International Journal of Research in Orthopaedics

Singh A et al. Int J Res Orthop. 2018 May;4(3):484-487

http://www.ijoro.org

Original Research Article

DOI: http://dx.doi.org/10.18203/issn.2455-4510.IntJResOrthop20181803

Improved rehabilitation and functional outcome with dedicated joint irrigation at the end of ACL reconstruction

Ajeet Singh1*, Rakesh Kumar2, Rajni Ranjan2, Avijit Mahajan3

Department of Orthopaedics, 1RK Life Line Hospital, Sirsa, Haryana, 2SMS&R, Sharda Hospital, Greater Noida, Uttar Pradesh, 3IVY Hospital, Hosiarpur, Punjab, India

Received: 20 January 2018

Revised: 05 March 2018

Accepted: 07 March 2018

*Correspondence:

Dr. Ajeet Singh,

E-mail: ajeet01doc@gmail.com

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: ACL is most common ligament injured during sports. Postoperative pain and swelling is one of the major limiting factors for the rehabilitation of ACL reconstructed patients. Cryotherapy and intra-articular bupivacaine injection are few measures to reduce the pain. One of the main reason for pain is inflammatory mediators, by joint irrigation it reduce the inflammatory mediator that reduce pain and swelling.

Methods: We treated 33 patients of ACL injury with arthroscopic ACL reconstruction from July 2015 to April 2017. Postoperative pain and swellings were assed with VAS and suprapatellar fullness. VAS assessment done on 1st day, 2nd day and 12th day and for swelling 2nd day and 12th day. We had used closed loop endobutton for femur and bioscrew for tibia. In twenty patients at the end of the surgery we used 2 liter saline for joint irrigation.

Results: As a result of wash of pro inflammatory mediators and debris, there were reduced inflammation which reduces pain and swelling. Patients who received irrigation had less VAS score and suprapatellar fullness than the other group. There was better knee flexion on 12th day.

Conclusions: Adding up a dedicated joint irrigation at the end of surgery does not deviate from standard surgical protocol. No studies have stress upon joint irrigation. It reduce the pain and swelling by reducing inflammation which gives better result.

Keywords: Anterior cruciate ligament, Visual analogue scale, Suprapatellar fullness

INTRODUCTION

Knee is the frequent site for the sports injury. ACL is one of the frequently injured ligament in young athletes performing cutting and pivoting sports.1 Untreated patients predispose it to subsequent injury due to instability and early osteoarthritis.2-4 Arthroscopic ACL reconstruction is common and effective method for restoring joint stability.5-8 One of the main aim post reconstruction is to return to normal activity. Post operative pain and swelling is one of limiting factor for initiation and progression of rehabilitation. Cryotherapy is one of the common tools to reduce the post operative pain and swelling.9-14 Cryotherapy depends upon many variables like, temperature used, duration for the cryotherapy, time between surgery and the cryotherapy and the thickness of the dressing.15 Recent animal studies shows that drilling into inter-condylar notch increases Synovial expression levels of IL-1β, IL-6, and IL-8 as well as IL-1Ra were increased 2-3 which subsides after 3 to 4 weeks.16 Several studies focused on cell/tissue for source of soluble pro-inflammatory product and enzyme mediator (protein of MMP& ADAMT) that initiate inflammation and progressive cartilage loss.17 Theoretically like any other joint knee joint is also very sensitive to the debris arises from the drilling during tunnels, shaver and threads. With this concept, we changed our closing end of surgery by irrigating knee with two liter of saline post surgery to reduce the debris that initiate the inflammatory response.

METHODS

We treated 33 patients of ACL injury with arthroscopic ACL reconstruction between July 2015 to April 2017 at school of medical sciences and research, sharda hospital, greater noida. As the post operative protocol we assess patient’s pain on VAS on the day one, day two and day twelve at the time of suture removal. Swelling assessment done on the 2nd day and on 12th day depending upon suprapatellar fullness. All our patients received cryotherapy starting immediate post op till 72 hours for 20 minutes 4 times in a day. We had used closed loop endobutton (insta button, HIB surgical) for femur fixation and bioscrew (Stryker) for the tibial fixation. Informed written consent taken from all patients for arthroscopic ACL reconstruction. It’s a comparitive study where we have compared our earlier patients with the patients who received joint irrigation. In initial 13 patients surgery come to end with the fixation of the tibia with bioscrew. In further 20 patients we started using 2 liter of saline irrigation of the joint post fixation of tibia with 5.8 mm cannula sheath for inflow and outer sheath of shaver blade for out flow using pressure created by BP bulb with 16 gauge niddle in saline bottle (Figure 1). We had applied one standard gamjee roll from mid thigh to mid leg (Figure 2) and one 6 inch crepe bandage to all patients (Figure 3).

Figure 1: Apparatus to attached to saline bottle to create pressure for irrigation.
Figure 1: Apparatus to attached to saline bottle to create pressure for irrigation.

Debunking of the dressing done on the second day and surgical site sealed with T shaped dynaplast. Weight bearing started on second day with knee brace with support of axillary crutch. Amount of weight bearing and removal of axillary crutch was on patient’s pain tolerance.

Figure 2: Gamjee roll.
Figure 2: Gamjee roll.
Figure 3: 6” crepe bandage.
Figure 3: 6” crepe bandage.

Straight leg rising, static hamstring and heel touch knee flexion with passive knee extension was started on day two.

RESULTS

As a literature female athletes are 6 to 8 time more prone for ACL injury. Majority of our patients were male. We had 29 male and 4 female patients. 31 patients had injury while playing, one patient had a fall from height and one patient had road traffic accident. Out of 31, 20 of our patients had injury while playing Kabbadi, rest 11 had injury while playing football. None of our patients were trained competitive sports person. Average age of presentation to our hospital was 26.2 years. Average duration from trauma to first consultation was 5.8 months. All patients seek the second consultation due to instability symptom like fear of falling from the stairs, inability to walk on uneven surface. Average duration of surgery was 72.8 minutes. All surgery was performed by same surgeon with same nursing assistant. As we divided the patients in groups, patients who did not receive irrigation were group A and patients who received irrigation were Group B. In our study it was an observation and institutional modification of treatment on theoretical phenomena, no ethical clearance was required.

VAS was the integral part of our post op rehabilitation as a standard.VAS was recorded maximum pain experienced on the days when patients need a supplementation along with its regular anti-inflammatory drug and on day 1 it was almost 10 for all patients. VAS for group A patients on days 1, 2, and 12 were respectively 10, 7.6, 2.1 VAS for group B patients on days 1, 2 and 12 were respectively 10, 6.2, 1.3. As it was an observation but suprapatellar fullness was less in Group B patients. Average knee flexion with heel touch was in group A 80 degree while in group B it was 86 degree on 4th week follow up.

Figure 4: Mode of injury. | Kabaddi Football
Figure 4: Mode of injury.
Figure 5: VAS on post operative day 1, day 2 and day 12. | DAY 2 DAY 12 0 2 4 6 8 10 GROUP B DAY 1 DAY 2 DAY 12 DAY 1 GROUP A
Figure 5: VAS on post operative day 1, day 2 and day 12.
Figure 6: Number of male or female patients. | 0 5 10 15 20 25 30 35 No of male Pt No of Female Pt Total Pt Male & Female Pt
Figure 6: Number of male or female patients.

DISCUSSION

ACL reconstruction is most common arthroscopic surgery performed in the knee joint. Post reconstruction rehabilitation is one of the major determining factors for the outcome. Pain and swelling is main limiting factor for the initiation of rehabilitation. Intra – articular injection of bupivicane or mixture of bupivicane and morphine, use of cold saline are few alternative to reduce the pain. Intra articular injection has a role for 48 hours without any significant advantage and its main function is by its analgesic effect.18 Use of cold saline shows that, there was no significant difference between cold and normal temperature solution used for arthroscopy.19 It has shown that multiple joint tissues contribute to inflammation particularly after injury, synovial macrophages, fibroblasts and chondrocytes are sources of cytokines and chemokines and other inflammatory molecules.20 It’s a comparative study between our two groups. Our concept of using post surgery irrigation was to wash out all debris and pro inflammatory mediators, that reduces inflammation and inflammation is one of the mainstay for pain and swelling. No other study had a stress upon dedicated irrigation of the joint at the end of surgery. Long follow up with large sample size is needed.

CONCLUSION

Post tibial screw fixation, irrigation of knee joint with normal saline does not deviate from any major changes in the surgical protocol. It gives us a chance look for reconstructed ACL along with wash of all content in the joint. We found out that pain and swelling were decreased in the group B. Though our sample size was small but no other addition to the treatment required. It’s a more of a clinical practice which is cost effective.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the institutional ethics committee

REFERENCES

  1. 1. Hirshman HP, Daniel DM, Miysaka K. The fate of unoperated knee ligament injuries. In: Daniel DM, Akeson W, O’Connor J, eds. Knee Ligaments: Structure, Function, Injury and Repair. Raven Press; New York; 1990: 481-503.
  2. 2. Beynnon BD, Johnson RJ, Abate JA, Fleming BC, Nichols CE. Treatment of anterior cruciate ligament injuries, part 2. Am J Sports Med. 2005;33:1751-67.
  3. 3. Gillquist J, Messner K. Anterior cruciate ligament reconstruction and the long-term incidence of gonarthrorsis. Sports Med. 1999;27:143-56 .
  4. 4. Keays SL, Newcombe PA, Bullock-Saxton JE, Bullock MI, Keays AC. Factors involved in the development of osteoarthritis following anterior cruciate ligament surgery. Am J Sports Med. 2010;38:455-63.
  5. 5. Brown CH, Carson EW. Revision anterior cruciate ligament surgery. Clin Sports Med. 1999;18:109-71.
  6. 6. Cohen SB, Sekiya JK. Allograft safety in anterior cruciate ligament reconstruction. Clin Sports Med. 2007;26:597-605.
  7. 7. Harner CD, Olson E, Irrgang JJ, Silverstein S, Fu FH, Silbey M. Allograft versus autograft anterior cruciate ligament reconstruction: 3-to 5-year outcome. Clin Orthop. 1996;324:134-44.
  8. 8. Johnson RJ, Eriksson E, Haggmark T, et al. Five- to ten-year follow-up evaluation after reconstruction of the anterior cruciate ligament. Clin Orthop. 1984;183:122-40.
  9. 9. Cohn BT, Draeger RI, Jackson DW. The effects of cold therapy in the postoperative management of pain in patients undergoing anterior cruciate ligament reconstruction. Am J Sports Med. 1989;17:344–9.
  10. 10. Daniel DM, Stone ML, Arendt DL. The effect of cold therapy on pain, swelling, and range of motion after anterior cruciate ligament reconstructive surgery. Arthroscopy. 1994;10:530–3.
  11. 11. Edwards DJ, Rimmer M, Keene GC. The use of cold therapy in the postoperative management of patients undergoing arthroscopic anterior cruciate ligament reconstruction. Am J Sports Med. 1996;24:193–5.
  12. 12. Konrath GA, Lock T, Goitz HT, Scheidler J. The use of cold therapy after anterior cruciate ligament reconstruction: a prospective, randomized study and literature review. Am J Sports Med. 1996;24:629–33.
  13. 13. Scheffler NM, Sheitel PL, Lipton MN. Use of Cryo/Cuff for the control of postoperative pain and edema. J Foot Surg. 1992;31:141–8.
  14. 14. Bert J, Stark J, Maschka K. The effect of cold therapy on morbidity subsequent to arthroscopic lateral retinacular release. Orthop Rev. 1991;20:755–8.
  15. 15. Knight KL. Cryotherapy in Sport Injury Management. Champaign, IL: Human Kinetics; 1995.
  16. 16. Huebner KD, Shrive NG, Frank CB. New surgical model of post-traumatic osteoarthritis: isolated intra-articular bone injury in the rabbit. J Orthop Res. 2013;31:914–20.
  17. 17. Haslauer CM, Elsaid KA, Fleming BC, Proffen BL, Johnson VM, Murray MM. Loss of extracellular matrix from articular cartilage is mediated by the synovium and ligament after anterior cruciate ligament injury. Osteoarthritis Cartilage. 2013;21:1950–7.
  18. 18. Danieli MV, Neto AC, Herrera PA. Intra-articular bupivacaine or bupivacaine and morphine after ACL reconstruction Acta Ortop Bras. 2012;20(5):258–61.
  19. 19. Fincher AL, Woods GW, O'Connor DP. Intraoperative Arthroscopic Cold Irrigation Solution Does Not Affect Postoperative Pain and Swelling. J Athl Train. 2004;39(1):12–6.
  20. 20. Bondeson J, Blom AB, Wainwright S, Hughes C, Caterson B, van den Berg WB. The role of synovial macrophages and macrophage-produced mediators in driving inflammatory and destructive responses in osteoarthritis. Arthritis Rheum. 2010;62:647–57.