Question: In patients with inflammatory arthritis, what is the
relative effectiveness of arthroscopic lavage plus corticosteroids,
arthroscopic lavage alone, and joint aspiration plus corticosteroids?
Design: Randomized (allocation concealed), partially blinded
(outcome assessors), placebo-controlled trial with 9-month follow-up.
Setting: A university medical center in The Netherlands.
Patients: 78 patients who were =18 years of age (mean age 54 y,
55% women) and had arthritis of the knee not due to gout, osteoarthritis, or
infection. Exclusion criteria were hemorrhagic disease, oral prednisone >10
mg/day, recent (<6 weeks) change of disease-modifying antirheumatic drugs,
recent joint infection, or hypersensitivity to methylprednisolone or local
anesthetics. Follow-up was 96%.
Intervention: 26 patients were allocated to arthroscopic lavage plus
corticosteroids, 26 to arthroscopic lavage plus placebo, and 26 to joint
aspiration plus corticosteroids (methylprednisolone, 80 mg in 2 mL). For all
interventions, synovial fluid was maximally aspirated from the suprapatellar
pouch, 30 mL of lidocaine 0.5% was injected intra-articularly through the
aspiration needle, and the skin and joint capsule was additionally infiltrated
with 10 mL of lidocaine 1%. For arthroscopic lavage, the skin inferolateral to
the patella was also injected with 10 mL of lidocaine 1%. Two trocars were
placed into the joint cavity through 2 skin incisions: 1 inferior for the
camera and saline solution, and 1 superior for drainage of the irrigation
fluid and use of biopsy forceps. 1000 mL of saline solution was flushed
through the joint. During lavage, 15 to 20 synovial biopsy samples were
obtained with 2.0-mm forceps. Bupivacaine (30 mg in 6 mL) plus corticosteroids
(methylprednisolone, 80 mg in 2 mL) for 1 group and bupivacaine alone
("placebo") for the other was injected through the inferior
trocar. For joint aspiration, a single skin incision was made and 1 trocar
placed. After synovial biopsy samples (15 to 20) were obtained, a mixture of
methylprednisolone (80 mg in 2 mL) and bupivacaine (30 mg in 6 mL) was
injected into the joint.
Main outcome measures: Event-free survival (time from treatment
until local re-treatment because of recurrence or persistence of arthritis of
the knee).
Main results: The median event-free survival time was 9.6 months
after arthroscopic lavage plus corticosteroids, 3.0 months after joint
aspiration plus corticosteroids, and 1.0 month after arthroscopic lavage plus
placebo. Patients in the arthroscopic lavage plus corticosteroids group had a
lower risk of arthritis recurrence than patients in the other 2 groups
(Table). Patients in the joint aspiration group had a lower risk of arthritis
recurrence than patients in the arthroscopic lavage plus placebo group
(Table).
Conclusion: In patients with inflammatory arthritis of the knee,
arthroscopic lavage plus corticosteroids was more effective than arthroscopic
lavage plus placebo or joint aspiration plus corticosteroids.
Some important features of this article should be emphasized:
First, this is a study of patients with inflammatory arthritis (e.g.,
rheumatoid arthritis). Second, arthroscopy was performed in an office setting
with the patient under local anesthesia and with use of 2 ports—one for
a camera and inflow, and another for synovial biopsy and outflow. The
articular cartilage and menisci were not evaluated or treated during the
procedure. Thus, I am not sure how applicable this study is to the average
orthopaedist who performs arthroscopy. Third, the outcome measures (e.g.,
event-free survival until local re-treatment) did not include health-status
measures such as the Western Ontario and McMaster Universities Osteoarthritis
Index (WOMAC) or the Arthritis Impact-Measurement Scales (AIMS).
Furthermore, although blinding of the patients and physicians was possible
for the 2 groups that received arthroscopic lavage, the aspiration group had
only 1 port made, which means that the patients and physician-assessors of
this group were not blinded to treatment. This lack of blinding could explain
the inferior results of the aspiration-plus-corticosteroid group compared with
those of the arthroscopy-plus-corticosteroid group.
In conclusion, I believe that this study does show the benefit of the use
of intra-articular corticosteroids in patients with inflammatory arthritis who
are having arthroscopic surgery; however, I remain unconvinced that joint
lavage in these patients is beneficial. The practical implication for an
orthopaedist who is performing an arthroscopy on a patient with inflammatory
arthritis is to inject corticosteroids at the end of the procedure.