Arthroscopy of the Knee: Is it the Answer for OA?

Peter B. MacDonald, M.D., FRCSC
Professor of Orthopaedics
University of Manitoba
Winnipeg, MB

Introduction

The other day we were discussing a residents performance at our Postgraduate meeting when one of my spine colleagues made a suggestion about a struggling resident. This resident, he said, should be encouraged to go into an easy area of orthopaedics like scoping knees It later struck me that despite the fact that arthroscopy can be incredibly challenging and technically difficult, knee arthroscopy and debridement or scoping for dollars, as some refer to it, has been abused to the point of being open to ridicule. This operation, along with meniscal trimming, is regarded as easy, quick, simple, remunerative and, as such, becomes an attractive area for many general orthopaedic surgeons or marginal sports medicine specialists. Even total joint specialists are tempted to insert these cases as fillers into their slates for both remunerative reasons and to pacify patients on long waiting lists for knee replacement. When the operation is done poorly or for the wrong reasons, it becomes easy to dodge the scrutiny of the patient by stating: Well, the arthritis was worse than we thought or We now realize that you need a knee replacement. Occasionally, even in the face of a poorly done procedure, the patient is delighted with the outcome because of a placebo effect or limited benefit from a simple wash out of the knee. Because of a lack of clear peer-review literature-based guidelines, which result in our inability to spell out its indications, the abuse of this operation is common.

New Scrutiny

The debate over the role of this procedure reached new heights recently with publication of the studies by Moseley9 and subsequently by Wai14, both in 2002. Moseleys study, which received the most attention with its appearance in the New England Journal of Medicine, was a well-constructed randomized placebo control trial. It concluded that outcomes after arthroscopic lavage or arthroscopic debridement were no better than a placebo procedure. This caused HMOs in the United States and Regional Health Authorities in Canada to lick their "chops" at potential money savings while simultaneously suggesting that this procedure be discontinued altogether. The problem with Moseleys study is that it failed to distinguish those with poor alignment or advanced degenerative changes. The latter comprised 68-71% of their study group.

Wais study from the Journal of Bone and Joint Surgery looked at arthroscopic debridement for patients 50 years and over in the Province of Ontario. He identified 14,391 such procedures and found that 9.2% required total knee arthroplasty within one year and 18.2% within three years. Patients over 70 years were 4.7 times as likely to have total knee arthroplasty within one year as those under age 60. They also cited significant regional differences, and concluded that the procedure may be over utilized. Again, they were unable to stratify severity of disease or factors such as alignment.

Indications and Results

As always, surgeons should exhaust nonoperative measures prior to embarking on surgery. In this patient population, this includes weight loss and attention to general condition, wedged insoles, NSAID use, bracing, and visco-supplementation.
Surgical debridement of the knee involves lavage, partial menisectomy, excision of osteophytes, loose body removal and cartilage shaving or thermal chondroplasty2,4. A thorough history and physical exam are extremely important in determining whether or not surgery will be of benefit. This should include confirming the presence or absence of mechanical symptoms, including locking or giving way, as well as localized physical symptoms of discrete joint line tenderness. All too often the clinician gets caught up in the results of an X-ray or MRI. A failure to clearly define patient complaints and addressing the surgery as a function of imaging, rather than symptoms, will lower success rates. Having said that, one cannot emphasize enough the X-ray assessment of alignment (Figure 1). If the mechanical axis of the knee passes through the symptomatic area, then, clearly, the surgery will be unsuccessful5,11. There should be normal, or near normal alignment with only mild-moderate degenerative changes8. Patients with a history of previous surgery or arthroscopic evidence of severe (Grade 4) chondromalacia are at risk of a poor outcome4,5,6,7 (Figure 2). Patients with mild to moderate changes and localized mechanical symptoms with normal alignment can be expected to have reasonable results2,4,5,6.

Even when the outcome is favorable, results may be short lived6,14. Complications, including DVT and pulmonary embolism, are not to be underestimated and have ranged in series from 7-31% with a higher prevalence in older patients12.

Technical Considerations and New Frontiers

There have been many new and exciting advances in the arthroscopic treatment of degenerative lesions including microfracture13, osteochondral autograft transfer1 (Arthrex; Naples, Florida) or Mosiacplasty3 (Smith and Nephew; Andover, Massachusetts) and well as autologous chondrocyte transfer10 (Genzyme; Cambridge, Massachusetts). Although these techniques are most successful for localized lesions in younger patients1,3,10,13, they represent a new frontier in treatment that in the future could include cell and genetic engineering, eliminating the necessity for a large number of joint replacements. Surgeons treating these patients should be aware of these evolving techniques and their indications.

Conclusions and Recommendations: Is the Answer No?

  1. The real answer to choosing this procedure is Sometimes yes, sometimes no.
  2. Stick to the indications and avoid abuse of the procedure.
  3. Know how to do the procedure properly. Avoid the attitude that these procedures are easy. Adopt a meticulous and thorough approach.
  4. Be aware of new techniques and dont hesitate to refer patients on if necessary. Surgeons should be doing a minimum of 50 cases per year to maintain skills.
  5. We need further well-constructed prospective randomized studies, including cost/benefit analysis, to further narrow indications. These studies must be large enough to stratify results and avoid blanket endorsement or condemnation of this procedure.



References

  1. Carter, T. Osteochondral Allograft Transplantation. Sports Med. and Arthroscopy Review. 11: p264-271. 2003
  2. Fond, J. et al. Arthroscopic Debridement for the Treatment of Osteoarthritis of the Knee. Arthroscopy, 18. P829-834. 2002.
  3. Hangody, L. et al. Mosiacplasty for the treatment of Articular Defects of the Knee and Ankle. Clin. Orthop.: 391S: pS328-S336.2001.
  4. Hanssen, A.D. et al. Surgical Options for the Middle-Aged Patient with Osteoarthritis of the Knee Joint. Journal of Bone and Joint Surg. 82-A. p1768-1781. 2000.
  5. Harwin, S.F. Arthroscopic Debridement for Osteoarthritis of the Knee: Predictors of Patient Satisfaction. Arthroscopy: 15: P142-146. 1999.
  6. Jackson, R.W. and Dieterichs, C. The Results of Arthroscopic Lavage and Debridement of Osteoarthritic Knees Based on the Severity of Degeneration. Arthroscopy: 19: p13-20. 2003
  7. Linschoten, N.J. and Johnson, C.A. Arthroscopic debridement of the knee joint arthritis: effect of advancing articular degeneration. J. Southern Orthop. Assn., 6:25-36, 1997.
  8. Merchan, E.C. and Galindo, E. Arthroscope-guided surgery versus non-operative treatment for limited degenerative osteoarthritis of the femoral-tibial joint in patients over 50 years of age. Clin. Orthop., 229: p193-200, 1988.
  9. Moseley, J.B. et al. A Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee. New England Journal of Medicine. 347: p81-88, 2002.
  10. Peterson, L. et al. Autologous Chondrocyte Transplantation. Am. J. Sports. Med: 30: p 2-14. 2002
  11. Salisbury, R.B., Nottage, W.M., and Gardner, V. The effect of alignment on results of arthroscopic debridement of the degenerative knee. Clin. Orthop., 271: p96-100. 1991.
  12. Sherman, O.H. et al. Arthoscopy-no-problem surgery. An analysis of complications in Two thousand six hundred and forty cases. J. Bone Joint Surg.,68-A: p256-265. 1986.
  13. Steadman, J.R., Rodkey, W.G., and Briggs, K.K. Microfracture Chondroplasty. Sports Med. Arthroscopy Review. 11: p.236-244. 2003
  14. Wai, E.K., Kreder, H.K. and Williams, J.I. Arthroscopic Debridement of the Knee for Osteoarthritis in Patients Fifty Years of Age or Older. J. Bone Joint Surg. 84-A, p17-22. 2002.

Legend

 

Figure 1. Normal Axial Alignment
macdonald figure 2
Figure 2. Advanced OA unsuitable for scope

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