To initially observe the clinical efficacy of local anesthetic arthroscopic limited cleanup for osteoarthritis of the knee. [Methods] We retrospectively analyzed the short-term clinical treatment results of a total of 63 cases with 77 knees treated with local anesthesia arthroscopic limited cleanup for osteoarthritis of the knee in the past year. There were 11 male cases and 52 female cases; age ranged from 38 to 71 years, with an average of 56.5 years.
All 63 cases were followed up for 6 months to 1 year, including the JOA knee function score and patient satisfaction with the procedure. [Results] The JOA knee function score increased from 41 points before surgery to 78 points after surgery.
Osteoarthritis (OA) is a common and frequent disease in middle-aged and elderly people. Osteoarthritis of the knee joint can cause pain and dysfunction and seriously affect walking function. Although there are many treatment methods, the efficacy of traditional treatment methods is often poor. In the past year, our hospital used local anesthesia arthroscopic limited cleanup to treat osteoarthritis in 63 cases and 77 knees, and achieved good results, which are summarized as follows.
1. Information and methods
1.1 Clinical data
In the past year, 63 cases of osteoarthritis of the knee were treated in our hospital, with a total of 77 knees. There were 11 male cases and 52 female cases; 36 cases in the left knee and 41 cases in the right knee; age ranged from 38 to 71 years old, with an average of 56.5 years old, of which 38 cases (55.6%) were patients over 60 years old. All cases met the diagnostic criteria for osteoarthritis of the knee of the american college of rheumatology (ACR). None of the affected knees had undergone arthroscopy or other types of surgery, and 14 of them had combined free bodies and 3 had combined N-fossa cysts. The duration of the disease ranged from 1 month to 10 years, with a mean of 22.3 months.
1.2 Indications for surgery
(1) Knee pain, especially when walking up and down stairs, squatting and standing up, is more severe, and non-operative treatment is less effective;
(2) Pressure pain in the joint space and patellar rim, limited patellar pushing movement, positive patellar grinding test, positive quadriceps retraction test;
(3) Synovial villus hyperplasia, embedded in the joint space, affecting movement;
(4) Articular cartilage degeneration, exfoliation, free bodies in the joint cavity, and meniscal damage, causing joint locking symptoms;
(5) Frequent and repeated accumulation of fluid in the joint;
(6) Cases in which conservative treatment is ineffective and the degree of lesion is not sufficient for joint replacement.
1.3 Surgical methods
1.3.1 Anesthesia
After mixing 10 ml of 2% lidocaine, 40 ml of 0.5% procaine and 0.1% epinephrine injection 0.1%, the knee joint cavity was injected and the operation was started after 10 min, and the remaining part was used as local infiltration anesthesia for the surgical entrance. The perfusion solution was 3,000 ml of saline added with 0.1% epinephrine injection 1 ml, and the surgery was completed without a tourniquet state to maintain a clear intraoperative visualization.
1.3.2 Surgical technique
A conventional medial-lateral approach to the patellar tendon was taken, and the suprapatellar capsule, patellofemoral joint, lateral sulcus, lateral femoral tibiofemoral compartment, intercondylar fossa, medial femoral tibiofemoral compartment and lateral sulcus were first examined sequentially to obtain a comprehensive understanding of the intra-articular lesion. The procedure includes revision of the worn meniscus, removal of the free body, grinding of the stepped cartilage defect area and bony obstruction affecting joint movement, gentle grinding of the patellofemoral joint with a planer, and drilling of the cartilage defect area for decompression;
Microscopic shaving of part of the hyperplastic synovial tissue; large amount of saline for joint irrigation, removal of pain-causing substances in the joint, removal of exfoliated and unstable cartilage debris.
1.3.3 Postoperative treatment
After surgery, the knee was wrapped with pressure and an ice pack was applied to the knee for 48-72 h to stop bleeding and pain, and antibiotics were applied prophylactically for 3 d. Immediately after surgery, quadriceps muscle strength and knee flexion and extension exercises were performed, and the knee could be walked on the ground after pain relief.
1.4 Evaluation of therapeutic efficacy
The evaluation of knee function before and after surgery was based on the evaluation criteria for osteoarthritis of the knee published by the Japanese Orthopaedic Association (JOA), including: walking ability 30 points, ability to walk up and down steps 25 points, knee mobility 35 points, swelling 10 points, out of 100 points. The patient’s subjective assessment was graded as excellent: the pain and swelling of the joint disappeared, the range of motion and function were normal, the patient could work and live normally, and the patient was satisfied with the treatment effect;
Good: joint swelling and pain disappeared, range of motion improved, function was mildly restricted, patients were satisfied with the efficacy; OK: pain was significantly reduced, range of motion did not improve, patients were satisfied with the efficacy; Poor: postoperative symptoms did not improve or worsened, patients felt unsatisfied.
2.Results
All patients were followed up through outpatient clinics or by telephone, and the follow-up time for this group was 6 months to 1 year. the JOA knee function score increased from an average of 41 points before surgery to an average of 78 points after surgery. The patients’ subjective ratings were: excellent 31 knees (40.2%), good 28 knees (36.3%), acceptable 12 knees (15.6%), poor 6 knees (7.8%), with an excellent rate of 76.6%.
3.Discussion
Osteoarthritis occurs in the middle-aged and elderly population, and the incidence increases with age. Its pathology is based on degenerative changes of articular cartilage and chronic proliferative inflammation of synovial tissue, resulting in destruction of articular cartilage and bone growth, causing joint pain, swelling and fluid accumulation and functional impairment, which can eventually seriously affect the quality of life of patients. Although there is no real cure for osteoarthritis, with the development of arthroscopic technology, the superiority of arthroscopic treatment of osteoarthritis of the knee has been generally recognized and has been reported in the domestic and international literature (1-3).
Arthroscopic joint cleaning has become a common method for the treatment of osteoarthritis of the knee. In recent years, there have been controversies and improvements in its surgical approach. Extensive arthroscopic debridement excises too much normal synovial tissue, excessively disrupts the physiological function of the joint, is traumatic and blind, and is detrimental to the improvement of postoperative joint function and symptoms and prolongs the rehabilitation period.
Therefore, there is a trend toward limited cleanup, and it is believed that simple and effective cleanup is better than extensive cleanup, with good early postoperative efficacy and less traumatic reaction, which can significantly improve the excellent rate and is more conducive to early recovery of patients, thus giving full play to the advantages of minimally invasive arthroscopic surgery.
Arthroscopy is minimally invasive, yet has a good intra-articular field of view, enabling a comprehensive and detailed observation of various structures in the joint cavity. Lesions that are difficult to identify with other examinations, such as articular cartilage destruction, degenerative meniscal tears, synovial hypertrophy and intercondylar fossa stenosis, can be fully understood and the extent of intra-articular lesions and injuries can be clarified. Therefore, selective manipulation for specific intra-articular lesions allows for more delicate surgery and minimizes trauma.
In limited joint debridement, care should be taken to operate gently on various osteoarthritic lesions, including removal of cartilage fragments and free bodies that have been exfoliated and separated; surface wear of the meniscus should be planed and repaired smoothly, and meniscal tears should be partially excised; moderate cleaning and polishing of the degenerated cartilage surface should be focused on cleaning the cartilage flap that is about to be exfoliated and polishing the peripheral unevenness formed after cartilage exfoliation; For the subchondral bone area that is exposed and hardened after cartilage debridement, the method of drilling can be adopted by means of a kerf needle; only the bone flap that affects the joint activity should be ground;
For cases with patellofemoral pain, only the hyperplastic synovial tissue in the patellofemoral joint, femoro-tibial joint and intercondylar fossa should be shaved. Therefore, limited arthroscopic debridement can be used to treat osteoarthritic lesions in a targeted and comprehensive manner, while reducing unnecessary operations in the joint, thus reducing the disturbance of normal joint function and maximizing the advantages of minimally invasive arthroscopic surgery.
It can also reduce postoperative bleeding, decrease the reaction of the joint to surgery, and help shorten and accelerate the recovery process. Among the six cases with poor postoperative results in our group, the authors found that in three cases, too much synovial tissue was removed intraoperatively, resulting in persistent postoperative joint swelling and insignificant pain relief, and in one case, recurrent blood and fluid accumulation in the joint, which aggravated the postoperative pain.
In order to perform limited cleanup, our hospital tried to operate under local anesthesia, which is more in line with the modern concept of minimally invasive treatment, and the operation results proved that local anesthesia can fully meet the needs of the operation. Preoperative communication can eliminate the patient’s nervousness, and some patients can be sedated with drugs to relax the muscles of the lower limbs and cooperate with the operation.
The advantages of surgery under local anesthesia include avoiding the anesthetic risks that may be brought about by general and spinal anesthesia, and the small amount of drugs, which is less likely to cause adverse reactions such as drug toxicity, can expand the surgical adaptation group, eliminate the patient’s fear of anesthesia, and make it easier for them to accept arthroscopic debridement. Simplify postoperative care, shorten bed rest and hospitalization time, thus reducing costs. Due to the use of local anesthesia, patients are unable to tolerate the use of tourniquets and are therefore not suitable for intraoperative tourniquets.
By adding epinephrine to the local anesthetic and irrigation solution, elevating the perfusion pressure, keeping the water outlet open, and less intra-articular manipulation, clear surgical views can be obtained, and tissue edema and vascular contusions caused by tourniquet compression can also be avoided, preventing the formation of deep vein thrombosis. In this group, three patients with poor outcomes had severe internal and external knee deformities, significant narrowing of the joint space, large arthroscopic exposure of subchondral bone, and severe degeneration or breakdown of the meniscus.
The other 11 patients with insignificant postoperative improvement were all of advanced age, had a disease duration of more than 5 years, had mild internal derangement of the knee, and had heavy cartilage wear observed microscopically. Therefore, the efficacy was satisfactory for patients with early to mid-stage osteoarthritis, especially for those with predominant patellofemoral joint pain, a short duration of disease and acute attacks, combined with free bodies and mechanical symptoms that can be rapidly relieved from joint locking after surgery, the postoperative symptom improvement was very obvious and the patient’s self-evaluation satisfaction was high. Some patients with advanced age, long disease duration, severe cartilage defects, and combined internal derangement of the knee have poorer postoperative results or even deterioration after surgery.
Therefore, strict selection of indications is essential. Arthroscopic surgery does not fundamentally improve the developmental process of the lesion, and for those with intermediate to advanced knee osteoarthritis, especially those with advanced age, severe articular cartilage degeneration, internal and external knee deformity, and improved lower extremity force lines, who are expected to have poor postoperative outcomes, total knee replacement should still be the first choice and arthroscopic surgery should not be implemented reluctantly (5). Therefore, careful preoperative case selection is also an important factor in improving the efficacy of arthroscopic surgery.
In conclusion, local anesthesia arthroscopic debridement for osteoarthritis of the knee is a delicate and targeted procedure with few complications and is safe, especially for the elderly and infirm with poor general condition, and its short-term efficacy is precise, which can effectively relieve joint pain, restore joint movement early, prolong the pathological development of osteoarthritis, and improve the quality of life of the disease.