Knee Arthroscopy with the Use of Local Anesthesia An Increased Risk for Repeat Arthroscopy?

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1 /102/ $02.00/0 THE AMERICAN JOURNAL OF SPORTS MEDICINE, Vol. 30, No American Orthopaedic Society for Sports Medicine Knee Arthroscopy with the Use of Local Anesthesia An Increased Risk for Repeat Arthroscopy? A Prospective, Randomized Study with a Six-Month Follow-up Eva Jacobson,* MD, Magnus Forssblad,* MD, Lars Weidenhielm, MD, PhD, and Per Renström, MD, PhD From the *Artro Clinic, St. Göran s Hospital, and the Department of Orthopaedics, Karolinska Hospital, Stockholm, Sweden ABSTRACT 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. Outpatient knee arthroscopy is a common procedure today. It is performed with the patient under general, local, or spinal anesthesia. Local anesthesia offers several advantages and its use is well documented. 1,6 8 Although good results with local anesthesia have been reported, 2,4 it is not used as a standard anesthetic. Concerns about local anesthesia include the fear of prolonged surgery, which could lead to inadequate anesthesia, thus causing the patient unnecessary discomfort. 8 At our institution, we have shown that 90% of our patients have been satisfied with local anesthesia in the perioperative period. 5 However, despite such a high rate of patient satisfaction, knee arthroscopy performed with local anesthesia can still be associated with problems. If there is clinically significant synovitis, local anesthesia is not always adequate. 5 A narrow joint space may be anatomic (varus knee) or may occur if the patient senses pain and has difficulty relaxing. Such narrowing will result in an incomplete examination. Surgery may also be accelerated or interrupted because of a patient s pain, and procedures may not be completed. These problems may result in a higher frequency of repeat arthroscopy. The purpose of this study was to compare local, spinal, and general anesthesia and evaluate the risk of repeat arthroscopy and the patient satisfaction rate up to 6 months after knee arthroscopy under local anesthesia. MATERIALS AND METHODS Patients Address correspondence and reprint requests to Eva Jacobson, MD, Artro Clinic/Tipskliniken, St Göran s Hospital, S Stockholm, Sweden. No author or related institution has received any financial benefit from research in this study. After we obtained approval from the Ethics Committee of the Karolinska Hospital and informed consent from the subjects, 400 patients scheduled for primary elective knee 61

2 62 Jacobson et al. American Journal of Sports Medicine arthroscopy were enrolled in the study. The inclusion criteria were as follows: patients were scheduled for primary knee arthroscopy, patients had a physical status of class I or II according to the American Society of Anesthesiologists 10 (Table 1), knee range of motion was at a minimum of 0 to 90, and age was 18 years or older. Exclusion criteria were the presence of neurologic or neuromuscular disease, local infection at the selected portal and injection sites, allergy to local anesthesia, and allergy to nonsteroidal antiinflammatory drugs. The 400 patients included for study were selected from a group of 1062 patients who were asked to participate and were then examined. Of this group, 516 patients were excluded: 340 did not want to participate, 176 rejected the type of anesthesia specified for use (55 rejected local anesthesia, 15 rejected general anesthesia, 19 rejected spinal anesthesia, and 87 wanted local anesthesia). One hundred forty-six patients did not fulfill the inclusion criteria. The patients were allocated to a local anesthesia (200 patients), spinal anesthesia (100 patients), or general anesthesia (100 patients) group by drawing a sealed envelope with a number. Because many patients were expected to drop out after randomization to the local anesthesia group and no differences were expected between the spinal and general anesthesia groups, 200 patients were randomized to the local anesthesia group and 100 each were randomized to the other two groups. The randomization was done at the time of scheduling for surgery. The reason for this was practical; at the clinic, knee arthroscopy with the patient under local anesthesia is performed at a special unit, where conversion to general anesthesia is not possible if the anesthesia is inadequate. Fifty-eight patients were excluded after randomization (Table 2). Anesthesia Protocol Eight orthopaedic surgeons with varying experience in arthroscopic surgery (from resident to consultant level) participated in the study. All arthroscopic procedures were performed on an outpatient basis using a lateraloutflow cannula with a continuous pressure-irrigation system. Local Anesthesia. In the local anesthesia group, each of the three portal sites was infiltrated with 10 ml of 0.5% prilocaine with adrenaline, and then 20 ml was injected into the joint (total, 40 to 70 ml). Thirty minutes after administration of the anesthetic, surgery was started. One gram of rectally administrated paracetamol and 20 mg Class I II III IV V TABLE 1 American Society of Anesthesiology Classification Description Healthy patient Patient with a mild systemic disease Patient with a severe systemic disease, not incapacitating and controlled by medication Patient with incapacitating systemic disease that is a constant threat to life Moribund patient TABLE 2 Reasons for Exclusion after Randomization to One of the Three Different Groups ketorolac intravenously was given immediately preoperatively. No other drugs were allowed intraoperatively. Spinal Anesthesia. Premedication consisted of 10 mg of oral diazepam and 1 g of rectal paracetamol administered 1 hour before the start of anesthesia. The intrathecal block was performed according to hospital protocol. Hyperbaric lidocaine (60 to 90 mg) was used. Hypotension was treated with 5 to 10 mg of ephedrine. Just before the start of the surgical procedure, ketorolac (20 mg) was administered intravenously. The surgeon injected 10 ml of prilocaine (0.5%) with adrenaline at each of the three portals at the beginning of the surgery. At the end of the procedure 20 ml of prilocaine (0.5%) with adrenaline was administered into the joint. General Anesthesia. Premedication was the same as for the spinal anesthesia patients. Propofol (induction and maintenance) and alfentanil were used according to hospital protocol. The patients were breathing spontaneously during surgery and were supplied with oxygen. Ketorolac (20 mg) was administered intravenously immediately before surgery. Intravenous alfentanil was given at the discretion of the anesthesiologist. The surgeon injected 10 ml of prilocaine (0.5%) with adrenaline at each of the three portals at the beginning of the operation. After surgery, 20 ml of prilocaine (0.5%) with adrenaline was given intraarticularly. Postoperative Analgesics To standardize the postoperative analgesic consumption, each patient in the study was supplied with 30 tablets of paracetamol (500 mg each). Evaluation Reasons for exclusion Treatment groups a LA SA GA Patient declined surgery or indication no longer present Did not fulfill inclusion criteria at time of surgery Patient did not accept randomized anesthetic method Anesthesia-related problems b Surgical reasons (arthrotomy) 1 Lost to follow-up Total number of patients a LA, local anesthesia; SA, spinal anesthesia; GA, general anesthesia. b Problems included incorrect premedication, technical problems, and anticipated airway problems. All patients were assessed for pain perioperatively. A 100-mm visual analog scale with the anchor words no pain (0) and most intense pain ever (100) was used. The surgeons were asked to grade the technical difficulty of the procedure on a visual analog scale with the anchor words not complicated (0) and very complicated (100).

3 Vol. 30, No. 1, 2002 Knee Arthroscopy with Local Anesthesia 63 All enrolled patients were asked to complete a questionnaire 6 months after surgery (Table 3). The follow-up interval of 6 months was chosen based on our clinical experience. We wanted the patients to have a chance to fully rehabilitate but still have some memory of the surgical event. In addition, the risk of new or secondary pathologic knee problems increases with a longer followup. The questionnaire responses were treated confidentially. All of the patients medical records were reviewed. All patients who did not answer the questionnaire were contacted again, first by a reminder letter, and then personally by phone. Statistics The data were analyzed using a chi-square test or a Fisher exact test (the frequency of repeat arthroscopy). A P value of less than 0.05 was considered significant. RESULTS TABLE 3 Questions in Questionnaire 1. Do you consider yourself recovered from the arthroscopy? Yes/No 2. Are you satisfied with the result of the procedure? Yes/No If no; how is your knee? Worse/Unchanged/Slightly better 3. Would you choose another anesthesia if you were to have a new arthroscopy? Yes/No 4. Have you had another arthroscopy of the same knee? Of the 400 patients enrolled, 342 were able to be included as participants in the study. Of these 342 patients (180 local, 74 spinal, and 88 general anesthesia patients), 324 (169 local, 68 spinal, and 87 general anesthesia patients) returned the questionnaire (95%). There were 53 women (mean age, 43 years) and 116 men (mean age, 45 years) in the local anesthesia group, 31 women (mean age, 47 years) and 37 men (mean age, 46 years) in the spinal anesthesia group, and 34 women (mean age, 44 years) and 53 men (mean age, 41 years) in the general anesthesia group. The 18 missing patients could not be reached by letter or phone. Their records at our hospital were reviewed. Twenty-five (14%) of the 180 patients in the local anesthesia group, 8 (11%) of the 74 patients in the spinal anesthesia group, and 16 (18%) of the 88 patients in the general anesthesia group had only diagnostic arthroscopy. The rest of the patients had intraarticular procedures performed, including resecting plicas, shaving synovial or chondral defects, and, most commonly, partial meniscectomy (120 of 180 local anesthesia patients, 67%). No patients with meniscal repairs or ACL reconstructions were included. The major postoperative diagnoses for all of the patients are presented in Table 4. There was no significant difference in the duration of surgery between the groups. The surgeons assessed surgery to be more complicated to perform in the local anesthesia group (visual analog scale: median, 10; mean, 17.0; range, 0 to 93) as compared with the spinal and general anesthesia groups. The visual analog scores for pain intensity at rest and during movement did not differ between the three groups during the postoperative course (from 1 hour until the 2nd day after surgery). There were no repeat arthroscopies in the spinal and general anesthesia groups. Three repeat arthroscopies were performed in the local anesthesia group at our hospital within 6 months of the original arthroscopy for persistent knee symptoms (residual medial knee pain and synovitis). The difference between the groups was not statistically significant (P 0.43). On reviewing the records of the patients who underwent repeat arthroscopy, we found that no technical difficulties (for example, narrow joint or severe synovitis) were described in the first two cases, but symptoms persisted after surgery. In both of these cases a partial medial meniscectomy of the posterior horn had been performed. At the repeat arthroscopic procedures under general anesthesia, small, residual tears of the posterior horn of the meniscus were found and further resections were made. In one of these patients an irregular and hard surface of the tibial cartilage adjacent to the meniscal tear was noted. This patient improved but did not fully recover after this second procedure. The second patient recovered completely. In the third repeat arthroscopy the original diagnosis had been patellofemoral arthrosis with chondral defects, with no other pathologic intraarticular abnormalities found. Surgery had to be accelerated because of pain. Persistent symptoms after surgery led to the performance TABLE 4 Major Postoperative Diagnoses for All 342 Operated Patients Local Spinal General N (%) N (%) N (%) Medial meniscal tear 68 (38) 17 (23) 31 (35) Osteoarthritis 24 (13) 11 (15) 8 (9) Medial meniscal tear and 42 (23) 23 (31) 21 (24) osteoarthritis ACL tear 16 (9) 8 (11) 11 (13) Normal 10 (6) 4 (5) 8 (9) Other 20 (11) 11 (15) 9 (10) Total 180 (100) 74 (100) 88 (100)

4 64 Jacobson et al. American Journal of Sports Medicine TABLE 5 Number of Patients Considering Themselves as Not Recovered 6 Months after Surgery and Their Main Postoperative Local (N 169) Spinal (N 68) General (N 87) Medial meniscal tear Osteoarthritis Medial meniscal tear and osteoarthritis ACL tear Normal Other Total of a repeat arthroscopy, but no new pathologic lesions were found. This patient did not recover completely after the second procedure, which included shaving of the chondral defects. One hundred eighteen local anesthesia patients (70%), 52 spinal anesthesia patients (76%), and 59 general anesthesia patients (68%) considered themselves completely recovered from the arthroscopy (question 1), a nonsignificant difference (P 0.47). The postoperative diagnoses of patients who considered themselves not recovered are presented in Table 5. There were 98 local anesthesia (58%), 45 spinal anesthesia (66%), and 50 general anesthesia patients (57%) who were satisfied with the result of the procedure (question 2). Three local anesthesia, five spinal anesthesia, and three general anesthesia patients were satisfied with the result of their procedure but stated that the condition of their knee was unchanged or slightly better. They were not included in the satisfied group. Two unsatisfied patients did not grade their current knee status (one local and one spinal anesthesia patient). There were 37 local anesthesia, 8 spinal anesthesia, and 15 general anesthesia patients who considered their knee condition to be slightly better. Twenty-two local anesthesia, 10 spinal anesthesia, and 17 general anesthesia patients stated that their knee condition was unchanged. Eleven local anesthesia, four spinal anesthesia, and five general anesthesia patients considered their knee to be worse (Table 6). The TABLE 6 Number of Patients Considering Their Knee Problem Worse 6 Months after the Arthroscopy and Their Main Postoperative Local (N 169) Spinal (N 68) General (N 87) Medial meniscal tear Osteoarthritis Medial meniscal tear and osteoarthritis ACL tear Normal Other Total differences between the anesthesia groups were not significant (P 0.53). Ten of the patients who considered their knee to be worse (four local, four spinal, and two general anesthesia patients) and two of the patients who later had a repeat arthroscopy had had their surgery performed by the least-experienced surgeon. Thirty-seven local anesthesia (22%), 20 spinal anesthesia (29%), and 11 general anesthesia patients (13%) stated that they would prefer another type of anesthesia if they were to have knee surgery again (question 3). DISCUSSION In this study we found that the satisfaction rate for patients 6 months after knee arthroscopy does not depend on the type of anesthesia used. The choice of anesthesia did not influence the patient s opinion on knee status or the frequency of repeat arthroscopy 6 months after surgery. We could not identify a particular diagnosis that might predict failure in association with any specific type of anesthesia. The incidence of repeat arthroscopy was low, which is in accordance with the results of a previous study. 3 However, three repeat arthroscopies occurred in the local anesthesia group. Two of the three cases may have been the result of a narrow joint space, rendering the surgery technically more difficult, although this was not recorded by the surgeon at the time of the original arthroscopy. In one of these cases secondary chondral lesions were found at repeat arthroscopy, which may have caused the persistent symptoms after the first procedure. The third repeat arthroscopy was made necessary because of inadequate anesthesia during the first procedure. A second procedure was performed because the surgeon suspected a missed diagnosis. At the repeat arthroscopy no new lesions were found. Therefore, repeat arthroscopy with general anesthesia altered the clinical course in only one case. There were 18 patients (11 in the local anesthesia group) who did not return the questionnaire. This creates the possibility that more repeat arthroscopies could have been performed at another hospital without our knowledge. However, it is uncommon for patients to seek a second opinion at another unit in the Swedish medical system, where people are contracted to a specific hospital. In a previous study we have shown that local anesthesia can be used as the standard anesthetic for outpatient knee arthroscopy. 5 In that study, 90% of the 180 patients were satisfied with the local anesthesia at the time of surgery. Six months later 58% of the local anesthesia patients were pleased with both the anesthesia and the surgical result. It should be mentioned that the patients in this study had several different diagnoses, not all of which were treatable by arthroscopic knee surgery. Patients with complete ACL tears may have had low expectations about recovery, since some of them stated themselves as recovered at only 6 months after the arthroscopy. At that time, none of the patients, regardless of therapy, could have completely rehabilitated their knee. Time may have changed the patients perceptions of the immediate experience, and new pathologic knee lesions could have biased their opinions.

5 Vol. 30, No. 1, 2002 Knee Arthroscopy with Local Anesthesia 65 Rehabilitation after knee arthroscopy takes time, and it is not understood why some patients, although lacking severe intraarticular lesions, have problems with persistent synovitis months after surgery. In our clinical experience it is rare for this nonspecific postoperative synovitis to still be present 6 months after surgery. This was one of the reasons for choosing a 6-month follow-up interval. Other important factors we considered are that the patient should have some memory of the event and that the risk for new pathologic knee lesions to occur increases with a longer follow-up. No sedative was given as premedication. It is possible that the repeat arthroscopic procedures could have been prevented if the patients had been more relaxed. We believe that patients who undergo surgery under local anesthesia can have difficulty in expressing their sensations; for example, a diffuse discomfort or sensation of increased intraarticular pressure is sometimes perceived as pain. It is important to analyze the pain so that proper measures can be taken to correct it. Decreasing the intraarticular pressure can occasionally reduce the sensation of pain. The patient s personal preference of anesthesia type is by far the most important guideline for successful knee arthroscopy using local anesthesia. 9 An atmosphere of confidence, including an experienced surgeon, enhances surgery under local anesthesia. It should be remembered that patients who rejected local anesthesia were not included in the study. It is interesting that there were more patients who considered themselves fully recovered than there were patients who were satisfied with the result of the procedure. This shows the difficulty in asking the right questions to elicit patients real opinions. By twice asking almost the same question, we obtained different results, although the results were consistent within all three groups. This is why we analyzed the results of patients who stated that their knee was worse and patients who stated that they were not recovered. A few patients who were satisfied with the result of the procedure still stated that their knee condition was unchanged or slightly better and were therefore put into the unsatisfied group, since the statement on knee status was dependent on answering no to the question about satisfaction. This shows the importance of validating the evaluation form to be able to draw correct conclusions from the given answers. The advantages of local anesthesia in knee arthroscopy are well documented. 1 3,5 Local anesthesia is cost-effective, and the risk of severe complications is low. We conclude that the choice of anesthesia does not influence the frequency of repeat arthroscopy, patient satisfaction with the procedure, or recovery 6 months after knee arthroscopy. ACKNOWLEDGMENT We gratefully acknowledge the assistance of Elisabeth Berg from the Department of Medical Statistics at the Karolinska Institutet, Stockholm, Sweden. REFERENCES 1. Buckley JR, Hood GM, Macrae W: Arthroscopy under local anesthesia. J Bone Joint Surg 71B: , Eriksson E, Häggmark T, Saartok T, et al: Knee arthroscopy with local anesthesia in ambulatory patients. Methods, results and patient compliance. Orthopedics 9: , Forssblad M, Weidenhielm L: Knee arthroscopy in local versus general anaesthesia. The incidence of rearthroscopy. Knee Surg Sports Traumatol Arthrosc 7: , Hultin J, Hamberg P, Stenström A: Knee arthroscopy using local anesthesia. Arthroscopy 8: , Jacobson E, Forssblad M, Rosenberg J, et al: Can local anesthesia be recommended for routine use in elective knee arthroscopy? A comparison between local, spinal, and general anesthesia. Arthroscopy 16: , Lintner S, Shawen S, Lohnes J, et al: Local anesthesia in outpatient knee arthroscopy: A comparison of efficacy and cost. Arthroscopy 12: , Pellaci F, Beluzzi R, Martini A: Outpatient arthroscopy. Chirurgia Degli Organi di Movimento 81: , Shapiro MS, Safran MR, Crockett H, et al: Local anesthesia for knee arthroscopy: Efficacy and cost benefits. Am J Sports Med 23: 50 53, Shevde K, Panagopoulos G: A survey of 800 patients knowledge, attitudes, and concerns regarding anesthesia. Anesth Analg 73: , Wetchler BV (ed): Problems in Anesthesia. Volume 2. Philadelphia, Lippincott, 1988, pp 9 18