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Arthroscopic debridement of the osteoarthritic knee under local anaesthesia.

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Journal Acta orthopaedica Belgica
Year 2004
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This article is included in 2 Broad syntheses Broad syntheses (2 references) 1 Systematic review Systematic reviews (1 reference)

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This prospective study compared the efficacy of arthroscopic debridement in osteoarthritic knees under local, general or peridural anaesthesia. Between 1997 and 2001, 201 arthroscopic debridements were performed in 197 patients (173 partial meniscectomies, 192 articular trimmings, 119 microfractures, 201 lavage procedures) in 197 patients. Patients were treated under local (Group "L", n = 67), general (Group "G", n = 65) or peridural anesthesia ( Group "P", n = 65). No tourniquet was used. The follow-up ranged from 24 to 72 months (mean: 32 months). No major complication was noted. Results were assessed according to the scale of Baumgaertner et al independently from the type of anaesthesia used (p = 0.71). Results were excellent in 85 cases (L: 30, G: 27, E: 28), good in 75 (L: 25, G: 24, E: 26), fair in 27 (L: 9, G: 8, E: 10), poor in 14 (L: 7, G: 4, E: 3). Arthroscopic debridement of the osteoarthritic knee under local anaesthesia appears as an efficient, simple, safe, painless and cost-effective method of treatment.

Primary study

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Arthroscopic washout of the knee--a 5-year survival analysis.

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Authors Bernard J , Lemon M , Patterson MH
Journal The Knee
Year 2004
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This article is included in 3 Broad syntheses Broad syntheses (3 references) 2 Systematic reviews Systematic reviews (2 references)

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Arthroscopy and washout of the knee is commonly performed for early osteoarthritis. Very little information exists regarding long-term prognosis, especially in terms of avoidance of further surgery. Using a prospectively gathered database, 100 consecutive patients having knee arthroscopy with a finding of OA between 1991 and 1993 were identified and their outcome at 5 years ascertained. Ninety-nine patients with 100 arthroscoped knees were identified. Fifty-eight had isolated medial compartment disease and six had isolated lateral compartment disease. In 36, both compartments were affected. Eighteen knees had further major surgery during follow up; 11 had total knee replacement, four had high tibial osteotomy and three had unicondylar knee arthroplasty. Those requiring surgery were significantly older (62 cf. 53 years, P=0.008). Meniscectomy was not an important risk factor (chi2, P=0.67). The rate of knee survival without operation at 5 years was much lower in those aged over 60 years than in those younger (68% cf. 89%). (chi2, P=0.02). Only 18% of patients progress to major knee surgery within 5 years of arthroscopic washout for osteoarthritis. Age greater than 60 years worsens the prognosis considerably.

Primary study

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A prospective randomised trial comparing intra-articular Hyalgan injection and arthroscopic washout for knee osteoarthritis.

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Authors Forster MC , Straw R
Journal The Knee
Year 2003
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This article is included in 6 Systematic reviews Systematic reviews (6 references) 2 Broad syntheses Broad syntheses (2 references)

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Thirty-eight patients with symptomatic knee osteoarthritis without mechanical symptoms were randomised after informed consent to receive either a course of intra-articular Hyalgan injections or an arthroscopic washout. The patients were prospectively assessed pre-intervention, 6 weeks, 3 months, 6 months and 1 year using a 10 cm visual analogue pain score, the Knee Society function score and the Lequesne index. There was no significant difference between the two groups at 6 weeks, 3 months, 6 months or 1 year. The use of intra-articular Hyalgan injections in patients with knee osteoarthritis without mechanical symptoms gives results comparable with arthroscopic washout. Hyalgan is an alternative to arthroscopy in this patient group. Further study is needed to confirm these findings and improve patient selection.

Primary study

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Effect of arthroscopic débridement for osteoarthritis of the knee on health-related quality of life.

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Journal The Journal of bone and joint surgery. American volume
Year 2003
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This article is included in 2 Broad syntheses Broad syntheses (2 references)

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BACKGROUND: The available evidence supporting the use of arthroscopic débridement for the treatment of symptomatic osteoarthritis of the knee is largely retrospective and lacks validated health-related quality-of-life measures. The goal of the study was to prospectively assess a cohort of patients with osteoarthritis of the knee who were selected for arthroscopic débridement and determine which clinical criteria favor a sustained improvement in health-related quality of life after two years of follow-up. METHODS: One hundred and twenty-six patients with symptomatic primary osteoarthritis of the knee underwent arthroscopic débridement of the knee after failure of medical management. Two groups of surgeons (postgraduate fellows and attending staff) independently evaluated the patients preoperatively with use of a standardized assessment of clinical symptoms and signs and plain radiography. The intervention was arthroscopic débridement, which included resection of unstable chondral flaps and meniscal tears. Abrasion was not performed. Outcome measures included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), a disease-specific scale, and the Short Form-36 (SF-36), a generic outcome measure. RESULTS: Sixty-seven (53%) of the 126 patients were female, and the mean age (and standard deviation) was 61.7 +/- 8.6 years (range, forty-three to seventy-five years). The medial compartment was more frequently and severely involved, with 57% showing Grade-III or IV involvement, according to the system of Dougados et al. Seventy-nine patients (63%) had an unstable meniscal tear. Fifty-six patients (44%) were rated as having had a clinically important reduction in pain, as determined with the WOMAC pain scale, at two years after the arthroscopic débridement. Physicians were poor at predicting which patients would have improvement. The rate of accuracy of the fellows and staff was 54% and 59%, respectively, and their agreement was only slightly better than chance, with a kappa of 0.27 (95% confidence interval, 0.09 to 0.45). Only three variables were significantly associated with improvement: the presence of medial joint-line tenderness (p = 0.04), a positive Steinman test (p = 0.01), and the presence of an unstable meniscal tear at arthroscopy (p = 0.01). CONCLUSIONS: The prospectively evaluated quality-of-life benefit from arthroscopic débridement of the osteoarthritic knee is less than that reported in previous retrospective surveys on satisfaction. These results may serve as a baseline for comparison against more sophisticated procedures for resurfacing of the articular cartilage. Clinical variables were only partially helpful for predicting a successful result after arthroscopic débridement, and a search for other biologic markers (such as synovial fluid) may be of benefit. LEVEL OF EVIDENCE: Therapeutic study, Level IV (case series [no, or historical, control group]). See p. 2 for complete description of levels of evidence.

Primary study

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The value of knee arthroscopy in patients with severe radiological osteoarthritis.

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Journal Archives of orthopaedic and trauma surgery
Year 2002
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This article is included in 2 Broad syntheses Broad syntheses (2 references) 1 Systematic review Systematic reviews (1 reference)

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BACKGROUND: This study was performed to assess the value of knee arthroscopy in patients with radiological signs of severe osteoarthritis. METHODS: A total of 104 patients (50 men, 54 women, average age 60 years) with radiological knee osteoarthritis grade III/IV were followed up after knee arthroscopy between May 1989 and November 1996. The average follow-up time was 5.4 years after surgery. RESULTS: A significant ( p<0.01) increase in the Lysholm score was found, ranging from 40 points before arthroscopy to 69 points at the assessment. A total of 84 patients (81%) reported an increase in their activities of daily living, 44 patients (43%) were still without any complaints. The total outcome was rated very good or good by 67 patients (65%). Only 21 patients (20%) required further surgery before the assessment. CONCLUSIONS: Knee arthroscopy is a valuable treatment for patients with pain, swelling, and radiological signs of severe osteoarthritis. It improves the patients' activities of daily living and helps to postpone further surgery.

Primary study

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A controlled trial of arthroscopic surgery for osteoarthritis of the knee.

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Journal The New England journal of medicine
Year 2002
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This article is included in 12 Systematic reviews Systematic reviews (12 references) 1 Structured summary of primary studies Structured summaries of primary studies (1 reference) 2 Broad syntheses Broad syntheses (2 references)

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BACKGROUND: Many patients report symptomatic relief after undergoing arthroscopy of the knee for osteoarthritis, but it is unclear how the procedure achieves this result. We conducted a randomized, placebo-controlled trial to evaluate the efficacy of arthroscopy for osteoarthritis of the knee. METHODS: A total of 180 patients with osteoarthritis of the knee were randomly assigned to receive arthroscopic débridement, arthroscopic lavage, or placebo surgery. Patients in the placebo group received skin incisions and underwent a simulated débridement without insertion of the arthroscope. Patients and assessors of outcome were blinded to the treatment-group assignment. Outcomes were assessed at multiple points over a 24-month period with the use of five self-reported scores--three on scales for pain and two on scales for function--and one objective test of walking and stair climbing. A total of 165 patients completed the trial. RESULTS: At no point did either of the intervention groups report less pain or better function than the placebo group. For example, mean (+/-SD) scores on the Knee-Specific Pain Scale (range, 0 to 100, with higher scores indicating more severe pain) were similar in the placebo, lavage, and débridement groups: 48.9+/-21.9, 54.8+/-19.8, and 51.7+/-22.4, respectively, at one year (P=0.14 for the comparison between placebo and lavage; P=0.51 for the comparison between placebo and débridement) and 51.6+/-23.7, 53.7+/-23.7, and 51.4+/-23.2, respectively, at two years (P=0.64 and P=0.96, respectively). Furthermore, the 95 percent confidence intervals for the differences between the placebo group and the intervention groups exclude any clinically meaningful difference. CONCLUSIONS: In this controlled trial involving patients with osteoarthritis of the knee, the outcomes after arthroscopic lavage or arthroscopic débridement were no better than those after a placebo procedure.

Primary study

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Arthroscopic débridement of the knee for osteoarthritis in patients fifty years of age or older: utilization and outcomes in the Province of Ontario.

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Authors Wai EK , Kreder HJ , Williams JI
Journal The Journal of bone and joint surgery. American volume
Year 2002
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This article is included in 2 Broad syntheses Broad syntheses (2 references) 1 Systematic review Systematic reviews (1 reference)

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BACKGROUND: There is little available information regarding the effectiveness of arthroscopic knee débridement for the treatment of arthritis. The purpose of this study was to evaluate patterns of utilization of arthroscopic knee débridement and outcomes following that procedure for the treatment of degenerative arthritis in persons fifty years of age or older in the Province of Ontario. METHODS: All patients fifty years of age or older who underwent elective arthroscopic knee débridement for the treatment of degenerative arthritis between 1992 and 1996 were identified from administrative data sets. Surgical complications and subsequent knee replacements were noted. Population rates were compared across the sixteen District Health Council regions within Ontario. Outcomes were modeled as a function of patient age, gender, and comorbidity with use of multivariate regression analysis. RESULTS: We identified 14,391 eligible unilateral arthroscopic knee débridement procedures. There was a threefold difference in the population rate of arthroscopic débridement across geographic regions. Overall, 1330 (9.2%) of all patients required total knee arthroplasty within one year after the débridement. Of the 6212 patients with a minimum three-year follow-up, 1146 (18.4%) had undergone total knee replacement within three years following the débridement. Patients who were at least seventy years of age were 4.7 times more likely to have total knee arthroplasty within one year after the débridement than were those less than sixty years of age (19.0% compared with 4.0%; p < 0.05). Patients sixty years of age or older were more likely to have an early total knee replacement (within one year after the débridement) in District Health Council regions where the population rates of arthroscopic knee débridement were higher (p = 0.04). CONCLUSIONS: The higher rates of early total knee arthroplasty and the significant relationship between rates of early total knee arthroplasty and rates of utilization suggest that arthroscopic débridement for the treatment of osteoarthritis of the knee may be overutilized in elderly patients. Important clinical issues such as patient preference, risk perception, and functional outcome cannot be addressed just with the administrative data used for this study.

Primary study

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Visually-guided irrigation in patients with early knee osteoarthritis: a multicenter randomized, controlled trial.

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Journal Osteoarthritis and cartilage / OARS, Osteoarthritis Research Society
Year 2000
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This article is included in 2 Systematic reviews Systematic reviews (2 references) 1 Broad synthesis Broad syntheses (1 reference)

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OBJECTIVE: To determine if visually-guided arthroscopic irrigation is an effective therapeutic intervention in patients with early knee osteoarthritis. DESIGN: Ninety patients with knee osteoarthritis were randomized in a double-blind fashion to receive either arthroscopic irrigation with 3000 ml of saline (treatment group) or the minimal amount of irrigation (250 ml) required to perform arthroscopy (placebo group). The primary outcome variable was aggregate WOMAC score. RESULTS: The study did not demonstrate an effect of irrigation on arthritis severity as measured by aggregate WOMAC scores, the primary outcome variable; the mean change in aggregate WOMAC score at 12 months was 15.5 (95% CI 7.7, 23.4) for the full irrigation group compared to 8.9 (95% CI 4.9, 13.0) for the minimal irrigation group (P=0.10). Full irrigation did have a statistically significant effect on patients' self-reported pain as measured by the WOMAC pain subscale and by a visual analog scale (VAS) (the secondary outcome variables). Mean change in WOMAC pain scores decreased by 4.2 (95% CI -0.9, 9.4) for the full irrigation group compared with a mean decrease of 2.3 (95% CI -0.1, 4.7) in the minimal irrigation group (P=0.04). Mean VAS pain scores decreased by 1.47 (95% CI -1.2, 4.1) in the full irrigation group compared to a mean decrease of 0.12 (95% CI 0.0, 0.3) in the minimal irrigation group (P=0.02). A hypothesis-generating post-hoc analysis of the effect of positively birefrigent intraarticular crystals showed that patients with and without intraarticular crystals had statistically significant improvements in pain assessments and aggregate WOMAC scores at 12 months; patients with crystals had statistically greater improvements in pain. CONCLUSIONS: Visually-guided arthroscopic irrigation may be a useful therapeutic option for relief of pain in a subset of patients with knee OA, particularly in those who have occult intraarticular crystals.

Primary study

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Debridement arthroscopy. 10-year followup.

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Journal Clinical orthopaedics and related research
Year 1999
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This article is included in 2 Broad syntheses Broad syntheses (2 references) 2 Systematic reviews Systematic reviews (2 references)

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The treatment of osteoarthritis of the knee is a difficult problem. In the senior author's opinion, nonaggressive arthroscopic debridement of the knee is an effective procedure to relieve pain and restore function in patients with osteoarthritis of the knee. A subjective telephone interview of patients done 10 or more years after arthroscopic debridement evaluated the long term results of this treatment in patients with osteoarthritis of the knee. The patients all were candidates for total knee replacement who selected arthroscopy as a temporizing procedure. Of the 191 knees in patients undergoing arthroscopic debridement, 77 patients (91 knees) were contacted for followup. Sixty-seven percent of the 91 knees did not have total knee arthroplasty at an average of 13.2 years followup. The Tegner activity score averaged 3.5 and patient satisfaction averaged 8.6 on a 0 to 10 scale. Twenty-one patients (30 knees) or (33%) had total knee arthroplasty at an average of 6.7 years. Seven of these had total knee arthroplasty within 2 years of arthroscopic debridement. Six of these seven knees had Outerbridge Grade 4 articular cartilage changes and clinically significant meniscus tears. Seven of the 19 knees (37%) with Outerbridge Grade 4 changes in 80% of one knee compartment did not require total knee arthroplasty after greater than 10 year followup. The difficulties in long term followup in this patient population is evident, yet the number of patients who had a functional lifestyle after arthroscopic debridement was notable.

Primary study

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Articular debridement versus washout for degeneration of the medial femoral condyle. A five-year study.

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Authors Hubbard MJ
Journal The Journal of bone and joint surgery. British volume
Year 1996
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This article is included in 3 Systematic reviews Systematic reviews (3 references) 1 Broad synthesis Broad syntheses (1 reference)

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In a prospective randomised trial 76 knees with isolated degenerative changes in the medial femoral condyle of grades 3 or 4 were treated by either arthroscopic debridement (40) or washout (36). All knees were followed up for at least one year and 58 for five years. The mean follow-up time was 4.5 years in the debridement group and 4.3 years in the washout group. At one year 32 of the debridement group and five of the washout group were painfree and at five years 19 of a total of 32 survivors in the debridement group and three of the 26 in the washout group were also free from pain. The mean improvement in a modified Lysholm score was 28 for the debridement group at one year and 21 at five years. In the washout group it was only 5 at one year and 4 at five years. For knees with lesions of the medial femoral condyle of grades 3 or 4, arthroscopic debridement appears to be the treatment of choice with over half the patients free from pain after five years.