Review Question - QID 219222

Arthroscopic lavage and debridement carries a moderate recommendation AGAINST in the most recent update of the AAOS clinical practice guidelines (CPG) for the treatment of knee osteoarthritis.

Symptomatic knee osteoarthritis (OA) is very common, affecting a large subset of the population. The goal of the AAOS CPG was to provide overarching recommendations on the management of knee OA based on the available literature. In the most recent version of the CPG, strong recommendations FOR treatment include: a supervised exercise program, patient education, oral/topical NSAIDs, and acetaminophen. They also strongly recommended AGAINST lateral wedge insoles and oral narcotics. This means that tramadol is no longer recommended in this patient population. Other widely used treatments include corticosteroid injections which carry a moderate strength recommendation FOR and hyaluronic acid injections which carry a moderate strength recommendation AGAINST. While previously more popular, arthroscopic lavage and debridement is not recommended in arthritic knees as outcomes do not typically improve reliably and can actually worsen.

Brophy et al. published a systematic review outlining the recent 2021 AAOS clinic practice guidelines for the management of knee OA. They review all 29 recommendations, with 8 of them being strong recommendations. They propose a moderate strength recommendation AGAINST arthroscopic lavage and debridement. Finally, they note there is more investigation needed into the use of intra-articular corticosteroid injections, hyaluronic acid injections, and platelet-rich plasma injections.

Moseley et al. performed a single-blinded randomized controlled trial directly comparing arthroscopic debridement, arthroscopic lavage, and placebo sham surgery of the knee for patients with a primary diagnosis of osteoarthritis of the knee. The authors found that neither the debridement nor lavage group experienced any difference in pain or function as compared to the placebo group at any time point within the first two years of surgery. They concluded that there was no discernable benefit.

Laupattarakasem et al. performed a systematic review and meta-analysis of three randomized controlled trials comparing arthroscopic debridement to either placebo or conservative interventions in patients with primary or secondary arthritis of the knees. They reported that arthroscopic debridement was not significantly different from lavage, but demonstrated inferior functional outcomes at two weeks as compared to placebo and there was no significant difference at two years. One study found that debridement was associated with less knee pain than lavage at 5 years.

Incorrect Answers:
Answer 1: The use of an unloader brace carries a moderate strength recommendation FOR due to its ability to improve function, pain, and quality life in knee OA patients.
Answer 2: Intra-articular corticosteroid injections carry a moderate strength recommendation FOR given their ability to provide short-term relief in patients with symptomatic OA.
Answer 3: A weight loss program carries a moderate recommendation FOR due to its ability to improve pain and function in obese patients with knee OA.
Answer 5: Topical and oral NSAIDS both carry a strong recommendation FOR use due to their effectiveness and safety profile.