Arthroscopic surgery still plays a treatment role for specific patients with knee OA

Issue: April 2015

KOLOA, Hawaii — Despite previous controversy, recently published studies support the use of arthroscopy as treatment for select patients with knee osteoarthritis, according to Louis F. McIntyre, MD.

“There is some efficacy in delaying total joint arthroplasty in patients with osteoarthritis who are treated with arthroscopic surgery, and it is an important part of our armamentarium,” McIntyre, a solo practitioner in White Plain, NY, said during his presentation at Orthopedics Today Hawaii.

According to McIntyre, several published studies had indicated that patients with osteoarthritis (OA) of the knee did not fare well when treated with lavage, debridement, arthroscopic partial medial meniscectomy or meniscectomy alone.

“You have to look at these level 1 studies with a discerning eye and a clinical analysis,” McIntyre said.

McIntyre suggested surgeon experience may lead to better results for patients who undergo arthroscopic surgery for treatment of OA. He cited work by J. Richard Steadman, MD, and his colleagues who found an 83% survival rate at 3 years and 80% satisfaction rate in patients with severe OA treated with an arthroscopic regimen of lavage, debridement, meniscal resection, and contouring and resection of the anterior interval. A study from Korea showed 95% of patients who underwent arthroscopic medial meniscectomy for grade 4 OA of the medical compartment had no further surgery after 52-month follow-up. However, a study from Germany of 156 patients with Kellgren-Lawrence grade 2 OA showed 71% had a poor outcome after arthroscopy.

Louis F. McIntyre

“These are patients with severe disease, so in some people’s hands, arthroscopic treatment is effective in taking care of the osteoarthritic,” McIntyre said.

He cited a study by Michael J. Stuart, MD, and his colleagues which showed that patients with OA who underwent arthroscopic debridement experienced better results if they had acute onset associated with trauma, especially those with loose bodies or other mechanical problems. The study also showed the importance of patients having realistic expectations of surgery.

McIntyre also highlighted research by Dennis S. Meredith, BS, and his colleagues which showed poorer outcomes among patients with cartilage degeneration, ACL laxity, previous surgery and female sex. Similarly, Michael J. Salata, MD, and his colleagues found poorer clinical outcomes associated with total meniscectomy, degenerative tearing, obesity, ACL deficiency, chondral lesion and lateral meniscectomy.

“In my practice, most of these patients are going to get some type of conservative treatment whether it is physical therapy, steroid injections or viscosupplementation,” McIntyre said. “When they fail treatment and are still symptomatic, then arthroscopic surgery may be indicated.”

From his experience, McIntyre said patients with OA who have a history of trauma, a Kellgren-Lawrence grade of 2 or lower, mechanical symptoms and some type of mechanical derangement are best suited for arthroscopic surgery. He noted patients with extensive arthritis and meniscal resection, ACL deficiency and lateral meniscus tears may experience problems with arthroscopic treatment.

“Previous surgery is noted in the literature as a poor prognostic indicator, but I do not view it as a contraindication to surgery in my practice,” McIntyre said. “BMI may also be something you put into your calculations when you are picking these patients.” – by Casey Tingle

References:

Bin Si, et al. Arthroscopy. 2008;doi:10.1016/j.arthro.2007.08.028.
McIntyre LF. Is arthroscopy ever indicated in the OA patient? Presented at: Orthopedics Today Hawaii; Jan. 18-22, 2015; Koloa, Hawaii.
Meredith DS, et al. Arthroscopy. 2005;doi:10.1016/j.arthro.2004.10.003.
Salata MJ, et al. Am J Sports Med. 2010;doi:10.1177/0363546510370196.
Spahn G, et al. Arthroscopy. 2006;doi:10.1016/j.arthro.2006.07.003.
Steadman JR, et al. Arthroscopy. 2007;doi:10.1016/j.arthro.2007.03.097.
Stuart MJ, et al. Arthroscopy. 2006;doi:10.1016/j.artho.2006.01.008.

For more information:

Louis F. McIntyre, MD, can be reached at Westchester Orthopedics, 311 North St., Suite #102, White Plains, NY 10605; email: lfm@woapc.com.

Disclosure: McIntyre has stock options in Tornier Medical; received speaker fees from DePuy-Mitek and Quintiles Medical; and received a research grant from DePuy-Mitek.