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Arthroscopic Surgery in Knee Osteoarthritis

Editorial editorial

Prof. Dr. Dan Osvald Lucaciu
Rehabilitation Clinic
Cluj-Napoca, Romania

 

Osteoarthritis is the most common type of arthritis, representing a degeneration of joint cartilage and subchondral bone. It is most common in knees and hips, usually affecting people over 50 years, but can also be found in younger people as well. When symptoms cannot be controlled by conservative treatment including weight reduction, physiotherapy, intraarticular injections, topical or systemic drugs, then total knee replacement is the treatment of choice. Arthroscopy is a minimally invasive procedure for diagnosing and treating joint pathologies.

There has been a great debate over the last years regarding the role of arthroscopy in knee osteoarthritis. The need for an evidence-based decision required high quality randomized control studies, which now seem to clarify the indications and contraindications of arthroscopic surgical treatment in knee osteoarthritis.

Current evidence shows that there is no difference in functional scores, pain and quality of life between groups receiving physical therapy and groups undergoing arthroscopic treatment. Moreover, there has been no difference in groups receiving arthroscopic treatment and placebo surgery for knee osteoarthritis. As a result, American Academy of Orthopaedic Surgeons strongly recommend against performing arthroscopy in patients with primary symptomatic osteoarthritis of the knee.

On the other side, we consider that arthroscopy has its indications for associated pathologies in an osteoarthritic knee. Mechanical symptoms including locking and jamming of the knee due to lose bodies, catching of the knee due to meniscal or chondral flaps, represent indications for arthroscopic surgery. It is sometimes difficult to decide whether the knee pain is due to meniscal tears, which may be managed arthroscopically, or due to osteoarthritis. A pain with acute onset, limited to medial joint line (sometimes lateral joint line) and tenderness when palpating the medial or lateral joint line usually points acute meniscal pathology. Of great importance is that surgical outcomes might only reduce mechanical symptoms and not relieve pain or reduce knee swelling. Therefore the patient needs to be well informed regarding the possible outcomes. Furthermore, we consider that degenerative meniscus pathology should not be addressed arthroscopically, due to poor results in current literature.

A great importance is the presence of sub-chondral stress fractures associated to meniscal pathology, especially in elderly. In such cases, the stress fracture can produce the pain, and not the meniscal pathology. If partial meniscectomy is performed in such cases, pain can be aggravated by the procedure. Therefore, an MRI is an examination of great importance for a thorough examination of the knee pathology to prevent wrong surgical indication.

Another indication is a limited chondral lesion, usually medial. In this setting, marrow stimulation, matrix-induced autologous chondrocyte implantation, osteochondral autograft transfer and osteochondral allograft are of great importance with good outcomes, especially in younger patients. Intraarticular soft tissue pathology can also be addressed arthroscopically in case of acute onset, for example pigmented villonodular synovitis.

As a conclusion, arthroscopy has limited indications in knee osteoarthritis, but when this minimally invasive surgery is adequately performed, it can reduce symptoms and delay the need of a total knee replacement, sometimes even prevent it. However, in most cases, conservative treatment consisting in physiotherapy can have the similar effect on symptoms compared to arthroscopic surgery.