Debridement Chondroplasty & Lavage
An arthroscopic procedure that smoothes and polishes rough cartilage surfaces and removes cartilage debris and degenerative byproducts.
Background & Rationale
This procedure has been a mainstay of treatment of minor cartilage lesions for decades and remains a common intervention. Cartilage wear often manifests as surface irregularity that is rough, fibrillated and uneven. Burman reported improvement of arthritic pain with DCL in the 1930’s and has been routinely used by orthopedic surgeons. Techniques and instrumentation have evolved, but the principles remain the largely the same. Popularity of the procedure rests on the fact that it is relatively simple, has low morbidity and a quick recovery. It has been reported in many studies that results are generally favorable though may be short or intermediate term. However very few randomized and controlled studies have been performed. A recent study by Moseby, et al in the New England Journal of Medicine sparked controversy when it reported that there was no statistical difference in outcome between knee debridement arthroscopy and a placebo procedure in arthritic patients. This study has been refuted on several levels. Many surgeons believe that it has an important role in the surgical options for a patient, particularly as a first line procedure to relieve pain. This procedure does not regenerate cartilage. Pain relief is experienced through the removal of prostaglandins, enzymes, crystals, and cartilaginous debris. An additional important aspect of this minimalistic procedure is its diagnostic capacity, i.e., one can assess the extent of damage and better understand prognostic and future treatment possibilities.
As with most cartilage procedures, the results of the procedure are very dependent on the appropriate indications. Factors predicting a favorable outcome for debridement chondroplasty (as with most cartilage procedures) generally relate to the severity of cartilage disease. This procedure favors milder degrees of cartilage damage. The predictability increases in knees with normal alignment, early stages of cartilage damage (ICRS grades 2 and 3), smaller areas of cartilage injury, acute rather than chronic damage, low BMI, minimal radiographic evidence of degeneration with good preservation of the joint space.
The younger active patient who fits the above description, particularly with accompanying meniscal pathology, tends do very well with a DCL procedure. Patients who are elderly with more extensive degenerative disease do less predictably well.
The surgery is one of the most basic arthroscopic service procedures. The goal is to smooth down rough and fibrillated cartilage surfaces creating an improved gliding surface for the joint. Edge instability of a cartilage lesion can produce painful mechanical symptoms. These edges or flaps are removed and polished into a stable rim configuration. Intra-articular debris is removed. Fragments and loose bodies are removed. Small osteophytes may be removed. The voluminous irrigation during the procedure will reduce Intra-articular irritants and the synovium responds with decreased release of proteolytic enzymes and other factors that cause pain and effusion.
The procedure is performed through small (¼ inch) puncture incisions, usually 2 or 3, requiring one stitch each. It is an outpatient (same day) procedure. Most surgeons recommend general anesthesia. Small cannulas, 4 to 5 mm in diameter, are introduced into the joint through which the arthroscope and instruments are placed. Saline or Ringers irrigation insufflates the joint and is rapidly irrigated through the joint throughout the procedure. It is not uncommon to use 5 to 10 liters of fluid for this arthroscopy. Manual and motorized instrumentation is used to perform the debridement. Stress is placed on the knee in attempts to thoroughly assess all areas, including the medial, lateral and patello-femoral compartments. In addition to the articular surfaces, the ACL, PCL, popliteus tendon and menisci are visualized. The knee is moved through a range of motion to evaluate the tracking patterns of the joint articulations.
Numbing medication is injected prior to completion. A soft compressive dressing is applied. No brace is needed. The length of the procedure depends on the degree of damage, but tends be 30 to 60 minutes. The procedure is often performed under tourniquet. Blood loss is minimal, expected to be less than 15cc’s
Recovery is relatively quick. Pain is relatively minimal. Often acetaminophen (Tylenol) is all patients take for pain. One is encouraged to rest for 48hrs with ice and elevation. Crutches tend to be optional after the first day or 2. Light activity may resume at 72 hrs. Limited driving is usually possible within a week. Heavier physical activity may be 1 to 2 weeks. The safety and timing of any activity must be individualized. Return to activities of daily living is limited only by pain and swelling Patients tend to be 80% recovered at 6 weeks. Full recovery is expected by 2 to 3 months. Return to sport and exertional physical activity is allowed when range of motion and muscle strength are normal.
The results of this procedure are variable, according to the studies that have been published. As stated above, the procedure tends to yield favorable, mid-term results in patients with milder degrees of cartilage damage with a well-aligned extremity and minimal radiologic degenerative changes, however there are no rigid criteria for successful outcomes. To this extent, this surgery is often a first line procedure for early cartilage damage when the patient has failed conservative treatment, particularly when there is accompanying meniscal pathology.
Woodson et al. noted the following in a review of the literature. In a review by Sprague reported good results in 74% of patients at 13 months. Jackson showed subjective improvement in symptoms in 68% of patients at 3 years, and that age did not affect outcome following lavage, debridement, and partial meniscectomy. Baumgaertner showed that only 40% of patients over 50 years of age had good or excellent results after an average 33-month follow-up. Burks felt that the elderly benefit most from lavage, probably due to their lower level of activity. Insall, however, feels that the active middle-aged patient is ideal due to his or her ability to rehabilitate the knee appropriately. Multiple studies have looked at length of symptoms as a predictor for outcome. Baumgaertner and associates demonstrated improved results in patients with symptoms less than 12 months. Lotke and colleagues concurred with Baumgartner. Wouters demonstrated that pain duration of less than 3 months and a history of a twisting injury could be significant predictors of a favorable outcome.
On the negative side, a study in 2002 by Moseley and colleagues published in The New England Journal of Medicine prospectively reported on 180 patients randomly assigned to receive arthroscopic debridement, arthroscopic lavage, or "placebo" surgery consisting of anesthesia and incisions but no insertion of instruments. The results of the study showed no statistically significant differences with regard to pain and function over a 24-month period in any of the groups over any time period. The findings of this study have been challenged and criticized by the orthopaedic community.
Patients with worker's compensation claims or litigation tend to fare poorly compared with controls.