Arthroscopy involves a surgeon making a small incision in your knee and irrigating and removing loose pieces of cartilage. In the arthritic knee, there is a very limited role for an arthroscopy. Results of a “clean out” or a “wash out” are unpredictable at best and should be avoided.
There are some occasional clinical scenarios where an arthroscopy in the presence of arthritis may be considered:
- known or suspected septic arthritis
- symptomatic non-repairable meniscal tears after failure of an appropriate trial of a structured rehabilitation program
- symptomatic loose bodies
- surgeon assessed locked or locking knees
- traumatic or atraumatic meniscal tears that require repair
- inflammatory arthropathy requiring synovectomy
- synovial pathology requiring biopsy or resection
- as an adjunct to, and in combination with, other surgical procedures as appropriate for osteoarthritis: for example high tibial osteotomy and patello-femoral realignment
- diagnostic arthroscopy when the diagnosis is unclear on MRI or MRI is not possible, and the symptoms are not of osteoarthritis
What about degenerative and atraumatic meniscal tears?
Atraumatic meniscal tears are common on MRI. For example, 25 per cent of 50-year-olds will have a meniscal lesion on MRI, while 45 per cent of 70-year-olds will have a meniscal lesion on MRI. Up to 95 per cent of patients with osteoarthritis will have a meniscal tear. Secondly. atraumatic knee pain is often not due to a meniscal tear. Usually the pain is due to co-existing osteoarthritis and bone bruising. Thirdly, atraumatic meniscal tears are typically part of the osteoarthritis process. Pain, swelling and stiffness are common in osteoarthritis and are usually not due to a meniscal lesion seen on MRI.
How do you treat degenerative meniscal tears?
Treatment of degenerative meniscal tears is essentially the same treatment for acute arthritic knee pain.
- Pain relief such as NSAIDs. The benefits of paracetamol in isolation remain marginal. Opiates are best avoided, especially for chronic pain.
- Activity modification to low-impact activity such as bike riding.
- Quadriceps strengthening exercises and muscle strengthening (often with physiotherapy).
- Weight (BMI) reduction in overweight patients.
- Consider braces in those who undertake moderate-impact activity.
- Injectable therapy such as PRP and hyaluronic acid could be considered; however, the cost-benefits remain unclear. Corticosteroids can damage the joint and theirbenefit is mild, hence theyshould be used sparingly andonly in acute painful settings. Stemcells do not benefit patients.
- Occasionally, a patient with a repairable tear or obstructive (locked) symptoms may warrant arthroscopic surgery; however, most patients do not benefit from it.