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    Is There a Role for Arthroscopic Debridement in Knee OA?

    Dr. Timothy Reish provides evidence for the temporizing nature of this procedure in patients with early knee osteoarthritis.

    One of the most common challenges faced by orthopaedic surgeons is the patient with knee osteoarthritis (OA) that is not yet bad enough to warrant a knee arthroplasty. What options are available to relieve their symptoms?

    At the ICJR East meeting, Timothy G. Reish, MD, from the Insall Scott Kelly Orthopaedic and Sports Medicine Institute in New York, addressed the role of arthroscopic debridement in treatment of these patients. He reviewed the definition of arthroscopic debridement, as well as the indications for debridement in patients with knee OA, and concluded that there is, indeed, a place for this procedure.

    Arthroscopic debridement is a low risk, low stress procedure that is relatively easy to perform, has a low incidence of complications, and allows a quick recovery. But as Dr. Reish explained, it is important to define what arthroscopic debridement is – and what it is not.

    Arthroscopic debridement includes:

    • Removal of meniscus tears that may cause mechanical symptoms
    • Removal of any loose or fibrillated articular cartilage, either with a mechanical shaver device or with a radiofrequency coblation device. Recent research suggests that use of a radiofrequency coblation device may be less harmful to the surrounding healthy cartilage and bone, as well as the meniscus, compared with a motorized shaver.
    • Removal of loose bodies

    Arthroscopic debridement does not include:

    • Abrasion arthroplasty with effect to the subchondral bone
    • Microfracture, where the subchondral plate is penetrated
    • Cartilage substitution procedures
    • Osteochondral allograft or “scaffold” procedures

    Arthroscopic debridement removes structures that cause mechanical interference or irritation by:

    • Smoothing cartilage edges, which allows for easier movement of the joint
    • Providing lavage of inflammatory mediators. [1] According to Livesly, lavage may be more effective than physical therapy for early arthritis patients. [1]

    Dr. Reish described a number of studies – pro and con – evaluating arthroscopic debridement for knee OA.

    • A study by Mosely briefly put the benefits of arthroscopic debridement in doubt, concluding that it did not provide greater pain relief or functional improvement than placebo. [2]
    • Burkhart exposed the serious limitations of Mosely’s study, however: [3]
      • Selection bias
      • No selection criteria for stage of arthritis
      • Inadequate preoperative X-ray evaluation based on a single view
      • Invalid statistics
    • In McGinley’s study, 67% of knees treated with arthroscopic debridment did not go on to total knee arthroplasty at a minimum of 10 years of follow-up. [4] Only 33% required a arthroplasty at an average of 6.7 years after arthroscopic debridement.
    • A Level II study by Aaron examined 122 patients with knee OA who had failed treatment with a non-steroidal anti-inflammatory drug. [5] The OA grade was evaluated with proper X-rays and confirmed in the operating room during arthroscopy. Arthroscopic debridement was defined as listed above. Aaron found that patients with severe arthritis did poorly, and patients with mild arthritis did well.

    Dr. Reish concluded that arthroscopic debridement has a temporizing role in the treatment of early knee OA, but that patient selection is important. In particular, patients who benefit generally have:

    • Unilateral knee arthritis
    • Minimal deformity
    • Reasonable range of motion (usually > 100°)
    • “Acute” symptoms
    • Acute-on-chronic

    Patients with associated pathology such as meniscal tears will typically benefit from arthroscopy debridement.

    Equally important, Dr. Reish said, are educating the patient about the temporizing nature of the procedure and ensuring reasonable patient expectations.

    Dr. Reish’s presentation can be found here.

    References

    1. J Bone Joint Surg Br. 1991 Nov;73(6):922-6. Arthroscopic lavage of osteoarthritic knees Livesley PJ, Doherty M,Needoff M , Moulton A.
    2. N Engl J Med. 2002 Jul 11;347(2):81-8. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. Moseley JB, O’Malley K, Petersen NJ, Menke TJ, Brody BA, Kuykendall DH, Hollingsworth JC, Ashton CM, Wray NP.
    3. Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 18, No 8 (October), 2002: p 823. Do Statistics Ever Lie? Burkhart SS
    4. Clin Orthop Relat Res. 1999 Oct;(367):190-4. Debridement arthroscopy. 10-year followup. McGinley BJ, Cushner FD, Scott WN.
    5. J Bone Joint Surg Am. 2006 May;88(5):936-43. Arthroscopic débridement for osteoarthritis of the knee. Aaron RK, Skolnick AH, Reinert SE, Ciombor DM.