osteoarthritic knees were treated by arthroscopic lavage and physiotherapy, and a control group of 24 knees were treated by physiotherapy alone. There.
ARTHROSCOPIC
PETER
From
J. LIVESLEY,
Mansfield
A strong
MICHAEL
District
clinical
osteoarthritis
LAVAGE
General,
impression
of the
knee.
OF
DOHERTY,
Harlow
exists
MAURICE
Wood
that
A controlled
trial
joint was
OSTEOARTHRITIC
NEEDOFF,
Orthopaedic
lavage
and
often
conducted
ALAN
City
MOULTON
Hospitals,
provides
to test
KNEES
Nottinghamshire
symptomatic
this
hypothesis.
relief
for
A group
painful
of 37 painful
osteoarthritic knees were treated by arthroscopic lavage and physiotherapy, and a control group of 24 knees were treated by physiotherapy alone. There was better relief of pain in the lavage group, and the effect was still present at one year. An improvement in the signs of inflammation lasted for about three months. Pain was relieved more effectively in patients with slight radiographic changes than in those with advanced changes. Our results confirm the effectiveness of joint lavage in the management of painful osteoarthritis of the knee. Osteoarthritis bearing (Lowman
is present
radiographically
joints of 90% of people 1955 ; Keligren 1961)
affected joint is the knee (Heine impression exists that washing the pain (Burman, is true the simple improve
Finkelstein technique
the quality
All new assessed,
referrals those
derangement
exclude
with with
haematological aspiration. abnormalities,
disorders, We
many
and
no
signs. groups
Moulton, Mansfield Mansfield,
A.
Correspondence
©
The patients according to
Orthopaedic General
Registrar Hospital,
were
trial.
screened
should
be sent
to Mr
anteromedial
were
referred. alone
followed
performed A Key
used.
via Med
All
and
a
tourniquet
anterolateral
Olympus
knees
The (P)
by physio-
with
technique
portals.
a hook
initially
lavage
was
few
days;
Registrar England.
the
same
by
were
at one, three, rest, on activity,
six
4; tenderness
regime
with
and
arthroscope
treatable
lesions
IPB,
Surgery
followed
in both
up by the same
at thejoint
line graded
a
groups.
examiner pain at from 0 to
0 to 4; and duration
of stiffness after rest and in the morning, measured in minutes. The range ofmovement was measured, effusions
ifpresent and
were graded
0 to 3, warmth,
were
Patients
crepitus
sleep
disturbance,
were
also asked
England.
noted. swelling,
to give
stress were
and
pain,
wasting
questioned
walking
an overall
Hospitals,
of the
modified
Thomas
Synovial
fluid
effusions
P. J. Livesley.
employed
about
distance.
estimate
They
of their
knee
symptoms.
Nottinghamshire
Orthopaedic
was
and 12 months. He recorded and at night, on a scale graded
Radiographs
Joint
were
by physiotherapy
a standard
admission
FRCS, Orthopaedic Consultant District General and Harlow Wood Nottinghamshire, England.
they
treated
The patients To
were divided whichever of
NG5
Mansfield,
1991 British Editorial Society of Bone and 0301 -620X/9l/6259 $2.00 J Bone Joint Surg [Br] 1991 ; 73-B : 922-6.
922
the
were
MA, MD, MRCP, Senior Lecturer Unit, City Hospital, Nottingham
M. Needoff, FRCS, Mansfield District NGI9 7AY, England.
employing
mechanical
into
P. J. Livesley, BSc, FRCS, FRCS Ed, Orthopaedic Queen’s Medical Centre, Nottingham NG7 2UH, Doherty, Rheumatology
knee
obvious
all patients
surgeons were
were excluded from the trial. The remainder underwent lavage with two litres of normal saline at room temperature. Postoperatively physiotherapy was started within
of the
entered
group
the second by arthroscopic therapy (L + P).
and
METHODS
were
first
Arthroscopy
If this could
investigation, radiography and joint excluded patients with haematological urate crystals in the joint aspirate or
atypical radiographic into two treatment
M.
1934). lavage people.
osteoarthritis pain
two consultant
weight-
of 40 years commonly
A strong clinical knee can relieve
and Meyer of arthroscopic
AND
of the joint
other
1926). out the
of life of very
PATIENTS
in the
over the age and the most
separated
to were
knees
scoring samples the
from
study.
aspirated.
from
the
alizarin
red
crystals.
Pyrophosphate
dye
were
system
all knees At
The
debris
fluid
demonstrate
levels
using
a
et al 1975).
were
follow-up
supernatant to
assessed
(Thomas
obtained
all
knees
on with
in the
aspirate
was
and
stained
with
calcium-containing
and
enzyme
activity
were
t-test
or the
measured.
The
results
were THE
assessed JOURNAL
by the paired OF BONE
AND
JOINT
SURGERY
ARTHROSCOPIC
Mann-Whitney
U
test
as
appropriate.
LAVAGE
Scores
OF OSTEOARTHRITIC
were
KNEES
II). No significant
923
difference
was found
in the improve-
compared at each assessment with the baseline score of the group. An ‘improvement score’ was generated for each patient, being the difference between the score at
ment score for this symptom at any stage. Pain on activity was also reduced by both treatment regimes in the same pattern as rest pain. However, the improvement score
the initial
showed
scores
assessment
of the
and
two
Mann-Whitney
at follow-up.
groups
were
then
The
improvement
compared
by the
while
U test.
28 entered
the physiotherapy
of the trial. Four were lost to follow-up reviewed. Of the 41 patients who entered
(P) arm
and 24 the lavage
were and
physiotherapy (L + P) group of the trial, two had partial meniscectomies and two were lost to follow-up ; therefore 37 of these patients were reviewed. The two groups had a similar distribution of age, sex and radiographic severity of disease (Table I). Of the factors measured, stress pain and morning stiffness were worse in the P group ; swelling and effusions were more common in the L + P group. No difference was observed between the two
groups
at the
initial
features.
The
analgesic
at initial
assessment.
significant
difference
assessment intake
Although between
in other
P
Thomas
(7.9)
score
5.29
(2.7)
61 5.3
two
groups
(7.8)
showed
with
although show a tenderness unaffected
by
showed decreased
physiotherapy
73-B,
produced
no
between
(Table
III).
improvement
change.
score
L+ P
at
group
unaffected
showing
six
score
Joint warmth months while
However,
a greater
months.
the
by physiotherapy
benefit
Morning
im-
in
stiffness
but significantly
the
was
diminished
L + P group to three months. The improvement however, showed no difference. Stiffness after
activity creased
improved in both in the L + P group
did
last
groups.
only, six months.
beyond
remained between
low at the two
Joint
ofmovement improved Mean flexion increased
and
swelling
from
de-
but this improvement The rate of recurrent
1 2 months, a groups existed
significant up to six
in both from
groups 105#{176} to
104#{176} to 119#{176} in the L+P
group.
25 12
When
the patients
were
L+P
asked
Difference In Improvement score p value
IQR
p value
M
IQR
p value
1 0.5 0.5 1.5
1 0 0 0
tol to 1 tol to2
0.008 0.004
1 0 1
0
lto2 0 to 1 Otol Otol
0.002 0.025 0.01
Painon activity
0 3 6 12
2 2 2 2
2 1 1 1
to2 to 2 to 2 to3
0.05 0.06
2 2 2 2
2to3 1 to 2 1 to 2 lto2
0.00003 0.0002 0.0005
0.003 0.05
Painat night
0 3 6 12
1 1 0.5 2
0 to2 0 tol 0 tol 0.5to2
1 0 1 1
lto2 Otol Oto2 Otol
0.0005 0.02 0.006
0.01
0.06 0.1
to assess
(M) and assessment
M
1991
difference
months. up to six
0 3 6 12
No. 6, NOVEMBER
reduction,
score did not show a significant difference. improved in both groups up to 1 2 months, the
improvement
not
; the
a difference at three in the L + P group
provement Stress pain
P
Painat rest
immediate
the improvement score lavage. Peri-articular L + P group but was
Months postoperative
Symptom
L + P at three
The improvement score from L + P only at three showed an improvement
did from the
Table 11. Pain scores for the control group (P) and the lavage group (L + P). Median interquartile ranges (IQR) are given. The p values refer to the difference between the initial and the current score. In the last column the p value compares the scores of the two groups
VOL.
an
to six months
only at six months greater benefit decreased in
118.5#{176} in the P group, 13 11
from
fell late in the P group
a significant
persisting
months. The range to a similar extent.
(2.6)
Sex male female
scores
The signs of inflammation improved to a greater degree in the L + P group (Table III). Joint-line tenderness decreased in this treatment group up to 12 months,
effusions difference
L+P
60.7
in the L + P group the
in the score,
Table 1. Demographic details of the two groups (P and L + P) on entry to the trial. The average (standard deviation) is given for the patients’ ages and for the Thomas radiographic scores of the knees on entry to the trial
(years)
benefit
pain
L + P group
physiotherapy
measured
of both groups was similar it fell during the trial no the groups emerged.
Pain at rest improved in both groups, to six months in the P group and to 1 2 months in the L + P group (Table
Age
the
greater
Night
the effect lasting for 1 2 months. for night pain showed benefit months but sleep disturbance
RESULTS Of the 69 patients,
a significantly
and six months.
0.1
the current
P. J. LIVESLEY,
924
M. DOHERTY,
M. NEEDOFF,
A. MOULTON
Table III. The signs of inflammation for the control (P) and lavage groups (L + P). Median (M) and interquartile ranges (IQR) are given. The p values refer to the difference between the initial assessment and the current score. In the last column the p value compares the scores of the two groups
P
L+P
Differencein improvement
Months M
IQR
postoperative
Joint tenderness
0 3 6 12
1 1 0 1
Otol 0 to 1 0 to 1 0 to I
Peri-articular tenderness
0 3 6
0 0 1
0 to 2 0 to 1 Otol
0 0 0
0 to 2 0 to 0 OtoO
0.001 0.003
Warmth
0 3 6
0 0 0
OtoO OtoO OtoO
0 0 0
OtoO OtoO OtoO
0.01 0.03
0 3 6
1 1 1
1 to 1.5 Otol Otol
1 0 0
1 to 1 Otol Otol
0.001 0.001
0 3 6 12
15 10 15 17.5
5to25 Oto2O OtolS 0to75
10 5 10 I
Otol5 OtolO OtolS Oto3O
12
0 0 0 0
0 to 1 Otol Otol Otol
0 0 0 0
0 to 1 OtoO Otol Otol
0 3 6 12
0.5 0 1 1
Otol Otol Otol Otol
1 0 1 1
Otol Otol Otol Otol
0 3 6
1 0 0
Otol 0 to I Otol
1 0 0
Otol 0 to 1 Otol
Morning stiffness
0 3 6
Effusions
Swelling
Sleep disturbance
state of the knee, those in the P group reported improvement up to six months, those in the L + P group up to 1 2 months. However, the improvement score was three
significantly
different
between
months (Table IV). The L + P group was
which
might
presence
or
subdivided a good result
predict absence
of
an
effusion
the
two
groups
to assess factors from lavage. The was
found
not
subgroups.
The
scores
for
pain
at rest
and
to
in
activity improved significantly at six months in the group with slight radiographic changes. In the moderately damaged
three
subgroup,
months
pain
was
relieved
Synovial contain crystals.
cells, Three
pain
on
but in knees (Table
fluid
severe
was
improved
changes
from
all knees
debris and were found
were
at
only night found
0.001 0.02
0.02 0.02
p value
score
1 0 0 0
Otol 0 to 1 0 to 1 0 to 1
0.0003 0.002 0.06
0.02
Pyrophosphate joints were significantly
p value
0.07
0.07
0.03
levels
0.03 0.1 0.1
0.1 0.1 0.1
0.01 0.07
0.03
0.0007 0.05
0.1
and
enzyme
activity
measured on entry to the trial; from normal control values.
within
neither
the
differed
DISCUSSION Osteoarthritis of the knee presents principally with pain and functional impairment. Symptoms are often episodic but in the long-term deterioration is common and there is no specific
to
calcium-containing to have birefringent
crystals of calcium pyrophosphate within theirjoints ; no urate crystals were found. No change was noted in the crystals or debris present in samples taken at follow-up.
therapy
for the condition.
Although there exists a strong clinical impression that lavage of arthritic joints leads to symptomatic improvement, there have been few trials to test the validity of this belief. The first account of joint lavage, by
V).
samples
cartilage patients
activity
with
0.002
IQR
at
correlate with the result. Radiographic criteria were used to subdivide the 37 knees into those with slight (10), moderate (1 3), and severe (14) changes. There was no difference in the age or sex distribution between the three subgroups. Pain scores were found to have improved in all three
M
Symptom
Stress pain
only
p value
Burman
et
al
(1934),
reported
two
patients
who
obtained remarkable symptomatic relief after diagnostic arthroscopy. Both had ‘simple villous arthritis’, presumably osteoarthritis. Lavage with a small bore cannula has been shown to produce no greater benefit than aspiration of the joint (Lindsay et al 1971). Dawes, Kirlew and Haslock (1987) compared joint lavage, using a 14-gauge needle, with aspiration and injection ofsaline in a group of2O patients. They found no difference between the two groups at three months, though both had improved. Bird and Ring (1978) THE
JOURNAL
OF BONE
AND
JOINT
SURGERY
ARTHROSCOPIC
LAVAGE
OF OSTEOARTHRITIC
KNEES
925
Table IV. The patients assessment of their condition, scored on a scale from to + 1 . The p values refer to the change from initial assessment to the current assessment. The p value for the improvement score is also given L+P
P
Differencein Improvement score p value
Months
Table
V.
values, the
postoperative
M
0 3 6 12
1 0 0
Average
pain
determined
score
scores
IQR
-
Otol 0 to 1 1 to 1
for the
p value
0.003 0.05
1 0 0
ltol 0 to I 0 to 1
0.0003 0.003 0.03
U test,
weeks
0.05 0.1
0.1 0.05
2.1 1.8 1.9
2.4 1.8 2.0
3.4 2.4 2.7
0.05 0.02
2.8 2.0 2.3
1.8 1.4 1.3
3.2 2.5 2.5
2.1 1.7 1.8
0 3 6 0 3 6
50%
useful study
in rheumatoid was uncontrolled
selected patients Reviewing arthroscoped
had
was and and
at rest
maintained
their
improve-
that the procedure chondrocalcinosis
seronegative and included
was of but less
arthritis. only 14
Their highly
at a secondary referral centre. a series of patients with osteoarthritis to exclude
(1982)
found
of the
a meniscal
persisting
65 patients
lesion,
symptomatic who
underwent
Jackson
improvement lavage
of management.
To reduce
contact
between
of the
the
two groups of patients, the treatment allocated depended upon the consultant to whom the general practitioner referred the patient. This resulted in an inequality of numbers between the treatment and control groups, however, comparison of the initial assessment scores shows
Those degree lasted VOL.
no
other
significant
difference
between
them.
treated by joint lavage improved to a greater than did the control group, and the improvement longer. Pain relief persisted throughout the review 73-B, No. 6, NOVEMBER
1991
Pain
period
The
score
p
and
on activity
Difference
In
improvement score p value
0.05
2.0 1.5 1.6
and
the signs
of inflammation
(Doherty
et al 1988)
improved for between three and six months. Joint swelling and effusions were diminished for the same period. The patients who underwent lavage reported improvement in their condition ; many requested further lavage at a later date. The improvement in the lavage group persisted for the duration of the trial. The physiotherapy group initially
and
joint but no operative procedure (Jackson, Marans and Silver 1988). Similar results have not been reported by others. Despite the general consensus that joint lavage may be of some value, appropriate controlled trials have not been performed. Since a sham procedure was not possible, we decided to compare lavage with a conventional method
by lavage.
the initial
p value
0 3 6
only
treated
between
3.2 2.5 2.6
Slight
The conclusion in osteoarthritis
37 knees
Night pain score
Score
the effect of arthroscopic lavage of the knee, that 93% of patients improved at one week but
by four
of the
to the difference
Score
Months postoperative
ment. value
subgroups
refer
0.08
p value
Radiographic subgroup
Severe
Rouse
IQR
at assessment
Moderate
in 45%
M
radiographic
by the Mann-Whitney
Paiji
studied reporting
p value
I
experienced
an improvement
but
by the
end
of
the study they had returned to their pretreatment state. Direct comparison between the two groups by means of the improvement score showed the advantage of the L + P group over the P group, the benefit lasting for between three and six months. However, the improvement scores did
not
differ
between
perhaps
because
greater
Some patients degree and
radiographic
the
groups
the measure
benefited for a longer
changes
is too
in the
longer
term,
insensitive.
from the procedure period. Those with
experienced
more
pain
to a slight
relief
than
those enced
with severe changes, although all groups experisome improvement. The mechanism of relief of symptoms is unknown. Removal of cartilage debris, crystals (Halverson and McCarty 1979; Dieppe, Huskinson and Willoughby 1980; Goldenberg, Egan and Cohen 1982) and inflammatory factors (Byers et al 1973) may play a part. The temporary improvement in the signs of inflammation would
support
inflammatory
the
agents,
hypothesis
though
that
the
lavage
nature
removes
of
these
is
P. J. LIVESLEY,
926
unclear.
Whether
outcome requires
of the further
such disease, study.
We conclude
in any party
that
form related
modifies
symptomatically
simple
a day-case procedure, management of painful patients for whom other No benefits commercial article.
treatment
joint
M. DOHERTY,
the
lavage
performed
received or will be received or indirectly to the subject
Dieppe
as the in
from a of this
Doherty M, Richards N, Hornby J, Powell R. Relation fluid C3 degradation products and local joint rheumatoid arthritis, osteoarthritis and crystal pathy. Ann Rheum Dis 1988; 47:190-7. Goldenberg DL, degenerativejoint Halverson PB, in synovial Heine
RW,
Jackson Ring EF. 1978; 37 :78-9. HA,
Therapeutic
value
Burman MS, Finkeistein H, Meyer BoneJointSurg 1934; 16:255-68. Byers
of arthroscopy.
L. Arthroscopy
Ann Rheum of the
knee
joint.
Dis J
PH, Ward PA, Kellermeyer RW, Naff GB. Complement as a mediator of inflammation in acute gouty arthritis. II Biological activities generated from complement by the interaction of serum complement and sodium urate crystals. J Lab C/in Med 1973; 81 :761-9.
Dawes
PT, Kirlew results
ofa
C, Haslock I. Saline controlled study. C/in
Marans
washout Rheumato/
for knee osteoarthritis: 1987; 6:61-3.
64-B
Cohen
Rouse in patients
DW.
over
AS.
Identification Rheum 1979;
Silver
RS. The
of the knee.
Path
Joint
1926;
Anat
arthroscopic
J Bone
in
crystals 260:
treatment
Surg
[Br]
The results of partial arthroscopic 40 years of age. J Bone Joint Surg
of
1988 ; 70meniscec[Br] 1982;
:481-5.
Kellgren JH. Osteoarthrosis 1961 ; ii:l-6.
in patients
Lindsay DJ, Ring EF, Coorey PF, Jaysan rheumatoid arthritis. Acta Rheumato/ Lowman
synovitis
of hydroxyapatite 22 :389-95. Arch
of
between synovial inflammation in associated arthro-
Inflammatory 1982 ; 9:205-9.
J Rheumato/
Virchow’s
HJ,
arthritis
RW,
tomy
MS, disease.
deformans.
degenerative B:332.
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THE
JOURNAL
OF BONE
AND
JOINT
SURGERY
