Superior effect of arthroscopic lavage compared with needle aspiration in the treatment of inflammatory arthritis of the knee
M. van Oosterhout,
J. K. Sont1 and
J. M. van Laar
Department of Rheumatology, Leiden University Medical Centre and
1 Department of Medical Decision Making, Leiden University Medical Centre, Leiden, The Netherlands
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Abstract
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Objectives. To compare the duration of symptom relief after arthroscopic lavage versus needle aspiration in gonarthritis.
Methods. A retrospective chart analysis was performed in 50 patients with non-septic inflammatory arthritis of the knee who underwent arthroscopic lavage because of relapsing or persisting arthritis after needle aspiration. The primary outcome measure was the time until symptomatic recurrence of knee synovitis.
Results. Needle aspiration was associated with a 3.0 times greater risk of recurrence of arthritis compared with arthroscopic lavage within 12 months (P<0.001, 95% confidence interval 2.14.4). Patients with longer disease duration and who had used more disease-modifying anti-rheumatic drugs (DMARDs) had a significantly lower risk of recurrence of arthritis compared with patients with shorter disease duration and a lower number of previous DMARDs (P=0.04 and 0.02 respectively). Corticosteroids augmented the effect of both interventions.
Conclusions. Our results indicate that arthroscopic lavage is an effective therapeutic modality in the treatment of inflammatory arthritis of the knee refractory to joint aspiration, especially in patients with longstanding disease.
KEY WORDS: Arthroscopic lavage, Needle aspiration, Joint injection, Knee arthritis.
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Introduction
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Different therapeutic approaches are currently employed in the management of persistent or relapsing arthritis of the knee joint. Joint aspiration with or without corticosteroid injection is commonly used, while synovectomy by various means is usually reserved for therapy-resistant cases. Since the description of the beneficial effects of joint injection with steroids [1, 2], a number of publications have elucidated factors that contribute to a longer effect of the injection: (i) post-injection rest [3]; (ii) the use of a less soluble steroid compound [4]; and (iii) the evacuation of synovial fluid before steroid injection [5].
Several studies found a therapeutic effect of arthroscopic procedures involving lavage or washout of inflamed knees [69]. The therapeutic effect of both joint aspiration and lavage is attributed to the removal of cartilage degradation products, proinflammatory cells and destructive enzymes [813] as well as to an improvement of the anti-inflammatory effect of steroids. Joint aspiration yields immediate pain relief through decompression of the joint cavity [14, 15]. Furthermore, dilution of the steroid is greatly diminished when residual synovial fluid is minimized, possibly resulting in a better response [5, 10]. Arthroscopic or closed needle lavage of the arthritic knee has been advocated as a potentially more effective alternative to joint aspiration because lavage would enable more extensive removal of debris and inflammatory mediators [9, 12, 13]. This assumption is based on the longer duration of the washout procedure and the larger diameter of the portal used in arthroscopy. An additive effect of joint lavage with respect to steroid injection was described in a small number of rheumatoid arthritis patients using 60120 ml saline [16]. Lavage with at least 750 ml saline resulted in amelioration of local joint symptoms for up to 1 yr in an uncontrolled study [17]. Other studies, however, were unable to find a difference between needle aspiration and lavage [12, 13, 18]. Comparison of these contradictory studies is hampered by differences in study design and outcome measures.
We sought to evaluate retrospectively the potential therapeutic efficacy of arthroscopic lavage in a cohort of 50 patients with non-septic, inflammatory arthritis of a knee necessitating local treatment. The duration of effect after arthroscopic lavage was compared with the duration of effect after previous joint injection of the same knee in these 50 patients. We also evaluated potential predictive factors of clinical response.
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Materials and methods
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Study design
We performed a retrospective analysis comparing the therapeutic effect of needle aspiration with arthroscopic lavage in the same patients treated at a single centre (Leiden University Medical Centre). Chronologically, patients with inflammatory arthritis of the knee underwent needle aspiration and after recurrence of arthritis they were eligible for arthroscopic lavage. We compared the time until recurrence of arthritis after needle aspiration with the time until recurrence after arthroscopic lavage. Patients served as their own control in comparing the time until recurrence of arthritis after both interventions.
Patient selection
The charts of all patients who underwent arthroscopic lavage of a knee between December 1998 and October 2001 were reviewed (n=86). Patients who had not been treated with needle aspiration before the arthroscopic lavage were excluded (n=36). Arthroscopy in these patients was done for diagnostic and/or trial purposes. Consequently, 50 patients with non-septic, inflammatory arthritis of a knee treated with needle aspiration followed by an arthroscopic lavage of the same knee were included in the present analysis.
Patient characteristics
Patient characteristics are shown in Table 1
. Fifty patients were evaluated, of whom 29 were men (58%) and 21 were women (42%); their mean age at the time of arthroscopic lavage was 58.8 yr (range 4481, S.D. 9.1). Thirty-six patients had a diagnosis of rheumatoid arthritis (RA), 10 patients had mono- or oligoarthritis of unknown origin (AUO) and four patients suffered from spondylarthropathy (SpA). Mean disease duration was 8.3 yr (range 0.140, S.D. 9.0). Thirty-seven patients (74%) used disease-modifying anti-rheumatic drugs (DMARDs) with a mean total number of (previous plus current) DMARDs of 2.5 (range 07, S.D. 2.1). The mean number of previous joint injections, including the last before arthroscopy, was 3.1 (range 113, S.D. 2.9). Thirty of our 50 patients had erosive disease, (29 RA, one SpA) and all 23 rheumatoid factor-positive patients had RA. Radiographic scores were based on non-standardized anteroposterior knee radiographs (Kellgren score 04) for osteoarthritic signs [19]. The mean score in the whole cohort was 1.40 (range 04, S.D. 1.15). At needle aspiration, steroids were not applied in 12 patients and at arthroscopy, steroids were not applied in four patients. The reasons for not applying steroids were diagnostic aspiration in eight cases, diagnostic arthroscopy in four cases, and lack of effect of steroids in former joint aspirations in the remaining four cases.
Needle aspiration
After maximal aspiration of synovial fluid from the knee joint, an injection containing triamcinolone hexacetonide (AHP Pharma Wyeth Lederle BV, Hoofddorp, The Netherlands) and lidocaine 0.5% (35 ml) was given. The mean dose of steroid administered was 23 mg (range 060, S.D. 16). Patients were instructed to minimize physical activity involving the knee joint for at least 2 days.
Arthroscopic lavage
Arthroscopy was performed by experienced arthroscopists (MvO and JMvL) using a small-bore 2.7 mm arthroscope (Storz, Tuttlingen, Germany) and a sterile technique. After maximal needle aspiration, 30 ml of 0.5% lidocaine was applied through the same needle for intra-articular and skin anaesthesia. Inferolaterally to the patella, topical anaesthesia was achieved with 30 ml of 1% lidocaine. Two small skin incisions were made to introduce two portals into the joint. The lower portal was used for introduction of the arthroscope and instillation of saline. The upper portal was used for taking synovial biopsies with a 2.0 mm forceps and draining of the saline. Lavage was performed by flushing the joint with at least 1000 ml saline. At the end of the procedure, 68 ml of 0.5% bupivacaine and a mean dose of 34 mg (range 060, S.D. 13) of triamcinolone hexacetonide were administered. After removal of the two portals, both skin incisions were approximated with wound closure strips. Patients were instructed to minimize physical activity involving the knee joint for at least 2 days.
Outcome measures
The primary and single outcome measure after both interventions was defined as symptomatic recurrence of knee synovitis (swelling and/or effusion) assessed by the treating rheumatologist. All patients had recurrence of arthritis after needle aspiration because this was obligatory before arthroscopic lavage could take place.
Statistical analysis
The cumulative incidence of recurrences of knee synovitis for both treatments was determined by constructing KaplanMeier survival curves. A possible difference in recurrence rate between the treatments was examined through a variant of the Cox proportional hazards regression model, which allows for the participation of patients in both treatments by the use of robust variance estimates [20]. Dichotomous variables were created for clinical characteristics (Table 2
). The Cox model was used to evaluate the effect of clinical characteristics on the recurrence rate. Furthermore, we assessed whether the recurrence rate after both treatments differed between categories of clinical parameters. The Cox model produces a regression coefficient for each covariate which can be interpreted as a relative risk when taken exponentially. Other statistical analyses were performed using Student's t-test and the
2 test where appropriate. All statistical analyses were done with the statistical software package Stata 6.0 (StataCorp, College Station, TX, USA). Values of P<0.05 were considered statistically significant.
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TABLE 2. Relative risk of recurrence of arthritis between two categories of various clinical parameters after arthroscopic lavage and needle aspiration in all patients and RA patients
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Results
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The cumulative incidence of recurrence of arthritis at 1 yr of follow-up was 0.94 and 0.58 for needle aspiration and arthroscopic lavage respectively. The Cox regression analysis showed a 3.0-fold decrease (95% confidence interval 2.14.4, P<0.001) of recurrence rate after lavage compared with needle aspiration. A KaplanMeier survival curve for the duration of effect after both interventions is plotted in Fig. 1
. The mean and median duration of effect after joint aspiration was 4.7 (range 0.0377.6, S.D. 11.6) and 1.9 months respectively. At the time of analysis, 23 patients did not have recurrence of arthritis after lavage, with a mean follow-up time of 11.3 months. In 27 patients who had recurrence of arthritis after lavage, the duration of effect was 3.0 months (S.D. 2.3). The median time until recurrence after arthroscopic lavage was 4.8 months (no mean available because arthritis had not recurred in 23 patients). The time between needle aspiration and arthroscopy was 6.7 months (S.D. 12.1), with no differences between the diagnosis groups (data not shown). Patients with RA had significantly longer disease duration and had used a greater number of DMARDs previously, and more patients were on oral prednisone therapy, compared with patients with other causes of knee inflammation (Table 1
). The dose of steroids administered was 23 mg at joint aspiration and 34 mg at lavage (P<0.001, Student's t-test), with no differences between diagnosis groups (P
0.27 for both interventions). In 16 patients, the DMARD was changed between needle aspiration and lavage. Concomitant DMARD use at both interventions was comparable (P=0.50,
2 test). Sixteen and 10 patients respectively had a change of DMARD use in the follow-up period after lavage and needle aspiration (P=0.02,
2 test).

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FIG. 1. KaplanMeier survival curves for the recurrence of arthritis after lavage (bold) and aspiration (light) in all patients (n=50).
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Clinical prediction of response
In search of clinical parameters predicting the outcome of arthroscopic lavage and needle aspiration, we determined the relative risk of the recurrence of arthritis of a reference category vs an index category, as shown in Table 2
. This table shows the effect of a clinical parameter on recurrence of arthritis after lavage and needle aspiration in all patients and in the RA group. Patients with more previous DMARDs and longer disease duration were found to benefit more from lavage than patients of the other dichotomous categories. KaplanMeier survival curves for both interventions stratified for previous DMARD use are plotted in Fig. 2
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FIG. 2. KaplanMeier survival curves for the recurrence of arthritis after lavage (dashed curves) and aspiration for patients with >1 previous DMARD (bold curves) or 1 previous DMARD.
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Relative risk between interventions
The relative risks for recurrence of arthritis after arthroscopic lavage compared with needle aspiration within the strata of clinical parameters are shown in Table 3
. There was at least a 1.5-fold decrease in the recurrence rate after lavage compared with needle aspiration, which was statistically significant in all strata except for short disease duration (
2 yr) and application of no steroids or a low dose of steroids at the intervention (
20 mg). There was a significant difference in treatment effect between the reference and index category of number of DMARDs used previously in all patients (4.5 vs 1.8 for >1 vs
1; P=0.02) and for disease duration in all and RA patients (4.5 vs 1.5 and 5.7 vs 1.6 respectively for >2 and
2 yr; P=0.04 and 0.02 respectively).
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TABLE 3. Relative risks of recurrence of arthritis after needle aspiration compared with arthroscopic lavage in all patients and RA patients for various clinical parameters
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Effect of steroids
We compared the duration of effect after joint aspiration and lavage for various amounts of steroids injected at the intervention. The duration of effect after joint aspiration (mean±S.D.) was 1.1±2.2, 7.8±17.4 and 3.8±5.1 months respectively for 0, 20 and 40 mg triamcinolone hexacetonide injected. There were no statistically significant differences between groups. Cox regression analysis of the effect of steroids on each intervention separately showed a better response to treatment when steroids were injected (RR 2.0 and 3.1 for lavage and aspiration respectively; 0 vs
20 mg; only significant for aspiration; P=0.04). However, there was no dose effect of the amount of steroids injected (RR 1.3 and 0.8 for lavage and aspiration respectively; 20 vs 40 mg; both not significant).
Side-effects
Both procedures were well tolerated by patients. Some tenderness of the knee was reported by a minority of patients (seven out of 50) after arthroscopy. No bleeding or infectious complications occurred.
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Discussion
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In this analysis of patients with refractory inflammatory arthritis of the knee we found a statistically significant and clinically relevant difference in the effect of arthroscopic lavage compared with needle aspiration. Patients had a three times greater risk of recurrence of arthritis within 1 yr after aspiration compared with lavage. Cox proportional hazards regression analysis showed patients with more previous DMARDs and longer disease duration to benefit significantly more from lavage than patients from the other dichotomous category. Our results were not affected when adjusted for the amount of steroid injected, although the application of steroids itself led to a longer duration of effect after both interventions compared with no steroids injected.
Some studies [16, 17] have shown a beneficial effect of arthroscopic lavage compared with needle aspiration, although others have failed to demonstrate superiority of arthroscopic lavage [12, 13, 18]. Comparison of these contradictory results is difficult because of different study designs and outcome measures. We think the larger amount of saline used for lavage in our study, which leads to more extensive removal of joint debris, is the main reason why we found a difference compared with several others. Few studies have explored clinical parameters predicting a favourable outcome of needle aspiration or arthroscopic lavage [21, 22]. Only a higher erythrocyte sedimentation rate in juvenile idiopathic arthritis patients predicted a better outcome for joint injection of the knees [23]. In our study, longer disease duration and more previous DMARDs were predictive clinical parameters for a positive outcome of arthroscopic lavage. Because the number of DMARDs used is strongly correlated with disease duration, we assume that disease duration is the determining predictive clinical parameter. In accordance with the lack of evidence in the literature, we did not find a doseresponse effect of steroids after either intervention. However, this would contradict the hypothesis that the diminished dilution of injected steroids is responsible for the beneficial effect of synovial fluid aspiration [5, 10]. Maybe the removal of joint debris is of greater importance than a higher intra-articular concentration of steroids.
Because of its retrospective design, our study has some limitations, of which the assessment of knee inflammation and the difference in the amount of applied steroids are the most obvious. Some authors [2427] have suggested semiquantitative measurement for knee inflammation, but in our study recurrence of arthritis was assessed on the basis of the need for local treatment as it occurs in daily practice. This method has been employed before because of its clinical relevance [4, 28, 29]. We assume that errors in establishing recurrence of arthritis are balanced between both interventions. Although greater amounts of steroids were injected and a higher number of patients received steroids with lavage compared with aspiration, the lack of a doseresponse effect indicates that steroids had a limited contribution to the superior effect of lavage in our study. A frequent problem with joint injections is misplacement of the injection [30]. One study found that as many as 9% of needle injections for knee arthritis were extra-articular [31]. With arthroscopic techniques, the steroids are placed within the joint under vision by experienced arthroscopists. Some of the relapses after aspiration may have been caused by inaccurate placement, but we do not know how many injections were extra-articular. Another difficulty is the lack of a control group. Patients and doctors are biased to expect more effect after a more aggressive intervention.
Our results show that the patients with a longer disease duration responded better to arthroscopic lavage than the other patients. It is assumed that a patient with longstanding arthritis has suffered from inflammatory processes within the knee joint for a number of years and the joint is filled with debris from earlier inflammation (fibrin, rice bodies). These degradation products sustain the inflammation [8, 3234] and can lead to further damage of the cartilage. Removal of fibrin by lavage could therefore diminish the degree of inflammation. The difference in effect after lavage between RA and non-RA patients (relative risk 1.5, P=0.33) may be explained by the shorter disease duration in non-RA patients. In non-RA patients, however, there is still a 1.9 times greater chance of recurrence after joint aspiration compared with lavage. This suggests that not only the removal of fibrin (after years of inflammation) but also the more extensive removal of inflammatory cells and degradative enzymes might contribute to a decrease in inflammation.
In this study we showed a superior effect of arthroscopic lavage compared with needle aspiration, with a three times longer duration of effect. We compared the two interventions in 50 patients with several causes of knee arthritis and found an intrinsic therapeutic effect of lavage independent of the application of steroids. Because this study was biased by its retrospective design, we need to confirm these findings in a prospective controlled study. Arthroscopic lavage is a safe and well-tolerated out-patient procedure with therapeutic advantages, especially for patients with inflammatory arthritis of the knee that is refractory to joint injections.
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Acknowledgments
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We thank Dr R. J. Verburg for technical assistance in the arthroscopic procedures.
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Notes
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Correspondence to: M. van Oosterhout, Leiden University Medical Centre, Department of Rheumatology, C4R, PO Box 9600, 2300 RC Leiden, The Netherlands. E-mail: M.van_Oosterhout{at}lumc.nl 
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Submitted 14 March 2002;
Accepted 10 June 2002