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Arthroscopic debridement as an alternative to total knee replacement
ABSTRACTS
pital with average hospitalization being 3.2 days. Since 1983, eight patients have been operated on an outpatient basis. The duration of symptoms averaged 7 months. The procedure is tedious and requires at least four portals to carry out adequate synovial resection, changing portals for observation with those of synovial resection. Posterior synovectomy was not performed. Surgery averaged 94 rain per knee. Patients used crutches for 11 days average (median, 7) and three did not use them at all. Average return to work was 18 days (7 days median). Range of motion averaged 4°- 103° preoperatively and 1.4°-124.6 ° postoperatively. No patient lost motion. Average preoperative pain level was rated at 4.0 (scale 0-5) and postoperatively, 1.0. Eight patients reported no pain postoperatively. Patients were asked to rate their improvement from 0 to 100%. Five reported 100%; one, 95%; one, 90%; five, 75%; five, 50%; one, 40%; two, 25%; and one, 0%. There were two other patients not responding to the questionnaire that had no improvement, resulting in three of 26 knees or 11.5% with no improvement. There were only two complications, i.e., one pulmonary embolus I month postoperatively and one noninfected draining sinus. Arthroscopic synovectomy is a viable alternative to arthrotomy and synovectomy. It has less complications and equal or better short-term results than an open procedure.
123
fusion during surgery and wall suction. Hemovac drains were used for 24-48 h as was continuous passive motion postoperatively during hospitalization and home use. A proximal approach was used, exposing distal with 30° scope. Thorough knowledge of various prostheses is necessary. Posteriorlateral and posterior-medial approaches are mandatory with certain prostheses. Meticulous technique is necessary to.avoid scratching the prosthesis; bleeding is controlled with an electrosurgical unit, and a lateral release is performed with extensive lysis of adhesions and resection of scar tissue. In summary, the study included six men and three women. One woman had a revision due to a loose tibial component detected at arthroscopy. The study was conducted over the past 2½ years, with follow-up of 6-30 months. Eight patients have experienced less pain and an increase in flexion averaging 15° and extension 5°. There were no major complications. Arthroscopy in total knee replacements can be performed, although it's technically very difficult. Certain pathological conditions are observed and described. Safety to the patient, as far as sterile technique, is critical with infection being the most important potential danger. Patient selection is important. This group did benefit as far as relief of pain and increased motion.
Arthroscopy in Failed Total Knee Replacements. Edward D. Campbell, Jr. Phoenix, Arizona, U.S.A.
Arthroscopic Debridement as an Alternative to Total Knee Replacement. Jerome E. Jennings. WinstonSalem, North Carolina, U.S.A.
The purpose of this retrospective study was to define the indications for arthroscopy in total knee replacements and describe a reproducible surgical technique. Patients with infection, loose prosthesis, or malalignment of prosthesis were excluded. The selection criteria were painful knee, restriction of motion, not a candidate for open exploration or revision, and no improvement with closed manipulation. Arthroscopy was performed in a laminar flow operating room using gas-sterilized arthroscopes, lite cord, and draped camera. No cydex soaking was used. Preparation and draping were the same as for routine total joint replacements. Arthroscopic instrumentation included probes, baskets, scissors, power cutters, synovial resectors, electrosurgical unit, 30° and 70° arthroscopes, leg holder, and tourniquet when not contraindicated. IV antibiotics were given pre- and postoperatively for 48 h, and antibiotics were added to the lactated ringer in-
Total knee replacement is accepted as the treatment of choice for the painful, osteoarthritic knee with multiple compartment involvement. Advancement in design and fixation has improved results in total knee replacement but problems still exist including infection, loosening of components, postoperative pain, and thromboembolism. This study presents arthroscopic debridement as an alternative in selected patients with severely osteoarthritic knees who by symptoms, examination, and x-rays would be candidates for total knee replacement. Examples of patients so selected would be younger patients with traumatic arthritis, elderly patients who have low activity requirements, and patients in poor health who have pain at rest. Some patients refused total knee replacement or arthrodesis for various reasons but agreed to an arthroscopic procedure. Arthroscopic surgery was carried out on 62 Arthroscopy, Vol. 2, No. 2, 1986
124
ABSTRACTS
knees in 56 patients with severe osteoarthritis between October 1978 and November 1982. The procedure consisted of arthroscopic synovectomy, excision of osteophytes, removal of degenerative menisci and loose bodies, and drilling or abrasion of exposed subchondral bone. Postoperative care consisted of immediate range-of-motion and musclestrengthening exercises. Patients were encouraged to ambulate but remained non-weight-bearing for 8 weeks. "Second look" procedures were done in 20 (32%) knees. Follow-up evaluations were made every 3 months for 24-48 months. All patients claimed to have relief of pain in the immediate postoperative non-weight-bearing period. Evaluation at the 6-month postoperative interval related good results in 69% (43 knees); fair in 27%; and poor in 4% (two knees, one patient). At the 24-month evaluation, 80% (50 knees) revealed good, 10% fair, and
Arthroscopy, Vol. 2, No. 2, 1986
10% poor results. Results of knees evaluated at 48 months revealed 46 knees (74%) good, nine (15%) fair, and seven (11%) poor. No patient went from good to poor between 24 and 48 months, but patients did fluctuate between fair and good during this period. Conclusions from this study show that in selected patients arthroscopic debridement is an acceptable procedure for the severely osteoarthritic knee. The relief of pain is not consistently predictable but is present in a high percentage of patients. Hospitalization is short (2-6 days), and morbidity is minimal. Although arthroscopic debridement is not considered to be as definitive or as predictable as total knee replacement, it will certainly give significant relief of pain and increased activities in many patients.
pital with average hospitalization being 3.2 days. Since 1983, eight patients have been operated on an outpatient basis. The duration of symptoms averaged 7 months. The procedure is tedious and requires at least four portals to carry out adequate synovial resection, changing portals for observation with those of synovial resection. Posterior synovectomy was not performed. Surgery averaged 94 rain per knee. Patients used crutches for 11 days average (median, 7) and three did not use them at all. Average return to work was 18 days (7 days median). Range of motion averaged 4°- 103° preoperatively and 1.4°-124.6 ° postoperatively. No patient lost motion. Average preoperative pain level was rated at 4.0 (scale 0-5) and postoperatively, 1.0. Eight patients reported no pain postoperatively. Patients were asked to rate their improvement from 0 to 100%. Five reported 100%; one, 95%; one, 90%; five, 75%; five, 50%; one, 40%; two, 25%; and one, 0%. There were two other patients not responding to the questionnaire that had no improvement, resulting in three of 26 knees or 11.5% with no improvement. There were only two complications, i.e., one pulmonary embolus I month postoperatively and one noninfected draining sinus. Arthroscopic synovectomy is a viable alternative to arthrotomy and synovectomy. It has less complications and equal or better short-term results than an open procedure.
123
fusion during surgery and wall suction. Hemovac drains were used for 24-48 h as was continuous passive motion postoperatively during hospitalization and home use. A proximal approach was used, exposing distal with 30° scope. Thorough knowledge of various prostheses is necessary. Posteriorlateral and posterior-medial approaches are mandatory with certain prostheses. Meticulous technique is necessary to.avoid scratching the prosthesis; bleeding is controlled with an electrosurgical unit, and a lateral release is performed with extensive lysis of adhesions and resection of scar tissue. In summary, the study included six men and three women. One woman had a revision due to a loose tibial component detected at arthroscopy. The study was conducted over the past 2½ years, with follow-up of 6-30 months. Eight patients have experienced less pain and an increase in flexion averaging 15° and extension 5°. There were no major complications. Arthroscopy in total knee replacements can be performed, although it's technically very difficult. Certain pathological conditions are observed and described. Safety to the patient, as far as sterile technique, is critical with infection being the most important potential danger. Patient selection is important. This group did benefit as far as relief of pain and increased motion.
Arthroscopy in Failed Total Knee Replacements. Edward D. Campbell, Jr. Phoenix, Arizona, U.S.A.
Arthroscopic Debridement as an Alternative to Total Knee Replacement. Jerome E. Jennings. WinstonSalem, North Carolina, U.S.A.
The purpose of this retrospective study was to define the indications for arthroscopy in total knee replacements and describe a reproducible surgical technique. Patients with infection, loose prosthesis, or malalignment of prosthesis were excluded. The selection criteria were painful knee, restriction of motion, not a candidate for open exploration or revision, and no improvement with closed manipulation. Arthroscopy was performed in a laminar flow operating room using gas-sterilized arthroscopes, lite cord, and draped camera. No cydex soaking was used. Preparation and draping were the same as for routine total joint replacements. Arthroscopic instrumentation included probes, baskets, scissors, power cutters, synovial resectors, electrosurgical unit, 30° and 70° arthroscopes, leg holder, and tourniquet when not contraindicated. IV antibiotics were given pre- and postoperatively for 48 h, and antibiotics were added to the lactated ringer in-
Total knee replacement is accepted as the treatment of choice for the painful, osteoarthritic knee with multiple compartment involvement. Advancement in design and fixation has improved results in total knee replacement but problems still exist including infection, loosening of components, postoperative pain, and thromboembolism. This study presents arthroscopic debridement as an alternative in selected patients with severely osteoarthritic knees who by symptoms, examination, and x-rays would be candidates for total knee replacement. Examples of patients so selected would be younger patients with traumatic arthritis, elderly patients who have low activity requirements, and patients in poor health who have pain at rest. Some patients refused total knee replacement or arthrodesis for various reasons but agreed to an arthroscopic procedure. Arthroscopic surgery was carried out on 62 Arthroscopy, Vol. 2, No. 2, 1986
124
ABSTRACTS
knees in 56 patients with severe osteoarthritis between October 1978 and November 1982. The procedure consisted of arthroscopic synovectomy, excision of osteophytes, removal of degenerative menisci and loose bodies, and drilling or abrasion of exposed subchondral bone. Postoperative care consisted of immediate range-of-motion and musclestrengthening exercises. Patients were encouraged to ambulate but remained non-weight-bearing for 8 weeks. "Second look" procedures were done in 20 (32%) knees. Follow-up evaluations were made every 3 months for 24-48 months. All patients claimed to have relief of pain in the immediate postoperative non-weight-bearing period. Evaluation at the 6-month postoperative interval related good results in 69% (43 knees); fair in 27%; and poor in 4% (two knees, one patient). At the 24-month evaluation, 80% (50 knees) revealed good, 10% fair, and
Arthroscopy, Vol. 2, No. 2, 1986
10% poor results. Results of knees evaluated at 48 months revealed 46 knees (74%) good, nine (15%) fair, and seven (11%) poor. No patient went from good to poor between 24 and 48 months, but patients did fluctuate between fair and good during this period. Conclusions from this study show that in selected patients arthroscopic debridement is an acceptable procedure for the severely osteoarthritic knee. The relief of pain is not consistently predictable but is present in a high percentage of patients. Hospitalization is short (2-6 days), and morbidity is minimal. Although arthroscopic debridement is not considered to be as definitive or as predictable as total knee replacement, it will certainly give significant relief of pain and increased activities in many patients.