Late follow-up results of operative ankle arthroscopy in patients under local anaesthesia

Ankle Arthroscopy Without Tourniquet: A Mid-Term Follow-Up

Ankle arthroscopy is a surgical technique still most commonly performed with a tourniquet. In 2017, we published a randomized controlled trial comparing anterior ankle arthroscopy with and without the tourniquet use. The results showed feasibility of performing the anterior ankle arthroscopy without the tourniquet, as well as comparable functional outcomes at 3- and 6-month follow-up visits, regardless of the tourniquet use. The aim of the current study was to evaluate mid-term functional outcomes after a 5-year period and to document patient satisfaction with the surgery. All 49 available patients from the original study were asked to attend examination at the 60-month follow-up visit. Patients were assessed with the same functional scores, as well as with additional Munich Ankle Questionnaire (MAQ) to assess the postoperative subjective and objective outcome and Abdelatif questionnaire to evaluate patient satisfaction. Any new complications were noted. At the 60-month follow-up visit, 39 (79.6%) patients were available for examination. No significant difference was found between the groups regarding the functional outcomes or the MAQ. In comparison with the 3- and 6-month follow-up visits, no further improvement or decline of functional outcomes was present. High patient satisfaction was found in both groups. No new complications were noted during the follow-up period. Similar improvement in both groups reveals that the anterior ankle arthroscopy can be performed without the tourniquet with no negative impact on mid-term functional outcomes. In addition, high patient satisfaction can be expected even after 5 years from surgery, regardless of the tourniquet use.

Local anesthesia combined with intra-articular ropivacaine can provide satisfactory pain control in ankle arthroscopic surgery: A retrospective cohort study

BACKGROUND

Local anesthesia (LA) is widely used in knee arthroscopic surgery but not in ankle arthroscopy.

OBJECTIVE

To understand the effectiveness and safety of LA combined with ropivacaine in pain control for ankle arthroscopy.

STUDY DESIGN

Retrospective cohort.

METHODS

We retrospectively collected data for patients who underwent ankle arthroscopy from April 2012 to April 2017. Patients were grouped by anesthesia method: LA, LA with ropivacaine (LA+R), spinal anesthesia (SA), and SA with ropivacaine (SA+R). Intra- and postoperative visual analog scale (VAS) scores, complications, doses of supplemental pain medication, hospitalization cost and duration, and satisfaction with pain control during hospitalization were analyzed.

RESULTS

The study included 276 patients (LA: 93; LA+R: 124; SA: 31; SA+R: 28). The LA and LA+R groups had significantly higher intraoperative VAS scores (LA vs. SA, p = 0.001; LA vs. SA+R, p = 0.002; LA+R vs. SA, p = 0.00; LA+R vs. SA+R, p = 0.00), but fewer complications, than the SA and SA+R groups. The LA+R and SA+R groups had significantly better outcomes for postoperative pain control (LA vs. LA+R, p = 0.01; LA vs. SA+R, p = 0.01; SA vs. SA+R, p = 0.01; SA vs. LA+R, p = 0.03) and required less supplemental pain medication. Hospitalization cost was lower and duration shorter in the LA and LA+R groups than in the SA and SA+R groups. There was no significant difference in satisfaction among the four groups.

LIMITATIONS

This was a single-center retrospective and relatively short-term study.

CONCLUSIONS

LA+R which could be safely applied in ankle arthroscopy provided satisfactory pain control, reduced postoperative pain intensity, fewer complications, shorter hospital stay, and good cost-effectiveness. It can be safely applied in ankle arthroscopy for the specific patients with ankle osteoarthritis.

Preemptive Local Anesthesia in Ankle Arthroscopy

BACKGROUND

Complex anesthesia is increasingly used in order to reduce postoperative pain and accelerate rehabilitation. The aim of this study was to evaluate the efficacy and safety of preemptive local anesthesia combined with general or spinal anesthesia in ankle arthroscopy.

METHODS

From January 2014 to February 2016, 80 ankle anterior arthroscopies were performed. Patients were randomly assigned to one of 4 groups, depending on the type of anesthesia: A, general and local preemptive; B, spinal and local preemptive; C, general and placebo; D, spinal and placebo. After general or spinal anesthesia, each patient randomly received an injection of 7 mL of a mixture of local anesthetics or the same amount of normal saline. After 2, 4, 8, 12, 16, 24, 48, and 72 hours following the release of the tourniquet, the pain intensity level was measured with a visual analog scale (VAS). The use of additional analgesics and any adverse effects were also noted.

RESULTS

Preemptive local anesthesia (groups A and B) resulted in a significantly lower level of pain intensity during the first 24 hours after surgery. Until 8 hours after the release of the tourniquet, the pain intensity level was statistically lower in the groups A, B, and D in comparison to C. During hospitalization, none of the patients from groups A and B received on-demand ketoprofen intravenously. No side effects of local anesthetic agents were observed. Two patients had transient numbness and paresthesia in the field of sensory nerve innervation of the dorsal intermediate cutaneous nerve of the foot.

CONCLUSION

Preemptive operative site infiltration with a mixture of local anesthetics performed in ankle arthroscopy was a safe procedure. It reduced the level of intensity of postoperative pain and the amount of analgesics used.

LEVEL OF EVIDENCE

Level I, prospective randomized study.

Arthroscopic synovectomy, irrigation, and debridement for treatment of septic ankle arthrosis: a systematic review and case series

Septic arthrosis of the ankle is a rare, often devastating, infection, with a high potential for morbidity and mortality. Delay in treatment can lead to cartilage erosion, painful synovitis, and osteomyelitis. Septic ankle arthrosis deserves prompt recognition and intervention. However, quality, sound, protocol-directed arthroscopic treatment of septic ankle arthrosis of the ankle has not yet been reported. We performed a systematic review of the electronic databases and other relevant peer-reviewed sources to determine the outcomes and treatment protocols associated with septic ankle arthrosis treated with arthroscopic synovectomy, irrigation, and debridement. Nine studies, involving a total of 15 ankles, met our inclusion criteria. In addition, we present the short-term outcomes of a protocol-driven arthroscopic synovial biopsy, deep culture procurement, synovectomy, irrigation, and debridement approach for 8 ankles (8 patients). To our knowledge, this would be the largest individual case series specific to arthroscopic treatment of septic ankle arthrosis. The most common infectious organism reported in the systematic review and in our case series was methicillin-sensitive Staphylococcus aureus. Arthroscopic synovectomy, irrigation, and debridement represents an acceptable treatment method for septic ankle arthrosis and demonstrated outcomes similar to the more traditional open approach, with fewer complications. Additional, appropriately weighted, randomized controlled studies with long-term follow-up are warranted.

Arthroscopic treatment of impingement of the ankle reduces pain and enhances function

A consecutive series of 105 patients with a median age of 35 (16-62) years who were operated on with arthroscopic resection for impingement of the ankle using standardized technique without distraction is presented. All patients complained of painful dorsiflexion and had failed to respond to conservative treatment. A total of 177 diagnoses were found, soft tissue impingement or synovitis in 89, anterior bony impingement in 44, chondral lesion in 20, loose bodies in 16 and osteoarthritis in eight. At follow-up after 2 years, 65 patients were pain free while 28 patients had experienced reduction of pain. Gait was improved in 30/41 patients and 22 resumed sporting activities. The results were graded excellent in 67, good in 25, fair in six and poor in seven patients. There were four deep infections and one synovial fistula in this series. The deep infections all responded well to arthroscopic synovectomy and intravenous antibiotics. In one patient persistent symptoms were recorded. Ankle arthroscopy yielded good results in the treatment of anterior impingement of the ankle as it effectively reduced pain and enhanced function.

Local anesthesia for arthroscopic surgery of the ankle using pethidine or prilocaine

Investigation of the intraoperative and postoperative pain-reducing effect of pethidine (meperidine) as compared with local anesthetics given into the ankle joint was performed, in a comparative and double-blind fashion, in 20 patients subjected to arthroscopy of the ankle, diagnostic and surgical procedures. These patients were randomly assigned to one of two groups. Group A consisted of 10 patients receiving prilocaine 5% with adrenaline and the patients of group B received pethidine 5% with adrenaline intraarticularly. During arthroscopy, the patients reported on pain and discomfort using visual analog scales. Ratings did not differ between the two groups, but six patients would not have chosen the local anesthetic technique again. Postoperatively, all patients rated their pain and discomfort at rest and at movement (1, 2, 3, 5, 6, 8, and 24 hours and at three times during 2 following days). No differences were found between the two groups, except for pain at rest through the whole observation period when significant lower values for pethidine. There were no differences in use of analgesics between the two groups. The current study indicates that pethidine is a potential alternative to prilocaine in arthroscopy of the ankle.

Ankle arthroscopy under local and general anaesthesia for diagnostic evaluation and treatment

Improvements in techniques and instrumentation are extending the diagnostic and therapeutic indications for ankle arthroscopy. We aimed to study the diagnostic and therapeutic benefits and complication rate from 112 consecutive ankle arthroscopies performed between 1991 and 1994 under local and general anaesthesia. One-hundred and twelve outpatient ankle arthroscopies were performed in 72 male and 37 female patients, 16-64 years old. The patients were comparable in terms of gender and age in the arthroscopies done under local (n = 69) and the arthroscopies done under general anaesthesia (n = 43). The indications for surgery were pain in 75%, instability in 15%, limited function in 7% and swelling in 4%, and these criteria were similar in both groups. Antero-medial and anterolateral portals were used in all cases. No tourniquet was used and an external distractor was used in one case only. In 64 cases (57%) surgery was performed and included synovectomy, removal of loose bodies, shaving drilling of osteochondritic or other cartilage lesions, resection of impinging osteophytes, fibrosis and meniscoid lesions. In 95 ankles (85%) a definite diagnosis was established. Comparable diagnostic and therapeutic potentials were found between local and general anaesthesia. The complication rate was low. One patient who was operated on under general anaesthesia sustained a deep infection, and three suffered minor superficial nerve injuries. In conclusion, ankle arthroscopy may be performed under local or general anaesthesia with similar diagnostic value and with a low complication rate.