THE JOUR NAL OF BONE & JOINT SURGER Y JBJS.

ORG
VO L U M E 85-A N U M B E R 2 F E B R U A R Y 2003

E V I D E N C E -B A S E D O R T H O P A E D I C S

Evidence-Based Orthopaedics

Arthroscopic Lavage or Dbridement Did Not Reduce Pain

More Than Placebo Did in Patients with Osteoarthritis
Moseley JB, OMalley K, Petersen NJ, Menke TJ, Brody BA, Kuykendall DH, Hollingsworth JC,
Ashton CM, Wray NP. A controlled trial of arthroscopic surgery for osteoarthritis of the knee.
N Engl J Med. 2002 Jul 11;347:81-8.
Question: In patients with osteoarthritis, does
arthroscopic surgery of the knee relieve pain
and improve function?

knee, severe deformity, and serious medical

problems. 91% of the patients had complete
follow-up.

Design: Randomized (allocation concealed),

blinded (patients and outcome assessors), controlled trial with a 2-year follow-up.

Intervention: Patients were randomly allocated to arthroscopic dbridement (n = 59),

arthroscopic lavage alone (n = 61), or a placebo procedure (n = 60). In the dbridement
group, the joint was lavaged with 10 L of
fluid, rough articular cartilage was shaved
(chondroplasty was performed), loose debris
was removed, meniscal fragments were
trimmed, and the remaining meniscus was
smoothed to a stable rim. In the lavage group,
the joint was lavaged with 10 L of fluid, and
anything that could be flushed out through
arthroscopic cannulae was removed. In the
placebo group, a standard arthroscopic dbridement procedure was simulated without
insertion of the arthroscope.

Setting: A Veterans Affairs medical center in

Houston, Texas, USA.

Patients: 180 patients who were 75 years of
age (mean age, 52 years; 93% men), had osteoarthritis of the knee (defined by the American College of Rheumatology), reported at
least moderate knee pain on average (4 on a
visual analog scale that ranged from 0 to 10),
and had had no arthroscopy of the knee during
the previous 2 years. Exclusion criteria were a
severity grade of 9 for osteoarthritis of the

Main outcome measures: Pain in the study

knee (as measured with the Knee-Specific Pain

Scale, in which scores range from 0 to 100
[most severe]) at 24 months after the intervention was the primary outcome measure. Secondary outcome measures were arthritis pain
in general (assessed with the Arthritis ImpactMeasurement Scales 2 [AIMS2-P]), body pain
(assessed with the 2-item pain subscale of the
Medical Outcomes Study 36-item Short-Form
General Health Survey [SF-36-P]), and physical function (assessed with the 5-item
walking-bending subscale from the AIMS2
[AIMS2-WB] and the 10-item physical-function subscale from the SF-36 [SF-36-PF]).
Main results: The 3 treatment groups did not

differ with respect to pain in the study knee at

1 or 2 years (table) or in any secondary outcome measure. The study had a power of 90%
to detect a moderate effect size (0.55) at the 4%
level of significance.

Arthroscopic dbridement or arthroscopic lavage vs placebo for osteoarthritis of the knee

Mean Score
Outcome*

Dbridement

Pain at 1 y
Dbridement vs placebo
Lavage vs placebo

51.7

Pain at 2 y
Dbridement vs placebo
Lavage vs placebo

51.4

Lavage

Placebo

Mean Difference
(95% CI)

54.8

48.9
48.9

2.8 (5.9 to 11.5)

5.9 (2.0 to 13.8)

53.7

51.6
51.6

0.2 (8.8 to 9.2)

2.1 (6.9 to 11.1)

*Assessed according to the Knee-Specific Pain Scale (scores ranged from 0 to 100 [most severe]). All
mean differences were not significant, and they were calculated, as were the confidence intervals (CI),
from data in the article.

Conclusion: In patients with osteoarthritis of

the knee, neither arthroscopic lavage nor arthroscopic dbridement was better than a placebo procedure for reducing pain or improving
function.

Source of funding: U.S. Department of

Veterans Affairs.
For correspondence: Dr. N.P. Wray, Office of
Research and Development, Department of
Veterans Affairs (12), 810 Vermont Avenue
N.W., Washington, DC 20420, USA. E-mail
address: nwray@bcm.tmc.edu.

Commentary
This important randomized clinical trial has good internal validity that is further strengthened by the use of a sham arthroscopy arm.
The study confirms what many have suspectedthat arthroscopy will not
benefit patients with severe gonarthrosis. However, there are concerns regarding the studys external validity. First, malalignment was not precisely
reported. Malalignment, a commonly associated feature and a probable
cause of arthrosis, has been reported in other studies to adversely affect
the outcome of arthroscopic treatment1-3. Excluding patients with severe
deformity raises the questions: How many patients? and How severe? Second, the prevalence of mechanical symptoms in the study population was not provided. While pain is the primary complaint of patients
who have gonarthrosis, other symptoms cannot be overlooked when prescribing and evaluating treatment. Finally, as the investigators acknowledged, the study participants, who were older male veterans, may not
accurately represent the spectrum of appropriate candidates for arthro-

scopic treatment. These three concerns call into question the generalizability of the studys results and its conclusion.
Nevertheless, this clinical trial confirms the importance of patient selection and provides information that is useful for the physician
in advising patients who are seeking treatment for severe arthrosis.
Peter Fowler, MD, FRCSC
University of Western Ontario
London, Ontario, Canada
(1) Harwin SF. Arthroscopic debridement for osteoarthritis of the knee: predictors of patient satisfaction. Arthroscopy. 1999;15:142-6.
(2) Goldman RT, Scuderi GR, Kelly MA. Arthroscopic treatment of the degenerative knee in older athletes. Clin Sports Med. 1997;16:51-68.
(3) Salisbury RB, Nottage WM, Gardner V. The effect of alignment on results
in arthroscopic debridement of the degenerative knee. Clin Orthop.
1985;198:268-72.