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Scientific Articles   |    
Arthroscopic Débridement for Osteoarthritis of the Knee
Roy K. Aaron, MD1; Adam H. Skolnick, MD2; Steven E. Reinert, MS3; Deborah McK. Ciombor, PhD4
1 Department of Orthopaedics, Brown Medical School, 100 Butler Drive, Providence, RI 02906. E-mail address: roy_aaron@brown.edu
2 Department of Internal Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215
3 Department of Medical Computing, Rhode Island Hospital, The Coro Building, 167 Point Street, Suite 245, Providence, RI 02903
4 Orthopaedic Research Laboratory, Department of Orthopaedics, Brown Medical School, Coro West 4th Floor, One Hoppin Street, Providence, RI 02903
View Disclosures and Other Information
In support of their research for or preparation of this manuscript, one or more of the authors received grants or outside funding from the National Institutes of Health (grant AR 02128). None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at the Department of Orthopaedics, Brown Medical School, Providence, Rhode Island

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2006 May 01;88(5):936-943. doi: 10.2106/JBJS.D.02671
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Abstract

Background: The role of arthroscopic débridement in the treatment of osteoarthritis of the knee remains to be defined, and few clinical and radiographic characteristics have been quantitatively associated with the outcome. The hypothesis of this study was that the outcome of arthroscopic débridement for osteoarthritis of the knee is associated with preoperative clinical and radiographic features and intraoperative characteristics and that there are subsets of patients who are more and less likely to respond favorably to the treatment.

Methods: We performed a cross-sectional study of a consecutive cohort of 122 patients who underwent arthroscopic débridement for the treatment of osteoarthritis of the knee that had been unresponsive to anti-inflammatory therapy. One hundred and ten patients were followed for a mean of thirty-four months. Pain was assessed with the pain domain of the Knee Society scoring system. Radiographs were scored with the Kellgren-Lawrence method, and limb alignment and the widths of the medial and lateral joint spaces were measured. The severity of cartilage lesions was scored intraoperatively with a modified Noyes grading system. Specific methods of data collection and analysis were incorporated to minimize bias.

Results: Fifty-two (90%) of fifty-eight knees with mild arthritis, normal alignment, and a joint space width of =3 mm were improved after arthroscopic débridement. Conversely, only five (25%) of twenty knees with severe arthritis, limb malalignment, and a joint space width of <2 mm had substantial relief of symptoms. Of seventy-two patients who had improvement, forty-four (61%) had it within six months after the arthroscopy. The severity of the lesion was highly predictive of the clinical outcome both in patients with mild arthritis and in those with severe arthritis.

Conclusions: The severity of the arthritis, as assessed preoperatively with radiography and intraoperatively by rating the severity of cartilage lesions, influences the clinical outcome of arthroscopic débridement of an osteoarthritic knee. Knees with severe arthritis fare poorly, whereas those with mild arthritis fare well. We could not predict the outcome for knees with moderate arthritis. We believe that these observations are relevant for establishing indications for arthroscopy in patients with osteoarthritis of the knee and may be useful for designing studies with a more rigorous experimental design.

Level of Evidence: Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Munier Hossain
    Posted on May 11, 2006
    Arthroscopic Intervention for Osteoarthritis of the Knee
    Ysbyty Gwynedd, Penrhosgarnedd Road, Bangor LL57 2 PW , UK.

    EDITOR'S NOTE: The corresponding author was invited to respond to this letter but to date has not done so.

    To the Editor:

    I congratulate Aaron and co-authors for their endeavour to establish a scientific rationale for arthroscopic debridement as a treatment for osteoarthritis (OA) of the knee (1). However, I have a few questions to ask of the authors.

    They included patients in whom “treatment with oral anti-inflammatory medication had failed”, but we are not informed about their criteria for "failure". Quite often patients have not had a proper trial of anti-inflammatory medications (NSAID) before presenting to the orthopaedic surgeon. For how long did these patients take NSAIDS? Were there other reason(s) for this failure?(2) If so, were alternative medication(s) tried?

    It appears from figure 1 that patients had to wait at least six months after arthroscopic debridement before any substantial improvement in symptoms were noted, and they continued to improve for up to 2.5 years afterwards. It is doubtful that this time frame of symptomatic improvement can be attributed to the index procedure. The natural history of osteoarthritis is unpredictable. Symptoms may progess,remain static, or even improve temporarily (3). We also do not know how many patients were taking medication or other treatments in the post operative follow up period.

    It can be argued that the eight patients with crystal deposition are likely to be patients with inflammatory arthropathy and their inclusion introduces heterogeneity into the study population.

    I do not think we can conclude from this study that patients with mechanical symptoms fare poorly after arthroscopy. The series is not large enough to test this assertion. Sixty-two patients had mechanical symptoms pre- operatively. We are told that as a whole there was post-operative improvement in pain but we do not know how many of these patients had improvement of mechanical symptoms. There were fifty-eight knees with grade 2 OA and sixty-two patients with mechanical symptoms. We do not know if this sub-group of grade 2 OA had symptoms primarily attributable to OA or meniscal tear.

    Finally, it is probably premature to suggest that arthroscopic debridement is the preferred treatment for patients with minimal OA of the knee. There are various non-surgical treatment options available that might be equally, if not more effective at this stage and many of them have passed rigorous research standards (3,4).

    References:

    1. Aaron RK, Skolnick AH, Reinert SE, Ciombor DM. Arthroscopic Débridement for Osteoarthritis of the Knee .J Bone Joint Surg Am. 2006; 88:936-943.

    2. Hunter DJ, Felson DT. Osteoarthritis. BMJ 2006; 332: 639-42.

    3. Buckwalter JA, Stanish WD, Rosier RN, Schenck RC, Dennis DA, Coutts RD. The increasing need for nonoperative treatment of patients with osteoarthritis. Clin Orthop Relat Res 2001; 385: 36-45.

    4. Bjordal JM, Lopes-Martins RAB, Bogen B, Johnson MI. Physical treatments have valuable role in osteoarthritis. BMJ, 2006; 332:853.

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