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Arthroscopic cartilage regeneration facilitating procedure for osteoarthritic knee
© Lyu et al.; licensee BioMed Central Ltd. 2012
Received: 6 April 2012
Accepted: 17 November 2012
Published: 21 November 2012
The effectiveness of arthroscopic treatment for osteoarthritic knee is a controversy. This study presents the technique of a novel concept of arthroscopic procedure and investigates its clinical outcome.
An arthroscopic procedure targeted on elimination of focal abrasion phenomenon and regaining soft tissue balance around patello-femoral joint was applied to treat osteoarthritis knees. Five hundred and seventy-one knees of 367 patients with osteoarthritis received this procedure. There were 70 (19%) male and 297 (81%) female and the mean age was 60 years (SD 10). The Knee Society score (KSS) and the knee injury and osteoarthritis outcome score (KOOS) were used for subjective outcome study. The roentgenographic changes of femoral-tibial angle and joint space width were evaluated for objective outcomes. The mean follow-up period was 38 months (SD 3).
There were 505 knees in 326 patients available with more than 3 years follow-up and the mean follow-up period was 38 months (SD 3). The subjective satisfactory rate for the whole series was 85.5%. For 134 knees with comprehensive follow-up evaluation, the KSS and all subscales of the KOOS improved statistically. The femoral-tibial angle improved from 1.57 degrees (SD 3.92) to 1.93 degrees (SD 4.12) (mean difference: 0.35, SD 0.17). The joint space width increased from 2.02 millimeters (SD 1.24) to 2.17 millimeters (SD 1.17) (mean difference: 0.13, SD 0.05). The degeneration process of the medial compartment was found being reversed in 82.1% of these knees by radiographic evaluation.
Based on these observations arthroscopic cartilage regeneration facilitating procedure is an effective treatment for osteoarthritis of the knee joint and can be expected to satisfy the majority of patients and reverse the degenerative process of their knees.
Osteoarthritis (OA) of the knee affects a large population worldwide and is associated with an extremely high economic burden largely attributable to the effects of disability, comorbid disease, and the expense of treatment . To date the established therapies have been directed towards symptom control. Since the initiating events that result in the cartilage degradation are poorly understood, there has been very limited success in demonstrating disease modification in clinical trials of potential therapies .
Arthroscopy for the management of OA knees, as a relative minor procedure, is popular in spite of the controversy concerning its effectiveness. Joint lavage [3, 4], debridement [5–7], abrasion arthroplasty [7–11], and microfracture [12–14] are among the most commonly employed arthroscopic procedures for OA knees. The precise mechanism and consensus by which these procedures improve the course of degenerative conditions of the knee have not been established. A recent retrospective review of the current literature on the arthroscopic treatment of OA knee  has demonstrated limited evidence-based research to support the use of arthroscopy as a treatment method for OA knee.
In 2008, a concept of arthroscopic medial release (AMR) for the treatment of osteoarthritis of the medial compartment of the knee joint was reported . The clinical outcome of this series lured us to believe that, by eradication of the abrasion phenomenon between the tight, fibrotic and hypertrophied medial structure and the adjacent medial femoral condyle, the pain of most patients could be reduced and the degenerative process in the medial compartment of these patients might be decelerated or arrested. In this report, we propose a concept of arthroscopic cartilage regeneration facilitating procedure (ACRFP) that combines arthroscopic medial release (AMR), percutaneous lateral release (PLR) and conventional debridement as a rationale for the deliberate arthroscopic management of OA knee. We hypothesized that the elimination of the detrimental factors including synovitis, chondral flaps, and abnormal focal stress caused by medial abrasion and lateral compression phenomena will provide a preferable environment for the regeneration of damaged cartilage. The details of this procedure and its clinical results are reported in this study.
In a one-year duration, 571 knees of 367 patients with different grades of OA received this procedure. There were 78 (19%) male and 330 (81%) female. The age ranged from 29 to 82. The mean age of these patients at the time of surgery was 60 (SD 10). There were 406 knees (80.4%) of 269 patients received AMR and 99 knees (19.6%) of 57 patients received AMR+PLR. The anteroposterior standing and Merchant’s axial radiographs were evaluated for the severity of degeneration for each compartment. The radiographic grading of each compartment according to Kellgren and Lawrence  was given by the senior author who was the single surgeon performed all of the procedures. The inclusion criteria were patients with OA knee of any grade involving medial compartment or combined with patellofemoral compartment and have been treated conservatively including non-steroidal anti-inflammatory drugs, nutrition supplements (glucosamine sulfate and/or hyaluronic acid injection) and physiotherapy for more than six months. The exclusion criteria were apparent lateral compartment OA (radiographic grading of III or IV or arthroscopic grading of III or IV by modified Outerbridge classification ), instability due to previous ligament injury, major meniscus tear, or OA due to trauma. This study was approved by the Research Ethics Committee of Buddhist Dalin Tzu-Chi General Hospital, which has been certificated by the Department of Health, Taiwan (IRB Approval Number: B09704022). Informed consents were obtained from all patients participating in the study.
The standing extended anteroposterior radiographs of the knee were obtained at 55 KV with a focus of 1.25 mm2 and a focus-to-film distance of 100 cm, using 35 × 43 cm computed radiographic film (Kodak Digital Science, CR 400). Radiographs of the extended knee were obtained with the patella in central position . To assess the patellofemoral joint space, Merchant’s view was obtained at 45 degrees of knee flexion with X-ray beam projected caudad at 30 degrees. For magnification correction in each examination, a 4.0-mm steel ball was affixed to the skin over the head of the fibula (standing extended AP view) and center of patella (Merchant’s view) to permit correlation of the joint space width measurements .
All procedures were performed under spinal or general anesthesia. Bloodless surgical field was obtained by pneumatic tourniquet. A 4 milimeters 30 degrees arthroscope with 6.5 milimeters sheath was used. An electronic shaver and hand instruments were used as necessitated.
Additional file 1:Video 1. Arthroscopic medial release for medial abrasion phenomenon. An example of stage III medial compartment osteoarthritic knee with medial abrasion phenomenon treated by arthroscopic medial release is shown in this video clip. This is a 78 years old female suffering from left knee pain for more than 10 years. The arthroscopic examination revealed tightness of the medial facet of the patellofemoral joint and obliteration of the inferomedial region of the patella by hypertrophied medial plica and synovitis tissue. The abrasion phenomenon between fibrotic medial plica and medial femoal condyle could be reproduced by manipulation. After arthroscopic medial release, the medial gutter and the damaged medial femoral condyle could be clearly visualized and the medial abrasion phenomenon was also eliminated. (MPEG 16 MB)
Percutaneous lateral release
For the knees with lateral compression syndrome (Figure 1C), lateral release was performed by inserting the No.11 scalpel into the inferolateral portal and cut the lateral retinaculum percutaneously. The extent and adequacy of the release could be evaluated by direct vision through arthroscope (Figure 1F).
Synovectomy and chondroplasty
Any focal synovitis or loose chondral flaps on the cartilaginous surface was removed as conventional arthroscopic debridement for osteoarthritis of the knee. At the end of the procedure, thorough irrigation was performed to remove any debris in the knee joint. No bony procedure such as drilling or microfracture was performed.
Suction drain was used for 24~48 hours. The involved limb was protected by elastic bandage for one week. Full range of motion, full weight bearing and free ambulation were allowed as tolerated. The patient was discharged 2 days after the operation. Home exercise programs, including active range of motion and quadriceps strengthening, were emphasized. No supplementary treatment including oral glucosamine sulfate, steoid injection or intraarticular injection of hyaluronic acid was given during the whole post-operative follow-up period.
Follow-up and evaluation of clinical outcome
The patients were evaluated monthly for three months. Thereafter, they came back yearly for outcome assessment. The comparisons of both pre- and post-operative Knee Society score (KSS) and knee injury and osteoarthritis outcome score (KOOS) were used for outcome evaluation. Subjective satisfaction was assessed by direct question using a categorical scale prepared for this study: excellent, free of symptoms, no limitation in activities; good, greatly improved, occasional pain, normal activities; fair, same as pre-operative condition, no improvement; and poor, has received or considered further operative treatment. The outcome was regarded as satisfactory if subjective satisfaction was rated as “excellent” or “good”. The inquiry into subjective satisfaction and the evaluation of KSS and KOOS were conducted by nursing specialists. All investigations focused on individual knees in bilateral cases.
Evaluation of x-ray outcome
The radiographic outcome was interpreted by comparing the pre-operative standing extended anteroposterior and Merchant’s views with the ones taken at the last visit by digitized assessment (Image-Pro, Media Cybernetics, Inc., Bethesda, MD, USA). The interpreting parameters include: femoral-tibial angle (FTA), minimum joint space width (MJSW) , lateral tilt angle of patella , and the surface contour of the joint lines. Simplified outcomes of better, the same or worse was given to each knee after evaluation of the pre- and post-operative radiographs. The anatomic axis (femoral-tibial angle) was defined as the angle formed by the intersection of 2 lines originating from points bisecting the femur and tibia and converging at the center of the tibial spine tips . The same radiologist performed these measurements and interpretations.
All values were presented with means and standard deviations. Comparisons were made using one-way analysis of variance (ANOVA) to detect differences in the distribution of patient age in each grade of osteoarthritis. Statistical analysis for comparing preoperative and postoperative KSS, KOOS, femoral-tibial angle, and joint space width was performed using the paired t test. P < 0.05 was considered to be statistically significant. All statistical analysis was carried out using JMP, the Statistical Discovery Software (Version 184.108.40.206, SAS Institute Inc., Cary, NC, USA).
Age and sex distribution of different grade of medial compartment OA stratified by type of surgery
AMR + PLR
Hematoma with ecchymosis around the involved knee occurred in 16 knees (3.9%) in ten patients in AMR group and 8 knees (8.1%) in five patients in AMR+PLR group. All subsided uneventfully within one month.
Nine knees (2.2%) in seven patients in the AMR group and 4 knees (4%) in three patients in the AMR+PLR group experienced persistent effusion for more than one month after this procedure. After initial treatment including resting, compression bandaging and anti-inflammatory medication, the effusion subsided spontaneously within 2 weeks in 8 knees. The other 5 knees in three patients required aspiration of the knee to relieve the discomfort.
Irritable pain, catching or giving way sensation when moving the involved knees were commonly complained during the first post-operative month. This discomfort was tolerable in most patients after reassurance and would usually subside spontaneously. In 13 knees (2.6%) of 13 patients there was persistent discomfort due to wound irritation for more than three months. After conservative treatment including local heat, massage, and stretching exercise by bending knee passively, all alleviated within one year.
Subjective outcomes of different grade of medial compartment OA stratified by type of surgery
AMR + PLR (N=99)
Pre-operative and post-operative knee society score for different grade of medical compartment OA
AMR + PLR (N=29)
Pre-operative and post-operative KOOS of different grade of medial compartment OA
Radiographic outcome of different grade of medial compartment OA stratified by type of surgery
Medial compartment (AMR and AMR+PLR, N=134)
PF compartment (AMR+PLR, N=29)
Evidence of Cartilage Regeneration
Additional file 2:Video 2. Evidence of cartilage regeneration after ACRFP by a second-look arthroscopy. This 56 years old lady received ACRFP and have had experienced a satisfactory outcome until three years later when she suffered from a falling down accident with the same knee injured. We therefore had the chance to perform a second-look arthroscopy and visualized the evidence of cartilage regeneration over her previous chondral defect on the medial femoral condyle. (M4V 17 MB)
In this report we present the clinical and radiographic outcomes of our procedure of arthroscopic cartilage regeneration facilitating procedure (ACRFP) for OA knees involving mainly medial and patellofemoral compartments. Overall, the subjective satisfactory rate was 85.5%. Even in grade IV OA, 59% of satisfactory rate could be anticipated after at least 3 years’ follow-up. Besides the improvement of clinical symptoms and life quality according to the KSS and KOOS surveys, revitalizing of the degenerated cartilage and reversal of the degeneration process were perceived in 81.2% of the knees by radiographic evaluation.
Therapeutic arthroscopic techniques including lavage, debridement, abrasional chondroplasty and microfracture are widely used for OA knee despite their unpredictable outcomes. A double-blinded, randomized, placebo-controlled trial to compare the effectiveness of arthroscopic lavage and arthroscopic debridement versus a sham procedure has been performed and the data suggest that the benefits of arthroscopy for the treatment of osteoarthritis of the knee are to provide subjective pain relief via a placebo effect . The American Academy of Orthopaedic Surgeons (AAOS) clinical practice guideline on the treatment of OA knee also recommends against performing arthroscopy with debridement or lavage in patients with a primary diagnosis of symptomatic OA of the knee . Dandy’s abrasion chondroplasty  was popularized in the late 1980s. In 1993, Bert et al. found it appears to offer little benefit over partial meniscectomy and debridement in the degenerative knee . It was also thought that this technique provide unpredictable results. Concerns include the durability of the fibrocartilage repair tissue and thermal damage to subchondral bone and adjacent normal articular cartilage during this procedure . Microfracture, a modification of chondroplasty, might provide increase in joint space by growth of fibrocartilage and achieve functional improvement for patients with full-thickness chondral defects in the osteoarthritic knees . But an evidence-based systematic analysis declared that this technique could only provide short-term functional improvement. Shortcomings of this technique include limited hyaline repair tissue, variable repair cartilage volume and possible functional deterioration . Autologous chondrocyte implantation (ACI) has become an accepted option for the treatment of chondral defects in carefully selected patients. Current recommendations limit this procedure to younger patients, as insufficient data are available to conclusively evaluate outcomes in patients older than 45 years, especially in OA patients . The unconfirmed pathogenesis of OA knee and a lack of a clear consensus on the indications and surgical techniques as well as the variable outcomes make these commonly used arthroscopic techniques remain a source of controversy.
Abrasion or impingement phenomenon between the medial plica and the opposite medial femoral condyle has been described in recent studies in patients with medial compartment OA knee [30–33]. The consequent study  found that the repeated injuries elicited by this abrasion phenomenon might trigger IL-1ß production, thus enhance the expression of MMP-3. Their demonstration of the expression of IL1-ß mRNA, MMP-3 mRNA and MMP-3 in medial plica of early stage OA knee suggests that this structure and its interplay with the facing medial femoral condyle might play an important role in the pathogenesis of medial compartment OA knee. These findings coincide with the fact that eradication of this structure by arthroscopic release could be effective in symptom relief or even might modify the disease process of medial compartment OA knees [16, 35].
Based on these constitutional studies, we proposed a concept that by a purposeful eradication of all prejudicial factors in the degenerative knee, the jeopardized cartilage would have the chance to regenerate by its innate healing response. In comparison with the uncertain beneficial mechanism and the diversity of outcomes of current popular arthroscopic techniques for osteoarthritis of the knee, our concept of ACRFP had more precise rationale of treatment. The main theme of ACRFP was to remove any abnormal abrasion or impingement phenomenon and reestablish soft tissue balance around the patellofemoral joint. For knees demonstrating medial abrasion phenomenon, medial release  was performed to relief the tension and abrasion between the tight, fibrotic and hypertrophied medial plica and the adjacent medial femoral condyle. On the other hand, in knees demonstrating lateral compression syndrome over patellofemoral joint, percutaneous lateral capsular release that has the benefits of tension release and denervation [36–40] was added. The immediate effect of ACRFP was obtained by releasing the tension around patella caused by chronically inflamed soft tissue and by eradication of the hypertrophied and inflamed synovium that may cause pain in these degenerative knees over the medial compartment and patellofemoral joint. Furthermore, by eliminating these stress/inflammatory responses that are the key events on the onset and progression of osteoarthritis, this procedure would also bring forth to long-term favorable effects as a consequence of the global improvement of the environment of the knee joint for cartilaginous regeneration.
Although articular hyaline cartilage was classically considered having no or low potential for regeneration [41–46], some still thought that it does have the capacity to grow and remodel extensively during pre- and post-natal development and after trauma [47, 48]. Both direct and indirect evidence of articular cartilage regeneration have been reported after correction of varus deformity for osteoarthritis of the knee by some authors. According to their investigations about the beneficial effects of valgus osteotomy for medial gonarthrosis, the main repair feature was proliferation of fibrocartilage, which covered bone and areas of fibrillated cartilage and filled vertical clefts in hyaline cartilage. The hyaline cartilage was found to show an increased cellularity with numerous nests of proliferating chondrocytes . There was also arthroscopic visible improvement of the articular surface after this procedure . Moreover, it was observed by direct vision that mature regeneration was more frequently found in the knees with radiographic increased width of the medial joint space after high tibial valgus osteotomy, and this even happened in the knees with eburnation of the subchondral bone .
Recent studies also point out that, unlike the first impression of a more or less static tissue, articular cartilage shows a slow turnover. Anabolic and catabolic pathways were thought to be very much intermingled in articular cartilage metabolism . Under normal conditions, chondrocytes maintain the dynamic equilibrium between synthesis and degradation of extracellular matrix components. In osteoarthritic states, however, there is a disruption of matrix equilibrium leading to progressive loss of cartilage tissue . Thus, the aim of osteoarthritis therapy might neither to stimulate anabolism nor to knock down catabolism, but to titrate the balance of anabolic-catabolic activities. In this study, the clinical outcomes and the radiographic findings have given light to us that, by removal of all existed catabolic factors, the anabolism of the damaged cartilage might become dominant and regeneration unveiled.
Although it was claimed that compared with the extended weight-bearing anterior-posterior (AP) radiograph, posteroanterior (PA) imaging of the knee in 20–30 degrees flexion (the schuss position) increases the reproducibility of radiographic JSW measurements in OA knees , standing AP radiographic views of the knee have still been widely used to determine the rate of disease progression in OA knee by measuring joint space narrowing and bony alignment [21, 54–59]. Contrary to our observation, they all obtained the common finding of progressive narrowing of the joint space as the natural course of OA knee. Never the less, in order to get more convincing evidence, we need more precise methodology such as magnetic resonance images study for the evaluation of cartilage regeneration. Properly conducted randomized control clinical trials are also warranted.
According to the experience of performing this procedure, the data support our contention that arthroscopic cartilage regeneration facilitating procedure (ACRFP) is a good modality for the treatment of osteoarthritis of the knee joint if only medial and/or patellofemoral joint were involved. It could modify the natural course of this common disease. This novel concept of treatment might give hope to the majority of patients who are in the ambiguous stages of OA knee before arthroplasty could be beneficial for them.
Funding from Clinical Research Grant Program of Buddhist Dalin Tzu-Chi General Hospital.
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