Perioperatives Management in der ambulanten arthroskopischen Chirurgie des Kniegelenks

Zusammenfassung

Studienziel: Das ambulante Vorgehen ist mittlerweile Standard auch bei komplexeren arthroskopischen Eingriffen am Kniegelenk. Es ist das Ziel dieser Studie, erstmalig Daten zum perioperativen Management in der ambulanten Kniegelenkarthroskopie zu erheben. Methode: Es wurde ein Fragebogen mit 18 Fragen zu den Themen Antibiotikaprophylaxe, Thromboseprophylaxe, Blutsperre, Redon-Drainage, physikalische Therapie, Physiotherapie, Analgesie, Anästhesie und Notfallmanagement an 215 Mitglieder des Bundesverbands für Ambulante Arthroskopie (BVASK e. V.) verschickt. Mehr als 51 % der Fragebögen konnten statistisch ausgewertet werden. Ergebnisse: 62 % der Befragten führen bei jeder Operation eine Prophylaxe mit einem Antibiotikum durch. Eine Thromboseprophylaxe erfolgt in 96 %, überwiegend für 1 Woche. 50 % der Operateure setzen immer eine Blutsperre, 22 % immer eine Blutleere ein. Eine Redon-Drainage wird von 36 % bei jeder Operation und in 45 % bei Bedarf eingesetzt. 66 % der Befragten applizieren ein Lokalanästhetikum intraartikulär am Ende des Eingriffs. Die Eingriffe werden überwiegend in Allgemeinanästhesie (92 %) durchgeführt. Die telefonische Erreichbarkeit des Operateurs wird in 97 % eingerichtet. Schlussfolgerungen: Während die Thromboseprophylaxe, Allgemeinanästhesie, postoperative Kryotherapie und telefonische Erreichbarkeit standardmäßig durchgeführt werden, zeigen die anderen Parameter zur Beschreibung des perioperativen Managements in der ambulanten Kniegelenkarthroskopie eine große Varianz.

Abstract

Aim: Nowadays, complex arthroscopic procedures of the knee joint, such as ACL reconstruction, are routinely carried out on an outpatient basis. The reduced time spent with the patient places high demands on the surgeon with regard to the management of such cases. The aim of this study was to evaluate the current standards of perioperative management following outpatient arthroscopic surgery of the knee in Germany. Methods: A questionnaire consisting of 18 questions was sent to 215 members of the German Association of Outpatient Arthroscopy (BVASK e. V.), dealing with the following topics: antibiotic prophylaxis, DVT prophylaxis, use of a tourniquet and suction drain, physical therapy, physiotherapy, analgesia, anaesthesia and emergency management. More than 51 % of the forms were returned and considered suitable for statistical analysis. Results: A total of 62 % of the surgeons reported the use of an antibiotic prophylaxis (i. v. single shot) in every arthroscopic case, while 19 % administer antibiotics only occasionally, especially in ACL reconstruction. Postoperative antibiotic treatment was reserved for special situations, such as prior joint infection. Prophylaxis of DVT by means of low molecular weight heparin was carried out in 96 % of the cases. 51 % prescribed anticoagulant agents for 1 week, 39 % for the duration of reduced weight bearing. Half of the surgeons used a tourniquet cuff, 22 % exsanguinate the limb prior to cuff inflation. A suction drainage was applied by 36 % of the surgeons regularly and by 45 % occasionally. The drain is left for one day by 79 % of the surgeons, while 11 % reported a shortened use of only several hours. With regard to analgesia, 66 % of all surgeons apply some kind of local anaesthetic into the knee joint post surgery. Systemic preoperative analgesics or anti-inflammatory agents are given regularly in 56 % of the cases. A total of 92 % of the procedures are carried out under general anaesthesia. In 36 % of the cases, some kind of additional regional peripheral anaesthesia is used. With regard to postoperative care, cryotherapy is considered standard (97 %) and 64 % of the surgeons recommend physiotherapy. Nearly all surgeons (97 %) offer the patients the opportunity to reach them personally via mobile phone during the first night following arthroscopic surgery. Conclusions: DVT prophylaxis with LMWH, general anaesthesia, postoperative cryotherapy and personal availability by phone can be considered part of the standard perioperative management following outpatient knee arthroscopy in Germany. However, a wide variety of treatment options can be found regarding topics such as analgesia, antibiotic prophylaxis, tourniquet, knee drainage and physiotherapy.

Schlüsselwörter

ambulant - Arthroskopie - Kniegelenk - Infektion - Thrombose

Key words

outpatient - arthroscopy - knee joint - infection - thrombosis

Literatur

• 1 Müller-Rath R, Becker J, Ingenhoven E. Wie hoch ist das statistische Risiko einer Infektion nach ambulanter Arthroskopie? Eine Auswertung von über 50.000 Fällen anhand der Statistik des BVASK.  Arthroskopie. 2008;  21 87-91
• 2 Lüring C, Diedrich O, Köck F X et al. Current operative strategies for rotator cuff tears in German hospitals.  Orthopäde. 2007;  36 810-816
• 3 Bert J M, Giannini D, Nace L. Antibiotic prophylaxis for arthroscopy of the knee: is it necessary?.  Arthroscopy. 2007;  23 4-6
• 4 Wieck J A, Jackson J K, O'Brien T J et al. Efficacy of prophylactic antibiotics in arthroscopic surgery.  Orthopedics. 1997;  20 133-134
• 5 Kurzweil P R. Antibiotic prophylaxis for arthroscopic surgery.  Arthroscopy. 2006;  22 452-454
• 6 Ilahi O A, Reddy J, Ahmad I. Deep venous thrombosis after knee arthroscopy: a meta-analysis.  Arthroscopy. 2005;  21 727-730
• 7 Marlovits S, Striessnig G, Schuster R. Extended-duration thromboprophylaxis with enoxaparin after arthroscopic surgery of the anterior cruciate ligament: a prospective, randomized, placebo-controlled study.  Arthroscopy. 2007;  23 696-792
• 8 Michot M, Conen D, Holtz D. Prevention of deep-vein thrombosis in ambulatory arthroscopic knee surgery: a randomized trial of prophylaxis with low-molecular weight heparin.  Arthroscopy. 2002;  18 257-263
• 9 Wirth T, Schneider B, Misselwitz F. Prevention of venous thromboembolism after knee arthroscopy with low-molecular weght heparin (Reviparin): results of a randomized controlled trial.  Arthroscopy. 2001;  12 393-399
• 10 Ramos J, Perrota C, Badariotti G et al. Interventions for preventing venous thromboembolism in adults undergoing knee arthroscopy.  The Cochrane Library. 2008;  (Issue 2) 1-14
• 11 www.uni-duesseldorf.de/awmf/ll/003-001.pdf Stand: 18.3.2009
• 12 Kirkley A, Rampersaud R, Griffin S et al. Tourniquet versus no tourniquet use in routine knee arthroscopy: a prospective, double-blind, randomized clinical trial.  Arthroscopy. 2000;  16 121-126
• 13 Tibrewal S B. The pneumatic tourniquet in arthroscopic surgery of the knee.  International Orthopaedics. 2001;  24 347-349
• 14 Johnson D S, Stewart H, Hirst P et al. Is tourniquet use necessary for knee arthroscopy?.  Arthroscopy. 2000;  16 648-651
• 15 Kornbluth I D, Freeman M K, Sher L et al. Femoral, saphenous nerve palsy after tourniquet use: a case report.  Arch Phys Med Rehabil. 2003;  84 909-911
• 16 Dhawan A, Doukas W C, Papazis J A et al. Effect of drain use in the early postoperative period after arthroscopically assisted anterior cruciate ligament reconstruction with bone-patellar tendon-bone graft.  Am J Sports Med. 2003;  31 419-424
• 17 Klein J, Preifer T, Hardung M et al. Ist eine Drainage nach arthroskopischer Meniskusresektion notwendig?.  Arthroskopie. 1991;  4 189-192
• 18 Straw R, Coclough K, Geutjens G G. Arthroscopically assisted ACL reconstruction. Is a drain necessary?.  Knee. 2003;  10 283-285
• 19 McCormack R G, Greenhow R J, Fogagnolo F et al. Intra-articular drain versus no drain after arthroscopic anterior cruciate ligament reconstruction: a randomized prospective clinical trial.  Arthroscopy. 2006;  22 889-893
• 20 Raynor M C, Pietrobon R, Guller U et al. Cryotherapy after ACL reconstruction: a meta-analysis.  J Knee Surg. 2005;  18 123-129
• 21 Wheathley W B, Krome J, Martin D F. Rehabilitation programmes following arthroscopic meniscectomy in athletes.  Sports Med. 1995;  21 447-456
• 22 Pyne S W. Current progress in meniscal repair and postoperative rehabilitation.  Curr Sports Med Rep. 2002;  1 265-271
• 23 Coppola S M, Collins S M. Is physical therapy more beneficial than unsupervised home exercise in treatment of post surgical knee disorders? A systematic review.  Knee. 2009;  16 171-175
• 24 www.uni-duesseldorf.de/AWMF/ll/041-001.pdf Stand: 20.4.2009
• 25 Chu C R, Izzo N J, Papas N E et al. In vitro exposure to 0,5 % Bupivacaine is cytotoxic to bovine articular chondrocytes.  Arthroscopy. 2006;  22 693-699