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Use of Antibiotic Lavage in Total Knee Replacement to Prevent Postoperative Infection

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Purpose

To determine the effectiveness of using antibiotic lavage in preventing postoperative infections in total knee replacement (TKR) patients.

Methods

Data on all patients who underwent TKR, either primary or secondary, during the period from May 2015 to April 2019 were collected. Many factors (both patient-related and surgery-related) that can increase the risk of surgical site infection (SSI) were taken into consideration to eliminate confounding factors.

Results

A total of 685 patients were identified; out of those, 232 patients received intraoperative antibiotic lavage and 453 did not. We noted that out of all 13 patients who developed SSI, only one patient (7.7%) had received antibiotic lavage, while the other 12 (92.3%) patients did not receive antibiotic lavage. However, the difference was not statistically significant (p=0.078).

Conclusion

Using intraoperative vancomycin lavage was associated with a decrease in the incidence of SSI post-TKR, but the difference was not statistically significant. However, more studies are needed in this area.

Introduction

Lower limb arthroplasty is a common surgical procedure performed on a daily basis, especially total knee replacement (TKR). In 2030, the estimated number of TKR cases in the USA will be 3.48 million [1]. The implantation of a large foreign body increases the risk of a deep surgical site infection (SSI) and emerges the need for effective perioperative strategies. Prosthetic joint infections (PJI) are one of the most feared complications in orthopedic surgery. Even with antiseptic techniques, SSI and PJI are common complications after orthopedic surgery, which might lead to unpleasant and unfavorable consequences such as a higher rate of prosthesis failure, hospitalization, and morbidity [2,3]. There are a multitude of risk factors that are attributed to the increased chance of the development of SSIs and PJIs. Most risk factors are attributed to host factors like the presence of underlying diseases such as obesity, diabetes mellitus (DM), rheumatoid arthritis, preoperative anemia, and cardiovascular diseases [4-11]. Surgical factors can also increase the risk of infection with longer operative duration and hospital stay [12-17]. Also, Minnema et al. and Wymenga et al. suggested that a high American Society of Anesthesiologists score contributes to the development of SSIs [18,19].

Infection is a devastating complication that bothers both orthopedic surgeons and patients. It can have a big impact on health care costs and length of stay; that is why many surgeons consider intraoperative antibiotic use as an important step in reducing the infection rate in TKR; however, it still remains controversial internationally [11]. The prevention of PJIs and SSIs mostly depends on controlling patients’ underlying diseases and optimizing their condition. In a study conducted on diabetic patients, it was found that regardless of the diabetes type, if the blood sugar was uncontrolled, it doubled the infection rate and led to a significant increase in surgical complications and an increase in the mortality rate [9]. Despite guideline recommendations, several studies explored the use of intraoperative antibiotics such as vancomycin, which has shown the ability to reduce the infection rate by up to 50% and was found to be highly effective in the reduction of SSIs [20,21]. However, Brown et al. showed that the use of antibiotics has no benefit over normal saline in wound irrigation [22]. For an antibiotic agent to be used during irrigation, it should possess a broad spectrum of antimicrobial activity, be used frequently, be used with pulsatile lavage systems, and be left in the wound for approximately one minute before removal [23]. In this study, we attempted to determine whether the use of antibiotic lavage in TKR can reduce postoperative infection.

Materials & Methods

Setting and study population

Approval from the institutional review board at King Saud University – College of Medicine was obtained prior to starting the study. The study was also conducted according to the principles of the Helsinki Declaration. This is a retrospective observational study conducted from May 2015 to April 2019 at King Saud University Medical City (KSUMC) in Riyadh, Saudi Arabia. We included all patients who underwent either primary or secondary TKR during the study period. All data were extracted from the KSUMC electronic database using surgical terminology codes, and patients were then subdivided into two groups: patients receiving intraoperative antibiotic lavage and patients not receiving antibiotic lavage intraoperatively.

All patients received standard antibiotic prophylaxis with 2 g of cefazolin IV 30 minutes preoperatively. The antibiotic group received a lavage consisting of 2 g of vancomycin powder diluted in 2 L of normal saline (1000 mg/1 L) and irrigation was done after the installation of the prosthesis during the cementation period for around 15 minutes prior to the closure of the capsule. The dose of vancomycin is based on the current literature, which shows a safe and minimal toxic effect of vancomycin on osteoblast replication at the cellular level with a concentration of 1000 mcg/ml or less [24]. The no-antibiotic group received 2 L of normal saline irrigation alone after the installation of the prosthesis and prior to the closure of the capsule. In the postoperative period, all patients from both groups received a standard dose of 1 g of cefazolin for three doses. Patients were followed up in the clinic from two weeks to six months after the surgery. Surgical wounds were checked in every visit, and clips and sutures were removed two weeks postoperatively.

Data collection

Many factors (both patient-related and surgery-related) can increase the risk of SSI; thus, we collected further information on demographics, the patient’s comorbidities, surgical procedural duration, antibiotic prophylaxis use pre and postoperatively, type of procedure (unilateral or bilateral TKR), and whether the patient had an intraoperative or postoperative complication and if they developed an infection.

Data analysis

The analysis was performed using Statistical Package for Social Sciences version 22.0 software (SPSS, Inc., Chicago, IL, US) to determine the demographics and the value of using vancomycin lavage intraoperatively. Categorical data were expressed using frequency and percentage. A chi-square and Fischer’s exact test were used to compare the categorical data for the two groups: those who took an antibiotic and those who did not. We assumed statistical significance when the p-value was less than 0.05.

Results

The sample size of our study was 685 and included all patients who underwent primary TKR during our set study period from May 2015 to April 2019. Those patients were divided into two groups. The groups were determined by whether they received antibiotic lavage intraoperatively or not. The number of patients who did not receive antibiotic lavage intraoperatively was 453 (66.1%), and the number of patients who received vancomycin lavage intraoperatively was 232 (33.8%). Most of our patients were female: 351 of those who did not receive antibiotics were female (77.5%), and 117 of those who did receive them were also female (50.4%) (Table 1).

Variable Value No antibiotic lavage given (n = 453) Antibiotic lavage given (n = 232) P-value OR (95% CI)
Gender Male 102 (22.5%) 115 (49.6%) 0.416 1.21 (0.76, 1.94)
Female 351 (77.48%) 117 (50.4%)
Age ≤50 years 22 (4.85%) 13 (5.6%) 0.675 0.86 (0.42, 1.74)
>50 years 431 (95.14%) 219 (94.39%)
Duration of surgery ≤120 min 99 (21.85%) 27 (11.63%) 0.001 2.12 (1.34, 3.36)
>120 min 354 (78.14%) 205 (88.36%)
DM 209 (46.13%) 92 (39.65%) <0.0001 1.97 (1.41, 2.76)
HTN 255 (56.29%) 129 (55.6 %) 0.020 1.48 (1.06, 2.07)
Hypercholesteremia 170 (37.52%) 85 (36.63 %) 0.017 1.51 (1.08, 2.11)
Smoking 5 (1.1%) 5 (2.155%) 0.662 0.76 (0.22, 2.64)
Cancer 14 (3.09%) 11 (4.74 %) 0.908 0.95 (0.42, 2.14)
RA 21 (4.63%) 18 (7.75 %) 0.610 0.84 (0.44, 1.62)
Obesity 363 (80.13%) 194 (83.62 %) 0.289 0.80 (0.52, 1.21)
Infectious diseases 23 (5.07%) 9 (3.87 %) 0.099 1.94 (0.88, 4.29)
Enteropathies 68 (15%) 42 (18.10 %) 0.451 1.18 (0.77, 1.81)
Table
1: Summary of demographic data and risk factors

BMI: body mass index, DM: diabetes mellitus, HTN: hypertension, RA: rheumatoid arthritis.

When further evaluating the efficacy of the antibiotic lavage among those who underwent TKR, we noted that using the antibiotics lavage in those who underwent TKR replacement did not significantly reduce infections postoperatively. Out of our entire sample size of 685, only 13 had infections. Twelve of those patients were among the group who did not receive antibiotics (6.18%); the remaining one was from the other group (0.43%) (p=0.078) (Table 2).

Variables No antibiotic lavage given (n = 453) Antibiotic lavage given (n = 232) P-value OR (95% CI)
Location Unilateral 364 (80.35%) 159 (68.53%) 0.308 1.27 (0.80,1.99)
Bilateral 87 (19.2%) 30 (12.93%)
Infection 12 (6.18%) 1 (0.43%) 0.078 6.29 (0.81,48.64)
Intraoperative complications 10 (2.2%) 10 (4.3%) 0.131 0.50 (0.21,1.23)
Postoperative complications 40 (8.83%) 31 (13.36%) 0.064 0.62 (0.38,1.03)
Table
2: Summary of operative data

Of all patients, 650 (94.9%) were above the age of 50, which constitutes the majority of patients in both groups, 431 (95.14%) and 219 (94.39%), respectively (p=0.675).

Discussion

This is the first study, to the best of our knowledge, in Saudi Arabia to report the effect of the use of antibiotic lavage in TKR to prevent postoperative infection. Our study found that the infection rate was 1.89% in all patients (those with and without antibiotics) and showed a non-significant decrease in the incidence of SSI post-TKR (P=0.078). A similar study done by Conroy et al. showed no benefit from the use of antibiotic solutions over normal saline [25]. On the other hand, after the administration of diluted betadine lavage, the rate of infection was reduced from 0.97% to 0.15%, with a significant difference in the rate of infection (p = 0.04). Diluted betadine 10% solutions were found to decrease postoperative infectious complications in orthopedic procedures, including postoperative infections in TKR, in other studies and in other types of surgeries, with minimal side effects [26-28]. Betadine use was found to be a safe and inexpensive choice that is present in almost all operating rooms [27] and can be cost-effective in preventing infections in TKR [29].

Other studies have achieved a drop in the rate of infection by using a high concentration of antibiotics at the time of implant insertion, even with prolonged operation times or in revision procedures [21,29]. A meta-analysis that included 15 studies in different surgical specialties showed that the use of prophylactic antibiotic lavage was found to be effective over the use of saline, water, or no irrigation in 10 studies, while the other five showed no difference [30].

According to our findings, there was no association between the comorbidities or patient-related factors and the increase in infection rate except for DM, which was controlled by multivariate analysis. This is similar to a study conducted on diabetic patients, which found that if the blood sugar was uncontrolled, it doubled the infection rate in patients after total joint arthroplasty [9].

Limitations of the study

There are a couple of weaknesses in our study. First, this is a retrospective cohort study, which is subjected to inconsistency when it comes to the process of data collection. However, the prospective nature of our data collection may have played a role in reducing recall and selection bias. Second, the small sample size of our study, which included only 685 patients.

Conclusions

Using intraoperative vancomycin lavage was associated with a decreased incidence of SSI post-TKR, but there was no statistically significant difference. The multivariate analysis, after adjusting other variables in the model, showed that only DM was independently related to the outcome. For the establishment of a gold standard in intraoperative prophylactic antibiotic lavage, we recommend that a prospective randomized control trial aiming to prevent postoperative infections be conducted. That would eliminate all questions and show the difference in costs and antibiotic use’s adverse effects.

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Exactech Total Knee Failure Resulted in Revision Surgery, Lawsuit Alleges

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Safran indicates she underwent left knee replacement surgery in 2014, at which time she was implanted with an Exactech Optetrak Comprehensive Total Knee System. However, in May 2022, an MRI detected signs of debris in her right knee, and a CT scan found osteolysis occurring around the Exactech total knee implant.

After experiencing worsening pain and instability, Safran underwent right knee replacement revision surgery to remove the failed Exactech Total Knee implant. The lawsuit claims Exactech knew there were problems with the implants for years, but failed to warn patients or the medical community.

“Defendants, however, ignored reports of early failures of their Optetrak Device and failed to promptly investigate the cause of such failures or issue any communications or warnings to orthopedic surgeons and other healthcare providers,” Safran’s lawsuit states. “Before the date of Plaintiff’s initial knee replacement surgery, Defendants knew or should have known that the Optetrak Device was defective and unreasonably dangerous to patients, that the product had an unacceptable failure and complication rate, and that the product had a greater propensity to undergo substantial early polyethylene wear, component loosening and/or other failure causing serious complications including tissue damage, osteolysis, and other injuries as well as the need for revision surgery in patients.”

Exactech Knee Implant Failure Lawsuits

Safran’s claim joins dozens of Exactech knee lawsuits now being pursued in the federal court system, each involving similar allegations that the manufacturer knew or should have known about high failure rates associated with its implants long before doctors and patients were warned about the problems.

At least as early as 2017, lawsuits over Exactech knee implants indicated there were alarming rates of adverse event reports being submitted to the FDA involving premature knee replacement revision surgery, which resulted in what some said was a “silent” Exactech recall when the company began slowly and quietly replacing the tibial trays of some Optetrak models.

In November, the U.S. Judicial Panel on Multidistrict Litigation (JPML) centralized all Exactech lawsuits in an MDL, or multidistrict litigation, and transferred the claims to U.S. District Judge Nicholas G. Garaufis in the Eastern District of New York, to coordinated discovery into common issues in the claims, avoid conflicting pretrial schedules and to serve the convenience of common witnesses and parties involved lawsuits that were spread out throughout the federal court system.

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AAOS Updates Clinical Practice Guideline for Surgical Management of Osteoarthritis of the Knee

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ROSEMONT, Ill., Jan. 10, 2023 /PRNewswire/ — The American Academy of Orthopaedic Surgeons (AAOS) issued an update to the Clinical Practice Guideline (CPG) for Surgical Management of Osteoarthritis of the Knee, which replaces the previous edition released in 2015. This CPG provides two new evidence-based recommendations and updates to 19 of the 38 recommendations. In addition to providing guidelines for specific surgical techniques and procedures for knee osteoarthritis (OA), the CPG also highlights important lifestyle considerations including diabetes, BMI and opioid use, all of which can play a role in surgical outcomes and complications.

OA is the most common form of arthritis in the knee and can have a severe impact on activity levels. This degenerative “wear and tear” typically occurs in people 50 years of age and older and is often associated with joint pain, stiffness and difficulty with purposeful movement. Surgical interventions, such as arthroplasty for symptomatic OA of the knee, is performed to relieve pain and restore function.

“We want to do everything possible to help our patients undergoing knee OA surgery experience favorable functional outcomes while reducing the risk of operative and postoperative complications, including pain or reoperation,” said Ajay Srivastava, MD, FAAOS, co-chair of the clinical practice guideline workgroup and member of the AAOS Committee on Evidence-Based Quality and Value. “Updates to this CPG include a rigorous systematic process, resulting in a guide that provides physicians with the information needed for shared decision-making with their patients.”

Highlights of the CPG include:

  • A strong recommendation that the optimization of perioperative glucose control (<126mg/dl) after total knee arthroplasty should be attempted in diabetic and non-diabetic patients with HgbA1C <6.5, as hyperglycemia can lead to less favorable postoperative outcomes and higher complication rates.
  • A strong recommendation showing that there is no difference in postoperative functional scores between patients with a BMI less than 30 and obese patients (BMI 30-39.9); however, there may be an increased risk of complications of surgical site infections in morbidly obese patients (BMI greater than 40).
  • A strong recommendation that there is no difference between patellar surfacing (kneecap replacement) or non-patellar resurfacing in TKA.
  • A new strong recommendation stating that there is no difference in composite/functional outcomes or complications between kinematic or mechanical alignment principles in TKA.

“A total knee replacement with kinematic alignment often incorporates a technological aspect such as a robot or a custom jig, which can potentially add cost to the surgery,” said Dr. Srivastava. “Therefore, if the current evidence demonstrates no difference in outcomes, the extra cost might not be necessary.”

The updated CPG continues to recommend multimodal pain management techniques and ways to reduce opioid intake including a new recommendation of moderate strength focused on counseling patients to avoid opioids prior to their TKA. Studies have shown a decrease in postoperative functional scores and increased pain scores and complications when opioids are taken prior to surgery. Additionally, a strong recommendation for peripheral nerve blockades for TKA can lead to decreased postoperative pain and opioid requirements with no difference in complications or outcomes, and a strong recommendation for periarticular local infiltrations used in TKA also lead to decreased postoperative pain.

“New evidence demonstrates the effectiveness of both pain management techniques, especially when used together, to decrease postoperative pain without increasing complications,” said Jonathan Godin, MD, FAAOS, co-chair of the clinical practice guideline workgroup and member of the AAOS Committee on Evidence-Based Quality and Value. “However, if a surgical facility isn’t able to perform a peripheral nerve blockade, I’d still encourage the use of an injection with local anesthetic around the knee capsule to decrease postoperative pain.”

The use of robotics in TKA and unicompartmental knee arthroplasty are included in the CPG as new options and demonstrate no significant difference in function, outcomes, or complications in the short term between robotic-assisted and conventional surgery.

“What remains to be seen is the granular, midterm or long-term data pertaining to the use of robotics for these arthroplasty procedures,” said Dr. Godin. “In five years, the next work group will have access to midterm outcomes, and it will be very interesting to see if this continues to hold true or not.”

This CPG was prepared by the AAOS Surgical Management of Osteoarthritis of the Knee Guideline physician work group (clinical experts) with the assistance of the AAOS Clinical Quality and Value (CQV) Department (methodologists).

CPGs are not meant to be stand-alone documents, but rather serve as a point of reference and educational tool for both healthcare professionals managing patients knee OA and orthopaedic surgeons. CPGs recommend accepted approaches to treatment and/or diagnosis and are not intended to be a fixed protocol for treatment or diagnosis. Patient care and treatment should always be based on a clinician’s independent medical judgment, giving the individual patient’s specific clinical circumstances.

The full Clinical Practice Guideline for Surgical Management of Osteoarthritis of the Knee is intended for reference by orthopaedic surgeons and other physicians, and available through AAOS’ OrthoGuidelines website and free mobile app. For more information on the development process for AAOS clinical practice guidelines, please view the Clinical Practice Guideline Methodology.

About the AAOS
With more than 38,000 members, the American Academy of Orthopaedic Surgeons is the world’s largest medical association of musculoskeletal specialists. The AAOS is the trusted leader in advancing musculoskeletal health. It provides the highest quality, most comprehensive education to help orthopaedic surgeons and allied health professionals at every career level to best treat patients in their daily practices. The AAOS is the source for information on bone and joint conditions, treatments and related musculoskeletal health care issues and it leads the health care discussion on advancing quality.

SOURCE American Academy of Orthopaedic Surgeons

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Joint replacement: Myths and facts related to knee replacement surgery

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Joint Replacement Surgery involves replacing the worn out or damaged joint surfaces with artificial joints called prosthesis where knee, hip and shoulder joints are commonly replaced joints. Joint replacement surgeries are beneficial in relieving pain and restoring your lost mobility.

In total knee replacement surgery, all the three compartments (medial, lateral, patellofemoral) are replaced whereas in partial knee replacement surgery only the damaged compartment is replaced. Even though knee replacement surgery has good outcomes, there are some misconceptions regarding it.

In an interview with HT Lifestyle, Dr Anup Khatri, Senior Consultant- Orthopaedics at Global Hospital in Mumbai’s Parel, debunked some of these myths and revealed facts –

1. Myth: Bending of knee, stair climbing, sitting cross-legged or sitting on floor is not possible after knee replacement surgery.

Fact: Most prosthesis used nowadays (HIGH FLEXION type) allow the same range of movement as normal knee joint. It allows patients to bend knees, stair climbing, and sitting cross-legged as well. It depends mainly on the quality of surgery done and postoperative rehabilitation.

2. Myth: After surgery, a few weeks of bed rest is needed and it takes months to recover.

Fact: In fact, patients are able to walk on the same day of surgery and most people get back to their routine activities within few weeks of surgery.

3. Myth: The metal in artificial knee implants may induce allergic reactions in the body.

Fact: The metals used are inert and do not react with body tissues. Also there are implants with coating of titanium alloy popularly known as gold knee, which are proven to be non-allergic and long lasting.

4. Myth: It is not possible to undergo surgery after the age of 65 years.

Fact: Age is not a limiting factor for the surgery. As Osteoarthritis is age related wear & tear of cartilage, one can undergo knee replacement successfully even after 65 years of age.

5. Myth: The success rate of surgery is very low.

Fact: Research shows that knee replacement surgery has 95% success rates in most patients. After surgery, people are able to perform their daily activities comfortably and without pain.

6. Myth: After surgery lifelong physiotherapy is needed and recovery is very slow.

Fact: Long term physiotherapy is not needed. The exercises taught while in hospital can be done at home. After joint replacement surgery, patients’ recovery has been faster and patients can be discharged from hospital in 3 days due to the advanced minimally invasive surgical techniques followed. Preconditioning also helps, wherein preoperatively patients’ nutritional status and muscle strengths are optimised and same are followed after surgery.

However, like any other surgery, there are some benefits and risks for this surgery too. It is always better to clarify any misconceptions by consulting your doctor.

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A Road to Recovery After Knee Surgery: 6 Tips to Follow

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Recovery from knee surgery can be full of ups and downs, but there are steps you can take to make the process as smooth as possible.

We find that patients who know what to expect and are proactive in their recovery tend to do better overall. With that in mind, here are six tips to follow in your recovery after knee surgery.

1. Get Plenty of Rest

Get_Plenty_of_Rest.png

Most people know that getting a good night’s sleep is essential for feeling rested and alert the next day, but few realize just how important it is for recovering from surgery. This doesn’t mean you have to stay in bed all day – although you should take it easy for the first few days – it does mean getting enough sleep at night and taking periodic naps during the day.

Good rest is crucial for healing because it gives your body the time it needs to repair the damage from surgery. When you’re well-rested, you’ll also have more energy for physical therapy and other essential activities for recovery. The recovery timelines for patients who get adequate rest are usually shorter than for those who don’t. So, make sure to get your ZZZs.

2. Eat a Nutritious Diet

As with sleep, eating a nutritious diet is vital for everyone but especially crucial for people recovering from surgery. A healthy diet will give your body the nutrients it needs to heal properly and fight infection. It’s also essential to avoid constipation, which can be a problem after surgery due to pain medication and inactivity.

Eat_a_Nutritious_Diet.png

To stay on top of your nutrition, eat plenty of fruits, vegetables, and whole grains. These foods are packed with vitamins, minerals, and fiber that will help keep your digestive system moving and your body healthy. It would help if you also drank plenty of water to stay hydrated.

3. Stay Active

It may seem counterintuitive, but staying active is vital for recovery after knee surgery. Of course, you shouldn’t overdo it – too much activity can delay healing – but getting some gentle exercise will help keep your joints mobile and prevent stiffness. Physical therapy is a great way to get the proper exercise for your needs.

Walking is another excellent way to stay active while recovering from knee surgery. Just be sure to start slowly and increase your distance gradually. If walking is painful or makes your incision feel uncomfortable, stop and rest until the pain subsides. As long as you listen to your body, staying active will speed up your recovery.

4. Follow Your Physical Therapy Regimen

Physical therapy is essential to recovering from knee surgery, but it’s important to follow your therapist’s recommendations. Depending on the surgery you had, you may need to start physical therapy a week after your procedure. This may seem like a lot, but getting the rehabilitation process started early is vital.

Your physical therapist will design a customized exercise program that gradually increases in intensity as you heal. Sticking to this program even when you feel like you can do more is essential. Pushing yourself too hard can delay healing and lead to setbacks. Trust your therapist and follow their guidelines for a successful recovery.

5. Use Pain Medication as Directed

Recovering knee surgery can be painful, but taking pain medication only as directed is essential. Taking too much medication can be dangerous and make it difficult to gauge your level of activity. It’s vital to listen to your body and rest when necessary, even if that means taking a little extra medication.

Of course, you shouldn’t suffer unnecessarily. Talk to your doctor or surgeon about adjusting your medication regimen if your pain is severe or persistent. It’s also important to let them know if you have any concerns about the side effects of your medication. In most cases, the benefits of pain relief outweigh the risks, but it’s always best to err on the side of caution.

6. Be Patient

Recovery from knee surgery takes time, so it’s essential to be patient and realistic about your expectations. Depending on the procedure, it may be several months before you’re back to your old self. And even then, you may have some lingering stiffness or pain. It’s important to listen to your body and take things slowly to avoid setbacks.

If you’re having trouble staying positive, talk to your doctor or surgeon about ways to cope with the frustration of a long recovery. In the meantime, focus on following your rehabilitation program and taking care of yourself. The better you take care of yourself now, the sooner you’ll be back to your old self.

Following these tips will help you have a successful recovery after knee surgery. However, every patient is different, so talk to your surgeon about what you should expect during your recovery process. Just remember to listen to your body and take things one day at a time – before you know it, you’ll be back on your feet again.

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Preparing for Joint Replacement Surgery

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Contact friends and family for support. You may need help bathing, using the toilet, cooking meals, doing laundry or housework, shopping, going to your doctor’s office, and exercising for several weeks. Contact family members or friends ahead of time to make the necessary arrangements. If you don’t have someone to help you at home, ask your doctor about home caregivers. There are various support networks that can provide emotional support and, in many areas, there are also businesses that offer in-home support.

Get your home ready for your recovery. Store frequently used items such as cleaning supplies, food, remote controls, medications, and reading materials in easy-to-reach locations. Avoid very high or very low shelves as these may require you to use a step stool or kneel.

Plan for meals. Make and freeze meals or stock up on frozen dinners before surgery so that meal preparation is easier and requires less effort. You should plan on making enough meals for at least one week.

Check the safety of your home to prevent falls or tripping. Move long electrical and telephone cords against the wall, remove rugs, and place a non-skid mat in your bathtub. You may want to prepare a bed on the ground level of your home so you can avoid climbing stairs. Have an elevated chair or high-seated chair with arms in every room if possible.

A little time spent getting your home ready before your surgery can make a big difference in your recovery. Some ideas to get started, include:

  • Stock up on toilet paper, shampoo, toothpaste, medications, and other personal items
  • Put a chair in your shower
  • Get a hand-held shower head
  • Get a raised toilet seat
  • Get a shower sponge with a long handle
  • Put handrails in the shower and next to the toilet
  • Install nightlights throughout the house
  • Wash all your towels, linens, and dirty clothes
  • Place loose clothing and pajamas in upper drawers or closets
  • Reachers and grabbers will come in handy
  • To keep your hands free for balance, consider using a walker basket, hip-pouch, small backpack, or an apron with large pockets to hold things you’ll want nearby
  • Rent/buy/borrow plenty of books, movies, music, and puzzles
  • Call your local post office to request that mail be left at your front door instead of in your mailbox

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Everything You Need To Know About Arthroscopic Knee Surgery

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During this procedure, small incisions are made to insert the arthroscope so that surgery can be performed.

arthroscopic knee surgery It is a non-invasive surgical procedure, in which a small camera is used to look inside the knee and be able to see the joint as a whole.

During arthroscopic knee surgery, pain can be controlled in three ways:local anesthesia

The knee may be numbed with anesthetic medication and the patient may also be given medication to calm nerves and anxiety, although the patient will remain awake.

spinal anesthesia

It is injected into a vertebral space in the spine. Although the patient will be awake, he will not be able to feel anything from the waist down.

general anesthesia or regional anesthesia

The patient will be taken to the operating room for medicines, serum and anesthesia, the patient will be in a deep sleep and will not feel any pain.

General anesthesia within it also penetrates the regional nerve block (blockade of the femoral or adductor canal). This is another type of regional anesthesia. Anesthetic is injected around the nerve in the groin. You will be asleep during the operation. This type of anesthesia will block pain, so less general anesthesia is needed.

arthroscopic surgery in procedure

A cuff-like device may be placed around the thigh to help control bleeding during the procedure.

The surgeon will make 2 or 3 small incisions around the knee and salt will be inserted into the knee to enlarge it. A narrow tube with a small camera on the end will be inserted through one of the incisions.

The camera is connected to a video monitor that allows the surgeon to see the inside of the patient’s knee.

The surgeon may place other small surgical instruments into the knee through other incisions. He will then repair or correct your knee problem.

At the end of the surgery, the knee will drain the saline solution. The surgeon will close the incisions with sutures and cover them with a dressing.

Candidates for Arthroscopic Knee Surgery

Arthroscopy may be recommended in the following cases:

The meniscus is the cartilage that protects the space between the bones of the knee. Surgery is done to fix or remove it.

  • An anterior cruciate ligament (ACL) or posterior cruciate ligament (PCL) is damaged or torn.
  • Torn or damaged collateral ligament.
  • Inflammation or damage to the lining of the joint. This lining is called the synovial membrane.
  • Patella that is out of position.
  • Tiny pieces of torn cartilage in the knee joint.
  • Baker’s cyst removal. This is a swelling behind the knee that fills with fluid. Sometimes this happens when there is swelling and pain due to other causes such as arthritis.
  • Some fractures in the knee bones.

risk

are related to anesthesia and surgery

  • Allergic reaction to drugs
  • respiratory system problems
  • is bleeding
  • infection

Additional risks of this surgery may include:

  • bleeding within the knee joint
  • Damage to the cartilage, menisci or ligaments in the knee
  • blood clot in leg
  • injury to a blood vessel or nerve
  • knee joint infection
  • knee stiffness

Preparation before knee arthroscopy

  • You should not drink or eat anything for 6 to 12 hours before the procedure.
  • The medicines prescribed by your doctor should be taken with a small sip of water.
  • Usually you should wear a bandage over your knee dressing.
  • Most people can go home the same day as the surgery.
  • Your doctor will give you exercises to do, which you can start after your surgery. You may also be referred to a physical therapist.

arthroscopy results

Full recovery after knee arthroscopy will depend on the type of problem the doctor faced.

For example, problems such as a torn meniscus, torn cartilage, Baker’s cyst, and synovial membrane problems can often be easily corrected. Many people remain active after these surgeries.

In most cases, recovery is quick with simple procedures. However, you may need crutches for some time after some types of surgery.

Your doctor will also prescribe pain relievers to take during recovery.

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Video Evidence of Tissue Sliding Improvement by Ultrasound-Guided Hydrorelease on Scars After Arthroscopic Knee Surgery: A Case Report

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Postoperative scarring is a complication of arthroscopic knee surgery that causes a lack of terminal extension and tissue sliding defects. We present video evidence of tissue sliding before and after ultrasound-guided hydrorelease in a 53-year-old man. The patient presented with pain in the scarred area following arthroscopic knee surgery. His active and passive extension was -5° with restricted patellar mobility. Dynamic ultrasonography revealed scar tissue sliding defects. For ultrasound-guided hydrorelease, a needle (22G, 60 mm) was aimed at a site within 10 mm depth of the hypoechoic change in the scar area below the patella, and saline solution (10 mL) mixed with 1% lidocaine (10 mL) and 10 mg prednisolone was injected. Immediately after injection, the patient’s extension was 0° with no pain or limitation of patellar mobility, and dynamic ultrasonography showed tissue sliding improved. Video evidence from dynamic ultrasonography clarifies the direction of the inadequate slide and the indication for and efficacy of ultrasound-guided hydrorelease. This case highlights the benefits of video evidence from dynamic ultrasonography before and after ultrasound-guided hydrorelease.

Introduction

Postoperative scarring is a complication of arthroscopic knee surgery and contributes to progressive fibrosis in the infrapatellar fat pad, lack of terminal extension, anterior knee pain (AKP), and decreased patellar mobility [1,2]. The proposed treatments for this issue are anterior interval release [3,4] and manual therapy [5], although multiple arthroscopic surgeries may lead to additional complications. A less invasive treatment than arthroscopic surgery would be beneficial for patients suffering from these types of pathologies.

Ultrasound-guided hydrorelease has been performed for lower back pain [6] and postoperative scar tissue [7]. Machida et al. consider ultrasound confirmation of improved tissue sliding as the key to the success of this procedure regarding the treatment of scar tissue after arthroscopic surgery. However, no video evidence of improved tissue sliding has been presented [7]. We performed an ultrasound-guided hydrorelease in a patient who presented with a lack of terminal extension and AKP after arthroscopic surgery for medial meniscus injury. We present video evidence of tissue sliding before and after the procedure in this patient.

Case Presentation

A 53-year-old man (height: 170 cm; body weight: 80 kg; body mass index: 27.7 kg/m2), diagnosed with medial meniscus injury, presented with AKP after previous arthroscopic knee surgery. He developed left knee pain six months before surgery and underwent arthroscopic medial meniscus repair after conservative therapy failed to improve his pain. Arthroscopic surgery was performed according to the standard all-inside repair technique using FasT-Fix system (Smith & Nephew Endoscopy, Andover, USA) [8] (Figure 1), and range-of-motion exercise was started after two weeks of knee brace immobilization. However, his range of motion remained limited even at six weeks postoperatively, and the scar under the patella tightened during extension, causing him severe pain. Active and passive extension was -5° with restricted patellar mobility, passive flexion was 115°, and an 11-point numerical rating pain scale (NRPS; 0 (“no pain”) to 10 (“worst possible pain”)) was three in walking. The Knee injury and Osteoarthritis Outcome Score (KOOS) showed KOOS pain of 25.0, KOOS symptoms of 17.9, and KOOS activities of daily living (ADL) of 47.0 (Table 1) [9].

Figure
1:
Arthroscopic views in the patient’s left knee

A) Before repair: Horizontal tear of the medial meniscus (arrow). B) After repair: Horizontal tear of the medial meniscus repaired by the all-inside repair technique (arrow).

  Six weeks postoperative, before hydrorelease Seven weeks postoperative, after hydrorelease 15 weeks postoperative
Knee extension, degree -5 0 0
Knee flexion, degree 115 120 145
Pain in walking, NRPS 3 1 1
KOOS pain 25 N/A 66.7
KOOS symptoms 17.9 N/A 57.1
KOOS ADL 47 N/A 91.0
Table
1: The patient’s range of motion and function course

NRPS: Numerical rating pain scale; KOOS: The Knee injury and Osteoarthritis Outcome Score; ADL: Activities of daily living; N/A: Not available.

The dynamic ultrasonography six weeks postoperatively revealed scar sliding defects during quadriceps contraction (Video 1) and manual skin sliding (Video 2). We then performed ultrasound-guided hydrorelease, as reported by Machida et al. [7].

Video
1:
Dynamic ultrasonography at medial scar area during quadriceps contraction

A) Before ultrasound-guided hydrorelease: The hypoechoic area is present in the scar area. Tension from quadriceps contraction is not transmitted distally (arrow). B) After ultrasound-guided hydrorelease: Tension from quadriceps contraction is transmitted distally beyond the hypoechoic area of the scar (arrow).

Video
2:
Dynamic ultrasonography at medial scar area during manual skin surface sliding

A) Before ultrasound-guided hydrorelease: Manually sliding over the skin surface does not slide over the hypoechoic areas of the scar (arrow). B) After ultrasound-guided hydrorelease: The movement of the scar area during manual sliding on the skin surface is greater than before ultrasound-guided hydrorelease (arrow).

For the ultrasound-guided hydrorelease, the patient was positioned in 30° flexion of the knee joint in the supine position. Ultrasonography was performed using a three to 11 MHz B-mode linear array scanner (SONIMAGE MX1, Konica Minolta, Tokyo, Japan). For ultrasound-guided hydrorelease, a needle (22G, 60 mm) was aimed at a site within 10 mm depth of the hypoechoic change in the scar area below the patella, and saline solution (10 mL) mixed with 1% lidocaine (10 mL) and 10 mg prednisolone was injected: first on the lateral scar below the patella and then the same for the medial scar the following week, and Video 1 and Video 2 show the medial scar. Only one injection was performed for each, and the treatment time was approximately 10 minutes, including an ultrasound examination. All procedures were performed by one orthopedic surgeon with more than 10 years of experience.

Immediately after second injection, left knee extension was 0° without pain, flexion was 120°, and pain in walking was a score of one on the NRPS. Dynamic ultrasonography showed that scar tissue sliding improved (Video 1 and 2). After that, rehabilitation continued with a range of motion exercise, manual therapy [5], mobilization of the patella, and muscle strengthening. At 15 weeks postoperatively (i.e., at nine weeks post hydrorelease), his left knee extension was 0° with no pain or limitation of patellar mobility, flexion was 145°, and pain in walking was one on NRPS. KOOS pain, symptoms, and ADL scores were 66.7, 57.1, and 91.0, respectively. After the injections, the patient felt heaviness in the left knee for one day, which improved spontaneously without any specific treatment. After that, the heaviness never recurred. He was satisfied with the ultrasound-guided hydrorelease and subsequent rehabilitation and could return to work as an auto mechanic.

Discussion

The most important finding from this patient’s course was that ultrasound-guided hydrorelease to the scar after previous arthroscopic knee surgery improved the terminal extension with AKP. Furthermore, the video evidence showed that scar tissue sliding had indeed improved.

The patient’s terminal extension was ultimately improved by ultrasound-guided hydrorelease. A previous case series on arthroscopic anterior interval release showed that all patients with a lack of terminal extension had improved [10]. We believe ultrasound-guided hydrorelease may also be effective, as this patient’s progress demonstrates. The advantage of this procedure is that it is less invasive than arthroscopic anterior interval release, which may be beneficial for postoperative patients.

Notably, the video evidence objectively confirmed that scar tissue sliding improved. This highlights the effectiveness of dynamic ultrasonography. The video evidence also identifies the stimulus and direction of the sliding defects. With video evidence, we can clearly visualize the indications and results of ultrasound-guided hydrorelease. Evaluation of the anterior interval scar is recommended for patients suffering from lack of terminal knee extension, AKP, and decreased patellar mobility, which may be indications for arthroscopic release [4]. We recommend that surgeons confirm the scars in patients presenting with similar symptoms and attempt dynamic ultrasonography and ultrasound-guided hydrorelease before arthroscopic anterior interval release.

In a previous report by Machida et al. [7], who proposed this technique, the mechanism of tissue separation by ultrasound-guided hydrorelease may have improved tissue sliding. Therefore, confirmation of the sliding by ultrasonography will be the key to the success of this procedure. To the best of our knowledge, this is the first report to present video evidence of improved tissue sliding before and after ultrasound-guided hydrorelease for arthroscopic scars.

Ultrasound-guided hydrorelease has several strengths. It can immediately improve terminal knee extension in patients with AKP. Also, because of its less invasive procedure, knee brace immobilization or unweighting are not necessary, and exercise therapy can begin immediately. Another major strength is that the procedure is safe. The patient had no serious adverse events requiring specific treatment. Furthermore, no serious adverse events have been reported in previous studies [6,7,11]. Finally, ultrasound-guided hydrorelease can be presented on videos, which can aid in informing the patient before obtaining the patient’s consent for the procedure.

Despite these benefits, there are still some unknowns with ultrasound-guided hydrorelease. First, the timing of its application is unknown. In a previous study by Machida et al. [7], the patient was in the tenth month after arthroscopic knee surgery, whereas in this case report, the patient was in the sixth week after surgery. The second is an injection agent. We injected saline mixed with lidocaine and prednisolone because the patient felt severe pain. In previous studies, saline only [6,7], saline mixed with 0.5% mepivacaine hydrochloride [11], and bicarbonate Ringer’s solution [11] have been used. In a comparison of the analgesic effects of injectable agents, saline alone has been reported to be more analgesic than local anesthesia. [12].

Conclusions

Ultrasound-guided hydrorelease applied to the scar after arthroscopic surgery resulted in full extension of this patient’s knee joint without pain and video evidence of improved sliding was presented. Video evidence from dynamic ultrasonography has the advantage of clarifying the direction of the lack of sliding and the indication for and efficacy of ultrasound-guided hydrorelease. This case highlights the benefits of video evidence from dynamic ultrasonography before and after ultrasound-guided hydrorelease.


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Everything You Should Know Before Getting Knee Replacement Surgery

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If your goal is to postpone knee replacement surgery as long as possible, there are a number of things you can do to help manage your pain and stay active (via HealthPartners).

As counterintuitive as it may seem, exercising and moving your joints, in spite of the pain, can actually stimulate the flow of fluid around your knees, strengthen the muscles that support your knees, reduce stiffness, and increase flexibility. Stick to low-impact activities such as walking, swimming, strength training, and cycling. Any exercise that strengthens your core, hips, and legs, without damaging your knees any further, should help manage your pain.

Working with a physical therapist to get a personalized exercise plan you can do at home can also have long-term benefits — especially if you’re consistent about doing the exercises on your own. And if you’re even a little overweight, consider losing a few pounds. According to HealthPartners, even losing one pound eliminates four pounds of pressure on your knees, which is pretty impressive.

Cortisone shots and other injections that include hyaluronic acid (HA) help lubricate the inside of the knee and may provide short-term relief — up to about three months — from arthritis pain, says Johns Hopkins Medicine.

As for medications, steer clear of opioids if at all possible; they’re addictive, and aren’t proven to help long-term knee pain. And check with your doctor even before using over-the-counter drugs like ibuprofen and naproxen because they can have side effects.

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Gravidity, parity and knee breadth at midlife: a population-based cohort study

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Study population

This study utilized a subsample of prospective, population-based Northern Finland Birth Cohort 1966 (NFBC1966)16. Initially, NFBC1966 comprised pregnant women living in Northern Finland (i.e. the provinces of Oulu and Lapland) whose expected delivery dates fell between Jan 1 and Dec 31, 1966. The cohort included 12,068 mothers and 12,231 children, with a coverage of 96% of all births during 1966 in Northern Finland. Prospective data collection began in the 16th gestational week, and the NFBC1966 participants have been followed ever since. Broad questionnaires and clinical examinations have been used to gather information on the participants’ health status and lifestyle habits.

At age of 46, a total of 5861 individuals responded to questionnaires and participated in clinical examinations. Of them, 1946 individuals residing in the Oulu region (100 km radius) underwent radiography of the knee joint. Of these, 1131 individuals were excluded due to (1) male sex, (2) missing reproductive or confounder data, (3) previous knee surgery, (4) bone pathologies in the radiographs (mostly osteoarthritic changes), or (5) technically inadequate radiographs. Thus, the final sample of this study comprised 815 women.

Knee measurements

Knee breadth measurements were taken from digital radiographs of the right knee joint (Fig. 1) by an author of the study (A.K.). A detailed description of the procedure has been given in a previous publication17. Radiographs were accessed and measured using neaView Radiology software version 2.31 (Neagen Oy, Oulu, Finland). Posteroanterior radiographs were utilized, with individuals positioned in fixed flexion view18,19.

Figure 1

Knee measurements. FCML mediolateral breadth of femoral condyles, TPML mediolateral breadth of tibial plateau. Diameter of the calibration disc: 30 mm.

The following measurements were taken from each radiograph: (1) mediolateral breadth of the articular surface of the femoral condyles (FCML), and (2) mediolateral breadth of the articular surface of the tibial plateau (TPML). FCML was measured by drawing a line tangential to the inferiormost points of the femoral condyles; this line was transposed to the widest part between the femoral condyles. TPML was measured as close to the border of the tibial plateau as possible. Measurements were recorded to the nearest 0.1 mm. The initial measurements were converted into true sizes with the help of a metal calibration disc of 30 mm in diameter attached on the participant’s right leg. The technical error of measurement (TEM) and relative technical error of measurement (rTEM) were reported by Keisu et al.17, and the repeatability was high for all the measurements (TEM 0.1–0.5 mm, rTEM 0.1–0.6%).

Reproductive history

In the 46-year follow-up questionnaire, women were asked about the number of deliveries, ectopic pregnancies, miscarriages and abortions they had undergone during their lifetime. As described in a previous publication20, gravidity was calculated as the overall number of pregnancies, and parity as the number of deliveries of each woman. Women with no deliveries were classed as ’nulliparous’, those with one delivery as ’primiparous’, and those with a history of several deliveries were classed as ‘multiparous’. Those with ≥ 5 deliveries were classed as ‘grand multiparous’.

Confounders

In the clinical examination at the age of 46, a study nurse systematically measured the height and weight of each individual. Body mass index (BMI) in kg/m2 was calculated as weight divided by height squared.

Education, smoking history and leisure-time physical activity were elicited in the 46-year follow-up questionnaire. Education years, a proxy for socioeconomic status, was determined by asking: ‘What is your basic education? (1) Less than 9 years of elementary school, (2) elementary school, (3) matriculation examination’; and What is your vocational education? (1) None, (2) occupational course, (3) vocational school, (4) vocational college, (5) polytechnic, (6) university, (7) other, (8) unfinished course’. The responses were classed according to the Finnish education system as follows: < 9 years, 9–12 years, or > 12 years.

Smoking history was elicited using two questions: (1) ‘Have you ever smoked cigarettes (yes/no)?’ and (2) ‘Do you currently smoke (yes/no)?’. Individuals were classed as non-smokers, former smokers, or current smokers.

Leisure-time physical activity was elicited by asking: ‘How often do you participate in brisk physical activity/exercise [defined as causing at least some sweating and breathlessness] during your leisure time? (1) Daily, (2) 4–6 times a week, (3) 2–3 times a week, (4) Once a week, (5) 2–3 times a month, (6) Once a month or less often. The responses were regrouped as follows: < 1 times/week, 1–3 times/week, or ≥ 4 times/week.

Statistical analysis

SPSS software (IBM, Armonk, NY, USA) version 27, 64-bit edition was used for the statistical analyses. P values < 0.05 were considered statistically significant. Means with standard deviations (SDs), medians with interquartile ranges (IQRs) and percentages with frequencies were used as descriptive statistics. Characteristics of the sample were presented before and after stratification by parity.

The associations of gravidity and parity with knee breadth (i.e. FCML and TPML in mm) were analyzed using general linear models. Beta coefficients, 95% confidence intervals (CIs) and P values were documented from the output. Models were first constructed without adjustments (unadjusted models), and then confounder variables were added (adjusted models). Gravidity and parity were modelled as continuous variables (where beta coefficients are interpreted relative to one pregnancy/delivery), and by comparing groups with each other (e.g. multiparous vs. others, where beta coefficients represent mean difference between groups).

Ethical considerations

The study adhered to the principles of the Declaration of Helsinki, with voluntary participation and signed informed consent. Sensitive details were replaced by anonymous identification codes. The Ethics Committee of the Northern Ostrobothnia Hospital District approved the study.

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