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.
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.
Treinta y ocho pacientes con osteoartritis sintomática de rodilla sin síntomas mecánicos fueron asignados al azar después de consentimiento informado para recibir un curso de inyecciones intra-articulares Hyalgan o un lavado artroscópico. Los pacientes fueron evaluados prospectivamente antes de la intervención, 6 semanas, 3 meses, 6 meses y 1 año con un 10 cm de la escala visual analógica de dolor, la puntuación de la función de la Knee Society y el índice de Lequesne. No hubo diferencias significativas entre los dos grupos de 6 semanas, 3 meses, 6 meses o 1 año. El uso de inyecciones intra-articulares Hyalgan en pacientes con osteoartritis de la rodilla sin síntomas mecánicos ofrece resultados comparables con el lavado artroscópico. Hyalgan es una alternativa a la artroscopia en este grupo de pacientes. Se necesitan más estudios para confirmar estos resultados y mejorar la selección de los pacientes.
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.
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.
ANTECEDENTES: Muchos pacientes reportan alivio de los síntomas después de someterse a una artroscopia de la rodilla para la osteoartritis, pero no está claro cómo el procedimiento logra este resultado. Hemos llevado a cabo un estudio aleatorizado, controlado con placebo para evaluar la eficacia de la artroscopia para la osteoartritis de la rodilla. MÉTODOS: Un total de 180 pacientes con osteoartritis de la rodilla fueron asignados aleatoriamente para recibir desbridamiento artroscópico, lavado artroscópico, o una cirugía placebo. Los pacientes del grupo placebo recibieron incisiones en la piel y se les realizó un desbridamiento simulado sin inserción del artroscopio. Los pacientes y los evaluadores de resultado estaban cegados a la asignación al grupo de tratamiento. Los resultados se evaluaron en varios puntos durante un período de 24 meses con el uso de cinco auto-reporte de resultados - tres en las escalas de dolor y dos en las escalas de la función - y una prueba objetiva de caminar y subir escaleras. Un total de 165 pacientes completaron el ensayo. RESULTADOS: En ningún momento ninguno de los grupos de intervención reportan menos dolor o mejor función que el grupo placebo. Por ejemplo, la media (+ /-SD) las puntuaciones en la Escala de Dolor de la rodilla-específica (rango, 0 a 100, con puntuaciones más altas indican un dolor más severo) fueron similares en el grupo placebo, el lavado, y los grupos de desbridamiento: 48,9 + / -21,9 , el 54,8 + / -19,8 y 51,7 + / -22,4, respectivamente, en un año (p = 0,14 para la comparación entre el placebo y el lavado, p = 0,51 para la comparación entre el placebo y el desbridamiento) y 51,6 + / -23,7, 53,7 + / -23,7 y 51,4 + / -23,2, respectivamente, a dos años (P = 0,64 y P = 0,96, respectivamente). Por otra parte, los 95 intervalos de confianza para las diferencias entre el grupo placebo y los grupos de intervención excluye ninguna diferencia clínicamente significativa. CONCLUSIONES: En este ensayo controlado realizado en pacientes con osteoartritis de la rodilla, los resultados después de un lavado artroscópico o el desbridamiento artroscópico no eran mejores que los que después de un procedimiento placebo.
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.
OBJETIVO: Determinar si el riego artroscópica visualmente guiada es una intervención terapéutica eficaz en pacientes con osteoartritis de rodilla temprano. DISEÑO: Noventa pacientes con osteoartritis de rodilla fueron asignados al azar en un diseño doble ciego para recibir el riego artroscópica con 3000 ml de solución salina (grupo de tratamiento) o la cantidad mínima de riego (250 ml) necesario para realizar la artroscopia (grupo placebo). La variable de resultado primaria fue la puntuación de WOMAC agregado. RESULTADOS: El estudio no demostró un efecto del riego sobre la gravedad de la artritis según lo medido por agregados WOMAC, la variable de resultado primaria, la media del cambio en el agregado WOMAC a los 12 meses fue de 15,5 (IC 95% 7,7, 23,4) para el riego completo grupo en comparación con 8,9 (IC 95% 4,9, 13,0) para el grupo de irrigación mínima (P = 0,10). De riego completa tuvo un efecto estadísticamente significativo sobre los pacientes auto-reporte de dolor, medida por el dolor WOMAC subescala y por una escala visual analógica (EVA) (las variables de resultado secundarias). El cambio medio en las puntuaciones de dolor WOMAC disminuyó en un 4,2 (IC 95%: -0,9, 9,4) para el grupo de riego completo en comparación con una disminución media de 2,3 (IC 95%: -0,1, 4,7) en el grupo de irrigación mínima (P = 0,04). Media de las puntuaciones VAS de dolor disminuyó 1,47 (IC 95%: -1,2 a 4,1) en el grupo de riego completo en comparación con una disminución media de 0,12 (IC 95% 0,0, 0,3) en el grupo de irrigación mínima (P = 0,02). Una hipótesis de generación de post-hoc de análisis del efecto de los cristales intraarticulares positivamente birefrigent mostró que los pacientes con y sin cristales intraarticulares tenido mejorías estadísticamente significativas en las evaluaciones del dolor y el agregado WOMAC a los 12 meses, los pacientes con cristales tuvieron una mejoría estadísticamente mayores en el dolor. CONCLUSIONES: el riego artroscópica visualmente guiado puede ser una opción terapéutica útil para el alivio del dolor en un subgrupo de pacientes con OA de rodilla, sobre todo en aquellos que tienen cristales ocultos intraarticulares.
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.
En un ensayo prospectivo y aleatorizado 76 rodillas con aisladas cambios degenerativos en el cóndilo femoral interno de los grados 3 o 4 fueron tratados mediante desbridamiento artroscópico (40) o lavado (36). Todas las rodillas fueron seguidos durante al menos un año y 58 durante cinco años. La media de seguimiento fue de 4,5 años en el grupo de desbridamiento y 4.3 años en el grupo de lavado. En un año 32 del grupo de desbridamiento y cinco del grupo de lavado fueron sin dolor y en cinco años 19 de un total de 32 supervivientes en el grupo de desbridamiento y tres de los 26 en el grupo de lavado también estaba libre de dolor. La mejora media en la puntuación modificada de Lysholm fue de 28 para el grupo de desbridamiento de un año y 21 en cinco años. En el grupo de lavado fue sólo 5 menos un año y 4 menos cinco años. Para las rodillas con lesiones del cóndilo femoral medial de los grados 3 o 4, el desbridamiento artroscópico parece ser el tratamiento de elección con más de la mitad de los pacientes libres de dolor después de cinco años.
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
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8
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10), poor in 14 (L: 7
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4
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3). Arthroscopic debridement of the osteoarthritic knee under local anaesthesia appears as an efficient, simple, safe, painless and cost-effective method of treatment.
