This article is more than 5 years old. Information may no longer be current.
Surgical technique: Debridement of the arthritic knee
Debridement of the arthritic knee was originally introduced as an open surgical technique. The procedure involved an extensive arthrotomy with a radical debridement of the knee, occasionally including a patellectomy. Later, Pridie introduced the concept of drilling exposed subchondral bone, in an effort to obtain a reparative fibrocartilage in these areas, into the debridement procedures. The clinical recovery following these procedures was prolonged and had variable results.
It was only a natural transition to use arthroscopic surgical techniques for debridement of the arthritic knee. The recovery following an arthroscopic debridement was much less morbid than the previous open techniques, it produced less pain and a faster return to activities. The original arthroscopic debridement techniques varied and would often be influenced by the experience of new technology. The Pridie technique of drilling areas of subchondral bone was easily adapted to arthroscopic techniques. Lanny Johnson, MD, utilized an arthroscopic burr to introduce a variation in this concept known as an abrasion arthroplasty in the 1980s. Again, this was an attempt to restore a hyaline–like cartilage to these knees and involved a lengthy recovery with limited weight-bearing and continuous passive motion. Unfortunately, published clinical results of both of these surgical techniques did not demonstrate superior results to a more conservative debridement technique. More recently, Steadman has described a marrow stimulating technique called microfracture using a series of arthroscopic awls. The clinical results of this technique continue to emerge.
|
|
Images: Kelly MA |
Surgical technique
The clinical results of arthroscopic debridement techniques for the arthritic knee over the past 2 decades have helped influence my present surgical procedure. While some areas of the technique remain controversial, most procedures have become more conservative. Coblation techniques of diseased cartilage and meniscus have emerged recently. Most laser techniques have been abandoned and standard arthroscopic equipment can typically meet one’s needs.
The arthroscope is introduced anterolaterally and a working portal placed anteromedially. A separate inflow portal is not required. The technique proceeds from patellofemoral to the medial compartment, to the intercondylar region and finally the lateral compartment with the popliteus recess. Areas of articular cartilage fibrillation and unstable chondral flaps are debrided with a small synovial resector and arthroscopic forceps to remove potential joint debris.
I restrict use of coblation techniques to the peripheral chondral lesions in the arthritic femoral trochlea, where these lesions tend to enlarge with standard techniques. Consistent with the literature, I do not use abrasion arthroplasty or subchondral drilling in these arthritic knees. On rare occasion, I may use the microfracture technique, but have restricted this use to the femoral trochlea based on my own clinical results.
All mobile meniscal tears are resected using both hand instrumentation and shaving device. Loose bodies are removed. Typically, smaller loose bodies may be vacuumed out with a large diameter shaver and larger bodies retrieved with arthroscopic graspers. Minor synovectomy is performed typically in the prepatellar region and medial area.
On very rare occasions, I may remove an imipinging osteophyte usually either intercondylar or patellofemoral. An extensive lavage is performed. A final check for loose bodies should include the popliteal recess. Typically, the portals are injected with marcaine.
Postoperatively, immediate range of motion is stressed and weight bearing as tolerated is allowed. Exercise programs or supervised physical therapy are employed based on patient input.
|
|
Postoperative regimen
I find the clinical course following arthroscopic debridement quite variable. The precise role of this procedure remains controversial and realistic patient expectations are crucial.
I have performed a decreasing number of these debridement procedures in my knee practice as the long-term excellent clinical results of TKA have continued to emerge. I favor a relatively conservative surgical procedure, largely without marrow-stimulating techniques.
For more information
- Michael A. Kelly, MD, is at the Hackensack University Medical Center 300 Essex St., Suite 303, Hackensack, NJ 07601. He can be contacted at 201-336-8867, fax: 201-330-8873, or michaelkelly@humed.com