IS ANTIBIOTIC PROPHYLAXIS IN KNEE ARTHROSCOPY MANDATORY?

Methods

A total of 3000 patients who presented with knee complaints, to our sport medicine clinic in The Royal Rehabilitation Center of King Hussein Medical Center in Amman between January 2002 and February 2004, were assessed.  Patients who refused to be enrolled in the study, those who would need complex procedures as ACL reconstruction and accompanied arthrotmy and those with known medical diseases as diabetes mellitus, rheumatic diseases and immune deficiency diseases, as predisposing factors for infection, were excluded from the study, as shown in Table I.

One hundred eighty patients were included in the study and divided equally into two groups according to the admission number. Group A (with even admission numbers) and were given one gram 1^st generation cephalosporin (cephalothine) at the induction of anesthesia and group B (with odd admission numbers) were left without antibiotic prophylaxis (Table II).

The arthroscopy was for therapeutic purposes of simple knee pathologies as meniscal tears, synovial pathologies, plicas and diagnostic for some nondefinable knee complaints. Both anterolateral and anteromedial portals were used. All surgeries were conducted under general anesthesia with tourniquet and by the same surgeon. The instruments were sterilized using 2% glutaraldhyde (cidex) for 15 minutes. The duration of surgeries is shown in Table II.Patients  were  followed  up  for local and systemic signs of infection including swelling redness, hotness and fever.

Statistical analysis of the age, sex and duration of surgeries, diagnostic findings and therapeutic procedures was done using the students t –test with the probability value of <0.05 being significant.

Results

One hundred eighty patients were included in the study and divided equally into two groups.

There were no significant differences between the two groups in terms of age, sex and duration of surgeries (p>0.05) as shown in Table II. There were no significant differences between the two groups in term of pathologies detected in the knees and surgical procedures performed (p>0.05) (Table III and Table IV).

No cases of superficial or deep infections were detected during the follow up of patients. None of the patients in group A developed side effects, including allergy, to the antibiotic taken.

Discussion

Knee arthroscopy is one of the most commonly used orthopedic procedures possibly because of the lower morbidity compared to arthrotomy.⁽¹⁾ Infection is a rare to nearly absent complication.^(5-7) Rates of infection were reported as 0.02-0.04% by Wertheim, 0.1% by Sherman et al and 0.42% by Armstrong.^(8-10)  Wieck suggested that the routine use of antibiotic prophylaxis in patients undergoing knee arthroscopy and the slight risk of infection are outweighed by the cost of the antibiotics and the risk of allergic reactions.⁽¹¹⁾

In our study and likewise to Wieck, we do not suggest using antibiotic prophylaxis in routine knee arthroscopy although no complications of the antibiotic was encountered.

Kurzel suggested using prophylactic antibiotics to prevent deep infection, which would require a long term of antibiotic usage, and hospital stay.⁽¹²⁾ Angelo and Ogilvie reported 0.23 % of infection and suggested the use of first generation cephalosporin for reducing hospital cost and patient morbidity.⁽¹³⁾

Infection increases in those undergoing complex surgeries with long procedures, immuncompromized and those receiving intraarticular steroid after arthroscopic surgeries is recommended.^(2,10,14)

Conclusion

Our results are preliminary to an ongoing study with a larger number of patients but we can conclude that antibiotic prophylaxis in operative knee arthroscopy should not be routinely ordered.  The routine usage may be costly and may have side effects, as allergic reactions.  The administration of prophylactic antibiotics could be useful in complex knee surgeries as ligament reconstruction and for immune compromised patients.

References

1.    Wind WM, McGrath B. Infection following knee arthroscopy. Arthroscopy 2001; 17:878-883.

2.    Pierzchala A, Kusz D, Widuchowski J. Complication of arthroscopy of the knee. WiadLek 2003; 56:460-467.

3.    Jeffries JT, Gainor BJ. Injury to the popliteal artery as a complication of arthroscopic surgery.  Areport of two cases. Bone Joint Surgery 1987; 5:783-785.

4.    Vincent M, Stanish WD. False aneurysm after arthroscopic menisectomy: A report of two cases. Bone Joint Surgery 1990; 5:770-772.

5.    Petsche TS, Selesnick H. Arthroscopic meniscus repair with bioabsorbable arrows. Arthroscopy 2002; 18:246-253.

6.    Fond J, Rodin D. Arthroscopic debridment of osteoarthritis of the knee: 2 and 5 years results. Arthroscopy 2002; 18:829-834.

7.    Noyes FR, Barber-Westin SD. Arthroscopic repair of meniscus tears extending into the avascular zone with or without anterior cruciate ligament reconstruction inpatients 40 years of age and older . Arthroscopy 2000; 16: 822-829.

8.    Wertheim SB, Gilespies S. The role of prophylactic antibiotic in arthroscopic knee surgery. Arthroscopy 1993; 9: 367-371.

9.    Sherman OH, Fox JM. Arthroscopy, no problem surgery, analysis of complications in 2640 cases. J Bone Joint Surg Am1986; 68: 256-265.

10. Armstrong RW, Bolding F, Josef R. Septic arthritis following arthroscopy: Clinical syndromes and analysis of risk factors. Arthroscopy 1992; 8(2):213-223.

11. Wieck JA, Jackson JK, O'Brien TJ, et al. Efficacy of prophylactic antibiotics in arthroscopic surgery. Orthopedics1997; 20:133-134.

12. Kurzweil PR. Antibiotic prophylaxis for arthroscopic surgery.  Arthroscopy 2006; 22(40):452-454.

13. D' Angelo GL, Ogilvie Harris DJ. Septic arthritis following arthroscopy with cost benefit analysis of antibiotic prophylaxis. Arthroscopy 1988; 4(1):10-14.

14. Babcock HM, Carroll C, Matava M, et al. Surgical site infection after arthroscopy: Outbreak investigation and case control study. Arthroscopy 2003; 19: 172-181.