Elective Knee Arthroscopy Research Articles

Dexmedetomidine versus Dexamethasone as Adjuvant to Bupivacaine in Fascia Iliaca Block in Knee Arthroscopy for Postoperative Pain

Abstract Background Knee arthroscopy is one of the most frequently performed interventions in orthopedic surgery that is commonly performed on a day-case basis. It allows the diagnosis and management of a wide range of knee problems without making a large incision, thus decreasing soft tissue trauma. However, postoperative pain is a common upsetting symptom following arthroscopic knee surgery that if inadequately treated, leads to prolonged duration of the functional rehabilitation of the knee, recovery time and the length of hospital stay thus a significant increase in the medical care costs. Aim of the Work To compare the adjuvant effect of adding dexmedetomidine and/or dexamethasone to bupivacaine while using facsia iliaca block for knee arthroscopy and their efficacy in achieving postoperative analgesia. Patients and Methods The type of study was a prospective double – blinded randomized controlled Trial conducted in Ain Shams University hospitals, Cairo, Egypt at 6 months. Patients aged 20 to 60 years scheduled for elective knee arthroscopy under spinal anesthesia were included to receive FICB. Results In general, there was no significant difference between the three study groups regarding general patient characteristics as well as operative time. That ensured proper randomization conducted between our study groups. Additionally, that should nullify any bias that may have skewed the results in favor of one group rather than another one. There was statistically significant difference between groups according to heart rate from after 2hrs to after 24hrs this was also observed while measuring the systolic blood pressure and diastolic blood pressure but there was no significant difference between group B and C. Conclusion Our study shows that adding Dexmedetomidine and/or Dexamethasone (8mg) to Bupivacaine for FICB significantly prolonged the duration of block and decreased the requirement of rescue analgesics as compared to patients who received Bupivacaine alone. FICB is relatively easy and safe to perform. In our study we did not encounter any complication while doing the procedures and also by adding dexmedetomidine and/or dexamethasone (8mg).

Comparison of needle and conventional arthroscopy for visualisation of predefined anatomical structures of the knee joint: a feasibility study in human cadavers and patients

BackgroundIn terms of the optics used for Knee arthroscopy, a large number of different endoscopes are currently available. However, the use of the 30° optics in knee arthroscopy has been established as the standard procedure for many years. As early as the 1990s, needle arthroscopy was occasionally used as a diagnostic tool. In addition to the development of conventional optics technology in terms of camera and resolution, needle arthroscopes are now available with chip-on-tip image sensor technology. To date, no study has compared the performance of this kind of needle arthroscopy versus standard arthroscopy in the clinical setting in terms of the visibility of anatomical landmarks.In this monocentric prospective feasibility study, our aim was to evaluate predefined anatomical landmarks of the knee joint using needle arthroscopy (0° optics) and conventional knee arthroscopy (30° optics) and compare their performance during knee surgery.MethodsExaminations were performed on eight cadavers and seven patients who required elective knee arthroscopy. Two surgeons independently performed the examinations on these 15 knee joints, so that we were able to compare a total of 30 examinations. The focus was on the anatomical landmarks that could be visualized during a conventional diagnostic knee arthroscopy procedure. The quality of visibility was evaluated using a questionnaire.ResultsIn summary, the average visibility for all the anatomic landmarks was rated 4.98/ 5 for the arthroscopy using 30° optics. For needle arthroscopy, an average score of 4.89/ 5 was obtained. Comparatively, the needle arthroscope showed slightly limited visibility of the retropatellar gliding surface in eight (4.5/ 5 vs. 5/ 5), medial rim of the patella in four (4.85/ 5 vs. 5/ 5), and suprapatellar recess in four (4.83/ 5 vs. 5/ 5) cases. Needle arthroscopy was slightly better at visualizing the posterior horn of the medial meniscus in four knee joints (4.9/ 5 vs. 4.85/ 5).ConclusionNeedle arthroscopy is a promising technology with advantages in terms of minimally invasive access and good visibility of anatomical landmarks. However, it also highlights some limitations, particularly in cases with challenging anatomy or the need for a wide field of view.

Femoral nerve block using lower concentration ropivacaine preserves quadriceps strength while providing similar analgesic effects after knee arthroscopy

PurposeFemoral nerve block (FNB) is widely used in patients undergoing knee arthroscopy. However, the most commonly used concentration of ropivacaine (0.2% or above) may cause an unexpected decrease in the muscle strength of the quadriceps. Therefore, a lower concentration of ropivacaine (0.1%) for FNB was administered to investigate the effect on quadriceps strength and postoperative pain after knee arthroscopy.MethodsThis was a double-blind, randomized, controlled trial (ChiCTR2000041404). A total of 83 patients scheduled for elective knee arthroscopy were randomized to receive 0.1% or 0.2% ropivacaine for FNB under ultrasound guidance. The primary outcomes were quadriceps strength and numerical rating scale (NRS) pain score. Quadriceps strength was measured before surgery and 6 h and 24 h after surgery, while NRS score was recorded before surgery, at the postanaesthesia care unit (PACU), and 6 h and 24 h after surgery. Multiple linear regression tests were used to compare the differences in quadriceps strength and NRS score between the two groups. Two-factor analysis of variance, using the factors group and time of measurement, was used for repeated NRS scores. Secondary outcomes included knee mobility, side effects, patient satisfaction, and length of hospital stay.ResultsThe mean (SD) quadriceps strength at 6 h after surgery was 7.5 (5.7) kg for the 0.1% ropivacaine group and 3.0 (4.4) kg for the 0.2% ropivacaine group. The mean difference adjusted for baseline characteristics was − 5.2 (95% CI − 7.2 to − 3.1) kg (P < 0.001). There was no significant difference between the two groups in quadriceps strength at 24 h after surgery. The mean differences in the average NRS score and maximum NRS score in the PACU were − 0.6 (P = 0.008) and − 1.0 (P < 0.001), respectively. There was no significant difference in NRS score at 6 h or 24 h after surgery. Two-factor analysis of variance showed no significant difference in the interaction factors of time and group for average NRS score and maximum NRS score.ConclusionsCompared with 0.2% ropivacaine, 0.1% ropivacaine for FNB preserved quadriceps strength at 6 h after knee arthroscopy while providing similar analgesic effects.Level of evidenceI.

Comparison between micro-anchor skin dressing and liquid bonding agent for elective knee arthroscopy portal closure.

The objective of the current study was to evaluate outcomes of elective knee arthroscopy portal closure comparing two skin closure techniques. This was a randomised controlled trial including healthy volunteers aged ≥18 years undergoing elective knee arthroscopy that used two portals. At the time of surgery, each patient's two arthroscopy portal closures were randomised to one of two closure techniques; the first technique used approximation of the skin with a micro-anchor skin dressing (BandGrip Inc., US), while the second closure technique used an absorbable suture (Biosyn Monofilament, Medtronic) and a liquid bonding agent skin closure (Dermabond, Ethicon Inc., US). Postoperative complications and patient-reported outcomes were evaluated at the first visit after knee arthroscopy and at six weeks postoperatively. A total of 38 patients (76 portals) were enrolled in this study. No patients reported wound complications of either portal; thus, there was no significant difference (p>0.05) in wound complication rates between the skin closure techniques. Survey questions regarding any difference in appearance and cosmesis between the closure techniques' portal sites were responded to by 15 patients, all of whom indicated no difference in appearance between the portal sites. There was also no statistically significant difference between the two closure techniques with regards to appearance. There was no significant difference in presence of wound complications or appearance between skin closure with the micro-anchor skin dressing and the absorbable suture/liquid bonding agent skin closure.

Is the Synovium the First Responder to Posttraumatic Knee Joint Stress? The Molecular Pathogenesis of Traumatic Cartilage Degeneration.

The aim of this study was to evaluate if a similar catabolic and inflammatory gene pattern exists between the synovium, hyaline cartilage, and blood of patients with the knee joint tissues and if one precedes the other. A total of fifty-eight patients (34 females and 24 males) with a mean age of 44.7 years (range, 18-75) underwent elective knee arthroscopy due to previously diagnosed pathology. Full blood samples were collected preoperatively from synovium and cartilage samples intraoperatively. Real time PCR with spectrophotometric analysis was performed. Following genes taking part in ECM (extracellular matrix) remodeling were selected for analysis: MMP-1, MMP-2, MMP-8, MMP-9, MMP-13, MMP-14, ADAMTS-4 (Agg1) and ADAMTS-5 (Agg2) proteases, TIMP-1, and TIMP-2 - their inhibitors - and IL-1 and TNF-α cytokines. Analysis revealed a strong and significant correlation between gene expression in synovial and systemic blood cells (p <0.05 for all studied genes) with ADAMTS-4, ADAMTS-5, IL-1, TNF-α and TIMP-2 expression most positively correlated with an R>0.8 for each. An analysis between chondrocytes and systemic blood gene expression shown no significant correlation for all genes. Bivariate correlation of International Cartilage Repair Society grading and genes expression revealed significant associations with synovial MMP-1, MMP-2, MMP-8, MMP-9, IL-1, TNF-α and TIMP-2. We suggest that the synovial tissue is the first responder for knee joint stress factors in correlation with the response of blood cells. The chondrocyte's genetic response must be further investigated to elucidate the genetic program of synovial joints, as an organ, during OA development and progression.

A qualitative assessment of perceptions and attitudes toward postoperative pain and opioid use in patients undergoing elective knee arthroscopy.

Background:Orthopedic surgeons routinely prescribe opioids to manage post-operative pain. In the face of an opioid epidemic, a one-size-fits-all approach to pain management is no longer appropriate. Patient-centred prescribing practices should be used by surgeons; however, little is known about what influences patient attitudes toward postoperative pain and its management to inform such practices. We sought to explore patient attitudes toward postsurgical pain management, including opioids.Methods:We conducted qualitative, semistructured interviews of 11 opioid-naive patients (age 16–46 yr) who were scheduled to undergo arthroscopic knee surgery. Transcripts were analyzed thematically using a framework analysis that involved familiarization, developing a thematic framework, indexing, charting and mapping, and interpretation.Results:Participant attitudes toward postoperative pain and opioids were influenced by perceived tolerance to pain based on personal experience, perceived predisposition to addiction based on personal assumptions regarding addictive personality traits and risk factors, and perceptions of opioid use shaped by external influences, including family, friends and the media’s depiction of the opioid epidemic. Every patient expressed that preoperative counselling and education regarding postoperative pain management would be beneficial in improving their knowledge base, easing anxieties and clarifying misunderstandings.Conclusion:Surgeons can address the patient-reported factors identified in this study to help optimize a patient’s perioperative experience without relying solely on prescribed analgesia. By improving accessibility to education and promoting safe, patient-centred prescribing practices, we may reduce reliance on opioids in orthopedic surgery.

Machine-learning model successfully predicts patients at risk for prolonged postoperative opioid use following elective knee arthroscopy.

Recovery following elective knee arthroscopy can be compromised by prolonged postoperative opioid utilization, yet an effective and validated risk calculator for this outcome remains elusive. The purpose of this study is to develop and validate a machine-learning algorithm that can reliably and effectively predict prolonged opioid consumption in patients following elective knee arthroscopy. A retrospective review of an institutional outcome database was performed at a tertiary academic medical centre to identify adult patients who underwent knee arthroscopy between 2016 and 2018. Extended postoperative opioid consumption was defined as opioid consumption at least 150days following surgery. Five machine-learning algorithms were assessed for the ability to predict this outcome. Performances of the algorithms were assessed through discrimination, calibration, and decision curve analysis. Overall, of the 381 patients included, 60 (20.3%) demonstrated sustained postoperative opioid consumption. The factors determined for prediction of prolonged postoperative opioid prescriptions were reduced preoperative scores on the following patient-reported outcomes: the IKDC, KOOS ADL, VR12 MCS, KOOS pain, and KOOS Sport and Activities. The ensemble model achieved the best performance based on discrimination (AUC = 0.74), calibration, and decision curve analysis. This model was integrated into a web-based open-access application able to provide both predictions and explanations. Following appropriate external validation, the algorithm developed presently could augment timely identification of patients who are at risk of extended opioid use. Reduced scores on preoperative patient-reported outcomes, symptom duration and perioperative oral morphine equivalents were identified as novel predictors of prolonged postoperative opioid use. The predictive model can be easily deployed in the clinical setting to identify at risk patients thus allowing providers to optimize modifiable risk factors and appropriately counsel patients preoperatively. III.

BUTTER PAPER AS A COST EFFECTIVE DRESSING FOR SUPERFICIAL INTERMEDIATE THICKNESS BURN

Introduction Post-operative pain is very common distressing symptom after any surgical procedure.Different drugs in different routes have been used for controlling post-arthroscopic pain.We have compared the efficacy of analgesic effect of plain ropivacaine versus ropivacaine with dexmedetomidine as an adjuvant when administered through the intra-articular route in arthroscopic knee surgery. Materials and Methods From June 2017 to June 2019 sixty patients undergoing elective knee arthroscopy were randomly assigned to two groups (n=30). Group R received 19 ml of 0.50% ropivacaine and 1 ml of isotonic saline (total volume 20 ml) intraarticularly. Group RD received 100 μg (1 ml) of dexmedetomidine added to 19 ml of 0.50% ropivacaine intra-articularly(total 20ml).Pain was assessed using visual analogue scale(VAS) and diclofenac sodium given as rescue analgesia when VAS>4.Time of first analgesia request and total dose of rescue analgesics used in 24 hours were calculated. Results VAS score were significantly lower in Group RD, time to first analgesic requirement was significantly greater in Group RD than in Group R and total dose of analgesics used in Group RD patients was significantly less compared to patients in Group R. Conclusion Dexmedetomidine, added as adjunct to ropivacaine in patients undergoing arthroscopic knee surgery, improves the quality and duration of postoperative analgesia.

Efficacy of Intra-Articular Dexmedetomidine for Postoperative Analgesia in Arthroscopic Knee Surgery

Introduction Post-operative pain is very common distressing symptom after any surgical procedure.Different drugs in different routes have been used for controlling post-arthroscopic pain.We have compared the efficacy of analgesic effect of plain ropivacaine versus ropivacaine with dexmedetomidine as an adjuvant when administered through the intra-articular route in arthroscopic knee surgery. Materials and Methods From June 2017 to June 2019 sixty patients undergoing elective knee arthroscopy were randomly assigned to two groups (n=30). Group R received 19 ml of 0.50% ropivacaine and 1 ml of isotonic saline (total volume 20 ml) intraarticularly. Group RD received 100 μg (1 ml) of dexmedetomidine added to 19 ml of 0.50% ropivacaine intra-articularly(total 20ml).Pain was assessed using visual analogue scale(VAS) and diclofenac sodium given as rescue analgesia when VAS>4.Time of first analgesia request and total dose of rescue analgesics used in 24 hours were calculated. Results VAS score were significantly lower in Group RD, time to first analgesic requirement was significantly greater in Group RD than in Group R and total dose of analgesics used in Group RD patients was significantly less compared to patients in Group R. Conclusion Dexmedetomidine, added as adjunct to ropivacaine in patients undergoing arthroscopic knee surgery, improves the quality and duration of postoperative analgesia.

POST-OPERATIVE ANALGESIA IN ARTHROSCOPIC KNEE SURGERY: A COMPARISON BETWEEN INTRA-ARTICULAR CLONIDINE AND DEXMEDETOMIDINE

Background: Arthroscopic surgery is associated with variable amount of postoperative pain and sometimes the pain is considerable. To provide postoperative analgesia after arthroscopic knee surgery, various medications have been administered intra-articularly. Aim: To compare the postoperative analgesic effects of intra-articular clonidine and dexmedetomidine administered as adjuvants with local anesthetic levobupivacaine in patients undergoing arthroscopic knee surgery. Methods: Sixty patients undergoing elective knee arthroscopy were randomly assigned to one of the following groups containing 20 patients each. Group L patients received 19 ml of 0.25% levobupivacaine and 1 ml of isotonic saline (20 ml in total) intra-articularly. Group C patients received 150µg [1ml] of clonidine added to 19 ml of 0.25% levobupivacaine intra-articularly (total volume 20 ml). Group D patients received 100 µg (1 ml) of dexmedetomidine added to 19 ml of 0.25% levobupivacaine intra-articularly (total volume 20 ml). Analgesic effect was evaluated by measuring pain intensity (VAS score) and duration of analgesia. Results: A longer delay was observed between intra-articular injection of study medication and first requirement of supplementary analgesic in group C (10.44 ± 4.6 hours) and in group D (10.72 ± 5.6 hours) compared to group L (6.18 ± 1.8 hours). Total consumption of diclofenac sodium in first 24 hours in postoperative period was significantly less in group C and D. No significant side effects were noted. Conclusion: Both clonidine and dexmedetomidine, added as adjuncts to levobupivacaine in patients undergoing arthroscopic knee surgery, improve the quality and duration of post operative analgesia.

Body Mass Index as a Risk Factor for 30-Day Postoperative Complications in Knee, Hip, and Shoulder Arthroscopy

To use the American College of Surgeons National Surgical Quality Improvement Program database to determine whether body mass index (BMI) is associated with 30-day postoperative complications following arthroscopic surgery. Cases of elective knee, hip, and shoulder arthroscopy were identified. A retrospective comparative analysis was conducted, and the overall rates of morbidity, mortality, readmission, reoperation, and venothromboembolism (VTE) were compared using univariate analyses and binary logistic regressions to ascertain the adjusted effect of BMI, with and without diabetes, on morbidity, readmission, reoperation, and VTE. There were 141,335 patients who met the criteria. The most common complications were deep vein thrombosis (0.27%), superficial surgical site infection (0.17%), urinary tract infection (0.13%), and pulmonary embolism (0.11%). Obesity class III with diabetes was a risk factor for morbidity (odds ratio [OR]= 1.522; 95% confidence interval [CI], 1.101-2.103) and readmission (OR= 2.342; 95% CI, 1.998-2.745) following all procedures, while obesity class I was protective toward reoperation (OR= 0.687, 95% CI, 0.485-0.973). Underweight patients were at higher risk for morbidity following shoulder arthroscopy (OR= 3.776; 95% CI, 1.605-8.883), as were the class I obese (OR= 1.421; 95% CI, 1.010-1.998) and class II obese (OR= 1.726, 95% CI, 1.159-2.569). BMI did not significantly affect morbidity following knee arthroscopy. VTE risk factors included being overweight (OR= 1.474; 95% CI, 1.088-1.996) or diabetic with class I obesity (OR= 1.469; 95% CI, 1.027-2.101). Arthroscopic procedures are safe with very low complication rates. However, underweight and class I and class II obese patients are at higher risk for morbidity following shoulder arthroscopy, and diabetic patients with class III obesity are at higher risk for morbidity and readmission following all arthroscopy. Because BMI is a modifiable risk factor, these patients should be evaluated carefully before being considered for outpatient arthroscopic surgery. Level III, retrospective comparative study.

Intra-Articular Morphine versus Dexmedetomedine for Knee Arthroscopy under Local Anesthesia.

Background:Knee arthroscopy has both diagnostic and therapeutic applications which can be performed under general, regional, or local anesthesia. Morphine is used as an additive to local anesthetics. Dexmedetomedine, the highly selective alpha-2 (α2)-adrenoceptor agonist with the sedative and analgesic effect can be used also to augment local anesthetic effect.Patients and Methods:Sixty patients submitted for elective knee arthroscopy whose age between 25 and 45 years, of either sex, the American society of anethesiologists physical status Classes I and II at a university hospital were enrolled in this study. Patients were classified into two groups. Morphine Group (M) (n = 30): Patients received 20 ml of 0.5% bupivacaine plus 5 ml of 0.2% lidocaine with epinephrine 1:200,000 plus 1 mg morphine. Dexmedetomedine Group (D) (n = 30): Patients received 20 ml of 0.5% bupivacaine plus 5 ml of 0.2% lidocaine with epinephrine 1:200,000 plus 1 μg/kg dexmedetomedine.Results:Demographic data of patients showed no significant difference among the studied groups. Heart rate (HR) was significantly lower in (D) Group compared to that of (M) Group 5 min from the start of procedure to immediately postoperatively. Moreover, (D) Group showed a significant decrease in HR 10 min up to 35 min intraoperatively compared to the basal value. Furthermore, mean arterial blood pressure (MBP) was significantly lower in (D) Group compared to that of (M) Group 15 min from the start of surgery up to 1 h postoperatively. Furthermore, (D) Group showed a significant decrease in MBP 15 min intraoperative up to 2 h postoperatively compared to the basal value. While there was no significant difference in (visual analogue score [VAS], onset and total consumption of ketorolac, surgeon and patients’ satisfaction, side effects in (D) Group compared to (M) Group, respectively.Conclusion:Addition of either morphine or dexmedetomidine to bupivacaine intraarticularly improved both intraoperative anesthesia and postoperative analgesia with minimal side effects or complications in knee arthroscopy, with superiority of dexmedetomidine compared to morphine on hemodynamic stability.

Takotsubo cardiomyopathy secondary to needle phobia

SummaryA 55‐year‐old female scheduled for elective knee arthroscopy became significantly dyspnoeic in the anaesthetic room prior to peripheral venous cannulation. The subsequent clinical course and later investigations led to a diagnosis of takotsubo cardiomyopathy precipitated by needle phobia‐induced anxiety. This example highlights a rare but significant manifestation of needle phobia and prompts a discussion about the optimal techniques available to ameliorate the response in the peri‐operative period.

Combined Sciatic-Lumbar Plexus Block with General Anesthesia: Efficacy in Preventing Tourniquet-Induced Hemodynamic Changes

Background: Pneumatic arterial tourniquet is a utilized strategy in limb surgeries to provide bloodless field to facilitate surgical procedure. Be that as it may, arterial tourniquet has numerous injurious impacts including hemodynamic changes and tourniquet-induced pain which sometimes can be severe and intolerable. Objectives: Our primary aim was to assess the impact of performing “Lumbar Plexus Block and sciatic nerve block” with General Anesthesia (GA) on the degree of arterial tourniquet-induced hemodynamic effects. On the other hand, our secondary aims were: amount of postoperative analgesic prerequisites, patient satisfactory score and documented side effects. Settings and Design: Ain Shams University, Orthopedic operating theatre; a prospective, randomized, double-blind study. Methods and Material: The physical status of 50 patients (both sexes) including I and II patients from American Society of Anesthesiologists, whose ages are from 20 - 40 years, is not so ideal when they are undergoing elective knee Arthroscopy. The duration lasts no more than ninety minutes under GA with application of tourniquet. Patients were allotted haphazardly to one of two groups. In Group C (Control group): Only GA. In Group B: LPB and sciatic nerve block were performed just before GA administration. Intraoperative hemodynamics was recorded at specific timings. Results: Incidence of tourniquet induced hypertension (TIH) was markedly less with Group B at: forty five, sixty, seventy five mins after tourniquet inflation and just before tourniquet deflation. Also, the total ketorolac consumption during first 24 hours of postoperative period was significantly less with Group B (p < 0.001). Finally, patient satisfaction was significantly higher in Group B. Conclusions: Combined Sciatic-Lumbar plexus blocks when combined with general anesthesia were very effective in attenuating TIH.

Efficacy of quadriceps femoris fasciculation induced by low-current nerve stimulation when used to assist ultrasound-guided lumbar plexus block

Objective To evaluate the efficacy of quadriceps femoris fasciculation induced by low-current nerve stimulation when used to assist ultrasound-guided lumbar plexus block. Methods One hundred patients of both sexes, aged 18-45 yr, of American Society of Anesthesiologists physical status Ⅰ or Ⅱ, weighing 50-85 kg, scheduled for elective unilateral knee arthroscopy, were selected and randomly divided into 2 groups(n=50 each)using a random number table: ultrasound assisted by nerve stimulator group(group SU)and ultrasound group(group U). The shamrock method was used to perform the ultrasound-guided lumbar plexus block in two groups.In group SU, the nerve stimulator with current 0.35 mA and frequency 1 Hz was used in the process of puncture, and 0.5% ropivacaine 0.4 ml/kg was administrated when quadriceps femoris fasciculation was induced.In group U, when the tip of the nerve stimulating needle was located around the lumbar plexus, which was confirmed by ultrasound, 0.5% ropivacaine 0.4 ml/kg was administrated.The time of puncture, depth of needle insertion, onset time of block and effective block were recorded.Motor block was assessed using the modified knee score, and the development of complications was recorded within 24 h after block. Results Compared with group U, the onset time of block was significantly shortened, the rate of effective block was increased, the degree of motor block was aggravated(P 0.05). No complications were observed in two groups. Conclusion Low-current(0.35 mA)nerve stimulation-induced quadriceps femoris fasciculation when used to assist location can improve the efficacy of ultrasound-guided lumbar plexus block. Key words: Transcutaneous electric nerve stimulation; Ultrasonography; Lumbosacral plexus; Nerve block

Analgesia and side effects of the addition of 10 or 20µg fentanyl to articaine in spinal anesthesia for knee arthroscopy: a randomized and observer-blinded study.

Articaine, a popular and rapidly acting local anesthetic in dentistry, has been also found to be beneficial in ambulatory spinal anesthesia. Analgesia in the intraoperative and immediate postoperative period may be further improved by adding fentanyl to the local anesthetic solution for spinal anesthesia. The aim was to evaluate dose-dependency of analgesia and side effects associated with intrathecal fentanyl additive to articaine for spinal anesthesia in knee arthroscopy patients. In this randomized, observer- and patient-blinded study, 90 adult patients scheduled for elective ambulatory knee arthroscopy under spinal anesthesia were randomized into three groups: plain articaine 60mg with saline (group AF0), articaine 60mg with fentanyl 10µg (group AF10) or 20µg (group AF20) in a total volume of 1.9ml. The blinded observer tested the sensory and the motor block, and performed telephone interviews on the first and seventh postoperative days. The median (IQR) duration of sensory block at the dermatomal level of T10 was significantly longer in groups AF10, 69min (56) and AF20, 69min (45) than in group AF0, 41min (35) (p=0.013). Motor block duration was similar in all groups (median 120min). Group AF20 patients experienced pruritus significantly more often than patients in the other groups (p=0.039). No acute or late anesthetic side effects occurred, and satisfaction with the anesthetic technique was the same in all groups (97% satisfied). Fentanyl 10 or 20µg as additive to articaine for spinal anesthesia prolonged the duration of sensory block significantly and similarly. Fentanyl 20µg was more often associated with pruritus than fentanyl 10µg.

Venous Thromboembolism After Knee Arthroscopy in Undiagnosed Familial Thrombophilia.

Venous thromboembolism is uncommon after knee arthroscopy, and there are no guidelines for thromboprophylaxis in elective routine knee arthroscopy. Preoperative evaluation of common thrombophilias should provide guidance for postarthroscopy thromboprophylaxis in otherwise healthy patients who are at high risk for venous thromboembolism. This study assessed 10 patients with venous thromboembolism after total hip or knee arthroplasty. Patients were assessed if venous thromboembolism occurred within 6 months after knee arthroscopy (n=10) or total hip or knee arthroplasty (n=21). This study assessed gene mutations (factor V Leiden, prothrombin G20210A, plasminogen activator inhibitor, methylenetetrahydrofolate reductase) and serologic thrombophilias (high levels of factors VIII and XI, homocysteine, anticardiolipin immunoglobulin G and immunoglobulin M antibodies, and lupus anticoagulant; low antigenic protein C, S, and free S; and antithrombin III deficiency). The same coagulation data were obtained for normal subjects (n=110). The major thrombophilias in the arthroscopy group were factor V Leiden heterozygosity (40%), high factor VIII level (50%), and high homocysteine (30%). The respective values in control subjects were 2% (P=.0004), 7% (P=.0011), and 5% (P=.02). When the arthroscopy group was compared with the 21 patients who had venous thromboembolism after total hip or knee arthroplasty, the sole difference was factor V Leiden heterozygosity, which was 40% vs 0%, respectively (P=.007). Although venous thromboembolism after knee arthroscopy is uncommon, to identify high-risk patients and guide postoperative thromboprophylaxis, the authors suggest routine preoperative measurement of 3 common familial thrombophilias: factor V Leiden, factor VIII, and homocysteine. [Orthopedics. 2016; 39(6):e1052-e1057.].

EFFICIENCY OF ULTRASOUND GUIDED LOWER LIMB PERIPHERAL NERVE BLOCKS IN PERIOPERATIVE PAIN MANAGEMENT FOR KNEE ARTHROSCOPY IN CHILDREN. A RANDOMIZED STUDY.

Ultrasound guided lower limb peripheral nerve blocks are efficient for perioperative pain treatment in children. The aim was to see if lower limb peripheral nerve blocks reduced the amount of propofol and opioid analgesics used intraoperatively, as well as the level of pain and consumption of systemic analgesics postoperatively. A randomized, prospective clinical trial was carried out. It included 60 children between 11 and 18 years of age scheduled for elective knee arthroscopy. The patients were divided into two groups. Group A received general anesthesia, group B received lower limb peripheral nerve blocks with sedation or general anesthesia. Postoperative level ofpain was assessed using visual analogue scale. Less propofol and fentanyl was used to induce and maintain anesthesia in group B (p < 0.001). The level of postoperative pain was significantly lower in group B (p < 0.001), as well as the postoperative consumption of analgesics (p < 0.001). As mahbny as 47% of the patients were discharged without receiving any analgesics postoperatively. The average duration of peripheral nerve blocks was 468 minutes. Ultrasound guided lower limb peripheral nerve blocks are an efficient technique of regional anesthesia in children. They reduce the amount of general anesthetics and opioid analgesics needed intraoperatively as well as the level of postoperative pain and consumption of analgesics postoperatively.

Detection of a Traumatic Arthrotomy in the Pediatric Knee Using the Saline Solution Load Test

The objective of this study was to quantify the load volume needed for a positive diagnosis of a traumatic arthrotomy in the pediatric knee with use of the saline solution load test (SLT). From February 2013 to June 2014, eighty-seven pediatric patients who were undergoing elective knee arthroscopy were prospectively enrolled in this study. An SLT was performed in each patient using a 5-mm superolateral portal as the arthrotomy site, with injection of the saline solution into the lateral aspect of the knee. The 50th, 75th, 90th, and 95th percentiles of saline solution load volume required for a positive result were identified. Univariate linear regression was used to identify possible relationships between demographics (age, height, weight, and body mass index [BMI]) and load volume. Forty-one female and forty-six male patients with a mean age (and standard deviation) of 13.4 ± 3.0 years (range, five to eighteen years) and a mean BMI of 21.9 ± 5.0 kg/m(2) (range, 12.9 to 36.2 kg/m(2)) were enrolled. The mean saline solution load volume was 28.9 ± 14.2 mL (range, 7.0 to 78 mL). The 50th, 75th, 90th, and 95th percentiles of saline solution load volume were 27, 37, 47, and 58 mL, respectively. The mean load volume did not differ significantly between male and female patients (28.8 ± 13.9 versus 29.0 ± 14.7 mL, respectively; p = 0.92). Load volume was significantly correlated with age, height, weight, and BMI. On the basis of our findings, a saline solution load volume of 47 mL is required to detect 90% of superolateral traumatic arthrotomies of 5 mm in the pediatric knee with use of the SLT.

Effects of intraarticular levobupivacaine, fentanyl-levobupivacaine and tramadol- levobupivacaine for postoperative pain in artroscopic knee surgery

The aim of this study was to compare the postoperative analgesic efficacy of intra-articularly injected levobupivacaine, levobupivacaine-fentanyl, and levobupivacaine-tramadol combinations. Eighty patients scheduled for elective knee arthroscopy were divided randomly into 4 groups of 20 patients each. Group 1 (the control group) received intra-articular saline, Group 2 received levobupivacaine 2.5 mg/ml, Group 3 received levobupivacaine 2.5 mg/ml + tramadol 50 mg, and Group 4 received levobupivacaine 2.5 mg/ml + fentanyl l50 mcg. All patients were operated on under general anesthesia, and a total of 20 ml study solution was injected: 7 ml subcutaneously before surgery and 13 ml intra-articularly upon completion of surgery. For postoperative, pain visual analogue scale (VAS) was assessed at the 1st, 2nd, 4th, 8th, 12th, and 24th hours postoperatively. Patients with a VAS score over 5 received diclofenac sodium, and the need for rescue analgesics was recorded. At the 1st, 2nd, 4th, 8th, 12th, and 24th postoperative hours, Group 3 and Group 4 had statistically significant lower VAS scores of pain (p<0.01). Postoperative rescue analgesic requirements were different among the groups. The postoperative 1st hour analgesic requirement was statistically significantly lower in Group 3 and Group 4 when compared to the other groups (p<0.01). At the postoperative 2nd and 4th hours, analgesic requirements were statistically significantly lower in Group 3 than in the other groups (p<0.01). Analgesic requirements were statistically significantly lower in Group 3 and Group 4 than in the other groups (p<0.01). Analgesic requirements at the 12th and 24th postoperative hours did not show any statistically significant difference (p>0.05). The results indicated that levobupivacaine combined with either fentanyl or tramadol decreased rescue analgesic requirements when compared to levobupivacaine alone.