Full text of DOI:10.1007/s00402-002-0425-4

Arch Orthop Trauma Surg (2002) 122:451–453
DOI 10.1007/s00402-002-0425-4
ORIGINAL ARTICLE
Michael Bohnsack · Wolfram Lipka · Oliver Rühmann ·
Gabriela Peters · Stefan Schmolke · Carl Joachim Wirth
The value of knee arthroscopy in patients
with severe radiological osteoarthritis
Received: 15 October 2001 / Published online: 2 July 2002
© Springer-Verlag 2002
Abstract Background: This study was performed to as- morbidity to gain time until joint replacement becomes
sess the value of knee arthroscopy in patients with radio- necessary [12]. Since the early days of knee arthroscopy,
logical signs of severe osteoarthritis. Methods: A total of its therapeutic role in the elderly patient and patients with
104 patients (50 men, 54 women, average age 60 years) severe degenerative knee disorders has been assessed in
with radiological knee osteoarthritis grade III/IV were fol- several studies and discussed heatedly [1, 3, 4, 6, 11]. In
lowed up after knee arthroscopy between May 1989 and particular, the well-known advantages of arthroscopic sur-
November 1996. The average follow-up time was 5.4 years gery, such as reduced soft-tissue trauma, short rehabilita-
after surgery. Results: A significant (p<0.01) increase in tion times, and low complication rates were taken as an
the Lysholm score was found, ranging from 40 points be- argument for the arthroscopic treatment of those patients.
fore arthroscopy to 69 points at the assessment. A total of While there is general agreement that the procedure pro-
84 patients (81%) reported an increase in their activities vides at least short-term benefits in some patients, few
of daily living, 44 patients (43%) were still without any studies have followed the results of arthroscopic debride-
complaints. The total outcome was rated very good or ment for longer than 2 years [8].
good by 67 patients (65%). Only 21 patients (20%) re-
This study was performed to assess the value of arthros-
quired further surgery before the assessment. Conclu- copy in cases of severe radiologic signs of knee osteo-
sions: Knee arthroscopy is a valuable treatment for pa- arthritis, especially concerning its total outcome in pa-
tients with pain, swelling, and radiological signs of severe tients under the age of 60 years and the necessity of fur-
osteoarthritis. It improves the patients’ activities of daily ther surgical treatment.
living and helps to postpone further surgery.
Keywords Radiology · Osteoarthritis · Knee ·
Arthroscopy
Patients and methods
From May 1989 to November 1996, we performed knee
arthroscopy on 104 patients with a history of knee pain, swelling,
and radiological signs of severe osteoarthritis, who had a minimum
follow-up of 24 months. The objective in the younger patients
group (under the age of 60 years) was to gain time until further
surgery would become necessary, whereas we decided for arthro-
scopic treatment for patients over 60 years old according to indi-
vidual considerations. There were 50 men and 54 women, and their
mean age was 60 (range 50–83) years (Fig.4). The radiographs
were graded using the score of Jäger and Wirth [5] (Fig.1). All pa-
tients in our study showed degenerative radiological changes of
grade 3 (joint space half, osteophytes, severe subchondral sclero-
sis) or 4 (joint space less than half, joint destruction, subchondral
cysts, tibiofemoral subluxation) in the medial or lateral compart-
Introduction
In cases of severe radiological signs of osteoarthritis, a his-
tory of pain and swelling in the knee, and a reduced activ-
ity level, monocondylar or total knee arthroplasty is most
frequently performed in the elderly patient. The clinical
long-term results are well known to be excellent or good
in most cases. In contrast to this, younger patients with
severe knee osteoarthritis and failed conservative treat-
ment often require a quick surgical treatment with low ment. The average follow-up was 5.4 years (range 24–118 months)
after surgery. The total outcome was rated using the score of
Lysholm and Gillquist [7]. The data was analyzed using a statisti-
cal programm (SPSS version 10.0; SPSS, Chicago, Ill., USA), es-
M. Bohnsack (✉) · W. Lipka · O. Rühmann · G. Peters ·
S. Schmolke · C.J. Wirth
pecially performing a two-level, single-factor analysis of variance
with a significance level of α=0.05, a single-factor regression
analysis (ANOVA), and the Mann-Whitney U-ranking test.
Department of Orthopedic Surgery, Hannover Medical School,
Anna-Von-Borries-Str. 1–7, 30625 Hannover, Germany
e-mail: bohnsack@annastift.de,
Tel.: +49-511-5354340, Fax: +49-511-5354682

452
Fig.2 The intraoperative grading of osteoarthritis was performed
according to the Outerbridge score [10]. The figure shows the dis-
tribution of osteoarthritis grade 3 or 4 according to the knee com-
partments at arthroscopy
Fig.1 The grading of osteoarthritis was performed according to
the score of Jäger and Wirth [5] on the preoperative standard
weight-bearing radiographs
Results
The meniscal findings at arthroscopy are presented in
Table 1. A partial, subtotal, or total meniscectomy was
performed in 76 cases [73%; medial meniscectomy on
50 patients (48%) and lateral meniscectomy on 26 pa-
tients (25%)]. In 92 patients (89%), we found a local or
general synovitis, 29 patients (28%) had a partial or total
synovectomy. On the day of surgery, only 11 patients
(11%) had an effusion of the knee as a clinical sign of ac-
tivation. In 11 cases (11%), one or more loose bodies could
be removed, in 36 patients (35%), a shaving of the articu-
lar surface was performed, and in 1 case (1%), a plica
mediopatellaris was dissected. In only 11 patients (11%)
was the knee arthroscopy simply diagnostic, without any
further surgical procedure. An ACL rupture was found in
13 (13%), a PCL rupture in 2 (3%), a lateralization of the
patella in 57 (55%), and a chondromatosis in 1 (1%). The
degenerative changes of the articular surface (osteoarthri-
tis) were graded using the classification system of Outer-
bridge [10] (Fig.2).
Fig.3 Rating of the knee arthroscopy using the Lysholm and
Gillquist score [7]. Group 1: all patients (n=104), group 2: all pa-
tients who had no further surgery until the examination (n=93),
group 3: patients with radiological signs of osteoarthritis grade 4
in the medial or lateral compartment (n=21), group 4: patients
<60 years (n=57), group 5: patients >60 years (n=47)
The number of patients who regularly required pain-re-
ducing drugs was 44 before and 20 at the follow-up.
A significant (p<0.01) increase in the Lysholm and
Gillquist score [7] was found, ranging from an average of
40 points before arthroscopy to 69 points at the time of
examination for the whole study group (Fig.3). Patients
under the age of 60 years (n=57) showed a significantly
higher increase in the score rating (38 to 73 points,
p<0.05) than patients over 60 years (n=47; 42 to 68
points), whereas the grade of chondral lesions was equally
distributed between both age subgroups. Patients with
monolateral signs of osteoarthritis (grade III or IV) on the
preoperative radiographs (n=62) had a significantly (p<
0.05) higher increase in the Lysholm score (41 to 74 points)
than patients with bilateral radiological osteoarthritis (n=42;
39 to 62 points). Meniscectomy or shaving of the articular
surface did not have a significant influence on the total
outcome of knee arthroscopy. A total of 84 patients (81%)
reported a subjective increase in their activities of daily
living, 44 patients (43%) were still without any com-
plaints. The total outcome was rated excellent or good by
67 patients (65%). We did not find a significant correlation
Table 1 Meniscal findings at knee arthroscopy; n=patients (per-
cent of the total group)
Medial meniscus
Lateral meniscus
Degenerative
Torn meniscus
After meniscectomy
Normal
49 (47%)
15 (15%)
21 (20%)
19 (18%)
34 (33%)
8 (8%)
11 (11%)
51 (49%)

453
mean follow-up of 5.4 years postoperative. We found a
significant (p<0.01) increase in the Lysholm and Gillquist
score [7] for all patients in our study, which was even sig-
nificantly (p<0.05) higher for the patients under the age of
60 years than for the patients over 60 years old. Several
clinical studies found that moderate or severe degenera-
tive changes on the preoperative standard radiographs had
a statistically significant negative effect on the arthro-
scopic outcome, whereas their reported rates of good or
excellent results after knee arthroscopy in osteoarthritic
patients vary between 21% and 80% [9, 14, 15]. In addi-
tion, the subjective contentment of the patients in our
study and their increased daily activity through knee
arthroscopy plus the fact that only 20% of them required
further knee surgery until the follow-up were the most im-
portant factors for us.
Fig.4 Age distribution of the evaluated patient group (n=104)
In conclusion, knee arthroscopy is a valuable treatment
for patients with radiological signs of severe osteoarthri-
tis. It improves their activities of daily living and helps to
postpone further surgery. The necessity of further surgical
treatment cannot be predicted by either the radiological or
the arthroscopic diagnosis or treatment.
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Fig.5 The surgical outcome (average rating according to the Lys-
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grade of osteoarthritis
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Discussion
According to the Framingham study [2], the number of
people 65 years and older is increasing 2.5 times faster
than the overall population. As the prevalence of knee os-
teoarthritis is 30% in those patients, and knee osteoarthri-
tis is more likely to result in disability than osteoarthritis
of any other joint, there is a high demand for therapeutic
solutions. Timoney et al. published a mid-term follow-up
(4.2 years) of arthroscopically treated severely osteo-
arthritic knees and found a 63% success rate, although he
noted deterioration of results over time, too [13]. In our
study, the success rate was similar with an overall excel-
lent or good clinical outcome for 65% of all patients at a
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