The use of arthroscopic debridement for osteoarthritis of the knee has been the subject of two controversies in recent years: approval and denial. We have recently found, while attending some international symposia, that some academic organizations have even abandoned arthroscopic debridement surgery in their outlines of treatment for osteoarthritis of the knee. However, a review of the literature reveals that the analysis of the nature of the disease in knee OA is clearly overlooked in the controversy over the different views on the choice of surgery for treatment or not.
For the treatment of knee OA, if the treatment does not address the occurrence and development of the disease, but only the local pain and degeneration, the use of arthroscopic debridement is the same as the use of pain management for headache patients: it can only relieve the pain for a while, but it is difficult to treat the disease at the root. Even with the conclusions of a rigorous, scientifically controlled trial study, the same follow-up results as the control group will be achieved as the “analgesic” effect wears off.
Thus, the controversy over whether arthroscopic clearance of knee OA is or is not, should not be limited to the level of symptomatic treatment of knee OA and deviate from a comprehensive understanding of the disease and the use of effective treatment track.
First, knee OA is a degeneration of articular cartilage, joint dynamic, static stability structure, proprioceptive function of the pathological process of lesions
Currently, the clinical degree of cartilage damage to the severity of knee OA typing. This classification of local pathological manifestations is adopted by clinicians and treated accordingly, which is the theoretical basis for treatment. With the in-depth research on knee OA in recent years, it has been gradually recognized that the dynamic and static stabilizing structures of the knee joint, especially the dynamic stabilizing structures, including the extensor muscles (quadriceps) and flexor muscles (N cord), are important factors influencing the development of knee OA lesions.
Knee stability is the basis for treatment outcome, especially the weakening of the knee flexor group (N cord) directly affects the course of the disease and treatment outcome. Imbalance of the dynamic stabilizing structures will also accelerate the development of the joint lesion and even cause abnormal force states in the adjacent hip and ankle joints, which will worsen the knee lesion. Injury and inflammation of the internal structures of the knee joint (patella, meniscus, ligaments, cartilage, synovium, etc.) reflexively inhibit the extension and flexion of the joint muscles, and the decrease in muscle strength and joint instability contribute to the degeneration and wear of the articular cartilage, which interact with each other to prolong the course of knee OA and aggravate the disease.
Primary damage to tissues and structures within the knee joint and degeneration of intra-articular cartilage, meniscus and ligaments in knee OA cause a decrease in proprioceptive function on the surface of these tissues and structures. Knee proprioception plays an important role in maintaining normal knee function, regulating the central and joint as well as intra- and extra-articular dynamic and static force stability. Decreased muscle tolerance, joint vulnerability to injury and slower improvement in muscle strength during treatment in patients with knee OA have been associated with proprioceptive dysfunction.
Therefore, the pathological manifestations of knee OA should include three main aspects: degeneration of intra-articular tissues represented by cartilage; reduction or loss of dynamic and static joint stabilization; and proprioceptive reflex dysfunction. The latter two are often important links that contribute to the aggravation of intra-articular tissue lesions in the knee.
Second, the analysis of the effect of arthroscopic cleaning of knee OA
Arthroscopic cleaning of the knee OA treatment of more clinical and experimental reports, most of them have certain efficacy, there is also a negative attitude. The problem is that most of the clinical reports only target the treatment of intra-articular cartilage, meniscus, synovium and other diseased tissues, and lack treatment for knee muscle lesions and reduced proprioceptive function. As a result, postoperative clinical outcomes are generally satisfactory, but over time, intermediate and long-term clinical outcomes are poor.
It is undeniable that various inflammatory factors in the joints of patients with knee OA, such as matrix metalloproteinases (MMPs), interleukin-1 (IL-1) and tumor necrosis factor-α (TNF)α, and other inflammatory cytokines, inflammatory mediators and free radicals, are both products of intra-articular tissue lesions and factors that promote further damage and degeneration of intra-articular tissues. Therefore, removal of these products, as well as degenerative strangulation of the meniscus and free bodies, should provide relief and facilitate the course of knee OA treatment.
The problem is that the damage to the power-stable structures and muscle imbalance in knee OA, as described previously, the reduced proprioceptive function of the knee joint, and the decreased core muscle strength of the trunk, which has been a concern in recent years, have resulted in reduced stability of the knee joint in patients, loss of joint protection, and imbalance in the regulation of functional academic stability of the joint, all of which adversely affect patients with knee OA, especially during standing and weight-bearing walking, and do not stop the course of the disease progression.
The symptoms of the knee, in the functional state of the joint as described above, recur sooner or later. Especially if the patient mistakenly believes that the transient symptom reduction or disappearance after surgery is the cure of the lesion, increasing the load on the knee joint before the recovery of knee muscle strength, joint stability, proprioception, etc., may even aggravate the lesion.
Third, how to evaluate the role of arthroscopic cleanup of knee OA
Foreign scholars once used a rigorous scientifically controlled clinical study to conclude that the therapeutic effect of minimally invasive arthroscopic surgery for intra-articular cleanup was not statistically different from that of the control group, proving its clinical ineffectiveness. The paper caused a strong reaction from the surgical community. Some professional academic organizations have even removed minimally invasive arthroscopic surgery from the principles of treatment for osteoarthrosis in the elderly, and so on, all of which I fear are factors in clinicians’ incomplete understanding of knee OA.
The results of a controlled study showed that: standardized rehabilitation training was taken after arthroscopic cleanup of knee OA, and isometric muscle strength and surface EMG tests were performed at 3 and 6 months after surgery, respectively, and the results showed that: at 3 months after surgery, the maximum torque of the extensor and flexor muscles increased compared with the preoperative period, but the difference was not statistically significant; while at 6 months after surgery, the maximum torque of the extensor and flexor muscles increased significantly compared with the preoperative period, and the extensor muscles (lateralis femoris, rectus femoris The RMS of the extensor muscles (lateral femoral, rectus femoris, and medial femoral muscles) was significantly higher than that before surgery at 6 months. The medial femoral/lateral femoral RMS ratio increased at 3 months postoperatively compared to preoperatively; the ratio further increased at 6 months postoperatively compared to 3 months postoperatively.
The above study showed that postoperative rehabilitation after arthroscopic cleanup of knee OA improved contractile function of the extensor and flexor muscles, especially the extensor group, which helped stabilize the joint, but required a longer period of muscle rehabilitation compared with the general postoperative period after minimally invasive knee injury. It is worth noting that patients with knee OA are mostly characterized by atrophy and functional decline of the medial femoral muscles first, and after effective plyometric training, significant improvement occurs 3 months after surgery, thus achieving a balance of strength in the extensor muscle groups, which is very beneficial to the improvement of joint function.
Thus, it can be seen that postoperative rehabilitation training for knee OA has a certain effect on muscle strength improvement and joint stability, while in patients who do not use rehabilitation training, the decrease in muscle strength and loss of joint stability will lead to joint dysfunction and aggravate the condition of knee OA.
According to the viewpoint of disease therapeutics, the treatment plan should be implemented according to the etiology, pathological changes and pathogenesis of the disease. From this perspective, modern rehabilitation medicine, such as exercise therapy, joint training program, load training and proprioceptive training, should be the whole treatment program for knee OA.
The main elements of the rehabilitation training program include.
(1) muscle strength training: improve muscle status, improve muscle strength or slow down the decline in muscle strength, and regulate muscle balance, which can effectively restore and maintain the stability of the knee OA joint.
(2) Joint mobility training and joint step load training: improve joint circulation, promote the balance of the intra-articular environment, promote the metabolism of cartilage, meniscus and bursa, avoid joint stiffness, maintain the stress load on cartilage, thus slowing down the degeneration of knee OA cartilage and improving the function of cartilage.
(3) proprioceptive training: it can promote the recovery of normal function of degenerated tissues and proprioceptive receptors in knee OA joints, establish a good joint proprioceptive reflex arc, improve joint responsiveness and flexibility, reduce or avoid accidental joint injury, and improve the effect of muscle training [8]. While introducing advanced rehabilitation concepts from the West, the domestic rehabilitation community focuses on the advantages of our physical therapy profession.
Clinical practice has proven that microwave, ultrashort wave, intermediate frequency, magnetic therapy, laser, hydrotherapy, and wax therapy can effectively relieve joint swelling, intra-articular fluid accumulation, and eliminate synovitis and joint pain in the process of rehabilitation training for different conditions. However, the rehabilitation process is affected by intra-articular free body, patellar fixation and meniscal impaction, while intra-articular inflammatory synovitis seriously affects the training of joint mobility, muscle strength, etc.
The use of minimally invasive techniques – i.e., arthroscopic debridement of these lesions – would be beneficial to the rehabilitation process and improve treatment outcomes. In this regard, arthroscopic debridement seems to make more sense as a part of the overall treatment of knee OA. Therefore, arthroscopic debridement for knee OA is Yes and No. Yes is as a part of the full treatment, the effect is positive; No indicates that if the pathological changes and pathogenesis of knee OA are recognized in a limited way, there are some problems with the final effect of pure arthroscopic debridement and ignoring postoperative rehabilitation.
IV. Countermeasures and outlook
With the serious problem of aging in the international society, the impact of knee osteoarthritis on the quality of life of the elderly has drawn great attention from the medical community. As an emerging discipline, rehabilitation medicine has developed rapidly in just a few decades and formed Chinese characteristics in the field of joint motion rehabilitation. On the basis of advanced rehabilitation technology from abroad, combined with the advantages of China’s physical therapy profession, after years of clinical practice, a distinctive treatment system has been formed.
On the basis of comprehensive analysis of the pathogenesis and pathological process of knee OA in the elderly, the combination of minimally invasive techniques of joint surgery with rehabilitation sports therapy and related comprehensive treatment system can definitely control the course of knee OA, alleviate clinical symptoms and improve the quality of life of middle-aged and elderly people to a certain extent. The current problem is to strengthen the popularization, exchange, summary and improvement of knowledge of related disciplines, combined with the integration, innovation and coordinated development of disciplines under the conditions of the domestic medical system in order to give full play to this advantage and truly solve this problem that has plagued doctors and patients for many years.