Early and Late-Term Results of Arthroscopic Surgery on Patients with Gonarthrosis

Objective: To provide guidance in the selection of the appropriate patient for arthroscopic debridement. Materials and Methods: Ninety patients who were diagnosed with gonarthrosis according to modified American College of Rheumatology (ACR) criteria and who underwent arthroscopic debridement and meniscectomy were evaluated. Functional assessment of patients was made based on preoperative as well as 1 month and 1 year postoperative results of the Lysholm Knee Score and the Visual Analog Scale (VAS). One year postoperatively, the Tapper-Hoover Scoring System was used to calculate long-term results. Analyses were conducted using SPSS 18 software. For this study ethics committee approval was received from the ethics committee of Ataturk University Medical Studies Department Head on 08.10.2010 at the 6th meeting with regards to the document written on 16.06.2010 with number 998. Results: Differences between preoperative and 1-month and 1-year postoperative values in the Western Otorino and McMaster Universities Osteoarthrosis (WOMAC) Index, Lysholm and VAS were found to be statistically significant (p<0.001) (Table 1). According to TapperHoover results, 82.8% of patients benefited from arthroscopic debridement in the long term (Table 2). Among body mass index (BMI) groups, the WOMAC, Lysholm and VAS values of obese patients were worse than those of normal weight and underweight patients, and the difference was statistically significant (p<0.005). Late-term results of patients younger than 55 were superior to those over 55. Conclusion: In the treatment of patients with gonarthrosis, arthroscopic debridement is a good option. Patients who have a low BMI and are younger than 55 years old experience more benefit from arthroscopic debridement.


Introduction
Osteoarthritis (OA) is the most frequently encountered disease of synovial joints, and it is characterized by cartilage destruction, osteophyte formation and subchondral sclerosis and is a progressive, non-inflammatory, degenerative, chronic disease occurring primarily in load-bearing joints.
This disease, also referred to as degenerative arthritis, osteoarthrosis or hypertrophic joint arthritis, is associated with progressive cartilage loss, which is accompanied by insufficient cartilage repair, subchondral sclerosis and, commonly, osteophyte formation.Although OA can affect any joint, concentration in the knee joints, also known as gonarthrosis, is widely observed.Gonarthrosis is the mostly commonly observed peripheral joint osteoarthritis and ranks second only to the spine in terms of involvement in the body overall [1,2].
Conservative treatment methods, including nonsteroidal anti-inflammatory medicines, analgesics, physiotherapy methods, intraarticular corticosteroid and intraarticular hyaluronic acid injections, are used in the treatment of gonarthrosis to alleviate pain and restore physiologic range of motion and healing.Surgical methods are reserved for patients who do not respond to conservative methods and have progressive disabilities [3].
Arthroscopic debridement is the surgical method of choice to prolong time before arthroplasty, especially in young patients.During debridement, joint lavage is applied, free particles are extracted until stable perimeter degenerative meniscus tears are excised, unstable portions of cartilage are trimmed, synovectomy is applied where necessary, and osteophytes causing cramps are cleared [4].
For the patients with osteoarthritis of the highest degree and who have not benefited from the previously described treatment methods, surgical osteotomy and total joint arthroplasty are utilized with the goal of alleviating pain and improving function.
Many studies have demonstrated that arthroscopic debridement is a successful method for the treatment of gonarthrosis.However, the same studies also note that different patient groups do not experience the same amount of benefit from the method.The main reason for this difference has been inappropriate selection of patients for this treatment.In the present study, our goal was to both determine the effectiveness of this treatment and to assist in identifying the most appropriate patient by examining patients with primary gonarthrosis who have undergone arthroscopic debridement and assessing them pre-and postoperatively when grouped by BMI, age, and gender.We then analyzed the clinical results of patients having arthroscopic debridement to determine any relationship with BMI, age and gender.

Materials and Methods
In this study, 90 patients (26 men and 64 women) who were admitted to the Orthopaedics and Traumatology Clinic between 2008 and 2010 for arthroscopic debridement and meniscectomy after being diagnosed with meniscus tear and cartilage destruction were evaluated.The patients were between 38 and 82 years of age, had been diagnosed with gonarthrosis according to the modified ACR criteria and had been treated with conservative techniques for 6 months but were still experiencing pain.
All patients in this study underwent standard arthroscopic debridement surgery by faculty members of our clinic.During this procedure, unstable meniscus tears and flaptype cartilage distortions were resected, free particles were extracted, and joint lavage was applied with normal saline.Based on the findings during arthroscopy, laser chondroplasty and synovectomy processes were also applied.
Immediately after the surgery, every patient received cold therapy for two weeks, and an exercise program was started to strengthen the quadriceps muscle.Patients were allowed to ambulate when they were able to tolerate the pain.
The quality of life and functional assessment of patients preoperatively and 1 month and 1 year postoperatively were calculated using the WOMAC, Lysholm, VAS and Tapper-Hoover scoring systems.By grouping patients according to their BMI, age and gender, it was possible to identify relationships between these factors and arthroscopy results.
In this study, the inclusion criteria were as follows:

Results
The data are reported in terms of number, percent and standard deviation.Analysis was made using Statistical Package for the Social Scienses (SPSS) software version 18 (IBM, Illinois, USA).The patients were grouped into 3 BMI groups, 3 age groups, and 2 gender groups, and the WOMAC, Lysholm and VAS scores were compared with ANOVA repeated measures testing.Dual groups were compared with Wilcoxon signed ranks.The Tapper-Hoover scores for BMI, age and gender groups were compared by chi-square testing.Statistical significance was defined as p<0.005.
As shown in Figure 1, when the Tapper-Hoover scores of patients in different BMI groups were compared, we observed that the patients experiencing perfect or good results tended to be in lower BMI groups and that patients with moderate or bad results were more likely to be in the higher BMI groups.Figure 2 illustrates that when the Tapper-Hoover scores of patients in different BMI groups were compared, the patients having perfect results were younger.
In Table 3 and Figures 1 3 and 4, we show that when the WOMAC, Lysholm and VAS scores of patients in different BMI groups were compared, there was no significant difference between patients with lighter weights and those with normal weights.When gonarthrosis patients of normal weight and obese patients were compared, as well as when patients with lighter weights and obese patients were compared, meaningful differences were found.These outcomes show us that obese patients benefited less from arthroscopy and experienced less pain relief after arthroscopy.
As shown in Table 4 and Figure 5, when Tapper-Hoover scores of BMI groups were compared, because of the lowerthan-necessary number of patients, the moderate and bad result groups were combined.For patients with lower BMI values, a higher number of perfect results was obtained, and moderate and bad results were observed less frequently.Similarly, for patients with higher BMI values, moderate and bad results were usually observed, and perfect results were seen less often.This finding suggests that patients with a lower BMI benefit more from arthroscopy in the late term, and there is a disproportional relationship between BMI and arthroscopy benefit.To understand how much patients benefited from arthroscopy, patients were divided into 3 groups: patients under age 55, patients between 55 and 64, and patients over 65.When preoperative WOMAC, Lysholm and VAS scores of all groups were compared with 1 month and 1 year postoperative results, in all the groups, statistically meaningful results were obtained.This suggests that all age groups benefited from arthroscopy.However, when the WOMAC, Lysholm and VAS scores of each age group were compared with each other, statistically meaningful results could not be reached.
When the Tapper-Hoover scores were analyzed, it was observed that all the groups benefited from arthroscopy in the late term.In particular, in the case of patients under 55 years, a higher number of perfect results was observed.However, when the age groups were compared with each other, no statistically meaningful result was obtained.
When the results between male and female participants were analyzed, statistically meaningful results were observed for preoperative results.However, when the results of each gender group were compared with the other, not only in early term but also in the late term, no meaningful differences were obtained.

Discussion
Osteoarthritis, characterized by cartilage destruction, osteophyte formation and subchondral sclerosis, is a progressive, non-inflammatory, degenerative, chronic disease commonly observed in load-bearing joints in patients after their forties.No treatment methods have been able to provide  Patient training, weight loss, physiotherapy, exercise, helping tools, orthoses, pharmacological treatment methods (topical, systematic, and intraarticular) and surgery are typical methods of gonarthrosis treatment.Arthroscopic debridement is also a treatment method, but there are many conflicting findings regarding its effectiveness.
Although there is an extensive body of literature on arthroscopic debridement, because the treated pathology has not been well defined, applied treatment methods have not been standardized, and there is no consensus on the indications for surgery and its effects.This has caused some unscientific and irrational discussions.There are a number of publications implicating that arthroscopic debridement is still debatable and that its effectiveness has not been proven by high-quality scientific studies [5,6].
Arthroscopy in gonarthrosis treatment is still controversial, although it has been used for 30 years.This is likely due to the use of nonstandard methods.Through arthroscopic washing, the accumulated debris in the joint and degenerative enzymes are drained, thus reducing patient complaints.However, the need for arthroscopy, which will allow this benefit, is contro-   versial.One of the most important publications in the literature was conducted by Moseley et al. [7] and published in 2002 in New England Journal of Medicine.According to this study, 180 patients with gonarthrosis were divided into 3 groups, with one group receiving only lavage, one receiving lavage and debridement and the last group receiving only an arthroscopic portal incision; patients were followed up for two years.Results indicated that none of the patients experienced pain during the first and second years.The conclusion of this study, according to the authors, was that arthroscopy was unnecessary for patients with gonarthrosis due its higher costs.Wray et al. [8] in the Journal of Bone and Joint Surgery (JBJS) and Lohmande et al. (2002) in Lakartidningen stated that randomized placebo-controlled double-blind arthroscopic debridement study results indicate that there is no difference between arthroscopic debridement, lavage and placebo surgery after two years of follow up [9].Many other publications in the literature have drawn similar conclusions.Conversely, numerous publications have shown that arthroscopic debridement is beneficial, and many researchers have reported success rates of approximately 70% and contend that other positive effects are more longstanding than lavage-only procedures.
Hubbard [10] reported on 76 patients with medial knee arthrosis, and after they were examined after the first year, there were no pain complaints in 80% of the debridement applied group compared with 14% of the arthroscopic lavage group; after 5 years, there were no pain complaints in 59% of the debridement group compared with 12% of the arthroscopic lavage group (74).Forster and Straw [11] and Casscells [12] reported that when arthroscopic lavage and arthroscopic lavage with debridement treatment methods were compared, the arthroscopic washing with debridement was the treatment of choice for the more than 2 years of activity reported.
Goldman et al. [13] examined 678 arthroscopic debridements for knee osteoarthritis among 8 case series.It was reported that 68% of patients had good results and alleviation in pain, and the bad results belonged to patients with advanced osteoarthritis.Jackson and Dieterichs [14] followed up patients with degenerative alterations in their knee joint cartilage and applied debridement and reported a 91% perfect success rate.For patients having fibrillation in their joint cartilage, Jackson and Dieterichs [14] also advised limited debridement.
Obesity is widespread among people over 40 years old.People over 40 years old are also in a higher risk group in terms of gonarthrosis.Thus, it is not surprising how common a problem obesity is for those with gonarthrosis.Consider that during normal walking conditions, the knee joint carries 4 times the body weight, and this proportionally increases with increasing body weight.The increase in the load in accordance weight gain and the incompatibility of the shockabsorbing mechanisms in the knee, namely, the meniscus and cartilage, can cause destruction of the knee joint [15,16].
Ford et al. [17] researched the relationship between BMI and meniscus injuries for both genders.According to this study, both the risk of meniscus injuries and the risk of meniscus surgery increase with increasing BMI.
Başaran et al. [18] used the Lysholm Knee Score and grouped patients by BMI, age and gender; however, they found no statistically meaningful results.
Harrison et al. [19] compared overweight female patients with normal weight female patients for 4 to 11 years after knee arthroscopy.Patients were divided in two groups as obese and not obese according to BMI, and the results indicated that the obese patients benefited less from arthroscopy than did the normal weight patients according to the SF-36 and WOMAC osteoarthritis index.
Burks et al. [20] published the results of 15 years of follow up in patients who had arthroscopic meniscectomy.Patients' clinical situations were analyzed using the Lysholm Knee Score.The patients with ACL tear and medial meniscectomy were compared to those with no ACL tear and medial meniscectomy.The group with ACL tears was reported to have statistically meaningful worse results than the stable group.Furthermore, no relationship was found regarding the ages of patients, and no statistically meaningful difference was observed between male and female patients.
As the aforementioned findings demonstrate, conflicting results have been reported.The two main reasons of for this are controversy about the treatment protocols as well as insufficient and incorrect patient selection criteria.Long-lasting complaints, resting pain, arthrosis in 2 to 3 compartments, obesity, prior surgery, a prominent axis disorder, ligament instability, advanced degree radiological gonarthrosis findings, level 3-4 cartilage destruction according to Quterbridge, chondrocalcinosis and more than 10 degree flexion contractures are the common features of patients in whom we would expect poor outcomes.Similarly, minimal degenerative alterations, no axis disorder, low BMI, acute mechanic complaints and meniscus tears, level 1-2 cartilage destruction according Quterbridge and joint mouse are the common features of patients deemed most appropriate for arthroscopic debridement.
Although we were unable to pay the necessary attention to the selection of patients for this study, our results are consistent with those of previously published studies.Ninety patients with an average age of 58.26±8.739were observed to have a Lysholm Knee Score of 42.4±9.895preoperatively, 79.33±16.79 1 month postoperatively and 72.21±20.84 1 year postoperatively.The WOMAC score of patients was found to be 37.96±9.713preoperatively, 80.83±20.33 1 month postoperatively and 72.33±27.04 1 year postoperatively.The VAS scores of patients were 8.58±0.73preoperatively, 2.91±2.267 1 month postoperatively and 4.02±2.907 1 year postoperatively.The Tapper-Hoover scores of patients, who were followed up for 2 years, were 23.3% perfect, 26.7% good, 32.2% moderate and 17.8% bad.Hence, in the late term, 82.8% of patients benefited from arthroscopic debridement.
The WOMAC and Lysholm scores of patients with a lower BMI increased more than in patients with a higher BMI, and the VAS scores of this group decreased more than in the patients with a higher BMI.Moreover, when late-term Tapper-Hoover scores were examined, we observed that patients with a lower BMI experienced a higher number of perfect and good results than the patients with a higher BMI.
In this study, we did not find any statistically meaningful difference among groups according to age and gender when compared using the WOMAC, Lysholm, VAS and Tapper-Hoover instruments.However, we did find that in the late term, patients under age 55 benefited from arthroscopy more than the patients over 55.

Figure 5 .
Figure 5.Comparison of Tapper-Hoover Results of BMI groups.

Table 1 . Statistical Results for WOMAC, Lysholm, and VAS Scores of Patients
BMI: body mass index; WOM AC: Western Otorino and McMaster Universities Osteoarthrosis

Table 2 . Tapper-Hoover Results of BMI and Age Groups
BMI: body Mass Index

Table 3 . Comparison of WOMAC, Lysholm and VAS Scores of BMI Groups
BMI: body Mass Index; WOMAC: Western Otorino and McMaster Universities Osteoarthrosis; VAS: visual analog scale

Table 4 . Comparison of Tapper-Hoover Results of BMI Groups
BMI: body mass index