Treating Osteoarthritis of the Knee with Arthroscopy - James T. Mazzara, MD

Dr. Sechrest: Hello, I'm Dr. Randale Sechrest, your host for eOrthopod.TV. Today I have as my guest, Dr. Jim Mazzara. Dr. Mazzara did his medical school training at New York Medical College. He then went on to complete an orthopaedic residency at St. Luke Roosevelt Hospital, which is a teaching hospital affiliate of Columbia University. Good morning, Dr. Mazzara.

Dr. Mazzara: Good morning.

Dr. Sechrest: Dr. Mazzara, what I'd like to discuss now is something orthopaedic surgeons have been doing for years and that is using arthroscopy to try and treat arthritis of the knee, or degenerative arthritis of the knee. It's waxed and waned in terms of how we do this, but what I'd like to do is have a discussion about how we go about making that choice, what are the risks and the benefits, and what patients can expect from that type of procedure to treat an arthritic knee. So first, let's define what we're talking about. The degenerative knee – what's going on there?

Dr. Mazzara: Well, in arthritis of the knee what we're really saying is wear and tear of the surface of the joint, the surface cartilage of the joint, sometimes and very frequently, combined with meniscus tears. There are two types of cartilage in the knee. The first type of cartilage is articular cartilage which serves as a surface to the lower part of the femur or the thigh bone and the upper part of the tibia and the lower leg bone and the back of the patella. In addition to that, there is some other cartilage of the knee called the meniscus and each knee has two menisci, one is on the inside, the other is on the outside of the knee. Many patients, they come in with a combination of arthritis which is a wear and tear of the surface of the joint and a meniscus tear. Those I find very challenging to treat because they have pain potentially from multiple sources. Patients come in and they say, "My knee hurts" and as orthopaedic surgeons it's our job to find why their knees hurt. In many cases, if we localize the condition just to the knee, they may have a bit of arthritis or wear and tear which we can see either on exam or x-ray, or they may have a meniscus tear which may suspect on exam and confirm by means of an MRI. So those are the kinds of patients that I see in the office and so in many cases, it's a range or a spectrum of wear and tear problems in the knee, sometimes combined with other mechanical problems like that meniscus tear I mentioned.

Dr. Sechrest: Now, when that patient presents and you've gone through an evaluation and you've done the MRI scan, the x-rays, and this person has what you would consider a relatively early onset of degenerative arthritis, meaning that it's not that the knee is completely worn out and you're going to tell that person, "Well, the only option we have is an artificial knee replacement". We're in that middle ground, where you're going to try to reduce some of the pain with an arthroscopy. How do you prepare that patient for surgery? What do you do to get to that point and how do you advise that patient?

Dr. Mazzara: Well, if we're at the point where we're talking about arthroscopy, that really has to make certain assumptions that we have made sure that we have done everything else that's not surgical first. So, the initial non-surgical treatment for somebody who may have just an arthritic knee would be activity modification, anti-inflammatories, sometimes cortisone shots, sometimes what we call viscous supplementation or lubricant shots into the knee. The concept that we relay to patients is very often we're going to smooth the inside surface of the knee with these lubricant shots. What it actually does it restores some of the joint fluid to a more normal physiology, coats the nerve endings, and can relieve some of the pain by doing so, but at the same time can make a difference in patients who have milder, sometimes moderate, degrees of arthritis. If we're getting to the point where we're talking about arthroscopy, we really want to help the patient understand that if they have an arthritic knee, we can go in and remove and debride some of those loose flaps and pieces of articular cartilage and sometimes make a difference. The real pain and the real benefit of doing arthroscopy in the arthritic knee is when the patient also has a meniscus tear. In those patients who have mild to moderate arthritis, if they also have a meniscus tear, those people will see all of the meniscus-related pain go away. But what we can't predict in those individuals is how much of that pain from the arthritis may go away. They may not have much relief, they may have a lot of relief and everybody is very, very different, but those patients need to be counseled preoperatively so that after surgery, if they come back and we've found they have some arthritis, they are able to participate and cooperate with some of the postoperative care that's required for treating that residual discomfort after surgery. If you have a pristine knee and a meniscus tear and there's no evidence of any arthritis, that patient may come back within a week and say, "All my pain's gone and I can do most of my activities." On the other hand, if you have an arthritic knee and a meniscus tear, that patient may come back at a week or two and say, "You know, I'm still having some pain and swelling". Instead of great recovery by 2-3 weeks, that same patient with the arthritic knee and the meniscus tear may take 2-3 months to get better. Sometimes you never get a perfect result and so helping those folks understand that is an important part of what we, as orthopaedic surgeons, need to do.

Dr. Sechrest: Now you mentioned making sure that you had tried everything up to arthroscopy.

Dr. Mazzara: Yes.

Dr. Sechrest: That arthroscopy is not that first knee-jerk reaction, "Aw, this person has knee pain, let's put scope in, look around, see what's going on, clean things up" and they'll be good as new.

Dr. Mazzara: Right.

Dr. Sechrest: How have you found these other conservative modalities such as the Synvisc or the Hyalgan type medications that you inject into the knee, anti-inflammatories, and you mentioned activity restriction. How do these things all play together? And when you use the term ‘activity restriction' what are we talking about? Are we talking about keeping people from doing the things they like or what?

Dr. Mazzara: Well, sometimes they just may have to do them a little differently. So somebody who wants to exercise and go to the gym may not be able to do running on the treadmill. They may have to choose a different kind of aerobic conditioning exercise that they find suitable. If they're doing weight-training, for example, and their doing leg extension exercises and they're having patellofemoral osteoarthritis of the knee, how they do those exercises makes a difference. If you do full arc extension exercises and bend your knee to 90° as you're lifting heavy weights, that may aggravate the arthritis in the knee significantly; but if you shorten the arc of your strengthening exercise and maybe flex your knee to 40-45°, that can diminish it. Sometimes it's just a matter of finding out where the arthritis is and how can we modify their activity – not that we want them to sit down and do nothing – that's not advisable. But at the same time, maybe changing their exercise approach may be beneficial for them. The viscous supplements that we inject can be very helpful in patients who have milder to moderate arthritis and so I see patients, in maybe the 70-80% range, seeing some improvement in their knee pain with these viscous supplement injections. Now what that means is that 7 out of 10 may get great improvement, but you still have 3 out of 10 people who have not seen any kind of improvement in their knee pain with these lubricant shots and then we have to talk about other interventions.

Dr. Sechrest: Now, can you differentiate a cortisone injection from one of these viscous supplementation injections. How do they differ?

Dr. Mazzara: Cortisone is a single injection that you give when somebody has an acute flare-up and an inflammatory component of their pain. What that means is when you look at their knee they may have some fluid or swelling and every part of the knee tends to be tender when you touch it. They may have some stiffness, aching when they sit for a long time. That stiffness, that start-up pain, tends to work itself out as they go through their daily activities or heat up the knee a little bit. It tends to be short-lived though. It doesn't really solve the problem long-term. So, while it's very effective for certain circumstances, it may or may not give people months and months of relief, and that's where the viscous supplements come into play, where those are a series of injections and, depending on the version of the lubricant shot, you inject maybe 3 or 5, those people may get 6 months of relief and sometimes longer. The more advanced their arthritis, the less likely that is to work, however. So when somebody comes in and you take a properly positioned set of standing x-rays, those patients who have a significant deformity in the knee, who may also have bone touching on the bone and they have a complete absence of the cartilage in a certain part of the knee, those are people who will probably not get a lot of relief from either arthroscopy or from any kind of viscous supplementing injections. You may buy them a little bit of time with an anti-inflammatory or a cortisone shot, eventually those people end up needing some other treatment and eventually get to the point where they need to have the knee replaced. Individuals with milder forms of arthritis, let's say they have a few millimeters of cartilage or just a slight amount of joint space narrowing on the standing x-rays, those are people who may actually do well with anti-inflammatories, with physical therapy sometimes to stretch the stiff painful parts of the knee. If done properly it can be very effective, but in many cases, you have to be careful about how aggressively you do therapy because just like exercise that can aggravate knee pain, so, too, can physical therapy aggravate your knee pain. So how it's done and who does it for you is very important.

Dr. Sechrest: Do you know or do you have recommendations about the downsides of these types of injections? The cortisone injection and the visco-supplementation – what are the downsides of those injections?

Dr. Mazzara: Well, when you're dealing with cortisone, obviously, you don't want to do excessive amounts of cortisone. It wouldn't be unreasonable to try a series of cortisone injections, maybe one, and then several, 3-4, months later consider another one, only if they've had a substantial degree of relief. If somebody comes back and they've said, "Well, I got a week of relief after my first cortisone shot", that tells me it didn't work and more cortisone is not the answer. When it comes to the visco-supplement injections, under the circumstances of getting relief, if somebody gets 6 months of relief, in many cases, they can have it repeated. It depends on the version of the medication that you inject. But, for the most part, if you get some kind of relief it can be repeated up to a point where it's not effective not anymore. So, while cortisone and medication and these injections are helpful, we have to see some benefits from that. You just don't keep repeating cortisone or repeating the lubricant shots if it's not working for you. And when you think about the visco-supplement injections to the knee, you do have to complete the course of treatment. You can't have one shot and say, "Well, I don't want to have the other two because the first one didn't work". Sometimes you have to have all 3 or, depending on the brand, all 5, and then give it a little time; and in many cases, you'll see people getting some relief some time after that.

Dr. Sechrest: What is your opinion of the oral supplements like glucosamine chondroitin sulfate? Do you traditionally prescribe those, and do you think they're a benefit in osteoarthritis of the knee?

Dr. Mazzara: I think there is. I don't there is a perfectly designed scientific study that says this absolutely, positively makes a difference, but I think we have a lot of other studies that may be flawed to one degree or another that very strongly suggest that there are real benefits to taking things like glucosamine and chondroitin. I generally recommend for my patients that they do different things that have very, very low risk. Glucosamine chondroitin is one of them. Weight loss is another, and sometimes depending on the pattern of arthritis, we'll recommend a little heel wedge for patients to either unload one part of the joint or another, depending on where their arthritis is. Usually in patients who have arthritis in the inside half of their knee, we'll recommend what's called a lateral heel wedge. What that does is that shifts some of the weight to the outside compartment of the knee where there is a little bit less arthritis. It doesn't help everybody, but if you do several different things and each of those things really help the patient just a little bit, all of the sudden they're feeling a lot better; and each one of those things may have a cumulative effect.

Dr. Sechrest: When you're trying to help people determine how to modify their activities, is this something you do in the office? Or is this something that you rely on physical therapists to help a patient determine what activity is best for them with the least risk to their knee?

Dr. Mazzara: I think it's a combination of both. I always have that discussion and I always want to ask the patient, "What do you really want to do? Are you interested in going out and running 20 miles a day? If you are, your knee is going to hurt. If you want to modify that and stay fit and exercise, you may need to think another type of exercise if you don't want to aggravate your knee arthritis." So while I do that I also expect a therapist to do that as well, and it's an ongoing discussion. It's part of taking a good history and just finding out what your patients expect of the treatment. I think one of the things that it's important for patients to understand is when you consider having an arthroscopy of the knee, and you have arthritis, the outcome can strongly depend on how much arthritis there is. So somebody bone touching the bone in advanced arthritis and deformity is not somebody for whom I'd recommend any arthroscopy. If they have a meniscus tear in the knee and milder or moderate degrees of arthritis I might recommend that patient have an arthroscopy to clean up the knee and remove the loose flaps of cartilage, but they also need to understand that I can't make their knee feel like it's 19 years old again. So there are limits to what we can do.

Dr. Sechrest: When you're looking inside a patient's knee that has early onset of degenerative arthritis, what are you actually looking for and what are you trying to find to help that patient when you're doing the arthroscopy?

Dr. Mazzara: We're trying to find loose flaps of cartilage that have peeled away from or delaminated from the bone attachment underneath. Arthritis is a process that initially starts with a little bit of softening of the cartilage. That softening eventually leads to little tiny cracks and crevices in the joint and those cracks and crevices eventually coalesce and all of the sudden the cartilage starts to peel away from the surface underneath. The cartilage is normally securely attached to the bone, as it becomes weak and arthritic it peels away from the bone. The benefit of arthroscopy is that we can go into the knee and remove some of those loose pieces, and take some of that mechanical debris from inside of the knee and get it out of there. If the patient has a bit of cartilage left and they're willing to understand that therapy and extra treatment may be beneficial after the surgery, they may be a good candidate for having an arthroscopy. But helping that patient understand that we can't make them perfect is very important.

Dr. Sechrest: Now, over the years there have been lots of different techniques that have been tried and designed to treat the actual surface of the joint that is arthritic during arthroscopy.

Dr. Mazzara: Right.

Dr. Sechrest: They've varied from essentially taking a burr and burring off that surface to try to get new cartilage to grow. There have been drillings into that area, the microfracture technique, and now even with smaller lesions, cartilage replacement and those sorts of things. What is your approach to those procedures? Are we still seeing any benefit from those? Do you do any of those in your practice? Or do you think they've gone by the wayside.

Dr. Mazzara: No, I think they're very valuable for patients. I think the initial procedure you mentioned, called the abrasion arthroplasty, is not really done as much at this point, is not very effective, so that's not a procedure that I think is of great value to patients. You're probably better off doing a simple arthroscopic debridement as opposed to burring it down to the bone. The microfracture procedure is very helpful in selected patients. So in somebody whose inside of the knee is not extremely arthritic, they might have a focal defect, and they have good alignment of the knee and they're not somebody who is considerably overweight, those are people who can actually benefit from a microfracture procedure. The way that works is we go on into the knee, and if the surrounding cartilage is actually in pretty good shape but there's an area where it's damaged, we can remove some of the loose cartilage and sharpen the edges of the defect. Then we take a little microscopic awl or a pick and we puncture the bone underneath. What that does is that allows little bone tunnels to be created into the joint. The cartilage itself has no circulation. The only way to get cartilage or blood into the knee, and blood is essential for healing, is to do this microfracture technique to open these channels through the bone into the subchondral bone allowing the blood to come into the knee, and fills this little defect that we've created surgically with blood; and that blood creates a patch and that patch differentiates over a period of time into what's called fibrocartilage. While it may not be as perfect as the stuff we're born with, it is probably the best way to resurface an isolated defect in the knee. When we do that, we look at the data from that procedure and compare it to the relocation of bone plugs or what's called an OATS (osteochondral autograft transfer system) procedure from one part of the knee to the other, the microfracture procedure is actually very effective and comparable to any OATS one might do. There are other procedures that can be often discussed with individual patients where we actually go in and harvest cells, reproduce some of those cartilage cells, the patient's own cells, and then re-implant it at a second procedure. I do that procedure under selected circumstances for certain patients, but there are certain criteria they have to fulfill. They have to have an otherwise good cartilage in the knee and a good intact meniscus in the knee as well. So for somebody who may have more extensive damage, for somebody who may have a meniscectomy on that side of the knee, the re-implantation of the cartilage cells into the knee may not be effective. You may buy that individual some time with the microfracture procedure, but to relocate cartilage to that part of the knee may not be the best option. I also see patients who come in who are in need of a knee replacement. They have advanced knee arthritis, and those people very commonly want to know if I can grow their cartilage and re-implant it; and I unfortunately have to tell them they're about 30 years too late for that procedure, and their arthritis is quite advanced, so those are individuals who are looking for something that's less invasive than a knee replacement, but still aren't appropriate candidates for the less invasive procedures.

Dr. Sechrest: Yeah, I think it's a real misperception about the cartilage re-growth and regeneration. That really, in my experience, is for relatively young patients who have an articular injury.

Dr. Mazzara: Yes.

Dr. Sechrest: Where they have one focal area that, for some reason, that cartilage has been damaged and you've got normal cartilage all around, so it's really fixing a hole, like a pothole, rather than taking a whole surface of a femoral condyle that is completely degenerative. You can't really get cartilage to grow on that.

Dr. Mazzara: No, you can't. You're absolutely right. So again, it's great technology, but that great technology has to be applied to the correct patient for it to be beneficial. So not every patient who comes in with knee pain can have the same procedure. Even though we can do a lot of surgery arthroscopically, the results and outcomes are somewhat different because each patient's condition is very different, and each patient starts with a different preoperative status and preoperative function, and a different injury internally. So, you have to help those people understand that this is the condition of "your knee", and so you might not get the same result that your neighbor did who's 20 years younger than you are who doesn't have any osteoarthritis of the knee, who had a simple meniscus tear. You're knee may be better but not perfect but there are ways we can help you with that, and I really find after 16 years of practice, I find that counseling patients on what you can do for them is very helpful and helping them understand what you can't do, is probably more helpful and helping those people through their postoperative course is very beneficial to both of you because you establish a very good relationship with those individuals. I think they understand that you're doing your best for them and their condition may just be worse than their neighbor's.

Dr. Sechrest: On the same note, I think patients have this misperception about arthroscopy as this is something we come in, we have as day surgery, you go home and 3 days later, you're back running a marathon.

Dr. Mazzara: Right.

Dr. Sechrest: How do you try to counsel patients in terms of your recovery, a lot of it depends on what we find in your knee and what the problem is in your knee and what we've done for it. For example, if you do a microfracture technique, that's a lot more surgery done through those two little puncture wounds, or maybe three little puncture wounds, but there's a lot more to heal there. So how do you advise your patients to expect their postoperative course to go?

Dr. Mazzara: Well, it's going to depend on what we find, as you said that's absolutely correct, so somebody who has a pristine beautiful knee except for meniscus tear, might be able to get up and walk immediately after surgery and that patient may come in within a week or two of surgery and have minimal to no pain, no swelling, get back to all their activities based on how they feel. Somebody who has got arthritis in the knee may take 2 or 3 months to get better. That person however, who has the microfracture, might be on crutches for 6 weeks, sometimes 8 weeks, depending on where the lesion is. They might need a lot of therapy and they may have a lot more swelling in the knee than either of those other two patients, either with the arthritis or the simple meniscus tear. So, telling patients that you might find something that requires extra treatment in there is important. In many instances, prior to surgery, when you look at the x-ray and you look at the MRI, you'll be able to give that patient a very good indication of what their postoperative course is going to be, and a large part of our job is helping people with postoperative expectations and results of surgery regarding those expectations. So a lot of people will come through and say, "Okay, I understood what I was in for", and they can help with their own care, and I think that's important. People who don't have a lot of arthritis may not need a lot of physical therapy after surgery. Somebody who's got moderate arthritis in the knee, who needs a cleanup and a meniscectomy, might need physical therapy for a month or two, and the patient who has the microfracture may actually need therapy for a couple of months and may need to do therapy, sometimes on their own at home, for 4-6 months. I find those people who have the microfracture procedure do pretty well in the first 6 weeks and the reason is that they're not really walking it, they're not stressing it, they're not straining it. That second 6 weeks, after the microfracture procedure, tends to be a little bit more stressful for them, they have a little bit more pain, more swelling, because they're now starting to bear weight, and they may have pain and discomfort and swelling. From 3 months to 6 months, those people really seem to turn a corner, and seem to do better, so somebody who's got a microfracture for an isolated cartilage defect in their knee, could take as long as 3-6 months to see the benefit of that. Somebody who has got the meniscus tear, in a week. But externally, you look at their knee, they just have two small punctures. So you don't really know what you've done inside until you talk to the surgeon or look at the pictures, because we can do a lot from tiny arthroscopic incisions these days.

Dr. Sechrest: I think the other thing we should discuss, too, is a lot of people have this notion that, "I've failed all of these things – the injections, the medications, the physical therapy, and now I have surgery, and all of these things are not useful anymore." What is your feeling about the role of even the visco-supplementation, some of the medications after surgery? I'm assuming you still use some of those things after surgery to control those symptoms.

Dr. Mazzara: Absolutely. I think that's a very good point because once you debrided the inside of the joint and you've taken all the mechanical debris and the loose flaps of cartilage out of there, you can still see some tremendous value to anti-inflammatories, and therapy, and a cortisone shot, and lubricant shots to the knee. They can still be helpful now that the big loose flaps of cartilage are gone, it's still something to recommend to the patient. So just because they had it before and it may not have been effective, doesn't mean it can't be discussed again, and even recommended down the line. But it's going to depend on what the inside of the knee looks like.

Dr. Sechrest: Now, as we close on this discussion, which I think there is such a high prevalence as we age of knee problems that nearly 80% of the population is probably going to be faced with this decision at some point - what to do with an arthritic knee. What advice would you have both from a preventative standpoint, and then, as we are trying to make these decisions for ourselves, what to look at in terms of treatment. Any advice you would have along those lines of patients.

Dr. Mazzara: Well, I think people need to recognize that we all go through a wear and tear process, and as we stay healthier for a longer period of time in our lives and we live much longer, Mother Nature doesn't recognize these technology advances and our joints still wear out at the same rate that they did thousands of years ago. The problem is that we're living longer and expect more. So we have to help our patients understand that there are things we can do to make them better, and we can't always make their knees perfect, and having our patients have discussions with us about the options that are available is very important in creating realistic expectations for any kind of treatment. It is also an important part of our job. So when we talk about medicine or shots or therapy or surgery, we have to have our patients understand what the likely outcome of that is, but that's part of a discussion that we have with each individual patient, and quite honestly, each patient is very, very different in terms of what they expect and what condition they bring to the office.

Dr. Sechrest: Well, thanks for an interesting discussion. I think it's all good information.

Dr. Mazzara: Thank you.

Dr. Sechrest: Thanks for watching today. If you have questions about the topic that we discussed today, or any orthopaedic topic, be sure to visit eOrthopod.com. If you're an orthopaedic surgeon or healthcare provider interested in participating as a guest on eOrthopod TV, you'll also find instructions on how to apply to become a guest on eOrthopod TV. Thanks for watching.