Should antibiotics be administered before arthroscopic knee surgery? A systematic review of the literature

AIM To explore the current evidence surrounding the administration of prophylactic antibiotics for arthroscopic knee surgery. METHODS Databases were searched from inception through May of 2018 for studies examining prophylactic antibiotic use and efficacy in knee arthroscopy. Studies with patient data were further assessed for types of arthroscopic procedures performed,number of patients in the study,use of antibiotics,and outcomes with the intention of performing a pooled analysis. Data pertaining to "deep tissue infection" or "septic arthritis" were included in our analysis. Reported data on superficial infection were not included in our data analysis. For the pooled analysis,a relative risk ratio was calculated and χ~2 tests were used to assess for statistical significance between rates of infection amongst the various patient groups. Post hoc power analyses were performed to compute the statistical power obtained from our sample sizes. Number needed to treat analyses were performed for statistically significant differences by dividing 1 by the difference between the infection rates of the antibiotic and no antibiotic groups. An alpha value of 0.05 was used for our analysis. Study heterogeneity was assessed by Cochrane's Q test as well as calculation of the I~2 value.RESULTS A total of 49682 patients who underwent knee ar-throscopy for a diverse set of procedures across 19 studies met inclusion critera for pooled analysis. For those not undergoing graft procedures,there were 27 cases of post-operative septic arthritis in 34487 patients(0.08%) who received prophylactic antibiotics and 16 cases in 10911(0.15%) who received none [risk ratio(RR) = 0.53,95% confidence interval(CI): 0.29-0.99,P = 0.05]. A sub-group analysis in which bony procedures were excluded was performed which found no significant difference in infection rates between patients that received prophylactic antibiotics and patients that did not(P 0.05). All anterior cruciate ligament reconstruction studies used prophylactic antibiotics,but two studies investigating the effect of soaking the graft in vancomycin in addition to standard intravenous(IV) prophylaxis were combined for analysis. There were 19 cases in 1095 patients(1.74%) who received IV antibioitics alone and no infections in 2034 patients who received IV antibiotics and had a vancomycin soaked graft(RR = 0.01,95%CI: 0.001-0.229,P 0.01).CONCLUSION Prophylactic antibiotics are effective in preventing septic arthritis following simple knee arthroscopy. In procedures involving graft implantation,graft soaking reduces the rate of infection.     

Varicocoele surgery as day surgery—a regional hospital experience

From July 1994 to February 2001, 60 patients underwent varicocoele surgery in the Day Surgery Centre, Department of Surgery, Kwong Wah Hospital, Hong Kong SAR, PRC. The mean age of these patients was 25.9 years (ranged 9–66). Their symptoms included pain/discomfort (41.7%), mass/swelling (36.7%), infertility (8.3%) and cosmetic reasons (1.7%). In seven patients the indication was not clearly defined. 31 (51.7%) varicocoele operations were laparoscopically performed, 26 (43.3%) by an open method and in four patients (6.7%) the method was not mentioned. The median operative time was 34 min. We successfully reduced or abolished the symptoms of varicocoele in 68.7% of patients whose indication was pain or discomfort and restored fertility in 80% of patients whose indication was infertility. There was only one unplanned hospital admission. There were no anaesthetic or post-operative complications. Varicocoele surgery performed on a day surgery basis is feasible, with a high operative success rate and potential cost reduction.     

How valid is the arthroscopic diagnosis of cartilage lesions? Results of an opinion survey among highly experienced arthroscopic surgeons

Aim  In general, arthroscopy is considered the “gold standard” for the evaluation of cartilage lesions. In this multicenter survey, we ascertained the general opinion of surgeons regarding arthroscopic cartilage diagnoses. Method  A total of 301 highly experienced arthroscopists (instructors of the AGA, the German-speaking society of arthroscopy) were contacted in writing with a request to complete the survey. Results  The data from 105 respondents (34.8% of those contacted) were used for the investigation. In the grading of the cartilage lesions, the Outerbridge classification was most frequently used (n = 87), followed by the ICRS protocol (n = 8) and the Insall score (n = 3). The majority (61%) of the arthroscopic surgeons felt that differentiation between healthy cartilage and low-grade cartilage lesions was simple. For differentiation between grade I and grade II lesions, and for differentiation between grade II and grade III lesions, 41.9 and 51.4%, respectively, thought that there was a “need for improvement”. In the case of grade IV lesions, 70.5% of the surgeons thought that the diagnosis was valid. The respondents also judged the utility of incorporating objective measurements (e.g., intraoperative biomechanical tests): 13.3% (n = 14) responded that such measurements would be “very useful” and 61.9% (n = 65) responded that they would be “somewhat useful”. Conclusions  Among surgeons, arthroscopy was not perceived to be as reliable as a “gold standard” for the diagnosis of cartilage lesions. The majority of experienced arthroscopists felt unsure of the results in general, or at least in some cases. A universal and definitive grading system for lesions appears to be needed. For questionable cases, measurement devices are needed for objective cartilage grading.     

Prognostic factors affecting clinical outcomes after arthroscopic rotator cuff repair: importance of functional recovery by 3 months after surgery

Background

To examine important factors that affect clinical outcomes following arthroscopic rotator cuff repair (ARCR).

Methods

Among 163 patients who underwent ARCR, we included 71 shoulders in 71 patients whose progress was monitored for >?2?years, postoperatively. We divided the patients into groups A (scores ≥?83 points, 59 patients) and B (scores <?83 points, 12 patients) using the Japanese Orthopedic Association (JOA) score at 24?months. We then conducted univariate and multivariate analyses of pre- and postoperative (2 and 3?months, respectively) factors.

Results

The mean JOA score for all patients significantly improved from 63.7?±?11.5 points preoperatively to 90.3?±?9.6 points at 24?months postoperatively (P?<?0.05). However, there were no significant between-group differences in the preoperative scores. In addition, there were no significant differences in the postoperative re-tear rate. Univariate analysis revealed that the range of motion (preoperative abduction and postoperative elevation, abduction, internal rotation, and external rotation), muscle strength (external rotation 3?months postoperatively), postoperative pain level [visual analog scale (VAS) maximum score, 10 points], partial repair, Cofield classification, and preoperative width were significant factors (P?<?0.05 for all factors). Multivariate and receiver operating characteristic curve analyses showed that VAS at 2?months postoperatively and elevation at 3?months postoperatively were significant factors.

Conclusions

To obtain a JOA score of ≥?83 points at 24?months postoperatively, following ARCR, a postoperative VAS of <?5 points at 2?months and postoperative elevation of ≥?110° at 3?months should be achieved.

     

Why choose cardiothoracic surgery as a career?

The future of cardiothoracic surgery faces a lofty challenge with the advancement of percutaneous technology and minimally invasive approaches. Coronary artery bypass grafting (CABG) surgery, once a lucrative operation and the driving force of our specialty, faces challenges with competitive stenting and poor reimbursements, contributing to a drop in applicants to our specialty that is further fueled by the negative information that members of other specialties impart to trainees. In the current era of explosive technological progress, the great diversity of our field should be viewed as a source of excitement, rather than confusion, for the upcoming generation. The ideal future cardiac surgeon must be a "surgeon-innovator," a reincarnation of the pioneering cardiac surgeons of the "golden age" of medicine. Equipped with the right skills, new graduates will land high-quality jobs that will help them to mature and excel. Mentorship is a key component at all stages of cardiothoracic training and career development. We review the main challenges facing our specialty--length of training, long hours, financial hardship, and uncertainty about the future, mentorship, and jobs--and we present individual perspectives from both residents and faculty members.     

Laparoscopic cholecystectomy as a ‘session’ surgery

Aims: To introduce laparoscopic cholecystectomy to our Day Surgery Unit and assess the implications of a 6 h postoperative stay in unselected patients. Methods: A retrospective analysis of data was performed in which the case notes of a series of 170 consecutive patients undergoing day case laparoscopic cholecystectomy were studied. All patients with symptomatic gallstones were considered for day case laparoscopic cholecystectomy. Patients were excluded if there was major medical co-morbidity but not solely on the basis of age or Body Mass Index (BMI). Surgery was performed in a dedicated Day Surgery Unit and cholangiography was performed selectively. All patients were assessed at 6 h postoperatively for discharge and followed up by telephone at 24, 48 h and 2 weeks postoperatively. Results: Of 170 patients 121 (71.1%) were discharged at 6 h, 116 reported no problems and were satisfied with day case treatment. Two (1.6%) patients required a GP visit at home within 24 h and three (2.5%) patients required readmission. Forty-nine (28.9%) patients required admission, the commonest cause for admission being postoperative pain and nausea (10.6%) in approximately equal proportions. Three were admitted as they had open surgery. One patient required further surgical intervention (laparoscopy). Conclusion: Laparoscopic cholecystectomy as a ‘session’ surgery, with planned discharge 6 h after operation, is successful in the majority of unselected patients even though a significant number of overnight admissions are to be anticipated.     

Muscle strength and function of shoulders with Bankart lesion after successful arthroscopic treatment: interlimb comparison 24 months after surgery

Background

The purpose of this study was to examine outcomes following arthroscopic Bankart repair with the focus on strength after the repair.

Methods

56 shoulders with Bankart lesion were operated on arthroscopically. Gender, mechanism of the first dislocation, number of dislocations, dominant side, operated side and the number of anchors used for surgery were recorded. DASH and Oxford instability scoring systems were applied preoperatively and compared to scores at the 24-month follow-up. The scoring systems were also applied to contralateral shoulders at the 24th month of follow-up. Range of motion was measured with a goniometer. Muscle strength was analyzed with a dynamometer simultaneously with the muscle activity of four perishoulder muscles. The data were recorded with surface EMG. Range of motion, muscle strength and activity were evaluated according to the contralateral shoulder at the 24th month of follow-up.

Results

Male/female ratio was 42/14 with a mean age of 32 years. The mean number of dislocations was 3 ± 1 and all were traumatic dislocations. The number of mean anchors used was 3.1 and the mean follow-up period was 24 months. In clinical evaluation, the preoperative and postoperative results of the DASH and Oxford instability scores of the unstable shoulders were significantly different. In the comparison between the operated and contralateral shoulders, there was no significant difference in DASH and Oxford instability scores at the 24th month of follow-up. There was no significant loss of range of motion. Only internal rotation strength was significantly reduced and there was no significant change in the EMG patterns.

Conclusions

Although good clinical results can be achieved, internal rotation strength is reduced after arthroscopic surgery, but daily activities are not affected. There is no guarantee for patients of excellent recovery.

Level of evidence

Level III cohort study.     

Posterior “back and forth” approach in arthroscopic surgery on the posterior knee compartments

We report the feasibility, indications, and usefulness of an arthroscopic approach to the posterior knee compartments. We developed an arthroscopic approach to the posterior knee compartment involving use of a posteromedial portal and a posterolateral portal opposite each other. Each posterior portal is used in alternation for the arthroscope and instruments. The posterior portals are established using an original “back and forth” technique. The feasibility of the technique was evaluated on a cadaver. It allowed us to define safety rules to protect the vessels and nerves that course through the popliteal fossa. The approach provided a broader field of view compared with classical techniques. After removal of the septum dividing the posterior compartment, the synovial fold enclosing the posterior cruciate ligament and lining the upper and posterior parts of the posterior capsule was readily accessed, suggesting that this approach may be particularly valuable for total synovectomy. This was confirmed in 6 patients with villonodular synovitis, in whom the new approach was used in combination with arthroscopic anterior synovectomy. This technique allows removal of parts of the synovium that are difficult to access through conventional arthroscopic approaches. For total synovectomy, it can be used as an alternative to open posterior synovectomy, in combination with arthroscopic anterior synovectomy.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 19, No 3 (March), 2003: pp 321–325     

Percutaneous fixation of scaphoïd fractures with arthroscopic assistance

We report the results of a series of 37 recent fractures of the scaphoid treated by percutaneous screwing under X-ray control with systematic realization of a wrist arthroscopy. In 22 cases the factures were undisplaced and we had 15 displaced fractures. In all the cases the wrist arthroscopy allows to check the quality of the reduction, the good positioning of the screws and the correct reduction of fragments. Union was obtained in all cases with an average of 62 days (range 45-80). The functional recovery of the operated wrists was good with an early return to work on average 21 days (between 0 days and 3 months). The systematic association of wrist arthroscopy to the percutaneous screwing secures the procedure which can be proposed to motived patients interested by a fast return to the active life. The quality and the stability of the reduction are controlled and avoid complications due to bad positioning of the material. The possibility of treating in the same time the associated intra carpal ligaments tears lesions is possible.     

Airway obstruction during arthroscopic shoulder surgery: anesthesia for the patient or for the surgeon?

Two cases of airway obstruction as a result of oedema of laryngeal structures which arose during protracted arthroscopic shoulder surgery, in which single-shot interscalene blocks had been performed, are reported. In these 2 cases, the complexity of the pathologies and the fact that the surgeons were at the beginning of their surgical experience are the most likely causes of the conditions which led to tracheal compression from extra-articular leakage of fluid. Therefore, we recommend a combined peripheral block and general anaesthesia with tracheal intubation for procedures performed by surgeons without an adequate experience and on obese patients, patients placed in a lateral decubitus, or procedures in which difficulties are expected. The advantages of regional anaesthesia with a constant control of the airways are underlined.     

Laparoscopic surgery and ergonomics: It’s time to think of ourselves as well

Surgical Endoscopy -     

Gastrointestinal bleeding as presentation of small bowel metastases of malignant melanoma: Is surgery a good choice?

INTRODUCTIONMelanoma shows a particular predilection in involving small intestine both in a single site and in multiple localization and acute or chronic gastrointestinal bleedings are often the first sign of tumour.PRESENTATION OF CASEWe report two cases of GI metastases of malignant melanoma, one presented with only a big mass that cause intestinal obstruction and the other with a tumour spread throughout the small intestine that produce enterorrhagia.DISCUSSIONDiagnosis and follow-up are very difficult: CT scan, PET-CT scan and capsule endoscopy should be complementary for the assessment of patients with GI symptoms and melanoma history.CONCLUSIONWhat is the role of surgery? Several studies suggest metastasectomy to achieve both R0 results and palliative resolutions of acute symptoms, such as obstruction, pain, and bleeding.     

Is age an independent determinant of mortality in cardiac surgery as suggested by the EuroSCORE?

Background  

The proportion of older patients in cardiac surgery is continuously increasing. 37% of patients undergoing heart surgery in Germany in the year 2000 were 70 years of age and older. We have studied the role of age as a determinant of mortality in cardiac surgery in our institutional patient population.     

The status of vascular surgery as an independent specialty in Europe: are the relationships with general and cardiothoracic surgery a problem?

Vascular surgery has established a clear clinical and scientific profile in Europe over the last decade, but it presents a highly complex, disorganized, and unplanned pattern. It is a specialty in the majority of the present member states of the European Union (EU), but in the United Kingdom, Germany, the Netherlands, and Sweden this is not the case. With the current expansion of the EU with 13 countries, mainly from the former Eastern Bloc, it will be even more necessary to ensure at least some level of convergence in the standards of training, certification, quality assured practice, continuing medical education, recertification, access to and quality of care, etc, because free migration of doctors, and patients, is a derivative of the cornerstones of the EU treaties, namely free movement of the citizens (and capital). The profession has been successful in creating a simple and coherent system for organization within the European Union of Medical Specialists with a board of vascular surgery, for a (voluntary) European proficiency test for specialists (the EBSQ-Vasc), and for European continuing medical education, all in close collaboration with the premier scientific society, the European Society for Vascular Surgery. The fantastic reductions in working hours for young doctors in the EU represent a serious threat to standards of training and, ultimately, to the patients. This, in connection with increased litigation and compensation demands for incompetence and negligence, makes it even more necessary to establish European minimum standards for training, professional competence, and an obligatory European specialist examination. A key element in this difficult process is the establishment of vascular surgery as a specialty in all member states. Day-to-day collaboration with radiologic interventionalists has developed pragmatically at the local level in most places, but only when the administrative structures mature and vascular surgery becomes a specialty in all countries will the necessary tools be available for the avoidance of professional conflicts with colleagues from other specialties.     

Foot drop as a complication of weight loss after bariatric surgery: Is it preventable?

Background Although rare, the relationship between peroneal nerve palsy and weight loss has been well documented over the last decades. Of the 160 patients operated for persisting foot drop in our institution, weight loss was considered to be the major contributing factor for 78 patients (43.5%). Methods We compared patients who developed a foot drop after bariatric surgery with a control group of patients who underwent bariatric surgery (gastric banding) but did not develop peroneal neuropathy. Results 9 patients developed foot drop after bariatric surgery. The mean weight loss for these patients was 45 kg.Weight reduction took place during a mean period of 8.6 months. Our control group consists of 10 patients.The mean weight loss of these patients was 43.8 kg, and the weight reduction took place during a mean period of 21.7 months. Conclusion In contrast to earlier studies, we demonstrated that significant weight loss is correlated with a higher risk to develop foot drop and that the time period in which the weight loss is achieved is important. A rapid reduction of body weight is correlated with a higher risk to develop foot drop.     

Treatment of intra-articular fractures of the distal radius: fluoroscopic or arthroscopic reduction?

In a randomised prospective study, 20 patients with intra-articular fractures of the distal radius underwent arthroscopically- and fluoroscopically-assisted reduction and external fixation plus percutaneous pinning. Another group of 20 patients with the same fracture characteristics underwent fluoroscopically-assisted reduction alone and external fixation plus percutaneous pinning. The patients were evaluated clinically and radiologically at follow-up of 24 months. The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and modified Mayo wrist score were used at 3, 9, 12 and 24 months postoperatively. In the arthroscopically- and fluoroscopically-assisted group, triangular fibrocartilage complex tears were found in 12 patients (60%), complete or incomplete scapholunate ligament tears in nine (45%), and lunotriquetral ligament tears in four (20%). They were treated either arthroscopically or by open operation. Patients who underwent arthroscopically- and fluoroscopically-assisted treatment had significantly better supination, extension and flexion at all time points than those who had fluoroscopically-assisted surgery. The mean DASH scores were similar for both groups at 24 months, whereas the difference in the mean modified Mayo wrist scores remained statistically significant. Although the groups are small, it is clear that the addition of arthroscopy to the fluoroscopically-assisted treatment of intra-articular distal radius fractures improves the outcome. Better treatment of associated intra-articular injuries might also have been a reason for the improved outcome.