Is There a Role for Arthroscopy in the Treatment of Knee Osteoarthritis?

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Chapter 94 Is There a Role for Arthroscopy in the Treatment of Knee Osteoarthritis?

CHRISTOPHER C. DODSON, MD, ROBERT G. MARX, MD, MSc, FRCSC

Arthroscopy was first described to treat osteoarthritis (OA) of the knee by Burman and coauthors ¹ in 1934. Over the past several decades, arthroscopic debridement of the degenerative knee has become a commonly performed orthopedic procedure. Despite its popularity, the exact role of arthroscopy in treating OA is controversial. Older, primarily uncontrolled cohort studies have suggested that arthroscopy has a variety of benefits in patients with early OA.²^–⁶ However, a more recent study has suggested that the placebo effect may be responsible for the benefit related to arthroscopic treatment.⁷ The variety of arthroscopic procedures, the retrospective nature of the majority of published studies, and the lack of control subjects probably adds even more confusion as to which patients will benefit from arthroscopy.⁸

Additional prospective, randomized, controlled studies are needed to try and define the role of arthroscopic debridement in the treatment of OA of the knee. This is essential because it would allow for a greater efficiency in the management of these patients; those who would benefit from surgery can be indicated, whereas those who would not can be spared the unnecessary expense and operative risk of a surgical procedure. In the meantime, it is important to analyze the current literature in an effort to determine which patients are most likely to benefit from arthroscopy. The goal of this chapter is to summarize the current literature in an effort to determine whether there is, in fact, a role for arthroscopy in the treatment of OA.

OPTIONS

Numerous treatment options are available for the patient with OA of the knee. Generally speaking, nonoperative treatments are indicated initially, followed by surgical options if the former are not effective. The degree of OA in the involved knee also plays a role in the decision-making process.

Nonoperative management begins with activity modification, physical therapy, and a trial of anti-inflammatory medications. Many patients will often experience significant relief after intra-articular corticosteroid injections and hyaluronate injections. It is important to note that the degree of pain relief, as well as how long it lasts, can be varied.⁹

Surgical management includes arthroscopic debridement and lavage, osteotomies to correct deformities, unicompartmental arthroplasty, and total knee arthroplasty. Osteotomy is indicated in younger patients with deformity and degenerative changes on one side of the knee. Unicompartmental arthroplasty is reserved for patients who have degenerative changes in primarily 1 compartment, good motion, knee stability, and no significant deformity. Finally, total knee arthroplasty is indicated in older patients with significant degenerative changes and multicompartment involvement of the knee. The role of arthroscopy in the osteoarthritic knee is not clear.

EVIDENCE

Several studies have been conducted in an effort to examine the effectiveness of arthroscopy in treating OA of the knee (Table 94-1). However, after conducting an evidence-based review of the current literature, we found only 1 study that contained Level I evidence. This study, by Moseley and colleagues,⁷ was a prospective, randomized, placebo-controlled trial of 180 patients with OA who were assigned to receive arthroscopic debridement, arthroscopic lavage, or placebo surgery. Their inclusion criteria included: (1) age < 75 years, (2) OA as defined by the American College of Rheumatology, (3) knee pain despite at least 6 months of conservative management, and (4) no arthroscopy performed on the knee in the previous 2 years. The severity of OA was assessed radiographically and graded from 1 to 4. The scores from all 3 compartments were added for a total of 0 to 12. Of note, patients were excluded for severe deformity, for a score of more than 9 on the scale, or if there was a medical contraindication. Patients and assessors of outcome were blinded to the treatment group assignment, and outcomes were assessed at multiple points over a 24-month period with the use of 5 self-reported scores. The authors conclude that the outcomes after arthroscopic lavage or arthroscopic debridement were no better than those after a placebo procedure.

TABLE 94-1 Recent studies with their respective levels of evidence regarding the treatment of knee osteoarthritis with arthroscopy

Several details about this study require a more in-depth evaluation because they are certainly relevant to the authors’ conclusion that surgical intervention provided no benefit compared with placebo surgery. Forty-four percent of the eligible participants declined to participate in the study, which creates a selection bias; that is, it is possible that the patients who declined to participate had lower grades of OA and, therefore, might have experienced the best outcome.¹⁰ In addition, the presence or absence of joint effusion was not reported. This is significant because some of the indications for knee arthroscopy, such as loose bodies or meniscal tears, can be manifested clinically by a joint effusion. Finally, the method of grading OA may lead to conflicting results. For example, a patient with one severely arthritic compartment may receive the same score as a patient with mild arthritis in all three compartments. These patients are probably not comparable clinically and would most likely have different outcomes after surgical intervention. Despite these criticisms, this investigation is still the only Level I study that addresses the role of arthroscopy in OA; therefore, the authors’ conclusion should be acknowledged and taken into account when treating these patients.

Patients with symptomatic OA of the knee have a reported incidence rate of meniscal tears in up to 91% of magnetic resonance imaging (MRI) scans.¹¹ Some surgeons have proposed that patients who have pain secondary to clinically significant meniscal tears will benefit from arthroscopic mensical debridement. Dervin and investigators,⁸

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