Local anesthesia in outpatient knee arthroscopy: a comparison of efficacy and cost

Health Economic Evaluations of Hip and Knee Interventions in Orthopaedic Sports Medicine: A Systematic Review and Quality Assessment

BACKGROUND

The economic burden of musculoskeletal diseases is substantial and growing. Economic evaluations compare costs and health benefits of interventions simultaneously to help inform value-based care; thus, it is crucial to ensure that studies are using appropriate methodology to provide valid evidence on the cost-effectiveness of interventions. This is particularly the case in orthopaedic sports medicine, where several interventions of varying costs are available to treat common hip and knee conditions.

PURPOSE

To summarize and evaluate the quality of economic evaluations in orthopaedic sports medicine for knee and hip interventions and identify areas for quality improvement.

STUDY DESIGN

Systematic review; Level of evidence, 3.

METHODS

The Medline, AMED, OVID Health Star, and EMBASE databases were searched from inception to March 1, 2020, to identify economic evaluations that compared ≥2 interventions for hip and/or knee conditions in orthopaedic sports medicine. We assessed the quality of full economic evaluations using the Quality of Health Economic Studies (QHES) tool, which consists of 16 questions for a total score of 100. We classified studies into quartiles based on QHES score (extremely poor quality to high quality) and we evaluated the frequency of studies that addressed each of the 16 QHES questions.

RESULTS

A total of 93 studies were included in the systematic review. There were 41 (44%) cost analyses, of which 21 (51%) inappropriately concluded interventions were cost-effective. Only 52 (56%) of the included studies were full economic evaluations, although 40 of these (77%) fell in the high-quality quartile. The mean QHES score was 83.2 ± 19. Authors consistently addressed 12 of the QHES questions; questions that were missed or unclear were related to statistical uncertainty, appropriateness of costing methodology, and discussion of potential biases. The most frequently missed question was whether the cost perspective of the analysis was stated and justified.

CONCLUSION

The number of studies in orthopaedic sports medicine is small, despite their overall good quality. Yet, there are still many highly cited studies based on low-quality or partial economic evaluations that are being used to influence clinical decision-making. Investigators should follow international health economic guidelines for study design and critical appraisal of studies to further improve quality.

Protocol of DEXPED trial: efficacy of intravenous dexamethasone, administered at the time of analgesic blocking of the lower limb, on postoperative pain in children: a randomised, placebo-controlled, double-blind trial

INTRODUCTION

Dexamethasone is a drug used to prolong the postoperative analgesia in children after peripheral nerve blockade, although the dose usually used (0.2 mg/kg) has not been studied yet. This study is a monocentric, prospective, randomised, placebo-controlled, double-blinded study in a university hospital in France. The primary objective of the study is to evaluate the efficacy of 0.2 mg/kg intravenous dexamethasone on early postoperative pain in children aged 6-15 years, who require a lower limb peripheral nerve block following general anaesthesia.

METHODS AND ANALYSIS

Eighty children, aged 6-15 years, undergoing surgery for which peripheral nerve lower limb blockade with ropivacaine following general anaesthesia are included. The inclusion criteria are: children aged 6-15 years, with American Society of Anaesthesiologists physical status I or II and scheduled for surgery requiring a peripheral block of the lower limb for analgesic purposes, with a preoperative anaesthetic evaluation between 90 and 2 days before the surgery, with informed consent from legal representatives. General anaesthesia is performed. The patient receives, according to his group, either 0.2 mg/kg of dexamethasone intravenously at the start of anaesthetic induction or the same volume of placebo. Then, the peripheral block of the lower limb is performed with ropivacaine. The primary outcome is the total doses of opioid administered (in mg/kg of morphine equivalent) within 24 hours postoperatively. The secondary objectives are the evaluation of the effect of a single-dose intravenous dexamethasone at the time of anaesthetic induction, on the following parameters: onset of postoperative pain, duration of motor block, postoperative nausea and vomiting within 24 hours.

ETHICS AND DISSEMINATION

This study is conducted according to the principles of the Declaration of Helsinki and has been approved by the French national ethics committee and the National Drug Safety Agency. Findings of this study will be widely disseminated through conference presentations, reports, factsheets and academic publications.

TRIAL REGISTRATION NUMBER

NCT03618173.

Partial Medial Meniscectomy Using Needle Arthroscopy and a Standardized Local Anesthetic Protocol

Needle arthroscopic procedures of the knee offer potential advantages over standard arthroscopic procedures. The small size of the instruments allows for surgery without the use of a scalpel or suture, potentially decreased recovery times, and potentially reduced complication rates compared with traditional arthroscopy. In some patients, the procedure can be performed without the use of either general anesthesia or sedation. The purpose of this article is to provide a standardized technique guide for needle arthroscopic partial medial meniscectomy under local anesthesia.

Diagnostic and therapeutic arthroscopy in the standing horse

This article describes diagnostic arthroscopy and arthroscopic management of selected lesions in the standing equine patient. Details on case selection, patient and operating room preparation, and surgical technique are presented. This information will add techniques that avoid general anesthesia to the equine surgeon's armamentarium.

The role of local anaesthesia in knee arthroscopy

INTRODUCTION

In current times, knee arthroscopy is the most common orthopaedic procedure. Over the years, the preferential method of anaesthesia has been general or spinal anaesthesia. The use of local anaesthesia (LA) in knee arthroscopies has been mentioned in surprisingly few orthopaedic publications over the past few decades. This reflects the very moderate role of LA in general compared to other forms of anaesthesia, even though the majority of operations in orthopaedic practice can be regarded as minor procedures. The aim of this study is to assess the efficacy of LA in knee arthroscopies.

METHODS

We performed a retrospective analysis of the efficacy of local anaesthesia in patients undergoing knee arthroscopy under LA over a period of 5 years. The anaesthetic routinely used is Xylocaine 2% with adrenaline. We evaluated pain during procedure and after the procedure by recording a Visual Analogue Score (VAS).

RESULTS

Over a 5 year period (07/2005-06/2010), 433 knee arthroscopies have been performed under LA. The male:female ratio was 52:48%, mean age 48 years (range 14-84). The mean VAS during injection was 1.8 (SD 2) and during the procedure 0.9 (SD 1.7). There has been no complication reported related to LA. We have not encountered any type 1 allergic reactions.

CONCLUSION

Our experience demonstrates that LA in arthroscopies is a convincing alternative to other forms of anaesthesia and should further be considered as gold standard anaesthesia in knee arthroscopy.

Wide-Awake Wrist Arthroscopy and Open TFCC Repair

The wide-awake approach to hand surgery entails the use of local infiltration anesthesia using lidocaine with epinephrine and no tourniquet. The technique provides practitioners with an option to perform advanced hand surgical care in an ambulatory setting, without the need for general or regional anesthetics. We present our results using wide-awake approach in wrist surgery, both open and arthroscopic. Between June and August 2011, the wide-awake approach was used in nine elective wrist surgery cases; three arthroscopic procedures, four open triangular fibrocartilage complex (TFCC) repairs, and two combined arthroscopy/open surgery (eight men/one woman). The arthroscopic patients were anesthetized using dorsal infiltration of lidocaine with epinephrine (20 mL) with an additional intra-articular 5 mL injection 30 minutes before surgery. The open surgery patients received 40 mL of lidocaine with epinephrine around the ulnar aspect of the forearm, from 8-cm proximal to 3-cm distal to the distal radioulnar joint. Standard diagnostic radio- and midcarpal arthroscopies were performed, where one patient had a loose body removed and two patients underwent TFCC debridements due to central TFCC tears. The six open cases were all due to TFCC foveal disruptions, which were reinserted using osteosutures in the distal ulna. Following placement of the ligament sutures, a preliminary knot allowed active and passive motion testing of pronosupination, to determine the adequate amount of tension in the ligaments. The wide-awake approach to wrist surgery is a plausible and reliable technique that eliminates the need for general anesthesia, removes the need of a tourniquet, and provides a cost-efficient and safe approach to wrist surgery. The ability to control ligament reconstructions using active motion may additionally enhance the rehabilitation of these patients, both through early proprioceptive awareness and adequate tensioning of soft tissues.

Outpatient arthroscopic knee surgery under combined local and intravenous propofol anesthesia in children and adolescents

BACKGROUND

This prospective observational study included a case series of children and adolescents receiving light intravenous propofol anesthesia combined with local anesthesia (LA) for arthroscopic knee procedures. The aim was to examine the merits of anesthesia, to discuss the indications for the procedure and to analyze recovery/discharge times from the postanesthesia care unit (PACU).

METHODS

A cohort of 147 children and adolescents (ASA 1 and 2) aged 12-18 years admitted for outpatient arthroscopic knee procedures between January 2004 and May 2005 were studied. After IV access in the operating theater, the patients received propofol (10 mg.ml(-1)). Arthroscopy was performed approximately 15 min after injecting local anesthetic (15 ml 2% lidocaine with epinephrine 1:200,000) partly at the site of insertion of the arthroscope and other instruments (5 ml), and the rest intra-articular. The following parameters were assessed: airway patency, propofol requirement, vital signs, procedure time, surgical operating conditions, patient satisfaction score, time to discharge, postoperative analgesia and adverse events.

RESULTS

Of 147 patients, 133 patients (90.5%) underwent arthroscopic knee surgery, whereas knee arthroscopy alone was performed in 14 patients (9.5%) without indication for operative treatment. The arthroscopy was well tolerated in 96.6% patients (no pain, movement or discomfort during the procedure) and only five patients required conversion to general anesthesia. Pain experienced during the injection of lidocaine was more severe than pain experienced during the surgical procedure itself (P < 0.001). The surgical evaluation of operative conditions (visualization and access to intra-articular structures) was generally satisfactory and completely acceptable. Almost 94% (138/147) of patients said they would have the same procedure again under the same type of anesthesia. The mean propfol induction dose was 1.4 mg.kg(-1) (range: 0.9-3.8) and mean propofol infusion rate 167 microg.kg(-1).min(-1) (range: 130-250). Movement was more likely at lower infusion rates (mean: 151 microg.kg(-1).min(-1)). The maximal decrease in respiratory rate was 5.9 +/- 5.1 br.min(-1) (27.2 +/- 21%) and no patient became hypoxic. Patients recovered to preoperative values at 9.8 +/- 7.5 min following infusion discontinuation. There were no respiratory or cardiovascular complications. The mean stay in PACU was 47 min (range: 32-150). As many as 71% (105/147) of patients required no analgesics during the first two postoperative hours.

CONCLUSIONS

The combination of light intravenous propofol anesthesia combined with local anesthesia for arthroscopic knee procedures provided effective sedation, good preservation of upper airway patency, rapid recovery and pain relief without major side effects and offers a good alternative to the methods already available. The majority of patients did not require postoperative analgesia.

Purely intra-articular versus general anesthesia for proposed arthroscopic partial meniscectomy of the knee: a randomized controlled trial

PURPOSE

The aim of this study was to compare intra-articular anesthesia alone versus general anesthesia with regard to ease of the procedure, level of postoperative pain, and patient satisfaction when partial meniscectomy is anticipated.

METHODS

We prospectively randomized to general anesthesia or to intra-articular anesthesia 107 patients who were about to undergo knee arthroscopy, in whom partial meniscal resection was anticipated on the basis of clinical or radiologic grounds. Technical difficulty of the procedure, level of postoperative pain and nausea, and overall patient satisfaction were assessed.

RESULTS

The ease of obtaining arthroscopic views, the adequacy of these views, and the ease of performing partial meniscal resection or another procedure were similar in both groups according to scores assigned by the operating surgeon. Pain at 6 hours postoperatively was significantly less in the intra-articular anesthesia group but was similar in the 2 groups at 24 and 48 hours. Patients who were given intra-articular anesthesia reported higher satisfaction rates in understanding the underlying disease of the knee.

CONCLUSIONS

We propose that intra-articular anesthesia alone can be effectively used in knee arthroscopies in which partial meniscal resection is anticipated.

LEVEL OF EVIDENCE

Level I, high-quality randomized controlled therapeutic trial.

Outpatient arthroscopic knee surgery under multimodal analgesic regimens

PURPOSE

To investigate whether diclofenac could be used in preemptive and multimodal fashion with local anesthesia (LA) during arthroscopic knee surgery.

METHODS

A cohort of 628 patients (age range, 14 to 60 years) underwent outpatient arthroscopic knee surgery under LA with 15 mL of 2% lidocaine with epinephrine. Diclofenac 1 mg/kg was administered immediately before the procedure was performed. Pain was intraoperatively assessed with a 10-cm visual analogue scale (VAS). Patients' and surgeons' satisfaction with the quality of anesthesia was estimated by a special questionnaire and VAS score.

RESULTS

From the technical point of view, arthroscopic procedures were successfully completed in 98.2% of patients. Pain experienced during injection of lidocaine (VAS score: median, 2.9; mean, 3.4; standard deviation [SD], 3.2; range, 0 to 10) was more severe (P = .0001) than pain experienced during the surgical procedure itself (VAS score: median, 1.8; mean, 2.4; SD, 2.2; range, 0 to 5.2). Arthroscopy was well tolerated by most patients (98.5%), and only 1.4% of procedures had to be terminated prematurely because of patient discomfort. Almost 95.7% of patients reported that they would undergo the same procedure again under the same type of anesthesia. In 4.7% of patients, LA was not considered optimal by the performing surgeon.

CONCLUSIONS

Arthroscopic knee surgery with diclofenac and LA with no premedication is an efficient and well-tolerated method used in outpatient practice with no major adverse effects.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

A prospective randomized comparison of spinal versus local anesthesia with propofol infusion for knee arthroscopy

PURPOSE

Knee arthroscopy is the most common orthopaedic procedure performed in the United States, and there are few randomized studies comparing local anesthesia, in conjunction with propofol, with regional anesthesia for knee arthroscopy. The purpose of the study was to test the hypothesis that patients receiving local anesthesia combined with propofol infusion (LAP) will recover from anesthesia faster and experience less postoperative headache and back pain compared with spinal anesthesia (SA).

TYPE OF STUDY

Randomized trial.

METHODS

A randomized trial was used to compare SA and LAP in adults undergoing knee arthroscopy. A simple randomization scheme in sealed envelopes was used. An independent observer collected data the day of surgery and contacted patients by telephone on the first postoperative day to inquire about back pain or headaches, and to have them rate their anesthesia (excellent, good, fair, or poor).

RESULTS

Eighteen patients (average age, 53 years) received LAP and 14 received SA. Baseline assessment of the 2 groups was similar. The mean time spent in the postoperative anesthesia care unit (PACU) was 2.8 hours for the LAP group and 4.0 hours for the SA group (P < .0001). Spinal anesthesia was associated with back pain in 5 of 14 patients in the SA group compared with none in the LAP group (P = .004). There were no statistically significant differences between the 2 groups with respect to headache (P = .5) or overall patient satisfaction (P = .3). The amount of time required to administer anesthesia was similar between the 2 groups (P = .2). The number of patients requiring additional sedation intraoperatively was higher in the LAP group compared with the SA group, 9 of 18 and 1 of 14, respectively (P = .02).

CONCLUSIONS

Although subjects receiving LAP were more likely to require additional sedation intraoperatively compared with the SA group, LAP was associated with significantly less time to home readiness as measured by time in the PACU.

LEVEL OF EVIDENCE

Level I.

Spinal versus general anesthesia for orthopedic surgery: anesthesia drug and supply costs

Total hip or knee replacement surgeries are common orthopedic interventions that can be performed with spinal anesthesia (SA) or general anesthesia (GA). No study has investigated the economic aspects associated with the two anesthetic techniques for this common surgery. We randomized 40 patients to receive either SA or GA and analyzed the drug and supply costs for anesthesia und recovery. Anesthesia-related times, hemodynamic variables, and pain scores were also recorded. Total costs per case without personnel costs were almost half in the SA group compared with the GA group; this was a result of less cost for anesthesia (P < 0.01) and for recovery (P < 0.05). This finding was supported by a sensitivity analysis. There were no relevant differences regarding anesthesia-related times. Patients in the GA group were admitted to the postanesthesia care unit with a higher pain score and needed more analgesics than patients in the SA group (both P < 0.01). We conclude that SA is a more cost-effective alternative to GA in patients undergoing hip or knee replacement, as it is associated with lower fixed and variable costs. Moreover, SA seems to be more effective, as patients in the SA group showed lower postoperative pain scores during their stay in the postanesthesia care unit.

Knee block anesthesia for arthroscopic procedures

Knee block anesthesia frequently is used for arthroscopic knee procedures by orthopedic surgeons and anesthesia care providers at Bronson Methodist Hospital, Kalamazoo, Mich. This type of regional anesthesia using local anesthetic medications provides excellent surgical conditions and prolonged postoperative analgesia. Use of this anesthetic technique avoids many of the side effects of general, spinal, and epidural anesthesia and saves time and money for patients and facilities.

Simultaneous live video presentation during knee arthroscopy

To improve patient understanding, we evaluated prospectively the effect of patient-observed simultaneous surgeon-explained live video during knee arthroscopy. Patient satisfaction, understanding, and tolerance of the tenderness and pain were measured by a questionnaire completed immediately after the procedure. There were 72 patients (41 men, 31 women) with a mean age of 47 years; 76 joints were treated among them. All but one were comfortably able to watch the live video of the procedure, and 89% of the patients reported a good understanding of and satisfaction with the procedure. Moreover, if the patients ever had to have another arthroscopy, 66% answered that they "certainly" wanted a live video presentation, and 25% "somewhat" desired it. Live video-presented outpatient arthroscopic knee surgery could be considered a method for improving patient understanding of knee pathology.

Anaesthesia for outpatient knee surgery

Surgical procedures of the knee are increasingly common in outpatient centres. Advances in arthroscopy and other technologies allow more complex knee procedures to be performed on an outpatient basis. This chapter focuses on the application and advantages of peripheral nerve block regional anaesthesia in the anaesthetic management of knee surgery patients. Specific nerve blocks and local anaesthetics suitable for various knee procedures are discussed. The use of perineural catheters in the outpatient management of major knee surgery patients is also considered.

Arthroscopic removal of dorsoproximal chip fractures of the proximal phalanx in standing horses

OBJECTIVE

To report a technique for, and outcome after, arthroscopic removal of dorsoproximal chip fractures of a proximal phalanx in standing horses.

STUDY DESIGN

Retrospective study.

ANIMALS OR SAMPLE POPULATION

A total of 104 horses, 1 to 13 years of age, with a dorsoproximal chip fracture of a proximal phalanx.

METHODS

Horses were restrained in standing stocks and sedated with intravenous xylazine, detomidine, or a combination of both drugs. Local analgesia was achieved with 2% mepivacaine administered intra-articularly and by subcutaneous infiltration in a crescent-shaped block dorsal to the fetlock. Sterile drapes were placed on the surgical field, and impervious drapes were used on the hoof and floor. Arthroscopic portals were created in the dorsal pouch of the metacarpophalangeal or metatarsophalangeal joints to remove chip fractures. Statistical analysis was performed on race records for all Thoroughbred racehorses and compared with previously published studies. Operative and hospitalization times were compared with those of the general hospital population, and risks associated with general anesthesia were examined.

RESULTS

No major operative or postoperative complications occurred. Ninety-one percent of racehorses raced after surgery with 78% returning to race at the same or higher level.

CONCLUSION

Standing arthroscopic surgery can be performed successfully to remove dorsoproximal chip fractures of the proximal phalanx.

CLINICAL RELEVANCE

Standing arthroscopic surgery is a valid alternative treatment for experienced surgeons to avoid the expense and potential risks associated with general anesthesia.

Knee arthroscopy with the use of local anesthesia--an increased risk for repeat arthroscopy? A prospective, randomized study with a six-month follow-up

Although there have been many reports of good results when local anesthesia is used with knee arthroscopy, it is not used as a standard anesthetic. Concerns about local anesthesia include the fear of prolonged surgery, which could result in inadequate anesthesia, thus causing the patient unnecessary discomfort. The purpose of this study was to evaluate the risk of repeat arthroscopy and the patient satisfaction rate up to 6 months after knee arthroscopy under local anesthesia. In this prospective, randomized study, 400 patients scheduled for elective knee arthroscopy were allocated to one of three groups: local anesthesia (200 patients), spinal anesthesia (100 patients), or general anesthesia (100 patients). All enrolled patients were asked to complete a questionnaire 6 months after surgery and all of their medical records were reviewed. No repeat arthroscopies occurred in the spinal and general anesthesia groups and only three occurred in the local anesthesia group, a nonsignificant difference. In only one of these three cases was the clinical course altered by the repeat arthroscopy. There was no difference in the satisfaction rate between the three anesthesia groups. We conclude that the choice of anesthesia does not influence the frequency of repeat arthroscopy, satisfaction with the procedure, or recovery at 6 months after knee arthroscopy.

The preemptive analgesic effect of intraarticular bupivacaine and morphine after ambulatory arthroscopic knee surgery

Intraarticular (IA) morphine provides effective postoperative analgesia after arthroscopic knee surgery. Some investigators have suggested that the preemptive administration of opioids may reduce postoperative analgesic requirements and hypersensitivity. We evaluated the analgesic effect of administering IA morphine either before or after surgical incision in patients undergoing arthroscopic knee surgery under local anesthesia. Forty patients undergoing arthroscopic meniscectomy were randomized into two groups. All patients received IA bupivacaine 0.25% before and after surgery together with IV sedation using midazolam and propofol. The Preemptive IA Morphine group received a single 3-mg dose of morphine with their preoperative bupivacaine. The Post-IA Morphine group received 3 mg of morphine at the completion of surgery with the postoperative bupivacaine. After surgery, pain scores, the time to first opioid use, and 24-h analgesic use were recorded. Analgesic duration, defined as the time from completion of surgery until first opioid use, was significantly longer in those patients receiving preoperative (953 +/- 209 min) versus postoperative (556 +/- 121 min) IA morphine. The 24-h acetaminophen and oxycodone use was less in the Preemptive group (2.2 +/- 1.2 pills) versus the Postoperative group (3.0 +/- 1.2 pills). We conclude that IA morphine provides a longer duration of postoperative analgesia with less 24-h opioid use when administered before surgery.

IMPLICATIONS

The administration of intraarticular morphine 3 mg before arthroscopic knee surgery provides a longer duration of analgesia with less 24-h opioid use compared with the administration of the drug at the completion of surgery.

A unique approach to postoperative analgesia for ambulatory surgery

Postoperative analgesia for the ambulatory surgery patient is frequently inadequate. Continuous regional analgesia improves outcome and patient satisfaction in hospitalized patients. This paper describes the successful use of continuous regional analgesia following orthopedic surgery in the ambulatory setting.

Regional anesthesia for ambulatory surgery

Ambulatory surgery is increasing at unprecedented rates with more complex procedures being performed. This article reviews the benefits of the use of regional anesthesia during ambulatory surgeries. Regional anesthesia, by putting the anesthetic at the surgical site, provides ideal conditions for ambulatory surgery and provides a smooth, predictable post-operative course.

Can local anesthesia be recommended for routine use in elective knee arthroscopy? A comparison between local, spinal, and general anesthesia

Local anesthesia (LA) for outpatient knee arthroscopy is not a standard procedure at most hospitals. To evaluate the LA technique for knee arthroscopy on medically healthy patients, this study compared 3 anesthesia techniques. Four hundred patients were randomized to either local (n = 200), general (n = 100), or spinal (n = 100) anesthesia. Evaluated outcomes included the patient's subjective view of the procedure, and nausea and pain at rest and during active movement. All variables were recorded perioperatively and postoperatively. In addition, the performing surgeon's opinion of the degree of patient pain and the technical difficulty of the procedure were noted. Three hundred forty-two patients completed the study. In the group receiving local anesthesia (n = 180) the median visual analog scale pain score during surgery was 6 mm (mean, 17.5; SD, 23.2; range, 0 to 100 mm). Twenty-one LA patients would have preferred another form of anesthesia. In 29 patients, LA was not considered as the optimal anesthesia by the performing surgeon. Eight LA patients agreed with the surgeon that the anesthesia method used was not optimal, of these patients, 5 had synovitis (3%). In 5% of the LA patients there were technical problems. Thus, this study shows that elective knee arthroscopy can be performed under local anesthesia in 92% of the patients from a technical point of view. Excluding patients who do not choose local anesthesia and those who have hypertrophic synovitis preoperatively, knee arthroscopies can be performed as safely and effectively under local anesthesia as under any other form of anesthesia. For most patients, local anesthesia can be recommended as the standard procedure for outpatient knee arthroscopy.