More than 80 percent of patients returned to walking, yardwork and other light activity one week after undergoing knee arthroscopy, according to a study published in the January 2008 issue of Arthroscopy: The Journal of Arthroscopic and Related Surgery. The study is the first to quantify recovery times for patients having the minimally-invasive procedure.
Knee arthroscopy, one of the most commonly performed surgical procedures, uses a small camera to diagnose and treat abnormalities inside the knee joint. It has revolutionized orthopaedic surgery in many ways, including the diagnosis and treatment of a wide variety of musculoskeletal ailments.
The pencil-sized arthroscope is inserted into the knee joint through a small incision to give orthopaedic surgeons a clear view inside the knee. The camera is attached to a video monitor allowing the surgeon to thoroughly examine the interior of the knee and determine the source of the problem. During the procedure, the surgeon also can insert surgical instruments through other small incisions in the knee to remove or repair damaged tissues.
The study was conducted to test the hypothesis that a majority of patients return to unrestricted activity within four weeks after knee arthroscopy. The study found:
- 88 percent of patients described knee-related activity restriction before surgery
- 82 percent of patients returned to walking and other light activity one week after surgery.
This improved to 94 percent after two weeks and 100 percent after four weeks.This is good news for baby boomers and athletes alike. For people where non-surgical treatments did not work for their knee damage, arthroscopy appears to yield promising results for people who want to get back on their feet shortly after surgery.
Researchers had 72 knee-surgery patients – whose median age was 44 years of age – compete diaries before the surgery and at intervals up to 24 weeks after surgery.
While most arthroscopies are performed on patients between 20 and 60 years of age, people younger than 10 and older than 80 have benefited from the procedure. Typical candidates for the surgery are active people in their 30’s and 40’s who are starting to experience knee pain from decades of running, skiing, basketball and other sports. The knee pain usually includes:
- swelling
- catching,
- giving way, and
- general loss of confidence in knee function
When non-surgical treatments such as medications, knee supports and physical therapy provide no significant improvement, orthopaedic surgeons may suggest arthroscopy for certain conditions.
In my own experience, I have found that patients with a meniscus tear and no arthritis will do very well after surgery. These patients recover quickly and have little if any long term pain.
Those with arthritis and a meniscus tear may continue to have some pain even after the surgery due to the presence of the arthritis. How much pain can vary.
Below is some info from a newsletter that I provide to patients preoperatively in the office.
Knee Arthroscopy and the Arthritic Knee
Osteoarthritis is one of the most common causes of adult knee pain, and symptomatic disease of the knee affects up to 6% of the adult population. Arthroscopic débridement is considered when medical management has failed to satisfactorily alleviate symptoms. This procedure involves placing an arthroscope into the knee to remove any loose pieces of joint or meniscus cartilage that may exist.
Knee arthroscopy is the treatment of choice for meniscus tears of the knee with a very high rate of patient satisfaction. However, when meniscus tears of the knee are combined with arthritis of the knee the results become less predictable. The results of knee arthroscopy under these circumstances will depend on what portion of the knee pain is due to the arthritis and how much is due to the meniscus tear. Predicting the amount of pain relief before surgery can be difficult and a successful operation depends on the degree of arthritis.
The reasons why arthroscopic débridement of osteoarthritic knees is so commonly performed are understandable. It is an outpatient procedure with less serious potential complications than other surgical treatments for osteoarthritis. The postoperative course is predictable, and the risk of complications is acceptably small for most patients. It does not preclude later definitive surgery, and so patient and surgeon may feel it is “worth a try.” Some studies have found that as only 44% of the patients had a successful outcome from arthroscopic débridement for arthritis. Nevertheless, the finding that some patients have clear improvement has encouraged surgeons to modify the intervention and improve patient selection so that the proportion of patients with a successful outcome is increased.
Patient Variables
Several studies have detailed the influence of certain variables on outcome following arthroscopy. Negative prognostic factors (indicators of a possible poor outcome) include limb malalignment (bow-legged or knock-kneed alignment due to loss of joint cartilage), severe osteoarthritis of the medial (inner) compartment, and a longer duration of preoperative symptoms. The severity of osteoarthritis, as measured by joint-space narrowing on the preoperative weight-bearing x-ray, indicates a higher likelihood of a poorer outcome after arthroscopy due to the presence of continued pain from arthritis.
Obesity is a risk factor for both the development of osteoarthritis and for radiographic progression. However, it does not negatively affect the outcome after arthroscopic débridement and should not be held as a negative prognostic factor for this procedure.
Female patients reported a greater degree of pain than males at baseline, which, although it was not significant, is worth noting. This observation has been noted in previous studies of patients managed with knee arthroplasty because of osteoarthritis. It is also particularly relevant because female patients reported a significant improvement in function and a trend toward greater improvement in pain, and they may be especially good candidates for this procedure if other indications are appropriate.
The Degree of Arthritis Affects Outcome
Osteoarthritis has a clinical spectrum of severity, with or without coexisting mechanical derangements. Generally speaking, about two-thirds of knees with osteoarthritis have a good clinical response to arthroscopy. The authors of one study reported clinical success rates of 80% at twelve months postoperatively and 59% at sixty months.
In general, 90% of knees with mild osteoarthritis and a joint space width of 
3 mm were improved after arthroscopic débridement, and we believe that the procedure should be strongly considered as appropriate treatment in such cases.
Conversely, only 40% of knees with severe osteoarthritis limb malalignment, and a joint space width of <2 mm have clear-cut relief of symptoms. Arthroscopic débridement probably should be approached carefully for such patients; it could be recommended for specific treatment goals (for example, alleviation of mechanical locking).
Valgus knees (knocked kneed) do particularly poorly with arthroscopic débridement but mild varus alignment (bow-legged) is compatible with pronounced pain relief.
Still unresolved is the role of arthroscopy for patients with moderate osteoarthritis. For this group, the severity of the cartilage lesions measured intraoperatively was the only strong indicator of clinical outcome, and the likelihood of substantial pain relief could not be predicted preoperatively. Patients need to be counseled that their clinical outcome may depend on the severity of the cartilage lesions identified at surgery and that their expectations of benefit must take this factor into account.
Limb alignment can only be measure on properly performed weight-bearing x-rays. If your x-rays were performed with you lying flat and were not performed standing they should be repeated in the office before continuing treatment.
In our main office at the
Surgical Options
Arthroscopic meniscectomy
Arthroscopic partial meniscectomy is a well-tolerated and effective procedure in patients who are at least forty years old and without substantial degenerative changes. The role for resection of degenerative meniscal tears with coexisting joint cartilage wear is more contentious. In one study, a retrospective review of the cases of patients who were more than forty years old when they had a partial meniscectomy, found considerably worse outcomes in those with degenerative tears (an absence of trauma and fissured, horizontal cleavage tears) than in those with traumatic tears (a history of trauma and bucket-handle or parrot-beak tears). Others reported satisfactory short-term results at a mean of 2.5 years after arthroscopic partial meniscectomy in 80% of patients with degenerative joint wear and tear changes (arthritis) compared with 95% of those without degenerative change. The balance of the evidence suggests that partial meniscectomy is an effective treatment in mild-to-moderate forms of osteoarthritis.
In summary, our review of the literature suggested that arthroscopic débridement, consisting of resection of chondral flaps and unstable meniscal tears, can offer a substantial therapeutic advantage
Arthroscopic Débridement
During arthroscopic lavage, the joint is visualized and irrigated with normal saline or lactated Ringer’s solution. Débridement procedures excise damaged portions of articular (joint) cartilage, meniscus, synovial membrane, or ligaments found within the joint. The success of lavage and débridement has been attributed to a decrease in free particles and damaged portions of cartilage and meniscus that stimulate inflammation of the synovial tissue, cause joint effusions, increase the levels of proteolytic enzymes in the synovial fluid, and increase collagenolytic activity that causes friability of the articular cartilage. Lavage alone dilutes the joint fluid, thereby decreasing the concentrations of degradative enzymes in the knee and consequently slowing the breakdown of joint cartilage maintaining the integrity of the joint. The removal of tissue debris during débridement improves symptoms by reducing the source of irritation of the synovial tissue. Patients with mechanical disturbances caused by cartilage and meniscal fragments have demonstrated substantial improvement in function and symptoms when these fragments are removed by arthroscopic techniques. The efficacy of débridement procedure may correlate with the extent of disease.
Although this technique may temporarily improve patient symptoms, they cannot stop the disease process and often provide no benefit to patients with severe disease. In older arthritic patients who had had no success with other methods of nonsurgical treatment and maintained low activity levels, arthroscopic débridement only 52% of patients experienced benefit; 39% had no benefit; and 9% experienced only temporary improvement. Clearly, the severity of the disease has implications for the outcome of treatment.
Some suggest that aggressive removal of tissue may aggravate the patient’s problem. Most commonly, studies report that some patients have maintained improvement, some show no improvement, and some are made worse by these techniques. No consensus favors or opposes arthroscopic lavage and débridement techniques in treating osteoarthritis of the knee. However, patients with extensive loss of articular cartilage, malalignment, instability, restricted range of motion, and marked radiographic evidence of osteoarthritis seem to have a lower probability of experiencing any significant benefits from these techniques. Patients with more advanced arthritis usually require total joint replacement.
Meniscectomy
Patients with meniscus tears usually benefit from arthroscopy to remove or repair the torn meniscus. Many of those patients may also have concurrent arthritis that makes to outcome of arthroscopic meniscectomy less predictable. In an older population (>40 years) with osteoarthritis and a meniscus tear 80% excellent or good results at 2.5-year follow-up are expected. In these patients the degree of arthritis is a predictor of outcome. 80% of patients with severe arthritis who undergo partial medial meniscectomy rated their improvement as significant or moderate at 3.3 years. Those with mild arthritis demonstrate better pain relief than did those with more severe arthritis.
How the tear occurs also affects the outcome of arthroscopic meniscectomy. There are two type of meniscus tears: degenerative (gradual onset, not related to any specific event) and traumatic (related to some event, sudden onset). When comparing the results of traumatic tears to degenerative tears, there is a 95% satisfaction rate at 3-year follow-up with traumatic tears versus 65% with degenerative tears. In patients with degenerative tears, the presence of advanced osteoarthritis was associated with a less favorable outcome.
Patients with normal preoperative radiographs had a greater chance of excellent or good outcomes (90%) than do patients with moderate degenerative changes (21%). Partial meniscectomy in osteoarthritic patients with a documented tear and mechanical symptoms appears to be an effective procedure for the relief of pain at short-term follow-up. However, as the severity of osteoarthritis increases, the results become less favorable.
Microfracture
Microfracture technique is a technique that may be appropriate for certain type of joint cartilage injuries. It is most effective when the defect is isolated, with surrounding normal joint cartilage, in a knee that is properly aligned, in patients with a normal body mass index.
The lesion is débrided and subchondral bone exposed. An arthroscopic awl is used to make “microfractures” in the subchondral bone by picking three or four holes per cm2 to a depth of about 4 mm. There is a 75% improvement at 3- to 5-year follow-up using the micro-fracture technique with arthroscopic awls in all patients having the procedure. Continuous passive motion and no weight bearing for 6 to 8 weeks is essential for both the gross healing of the defect and the reduction of pain.
Conclusion
Although the overall benefits of these procedures for osteoarthritic patients remain unclear, certain factors have been associated with a better or worse prognosis. Based on the review of the literature, relevant prognostic factors for the success of arthroscopic management of osteoarthritis of the knee can be established. Four categories are considered—history and symptoms, physical examination, radiographic findings, and surgical findings.
Sudden onset of symptoms related to trauma or symptoms of mechanical damage are associated with better outcomes. Physical findings of malalignment and ligament instability are associated with worse outcomes. The extent and severity of disease play an important role in patient outcome. Patients with radiographic findings of loose bodies and normal alignment have better results than do those with evidence of severe degenerative disease, such as loss of joint space. Knees with isolated lesions at the time of surgery fare better than do knees with diffuse disease. One study found a correlation of outcome with the absolute number of pathologic findings and severity of degenerative changes at the time of surgery. In addition, patients who had a higher pretreatment function fared better than did those with more severe dysfunction. Poor clinical results and higher rates of additional surgery also have been observed when severe chondromalacia is present and only eburnated bone remained.
Thanks.
JTM, MD