Abstract Objective:
To compare improvement after arthroscopic lavage in
osteoarthritis of knee joints with conventional treatment.
Design: Open Control Trial
Setting: Tertiary care hospital
Intervention: Arthroscopic lavage and conservative
treatment.
Participants: 48 knees of 29 osteoarthritis patients
attending orthopaedic OPD from 30th January 2003 to 30th January
2004. Patients who scored < 24 on WOMAC scale were excluded.
Main outcomes measured: Functional capacity of knee by
WOMAC index at pre treatment 4th, 8th week, 12 week of follow up
after treatment. 21 knees in 13 patients received conservative
treatment. 24 knees in 16 patients received Arthroscopic lavage
with add on the conservative treatment.
Results: Both on pain and function scores cases were
worse pre treatment as expected because only patients with
severer disease were likely to opt for Arthroscopic treatment.
However, patients treated arthroscopically did better both
clinically and statistically both in respect of function and
pain. However, the difference became lesser with time.
Conclusions: Cases initially worst than controls did
statistically and clinically better in terms of pain and
function up to 12th week of follow up without complication.
Given the low incremental cost and simplicity of this day care
procedure arthroscopic lavage is a simple useful and safe
adjunct to conventional treatment in O.A of knee, which shows a
trend to delay the progress of the disease. When is a repetition
needed and how effective will it be remain to be answered.
J.Orthopaedics
2006;3(4)e3
Introduction:
70% of above 50 years old seek treatment of symptomatic
Osteoarthritis of knee or hip. The alternatives of conservative
treatment is in effective and effective surgical procedures like
Total Knee Replacement are either too costly, undoable on such
large numbers or give results not socially acceptable in
developing country settings where activities of daily living
necessitate squatting and cross legged sitting. To preserve the
knee as long as possible and avoid or delay TKR and THR thus
becomes much more important in such settings both as a measure
of cost containment and complying with the patients social
needs. Arthroscopy fits into this gap where the simple
conservative treatment has proved in effective or dangerous
given long term toxicity of NSAID's and where the cost,
doability or social inhibitions imposed by Joint replacement are
unacceptable.
The treatment of osteoarthritis is aimed at reducing pain,
maintaining mobility and minimizing disability. The vigor of
the therapeutic intervention should be dictated by the severity
of the condition in the individual patients. The various
modalities available for the treatment represent a spectrum
ranging from simple instruction in joint protection principles.
Thermal therapy, shoes with well cushioned soles, heel wedges,
canes, quadriceps strengthening exercise, aerobic exercises,
intraarticular steroid and hyaluronic acid therapy, paracetamol
and NSAIDS and glucosamine and chondrotin sulphate are non
invasive treatments tried in every patient. However, sooner or
later some of the patients are no longer helped by these
modalities and surgical intervention like lavage debridement,
Osteotomy, chondroplasty and finally the joint replacement has
to be resorted to. The guiding principle in the choice of
treatment is the minimum effective treatment. Minimum in terms
of incremental cost, ease of doing, safety and cost of
infrastructure needed to do it. Given the huge burden of disease
cost and infra structure factors can not be ignored in
developing a treatment strategy for this extremely common
disease.
Arthroscopy lavage that flushes the mediators of inflammation
from the joint, leading to removal or dilution of enzymes that
are a part of degenerative process of osteoarthritis.
However, before adopting this technique into the standard
orthopedic armamentarium of a tertiary hospital, given the large
acquisition costs of equipment for arthroscopic lavage because
but low incremental costs of this large scale intervention,the
benefit must be proved by rigorous methodology like a randomized
controlled trial. However, due to ethical constrains and a very
large proportion of the patients coming with the fixed mind for
this or that treatment, informed consent could not be obtained
for randomization in a large proportion of cases. Accordingly,
an open quasi-random allocation trial was conducted where
allocation was dependent upon whether the patients chose
conservative treatment or arthroscopic lavage after being fully
informed in writing about the likely results of equivalence
between both, as per existing evidence.
Still the questions of will the procedure avoids TKR, THR,
delay them can be answered in much longer follow-up studies and
are beyond the scope of the present work.
Materials and methods
This is a consent based allocation trial comparing
conservatively treated cases of osteoarthritic knee (n - 21
knee) with those treated with add on arthroscopic lavage (n - 24
knee).
Study Population: All such patients with clinical
features suggestive of osteoarthritis of knee joint ranking more
than 24 or worse than on the modified WOMAC index were included
in the study reporting to the orthopedic out patient department
of BP Koirala Institute of Health Sciences, a tertiary care
orthopedic teaching facility in eastern Nepal from January 2003
t0 January 2004 were eligible. Specific inclusion criteria were
a. Inclusion criteria:
i. Knee pain
ii. Radiographic osteophytes and at least 1 of the following 3
items.
1. Age > 40
2. Morning stiffness < 30 min.
3. Crepitus on motion
b. Exclusion criteria:
i. Advanced osteoarthritis of knee
ii. Patients who have undergone arthroscopic lavage, debridement
and surgery of knee
iii. Secondary osteoarthritis of knee
iv. Excessive malalignment of knee
Intervention:
a. Control Group: The control group was given patient education,
physical therapy, range of motion exercises, quadriceps
strengthening exercises and occupational therapy besides
pharmacological therapy including non opioid analgesic (ex.
Acetaminophen), topical analgesics, NSAID and opiod analgesics
(ex. Propoxyphone, Codeine)
b. Test Group: The test group received in addition to above
arthroscopic lavage of the knee joint with 3 to 5 liter of
normal saline.
Material required: Arthroscopic lavage instruments for local
anaesthesia, solution containing 30ml of 2% xylocaine + 30ml of
xylocaine with adrenaline +60 ml of normal saline, 18 Gauge
needle, 20ml syringe, 7.5% providone 50, Surgical spirit, 3 to 5
liters of Normal saline, Mersilk suture No.1 with cutting needle
and Handi plast.
Technique: After informed consent and xylocaine sensitivity
testing the patient was put supine on the operation table.
Local infiltration of skin was done with 1% lignocaine (2%
lignocaine with adrenaline is diluted to 1% by distilled water).
- Para patellar pain points usually found on the supero -
lateral angle of the patella was identified by palpation and
depomedrol xylocaine infilteration used to treat it.
- The knee joint was then distended using 20ml syringe and
18 Gauge needle by 30-50 ml of 1% local anaesthesia through
the supra patellar pouch. The knee was then flexed up to 900
and the inferolateral portal was infiltrated by the prepared
solution.
- A cruciate stab incision was made by the surgical blade
No.15 dividing the skin and subcutaneous tissue including the
articular capsule above the infra patellar pad of fat.
- The Arthroscope sleeve with the blunt trocher was put
through the incision and aimed at the center of the
intercondylar notch; it was inserted through the capsule into
the joint, till it struck the intercondylar notch.
- Gentle pressure was applied as the knee was extended so
that the trochar slid between the patella and intercondylar
notch into the suprapatellar pouch.
The trochar was then replaced by 300 and 4 mm arthroscope and
connected to light source.
- The supra patellar pouch was scanned from side to side
from proximal to distal with the arthroscope moving in an arch
directed superiorly fill the upper edge of the patella could
be visualized. The arthroscope was then advanced medially till
the medial synovial plicae could be seen. After scanning the
patella and the supra patellar pouch arthroscope was moved for
visualization of medial tibio-femoral gutter till the medial
tibio-femoral joint line could be seen and scanned. The medial
meniscus was scanned and probed from post to anterior. Then
cruciate ligament was visualized from the femoral insertion to
tibial insertion. The lateral meniscus along with the tibial
and femoral articular surface and the post cruciate ligament
was scanned.
- The joint was washed till the haziness because of detritus
cleared. The arthroscope was removed and the trochar
withdrawn gently while pressure applied around the knee so
that collected fluid escaped. The incision was closed by one
or two stitches and covered with medicated adhesive strip
(Band aid).
- After care: Patient was made to stand and walk
immediately. The improvement status was evaluated on the
basis of modified WOMAC index and the visual analogue scale.
Quadriceps exercises were started as soon as possible. This
was followed by stitch removal on 7th day and patients were
followed on 4th, 8th week and 12th week. The parameters
were assessed in each follow-up.
- Statistical analysis:
Measurements done by WOMAC index and VAS at various visits
were recorded and entered in the Microsoft EXCEL 8 file.
Magnitude of difference was measured as difference between
mean improvement in the control and test group and
significance of improvement was measured by using ANOVA/KRUSKAL
WALLIS statistics.
Results
The comparability of the two groups was tested by comparing
demographic and disease characteristics between the two groups
as shown in Table1a, 1b, 1c, 1d, 1e and it was found that the
patients in the arthroscopy group were significantly worse of
both in terms of pain and function than controls before the
intervention.
The readings on VAS and WOMAC function scale at immediate
post op, 4th , 8th, and 12th week were compared to the base line
to define improvement in the two groups and the mean ± SD of
improvement at the 4 follow ups are reported in Table 2 along
with a column on p value showing whether the difference between
cases and controls was significant or not. Despite the cases
being initially worst than controls the arthroscopy group did
better on VAS and all parameters of function, both magnitude and
significance wise, in all follow ups but the difference was
reduced with time.
Discussion
This study proves arthroscopic lavage as a simple, useful and
safe adjunct to convention treatment in osteoarthritis of knee.
They also agree that the initial cost of equipment and hesitancy
by general orthopaedic specialist in mastering their use may be
main reasons to prevent wide spread use of this safe effective
procedure fore solution of the huge burden of morbidity that
osteoarthritis knee imposes on the community, Health managers
must find ways of circumventing these hurdles. The
controversies demanding answers are what should be the minimal
volume of irrigation and does debridement help – serial
1,2,3,4,5,6,7– feel YES
Conclusion:
Cases initially worst than control did statistically and
clinically better in term of pain and function up to 12th weeks
of follow-up and no complication. By persual of the above
mentioned ii may be concluded that the abobe literature in its
entirely agrees with the present study that arthroscopic lavages
is a simple, useful and safe adjunct to convential treatement in
osteoarthritis of knee. They also agree that the initial cost of
equipment and hesitency by general orthopaedic specialist in
mastering their use may be main resion to prevent wide spreae
use of its safe effecative procedure for solution of the huge
burden of morbidity that osteoarthrits knee imposes on the
community. Health manaager must find ways of circumventing those
hundles.
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