Arthroscopy for mechanical symptoms in osteoarthritis: a cost-effective procedure

Abstract

Purpose:
The place of knee arthroscopy as a therapeutic option for osteoarthritis (OA) has been the subject of some debate. The hypothesis for this study was that arthroscopic debridement is beneficial in patients with OA who have significant mechanical symptoms.

Methods:
Forty-three patients with radiological OA on plain radiographs and mechanical symptoms were prospectively followed. No further imaging was obtained. They were assessed pre- and postoperatively with an Oxford Knee Score (OKS) and pain visual analogue score (VAS). Postoperative patient satisfaction was measured with a VAS. A cost-benefit analysis was performed using a transformed OKS to generate a quality-adjusted life year (QALY) measurement.

Results:
At a mean of 1.5 years, seven patients (16 %) had undergone total knee arthroplasty at a mean of 8.2 months postarthroscopy. For the remaining 35 patients, there were significant improvements in pain (median 7-5, p < 0.05) and OKS (median 24-36.5, p < 0.05). Satisfaction was a median 6.2 for all patients. The mean calculated EQ-5D improved from 0.43 (SD 0.16) to 0.79 (SD 0.23), which gave a gain of 0.52 QALYs in the study period. This generated a cost per QALY of £2,088, well below the threshold of £30,000 quoted by the UK National Institute for Health and Care Excellence as demonstration of cost-effective treatment.

Conclusions:
This prospective study demonstrates that although not universally effective, arthroscopic debridement for patients with knee OA and mechanical symptoms can result in significant improvements in pain and function. The procedure gave good patient satisfaction, and even at an early follow-up period proves to be cost-effective. LEVEL OF EVIDENCE: IV.

Full text

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Knee Surgery, Sports Traumatology,
Arthroscopy
ISSN 0942-2056
Knee Surg Sports Traumatol Arthrosc
DOI 10.1007/s00167-014-3220-1
Arthroscopy for mechanical symptoms in
osteoarthritis: a cost-effective procedure
Jonathan R.B.Hutt, Johnathan Craik,
Joideep Phadnis & Andrew G.Cobb

1 23
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1 3
Knee Surg Sports Traumatol Arthrosc
DOI 10.1007/s00167-014-3220-1
KNEE
Arthroscopy for mechanical symptoms in osteoarthritis:
a cost‑effective procedure
Jonathan R. B. Hutt · Johnathan Craik ·
Joideep Phadnis · Andrew G. Cobb
Received: 18 November 2013 / Accepted: 28 July 2014
© Springer-Verlag Berlin Heidelberg 2014
Conclusions This prospective study demonstrates that
although not universally effective, arthroscopic debride-
ment for patients with knee OA and mechanical symptoms
can result in significant improvements in pain and function.
The procedure gave good patient satisfaction, and even at
an early follow-up period proves to be cost-effective.
Level of evidence IV.
Keywords Arthroscopy · Knee · Osteoarthritis ·
Debridement
Introduction
Osteoarthritis (OA) of the knee is a growing problem, and
surgery for this condition is on the rise [6]. Surgeons are
often faced with the conundrum of a significantly symp-
tomatic patient with only mild or moderate radiographic
evidence of OA. Knee arthroplasty is a major undertaking
with up to 20 % of patients said to be dissatisfied with their
outcome [20], but the value of other interventions is con-
troversial. Arthroscopic debridement of degenerate menis-
cal tears, unstable chondral flaps and removal of loose bod-
ies was a previously widely used technique [2, 7, 12], with
cited advantages including low risk, quick recovery and
rapid improvement in symptoms for many patients. How-
ever, other studies have been less favourable towards such
intervention. Moseley et al. [13] compared arthroscopic
lavage, arthroscopic debridement and sham surgery in
165 patients and did not demonstrate any benefit of either
arthroscopic procedure over placebo surgery. In addition,
Kirkley et al. [10] did not demonstrate any significant ben-
efit of a treatment programme including arthroscopic lav-
age, debridement and physical and medical therapy, ver-
sus physical and medical therapy alone. Herrlin et al. [7]
Abstract
Purpose The place of knee arthroscopy as a therapeutic
option for osteoarthritis (OA) has been the subject of some
debate. The hypothesis for this study was that arthroscopic
debridement is beneficial in patients with OA who have
significant mechanical symptoms.
Methods Forty-three patients with radiological OA on
plain radiographs and mechanical symptoms were pro-
spectively followed. No further imaging was obtained.
They were assessed pre- and postoperatively with an
Oxford Knee Score (OKS) and pain visual analogue score
(VAS). Postoperative patient satisfaction was measured
with a VAS. A cost-benefit analysis was performed using
a transformed OKS to generate a quality-adjusted life year
(QALY) measurement.
Results At a mean of 1.5 years, seven patients (16 %) had
undergone total knee arthroplasty at a mean of 8.2 months
postarthroscopy. For the remaining 35 patients, there were
significant improvements in pain (median 7–5, p < 0.05)
and OKS (median 24–36.5, p < 0.05). Satisfaction was a
median 6.2 for all patients. The mean calculated EQ-5D
improved from 0.43 (SD 0.16) to 0.79 (SD 0.23), which
gave a gain of 0.52 QALYs in the study period. This gener-
ated a cost per QALY of £2,088, well below the threshold
of £30,000 quoted by the UK National Institute for Health
and Care Excellence as demonstration of cost-effective
treatment.
J. R. B. Hutt · J. Craik · J. Phadnis · A. G. Cobb
Epsom General Hospital, Dorking Road, Epsom,
Surrey KT18 7EG, UK
J. R. B. Hutt (*)
3535 Av Papineau, Apt 406, Montreal, QC H2K 4J9, Canada
e-mail: drhutt@hotmail.com
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Knee Surg Sports Traumatol Arthrosc
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compared arthroscopic meniscectomy and physiotherapy
with physiotherapy alone in patients with atraumatic
meniscal tears and were unable to identify any significant
benefit from arthroscopy. Vermesan et al. [23] conducted
a randomised trial of arthroscopic meniscectomy versus
steroid injection for degenerative meniscal tears and asso-
ciated arthritic change and found improvements with both
techniques but no significant differences between them
at 1 year. The effect at a local level has been a reluctance
of primary care bodies to fund arthroscopic procedures in
degenerative disease despite some surgeons still advocating
its use in certain circumstances. The current UK National
Institute for Health and Care Excellence (NICE) guidelines
state that arthroscopic surgery should not be offered in the
presence of OA unless there is a ‘clear history of mechani-
cal locking (not gelling, giving way or x-ray evidence of
loose bodies)’ [15]. However, such broad statements do not
take into account specific cohorts of patients who may ben-
efit. Arthroscopic surgery with partial meniscectomy, chon-
droplasty and removal of loose bodies in carefully selected
patients to address mechanical symptoms could help with
relieving pain and maintaining function and may postpone
the need for arthroplasty [18, 22].
The hypothesis for this study was that knee arthroscopy
for certain patients would provide significant clinical ben-
efit. In contrast to other studies, patients were included
using specific symptomatic criteria with evidence of degen-
erative change on radiographs that gave a diagnosis of OA
but would not make them candidates for arthroplasty. The
benefits of arthroscopy in this group are likely to be tem-
porary. Further analysis was performed to examine a fur-
ther hypothesis that despite this, arthroscopy would dem-
onstrate a favourable cost-benefit profile when compared
with national standards for the use of procedures in clinical
practice.
Materials and methods
Patients were prospectively recruited for inclusion if they
had radiographic evidence of OA of the knee and the pres-
ence of one or more specific mechanical symptoms in the
form of locking, giving way, clicking and sharp pains. They
were specifically examined for the presence of an effusion,
point tenderness and for a positive McMurray’s meniscal
provocation test. All patients had failed a trial of nonopera-
tive treatment that included appropriate analgesia, activity
modification and physiotherapy. Patients who had already
been given an intra-articular injection of steroid or visco-
supplementary products were excluded. The study was
approved by the institutional review board, and informed
consent for data collection was taken from each participant
in the study. Preoperative standing anteroposterior and lat-
eral radiographs were taken for all patients, and the degree
and pattern of arthrosis was recorded using the Kellgren–
Lawrence grading [9]. Patients with grade IV changes
were excluded. No further imaging was performed prior to
surgery.
Operative technique
All patients underwent arthroscopic surgery as a day case
procedure performed by or under the direct supervision of
the senior author. Standard anterolateral and anteromedial
portals were utilised to perform a systematic examina-
tion of the knee joint. The degree of arthrosis was graded
according to the Outerbridge system [16]. At surgery, any
unstable meniscal tears and chondral flaps were debrided
to stable edges and loose bodies were removed. No other
meniscal procedures, microfracture or any other form
of cartilage augmentation surgery was performed in this
cohort of patients. About 10 ml of 0.5 % marcaine was
instilled into the knee joint at the end of the procedure.
Patients were discharged on the same day after consultation
with a physiotherapist with immediate weight bearing and
full range of knee motion permitted.
The outcomes studied pre- and postoperatively were the
Oxford Knee Score (OKS) and pain visual analogue score
(VAS). Patient satisfaction was also evaluated at follow-
up with a VAS, and progression to arthroplasty was docu-
mented. A cost-benefit analysis was performed to assess
the economic impact of the procedure expressed as cost per
quality-adjusted life years (QALYs).
Statistical analysis
Pre- and postoperative OKS and VAS were compared with
the Wilcoxon signed rank test. For inclusion in the analy-
sis, patients who had undergone arthroplasty were assumed
to have neither improved nor worsened after their arthros-
copy. A power analysis using previously published data on
the OKS [14] with a SD of 10 points and a conservative
minimally important clinical difference of 5 points calcu-
lated that a minimum of 34 patients would be required to
achieve a power of 80 % and an alpha value of 0.05.
For the cost-benefit analysis, preoperative OKS and
postoperative OKS were converted to an EQ-5D score
using a published mapping algorithm [3]. For compari-
son, the assumption was made that without intervention,
the OKS on presentation would neither have improved nor
worsened, and similarly that the intervention had no effect
on those patients who progressed to total knee arthroplasty
(TKA). The EQ-5D score was then used to calculate any
gain in QALYs.
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Results
Forty-three patients were recruited into the study, with a
male to female ratio of 20:23 and a mean age of 64 years
(range 35–82). Thirty-one patients had grade 2 radio-
graphic changes in at least one compartment; the remaining
12 patients had grade 3. The worst intra-operative Outer-
bridge grade in any compartment was 3 in 22 patients and 4
in 21. The prevalence of mechanical symptoms and preop-
erative findings is shown in Table 1. At surgery, all patients
had chondral flaps that were debrided, but only 27 patients
had an identifiable meniscal tear.
The latest follow-up was at a mean of 1.5 years; with a
minimum follow-up of 1 year. Seven patients (16 %) had
undergone TKA at a mean of 8.2 months post arthroscopy.
Pre- and postoperative scores are shown as box and whisker
plots in Fig. 1. The median OKS improved from 24 (range
12–42) to 36.5 (range 14–48) (p < 0.05). The median
pain VAS improved from 7 (range 3–10) to 5 (range 0–8)
(p < 0.05). Patient satisfaction was a median of 6.2 (range
0–10) for all patients.
The mean calculated EQ-5D score improved from 0.43
(SD 0.16) to 0.79 (SD 0.23). Over the time period stud-
ied, this equated to a gain in QALYs of 0.52. A cost-ben-
efit analysis was then performed. The NHS trust where the
study was performed receives £1,105 per procedure, giving
a cost per QALY of £2,088.
Discussion
The most important finding of this prospective study is
that arthroscopic debridement in the presence of OA and
mechanical symptoms, although not universally effective,
can have significant clinical benefit in selected patients and
gives good patient satisfaction with a very reasonable cost-
to-benefit ratio even at short-term follow-up.
This study has its limitations. Although prospective,
it is only a small cohort of patients. Quality of life scores
were not collected prospectively, and although the mapping
algorithm provides a useful estimate in order to allow us
to undertake a cost-benefit analysis, it is probably not as
accurate.
Table 1 Prevalence of mechanical symptoms and examination find-
ings
Number (total n = 43)
Symptom
Clicking 21
Locking 16
Giving way 19
Sharp pain 34
Examination findings
Effusion 23
Pain localisation 28
Positive McMurray’s test 22
Fig. 1 Outcome scores
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Presumably on the basis of the available evidence so
far, the popularity of performing arthroscopy for the treat-
ment of OA has declined [6, 17], and currently, neither the
American Academy of Orthopaedic Surgeons in the US
or NICE in the UK recommends arthroscopic debride-
ment for patients with symptomatic OA of the knee. One
possible reason that our findings differ from other, above-
mentioned studies is their more diverse patient cohorts. As
a result, benefits to a subgroup of patients may have been
missed. Kirkley et al. [10] only included patients with mod-
erate to severe OA, and Moseley et al. [13] enroled partici-
pants that demonstrated a greater degree of OA than those
who declined involvement. Vermesan et al. [23] included
all symptomatic patients with MRI proven degenerative
changes in the medial compartment but did not provide
information on radiographic severity or symptomatology.
The arthroscopic group did demonstrate improvement,
however there was significant cross-over from the steroid
injection cohort. A prospective study by Aichroth et al. [1]
demonstrated that patients presenting with less advanced
arthritis both radiologically and arthroscopically demon-
strated improved outcomes following arthroscopy, with
high satisfaction rates reported and a more favourable out-
come associated with patients of a younger age.
In the presence of degenerative disease, it is also unclear
how to delineate the various intra-articular pathologies in
terms of their contribution to patient symptoms. A recent
randomised trial by Sihvonen et al. [21] in patients with
degenerative meniscal tears did not demonstrate differ-
ence in outcome between arthroscopic meniscectomy and
washout. The study was performed specifically in patients
with no evidence of radiographic OA; thus, the assumption
was that the meniscus was the main surgical target. Herrlin
et al. looked at a similar randomised cohort of patients with
degenerative meniscal tears detected on MRI and minimal
evidence of OA on radiographs. There were no differences
in outcomes between exercise therapy alone or therapy
combined with arthroscopy either in the short or longer
term [7, 8]. Interestingly, although all patients in the cur-
rent study had chondral flaps debrided at arthroscopy, only
27 (63 %) had an identifiable meniscal tear, suggesting that
further preoperative imaging such as an MRI scan would
not have necessarily have helped with patient selection and
that multiple intra-articular pathologies were contributing
to the problem. Of further interest from the study by Herrlin
et al. was that approximately a quarter of the nonsurgical
group had significantly worse early outcomes. Their scores
did improve to the level of the remainder of the cohort but
only after they underwent arthroscopy prior to the later
follow-up points, suggesting that there may be a subgroup
for which surgery is beneficial. This study selected patients
on the basis of particular symptoms and signs, and other
studies have also shown that preoperative symptoms and
examination findings may be of value when predicting
outcomes following arthroscopy in the presence of OA. A
prospective study by Dervin et al. [4] demonstrated that the
presence of medial joint line tenderness, a positive Stein-
man’s test or the presence of an unstable meniscal tear were
significantly associated with an improved outcome. In addi-
tion, Fond et al. [5] demonstrated high satisfaction rates
following arthroscopy at 5-year follow-up in patients with
less severe preoperative symptoms or preoperative flexion
contractures of <10 °. A recent survey of 170 European sur-
geons demonstrated significant agreement for the potential
of arthroscopy to improve symptoms in young patients with
low-grade OA. Treatments considered successful included
meniscectomy and notchplasty, whereas removal of osteo-
phytes or joint lavage were not [11].
It is likely that any benefit from arthroscopy will only be
temporary, as the degenerative process has already begun.
All the patients in this study had only moderate degrees of
arthritis, significant enough to be noticeable radiographi-
cally, but not necessarily to a level advanced enough for
consideration of TKA. A retrospective cohort study by Har-
ris et al. [6] demonstrated that 21.5 % of patients over the
age of 65 undergoing knee arthroscopy proceeded to TKA
within 24 months suggesting that there may be limited
benefit for arthroscopy in patients of this age. Raaijmaak-
ers et al. [19] demonstrated a similar arthroplasty rate in a
cohort of patients over the age of 65 at mean follow-up of
38 months. However, the temporal value of a procedure is
not measured only by clinical outcomes but also in terms of
healthcare costs, and it is for this reason that the cost analy-
sis was included in this study, as even short-term benefits
from interventions can prove cost-effective.
Conclusion
Along with other authors, we would not advocate for a
role for arthroscopy in all patients, but we believe there is
a role for it in patients without advanced disease present-
ing in a specific way. It is a straightforward and relatively
cheap operation. NICE has previously suggested that a cost
per QALY of £30,000 represents a cost-effective treatment:
That is well above the calculated value in the cost-benefit
analysis for this study. Further research is required to fur-
ther clarify which cohorts of patients with symptomatic
early OA may benefit from arthroscopic intervention.
References
1. Aichroth PM, Patel DV, Moyes ST (1991) A prospective review
of arthroscopic debridement for degenerative joint disease of the
knee. Int Orthop 15:351–355
Author's personal copy

Knee Surg Sports Traumatol Arthrosc
1 3
2. Baumgaertner MR, Cannon WD Jr, Vittori JM, Schmidt ES,
Maurer RC (1990) Arthroscopic debridement of the arthritic
knee. Clin Orthop Relat Res 253:197–202
3. Dakin H, Gray A, Murray D (2013) Mapping analyses to estimate
EQ-5D utilities and responses based on Oxford knee score. Qual
Life Res 22:683–694
4. Dervin GF, Stiell IG, Rody K, Grabowski J (2003) Effect of
arthroscopic débridement for osteoarthritis of the knee on health-
related quality of life. J Bone Joint Surg Am 85-A:10–19
5. Fond J, Rodin D, Ahmad S, Nirschl RP (2002) Arthroscopic
debridement for the treatment of osteoarthritis of the knee: 2- and
5-year results. Arthroscopy 18:829–834
6. Harris IA, Madan NS, Naylor JM, Chong S, Mittal R, Jalaludin
BB (2013) Trends in knee arthroscopy and subsequent arthro-
plasty in an Australian population: a retrospective cohort study.
BMC Musculoskelet Disord 14:143
7. Herrlin S, Hållander M, Wange P, Weidenhielm L, Werner S
(2007) Arthroscopic or conservative treatment of degenerative
medial meniscal tears: a prospective randomised trial. Knee Surg
Sports Traumatol Arthrosc 15:393–401
8. Herrlin SV, Wange PO, Lapidus G, Hållander M, Werner S, Wei-
denhielm L (2013) Is arthroscopic surgery beneficial in treating
non-traumatic, degenerative medial meniscal tears? A five year
follow-up. Knee Surg Sports Traumatol Arthrosc 21:358–364
9. Kellgren JH, Lawrence JS (1957) Radiological assessment of
osteo-arthrosis. Ann Rheum Dis 16:494–502
10. Kirkley A, Birmingham TB, Litchfield RB, Giffin JR, Willits
KR, Wong CJ, Feagan BG, Donner A, Griffin SH, D’Ascanio
LM, Pope JE, Fowler PJ (2008) A randomized trial of arthro-
scopic surgery for osteoarthritis of the knee. New Engl J Med
359:1097–1107
11. Mayr HO, Rueschenschmidt M, Seil R, Dejour D, Bernstein
A, Suedkamp N, Stoehr A (2013) Indications for and results of
arthroscopy in the arthritic knee: a European survey. Int Orthop
37:1263–1271
12. McGinley BJ, Cushner FD, Scott WN (1999) Debride-
ment arthroscopy. 10-year followup. Clin Orthop Relat Res
367:90–194
13. Moseley JB, O’Malley K, Petersen NJ, Menke TJ, Brody BA,
Kuykendall DH, Hollingsworth JC, Ashton CM, Wray NP (2002)
A controlled trial of arthroscopic surgery for osteoarthritis of the
knee. New Engl J Med 347:81–88
14. Murray DW, Fitzpatrick R, Rogers K, Pandit H, Beard DJ, Carr
AJ, Dawson J (2007) The use of the Oxford hip and knee scores.
J Bone Joint Surg Br 89:1010–1014
15. NICE CG59 Osteoarthritis: NICE guideline. Guidance/Clinical
Guidelines
16. Outerbridge RE (1961) The etiology of chondromalacia patellae.
J Bone Joint Surg Br 43-B:752–757
17. Potts A, Harrast JJ, Harner CD, Miniaci A, Jones MH (2012)
Practice patterns for arthroscopy of osteoarthritis of the knee in
the United States. Am J Sports Med 40:1247–1251
18. Price A, Beard D (2014) Arthroscopy for degenerate meniscal
tears of the knee. BMJ 348:g2382–g2382
19. Raaijmaakers M, Vanlauwe J, Vandenneucker H, Dujardin J, Bel-
lemans J (2010) Arthroscopy of the knee in elderly patients: car-
tilage lesions and their influence on short term outcome. A retro-
spective follow-up of 183 patients. Acta Orthop Belg 76:79–85
20. Scott CEH, Howie CR, MacDonald D, Biant LC (2010) Predict-
ing dissatisfaction following total knee replacement: a prospec-
tive study of 1217 patients. J Bone Joint Surg Br 92:1253–1258
21. Sihvonen R, Paavola M, Malmivaara A, Itälä A, Joukainen A,
Nurmi H, Kalske J, Järvinen TLN, Finnish Degenerative Menis-
cal Lesion Study (FIDELITY) Group (2013) Arthroscopic partial
meniscectomy versus sham surgery for a degenerative meniscal
tear. N Engl J Med 369:2515–2524
22. Thorlund JB, Christensen R, Nissen N, Jørgensen U, Schjerning
J, Pørneki JC, Englund M, Lohmander LS (2013) Knee Arthros-
copy Cohort Southern Denmark (KACS): protocol for a prospec-
tive cohort study. BMJ Open 3:e003399
23. Vermesan D, Prejbeanu R, Laitin S, Damian G, Deleanu B,
Abbinante A, Flace P, Cagiano R (2013) Arthroscopic debride-
ment compared to intra-articular steroids in treating degen-
erative medial meniscal tears. Eur Rev Med Pharmacol Sci
17:3192–3196
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