Archive for April 23rd, 2008

There have been, in different forms, some prospective studies examining the effect of arthroscopy in osteoarthritis, the knee. In 1991 a couple of groups in Nottingham took advantage – there were different referral patterns in the two orthopedists in town. Some went and always got arthroscopy and some went and always got physiotherapy. So over a couple of years looked at … they ended up with 39 patients undergoing lavage and 24 undergoing physiotherapy and at the end of 6 and 12 months of follow-up there was a trend. And it reached some significance that the lavage people had a bit more pain relief. Cialis professional at Canadian pharmacy. A smaller study looking at patients who underwent arthroscopic debridement versus arthroscopic lavage actually found not only no difference between the two, but no benefit really in either group after a short term follow-up. A larger, very ambitious study done years ago in Chicago by Bing Chang and Bill Arnold and others looked prospectively as arthroscopic debridement versus title irrigation; title irrigation being a wash out of the knee with a liter of fluid put through a large port cannula. After 12 months of follow-up in their study, which comprised 18 in the surgery group and 14 in the titled irrigation group, there was really no difference between the two in all various outcome measures.
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So that was perhaps countered a bit by this study from Hubbard, although his group was a different type and his procedure was different. These are people with normal x-rays on whom he saw some cartilage disruption and then took his basket forceps and chopped out the loose cartilage. This is different from the usual arthroscopic debridement in osteoarthritis when there is a quite a bit of work on things like disrupted menisci. If you had a disrupted meniscus in his study, you weren’t included in the final analysis. Over the course of about five years – which was his follow-up – there was a trend that the folks who got this chopped out bit with their otherwise normal knees did a little bit better. I’m not sure that supports the use of arthroscopy in the kind of patients we consider to have osteoarthritis.
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Finally, a small study that was listed as a pilot study to be continued – unfortunately, we haven’t seen data since ’96 – the Houston VA looked at groups – 10 patients total. Three underwent arthroscopic debridement, 2 underwent arthroscopic lavage and 5 were taken to the operating room, put to sleep and at the other end, after their leg was draped, had the three arthroscopic portals made not quite to the capsule and noises made as if arthroscopic surgery was being done. Well, at the time of follow-up there were no major differences between any of the groups regardless of what was done. So, I’m not sure what this is telling us about arthroscopy. I think overall, what it is telling us is that if there anything about arthroscopy that may help it may be the arthroscopic lavage. Now this is an observation that goes back 60-70 years. You know that in osteoarthritic synovial fluids there is junk there that the lab doesn’t tell you about. But these are small pieces of cartilage that have come loose from the joint. This is what happens if you centrifuge that down and stain it. These are hyalin cartilage that has come loose from the degenerating joint surface. Those probably helped to promote some of the focal inflammation that may cause some pain in knee osteoarthritis. Removing them one way or another can relieve pain in a number of different postulated ways. Removing those particles may help limit the synovitis that they produce. You also may be removing crystals. There are some temporary effects of lavage that may help, like pooling and dilution of degradative compounds. Not many OA joints have adhesions, or fibrosis but you do stretch the joint during lavage. And of course -especially with that Houston VA study – we can’t discount a placebo effect of doing a somewhat major procedure on someone with knee complaints. Generic cialis 20 mg

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I want to show you a quick example here of doing a quadriceps setting exercise but doing it in the functional position, so the person is standing and they are getting the motor learning they need to contract the quadriceps at the proper time and gait. We did our best, we did all we could, however after four weeks of doing his exercises there was still pain and swelling, minimal strength gains and no change in his sense of stability. So I referred him back to my favorite rheumatologist.
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Disappointed patient post arthroscopy is something else going on. Unfortunately it is not an uncommon reason for an occasional visit to a rheumatologist. This 33-year-old man does have some issues. Certainly there are other more common causes of post arthroscopy persistent troubles. More serious ones at least, concern about infection, concern about bleeding. We are not going to address those here. We are going to look and try to answer the question of what else might be going on. One of the first thing to do is to review the arthroscopic data if available. The report on this man was that what he actually had was a partial medial meniscectomy of his posterior horn, along with chondroplasty and there was mention by the orthopedist of focal grade III changes in the medial tibiofemoral compartment. This means disruption of cartilage almost down to bone, quite fibrillated but no exposed bone. And the physical findings were indicating that he had arthritis in his knee, had a slight warmth, some wall effusion, medial joint line tenderness and medial tibiofemoral crepitus. Although his plain films didn’t show osteoarthritis, taking him into the most sensitive x-ray view, that is a skiers view where they bend about 45 degrees bearing weight, showed narrowing of the medial joint space. So what this man had is not this. This might have worked out better after an arthroscopy. This is a traumatic flat tear of the medial meniscus and during arthroscopy that is resected to a stable edge and they usually do quite a bit better. His was probably more like this. This is degenerative tear of the posterior horn of the medial meniscus, a very common finding in a painful osteoarthritic knee. Whether it causes pain or not, whether or not it should be removed, is still rather controversial. Although the trend is towards leaving all of this alone. There is also disruption here at the cartilage on either side and what this is, is this is probably the first thing to degenerate in response to altered biomechanics that eventually produce osteoarthritis.
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The use of arthroscopy in osteoarthritis is still pretty common. It is perceived as a minimally invasive procedure, certainly compared to other operations. And yet the data that supports its use is actually not very good. What often prompts the arthroscopy is a study such as this. This is an MRI done on somebody with osteoarthritis and knee pain. The report comes back where you have a tear on the posterior horn of the meniscus. Meniscal tear equals need for surgery, correct? Well this particular MRI is not one of my patients. It’s actually from an older paper by Felix Fernandez. It was written in nearby in Wayne State who looked at the knees by MRI of patients with OA which included a lot of asymptomatic knees. What he found was that many of the findings that we might be considering pathologic on the MRI are in fact very common and not associated with pain. Meniscal tears are extremely common in these asymptomatic knees. About the only difference is whether or not there is an effusion, although that was present in the asymptomatic knees as well. So basically, the recommendation for surgery on an MRI may be in error. Certainly in people with osteoarthritis. Generic pharmacy.

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