Arthroscopic Management for Degenerative Arthritis of the Knee

1. Arthroscopic Management for Degenerative Arthritis of the Knee ICL chapter 16 Michael J. Stuart, MD Presented by: Phillip A. Pullen, DO

2. Overview • Treatment of DJD in the young patient remains a challenge to date (due to the inability to reconstitute hyaline cartilage) • Restoration of articular cartilage defects is under investigation and involves 3 principle methods: repair, regeneration or replacement • The body is limited in its ability to repair hyaline cartilage

3. Overview • In the future, maybe growth factor stimulation of cells for repair • Other solutions include periosteal or perichondral autografting • Repair of defects is performed by inserting autogenic osteochondral plugs or fresh osteochondral allografts

4. Overview • Initial treatment of OA of the knee is non-surgical and involves: • Activity modification • PT for strengthening • Low impact aerobics • NSAIDS • Weight loss • Energy absorbing insoles • Ambulatory aids and bracing • Intra-articular steroid or hyaluronan injections

5. Overview • Symptoms refractory to the prior treatments may require: • Open or arthroscopic debridement • Osteotomy (HTO or DFO) • Prosthetic arthroplasty • Prosthetic arthroplasty should not be applied to the young, athletic population with DJD

6. Goals of Arthroscopy for the Painful OA knee • Define pathology and treatment plan • Treat a specific problem (degen. Meniscal tear) • Prolong the use of the knee • Burks RT: Arthroscopy and degenerative arthritis of the knee: A review of the literature. Arthroscopy 1990;6:43-47

7. Goals of Arthroscopy for the Painful OA knee • Arthroscopic lavage and debridement has resulted in short term relief in the majority of patients but the natural history of the disease process is most likely not altered • Significant controversy surrounding the arthroscopic debridement of the OA knee • Sharkey in the Journal of Arthroplasty, 1997, raised 3 fundamental questions that must be answered: does arthroscopy for OA change the natural history of the disease, is the outome related to a placebo effect, and how can any improvement be explained on a clinical or biochemical level.

8. Arthroscopic Debridement • Arthroscopic Debridement • May involve lavage, partial meniscectomy, limited synovectomy, excision of osteophytes, loose body removal, and cartilage shaving • Removal of joint irritants has been suggested to arrest the disease process and relieve symptoms • Some explanations for the relief of pain include: the anesthetic effect of saline, removal of particulate debris and degradative enzymes and the interruption of pain impulses by chloride ions.

9. Results of Arthroscopic Debridement • Sprague found small risks associated as well as improvement in 74% of his patients after 1 year • Timoney and associates revealed early failure at 6 months (27%) and 45% good results at 4 years follow up • Rand found that removal of unstable meniscal fragments combined with joint lavage was beneficial. He also found that degen. Changes adversely affected the results

10. Results of Arthroscopic Debridement • Anderson et al. found that preoperative xrays correlated well with outcome in a retrospective study of patients over the age of 50 • They found good to excellent results in 68% of knees with a joint space >1mm and only 29% good to excellent results in knees with a joint space <1mm on nonweightbearing films

11. Results of Arthroscopic Debridement • Salisbury and associates recommended that patients with varus deformities be excluded from consideration for arthroscopic debridement because they found only 32% of patients had pain relief and good results whereas 94% of normally aligned knees had good results.

12. Results of Arthroscopic Debridement • Ogilvie-Harris and Fitsialos found 2 yrs of relief following arthroscopic debridement for degenerative arthritis. • Best results occurred in patients with mild disease, normal alignment, and an unstable meniscal tear • Much lower success rates were found with bicondylar disease, malalignment and chondrocalcinosis

13. Results of Arthroscopic Debridement • McLaren and associates were unable to find and factors that correlated with outcome • They retrospectively reviewed 171 patients • They found marked but unpredictable improvement in 1 out of every 3 patients

14. Results of Arthroscopic Debridement • Gibson et al. did a prospective study on 20 patients with moderate unilateral OA. • They assigned the knees randomly for lavage vs debridement and removal of all osteophytes • Neither procedure improved their patients symptoms

15. Results of Arthroscopic Debridement • Merchan and Galindo took 80 patients and randomized them into surgical and non surgical groups • Entrance criteria: no patellofemoral involvement, limited radiographic degenerative changes, a normal mechanical axis, pain of sudden onset or pain less than 6 months, and no history of previous surgery • They found surgery to be a useful technique according to HSS scores at a mean follow up of 2 years • The main benefit was the treatment of other problems associated with the patients OA

16. Results of Arthroscopic Debridement • Moseley and associates performed a study to look at the placebo effect of arthroscopy • 10 patients: 5 placebo (only skin puncture wounds), 3 underwent lavage alone, and 2 had a standard debridement • All 5 reported improvement in their knee pain at 6 mos. 4 out of 5 recommended the procedure to family and friends

17. Indications for Arthroscopic Debridement • Indications for arthroscopic debridement, partial meniscectomy and or loose body removal include: • A discrete chief complaint • Acute onset of localized joint line pain • Persistent effusion • Catching or locking • Mild to mod. Degenerative changes on xray • Patients should be counseled on the limited goals and the possible need for reconstructive surgery in the future

18. Subchondral Drilling/Microfracture • Drilling or picking of the subchondral bone has been used along with debridement to treat localized areas of articular cartilage loss in degenerative knees • Theory is that the resultant hematoma transforms into reparative fibrocartilage with restoration of the joint surface countour, symptom relief and the delaying of TKA or UKA

19. Subchondral Drilling/Microfracture

20. Technique • An awl is used to make multiple holes in the exposed subchondral bone of the defect • The awl generates less heat and causes less thermal damage than the drill • This promotes adhesion of the hematoma to the subchondral bone which may enhance fibrocartilage formation • A CPM machine is then used for 6-8 hrs per day and TDWB is recommended for 8 weeks

21. Results of Subchondral Microfracture • Richards and Lonergan reported on 22 patients: improvement in 80% at 25 month follow up • Steadman and associates reported on 298 patients. 77 underwent second look arthroscopy • Better results were obtained in those that used the CPM for 6-8 hrs/day times 8 wks when evaluated arthroscopically • Pain improvement was also better at 6 yr follow up. 63% of the CPM group had pain improvement while 55% of the non CPM group still had improvement

22. Arthroscopic Microfracture • No firm conclusions can be made at present as to indications, limitations and efficacy • The durability of the reparative tissue remains to be a question

23. Abrasion Arthroplasty • Technique and clinical experience are the result of work done by Dr. Lanny Johnson • He found that intracortical defects created in sclerotic lesions without penetration of the subchondral bone uncovered small vessels • 2nd look arthroscopy showed islands of repair tissue at the sites of debridement • These sites remained vascular for 8 weeks and NWB was essential during this period to allow for fibrocartilage formation

24. Abrasion Arthroplasty • He recommended using a motorized cutting device to a depth of 1 to 2 mm

25. Results of Abrasion Arthroplasty • Performed on 104 patients with rest or night pain and xray evidence of degenerative arthritis. • 95 patients were available at 2 years follow up • 78% better, 15% unchanged, and 7% worse • 7 reoperations occurred: 1 arthrotomy, 3 osteotomies, and 3 TKA’s • 64 knees had pre and post operative standing radiographs • 31 had a wider joint space due to regeneration of fibrocartilage

26. Results of Abrasion Arthroplasty • Friedman and associates had 73 patients with improvement of symptoms in 60% • However, pain was still present in 83% of patients after an average follow up of only 12 months • Best results in patients < 40 yrs old

27. Results of Abrasion Arthroplasty • Bert and Maschka studied unicompartmental gonarthrosis • 67 patients – debridement alone • 59 patients – abrasion arthroplasty and debridement • The patients who refused to be NWB for 6 wks were offered the debridement alone procedure

28. Results of Abrasion Arthroplasty • Results were obtained up to 5 yrs following surgery • Abrasion arthroplasty group – 51% good/excellent results, 16% fair, and 33% poor • Debridement alone group – 66% good/excellent results, 13% fair results, and 21% poor

29. Abrasion Arthroplasty • Meticulous surgical technique can stimulate the formation of reparative fibrocartilage • Contraindicated in pts with: • Inflammatory arthritis • Presence of significant knee stiffness • Deformity • Or instability • Pts unwilling to be NWB for 2 months • Results are unpredictable

30. Complications of Arthroscopy • Infrequent and usually minor • Risk increases as techniques become more technically demanding • Rates have been reported from 7-31% • Pre-op screening and attention to detail minimizes these risks

31. Equipment failure Ligament injuries (MCL) Peripheral nerve injuries (saphenous, peroneal) Tourniquet related problems Vascular injuries Hemarthrosis Stiffness Increased pain RSD Compartment syndrome Infection Thromboembolism Tibial plateau fx Femur fx Prepatellar bursitis Anesthesia related Local – skin slough, grand mal seizure, blistering, infection at injection site Spinal – urinary retention, cardiac arrest, resp. arrest, ascending paralysis General – arrhythmias, pneumonia, aspiration pneumonitis Complications of Arthroscopy

32. Conclusions • Hyaline articular cartilage is remarkably durable and is critical to joint function but has very limited potential for repair • Etiology of OA remains obscure • Chondral and osteochondral defects, loss of menisci, recurrent instability and axial malalignment contribute to the degeneration of joint surfaces

33. Conclusions • Prevention of this deterioration is critical because there is no reliable way to restore the articular cartilage at present • Degenerative arthritis still remains a problem in the younger more active patient • Arthroscopy may help by buying time before a reconstructive procedure is needed • However these methods of treatment provide unpredictable, incomplete and short term relief

34. Conclusions • Patients with mild to moderate degenerative disease can be considered for arthroscopic debridement if a nonsurgical program is unsuccessful • Indications are as previously mentioned: acute onset, discrete pain, effusion, and catching or locking • Single most important factor when considering arthroscopy is axial alignment

35. Conclusions • If the mechanical axis extends through the lesion then arthroscopy is most likely going to be unsuccessful • Technique involves removal of only unstable meniscal fragments and the restoration of a smooth, well contoured rim • Osteophytes are only removed if they are causing painful impingement or blocking motion

36. Conclusions • Subchondral drilling or microfracture or abrasion arthroplasty are performed when there is focal full thickness articular cartilage defects on the femoral condyles • This must be an isolated finding without involvement of the rest of the knee • Additionally the patient must be willing to comply with the CPM machine and TDWB for 2 months