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LETTERS

Ambulatory Anesthesia for Knee Arthroscopy

Baystate Medical Center Tufts University School of Medicine Springfield, MA

To the Editor:

I read with interest the report by Mulroy et al. (1) on the comparison of spinal, epidural, and general anesthesia for outpatient knee arthroscopy. Although epidural anesthesia with 2-chloroprocaine provides comparable recovery and discharge times to general anesthesia with propofol and nitrous oxide, I do not believe it is the regional anesthetic technique of choice in the setting of a busy outpatient center. The use of arthroscopy under local anesthesia may be a suitable alternative if the patient desires to be alert and to participate during the surgical procedure. Epidural anesthesia takes a longer time to perform, has a slower onset of anesthesia, a higher failure rate, and requires more technical expertise than intraarticular local anesthesia. Arthroscopy under local anesthesia provides satisfactory operating conditions and a high patient acceptability for a variety of operative knee procedures (2–5). We have been utilizing this technique more frequently for outpatient knee arthroscopy at our institution (6,7). From our experience, these patients can bypass the Phase I postanesthesia care unit and be transferred directly to the Phase II area. In addition, the use of intraarticular analgesics provides for improved patient comfort and allows us to avoid the administration of opioids in the perioperative period (6,7). I believe this method is a safe, reliable, inexpensive, and practical alternative to the use of epidural, spinal, or general anesthesia for outpatient knee arthroscopy.

References

1. Mulroy MF, Larkin KL, Hodgson PS, et al. A comparison of spinal, epidural, and general anesthesia for outpatient knee arthroscopy. Anesth Analg 2000; 91: 860–4.[Abstract/Free Full Text]
2. Buckley JR, Hood GM, Macrae W. Arthroscopy under local anesthesia. J Bone Joint Surg 1989; 71: 126–7.
3. Yacobucci GN, Bruce R, Conahan TJ, et al. Arthroscopic surgery of the knee under local anesthesia. Arthroscopy 1990; 6: 311–4.[Medline]
4. Fruensgaard S, Johannsen HV. Outpatient arthroscopy of the knee under local anesthesia. Int Orthop 1990; 14: 37–40.[Web of Science][Medline]
5. Hutlin J, Hamberg P, Stenstrom A. Knee arthroscopy using local anesthesia. Arthroscopy 1992; 8: 239–41.[Medline]
6. Reuben SS, Connelly NR. Postarthroscopic meniscus repair analgesia with intraarticular ketorolac or morphine. Anesth Analg 1996; 82: 1036–9.[Abstract]
7. Joshi W, Reuben SS, Kilaru PR, et al. Postoperative analgesia for outpatient arthroscopic knee surgery with intraarticular clonidine and/or morphine. Anesth Analg 2000; 90: 1102–6.[Abstract/Free Full Text]

Response

Department of Anesthesiology B2-AN Seattle, WA

In Response:

We appreciate the reminder that local infiltration (LA) is an alternative anesthetic technique in many institutions for outpatient knee arthroscopy. Despite the favorable anecdotal reports Dr. Reuben cites, our surgeons have found that it requires more time—consistent with other reports (1)—and provides less analgesia and motor relaxation than our current techniques, and thus we did not include it as an alternative. A recent prospective randomized comparison of local infiltration with spinal and general anesthesia in 400 patients confirmed these impressions (2). The Swedish "surgeons assessed technical difficulties to be more intense" and "comprehended the patient’s pain as more intense during surgery in the LA group." They considered LA as not optimal in 16% of the patients, and 12% of the patients would have preferred another technique. This is consistent with older comparisons, which report as high as 16% of LA procedures as less than satisfactory for the patient (3). In contrast, in comparative studies the failure rate of spinal anesthesia is 1% (2,4). Other comparisons do support Dr. Reuben’s suggestion of smaller costs with LA (4,5). None of these studies have compared LA to epidural anesthesia, which had no failures and high patient and surgeon acceptance in our experience. Because LA appears to be satisfactory in Dr. Reuben’s institution, I would hope he would be able to provide us with a prospective randomized comparison to document the advantages he attributes to this technique.

References

1. Hultin J, Hamberg P, Stenstrom A. Knee arthroscopy using local anesthesia. Arthroscopy 1992; 8: 239–41.
2. 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 2000; 16: 183–90.[Web of Science][Medline]
3. Fairclough JA, Graham GP, Pemberton D. Local or general anaesthetic in day case arthroscopy? Ann R Coll Surg Engl 1990; 72: 104–7.[Medline]
4. Lintner S, Shawen S, Lohnes J, et al. Local anesthesia in outpatient knee arthroscopy: a comparison of efficacy and cost. Arthroscopy 1996; 12: 482–8.[Web of Science][Medline]
5. Trieshmann HW, Jr. Knee arthroscopy: a cost analysis of general and local anesthesia. Arthroscopy 1996;12:60–3.

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