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    Defining a Role for Arthroscopic Debridement of the Knee

    Dr. Timothy Reish evaluates the evidence for and against arthroscopic debridement of early osteoarthritis in the knee.

    Should surgeons consider arthroscopic debridement for patients with early osteoarthritis (OA) of the knee?

    Timothy G. Reish, MD, from the Insall Scott Kelly Institute in New York, New York, sought to answer that question at ICJR’s Transatlantic Orthopaedic Congress, and to do so, he first defined arthroscopic debridement.

    • It involves removal of meniscus tears, removal and contouring of loose articular cartilage, cartilage coblation, and removal of loose bodies.
    • It does not involve abrasion arthroplasty, microfracture, or use of cartilage substitutes or allograft.

    Arthroscopic debridement is a relatively low-risk procedure, with a low incidence of complications and a quick recovery time, Dr. Reish said. It’s believed to work by smoothing cartilage edges through mechanical debridement, as well as by removal of inflammatory mediators through lavage.

    Dr. Reish reviewed studies evaluating the efficacy of arthroscopic debridement in knee OA.

    • Mosely et al [1] concluded that arthroscopic debridement offers no benefit with regard to pain relief or functional improvement when compared with placebo. However, this study was criticized for patient selection bias, inadequate preoperative evaluation, and invalid statistics. [2]
    • McGinley et al [3] found that only 33% of patients went on to a total knee arthroplasty at 6.7 years after arthroscopic debridement, while 62% of patients did not require additional surgery after a minimum of 10 years of follow-up.
    • A Level II study by Aaron et al [4] evaluated 122 patients who had failed conservative treatment with a non-steroidal anti-inflammatory drug and went on to arthroscopic debridement. Patients with severe OA did poorly, while those with mild OA did well after arthroscopic debridement. The level of OA was defined by radiographs and observation in the operating room

    Due to the relatively low level of evidence in the studies evaluating arthroscopic debridement, Dr. Reish expressed his desire for more and larger randomized controlled trial (RCT) studies to better evaluate the potential benefit of the procedure.

    “So, is there are role for arthroscopic debridement in the treatment of early knee arthritis”? Dr. Reish asked. In his opinion, the answer is “yes” – but he cautioned that the effect of the procedure is temporizing and that the most critical step of arthroscopic debridement for early knee OA is patient selection.

    To that point, Dr. Reish advises surgeons to select patients with:

    • Unilateral knee OA
    • Minimal deformity
    • Excellent range of motion (>100°)
    • Acute versus acute-on-chronic symptoms
    • Associated pathology such as meniscus tears or loose bodies

    The most important aspect of patient selection, Dr. Reish said, is to coach these patients to make sure they have reasonable expectations of the outcome.

    This conclusion is in agreement with the Arthroscopy Association of North America, [5] which advises that “there is a sub-group of patients with knee arthritis that can be significantly helped with appropriate arthroscopic surgery.”

    Click the image above to watch Dr. Reish’s presentation from the Transatlantic Orthopaedic Congress.

    References

    1. Moseley JB, O’malley K, Petersen NJ et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med, Vol. 347, No. 2 July 11, 2002
    2. Burkhart SS. Editorial: Do statistics ever lie? The Journal of Arthroscopic and Related Surgery, Vol 18, No 8 (October), 2002: p 823
    3. McGinley BJ; Chushner FD, Scott WN. Debridement arthroscopy: 10-year follow-up. CORR no 367 p190-194, 1999
    4. Aaron RK, Skolnick AH, Reinert, SE, Ciombor, DM. Arthroscopic debridement for osteoarthritis of the knee. JBJS Vol 88-A no 5, p936-943, 2006
    5. Stuart MJ, Lubowitz JH. What, if any, are the indications for arthroscopic debridement of the osteoarthritic knee? Arthroscopy Vol 22, No 3 (March), 2006: pp 238-239