Arthroscopy: The Journal of Arthroscopic and Related Surgery
Volume 26, Issue 2 , Pages 143-144, February 2010

Is There a Role for Arthroscopy in the Treatment of Osteoarthritis?

Article Outline

 

Twenty-five years ago, in his editorial for the first issue of Arthroscopy: The Journal of Arthroscopic and Related Surgery,1 S. Ward Casscells, the Editor-in-Chief, noted that the role of this new journal was to “keep its readers abreast of new knowledge and techniques.” In that first volume, two articles specifically addressed the issue of arthroscopy and osteoarthritis of the knee. Both were looking at the treatment of degenerative meniscal tears in the face of osteoarthritis. The articles reached conflicting conclusions and the debate continues today. The article by Ferkel et al.2 concluded, “Because degenerative posterior horn tears had such a high percentage of unsatisfactory results, the question remains as to whether all these tears need to be removed.” In contrast to this, Rand3 concluded, “The results of arthroscopic partial meniscectomy in the older patient with osteoarthritis appears encouraging.”

That the debate continues today as to the role of arthroscopic surgery in the osteoarthritic joint is highlighted by two guidelines recently produced by the American Academy of Orthopaedic Surgeons.4, 5 The development of a guideline by the process employed by the Academy is a strict and formalized exercise requiring that, for a paper to be included, it must have a minimum 2-year follow-up and report patient-oriented outcomes. In this process, the presence of 2 or more Level I or II studies, with nonconflicting data, eliminates all lesser quality evidence from consideration. This demonstrates the relative importance given to higher quality data.

I had the privilege of chairing the work group from the Guideline and Evidence-Based Practice Committees of the AAOS that was charged with writing the guidelines for treatment of osteoarthritis of the knee (nonarthroplasty).4 The potential role for arthroscopic surgery fell within our charge. Although a number of Level I studies6, 7, 8 have failed to show benefit of arthroscopic debridement or lavage in patients with significant osteoarthritis (Kellgren-Lawrence stage ≥2) of the knee, when compared with less invasive treatment modalities, all eliminated those patients who were most likely to benefit from arthroscopy, the patients with significant meniscal tears.

I strongly believe that arthroscopic partial meniscectomy for a traumatic meniscal tear, in a well-aligned knee, is an extremely beneficial procedure for that patient with mild to moderate osteoarthritis (Kellgren-Lawrence stage 1-2), with significant symptoms from the torn meniscus. The AAOS Guidelines for the Treatment of Osteoarthritis of the Knee Prior to Joint Replacement Arthroplasty recommend that arthroscopic surgery is an option for this patient. Currently, there is an ongoing, multicenter study, funded by the National Institutes of Health, designed to answer that very question (Jeffrey N. Katz, M.D., personal communication, 2009). Its conclusion is likely 2 years away. We arthroscopic surgeons, who have as our over-reaching goal to improve our patients' lives through minimally invasive techniques, remain concerned that governmental regulatory agencies, in their zeal to cut costs, will choose to eliminate funding for meniscectomy if there is any degenerative arthritis. Medicare eliminated reimbursement for arthroscopic debridement or lavage of the knee within a year of the publication of the study from Moseley et al.,6 despite the lack of additional supporting research at that time.

The AAOS has just released the “Guideline for the Treatment of Osteoarthritis of the Shoulder.”5 Similar to our work on the knee, that Guideline on osteoarthritis of the shoulder was unable to recommend for or against the use of arthroscopy in the treatment of glenohumeral osteoarthritis because of inadequate evidence available in the literature. We have all become familiar with the hierarchy of the Levels of Evidence over the past 5 years. Our journal publishes the hierarchy table each month in our Instructions to Authors. While osteoarthritis of the shoulder is much less prevalent than osteoarthritis of the knee, this lesser number of available study subjects will make it difficult to complete randomized controlled trials (Levels I or II) to identify the role of arthroscopic surgical techniques in the treatment of osteoarthritis of the shoulder. I encourage all with an interest in this area to meet our Academy's strict guideline criteria by prospectively looking at their results with patient-oriented, validated outcome measures, and a minimum 2-year follow-up. The limited information available from Level I and Level II studies as to the role of arthroscopy in the treatment of osteoarthritis of the knee or shoulder highlights our need for randomized controlled trials of arthroscopy for specific indications within these conditions. In the era of evidence-based medicine, we must define where arthroscopic surgery is of benefit to our patients with these conditions. We owe our patients nothing less.

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References 

  1. Casscells SW. A new journal: Arthroscopy. Arthroscopy. 1985;1:1;(editorial)
  2. Ferkel RD, Davis JR, Friedman MJ, Fox JM, Del Pizzo W, Snyder SJ, et al. Arthroscopic partial medial meniscectomy: An analysis of unsatisfactory results. Arthroscopy. 1985;1:44–52
  3. Rand JA. Arthroscopic management of degenerative meniscus tears in patients with degenerative arthritis. Arthroscopy. 1985;1:253–258
  4. Richmond J, Hunter D, Irrgang J, Jones M, Levy B, Marx R, et al. Treatment of osteoarthritis of the knee (nonarthroplasty) (AAOS Clinical Practice Guideline Summary). J Am Acad Orthop Surg. 2009;17:591–600
  5. Osteoarthritis Shoulder Guideline reference. www.aaos.org/Research/guidelines/gloguideline.aspAccessed December 14, 2009
  6. Moseley JB, O'Malley K, Petersen NJ, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2002;347:81–88
  7. Herrlin S, Hållander M, Wange P, Weidenhielm L, Werner S. Arthroscopic or conservative treatment of degenerative medial meniscal tears: A prospective randomized trial. Knee Surg Sports Traumatol Arthrosc. 2007;15:393–401
  8. Kirkley A, Birmingham TB, Litchfield RB, et al. A randomized trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2008;359:1097–1107

PII: S0749-8063(09)01074-3

doi:10.1016/j.arthro.2009.12.003

Arthroscopy: The Journal of Arthroscopic and Related Surgery
Volume 26, Issue 2 , Pages 143-144, February 2010

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