Summary

Needle arthroscopic repair of meniscal tears under local anesthesia is safe and yields clinical outcome equal to more invasive traditional approaches, with less postoperative pain and less time spend on the surgical floor.

Abstract

Purpose

To compare patient experience and outcome of needle arthroscopic all-inside repair of meniscal tears using only local anesthesia with the traditional arthroscopic approach.

Methods

This was a pragmatic, prospective and comparative trial including 20 consecutive adult patients that suffered a traumatic meniscal tear in the red or red-white zone – equally divided between an innovation study arm and a control arm. In the innovation arm, procedures were performed using needle arthroscopy under local anesthesia. In the control arm, procedures were performed with traditional arthroscopy and under general or spinal anesthesia. Participants were allocated to a study arm based on shared decision making. The Hospital Anxiety and Depression Scale (HADS, 0-42, lower is better), Numeric Rating Scales (NRS, 0 – 10) of pain and satisfaction, use of pain medication (in addition to acetaminophen) and a Net Promotor Score (NPS, 0 – 10) were collected at baseline prior to the procedure, at discharge and at 1-day, 2-days, 7-days, 6-weeks and 3-months post-op. The KOOS domains, EQ5D-QoL and return to work were collected at baseline and 3-months post-op. Pain during the procedure was collected for needle arthroscopy patients, and procedure times for all participants. Occurrence of (serious) adverse events was monitored during the entire study. An a-priori power calculation with the baseline HADS as primary outcome measure indicated that 10 patients should be included in each group in order to detect a five-point difference between both groups.

Results

20 patients were included in each group. Mean age was 34 in the needle arthroscopy arm and 37 in the traditional arm (t=0.55, p=0.59). Patients in the needle arthroscopy group experienced a lower NRS of pain at discharge compared to the traditional arthroscopy group (2 vs 7, p = 0.048), and less needle arthroscopy group participants used pain medication (in addition to acetaminophen) at discharge (2 vs 8 patients, p=0.003) and at postoperative day 7 (4 vs 8 patients, p=0.012). The EQ5D-QoL at 3 months post-op was higher in the needle arthroscopy group (80 vs 70.5, p=0.041). Median NRS of pain during the needle arthroscopic procedure was 2 (IQR 1 – 6). At 3-month follow-up, there were no differences in HADS, NRS of pain, NRS of satisfaction, NPR, return to work, the KOOS domains, use of pain medication and ability to walk without supportive devices. Surgical time was longer in the needle arthroscopic group (27 vs 14 minutes, p=0.003), yet time between arrival in the OR and discharge to the ward was longer in the traditional group (53 vs 92 minutes, p=0.003). One patient from the traditional group was converted to a meniscectomy 9 months after the index procedure. There were no further complications.

Conclusion

This study indicates the feasibility of needle arthroscopic repair of meniscal tears under local anesthesia. In well selected and counseled patients, patient experience and outcome – including anxiety, satisfaction, pain and quality of life – is equal to the traditional arthroscopic approach. Postoperative pain and use of pain medication may be less and patients spend less time on the capacity constrained operative floor.