The effect of arthroscopy in osteoarthritis

23 April of 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. 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.

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.

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.

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