Arthroscopic débridement for osteoarthritis of the knee

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 > or = 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.     

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

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.     

Arthroscopic débridement of the knee for osteoarthrosis.

To evaluate outcome after arthroscopic débridement, the records of 171 patients with osteoarthrosis of the knee were reviewed. All patients were unresponsive to conservative management and were treated arthroscopically. Procedures included lavage, meniscectomy, chondrectomy, removal of free bodies and removal of limited osteophytes. Outcome assessment was retrospective, evaluating the need for further surgery, control of pain, improved function and patient satisfaction. Sixty-five percent of patients felt their symptoms were improved. There was excellent control of pain in 38% and improved function in 22%. Subsequent surgical procedures were required in 12% at an average follow-up of 25 months. No factors were identified that correlated with the outcome, including the extent of degenerative changes and of débridement and patient profile. Arthroscopic débridement is a temporizing procedure with good patient satisfaction. Marked, but unpredictable, improvement in symptoms is seen in one patient out of three.     

Arthrodiatasis for management of knee osteoarthritis

Osteoarthritic disease is the result of mechanical and biological events that destabilize the normal processes of degradation and synthesis of articular cartilage chondrocytes, extracellular matrix, and subchondral bone. Osteoarthritis of the knee can cause symptoms ranging from mild to disabling. Initial management of most patients should be nonoperative, but because of the progressive nature of the disease, many patients with osteoarthritis of the knee eventually benefit from operative treatment. Various procedures have been described for treatment of the osteoarthritic knee, ranging from arthroscopic lavage and debridement to total knee arthroplasty. The aim of this study was to evaluate the clinical results of distraction arthroplasty combined with arthroscopic lavage and drilling of cartilage defects for treatment of osteoarthritis of the knee. Nineteen patients (15 women and 4 men; age range, 39-65 years) were operated on. Pre- and postoperative findings were compared. A control group comprising 42 patients treated with only arthroscopic procedures was evaluated for comparison. Follow-up ranged from 3 to 5 years. Results were evaluated both clinically and radiologically postoperatively and throughout the follow-up period. Clinically, pain and walking capacity improved in most patients. Radiologically, joint space widening and improvement of the tibiofemoral angle was noted in nearly all patients.     

Primary osteoarthritis of the elbow: current treatment options

In the elbow, as in other joints, primary osteoarthritis is characterized by pain, stiffness, mechanical symptoms, and weakness. But primary osteoarthritis of the elbow is unique in that there is relative preservation of articular cartilage and maintenance of joint space, with hypertrophic osteophyte formation and capsular contracture. Medical treatment and physical therapy may be initiated in the early stages of the disease process. Surgical treatment options include arthroscopic osteocapsular débridement, open ulnohumeral arthroplasty, distraction interposition arthroplasty, and total elbow arthroplasty. The potential for instability and loosening following total elbow arthroplasty in the setting of primary osteoarthritis limits the clinical application of this procedure. This patient population is generally younger than that recommended for total elbow arthroplasty, and their higher functional demands have limited the long-term success of this treatment option. The improvement in arthroscopic débridement techniques is perhaps the greatest advancement in the treatment of osteoarthritis of the elbow in recent years.     

Outcome of Arthroscopic Débridement is Worse for Patients With Glenohumeral Arthritis of Both Sides of the Joint

Glenohumeral arthritis in the young patient presents a difficult problem with potentially devastating sequelae. Reports in the literature suggest a role for arthroscopic treatment in patients with symptomatic degenerative joint disease of the shoulder. However, no published study directly compares patients with unipolar versus bipolar cartilage lesions. We retrospectively reviewed 19 patients (20 shoulders) younger than 55 years with Outerbridge Grade 2-4 articular cartilage changes who underwent arthroscopic glenohumeral débridements. We obtained WOOS, SF-12, SANE and the American Shoulder and Elbow Society scores at last followup. The minimum follow up time was 12 months (average, 20 months; range, 12-33 months). Three patients progressed to shoulder arthroplasty. All but three patients reported their shoulder function at 60% or better based on the SANE score. The grade of the lesion did not influence outcome scores, but patients with unipolar lesions had higher outcome scores than patients with bipolar lesions. We believe arthroscopic glenohumeral débridement in young patients with shoulder arthritis can be an effective tool in managing symptoms and delaying the need for invasive resurfacing or prosthetic replacement.     

Konservative Therapie der Gonarthrose

Osteoarthritis of the knee is a degenerative joint disease with progressive degradation of articular cartilage and subchondral bone. Symptoms may include joint pain, tenderness, stiffness, locking and joint effusion depending on the stage of the disease. In an effort to delay major surgery, patients with knee osteoarthritis are offered a variety of nonsurgical modalities, such as weight loss, exercise, physiotherapy, bracing, orthoses, nonsteroidal anti-inflammatory drugs (NSAIDs) and intra-articular viscosupplementation or corticosteroid injection. In general, the goals of these therapeutic options are to decrease pain and improve function. Some of these modalities may also have a disease-modifying effect by altering the mechanical environment of the knee. Chondroprotective substances, such as lucosamine, chondroitin sulphate and hyaluronic acid are safe and provide short-term symptomatic relief while the therapeutic effects remain uncertain.     

Arthroscopic lavage of osteoarthritic knees.

A strong clinical impression exists that joint lavage often provides symptomatic relief for painful osteoarthritis of the knee. A controlled trial was conducted to test this hypothesis. A group of 37 painful osteoarthritic knees were treated by arthroscopic lavage and physiotherapy, and a control group of 24 knees were treated by physiotherapy alone. There was better relief of pain in the lavage group, and the effect was still present at one year. An improvement in the signs of inflammation lasted for about three months. Pain was relieved more effectively in patients with slight radiographic changes than in those with advanced changes. Our results confirm the effectiveness of joint lavage in the management of painful osteoarthritis of the knee.     

Arthroscopic capsular release and debridement of painful shoulder osteoarthritis can improve symptoms and delay arthroplasty: a mid- to long-term follow-up study

HypothesisIn patients with symptomatic osteoarthritis of the shoulder, arthroscopic débridement, and capsular release will provide relief of symptoms and improvement in function for a minimum of 2 years.MethodsProspective outcome data was collected from patients who underwent arthroscopic débridement and capsular release for painful idiopathic glenohumeral arthritis from 2005 to 2013 by one surgeon. The primary outcome was conversion to shoulder arthroplasty. UCLA and Simple Shoulder Test scores were also collected by phone or mailing. Preoperative radiographs were evaluated for Samilson and Prieto classification and Walch glenoid classification.ResultsThirty-three of 40 patients (82.5%) who met inclusion criteria with an average time since surgery of 6.4 years (range, 2-10 years) were reached for final follow-up. Eight of 33 respondents (24.2%) had conversion to arthroplasty within the study period at an average 1.75 ± 2.37 years (range, 0.5-7 years) postoperatively. Nine patients (36%) reported no pain at the time of survey. Of patients who reported current pain (16/25, 64%), 7 (43.7%) had improved pain since surgery. For patients with preoperative UCLA scores, scores were significantly higher at mid-term (P = .003) and long-term (P =0.017) follow-up. Patients who were less than 8 years since surgery had significantly higher SST (2-4 years, P =0.004; 5-7 years, P = .024) and UCLA (2-4 years, P = .004; 5-7 years, P = .011) scores than those who were 8-10 years since surgery. There were no significant differences in preoperative radiographic classifications and outcome.ConclusionArthroscopic débridement with capsular release in certain patients with osteoarthritis of the shoulder can provide long-term pain reduction, increased function, and can delay shoulder arthroplasty.Level of evidenceLevel IV; Prognostic Study; Case Series     

Infected total knee arthroplasty treated by arthroscopic irrigation and débridement

Sixteen patients with infected total knee arthroplasties (4 postoperative and 12 late hematogenous) were treated by arthroscopic irrigation and débridement. All patients had < or = 7 days of knee symptoms, and there were no radiographic signs of osteitis or prosthetic loosening. Six of the 16 original total knee arthroplasties (38%) did not need prosthesis removal at a mean follow-up of 64 months (range, 36-151 months). Ten other knees were treated with irrigation, débridement, and hardware removal within 7 weeks of the latest procedure used to try to retain components. Two (13%) of these cases ultimately required an arthrodesis for persistent infection. Although we still believe that this method is preferable to resorting immediately to implant removal for acute infections, arthroscopic débridement was less efficacious for most situations when compared with open treatment. We would use arthroscopic irrigation and débridement only under selected circumstances (medically unstable or anticoagulated patients).     

Degenerative meniscus: Pathogenesis,diagnosis, and treatment options

The symptomatic degenerative meniscus continues to be a source of discomfort for a significant number of patients. With vascular penetration of less than one-third of the adult meniscus, healing potential in the setting of chronic degeneration remains low. Continued hoop and shear stresses upon the degenerative meniscus results in gross failure, often in the form of complex tears in the posterior horn and midbody. Patient history and physical examination are critical to determine the true source of pain, particularly with the significant incidence of simultaneous articular pathology. Joint line tenderness, a positive McMurray test, and mechanical catching or locking can be highly suggestive of a meniscal source of knee pain and dysfunction. Radiographs and magnetic resonance imaging are frequently utilized to examine for osteoarthritis and to verify the presence of meniscal tears, in addition to ruling out other sources of pain. Non-operative therapy focused on non-steroidal anti-inflammatory drugs and physical therapy may be able to provide pain relief as well as improve mechanical function of the knee joint. For patients refractory to conservative therapy, arthroscopic partial meniscectomy can provide short-term gains regarding pain relief, especially when combined with an effective, regular physiotherapy program. Patients with clear mechanical symptoms and meniscal pathology may benefit from arthroscopic partial meniscectomy, but surgery is not a guaranteed success, especially with concomitant articular pathology. Ultimately, the long-term outcomes of either treatment arm provide similar results for most patients. Further study is needed regarding the short and long-term outcomes regarding conservative and surgical therapy, with a particular focus on the economic impact of treatment as well.     

Arthroscopic management of the degenerative knee

Out of a total 551 arthroscopic procedures for degenerative arthritis of the knee, 441 were studied at 2-8 years following their procedure. Sixty-eight percent of patients had at least 2 years or more relief of pain and symptoms. Fifty-three percent were still good at follow-up of 4.1 years. The best results were obtained after resection of an unstable flap tear of a meniscus in association with mild degenerative arthritis. The worst results were obtained in patients with bicondylar disease and in the presence of chondrocalcinosis. The results were much better in the normally aligned knee; the valgus knee did worst. Repeated arthroscopic procedures have a much lower success rate.     

Editorial Commentary: Degenerative Meniscal Tear: Sojourn to the Oracle

Degenerative meniscal tears are prevalent and give rise to more than 400,000 arthroscopic partial meniscectomies annually in the United States. These lesions often occur in the setting of knee osteoarthritis and are generally regarded as a component of the tissue damage (to cartilage, meniscus, bone, synovium among others) that comprises osteoarthritis. A wide array of clinicians, ranging from orthopaedic surgeons to general practitioners, regularly encounter symptomatic degenerative meniscal tears, especially among patients with knee osteoarthritis. Clinical evidence suggests that initial treatment for these injuries should be nonoperative, with arthroscopic partial meniscectomy reserved for those whose pain persists despite physical therapy.     

Meniscal transplantation

The aims of a meniscal replacement are: 1) to reduce the pain experienced by some patients following meniscus resection; 2) to prevent the degenerative changes of cartilage and the changes in subchondral bone following meniscus resection; 3) to avoid or reduce the risk of osteoarthritis following meniscus resection; 4) to restore optimally the mechanical properties of the knee joint after meniscal resection. The results of meniscus transplantation have been studied in animals. There is no proof from these experiments that replacement of a meniscus can reduce the risk of arthritis, but there are indications that it can decrease the development of cartilage degeneration. In humans, the results of meniscus transplantation have been reported in several series of patients, operated with different techniques. There are no controlled studies of meniscus replacement in humans. In case of meniscal allograft implantation surgery should be minimally invasive, not sacrificing the original meniscal insertion points. It appears preferable to use an open technique in medial transplantation, whereas the arthroscopic approach appears to allow for easier lateral implantation.     

Management of loose osteochondritis dissecans in an adolescent

Osteochondritis dissecans (OCD) of the knee joint affects subchondral bone first, and then it involves the articular cartilage. It can cause pain, effusion and loose body formation. Nonoperative treatment is for the stable lesion, but if the lesion is unstable and symptomatic, then operative management is needed. Short term goal of the treatment is pain relief, and the long-term goal is the prevention of early arthritis. Surgical treatment includes removal of loose body, microfractures, osteochondral autograft and allograft transplantation, autologous chondrocyte implantation (ACI), arthroscopic removal of the loose body and internal fixation of the fragment using k wire or screw. We successfully managed an adolescent with a loose OCD fragment with an arthroscopic evaluation, removal of the loose body and refixation of the loose fragment to the parent location, using three bio screws.     

Joint débridement--a complement to high tibial osteotomy in the treatment of degenerative arthritis of the knee

The management of unicompartmental osteoarthritis of the knee by high tibial osteotomy is enhanced by an associated joint débridement. A review of 120 patients who underwent the combined procedure, with follow-up to thirteen years, indicated that good or satisfactory results may be achieved in 82 per cent and that such results may be maintained over a prolonged period of review. This paper summarizes a long-term review of a series of one of us (D. L. M.), who since 1961 has practiced the combined procedure of tibial osteotomy and open joint débridement. The patient group was reviewed by him one year following surgery and then independently by the second author (R. P. W) in 1974, when 105 of the original 120 patients were available for detailed follow-up. Controversy surrounds the role of débridement when associated with osteotomy. This paper discusses both the rationale for and the results of combining these procedures. The over-all results confirm that these procedures are indeed complementary.     

Synovial entrapment: a complication of posterior stabilized total knee arthroplasty

BACKGROUND: We observed a complication of posterior stabilized total knee arthroplasty involving hypertrophy of tissue proximal to the patella associated with pain during active knee extension from 90 degrees of flexion. The purpose of this paper was to describe synovial entrapment and to determine if design features of the prosthesis predispose patients to the complication. METHODS: Between April 1990 and June 1999, we performed 459 consecutive posterior stabilized primary total knee arthroplasties using three prosthetic designs with different femoral intercondylar geometries. We identified twenty-six patients (twenty-seven knees) in whom arthroscopic débridement of the knee or open arthrotomy with débridement of the knee had been subsequently performed because of a diagnosis of synovial entrapment. We reviewed the records of these patients to identify the knee components that had been used and the symptoms and conditions that necessitated additional treatment. RESULTS: Symptoms (grating, crepitation, and pain with active knee extension from 90 degrees) necessitating subsequent débridement occurred in 13.5% (nineteen) of 141 knees treated with the Anatomic Modular Knee-Congruency implant, 3.8% (eight) of 212 treated with the Anatomic Modular Knee-Posterior Stabilized implant, and none of the 106 treated with the Press Fit Condylar Sigma-Posterior Stabilized implant. All patients had difficulty rising from a chair and climbing stairs; however, none had symptoms when standing or walking. No patient had a patellar clunk. The symptoms occurred at a mean of seven months after the arthroplasty in the patients with an Anatomic Modular Knee-Congruency implant and at a mean of twenty months after the arthroplasty in those with an Anatomic Modular Knee-Posterior Stabilized implant. Débridement of the frond-like hypertrophic synovial tissue at the distal aspect of the quadriceps tendon alleviated symptoms in all patients. No nodules were identified during the arthroscopy. CONCLUSIONS: Synovial entrapment is characterized by hypertrophic synovial tissue at the superior pole of the patella. Use of a posterior stabilized femoral component with a proximally positioned or wide femoral box is more likely to result in this complication.     

Arthroscopic management of septic arthritis of the shoulder joint

BACKGROUND: Nineteen patients with septic arthritis of the glenohumeral joint were treated with a combination of arthroscopic irrigation and débridement and systemic antibiotics according to bacterial sensitivity. We retrospectively reviewed the series to determine the efficacy and safety of this treatment. METHODS: There were seventeen men and two women, with a mean age of fifty-nine years. Underlying medical disease was present in thirteen patients, with six of them having diabetes. The average duration of symptoms prior to the arthroscopic lavage was three weeks. Fifteen patients had had local injections into the shoulder joint. The arthroscopic staging of the infection was based on the modified criteria of G?chter. The functional outcome was evaluated with use of the UCLA scoring system. RESULTS: As determined at arthroscopy, one infection was classified as stage I; seven, as stage II; nine, as stage III; and two, as stage IV. Staphylococcus was the most common organism identified. The infection was eradicated completely with a single arthroscopic procedure in fourteen patients. The mean UCLA score at the time of the last follow-up was 26 points, with a mean score of 23.7 points for the eleven patients with a rotator cuff tear and 29 points for the eight with an intact rotator cuff. Patients who had had symptoms for no more than two weeks prior to the arthroscopic lavage had better results than those who had had symptoms for longer than two weeks. CONCLUSIONS: Arthroscopic débridement for the treatment of septic arthritis of the shoulder is safe and efficient, particularly in the early stages of the disease. Underlying medical diseases such as diabetes, prior injections, or a preexisting rotator cuff tear were seen in a high proportion of these patients.     

Arthroskopische Operationen im Handgelenk

The indication for wrist arthroscopy is established on the basis of clinical examination and X-rays of the wrist. Cartilage, ligament and triangular fibrocartilage complex (TFCC) lesions can be diagnosed and, to a certain extent, treated arthroscopically. The most important ligament rupture concerns the scapholunate intercarpal ligament (SLIL). Partial tears can be débrided arthroscopically. In complete ruptures we prefer open reduction and ligament reconstruction. In osteoarthritis wrist arthroscopy serves in the planning for further open surgery. Occasionally, free osteochondral fragments can be removed. TFCC lesions are classified according to their location if traumatic in origin (1A-D), or according to their severity (2A-E) if degenerative in origin. Central TFCC tears are typically located close to the sigmoid notch of the radius and are either traumatic (1A) or degenerative in origin (2C+), the latter being associated with ulno-dorsal cartilage damage to the lunate cartilage. Central TFCC lesions can be treated by arthroscopic débridement using small joint punches or a bipolar high frequency system. Ulnar TFCC avulsions (1B) can be refixed arthroscopically.