The purpose of surgical treatment in knee osteoarthritis is to determine a sustained improvement in health-related quality of life by decreasing the pain level and by reestablishing as far as possible the normal joint mechanics. One of the most common surgical procedures performed for knee OA is arthroscopic debridement. Arthroscopic surgery has been evolving since the beginning of the 20th century. Eugen Bircher has published, between 1921 and 1926, several papers describing 60 arthroscopic knee procedures (using the Jacobeus thoracolaparoscope) that preceded an open meniscectomy. 4 In the 1950s Professor Harald H. Hopkins developed the rod lens system, which is still used today in the most modern arthroscopes. Nowadays, with the development of magnetic resonance imaging and other non-invasive diagnostic techniques, knee arthroscopy is used more often for the treatment of various knee pathologies. 5 Moseley et al. estimate that at least 650,000 arthroscopic debridement procedures are performed each year in the United States, making it the second most commonly used orthopaedic procedure, ranking behind the arthroscopy for nondegenerative conditions. 6
The advantages of arthroscopic surgery are: reduced post-operative morbidity, small incisions, less inammatory response resulting in less post-operative pain, reduced hospital costs, low complication rate, and an improved joint visualization. The disadvantages of this technique are few, such as working with small instruments in a conned area and the possibility to produce damage to the cartilage. 7
The aim of this study was to evaluate the effects of arthroscopic debridement in selected patients diagnosed with knee OA using an own clinical rating system. 0$7(5,$/$1'0(7+2' The patients, diagnosed with knee OA based on clinical symptoms and signs and X-rays, were considered for debridement arthroscopy if complaining of articular pain for at least one year with no alleviation of this symptom despite supervised physical therapy and comprehensive medical management or patients who refuse total knee replacement (TKR). The failing conservative treatment may have included oral and topical analgetics, nonsteroidal anti- inammatory medications and intra-articular injection of cortisone. This research is based on 103 patients (106 knees), aged between 45 and 75 years (mean age 62 years) who were submitted, between January 2000 and January 2004, to arthroscopic surgery for knee osteoarthritis. Seventy-four (71.84%) of these patients were females and according to the body mass index (BMI) 51 patients (42 females) were obese (BMI>30). The Kellgren-Lawrence scheme was used to grade the severity of radiographic knee osteoarthritis. 8 (Table 1) IahIe 1. R+J|u|+p|| |+J|| || |u| u|u+||||||| +J+p|J ||u| ||||| +|J |+W||) The arthroscopic evaluation and classication of degenerative cartilage damage was done using the criteria described by Outerbridge (1964). 9 (Table 2, Fig. 1)
IahIe 2. A||||uup| |+J|| || |u| u|u+||||||| +J+p|J ||u| 0u|||||J) The localization of the cartilage lesions was recorded for each compartment on an articular diagram. All patients had arthroscopy of the knee under spinal anesthesia. All surgery in this study was performed with use of standard anterolateral and anteromedial skin portals. The tourniquet was used in every case. 6rade 0rIterIa J |u||+| l uu|||u| |+||uW|| u| |u||| p+, pu||| u|up|]| J1|up||| ll ||||| u|up|]|, +||| u| (u||u|+|| |+||uW|| u| |u||| p+ lll |uJ|+| u|up|]|, J||||| |+||uW||, u| ||u|, pu||| |u||| J|u||||] lV |+| u|up|]|, |+||J |+||uW||, 1| ||u|, J||||| |u||| J|u||||] 6rade 0rIterIa J |u||+| ! A|||u|+| +||||+ u||||| +|J W|||| Z ||+|||+||u| +|J ||u||| || +| +|+ | ||+| !Z || |+|| |||) J|+||| 3 ||+|||+||u| +|J ||u||| || +| +|+ |+|| ||+| !Z || |+|| |||) J|+||| 4 E|u|u| u| +||||+ |u u||u|J|+| |u| _____________________________ 150 IM1 2005, eI. 55, 8e. 2
FIure 1. 0u|||||J |+J Z +||||+ ||u| According to the identied intraarticular lesions the surgical procedures chosen were: - segmentary synovectomy, done only with the purpose to obtain a better joint visualization and for an histopathological examination; - excision of hypertrophic synovial plicae; - abr asi on of mar gi nal cl i ni cal l y r el evant osteophytes; (Fig. 2) - resection of loose chondral aps and unstable meniscal tears; - loose bodies (articular mice) removal; - abrasion chondroplasty; - articular lavage. FIure 2. C||||+||] ||1+|| u|up|]| A meniscal tear was considered resectable if it was longitudinal and full-thickness, radial and more than 3 mm deep or if tears were complex. (Fig. 3) The unstable meniscal tears were contoured to a stable rim arthroscopically, leaving a maximum of normal tissue, chondral aps were removed and the rim of the cartilage lesion was contoured by abrasion to improve the transition between normal and abnormal cartilage. Only clinically symptomatic osteophytes were removed by abrasion. Drilling of the subchondral bone was not performed. FIure 3. u||+|| |||+| |+| The assessment of the results obtained after arthroscopy was done analysing subjective and objective parameters using an own method. The postoperative score was compared for each patient with the value obtained before surgery using the same method. This method of evaluation has a score with 60 points for pain, 3 points for morning stiffness, 20 points for range of motion and 17 points for function (walking and stair climbing); points are deducted for exion contracture, extension lag and and for aids used during daily activities, walking or stair climbing (canes, crutches or rail). (Table 3). Depending on the obtained total score the results are considered excellent (score=85-100), good (score=65-84), acceptable (score=50-64) or poor (score<50). 5(68/76 According to the radiographic ndings of the investigated joints the K\L grade was I in 3, II in 51, III in 39 and IV in 13 knees; the medial tibiofemoral joint was predominantly involved by osteoarthritis in 72 (67.92%) joints. The distribution of the severity of the chondral damage graded arthroscopically for all knees is shown in Figure 4. _____________________________ 0esIa 0. Fe et aI 151 IahIe 3. 0W| || ||||+| |+||| ]|| |u| J|||J||| +||||uup] 0 10 20 30 40 50 60 Grade 1 Grade 2 Grade 3 Grade 4 p e r c e n t
o f
c a s e s Medial Lateral Patellofemoral FIure 4. |||||u||u| u| || |+J u| || +|||u|+| +||||+ ||u| || || p+|||| || || p||| |uJ], +u|J|| |u || ]|| J|||J |] 0u|||||J, + J|||||J W||| +||||uup] u| || || u|p+||||| The medial compartment was more frequently and severely involved, with 62% of the knees showing grade 3 or 4 involvement, according to the system described by Outerbridge. In contrast, both the lateral and the patellofemoral compartment had grade 3 or 4 changes in 26% and 21% of the knees, respectively. Hypertrophied synovitis was detect in all knees, loose bodies in 12 joints and lesions of the anterior cruciate ligament (ACL) in 13 knees. Fifty-three patients had an unstable uniformly degenerative meniscal tear; 21 tears were in the medial meniscus, 9 were in the lateral meniscus and 23 were combined. The patients were evaluated, using the described method, before arthroscopy and at 6 months and one year after the surgical procedure. The last evaluation (average follow-up of 19 months) was performed in 84 patients. Twelve patients (11 females) with wide extended grade 4 cartilage lesions involving the medial and lateral tibiofemoral articular compartments in both knees, who complained of great knee pain, underwent total knee replacement (TKR) with cemented posteriorly stabilized endoprosthesis at 15 months (range 13 to 17 months) after arthroscopy while 7 patients didn t answer to our call. According to this evaluation method the average preoperative score was 60 (range: 36-90). At 6 months after arthroscopy the average score was 65 (range: 36-95), at one year 64 (range: 35-95) and at the last evaluation this score was 62 (range: 34-91). At one year after surgery the results were excellent and good in 53 (51.45%) patients, acceptable in 36 (34.95%) and poor in 14 (13.59%), while at the last evaluation the results were excellent and good in 46 (54.76%) patients, acceptable in 30 (35.71%) and poor in 8 (9.52%). (Figure 5) FIure 5. Ru|| +||1J || p+|||| W||| || 0A +||| J|||J||| +||||uup] 0 10 20 30 40 50 60 one year - 103 cases at last evaluation - 84 cases p e r c e n t
0eductIeas A|J. |+|| up +|J/u| JuW| |+||) Z/! W+|||| W||| +|/|u|| !/Z E/|||u| |+. > ZJ J 4 ||W| !J +|J ZJ J Z ||W| 5 +|J !J J ! < 5 J J ||/|u| u|||+|u|. > ZJ J 4 ||W| !J | ZJ J Z ||W| 5 | !J J ! +||| J IetaI scere _____________________________ 152 IM1 2005, eI. 55, 8e. 2 The short-term complications following arthroscopic debridement in these patients were represented by moderate diffuse knee pain lasting for more than 7 days in 11 patients, pain localized on both sides of the joints in 14 patients and clinical signicant swelling of the joints in 19 patients. Haemarthrosis was arthroscopically diagnosed and treated in 6 from these 19 patients. No septic arthritis or symptomatic deep venous thrombosis secondary to knee arthroscopy was recorded. ',6&866,21 The results obtained after arthroscopic debridement are difcult to evaluate through imagistic methods like the so called arthroscopic second-look or radiographic ndings. The purpose of this surgical technique is not to restore the cartilage integrity or the lower limb alignment but to remove the intraarticular irritating factors with the purpose to alleviate the knee pain and to slow down the OA evolution. The intraarticular irritating factors are represented by: 10-12
- little cartilage fragments oating in the synovial liquid (so called debris); - loose bodies or loose chondral aps; - pro-inammatory cytokines (interleukin-1, tumor necrosis factor- and transforming growth factor-) released by the hypertroed synovial membrane; - lytic enzymes released by chondrocytes; - osteophytes; - unstable meniscal tears. The effects of arthroscopic debridement were evaluated by numerous orthopaedic surgeons using different methods like self-administred quality-of-life instruments (WOMAC, SF-36, OXFORD, Tegner or ICRS Clinical Cartilage Injury Evaluation system- 2000) or clinical rating systems (Lysholm score or a modied HSS score). 13 Health-related quality-of- life measures are categorized into two broad forms, generic and disease-specic. Generic scales are useful for their comprehensive evaluation, and they allow comparisons of interventions for unrelated conditions. Disease-specic scales (WOMAC, SF-36) are generally more sensitive to change and are usually more relevant to the conditions they measure (especially pain). 14,15 They have been proved to be both reliable and valid for the evaluation of patients with OA of the knee that are treated especially with nonsteroidal medication and TKR. Although the importance of health-related quality-of-life measures is becoming increasingly acknowledged, the interpretation of changes in the scores has not been well dened. The clinical outcome measuring methods (Lysholm score, modied HSS score) are analysing more the objective ndings about the osteoarthritic knee joint and the function of the limb and less the characteristics of pain level during various types of movements. In comparison the described own-devised method (not self-administrated) evaluates in detail the pain during rest or different activity levels, the severity of morning stiffness according to its duration and the overall function (walking, stairs). This method does not evaluate the joint stability or limb alignment because debridment arthroscopy does not have the possibility to modify these parameters. The results, obtained using arthroscopic debridement for knee OA and published by numerous orthopaedic surgeons, are varied. The variety of arthroscopic procedures, the retrospective nature of the majority of published studies, the lack of controls and the suggestion that the placebo effect may be responsible for the benet related to arthroscopic treatment have cast doubts about the efciency of this technique. 16,17
Sprague (1981) reported in his study a reduction of the knee pain level in 74% of the patients, reduction maintained during one year after arthroscopy, while Timoney et al. (1990) reported favorable results in only 45% of the patients at four years follow-up. 18,19 In a study published in 1996 Jackson et al.reported favorable results in decreasing the knee pain level after arthroscopic lavage and debridement in 85% of his patients two years after surgery. 20 The author underlines the importance of minimal axial limb malalignment and biomechanical stable joints in achieving good results while chondral fractures and large osteophytes are responsible for poor results. Johnson (1996) was one of the rst orthopaedic surgeons who used this combined method of arthroscopic debridement and lavage in 99 arthritic knees. 21 In his study (two years follow-up) the author reported pain alleviation in 78% patients, no change in 15%, while 7% of his patients complained of greater knee pain. According to Hubbard (1996) the late results are better after debridement arthroscopy comparing to those obtained using only arthroscopic lavage. 22 The author reported in a prospective study (follow-up of 4.5 years) alleviation of knee pain level in 19 (59.37%) from 32 patients who underwent arthroscopic debridement compared to only 3 (11.53%) from 26 patients who underwent arthroscopic lavage. A recent survey of Canadian surgeons found _____________________________ 0esIa 0. Fe et aI 153 considerable disagreement about the utility of arthroscopy for the treatment of this disease in three hypothetical case scenarios; Wai et al. using administrative data sets shows that 18.4% of 6212 patients had had a total knee replacement within three years after arthroscopic dbridement. 23,24 Other authors disagree with these results suggesting that arthroscopy in arthritic knees has a placebo role. In a study published in 2002 by Moseley et al. the authors intended to demonstrate this effect in 180 patients with radiographic knee OA lesions. 25 These patients were divided in three therapeutic groups. The patients in the rst group underwent debridement arthroscopy, those in the second group underwent only lavage arthroscopy while for those in the third group (placebo group) the surgeon did only two supercial skin incisions without performing a real arthroscopy. The outcome in all patients was recorded according to pain and function scores with a follow-up of 24 months. The results of this randomized study showed no signicant differences between the three groups of patients; all patients reported symptom alleviation. The weakness of this study resides in the low representative population most of the patients were males from a Veteran Hospital, and in the absence of information about the meniscal pathology. Dervin et al. reported, in a study published in 2003, clinically important reduction in the pain score, according to the rating on the WOMAC pain scale, in fty-six patients (44%) at two years after arthroscopic debridement. 26 Most failures were evident in the rst year after surgery. Currently orthopaedic surgeons have not reached a consensus with regard to which patients should be applied this surgical procedure for the treatment of knee OA. This study reveals the role of debridement arthroscopy in signicant reduction of pain during rest and activity at 6 months and one year after arthroscopy in 51 (49.51%), respectively 42 (40.77%) patients, while at the last evaluation only 30 (35.71%) patients reported an alleviation of the pain level. Before arthroscopy 71 (68.93%) patients reported morning stiffness, at one year after surgery 9 (12.67%) of these patients conrmed an improvement, 51 (71.83%) did not conrm any improvement, while 11 (15.49%) reported worsening of this complaint; at the last evaluation in only 7 patients this improvement remains unchanged. At one year after arthroscopy 32 (31.06%) pacients reported the possibility to walk on longer distances and 21 (20.38%) patients were able to climb more stairs than preoperatively; at the last evaluation these results remained unchanged. A clinical signicant range of motion (ROM) improvement was not recorded at one year after surgery and at the last evaluation. At one year after surgery and at the last evaluation 25 patients needed aids for walking and/or stairs compared to 34 prior to surgery. Clinically signicant improvement of extension lag or exion contracture was not recorded at any evaluation. Favorable results were recorded in patients with mediolateral and anteroposterior instabillity less than 10 degrees respectivelly 5 mm, predominant unicompartmental degenerative radiographic lesions grade I, II and III according to the Kellgren-Lawrence scheme, limb axial malalignment of maximum 10 degrees, cartilage lesions grade 1,2 and 3 (Outerbridge), presence of unstable meniscal tears, large loose bodies, loose chondral aps and absence of total ACL tears. The best results were achieved in younger patients who complained of mechanical symptoms (like pseudoblocking, catching or giving-away, stable joints, mild radiographic changes (grade I and II), degenerative cartilage changes grade 1 and 2 and presence of unstable meniscal tears; in these patients the obtained results remained unchanged until the last evaluation. Poor results were recorded in obese patients with symptoms (especially rest pain) of long duration, limb alignment greater than 10 degrees, unstable joints, grade III and IV radiographic changes extended in all joint compartments, grade 4 cartilage lesions and large degenerative changes in both menisci &21&/86,216 Arthroscopic debridement is considered when medical management in knee osteoarthritis has failed to satisfactorily reduce symptoms. A great importance in achieving best results by performing arthroscopy in knees with degenerative lesions is to establish the correct indication; thus it is important to counsel patients about the limited indications and palliative results. An appropriate illness history and a proper clinical examination of the symptomatic knee are helpful in revealing mechanical problems like unstable meniscal tears, loose bodies or unstable chondral aps. Arthroscopic removal of these lesions is followed by successful recovery of joint function and knee pain alleviation. Decrease of the knee pain level is the most common short- and medium-term result obtained in selected patients by performing debridement arthroscopy for OA. _____________________________ 154 IM1 2005, eI. 55, 8e. 2 Several factors determine prognosis after arthroscopic lavage and debridement; the patients who benet most present with a history of mechanical symptoms, symptoms of short duration, normal alignment and a stable joint, only mild to moderate radiographic evidence of osteoarthritis and grade 1, 2 or 3 cartilage lesions with predominant unicompartmental localization. This own evaluation method may serve as an alternative to the existing and well known clinical rating systems and there is the possibility to add new variables in the aim to improve the results specicity. 5()(5(1&(6 1. Cole JB, Harner CD. Degenerative arthritis of the knee in active patients: evaluation and management. J Am Acad Orthop Surg 1999;7:389-402. 2. Felson DT et al. Osteoarthritis: new insights. Part 1: the disease and its risk factors. Ann Intern Med 2000;133:635-46. 3. Chang RW, Falconer J, Stulberg SD, et al. A randomized, controlled trial of arthroscopic surgery versus closed-needle joint lavage for patients with osteoarthritis of the knee. Arthritis Rheum 1993;36:289-96. 4. Kieser CW, Jackson RW. Eugen Bircher (1882-1956)- The rst knee surgeon to use diagnostic arthroscopy. Arthroscopy 2003; 19:771-6. 5. Bennett C, Chebli C. Knee Arthroscopy. Business Brieng North American Pharmacotherapy 2003;1-4. 6. Bernstein J, Quach T. Questioning the value of arthroscopic knee surgery for osteoarthritis. A perspective on the study of Moseley et al. Cleveland Clin J of Medicine 2003;70:401-10. 7. Phillips BB. General Principles of Arthroscopy. Campbells Operative Orthopaedics. Ed. ST Canale, 9th Edition, St Louis, Mosby. 1998:1,453-461,469. 8. Kellgren JH, Lawrence JS. Radiological assessment of osteoarthrosis. Ann Rheum Dis 1975;16:494-501. 9. Outerbridge RE. The etiology of chondromalacia patellae. J Bone Joint Surg 1964;46:752-7. 10. Felson DT, Buckwalter J. Debridement and lavage for osteoarthritis of the knee. N Engl J Med 2002;347:81-8. 11. Bouillon B, Tiling T, Shazadeh S. Stellenwert von arthroscopishem Debridement und Lavage bei der Therapie der Arthrose. Deutsche Zeitschrift Fr Sportmedizin 2003;6:215-7. 12. Ogilvie-Harris DJ, Fitsialos DP. Arthroscopic management of the degenerative knee. Arthroscopy 1991;7:151-7. 13. Tegner Y, Lysholm J. Rating system in the evaluation of knee ligament injuries. Clin Orthop 1985;198:43-9. 14. Warw JE Jr, Sherbourne CD. The MOS 36-item Short-form health survey (SF-36) I. Conceptual framework and item selection. Med Care 1992;30:473-83. 15. Bellamy N, Buchanan WW, Goldsmith CH, et al. Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J Rheumatol 1988;15:1833-40. 16. Moseley JB, Wray NP, Kuykendall D, et al. Arthroscopic treatment of osteoarthritis of the knee: a prospective, randomized, placebo-controlled trial. Results of a pilot study. Am J Sports Med 1996;24:28-34. 17. Moseley JB, Wray NP, Kuykendall D, et al. Arthroscopic treatment of osteoarthritis of the knee: a randomized, double-blind, placebo- controlled trial: two year follow up of 180 patients. Read at the Annual Meeting of the American Academy of Orthopaedic Surgeons; Feb 28-Mar 4 2001; San Francisco, CA. 18. Sprague NF. Arthroscopic debridement for degenerative knee joint disease. Clin Orthop 1981;160:118-23. 19. Timoney JM, Kneisl JS, Barrack RL, et al. Arthroscopy in the osteoarthritic knee: long-term follow-up. Clin Orthop 1990;19:371- 3;379-9. 20. Jackson RW. Arthroscopic treatment of degenerative arthritis. In McGinty JB, Caspari RN, Jackson RW, Poehling GG (editors), Operative Arthroscopy, 2nd Ed., Lippincott-Raven Philadelphia, 1996. 21. Johnson LL. Arthroscopic abrasion arthroplasty. In McGinty JB, Caspari RN, Jackson RW, Poehling GG (editors), Operative Arthroscopy, 2nd Ed., Lippincott-Raven Philadelphia, 1996. 22. Hubbard MJS. Articular debridement versus washout for degeneration of the medial femoral condyle. J Bone Joint Surg 1996;78-B:217-9. 23. Wright JG, Coyte P, Hawker G, et al. Variation in orthopaedic surgeons perceptions of the indications for and outcomes of knee replacement. CMAJ 1995;152:687-97. 24. Wai EK, Krader HJ, Williams JI. Arthroscopic debridement of the knee for osteoarthritis in patients fty years of age or older: utilization and outcomes in the Province of Ontario. J Bone Joint Surg Am 2002;84:17-22. 25. Moseley JB, OMalley K, Peterson NJ.et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med 2002;347:87-8. 26. Dervin GF, Stiell IG, Rody K, et al. Effect of arthroscopic debridement for osteoarthritis of the knee on health-related quality of life. J Bone Joint Surg 2003;85-A(1):10-19.