ARTHROSCOPIC

PETER

From

J. LIVESLEY,

Mansfield

A strong

MICHAEL

District

clinical

osteoarthritis

LAVAGE

General,

impression

of the

knee.

OF

DOHERTY,

Harlow

exists

MAURICE

Wood

that

A controlled

trial

joint
was

OSTEOARTHRITIC

NEEDOFF,

Orthopaedic

lavage

and

often

conducted

ALAN

City

MOULTON

Hospitals,

provides

to test

KNEES

Nottinghamshire

symptomatic

this

hypothesis.

relief

for

A group

painful

of 37 painful

osteoarthritic
knees were treated
by arthroscopic
lavage and physiotherapy,
and a control group of 24 knees
were treated
by physiotherapy
alone.
There was better relief of pain in the lavage group, and the effect was still present
at one year. An
improvement
in the signs of inflammation
lasted for about three months.
Pain was relieved more effectively
in
patients
with slight radiographic
changes than in those with advanced
changes.
Our results confirm
the effectiveness
of joint lavage in the management
of painful osteoarthritis
of
the knee.
Osteoarthritis
bearing
(Lowman

is present

radiographically

joints
of 90% of people
1955 ; Keligren
1961)

affected
joint
is the knee (Heine
impression
exists
that washing
the pain (Burman,
is true the simple
improve

Finkelstein
technique

the quality

All new
assessed,

referrals
those

derangement

exclude

with
with

haematological
aspiration.
abnormalities,

disorders,
We

many

and

no

signs.
groups

Moulton,
Mansfield
Mansfield,

A.

Correspondence

The patients
according
to

Orthopaedic
General

Registrar
Hospital,

were

trial.

screened

should

be sent

to Mr

anteromedial

were

referred.
alone

followed

performed
A Key

used.

via
Med

All

and

tourniquet

anterolateral

Olympus

knees

The
(P)

by physio-

with

technique

portals.

a hook

initially

lavage

was

few

days;

Registrar
England.

the

same

by

were

at one, three,
rest, on activity,

six

4; tenderness

regime

with

and

arthroscope

treatable

lesions

IPB,

Surgery

followed

in both

up by the same

at thejoint

line graded

groups.

examiner
pain
at
from 0 to

0 to 4; and duration

of stiffness
after
rest and in the morning,
measured
in
minutes.
The range ofmovement
was measured,
effusions

ifpresent
and

were graded

0 to 3, warmth,

were

Patients

crepitus

sleep

disturbance,

were

also asked

England.

noted.
swelling,

to give

stress
were

and

pain,

wasting

questioned

walking

an overall

Hospitals,

of the

modified

Thomas

Synovial

fluid

effusions

P. J. Livesley.

employed

about

distance.

estimate

They

of their

knee

symptoms.

Nottinghamshire

Orthopaedic

was

and 12 months.
He recorded
and at night,
on a scale graded

Radiographs

Joint

were

by physiotherapy

a standard

admission

FRCS,
Orthopaedic
Consultant
District
General
and Harlow
Wood
Nottinghamshire,
England.

they

treated

The patients
To

were divided
whichever
of

NG5

Mansfield,

1991 British
Editorial
Society
of Bone and
0301 -620X/9l/6259
$2.00
J Bone Joint Surg [Br] 1991 ; 73-B : 922-6.

922

the

were

MA, MD,
MRCP,
Senior
Lecturer
Unit,
City Hospital,
Nottingham

M. Needoff,
FRCS,
Mansfield
District
NGI9
7AY,
England.

employing

mechanical

into

P. J. Livesley,
BSc, FRCS,
FRCS
Ed, Orthopaedic
Queens
Medical
Centre,
Nottingham
NG7
2UH,
Doherty,
Rheumatology

knee

obvious

all patients

surgeons
were

were excluded
from the trial. The remainder
underwent
lavage with two litres of normal
saline at room temperature. Postoperatively
physiotherapy
was started
within

of the

entered

group

the second
by arthroscopic
therapy
(L + P).

and

METHODS

were

first

Arthroscopy

If this
could

investigation,
radiography
and
joint
excluded
patients
with
haematological
urate
crystals
in the joint
aspirate
or

atypical
radiographic
into
two treatment

M.

1934).
lavage
people.

osteoarthritis
pain

two consultant

weight-

of 40 years
commonly

A strong
clinical
knee can relieve

and Meyer
of arthroscopic

AND

of the joint

other

1926).
out the

of life of very

PATIENTS

in the

over the age

and the most

separated

to
were

knees

scoring
samples
the

from

study.

aspirated.

from

the

alizarin

red

crystals.

Pyrophosphate

dye

were

system

all knees
At

The

debris

fluid

demonstrate

levels

using

et al 1975).

were

follow-up

supernatant
to

assessed

(Thomas

obtained

all

knees

on
with

in the

aspirate

was

and

stained

with

calcium-containing

and

enzyme

activity

were

t-test

or the

measured.

The

results

were
THE

assessed
JOURNAL

by the paired
OF BONE

AND

JOINT

SURGERY

ARTHROSCOPIC

Mann-Whitney

test

as

appropriate.

LAVAGE

Scores

OF OSTEOARTHRITIC

were

KNEES

II). No significant

923

difference

was found

in the improve-

compared
at each assessment
with the baseline
score of
the group.
An improvement
score
was generated
for
each patient,
being
the difference
between
the score at

ment score for this symptom

at any stage.
Pain on activity
was also reduced
by both treatment
regimes
in the same
pattern
as rest pain.
However,
the improvement
score

the initial

showed

scores

assessment

of the

and

two

Mann-Whitney

at follow-up.

groups

were

then

The

improvement

compared

by the

while

U test.

28 entered

the physiotherapy

of the trial.
Four
were
lost to follow-up
reviewed.
Of the 41 patients
who entered

(P) arm

and 24
the lavage

were
and

physiotherapy
(L + P) group
of the trial,
two had partial
meniscectomies
and two were lost to follow-up
; therefore
37 of these patients
were reviewed.
The two groups
had
a similar
distribution
of age, sex and radiographic
severity
of disease
(Table
I). Of the factors
measured,
stress pain and morning
stiffness
were worse in the P
group ; swelling
and effusions
were more common
in the
L + P group.
No difference
was observed
between
the
two

groups

at the

initial

features.

The

analgesic

at initial

assessment.

significant

difference

assessment
intake

Although
between

in other

Thomas

(7.9)

score

5.29

(2.7)

61
5.3

two

groups

(7.8)

showed

with

although
show
a
tenderness
unaffected

by

showed
decreased

physiotherapy

73-B,

produced

no

between

(Table

III).

improvement

change.

score

L+ P

at

group

unaffected

showing

six

score

Joint
warmth
months
while

However,

a greater

months.

the

by physiotherapy

benefit

Morning

im-

in

stiffness

but significantly

the

was

diminished

L + P group
to three months.
The improvement
however,
showed
no difference.
Stiffness
after

activity
creased

improved
in both
in the L + P group

did

last

groups.

only,
six months.

beyond

remained
between

low
at
the two

Joint

ofmovement
improved
Mean
flexion
increased

and

swelling

from

de-

but this improvement

The rate of recurrent

1 2 months,
a
groups
existed

significant
up to six

in both
from

groups
105#{176}
to

104#{176}
to 119#{176}
in the L+P

group.

25
12

When

the patients

were

L+P

asked

Difference
In
Improvement
score p value

IQR

p value

IQR

p value

1
0.5
0.5
1.5

1
0
0
0

tol
to 1
tol
to2

0.008
0.004

1
0
1

lto2
0 to 1
Otol
Otol

0.002
0.025
0.01

Painon
activity

0
3
6
12

2
2
2
2

2
1
1
1

to2
to 2
to 2
to3

0.05
0.06

2
2
2
2

2to3
1 to 2
1 to 2
lto2

0.00003
0.0002
0.0005

0.003
0.05

Painat
night

0
3
6
12

1
1
0.5
2

0 to2
0 tol
0 tol
0.5to2

1
0
1
1

lto2
Otol
Oto2
Otol

0.0005
0.02
0.006

0.01

0.06
0.1

to assess

(M) and
assessment

1991

difference

months.
up to six

0
3
6
12

No. 6, NOVEMBER

reduction,

score
did not show
a significant
difference.
improved
in both groups
up to 1 2 months,
the

improvement

not

; the

a difference
at three
in the L + P group

provement
Stress pain

Painat
rest

immediate

the improvement
score
lavage.
Peri-articular
L + P group
but
was

Months
postoperative

Symptom

L + P at three

The improvement
score
from
L + P only at three
showed
an improvement

did
from
the

Table
11. Pain
scores
for the control
group
(P) and
the lavage
group
(L + P). Median
interquartile
ranges
(IQR)
are given.
The p values
refer to the difference
between
the initial
and the current
score.
In the last column
the p value compares
the scores
of the two groups

VOL.

an

to six months

only at six months

greater
benefit
decreased
in

118.5#{176}
in the P group,
13
11

from

fell late in the P group

a significant

persisting

months.
The range
to a similar
extent.

(2.6)

Sex
male
female

scores

The signs of inflammation

improved
to a greater
degree in the L + P group (Table
III). Joint-line
tenderness decreased
in this treatment
group up to 12 months,

effusions
difference

L+P

60.7

in the L + P group
the

in the
score,

Table
1. Demographic
details
of the two groups
(P and L + P) on entry
to the trial. The average
(standard
deviation)
is given
for the patients
ages
and for the Thomas
radiographic
scores
of the
knees
on entry
to the trial

(years)

benefit

pain

L + P group

physiotherapy

measured

of both groups
was similar
it fell during
the trial no
the groups
emerged.

Pain at rest improved

in both groups,
to six months
in the P group and to 1 2 months
in the L + P group (Table

Age

the

greater

Night

the effect lasting

for 1 2 months.
for night
pain showed
benefit
months
but sleep
disturbance

RESULTS
Of the 69 patients,

a significantly

and six months.

0.1

the current

P. J. LIVESLEY,

924

M. DOHERTY,

M. NEEDOFF,

A. MOULTON

Table III.
The signs of inflammation
for the control
(P) and lavage
groups
(L + P). Median
(M) and
interquartile
ranges
(IQR)
are given.
The p values
refer to the difference
between
the initial
assessment
and the current
score.
In the last column
the p value compares
the scores
of the two groups

L+P

Differencein
improvement

Months
M

IQR

postoperative

Joint
tenderness

0
3
6
12

1
1
0
1

Otol
0 to 1
0 to 1
0 to I

Peri-articular
tenderness

0
3
6

0
0
1

0 to 2
0 to 1
Otol

0
0
0

0 to 2
0 to 0
OtoO

0.001
0.003

Warmth

0
3
6

0
0
0

OtoO
OtoO
OtoO

0
0
0

OtoO
OtoO
OtoO

0.01
0.03

0
3
6

1
1
1

1 to 1.5
Otol
Otol

1
0
0

1 to 1
Otol
Otol

0.001
0.001

0
3
6
12

15
10
15
17.5

5to25
Oto2O
OtolS
0to75

10
5
10
I

Otol5
OtolO
OtolS
Oto3O

12

0
0
0
0

0 to 1
Otol
Otol
Otol

0
0
0
0

0 to 1
OtoO
Otol
Otol

0
3
6
12

0.5
0
1
1

Otol
Otol
Otol
Otol

1
0
1
1

Otol
Otol
Otol
Otol

0
3
6

1
0
0

Otol
0 to I
Otol

1
0
0

Otol
0 to 1
Otol

Morning
stiffness

0
3
6

Effusions

Swelling

Sleep
disturbance

state
of the knee,
those
in the P group
reported
improvement
up to six months,
those in the L + P group
up to 1 2 months.
However,
the improvement
score was
three

significantly

different

between

months
(Table IV).
The L + P group was

which

might

presence

or

subdivided
a good
result

predict
absence

of

an

effusion

the

two

groups

to assess factors
from lavage.
The
was

found

not

subgroups.

The

scores

for

pain

at rest

and

to

in

activity
improved
significantly
at six months
in the group
with slight
radiographic
changes.
In the moderately
damaged

three

subgroup,

months

pain

was

relieved

Synovial
contain
crystals.

cells,
Three

pain

on

but in knees
(Table

fluid

severe

was

improved

changes

from

all knees

debris
and
were found

were

at

only night
found

0.001
0.02

0.02
0.02

p value

score

1
0
0
0

Otol
0 to 1
0 to 1
0 to 1

0.0003
0.002
0.06

0.02

Pyrophosphate
joints
were
significantly

p value

0.07

0.07

0.03

levels

0.03
0.1
0.1

0.1
0.1
0.1

0.01
0.07

0.03

0.0007
0.05

0.1

and

enzyme

activity

measured
on entry to the trial;
from normal
control
values.

within

neither

the

differed

DISCUSSION
Osteoarthritis
of the knee presents
principally
with pain
and functional
impairment.
Symptoms
are often episodic
but in the long-term
deterioration
is common
and there
is no specific

to

calcium-containing
to have birefringent

crystals
of calcium
pyrophosphate
within
theirjoints
; no
urate
crystals
were found.
No change
was noted
in the
crystals
or debris
present
in samples
taken
at follow-up.

therapy

for the condition.

Although
there exists a strong
clinical
impression
that lavage
of arthritic
joints
leads
to symptomatic
improvement,
there
have been few trials
to test the
validity
of this belief. The first account
of joint lavage,
by

V).

samples

cartilage
patients

activity

with

0.002

IQR

at

correlate
with the result. Radiographic
criteria
were used
to subdivide
the 37 knees
into those
with
slight
(10),
moderate
(1 3), and severe (14) changes.
There
was no
difference
in the age or sex distribution
between
the three
subgroups.
Pain scores were found to have improved
in
all three

Symptom

Stress
pain

only

p value

Burman

et

al

(1934),

reported

two

patients

who

obtained
remarkable
symptomatic
relief after diagnostic
arthroscopy.
Both had simple
villous arthritis,
presumably osteoarthritis.
Lavage
with a small bore cannula
has been shown
to produce
no greater
benefit than aspiration
of the joint
(Lindsay
et al 1971). Dawes,
Kirlew
and Haslock
(1987)
compared
joint lavage,
using a 14-gauge
needle,
with
aspiration
and injection
ofsaline
in a group of2O patients.
They found no difference
between
the two groups at three
months,
though both had improved.
Bird and Ring (1978)
THE

JOURNAL

OF BONE

AND

JOINT

SURGERY

ARTHROSCOPIC

LAVAGE

OF OSTEOARTHRITIC

KNEES

925

Table IV. The patients

assessment
of their condition,
scored on a scale from to + 1 . The p values
refer to the change
from
initial
assessment
to the current
assessment.
The p value for the improvement
score is also given
L+P

Differencein
Improvement
score p value

Months

Table

V.

values,
the

postoperative

0
3
6
12

1
0
0

Average

pain

determined

score

scores

IQR

Otol
0 to 1
1 to 1

for the

p value

0.003
0.05

1
0
0

ltol
0 to I
0 to 1

0.0003
0.003
0.03

U test,

weeks

0.05
0.1

0.1
0.05

2.1
1.8
1.9

2.4
1.8
2.0

3.4
2.4
2.7

0.05
0.02

2.8
2.0
2.3

1.8
1.4
1.3

3.2
2.5
2.5

2.1
1.7
1.8

0
3
6
0
3
6

50%

useful
study

in rheumatoid
was
uncontrolled

selected
patients
Reviewing
arthroscoped

had

was
and
and

at rest

maintained

their

improve-

that the procedure

chondrocalcinosis

seronegative
and
included

was of
but less

arthritis.
only
14

Their
highly

at a secondary
referral
centre.
a series of patients
with osteoarthritis
to exclude

(1982)

found

of the

a meniscal

persisting

65 patients

lesion,

symptomatic
who

underwent

Jackson

improvement
lavage

of management.

To reduce

contact

between

of the

the

two groups of patients,

the treatment
allocated
depended
upon the consultant
to whom
the general
practitioner
referred
the patient.
This resulted
in an inequality
of
numbers
between
the treatment
and control
groups,
however,
comparison
of the initial
assessment
scores
shows

Those
degree
lasted
VOL.

no

other

significant

difference

between

them.

treated
by joint
lavage
improved
to a greater
than did the control
group, and the improvement
longer. Pain relief persisted
throughout
the review
73-B, No. 6, NOVEMBER

1991

Pain

period

The

score

and

on activity

Difference

In

improvement
score p value

0.05

2.0
1.5
1.6

and

the signs

of inflammation

(Doherty

et al 1988)

improved
for between
three
and six months.
Joint
swelling
and effusions
were diminished
for the same
period.
The patients
who underwent
lavage
reported
improvement
in their condition
; many requested
further
lavage at a later date.
The improvement
in the lavage group persisted
for
the duration
of the trial.
The physiotherapy
group
initially

and

joint but no operative

procedure
(Jackson,
Marans
and
Silver 1988). Similar
results
have not been reported
by
others.
Despite
the general
consensus
that joint lavage may
be of some value, appropriate
controlled
trials have not
been performed.
Since a sham procedure
was not possible,
we decided
to compare
lavage
with
a conventional
method

by lavage.

the initial

p value

0
3
6

only

treated

between

3.2
2.5
2.6

Slight

The conclusion
in osteoarthritis

37 knees

Night
pain
score

Score

the effect of arthroscopic

lavage
of the knee,
that 93% of patients
improved
at one week but

by four

of the

to the difference

Score

Months
postoperative

ment.
value

subgroups

refer

0.08

p value

Radiographic
subgroup

Severe

Rouse

IQR

at assessment

Moderate

in 45%

radiographic

by the Mann-Whitney

Paiji

studied
reporting

p value

experienced

an improvement

but

by the

end

of

the study they had returned

to their pretreatment
state.
Direct comparison
between
the two groups by means of
the improvement
score showed
the advantage
of the L +
P group over the P group, the benefit lasting for between
three and six months.
However,
the improvement
scores
did

not

differ

between

perhaps

because

greater

Some patients
degree and

radiographic

the

groups

the measure

benefited
for a longer

changes

is too

in the

longer

term,

insensitive.

from the procedure

period.
Those with

experienced

more

pain

to a
slight

relief

than

those
enced

with severe changes,

although
all groups
experisome improvement.
The mechanism
of relief of symptoms
is unknown.
Removal
of cartilage
debris,
crystals
(Halverson
and
McCarty
1979;
Dieppe,
Huskinson
and Willoughby
1980; Goldenberg,
Egan and Cohen
1982) and inflammatory
factors
(Byers et al 1973) may play a part. The
temporary
improvement
in the signs of inflammation
would

support

inflammatory

the

agents,

hypothesis

though

that

the

lavage

nature

removes

of

these

is

P. J. LIVESLEY,

926

unclear.

Whether

outcome
requires

of the
further

such
disease,
study.

We conclude

in any
party

that

form
related

modifies

symptomatically

simple

a day-case
procedure,
management
of painful
patients
for whom
other
No benefits
commercial
article.

treatment

joint

M. DOHERTY,

the

lavage

performed

received
or will be received
or indirectly
to the subject

Dieppe

as
the
in

from a
of this

Doherty
M, Richards
N, Hornby
J, Powell
R. Relation
fluid
C3 degradation
products
and local joint
rheumatoid
arthritis,
osteoarthritis
and crystal
pathy.
Ann Rheum
Dis 1988; 47:190-7.
Goldenberg
DL,
degenerativejoint
Halverson
PB,
in synovial
Heine

RW,

Jackson
Ring EF.
1978; 37 :78-9.
HA,

Therapeutic

value

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