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148 IM1 2005, eI. 55, 8e. 2


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Osteoarthritis (OA) is a spectrum of clinical entities,
ranging from focal chondral defects to established
arthritis resulting from biologic and biomechanical
hyaline cartilage failure. Osteoarthritis is characterized
_____________________________
0esIa 0. Fe et aI 149
histologically by loss of integrity of articular cartilage,
with diffuse fraying and brillation and hypertrophic
changes in adjacent bone.
1
Osteoarthritis is the most
prevalent form of arthritis and gonarthritis affects up
to 6% of the adult population.
2
It is estimated that 25
to 30% of persons aged 45 to 64 years and more than
85% of individuals older than 65 years of age have
radiographically detectable osteoarthritis.
3

The purpose of surgical treatment in knee
osteoarthritis is to determine a sustained improvement
in health-related quality of life by decreasing the pain
level and by reestablishing as far as possible the normal
joint mechanics.
One of the most common surgical procedures
performed for knee OA is arthroscopic debridement.
Arthroscopic surgery has been evolving since the
beginning of the 20th century. Eugen Bircher has
published, between 1921 and 1926, several papers
describing 60 arthroscopic knee procedures (using the
Jacobeus thoracolaparoscope) that preceded an open
meniscectomy.
4
In the 1950s Professor Harald H.
Hopkins developed the rod lens system, which is still
used today in the most modern arthroscopes. Nowadays,
with the development of magnetic resonance imaging
and other non-invasive diagnostic techniques, knee
arthroscopy is used more often for the treatment of
various knee pathologies.
5
Moseley et al. estimate that at
least 650,000 arthroscopic debridement procedures are
performed each year in the United States, making it the
second most commonly used orthopaedic procedure,
ranking behind the arthroscopy for nondegenerative
conditions.
6

The advantages of arthroscopic surgery are:
reduced post-operative morbidity, small incisions, less
inammatory response resulting in less post-operative
pain, reduced hospital costs, low complication rate,
and an improved joint visualization. The disadvantages
of this technique are few, such as working with small
instruments in a conned area and the possibility to
produce damage to the cartilage.
7

The aim of this study was to evaluate the effects
of arthroscopic debridement in selected patients
diagnosed with knee OA using an own clinical rating
system.
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The patients, diagnosed with knee OA based on
clinical symptoms and signs and X-rays, were considered
for debridement arthroscopy if complaining of
articular pain for at least one year with no alleviation
of this symptom despite supervised physical therapy
and comprehensive medical management or patients
who refuse total knee replacement (TKR).
The failing conservative treatment may have
included oral and topical analgetics, nonsteroidal anti-
inammatory medications and intra-articular injection
of cortisone. This research is based on 103 patients
(106 knees), aged between 45 and 75 years (mean age
62 years) who were submitted, between January 2000
and January 2004, to arthroscopic surgery for knee
osteoarthritis. Seventy-four (71.84%) of these patients
were females and according to the body mass index
(BMI) 51 patients (42 females) were obese (BMI>30).
The Kellgren-Lawrence scheme was used to grade
the severity of radiographic knee osteoarthritis.
8
(Table 1)
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The arthroscopic evaluation and classication
of degenerative cartilage damage was done using the
criteria described by Outerbridge (1964).
9
(Table 2,
Fig. 1)

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The localization of the cartilage lesions was
recorded for each compartment on an articular
diagram.
All patients had arthroscopy of the knee under
spinal anesthesia. All surgery in this study was
performed with use of standard anterolateral and
anteromedial skin portals. The tourniquet was used in
every case.
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150 IM1 2005, eI. 55, 8e. 2

FIure 1. 0u|||||J |+J Z +||||+ ||u|
According to the identied intraarticular lesions
the surgical procedures chosen were:
- segmentary synovectomy, done only with the
purpose to obtain a better joint visualization and for
an histopathological examination;
- excision of hypertrophic synovial plicae;
- abr asi on of mar gi nal cl i ni cal l y r el evant
osteophytes; (Fig. 2)
- resection of loose chondral aps and unstable
meniscal tears;
- loose bodies (articular mice) removal;
- abrasion chondroplasty;
- articular lavage.
FIure 2. C||||+||] ||1+|| u|up|]|
A meniscal tear was considered resectable if it
was longitudinal and full-thickness, radial and more
than 3 mm deep or if tears were complex. (Fig. 3) The
unstable meniscal tears were contoured to a stable
rim arthroscopically, leaving a maximum of normal
tissue, chondral aps were removed and the rim of the
cartilage lesion was contoured by abrasion to improve
the transition between normal and abnormal cartilage.
Only clinically symptomatic osteophytes were removed
by abrasion. Drilling of the subchondral bone was not
performed.
FIure 3. u||+|| |||+| |+|
The assessment of the results obtained after
arthroscopy was done analysing subjective and objective
parameters using an own method. The postoperative
score was compared for each patient with the value
obtained before surgery using the same method.
This method of evaluation has a score with 60
points for pain, 3 points for morning stiffness, 20
points for range of motion and 17 points for function
(walking and stair climbing); points are deducted for
exion contracture, extension lag and and for aids
used during daily activities, walking or stair climbing
(canes, crutches or rail). (Table 3).
Depending on the obtained total score the
results are considered excellent (score=85-100), good
(score=65-84), acceptable (score=50-64) or poor
(score<50).
5(68/76
According to the radiographic ndings of the investigated
joints the K\L grade was I in 3, II in 51, III in 39 and IV in
13 knees; the medial tibiofemoral joint was predominantly
involved by osteoarthritis in 72 (67.92%) joints.
The distribution of the severity of the chondral
damage graded arthroscopically for all knees is shown
in Figure 4.
_____________________________
0esIa 0. Fe et aI 151
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40
50
60
Grade 1 Grade 2 Grade 3 Grade 4
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The medial compartment was more frequently
and severely involved, with 62% of the knees
showing grade 3 or 4 involvement, according to the
system described by Outerbridge. In contrast, both
the lateral and the patellofemoral compartment had
grade 3 or 4 changes in 26% and 21% of the knees,
respectively.
Hypertrophied synovitis was detect in all knees,
loose bodies in 12 joints and lesions of the anterior
cruciate ligament (ACL) in 13 knees. Fifty-three
patients had an unstable uniformly degenerative
meniscal tear; 21 tears were in the medial meniscus, 9
were in the lateral meniscus and 23 were combined.
The patients were evaluated, using the described
method, before arthroscopy and at 6 months and
one year after the surgical procedure. The last
evaluation (average follow-up of 19 months) was
performed in 84 patients. Twelve patients (11
females) with wide extended grade 4 cartilage
lesions involving the medial and lateral tibiofemoral
articular compartments in both knees, who
complained of great knee pain, underwent total
knee replacement (TKR) with cemented posteriorly
stabilized endoprosthesis at 15 months (range 13 to
17 months) after arthroscopy while 7 patients didn
t answer to our call.
According to this evaluation method the average
preoperative score was 60 (range: 36-90). At 6
months after arthroscopy the average score was 65
(range: 36-95), at one year 64 (range: 35-95) and at
the last evaluation this score was 62 (range: 34-91).
At one year after surgery the results were excellent
and good in 53 (51.45%) patients, acceptable in 36
(34.95%) and poor in 14 (13.59%), while at the last
evaluation the results were excellent and good in 46
(54.76%) patients, acceptable in 30 (35.71%) and
poor in 8 (9.52%). (Figure 5)
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10
20
30
40
50
60
one year - 103 cases at last evaluation - 84 cases
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_____________________________
152 IM1 2005, eI. 55, 8e. 2
The short-term complications following
arthroscopic debridement in these patients were
represented by moderate diffuse knee pain lasting for
more than 7 days in 11 patients, pain localized on both
sides of the joints in 14 patients and clinical signicant
swelling of the joints in 19 patients. Haemarthrosis was
arthroscopically diagnosed and treated in 6 from these
19 patients. No septic arthritis or symptomatic deep
venous thrombosis secondary to knee arthroscopy
was recorded.
',6&866,21
The results obtained after arthroscopic
debridement are difcult to evaluate through imagistic
methods like the so called arthroscopic second-look
or radiographic ndings. The purpose of this surgical
technique is not to restore the cartilage integrity or the
lower limb alignment but to remove the intraarticular
irritating factors with the purpose to alleviate the knee
pain and to slow down the OA evolution.
The intraarticular irritating factors are represented
by:
10-12

- little cartilage fragments oating in the synovial
liquid (so called debris);
- loose bodies or loose chondral aps;
- pro-inammatory cytokines (interleukin-1, tumor
necrosis factor- and transforming growth factor-)
released by the hypertroed synovial membrane;
- lytic enzymes released by chondrocytes;
- osteophytes;
- unstable meniscal tears.
The effects of arthroscopic debridement were
evaluated by numerous orthopaedic surgeons using
different methods like self-administred quality-of-life
instruments (WOMAC, SF-36, OXFORD, Tegner
or ICRS Clinical Cartilage Injury Evaluation system-
2000) or clinical rating systems (Lysholm score or a
modied HSS score).
13
Health-related quality-of-
life measures are categorized into two broad forms,
generic and disease-specic. Generic scales are useful
for their comprehensive evaluation, and they allow
comparisons of interventions for unrelated conditions.
Disease-specic scales (WOMAC, SF-36) are generally
more sensitive to change and are usually more
relevant to the conditions they measure (especially
pain).
14,15
They have been proved to be both reliable
and valid for the evaluation of patients with OA of
the knee that are treated especially with nonsteroidal
medication and TKR. Although the importance of
health-related quality-of-life measures is becoming
increasingly acknowledged, the interpretation of
changes in the scores has not been well dened. The
clinical outcome measuring methods (Lysholm score,
modied HSS score) are analysing more the objective
ndings about the osteoarthritic knee joint and the
function of the limb and less the characteristics of
pain level during various types of movements. In
comparison the described own-devised method (not
self-administrated) evaluates in detail the pain during
rest or different activity levels, the severity of morning
stiffness according to its duration and the overall
function (walking, stairs). This method does not
evaluate the joint stability or limb alignment because
debridment arthroscopy does not have the possibility
to modify these parameters.
The results, obtained using arthroscopic
debridement for knee OA and published by numerous
orthopaedic surgeons, are varied. The variety of
arthroscopic procedures, the retrospective nature of
the majority of published studies, the lack of controls
and the suggestion that the placebo effect may be
responsible for the benet related to arthroscopic
treatment have cast doubts about the efciency of this
technique.
16,17

Sprague (1981) reported in his study a reduction of
the knee pain level in 74% of the patients, reduction
maintained during one year after arthroscopy, while
Timoney et al. (1990) reported favorable results in
only 45% of the patients at four years follow-up.
18,19
In a study published in 1996 Jackson et al.reported
favorable results in decreasing the knee pain level after
arthroscopic lavage and debridement in 85% of his
patients two years after surgery.
20
The author underlines
the importance of minimal axial limb malalignment
and biomechanical stable joints in achieving good
results while chondral fractures and large osteophytes
are responsible for poor results.
Johnson (1996) was one of the rst orthopaedic
surgeons who used this combined method of
arthroscopic debridement and lavage in 99 arthritic
knees.
21
In his study (two years follow-up) the author
reported pain alleviation in 78% patients, no change in
15%, while 7% of his patients complained of greater
knee pain.
According to Hubbard (1996) the late results are
better after debridement arthroscopy comparing to
those obtained using only arthroscopic lavage.
22
The
author reported in a prospective study (follow-up of
4.5 years) alleviation of knee pain level in 19 (59.37%)
from 32 patients who underwent arthroscopic
debridement compared to only 3 (11.53%) from 26
patients who underwent arthroscopic lavage.
A recent survey of Canadian surgeons found
_____________________________
0esIa 0. Fe et aI 153
considerable disagreement about the utility of
arthroscopy for the treatment of this disease in
three hypothetical case scenarios; Wai et al. using
administrative data sets shows that 18.4% of 6212
patients had had a total knee replacement within three
years after arthroscopic dbridement.
23,24
Other authors disagree with these results suggesting
that arthroscopy in arthritic knees has a placebo role.
In a study published in 2002 by Moseley et al. the
authors intended to demonstrate this effect in 180
patients with radiographic knee OA lesions.
25
These
patients were divided in three therapeutic groups. The
patients in the rst group underwent debridement
arthroscopy, those in the second group underwent only
lavage arthroscopy while for those in the third group
(placebo group) the surgeon did only two supercial
skin incisions without performing a real arthroscopy.
The outcome in all patients was recorded according
to pain and function scores with a follow-up of 24
months. The results of this randomized study showed
no signicant differences between the three groups of
patients; all patients reported symptom alleviation. The
weakness of this study resides in the low representative
population most of the patients were males from a
Veteran Hospital, and in the absence of information
about the meniscal pathology.
Dervin et al. reported, in a study published in
2003, clinically important reduction in the pain score,
according to the rating on the WOMAC pain scale, in
fty-six patients (44%) at two years after arthroscopic
debridement.
26
Most failures were evident in the rst
year after surgery.
Currently orthopaedic surgeons have not reached
a consensus with regard to which patients should be
applied this surgical procedure for the treatment of
knee OA.
This study reveals the role of debridement
arthroscopy in signicant reduction of pain during
rest and activity at 6 months and one year after
arthroscopy in 51 (49.51%), respectively 42 (40.77%)
patients, while at the last evaluation only 30 (35.71%)
patients reported an alleviation of the pain level.
Before arthroscopy 71 (68.93%) patients reported
morning stiffness, at one year after surgery 9 (12.67%)
of these patients conrmed an improvement, 51
(71.83%) did not conrm any improvement, while
11 (15.49%) reported worsening of this complaint; at
the last evaluation in only 7 patients this improvement
remains unchanged.
At one year after arthroscopy 32 (31.06%) pacients
reported the possibility to walk on longer distances and
21 (20.38%) patients were able to climb more stairs
than preoperatively; at the last evaluation these results
remained unchanged. A clinical signicant range of
motion (ROM) improvement was not recorded at one
year after surgery and at the last evaluation.
At one year after surgery and at the last evaluation
25 patients needed aids for walking and/or stairs
compared to 34 prior to surgery. Clinically signicant
improvement of extension lag or exion contracture
was not recorded at any evaluation.
Favorable results were recorded in patients with
mediolateral and anteroposterior instabillity less
than 10 degrees respectivelly 5 mm, predominant
unicompartmental degenerative radiographic lesions
grade I, II and III according to the Kellgren-Lawrence
scheme, limb axial malalignment of maximum 10
degrees, cartilage lesions grade 1,2 and 3 (Outerbridge),
presence of unstable meniscal tears, large loose bodies,
loose chondral aps and absence of total ACL tears.
The best results were achieved in younger patients
who complained of mechanical symptoms (like
pseudoblocking, catching or giving-away, stable
joints, mild radiographic changes (grade I and II),
degenerative cartilage changes grade 1 and 2 and
presence of unstable meniscal tears; in these patients
the obtained results remained unchanged until the last
evaluation.
Poor results were recorded in obese patients with
symptoms (especially rest pain) of long duration, limb
alignment greater than 10 degrees, unstable joints,
grade III and IV radiographic changes extended in all
joint compartments, grade 4 cartilage lesions and large
degenerative changes in both menisci
&21&/86,216
Arthroscopic debridement is considered when
medical management in knee osteoarthritis has failed
to satisfactorily reduce symptoms.
A great importance in achieving best results by
performing arthroscopy in knees with degenerative
lesions is to establish the correct indication; thus
it is important to counsel patients about the limited
indications and palliative results. An appropriate
illness history and a proper clinical examination of the
symptomatic knee are helpful in revealing mechanical
problems like unstable meniscal tears, loose bodies
or unstable chondral aps. Arthroscopic removal of
these lesions is followed by successful recovery of
joint function and knee pain alleviation. Decrease of
the knee pain level is the most common short- and
medium-term result obtained in selected patients by
performing debridement arthroscopy for OA.
_____________________________
154 IM1 2005, eI. 55, 8e. 2
Several factors determine prognosis after
arthroscopic lavage and debridement; the patients
who benet most present with a history of mechanical
symptoms, symptoms of short duration, normal
alignment and a stable joint, only mild to moderate
radiographic evidence of osteoarthritis and grade 1, 2 or
3 cartilage lesions with predominant unicompartmental
localization.
This own evaluation method may serve as an
alternative to the existing and well known clinical
rating systems and there is the possibility to add new
variables in the aim to improve the results specicity.
5()(5(1&(6
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