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T H E JOURNAL OF BONE & JOINT SURGERY IBJS.ORG

VOLUME 89-A NUMBER 5 MAY 2007

EVIDENCE-BASED O R T H O P A E D I C S

EVIDENCE-BASED ORTHOPAEDICS
Arthroscopic Lavage Plus Corticosteroids Was More
Effective Than Arthroscopic Lavage Plus Placebo or Joint
Aspiration Plus Corticosteroids for Arthritis of the Knee
van Oosterhout M, Sont )K, Bajema IM, Breedveld FC, van Laar JM. Comparison of Efficacy of Arthroscopic Lavage Plus
Administration of Corticosteroids, Arthroscopic Lavage Plus Administration of Placebo, and Joint Aspiration Plus Administration
of Corticosteroids in Arthritis of the Knee: A Randomized Controlled Trial. Arthritis Rheum. 2006 Dec J5;55:964-70.
Question: Jn patients with inflammatory arthritis, what is the relative effectiveness of arthroscopic
lavage plus corticosteroids, arthroscopic lavage
aJone, and joint aspiration plus corticosteroids?
Design: Randomized (aJlocation conceaJed),
partiaJJy hlinded (outcome assessors), placehocontroUed trial with 9-month follow-up.
Setting: A university medical center in The
Netherlands.
Patients: 78 patients who were >J8 years of age
(mean age 54 y, 55% women) and had arthritis
of the knee not due to gout, osteoarthritis, or infection. Exclusion criteria were hemorrhagic
disease, oral prednisone > JO mg/day, recent (<6
weeks) change of disease-modifying antirheumatic drugs, recent joint infection, or hypersensitivity to methylprednisolone or local
anesthetics. Follow-up was 96%.
intervention: 26 patients were allocated to arthroscopic lavage plus corticosteroids, 26 to ar-

throscopic lavage plus placebo, and 26 to joint

aspiration plus corticosteroids (methylprednisolone, 80 mg in 2 mL). For all interventions,
synovial fluid was maximaJJy aspirated from the
suprapateJlar pouch, 30 mL of lidocaine 0.5%
was injected intra-articularly through the aspiration needle, and the skin and joint capsule was
additionally infiltrated with 10 mL of lidocaine
1%. For arthroscopic lavage, the skin inferolateral to the patella was also injected with 10 mL
of lidocaine 1%. Two trocars were placed into
the joint cavity through 2 skin incisions: 1 inferior for the camera and saline solution, and 1
superior for drainage of the irrigation fluid and
use of biopsy forceps. 1000 mL of saline solution
was flushed through the joint. During lavage, 15
to 20 synoviaJ biopsy sampJes were obtained
with 2.0-mm forceps. Bupivacaine (30 mg in 6
mL) pJus corticosteroids (methylprednisolone,
80 mg in 2 mL) for 1 group and bupivacaine
alone ("placebo") for the other was injected
through the inferior trocar. For joint aspiration.

Recurrence of arthritis of the l<nee at 9 months in groups treated with ALP, ALC, or JAC*
Group Comparisons

Relative Risk Increase (95% Confidence Interval)

ALP vs ALC

370% (130 to 840)

120% (20 to 320)
100% (10 to 280)

JAC vs ALC
ALP vs JAC

a single skin incision was made and I trocar

placed. After synovial biopsy samples (15 to 20)
were obtained, a mixture of methylprednisolone
(80 mg in 2 niL) and bupivacaine (30 mg in 6
mL) was injected into the joint.
iVIain outcome measures: Event-free survival
(time from treatment until local re-treatment
because of recurrence or persistence of arthritis
of the knee).
iVIain resuits: The median event-free survival
time was 9.6 months after arthroscopic lavage
plus corticosteroids, 3.0 months after joint aspiration plus corticosteroids, and 1.0 month after
arthroscopic lavage plus placebo. Patients in the
arthroscopic lavage plus corticosteroids group
had a lower risk of arthritis recurrence than patients in the other 2 groups (Table). Patients in
the joint aspiration group had a lower risk of arthritis recurrence than patients in the arthroscopic lavage plus placebo group (Table).
Conciusion: In patients with inflammatory
arthritis of the knee, arthroscopic lavage plus
corticosteroids was more effective than arthroscopic lavage plus placebo or joint aspiration
plus corticosteroids.
Source of funding: No external funding.

*ALP = arthroscopic lavage plus placebo; ALC = arthroscopic lavage plus corticosteroids; JAC
joint aspiration and corticosteroids.

For correspondence: Dr. J.M. van Laar, Leiden

University Medical Center, Department of Rheumatology, Leiden, The Netherlands. E-mail address: j.m. van_laar@himc. nl

Commentary
Some important features of this article should be emphasized:
First, this is a study of patients with inflammatory arthritis (e.g.,
rheumatoid arthritis). Second, arthroscopy was performed in an office
setting with the patient under local anesthesia and with use of 2 ports
one for a camera and inflow, and another for synovial biopsy and outflow. The articular cartilage and menisci were not evaluated or treated
during the procedure. Thus, I am not sure how applicable this study is
to the average orthopaedist who performs arthroscopy. Third, the outcome measures (e.g., event-free survival until local re-treatment) did
not include health-status measures such as the Western Ontario and
McMaster Universities Osteoarthritis Index (WOMAC) or the Arthritis
Impact-Measurement Scales (AIMS).
Furthermore, although blinding of the patients and physicians
was possible for the 2 groups that received arthroscopic lavage, the as-

JBoneJointSurgAm. 2007;89:1137 doi:10.2106/JBJS.8905.ebol

piration group had only 1 port made, which means that the patients
and physician-assessors of this group were not blinded to treatment.
This lack of blinding could explain the inferior results of the aspiration-plus-corticosteroid group compared with those of the arthroscopy-plus-corticosteroid group.
In conclusion, I believe that this study does show the benefit of the
use of intra-articular corticosteroids in patients with inflammatory arthritis who are having arthroscopic surgery; however, I remain unconvinced that joint lavage in these patients is beneficial. The practical
implication for an orthopaedist who is performing an arthroscopy on a
patient with inflammatory arthritis is to inject corticosteroids at the end
of the procedure.
Bruce Moseiey, MD
Methodist Hospital, Houston, Texas

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