Successful Arthroscopy for Arthritis
Abstract & Commentary
Synopsis: A retrospective study with 2- and 5-year results finds arthroscopy beneficial in selected patients.
Source: Fond J, et al. Arthroscopic debridement for the treatment of osteoarthritis of the knee: 2- and 5-year results. Arthroscopy. 2002;18(8):829-834.
Arthroscopic treatment of mechanical complaints in patients with osteoarthritis has been an acceptable form of treatment for many years. A recent study in The New England Journal of Medicine by Moseley and associates has challenged that treatment by stating that arthroscopic treatment is no better than placebo.1 This study by Fond and colleagues looks at the mechanical effects of tibial osteophytes and notch impingement leading to decreased range of motion, and the results of arthroscopic treatment of the same.
Over a 4-year period, 64 patients underwent arthroscopic surgery for the diagnosis of osteoarthritis. Thirty-six patients were available for 5-year follow-up. All patients had failed nonoperative treatment and many had been recommended for total knee arthroplasty. Eleven had unicompartmental arthritis, 9 had bicompartmental arthritis, and 16 had tricompartmental arthritis. Patients with inflammatory disorders or severe angular malalignment were excluded. Treatment was dependent on demonstrated pathoanatomy, but typically included treatment of meniscal pathology, stabilization of chondral defects, removing impinging tibial and notch osteophytes, removal of sub patellar osteophytes, partial synovectomy, and lateral retinacular release. HHS scores and ROM were recorded at both follow-up time periods.
The mean preoperative HSS score was 29.2. The mean postoperative HSS score at 2-year follow-up was 48.0 and at 5-year follow-up was 43.2. Good or excellent results were obtained in 32 patients at 2-year follow-up, which deteriorated to 25 patients at 5-year follow-up. Eight patients were rated as failures and underwent further surgeries to include 7 total knee arthroplasties and 1 high tibial osteotomy. All failures were in patients with tricompartmental arthritis. Results also correlated highly with preoperative range of motion. The 4 early failures were in patients with a mean flexion contracture of 15.6°. The 11 patients with fair-to-poor results at 5-year follow-up also had a flexion contracture > 15°. These patients also had lower preoperative HSS scores, averaging < 22. The 25 patients with a satisfactory result had a mean preoperative flexion contracture of 7.3° and a mean HSS score of 33.
They concluded that arthroscopic treatment of osteoarthritis is indeed beneficial and removal of anteromedial tibial osteophytes that were blocking extension improved postoperative motion. Failures occurred in patients with preoperative tricompartmental disease, a greater than a 10° extension deficit, and HSS score of less than 22.
Comment by Col. Patrick St. Pierre, MD
This paper is very timely in that once again we have a study that supports the use of arthroscopy in the treatment of osteoarthritis in selected patients. It makes us question the wide brush conclusion of the Moseley article that arthroscopy in these patients is a waste of money and should not be performed. However, does it provide new and useful information concerning what has existed in the literature? Fond et al reference 13 previous retrospective studies citing the benefit of lavage, meniscectomy, debridement and abrasion chondroplasty, but note that previous studies did not focus on restoration of full extension. In fact, only one study by Baumgaertner and associates looked at preoperative range of motion and they did not note an effect on outcome.2 This study is unique in that they focus on anterior tibial and intercondylar notch osteophytes and the restoration of full extension in these patients.
This study has several limitations that are acknowledged by Fond et al. It is once again a retrospective study and has only a 56% follow-up at 5-years. This is significant, and if 28 patients had total knee arthroplasties done by other surgeons, the conclusions would be entirely different. However, looking at the patients available for evaluation, Fond et al were able to improve outcomes for patients with less than tricompartmental arthritis and flexion contracture of less than 10° by performing arthroscopic debridement. If these patients were contemplating total knee arthroplasty, then a service has been done by allowing them to have good-to-excellent function for 5 years and delay surgery. Also, if the natural history of the patients with less severe disease is to progress, then the surgery is beneficial in restoring full extension and maintaining a higher HSS score, delaying total knee arthroplasty.
However, this study may be more helpful in telling us who not to arthroscope. Patients with preoperative tricompartmental DJD, flexion contracture of > 10°, and low HSS scores all did poorly and went on rapidly to total knee arthroplasty. These conditions should be considered contraindications to arthroscopic debridement and total knee arthroplasty should be considered the operative treatment of choice.
The Moseley article has cast a shadow of doubt on the effectiveness of arthroscopic debridement in patients with osteoarthritis. Fond et al have provided useful information that we can use in selecting the appropriate patients for this procedure.
Dr. St. Pierre, Assistant Professor, Uniformed Services University, Orthopedic Co-Director, Primary Care Sports Medicine Fellowship, DeWitt Army Community Hospital, Ft. Belvoir, VA, is Associate Editor of Sports Medicine Reports.
References
1. Moseley JB, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2002;347(2):81-88.
2. Baumgaertner MR, et al. Arthroscopic debridement of the arthritic knee. Clin Orthop. 1990;253:197-202.
This study by Fond and colleagues looks at the mechanical effects of tibial osteophytes and notch impingement leading to decreased range of motion, and the results of arthroscopic treatment of the same.
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