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ORIGINAL ARTICLE
Role of Arthroscopic lavage in the Treatment of osteoarthritis
*Manju Jayaram, *Pankaj Kumar ,*G.K.Singh , *Navin Karn

*Department of Orthopaedics, B.P.Koirala Institute of Health Sciences, Nepal

Address for Correspondence

Pankaj Kumar
Assistant Prof., Department of Orthopaedics
B.P.Koirala Institute of Health Sciences, Dharan, Nepal
Phone
: 00977-25-525555-3260
Fax:
00977-525555-520251
Email:harishvk@yahoo.com

Abstract

Objective: To compare improvement after arthroscopic lavage in osteoarthritis of knee joints with conventional treatment.
Design: Open Control Trial
Setting: Tertiary care hospital
Intervention: Arthroscopic lavage and conservative treatment.
Participants
: 48 knees of 29 osteoarthritis patients attending orthopaedic OPD from 30th January 2003 to 30th January 2004.  Patients who scored < 24 on WOMAC scale were excluded.
Main outcomes measured: Functional capacity of knee by WOMAC index at pre treatment 4th, 8th week, 12 week of follow up after treatment.  21 knees in 13 patients received conservative treatment.  24 knees in 16 patients received Arthroscopic lavage with add on the conservative treatment.
Results: Both on pain and function scores cases were worse pre treatment as expected because only patients with severer disease were likely to opt for Arthroscopic treatment. However, patients treated arthroscopically did better both clinically and statistically both in respect of function and pain. However, the difference became lesser with time.
Conclusions: Cases initially worst than controls did statistically and clinically better in terms of pain and function up to 12th week of follow up without complication.  Given the low incremental cost and simplicity of this day care procedure arthroscopic lavage is a simple useful and safe adjunct to conventional treatment in O.A of knee, which shows a trend to delay the progress of the disease. When is a repetition needed and how effective will it be remain to be answered.

J.Orthopaedics 2006;3(4)e3

Introduction:

70% of above 50 years old seek treatment of symptomatic Osteoarthritis of knee or hip. The alternatives of conservative treatment is in effective and effective surgical procedures like Total Knee Replacement are either too costly, undoable on such large numbers or give results not socially acceptable in developing country settings where activities of daily living necessitate squatting and cross legged sitting. To preserve the knee as long as possible and avoid or delay TKR and THR thus becomes much more important in such settings both as a measure of cost containment and complying with the patients social needs. Arthroscopy fits into this gap where the simple conservative treatment has proved in effective or dangerous given long term toxicity of NSAID's and where the cost, doability or social inhibitions imposed by Joint replacement are unacceptable.

The treatment of osteoarthritis is aimed at reducing pain, maintaining mobility and minimizing disability.  The vigor of the therapeutic intervention should be dictated by the severity of the condition in the individual patients.  The various modalities available for the treatment represent a spectrum ranging from simple instruction in joint protection principles. Thermal therapy, shoes with well cushioned soles, heel wedges, canes, quadriceps strengthening exercise, aerobic exercises, intraarticular steroid and hyaluronic acid therapy, paracetamol and NSAIDS and glucosamine and chondrotin sulphate are non invasive treatments tried in every patient. However, sooner or later some of the patients are no longer helped by these modalities and surgical intervention like lavage debridement, Osteotomy, chondroplasty and finally the joint replacement has to be resorted to. The guiding principle in the choice of treatment is the minimum effective treatment. Minimum in terms of incremental cost, ease of doing, safety and cost of infrastructure needed to do it. Given the huge burden of disease cost and infra structure factors can not be ignored in developing a treatment strategy for this extremely common disease.

Arthroscopy lavage that flushes the mediators of inflammation from the joint, leading to removal or dilution of enzymes that are a part of degenerative process of osteoarthritis.

However, before adopting this technique into the standard orthopedic armamentarium of a tertiary hospital, given the large acquisition costs of equipment for arthroscopic lavage   because but low incremental costs of this large scale intervention,the benefit must be proved by rigorous methodology like a randomized controlled trial.  However, due to ethical constrains and a very large proportion of the patients coming with the fixed mind for this or that treatment, informed consent could not be obtained for randomization in a large proportion of cases.  Accordingly, an open quasi-random allocation trial was conducted where allocation was dependent upon whether the patients chose conservative treatment or arthroscopic lavage after being fully informed in writing about the likely results of equivalence between both, as per existing evidence.

Still the questions of will the procedure avoids TKR, THR, delay them can be answered in much longer follow-up studies and are beyond the scope of the present work.

Materials and methods

This is a consent based allocation trial comparing conservatively treated cases of osteoarthritic knee (n - 21 knee) with those treated with add on arthroscopic lavage (n - 24 knee). 

Study Population: All such patients with clinical features suggestive of osteoarthritis of knee joint ranking more than 24 or worse than on the modified WOMAC index were included in the study reporting to the orthopedic out patient department of BP Koirala Institute of Health Sciences, a tertiary care orthopedic teaching facility in eastern Nepal from January 2003 t0 January 2004 were eligible. Specific inclusion criteria were

a. Inclusion criteria:
i. Knee pain
ii. Radiographic osteophytes and at least 1 of the following 3 items.
1. Age > 40
2. Morning stiffness < 30 min.
3. Crepitus on motion

b. Exclusion criteria:
i. Advanced  osteoarthritis of knee
ii. Patients who have undergone arthroscopic lavage, debridement and surgery of knee
iii. Secondary osteoarthritis of knee
iv. Excessive malalignment of knee

Intervention:
a. Control Group: The control group was given patient education, physical therapy, range of motion exercises, quadriceps strengthening exercises and occupational therapy besides pharmacological therapy including non opioid analgesic (ex. Acetaminophen), topical analgesics, NSAID and opiod analgesics (ex. Propoxyphone, Codeine)
b. Test Group: The test group received in addition to above arthroscopic lavage of the knee joint with 3 to 5 liter of normal saline.
Material required: Arthroscopic lavage instruments for local anaesthesia, solution containing 30ml of 2% xylocaine + 30ml of xylocaine with adrenaline +60 ml of normal saline,  18 Gauge needle, 20ml syringe, 7.5% providone 50, Surgical spirit, 3 to 5 liters of Normal saline, Mersilk suture No.1 with cutting needle and Handi plast.
Technique: After informed consent and xylocaine sensitivity testing the patient was put supine on the operation table.  Local infiltration of skin was done with 1% lignocaine (2% lignocaine with adrenaline is diluted to 1% by distilled water).

  1. Para patellar pain points usually found on the supero - lateral angle of the patella was identified by palpation and depomedrol xylocaine infilteration used to treat it.
  2. The knee joint was then distended using 20ml syringe and 18 Gauge needle by 30-50 ml of 1% local anaesthesia through the supra patellar pouch.  The knee was then flexed up to 900 and the inferolateral portal was infiltrated by the prepared solution.
  3. A cruciate stab incision was made by the surgical blade No.15  dividing the skin and subcutaneous tissue including the articular capsule above the infra patellar pad of fat.
  4. The Arthroscope sleeve with the blunt trocher was put through the incision and aimed at the center of the intercondylar notch; it was inserted through the capsule into the joint, till it struck the intercondylar notch.
  5. Gentle pressure was applied as the knee was extended so that the trochar slid between the patella and intercondylar notch into the suprapatellar pouch.
    The trochar was then replaced by 300 and 4 mm arthroscope and connected to light source.
  6. The supra patellar pouch was scanned from side to side from proximal to distal with the arthroscope moving in an arch directed superiorly fill the upper edge of the patella could be visualized. The arthroscope was then advanced medially till the medial synovial plicae could be seen.  After scanning the patella and the supra patellar pouch arthroscope was moved for visualization of medial tibio-femoral gutter till the medial tibio-femoral joint line could be seen and scanned. The medial meniscus was scanned and probed from post to anterior.  Then cruciate ligament was visualized from the femoral insertion to tibial insertion.  The lateral meniscus along with the tibial and femoral articular surface and the post cruciate ligament was scanned.
  7. The joint was washed till the haziness because of detritus cleared.  The arthroscope was removed and the trochar withdrawn gently while pressure applied around the knee so that collected fluid escaped.  The incision was closed by one or two stitches and covered with medicated adhesive strip (Band aid).
  8. After care:  Patient was made to stand and walk immediately.  The improvement status was evaluated on the basis of modified WOMAC index and the visual analogue scale.  Quadriceps exercises were started as soon as possible.  This was followed by stitch removal on 7th day and patients were followed on 4th, 8th week and 12th   week.  The parameters were assessed in each follow-up.
  9. Statistical analysis:
    Measurements done by WOMAC index and VAS at various visits were recorded and entered in the Microsoft EXCEL 8 file.  Magnitude of difference was measured as difference between mean improvement in the control and test group and significance of improvement was measured by using ANOVA/KRUSKAL WALLIS statistics.

Results

The comparability of the two groups was tested by comparing demographic and disease characteristics between the two groups as shown in Table1a, 1b, 1c, 1d, 1e   and it was found that the patients in the arthroscopy group were significantly worse of both in terms of pain and function than controls before the intervention.

The readings on VAS and WOMAC function scale at immediate post op, 4th , 8th, and 12th week were compared to the base line to define improvement in the two groups and the mean SD of improvement at the 4 follow ups are reported in Table 2 along with a column on p value showing whether the difference between cases and controls was significant or not. Despite the cases being initially worst than controls the arthroscopy group did better on VAS and all parameters of function, both magnitude and significance wise, in all follow ups but the difference was reduced with time.

Discussion

This study proves arthroscopic lavage as a simple, useful and safe adjunct to convention treatment in osteoarthritis of knee.  They also agree that the initial cost of equipment and hesitancy by general orthopaedic specialist in mastering their use may be main reasons to prevent wide spread use of this safe effective procedure fore solution of the huge burden of morbidity that osteoarthritis knee imposes on the community, Health managers must find ways of circumventing these hurdles.  The controversies demanding answers are what should be the minimal volume of irrigation and does debridement help serial 1,2,3,4,5,6,7 feel YES

Conclusion:

Cases initially worst than control did statistically and clinically better in term of pain and function up to 12th weeks of follow-up and no complication. By persual of the above mentioned ii may be concluded that the abobe literature in its entirely agrees with the present study that arthroscopic lavages is a simple, useful and safe adjunct to convential treatement in osteoarthritis of knee. They also agree that the initial cost of equipment and hesitency by general orthopaedic specialist in mastering their use may be main resion to prevent wide spreae use of its safe effecative procedure for solution of the huge burden of morbidity that osteoarthrits knee imposes on the community. Health manaager must find ways of circumventing those hundles.

References

  1. Burman MS, Finkelstein H, Mayer L. Arthroscopy of the knee. J Bone joint Surg Am 1934, 16:255-268.
  2. Amold W J Mather S E Mostello N. et at: Tidal knee lavage in patients with chronic pain due to osteoarthritis of the knee. Arthritis Rheum, 28 (Suppl): S66, 1985.
  3. Ike RW, Amold WJ, Simon C, et al: Tidal Knee irrigation as an intervention for chronic pain due to osteoarthritis of the knee. Arthritis Rheum 30 (Suppl 1) : S17, 1987.
  4. Kalunian KC, Moraland IW, kLASHMAN dj, Brion PH, Concoff AL, Myers S, sINGH r, Lke RW, Seeger LL, Rich E, Skovron ML. Division of Rheumatology, Ucla School of Medicine, University of California, Los Angeles, Ca 90095, USA Osteoarthritis Cartilage 2000 Nov;8(6): 412-8.
  5. Jackson RW: Dept of Orthopedic Surgery, Baylor University Medical Ctr, Dallas, TX 75246, USA, Am J Knee Surg 1998 Winter; 11(1):51-4.
  6. Gynther CW, Holmlund AB, Dept of Oral and Maxillofacial Surgery, Huddinge University Hospital, Karolinska Institute, Sweden. J Oral Maxillofac Surg 1998 Feb, 56 (2): 147-51; discussion 152.
  7. Hocnberg MC, Altman RD, Brandt KD, Clark BM, Dieppe PA, Griffin MR, Moskowitz RW, Schnitzer TJ. University of Maryland School of Medicine, USA Arthritis Rheum 1995 Nov; 38(11): 1541-6

 

This is a peer reviewed paper 

Please cite as : Manju Jayaram: Role of Arthroscopic lavage in the Treatment of osteoarthritis

J.Orthopaedics 2006;3(4)e3

URL: http://www.jortho.org/2006/3/4/e3

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