Mechanical debridement versus radiofrequency in knee chondroplasty with concomitant medial meniscectomy: 10-year results from a randomized controlled study

Factors Affecting Choice of Surgical Treatment of Cartilage Lesions of the Knee: An Analysis of Data From 5143 Patients From the German Cartilage Registry (KnorpelRegister DGOU)

Background

Symptomatic full-thickness cartilage lesions of the knee joint are considered an indication for cartilage repair surgery. Patient- and lesion-specific factors like age, nutritional status, etiology of defect, or integrity of corresponding joint surface remain controversial in indicating cartilage repair surgery. Furthermore, the selection of the most suitable cartilage repair technique for a specific cartilage lesion remains debatable.

Purpose

To evaluate indications and choice of treatment method for cartilage repair surgery, depending on patient- and lesion-specific data from the German Cartilage Registry.

Study Design

Cross-sectional study; Level of evidence, 3.

Methods

A total of 6305 consecutive patients who underwent cartilage repair surgery of the knee evaluated and 5143 complete datasets were included in the analysis (follow-up rate, 81.5%). Patient-specific (age, body mass index, smoking status, previous operations, clinical leg axis) and lesion-specific (size, grading, location, etiology) data were provided by the attending surgeon at the time of surgery. Appropriate statistical tests were used to compare data depending on type and normality of data. Multivariable logistic regressions were calculated to investigate independent factors for the choice of specific cartilage repair techniques.

Results

The median size of treated cartilage lesions was 3.6 cm2, and most defects were of degenerative origin (54.8%). Of the registered patients, 39.2% were categorized as overweight and 19.6% as obese, while 23.3% were smokers. The most prevalently documented operative techniques were the autologous chondrocyte implantation (ACI) (52.4%), bone marrow stimulation (BMS) (17.3%), and BMS augmented with collagen scaffolds (9.3%). Independent factors that made the use of ACI more likely were bigger lesion size, previous surgery at the joint, and lesions located at the trochlea or the patella. On the contrary, BMS or augmented BMS were preferred in older patients, with damaged corresponding joint surface, and with more concomitant surgeries.

Conclusion

Cartilage repair surgery was indicated irrespective of nutritional status, smoking status, or etiology of the treated lesion. ACI was the most prevalent technique and was preferred for younger patients and patellar lesions. While older patients with degenerative changes to the joint were not excluded from cartilage repair surgery, the use of ACI was restricted.

Metacarpophalangeal Joint Arthroscopy: Indications and Techniques through a Clinical Series

Background  Metacarpophalangeal (MCP) joint arthroscopy has been available for many years but sparingly used in typical orthopaedic and hand surgery daily practice. Difficult problems are solved with this technique in a practical and minimally invasive manner. This study describes our diverse experience and broad clinical applications of MCP arthroscopy as well as clinical results. It aims to highlight this technique as one of the tools for a fully trained hand surgeon, avoiding open management and its high complications rates. Methods  We present a retrospective clinical series of 79 patients treated with MCP arthroscopy with a mean age of 44 years old. Demographics, surgery, and clinical outcomes were collected in standardized clinical assessments. Results  We divided the sample into 20 articular metacarpal or proximal phalanx acute fracture with full functional fist and range of motion at 60 days after surgery. Regarding collateral tears, 12 were classified as acute and 47 as chronic. Two patients were reoperated for further gain range of motion. Conclusions  We present an up-to-date publication of our experience in MCP arthroscopy and its applications, with a low complication rate and excellent clinical results. We encourage hand surgeons to incorporate this technique in MCP joint challenging issues. Level of Evidence  IV.

Sodium fluoride PET/CT with arthrography for cartilage evaluation of the knee

The presence of healthy cartilage in the knee joint, featuring smooth articular surfaces, is crucial for normal physiological knee function. However, noninvasive in-vivo assessment of cartilage quality in the knee remains challenging and has not been thoroughly investigated. We aimed to illustrate two clinical cases, a 62-year-old male and a 67-year-old male, presented to the orthopaedic outpatient clinic with severe knee complaints. The novel combination of sodium fluoride-18 positron emission tomography/computed tomography and intra-articular injection of a contrast agent (Na[18F]F-PET/CT arthrography) was performed to evaluate cartilage defects of the knee as part of a prospective patient study. The lesion size observed on the Na[18F]F-PET was substantially larger compared to the findings on CT. This might indicate that Na[18F]F-PET/CT arthrography was able to image osseous and chondral pathological changes in an early stage and in a single procedure. Na[18F]F-PET/CT arthrography is a promising imaging technique and might extend the diagnostic potential of nuclear and radiological imaging in the evaluation of cartilage defects.

Examining the Evidence Regarding Smoking and Patient Outcomes for Isolated Meniscus Pathology: A Comprehensive Systematic Review and Meta-Analysis

Smoking is a well-known cause of impairment in wound healing and postoperative outcomes; however, its effects on treating meniscus issues remain unclear. This study assesses the relationship between smoking and meniscus treatment outcomes. PubMed, Scopus, Cochrane, and CINAHL were searched from inception to 24 December 2023. Inclusion criteria encompassed studies examining smoking's impact on patient outcomes regarding meniscus pathology. A secondary PubMed search targeted randomized controlled trials (RCTs) in the top ten orthopedic journals focusing on meniscus pathology and smoking as a demographic variable. Meta-analysis of six studies (n = 528) assessed meniscus failure rate based on smoking status. Eighteen observational studies (n = 8353 patients; 53.25% male; mean age: 51.35 ± 11.53 years; follow-up: 184.11 ± 117.34 months) were analyzed, covering meniscus repair, meniscectomy, allograft transplant, conservative care, and arthroscopy. Results showed four studies (36.36%) linked smoking with worse meniscus repair outcomes, while seven studies (63.64%) did not find significant associations. Meta-analysis from six studies showed no significant impact of smoking on repair failure (p = 0.118). Regarding meniscectomy, one study (33.33%) identified a significant association with smoking, but two did not. Only one (3.8%) of the RCTs in leading orthopedic journals included smoking as a factor. The evidence on smoking's effect on meniscus treatment is mixed, necessitating further investigation.

Radiofrequency-Based Chondroplasty Creates a Precise Area of Targeted Chondrocyte Death With Minimal Necrosis Outside the Target Zone: A Systematic Review

Purpose

To systematically examine the effects of radiofrequency (RF) ablation or coblation (controlled ablation) on chondrocyte viability following knee chondroplasty in preclinical literature to determine the effectiveness and safety of RF-based techniques.

Methods

A literature search was performed in September 2022 using PubMed and Scopus using the following search terms combined with Boolean operators: "chondroplasty," "radiofrequency," "thermal," "knee," "chondral defect," "articular cartilage," and "cartilage." The inclusion criteria consisted of preclinical studies examining the effect of RF ablation or coblation on chondrocytes during knee chondroplasty. Exclusion criteria consisted of studies reporting chondroplasty in joints other than the knee, clinical studies, in vitro studies using animal models, case reports, non-full-text articles, letters to editors, surveys, review articles, and abstracts. The following data were extracted from the included articles: author, year of publication, chondral defect location within the knee and chondral characteristics, RF probe characteristics, cartilage macroscopic description, microscopic chondrocyte description, and extracellular matrix characteristics.

Results

A total of 17 articles, consisting of 811 cartilage specimens, were identified. The mean specimen age was 63.4 ± 6.0 (range, 37-89) years. Five studies used monopolar RF devices, 7 studies used bipolar RF devices, whereas 4 studies used both monopolar and bipolar RF devices. Time until cell death during ablation at any power was reported in 5 studies (n = 351 specimens), with a mean time to cell death of 54.4 seconds (mean range, 23.1-64) for bipolar RF and 56.3 seconds (mean range, 12.5-64) for monopolar RF devices. Chondrocyte cell death increased with increased wattage, while treatment time was positively correlated with deeper cell death.

Conclusions

In this systematic review, histologic analysis demonstrated that RF-based chondroplasty creates a precise area of targeted chondrocyte death, with minimal evidence of necrosis outside the target zone. Caution must be exercised when performing RF-based chondroplasty due to the risk of cell death with increased application time and wattage.

Clinical Relevance

Although RF ablation has demonstrated favorable results in preliminary trials, including smoother cartilage and less damage to the surrounding healthy tissue, the risks versus benefits of the procedure are largely unknown. Caution must be exercised when performing RF-based chondroplasty in the clinical setting due to the risk of cell death with increased application time and wattage.

After Chondroplasty, Patient Election to Proceed With Cartilage Transplantation Is Closely and Additively Associated With Preoperative AMADEUS (Area Measurement And DEpth Underlying Structure) Grade, Condylar Involvement, Knee Injury and Osteoarthritis Outcome Score Pain Score, and Veterans Rand 12-Item Health Survey Physical Score

Purpose

To identify risk factors for patient election to proceed with cartilage transplant after staging chondroplasty.

Methods

This study retrospective reviewed patients prospectively enrolled at the time of staging chondroplasty, with early election defined as patient decision to proceed to cartilage transplantation within 6 months of chondroplasty. Cox proportional hazards analysis was used to determine univariate predictors of conversion, and a predictive calculator, the Cartilage Early Return for Transplant score, was formulated using stepwise regression employing the Akaike information criterion. Receiver operator curves and the area under the curve were used to evaluate the predictive ability of the final model on the studied patient population.

Results

Sixty-five knees (63 patients) were evaluated, with an overall transplant election rate of 27.7% within 6 months after chondroplasty. Based on multivariate results, the final Akaike information criterion-driven Cartilage Early Return for Transplant score employed preoperative Knee Injury and Osteoarthritis Outcome Score Pain Score, Veterans Rand 12-Item Health Survey Physical Score, condylar involvement, and AMADEUS (Area Measurement And DEpth Underlying Structure) score to generate a 0- to 7-point risk-stratification system with a 3% early election to proceed to transplant risk in the 0- to 2-point score group, 33% risk in the 3- to 4-point group, and 79% risk in the 5+-point group (P < .01) and an overall AUC of 0.906 (P < .01).

Conclusions

Risk of early patient election to pursue cartilage transplantation after chondroplasty is closely and additively associated with preoperative AMADEUS grade, condylar involvement, Knee Injury and Osteoarthritis Outcome Score Pain Score, and Veterans Rand 12-Item Health Survey Physical Score.

Clinical Relevance

Understanding risk factors for conversion to cartilage transplantation may improve preoperative planning and counseling prior to staging chondroplasty.

The Arthroscopic Application of Radiofrequency in Treatment of Articular Cartilage Lesions

Articular cartilage lesion is a common disease to be treated by arthroscopic surgery. It will eventually progress to osteoarthritis without proper management, which can affect patients’ work and daily life seriously. Although mechanical debridement and laser have been used clinically for its treatment, due to their respective drawbacks, radiofrequency has drawn increasing attention from clinicians as a new technique with more advantages. However, the safety and efficacy of radiofrequency have also been questioned. In this article, the scope of application of radiofrequency was reviewed following an introduction of its development history and mechanism, and the methods to ensure the safety and effectiveness of radiofrequency through power and temperature control were summarized.

The Fragility of Statistical Significance in Cartilage Restoration of the Knee: A Systematic Review of Randomized Controlled Trials

OBJECTIVE

The purpose of this study was to utilize fragility analysis to assess the robustness of randomized controlled trials (RCTs) evaluating the management of articular cartilage defects of the knee. We hypothesize that the cartilage restorative literature will be fragile with the reversal of only a few outcome events required to change statistical significance.

DESIGN

RCTs from 11 orthopedic journals indexed on PubMed from 2000 to 2020 reporting dichotomous outcome measures relating to the management of articular cartilage defects of the knee were included. The Fragility Index (FI) for each outcome was calculated through the iterative reversal of a single outcome event until significance was reversed. The Fragility Quotient (FQ) was calculated by dividing each FI by study sample size. Additional statistical analysis was performed to provide median FI and FQ across subgroups.

RESULTS

Nineteen RCTs containing 60 dichotomous outcomes were included for analysis. The FI and FQ of all outcomes was 4 (IQR 2-7) and 0.067 (IQR 0.034-0.096), respectively. The average number of patients lost to follow-up (LTF) was 3.9 patients with 15.8% of the included studies reporting LTF greater than or equal to 4, the FI of all included outcomes.

CONCLUSIONS

The orthopedic literature evaluating articular cartilage defects of the knee is fragile as the reversal of relatively few outcome events may alter the significance of statistical findings. We therefore recommend comprehensive fragility analysis and triple reporting of the P value, FI, and FQ to aid in the interpretation and contextualization of clinical findings reported in the cartilage restoration literature.

Accurate Reporting of Concomitant Procedures Is Highly Variable in Studies Investigating Knee Cartilage Restoration

OBJECTIVE

Successful clinical outcomes following cartilage restoration procedures are highly dependent on addressing concomitant pathology. The purpose of this study was to document methods for evaluating concomitant procedures of the knee when performed with articular cartilage restoration techniques, and to review their reported findings in high-impact clinical orthopedic studies. We hypothesized that there are substantial inconsistencies in reporting clinical outcomes associated with concomitant procedures relative to outcomes related to isolated cartilage repair.

DESIGN

A total of 133 clinical studies on articular cartilage repair of the knee were identified from 6 high-impact orthopedic journals between 2011 and 2017. Studies were included if they were primary research articles reporting clinical outcomes data following surgical treatment of articular cartilage lesions with a minimum sample size of 5 patients. Studies were excluded if they were review articles, meta-analyses, and articles reporting only nonclinical outcomes (e.g., imaging, histology). A full-text review was then used to evaluate details regarding study methodology and reporting on the following variables: primary cartilage repair procedure, and the utilization of concomitant procedures to address additional patient comorbidities, including malalignment, meniscus pathology, and ligamentous instability. Each study was additionally reviewed to document variation in clinical outcomes reporting in patients that had these comorbidities addressed at the time of surgery.

RESULTS

All studies reported on the type of primary cartilage repair procedure, with autologous chondrocyte implantation (ACI) noted in 43% of studies, microfracture (MF) reported in 16.5%, osteochondral allograft (OCA) in 15%, and osteochondral autograft transplant (OAT) in 8.2%. Regarding concomitant pathology, anterior cruciate ligament (ACL) reconstruction (24.8%) and meniscus repair (23.3%) were the most commonly addressed patient comorbidities. A total of 56 studies (42.1%) excluded patients with malalignment, meniscus injury, and ligamentous instability. For studies that addressed concomitant pathology, 72.7% reported clinical outcomes separately from the cohort treated with only cartilage repair. A total of 16.5% of studies neither excluded nor addressed concomitant pathologies. There was a significant amount of variation in the patient reported outcome scores used among the studies, with the majority of studies reporting International Knee Documentation Committee (IKDC) and Knee Injury and Osteoarthritis Outcomes Score (KOOS) in 47.2% and 43.6% of articles, respectively.

CONCLUSIONS

In this study on knee cartilage restoration, recognition and management of concomitant pathology is inadequately reported in approximately 28% of studies. Only 30% of articles reported adequate treatment of concomitant ailments while scoring their outcomes using one of a potential 18 different scoring systems. These findings highlight the need for more standardized methods to be applied in future research with regard to inclusion, exclusion, and scoring concomitant pathologies with regard to treatment of cartilage defects in the knee.

Surgical Management of Osteochondral Defects of the Knee: An Educational Review

PURPOSE OF REVIEW

Numerous surgical techniques are available to treat osteochondral defects of the knee. The aim of this review is to analyse these procedures, including their methodology, outcomes and limitations, to create a treatment algorithm for optimal management.

RECENT FINDINGS

Osteochondral defects of the knee significantly alter the biomechanics of the joint. This can cause symptomatic and functional impairment as well as considerable risk of progressive joint degeneration. Surgical interventions aim to restore a congruent, durable joint surface providing symptomatic relief and reducing the risk of early arthritic changes. These methods include fixation, chondroplasty, microfracture, autologous matrix-induced chondrogenesis, autograft transplants, allograft transplants and autologous chondrocyte implantation. There is currently much debate as to which of these methods provides optimal treatment of osteochondral defects. The overall evidence supports the use of each technique depending on the individual characteristics of the lesion. New technologies provide exciting prospects; however, long-term outcomes for these are not yet available.

Use of a Novel Variable Power Radiofrequency Ablation System Specific for Knee Chondroplasty: Surgical Experience and Two-Year Patient Results

Introduction Although stabilisation of knee cartilage lesions (chondroplasty) may be performed with an arthroscopic shaver, more recently, radiofrequency (RF) ablation has gained in popularity. However, their remain some concerns about the avoidance of thermal injury, chondrolysis, and osteonecrosis with the use of RF devices. Methods We reviewed the outcomes of 85 knee chondroplasties performed with a new RF ablation wand designed for knee chondroplasty. Lesion details and Chondropaenia Severity Score (CSS) were recorded for each patient. We evaluated the occurrence of adverse outcomes, post-operative complications, and the need for further surgery. Post-operative outcomes scores (Oxford Knee Score [OKS], Knee injury and Osteoarthritis Outcome Score [KOOS], and International Knee Documentation Committee [IKDC] subjective knee outcome) were recorded at a minimum of one-year follow-up. Results At the final mean follow-up of 27.5 months (range: 12-46.6 months), 12 (14%) knees had undergone or were listed for further surgery. Four patients had corticosteroid injections for ongoing pain at a median 7.5 months (range: 5-20 months) post-operatively. There were no observed re-operations considered to be caused by complications related to thermal injury. Of the six patients listed for or undergoing knee arthroplasty, five (83%) had grade 4 lesions found at the arthroscopic chondroplasty. A negative correlation was noted between CCS, and post-operative IKDC subjective score (R=-0.35), KOOS Sports (R=-0.39), and KOOS QoL (R=-0.36). Conclusions We found that RF chondroplasty appeared safe, and there were no concerns with regard to thermal injury. Functional outcome appeared to be related to the quality of chondral and meniscal tissue throughout all knee compartments, with better results for isolated grade 2 and 3 cartilage lesions.

Arthroscopic debridement for focal articular cartilage lesions of the knee: A systematic review

BACKGROUND AND PURPOSE OF THE STUDY

Arthroscopic debridement, the most commonly applied surgical technique for focal cartilage lesions in the knee, is not included in most treatment algorithms because of discouraging results in the management of osteoarthritis of the knee. The present systematic review evaluates the outcome of arthroscopic cartilage debridement as the primary treatment of focal knee chondral lesions in adults, and defines its indications and role as the primary treatment of focal knee chondral lesions.

METHODS

Two independent investigators searched PubMed, Cochrane CENTRAL, and Virtual Health Library databases using the terms "knee", "cartilage", "chondral", "lesions", "injury", "damage", "debridement", "chondroplasty", "chondrectomy", alone and in combination. Clinical studies evaluating the effect of mechanical cartilage debridement in adults with symptomatic focal cartilage lesions in the knee joint regardless of the defect size and depth were included. We excluded studies if patients had a concomitant ligament or meniscus injury, and/or had additional debridement with monopolar radiofrequency energy.

MAIN FINDINGS

Available studies suggest good to excellent short and medium-term functional outcomes (KOOS, LKSS, Tegner scale) for focal cartilage lesions treated with debridement regardless of the defect size and depth. Data are lacking comparing cartilage debridement versus other cartilage repair techniques.

CONCLUSIONS

Arthroscopic debridement of focal articular cartilage lesions of the knee is associated with good to excellent short and medium-term postoperative outcomes, especially in terms of functional improvement. Arthroscopic debridement may be considered in the primary treatment of focal cartilage injuries regardless of the defect size and depth. However, available studies are limited and the level of evidence is low.

Wide Variation in Methodology in Level I and II Studies on Cartilage Repair: A Systematic Review of Available Clinical Trials Comparing Patient Demographics, Treatment Means, and Outcomes Reporting

BACKGROUND

The management of complex cartilage pathology in young, otherwise healthy patients can be difficult.

PURPOSE

To determine the nature of the design, endpoints chosen, and rate at which the endpoints were met in published studies and ongoing clinical trials that investigate cartilage repair and restoration procedures.

STUDY DESIGN

Systematic review.

METHODS

A systematic review of the publicly available level I/II literature and of the publicly listed clinical trials regarding cartilage repair and restoration procedures for the knee was conducted adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

Seventeen published studies and 52 clinical trials were included. Within the 17 published studies, the most common procedure studied was microfracture (MFX) + augmentation (N = 5; 29.4%) and the most common comparison/control group was MFX (N = 10; 58.8%). In total, 13 different cartilage procedure groups were evaluated. For published studies, the most common patient-reported outcome (PRO) measures assessed is the Knee Injury and Osteoarthritis Outcome Score (KOOS) and Visual Analog Scale-Pain (VAS) (N = 10 studies, 58.8% each, respectively). Overall, there are 10 different PROs used among the included studies. Ten studies demonstrate superiority, 5 demonstrate noninferiority, and 2 demonstrate inferiority to the comparison or control groups. For the clinical trials included, the most common procedure studied is MFX + augmentation (N = 16; 30.8%). The most common PRO assessed is KOOS (N = 36 trials; 69.2%), and overall there are 24 different PROs used among the included studies.

CONCLUSIONS

Recently published studies and clinical trials evaluate a variety of cartilage repair and restoration strategies for the knee, most commonly MFX + augmentation, at various time points of outcome evaluation, with KOOS and VAS scores being used most commonly. MFX remains the most common comparison group for these therapeutic investigations. Most studies demonstrate superiority versus comparison or control groups. Understanding the nature of published and ongoing clinical trials will be helpful in the investigation of emerging technologies required to navigate the regulatory process while studying a relatively narrow population of patients.

Cost-effectiveness analysis of Coblation versus mechanical shaver debridement in patients following knee chondroplasty

Background

To compare costs and outcomes following knee chondroplasty with Coblation versus mechanical shaver debridement (MSD) in patients with grade III articular cartilage lesions of the knee.

Methods

A decision-analytic model was developed to compare costs and outcomes of the two methods from a US payer perspective. We used published clinical data from a single-center randomized clinical trial (RCT) designed to compare outcomes between Coblation and MSD in patients with grade III articular cartilage lesions of the medial femoral condyle. Following primary knee chondroplasty, patients experienced either treatment success (no additional surgery required) or required a revision over the 4 year follow-up period. Costs associated with the initial chondroplasty, physical therapy sessions through the 6 week postoperative period, and revision rates at 4 years post-surgery were estimated using 2018 US Medicare Physician Fee Schedule. Sensitivity analyses including a 10 year time horizon and threshold analyses were performed to test the robustness of the model.

Results

The estimated total cost per patient was $4614 and $7886 for Coblation and MSD, respectively, resulting in cost-savings of $3272 in favor of Coblation, making it a dominant strategy because of lower costs and improved clinical outcomes. Threshold analysis showed that Coblation remained dominant even when revision rates were assumed to increase from the base case rate of 14–66%. Sensitivity analyses showed that cost-saving results were insensitive to variations in revision rates, number of physical therapy sessions and the time horizon used.

Conclusion

Coblation chondroplasty is a cost-saving procedure compared with MSD in the treatment of patients with grade III articular cartilage lesions of the knee.

Adjunct use of radiofrequency coblation for osteochondritis dissecans in children: A case report

RATIONALE

Osteochondritis dissecans (OCD) lesions involve disruption of the osteochondral unit along articular surfaces, with significant potential for joint deterioration if not managed appropriately.

PATIENT CONCERNS

A 15-year-old male presented with persistent and insidious right knee pain, which had worsened following a collision with another player during a basketball game, resulting in episodes of locking.

DIAGNOSES

Magnetic resonance imaging revealed a lateral trochlear OCD extending into the anterior lateral femoral condyle.

INTERVENTIONS

Chondral fraying was observed along the margins of the OCD. Retrograde drilling ensued with use of a 0.045-inch Kirschner wire throughout the lesion to a depth that would allow for penetration of healthy underlying subchondral bone to create an influx of healing factors. Three resorbable pegs were arthroscopically placed through an accessory portal overlying the lesion to stabilize the fracture and compress the gapped cartilage mantle to reduce flow of synovial fluid behind the lesion. Bipolar radiofrequency coblation was used to stabilize the chondral fraying and seal the gap along the periphery of the lesion.

OUTCOMES

The patient was put on a nonweight bearing protocol for 6 weeks, after which crutches and brace were discontinued, but therapy persisted. Repeat imaging at 3 months demonstrated excellent interval healing. The patient was released to slowly engage impact activities. Although he returned at approximately 8 months postoperatively with a contralateral anterior cruciate ligament tear, he reported the operative knee with the OCD was doing extremely well.

LESSONS

Radiofrequency coblation appears to be a viable strategy as an adjunct to management for OCD in children.

Radiofrequency Chondroplasty May Not Have A Long-Lasting Effect in the Treatment of Concomitant Grade II Patellar Cartilage Defects in Humans

The effect of radiofrequency chondroplasty on cartilage tissue is not well studied. This prospective pilot study investigates the effect of radiofrequency chondroplasty on International Cartilage Repair Society (ICRS) grade II patellar cartilage defects using high-resolution magnetic resonance imaging (MRI) with T2 mapping. Six consecutive patients were treated for ICRS grade II patellar cartilage defects using radiofrequency chondroplasty. Before surgery and at defined follow-ups (2 weeks, 4 and 12 months) a high-resolution morphological 3 Tesla MRI with quantitative T2 mapping was performed. At baseline MRI, global T2 values of cartilage defects were increased (46.8 ms ± 9.7) compared to healthy cartilage (35.2 ms ± 4.5) in the same knee which served as reference. Two weeks after treatment, global T2 values (39.2 ms ± 7.7) of the defect areas decreased. However, global T2 values of the defect areas increased beyond the preoperative levels at 4 months (47.4 ms ± 3.1) and 12 months (51.5 ms ± 5.9), respectively. Zonal T2 mapping revealed that the predominant changes in T2 values occurred at the superficial cartilage layer. T2 mapping appears to be an ideal method to monitor cartilage degeneration after chondroplasty. Based on the small sample size of this pilot study, radiofrequency chondroplasty may cause cartilage damage and may not have a long-lasting effect in the treatment of grade II patellar cartilage defects. In five out of six patients, postoperative cartilage damage was observed on quantitative MRI. This study was therefore terminated before completion. We recommend only addressing the pathology which indicated arthroscopy and leaving concomitant cartilage lesions untreated.

The time-dependent effects of bipolar radiofrequency energy on bovine articular cartilage

Purpose

The purpose of this study was to compare the effect of bipolar radiofrequency energy (bRFE) on chondroplasty at the different time durations in an in vitro experiment that simulated an arthroscopic procedure.

Methods

Six fresh bovine knees were used in our study. Six squares were marked on both the medical and lateral femoral condyles of each femur. Each square was respectively treated with bRFE for 0 s, 10 s, 20 s, 30 s, 40 s and 50 s. Full-thickness articular cartilage specimens were harvested from the treatment areas. Each specimen was divided into three distinct parts: one for hematoxylin/eosin staining histology, another for cartilage surface contouring assessment via scanning electron microscopy (SEM), and the last one for glycosaminoglycan (GAG) content measurement.

Results

bRFE caused time-correlated damage to chondrocytes, and GAG content in the cartilage was negatively correlated to exposure time. bRFE caused time-correlated damage to chondrocytes. The GAG content in the cartilage negatively correlated with the exposure time. The sealing effect positively correlated with the exposure time. Additionally, it took at least 20 s of radiofrequency exposure to render a smooth cartilage surface and a score of 2 (normal) in the scoring system used.

Conclusion

bRFE usage in chondroplasty could effectively trim and polish the cartilage lesion area; however, it induces a dose-dependent detrimental effect on chondrocytes and metabolic activity that negatively correlated with the treatment time. Therefore, cautions should be taken in the use of bRFE for treatment of articular cartilage injury.

Surgical interventions for symptomatic mild to moderate knee osteoarthritis

BACKGROUND

Osteoarthritis affecting the knee is common and represents a continuum of disease from early cartilage thinning to full-thickness cartilage loss, bony erosion, and deformity. Many studies do not stratify their results based on the severity of the disease at baseline or recruitment.

OBJECTIVES

To assess the benefits and harms of surgical intervention for the management of symptomatic mild to moderate knee osteoarthritis defined as knee pain and radiographic evidence of non-end stage osteoarthritis (Kellgren-Lawrence grade 1, 2, 3 or equivalent on MRI/arthroscopy). Outcomes of interest included pain, function, radiographic progression, quality of life, short-term serious adverse events, re-operation rates and withdrawals due to adverse events.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase up to May 2018. We also conducted searches of ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform for ongoing trials. Authors of trials were contacted if some but not all their participants appeared to fit our inclusion criteria.

SELECTION CRITERIA

We included randomised controlled trials that compared surgery to non-surgical interventions (including sham and placebo control groups, exercise or physiotherapy, and analgesic or other medication), injectable therapies, and trials that compared one type of surgical intervention to another surgical intervention in people with symptomatic mild to moderate knee osteoarthritis.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials and extracted data using standardised forms. We analysed the quality of evidence using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach.

MAIN RESULTS

A total of five studies involving 566 participants were identified as eligible for this review. Single studies compared arthroscopic partial meniscectomy to physical therapy (320 participants), arthroscopic surgery (debridement ± synovectomy ± chondroplasty) to closed needle joint lavage with saline (32 participants) and high tibial osteotomy surgery to knee joint distraction surgery (62 participants). Two studies (152 participants) compared arthroscopic surgery (washout ± debridement; debridement) to a hyaluronic acid injection. Only one study was at low risk of selection bias, and due to the difficulty of blinding participants to their treatment, all studies were at risk of performance and detection bias.Reporting of results in this summary has been restricted to the primary comparison: surgical intervention versus non-surgical intervention.A single study, included 320 participants with symptoms consistent with meniscal tear. All subjects had the meniscal tear confirmed on knee MRI and radiographic evidence of mild to moderate osteoarthritis (osteophytes, cartilage defect or joint space narrowing). Patients with severe osteoarthritis (KL grade 4) were excluded. The study compared arthroscopic partial meniscectomy and physical therapy to physical therapy alone (a six-week individualised progressive home exercise program). This study was at low risk of selection bias and outcome reporting biases, but was susceptible to performance and detection biases. A high rate of cross-over (30.2%) occurred from the physical therapy group to the arthroscopic group.Low-quality evidence suggests there may be little difference in pain and function at 12 months follow-up in people who have arthroscopic partial meniscectomy and those who have physical therapy. Evidence was downgraded to low quality due to risk of bias and imprecision.Mean pain was 19.3 points on a 0 to 100 point KOOS pain scale with physical therapy at 12 months follow-up and was 0.2 points better with surgery (95% confidence interval (CI) 4.05 better to 3.65 points worse with surgery, an absolute improvement of 0.2% (95% CI 4% better to 4% worse) and relative improvement 0.4% (95% CI 9% better to 8% worse) (low quality evidence). Mean function was 14.5 on a 0 to 100 point KOOS function scale with physical therapy at 12 months follow-up and 0.8 points better with surgery (95% CI 4.3 better to 2.7 worse); 0.8% absolute improvement (95% CI 4% better to 3% worse) and 2.1% relative improvement (95% CI 11% better to 7% worse) (low quality evidence).Radiographic structural osteoarthritis progression and quality of life outcomes were not reported.Due to very low quality evidence, we are uncertain if surgery is associated with an increased risk of serious adverse events, incidence of total knee replacement or withdrawal rates. Evidence was downgraded twice due to very low event rates, and once for risk of bias.At 12 months, the surgery group had a total of three serious adverse events including fatal pulmonary embolism, myocardial infarction and hypoxaemia. The physical therapy alone group had two serious adverse events including sudden death and stroke (Peto OR 1.58, 95% CI 0.27 to 9.21); 1% more events with surgery (95% CI 2% less to 3% more) and 58% relative change (95% CI 73% less to 821% more). One participant in each group withdrew due to adverse events.Two of 164 participants (1.2%) in the physical therapy group and three of 156 in the surgery group underwent conversion to total knee replacement within 12 months (Peto OR 1.76, 95% CI 0.43 to 7.13); 1% more events with surgery (95% CI 2% less to 5% more); 76% relative change (95% CI 57% less to 613% more).

AUTHORS' CONCLUSIONS

The review found no placebo-or sham-controlled trials of surgery in participants with symptomatic mild to moderate knee osteoarthritis. There was low quality evidence that there may be no evidence of a difference between arthroscopic partial meniscectomy surgery and a home exercise program for the treatment of this condition. Similarly, low-quality evidence from a few small trials indicates there may not be any benefit of arthroscopic surgery over other non-surgical treatments including saline irrigation and hyaluronic acid injection, or one type of surgery over another. We are uncertain of the risk of adverse events or of progressing to total knee replacement due to very small event rates. Thus, there is uncertainty around the current evidence to support or oppose the use of surgery in mild to moderate knee osteoarthritis. As no benefit has been demonstrated from the low quality trials included in this review, it is possible that future higher quality trials for these surgical interventions may not contradict these results.

The history of radiofrequency energy and Coblation in arthroscopy: a current concepts review of its application in chondroplasty of the knee

Radiofrequency energy has had widespread use for a variety of surgical procedures. Its application in orthopedic surgery initiated with shoulder instability. Over the last couple decades it has been applied as surgical tool for cartilage treatment as well. There have been significant gains in its technology and our understanding of its potential benefits. We address its history and advancements in becoming a surgical tool for cartilage lesions along with a review of recent long-term follow up studies.

Temporal trends and regional variation in the rate of arthroscopic knee surgery in England: analysis of over 1.7 million procedures between 1997 and 2017. Has practice changed in response to new evidence?

OBJECTIVES

We investigated trends and regional variation in the rate of arthroscopic knee surgery performed in England from 1997-1998 to 2016-2017.

DESIGN

Cross-sectional study of the national hospital episode statistics (HES) for England.

METHODS

All hospital episodes for patients undergoing a knee arthroscopy between 1 April 1997 and 31 March 2017 were extracted from HES by procedure code. Age and sex-standardised rates of surgery were calculated using Office for National Statistic population data as the denominator. Trends in the rate of surgery were analysed by procedure both nationally and by Clinical Commissioning Group (CCG).

RESULTS

A total of 1 088 872 arthroscopic partial meniscectomies (APMs), 326 600 diagnostic arthroscopies, 308 618 knee washouts and 252 885 chondroplasties were identified (1 759 467 hospital admissions; 1 447 142 patients). The rate of APM increased from a low of 51/100 000 population (95% CI 51 to 52) in 1997-1998 to a peak at 149/100 000 (95% CI 148 to 150) in 2013-2014; then, after 2014-2015, rates declined to 120/100 000 (95% CI 119 to 121) in 2016-2017. Rates of arthroscopic knee washout and diagnostic arthroscopy declined steadily from 50/100 000 (95% CI 49 to 50) and 47/100 000 (95% CI 46 to 47) respectively in 1997-1998, to 4.8/100 000 (95% CI 4.6 to 5.0) and 8.1/100 000 (95% CI 7.9 to 8.3) in 2016-2017. Rates of chondroplasty have increased from a low of 3.2/100 000 (95% CI 3.0 to 3.3) in 1997-1998 to 51/100 000 (95% CI 50.6 to 51.7) in 2016-2017. Substantial regional and age-group variation in practice was detected. In 2016-2017, between 11% (22/207) and 16% (34/207) of CCGs performed at least double the national average rate of each procedure.

CONCLUSIONS

Over the last 20 years, and likely in response to new evidence, rates of arthroscopic knee washout and diagnostic arthroscopy have declined by up to 90%. APM rates increased about 130% overall but have declined recently. Rates of chondroplasty increased about 15-fold. There is significant variation in practice, but the appropriate population intervention rate for these procedures remains unknown.

A Retrospective Study Assessing Safety and Efficacy of Bipolar Radiofrequency Ablation for Knee Chondral Lesions

OBJECTIVE

Bipolar radiofrequency (bRF) ablation is gaining popularity as a treatment modality for unstable knee chondral lesions of the knee. Limited reports of osteonecrosis and chondrolysis have been published; however, there is little data examining the safety of this treatment in larger series. This study aims to evaluate the safety and efficacy of bRF in the treatment of chondral lesions encountered during knee arthroscopy.

DESIGN

A retrospective evaluation of adverse outcomes in patients that underwent treatment of chondral lesions using bRF was undertaken. Secondary outcome measures included change in patient reported outcome scores and its correlation to patient demographics and quality of chondral and meniscal lesions using Chondropenia Severity Score.

RESULTS

Only 2.2% and 2.7% of the patients had a postoperative complication or required a reoperation, respectively. None of the complications were directly related to the use of bRF. A statistically significant difference was observed when comparing pre- and postoperative scores in all normalized categories ( P < 0.0001). No statistically significant correlation was found between change in self-reported scores and Chondropenia Severity Score.

CONCLUSION

Bipolar radiofrequency ablation is a safe modality in treatment of chondral lesions.

Patellofemoral Cartilage Repair

Purpose of Review

This review provides an overview of well-established and newly developed cartilage repair techniques for cartilage defects in the patellofemoral joint (PFJ). An algorithm will be presented for approaching cartilage defects considering the distinct anatomy of both the patellar and trochlear articular surfaces.

Recent Findings

Recent studies on cartilage repair in the PFJ have demonstrated improved outcomes in an attempt to delay or obviate the need for arthroplasty, and improve symptoms in young patients. While autologous chondrocyte implantation shows good and excellent outcomes for chondral lesions, osteochondral defects are adequately addressed with osteochondral allograft transplantation. In case of patellar malalignment, concomitant tibial tubercle osteotomy can significantly improve outcomes. Particulated cartilage and bone marrow aspirate concentrate are potential new alternative treatments for cartilage repair, currently in early clinical studies.

Summary

Due to the frequency of concomitant anatomic abnormalities in the PFJ, a thorough clinical examination combined with careful indication for each procedure in each individual patient combined with meticulous surgical technique is central to achieve satisfying outcomes. Additional comparative studies of cartilage repair procedures, as well as investigation of newer techniques, are needed.

Arthroscopic Chondral Debridement Using Radiofrequency Ablation for Patellofemoral Compartment Pathology

The purpose of this Technical Note is to introduce a surgical technique using a fluid pressure pump, mid-lateral portal, and radiofrequency ablation for visualization, assessment, and subsequent, accurate/adequate removal of patellofemoral articular lesions for the treatment of patellofemoral compartment pathology. With the patient in the supine position, and an inflated thigh tourniquet, standard lateral and medial portals are made. The medial-femoral compartment, notch, lateral-femoral compartment, and patellofemoral compartments are assessed. If pathology is seen within the patellofemoral compartment, a mid-lateral portal is made if chondral pathology cannot be addressed thoroughly. Addressing chondral pathology to achieve chondral stability is then performed using a combination of the radiofrequency ablator and chondrotome. This technique provides greater visibility and access to accurately and thoroughly smooth chondral pathology.

Arthroscopic Mechanical Chondroplasty of the Knee Is Beneficial for Treatment of Focal Cartilage Lesions in the Absence of Concurrent Pathology

Background:

Articular cartilage lacks the ability for intrinsic repair after acute injury, and focal articular cartilage lesions cause significant morbidity worldwide. Arthroscopic debridement (chondroplasty) represents the majority of cartilage procedures of the knee; however, limited data exist regarding outcomes after chondroplasty performed in isolation of concurrent procedures or not as a primary treatment for osteoarthritis (OA).

Hypothesis:

Arthroscopic mechanical chondroplasty is beneficial for patients with a focal cartilage lesion of the knee in the absence of meniscal pathology or OA.

Study Design:

Case series; Level of evidence, 4.

Methods:

Potential participants were identified by querying billing data from a 3-year period in a single-surgeon practice, and eligible patients were verified to meet inclusion criteria through electronic medical record review. OA was quantified through Kellgren-Lawrence (KL) scoring. Subjective patient-reported outcome (PRO) scores, including International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster Universities Arthritis Index (WOMAC), Tegner, Lysholm, and Veterans RAND 12-Item Health Survey (VR-12), were collected preoperatively and at follow-up intervals. International Cartilage Repair Society (ICRS) grade and lesion size were determined at arthroscopy. Linear regression was used to determine the effect of baseline score on final follow-up score. Correlated regression equations were used to assess the relationship of covariates and change in PRO scores.

Results:

Fifty-three of 86 (62%) eligible participants completed postoperative questionnaires at an average of 31.5 months (range, 11.5-57 months). The mean patient age was 37.3 ± 9.7 years and mean body mass index (BMI) was 27.7 ± 5.6 kg/m²; 33 (62%) participants were women. The mean treated lesion size was 3.3 ± 1.9 cm², of these, 36 (68%) were ICRS grade 2 or 3, and 42 (79%) patients had a KL score of 0 to −2. On average, the cohort demonstrated significant improvement from baseline for almost all PRO scores. Regression analysis of change in score versus baseline indicated participants with lower preoperative scores gained more benefit from chondroplasty. Correlated regression equations showed KL score >0 and male sex had a consistent positive effect on change in PRO scores, high ICRS grade had a consistent negative effect, and lesion size, age, and obesity had no effect. Eight patients (15%) required further surgical intervention within the follow-up period.

Conclusion:

The clinical efficacy of chondroplasty for repair of focal cartilage defects of the knee has not been studied in isolation from concurrent orthopaedic procedures. Our data show that arthroscopic mechanical chondroplasty is beneficial to patients, and response to surgical intervention is correlated with baseline PRO scores, sex, ICRS grade, and KL score.