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Arthroscopic Management for Degenerative Arthritis of the Knee

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Arthroscopic Management for Degenerative Arthritis of the Knee ICL chapter 16 Michael J. Stuart, MD Presented by: Phillip A. Pullen, DO Overview Treatment of DJD in ... – PowerPoint PPT presentation

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Title: 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 1990643-47

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 gt1mm and only 29 good
    to excellent results in knees with a joint space
    lt1mm 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 TKAs
  • 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 lt 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
Complications of Arthroscopy
  • 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

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
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