Orthopaedic Foundation, Stamford, Connecticut.
Montefiore Medical Center/Albert Einstein College of Medicine, The Bronx, New York.
JBJS Rev. 2024 Sep 19;12(9). doi: e24.00100. eCollection 2024 Sep 1.
Total knee arthroplasty (TKA) is the procedure of choice for osteoarthritis of the knee (OAK) when conservative treatment fails; however, high rates of dissatisfaction and poor implant longevity dissuade younger patients from TKA. There is a paucity of evidence that report outcomes and clinical effectiveness of arthroscopic knee procedures in patients with end-stage (grade 3-4) OAK. The purpose of this systematic review was to evaluate the efficacy of arthroscopic treatment for patients with moderate-to-severe (grade 3-4) OAK.
A systematic review of the literature was performed with the terms "Knee," "Osteoarthritis," and/or "Arthroscopic debridement," "Arthroscopic lavage," "Arthroscopic microfracture," "Arthroscopic chondroplasty," "debridement," "lavage," "chondroplasty," "microfracture," and/or "arthroscopy" in PubMed (MEDLINE), Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) databases in November 2023 according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Databases were searched for studies that evaluated outcomes (e.g., pain, function, and conversion to TKA) for patients with Kellgren-Lawrence grade 3 to 4 OAK after knee arthroscopy (including debridement, lavage, microfracture, or chondroplasty) at a minimum 6-month follow-up. Percent improvement from preoperative score was the primary outcome measure. Secondary outcome measures included achievement of minimal clinically importance difference and conversion to TKA.
Nine studies (410 knees with grades 3-4 OAK) were included. Arthroscopic debridement and lavage resulted in a 18.8% to 53.1% improvement at short-term follow-up (e.g., 6 months to 3 years) and a 50.0% improvement at long-term follow-up (e.g., 10 years) in knees with grade 3 OAK and a 15.0% to 41.3% improvement at short-term follow-up and a 46.9% improvement at long-term follow-up in knees with grade 4 OAK. Arthroscopic debridement and microfracture resulted in 1.6% to 50.8% improvement at short-term follow-up in knees with grade 3 OAK. No studies included long-term outcomes or evaluated knees with grade 4 OAK after arthroscopic debridement and microfracture. Conversion to TKA after arthroscopic debridement and lavage occurred in 21.9% of patients with grade 3 OAK and in 35.0% of patients with grade 4 OAK at short-term follow-up and in 47.4% of patients with grade 3 OAK and in 76.5% of patients with grade 4 OAK at long-term follow-up. Conversion to TKA after arthroscopic debridement and microfracture occurred in 10.9% of patients with grade 3 and 4 OAK at long-term follow-up.
Arthroscopic debridement, lavage, and microfracture can provide short- and long-term symptomatic relief and improvement in function by up to 50.0% in patients with grade 3 to 4 OAK. These procedures may result in fewer patients with grade 3 OAK undergoing TKA compared with patients with grade 4 OAK.
Level IV; systematic review of Level II-IV studies. See Instructions for Authors for a complete description of levels of evidence.
全膝关节置换术（TKA）是治疗膝关节骨关节炎（OAK）的首选方法，如果保守治疗失败；然而，较高的不满意率和较差的植入物寿命劝阻了年轻患者接受 TKA。目前缺乏证据表明关节镜膝关节手术在终末期（3-4 级）OAK 患者中的疗效和临床效果。本系统评价的目的是评估关节镜治疗中重度（3-4 级）OAK 患者的疗效。
根据《系统评价和荟萃分析的首选报告项目》指南，于 2023 年 11 月在 PubMed（MEDLINE）、Embase 和 Cochrane 对照试验中心注册数据库中使用“膝关节”、“骨关节炎”和/或“关节镜清创术”、“关节镜灌洗”、“关节镜下微骨折”、“关节镜下软骨成形术”、“清创术”、“灌洗”、“软骨成形术”、“微骨折”和/或“关节镜”等术语对文献进行系统评价。数据库搜索评估了 Kellgren-Lawrence 3 至 4 级 OAK 患者关节镜（包括清创、灌洗、微骨折或软骨成形术）后至少 6 个月随访时的患者（如疼痛、功能和转换为 TKA）结局（如疼痛、功能和转换为 TKA）的研究。术前评分的百分比改善是主要的观察指标。次要观察指标包括达到最小临床重要差异和转换为 TKA。
共纳入 9 项研究（410 例 3-4 级 OAK 膝关节）。关节镜清创术和灌洗术在短期随访（如 6 个月至 3 年）时可使 3 级 OAK 膝关节的改善率达到 18.8%至 53.1%，长期随访（如 10 年）时的改善率达到 50.0%，4 级 OAK 膝关节的改善率达到 15.0%至 41.3%，长期随访（如 10 年）时的改善率达到 46.9%。关节镜清创术和微骨折术在 3 级 OAK 膝关节的短期随访中可使改善率达到 1.6%至 50.8%。没有研究包括长期结局或评估关节镜清创术和微骨折术后 4 级 OAK 膝关节。关节镜清创术和灌洗术在 3 级 OAK 患者中的短期随访中转换为 TKA 的发生率为 21.9%，在 4 级 OAK 患者中的转换率为 35.0%，在 3 级 OAK 患者中的长期随访中转换率为 47.4%，在 4 级 OAK 患者中的转换率为 76.5%。关节镜清创术和微骨折术在 3 级和 4 级 OAK 患者中的长期随访中转换为 TKA 的发生率为 10.9%。
关节镜清创术、灌洗术和微骨折术可在 3-4 级 OAK 患者中提供长达 50.0%的短期和长期症状缓解和功能改善。与 4 级 OAK 患者相比，这些手术可能会使更少的 3 级 OAK 患者接受 TKA。
IV 级；二级至四级研究的系统评价。有关证据水平的完整描述，请参见作者说明。
