contributes to internal rotation of tibia. However, there is no indicator in MRI to reflect the rotation of knee joint. So the purpose of this study is to introduce two new measurements in MRI, femur-tibia angle (FTA) and patella-tibia angle (PTA), which reflect the rotation of knee joint and assess their role in diagnosing ACL tears.Methods: Present study retrospectively reviewed the cases of primary arthroscopic knee surgery from January 2018 to December 2019 from the Arthroscopy Database at Guangdong Provincial People's Hospital. Firstly, comparisons of different measurements were conducted between the ACL tears group and isolated meniscus injury group. Then, the measurements were tested in diagnosing complete or partial ACL tears. Diagnostic performance of different measurements was assessed by area under the curve (AUC) of receiver operating characteristic (ROC) curve and cutoff values were determined by Youden index. Results: FTA and PTA in ACL tears group had 4.79 and 7.36 degrees more than that of control group (p = 0.022 and < 0.001, respectively). Besides, ACL angle and distance of anterior tibial subluxation (D) also showed significant differences (p<0.05). In distinguishing complete ACL tear with intact ACL, the ROC curves indicated that ACL angle had the highest AUC of 0.906 (95% CI: 0.833-0.978) while AUC of PTA was 0.849 (95% CI: 0.763-0.936) and AUC of FTA was 0.809 (95% CI: 0.710-0.908). In distinguishing partial ACL tear with intact ACL, the ROC curves showed that FTA and PTA had the highest AUCs of 0.847 and 0.813 with 95% CI of 0.737-0.957 and 0.680-0.947, respectively. In contrast, the AUCs of ACL angle and D were only 0.519 and 0.387 with 95% CI of 0.292-0.745 and 0.227-0.546.Conclusion: Present study introduced two new quantitative parameters, FTA and PTA, to assess the rotation of knee joint. FTA and PTA increased when ACL tears and they might be valuable in diagnosing ACL tears, especially in distinguishing partial ACL tear with intact ACL which was poorly diagnosed in MRI.

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.