Description
Arthroscopic lavage and cartilage débridement are operative treatments for osteoarthritis (OA). Lavage is a procedure in which intra-articular fluid is aspirated and the joint is washed out, removing inflammatory mediators, debris or small, loose bodies from the osteoarthritic knee. Articular débridement involves removal of cartilage or meniscal fragments but also can include cartilage abrasion, excision of osteophytes and synovectomy. Débridement is intended to improve symptoms and joint function in patients with mechanical symptoms such as locking or catching of the knee.

The evidence base includes 2 large, well-designed controlled trials, one comparing arthroscopic débridement with lavage and placebo, and the other comparing arthroscopy and lavage along with medical and physical therapy to medical and physical therapy alone. These studies provide sufficient evidence to conclude that arthroscopic débridement and lavage, separately or together, do not improve symptoms of OA of the knee and, therefore, are considered not medically necessary.

Background
OA affects approximately 21 million people in the United States.¹ By age 65, most of the population has radiographic evidence of OA, and 11% have symptomatic OA of the knee. The diagnosis of OA is established using a combination of clinical information derived from history, physical examination, radiologic imaging and laboratory evaluation. An algorithm of diagnostic criteria for OA of the knee has been proposed by the American College of Rheumatology. The diagnosis of OA of the knee is defined as presenting with pain and meeting at least 5 of the following criteria: 

• Patient older than 50 years of age 
• Less than 30 minutes of morning stiffness 
• Crepitus (noisy, grating sound) on active motion 
• Bony tenderness 
• Bony enlargement 
• No palpable warmth of synovium 
• Erythrocyte sedimentation rate less than 40 mm/h 
• Rheumatoid factor less than 1:40 
• Noninflammatory synovial fluid.

The presence of clinical symptoms of OA does not always correlate well with the degree of abnormality seen radiographically. It has been noted that approximately 40% of patients who have severe findings on radiography film report no symptoms; conversely, patients with clinical symptoms may show no significant radiologic changes. 

Treatment for OA of the knee aims to alleviate pain and improve function to mitigate reduction in activity. However, most treatments do not modify the natural history or progression of OA and, thus, are not considered curative. Nonsurgical modalities that are used include exercise; weight loss; various supportive devices; acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen; nutritional supplements (glucosamine and chondroitin); and intra-articular viscosupplements. Corticosteroid injection may be considered when relief from NSAIDs is insufficient or the patient is at risk from gastrointestinal adverse effects. If symptom relief is inadequate with conservative measures, invasive treatments may be considered. Operative treatments for symptomatic OA of the knee include arthroscopic lavage and cartilage débridement, osteotomy and, ultimately, total joint arthroplasty. Surgical procedures intended to repair or restore articular cartilage in the knee, e.g., abrasion arthroplasty, microfracture techniques and autologous chondrocyte implantation, are appropriate only for younger patients with focal cartilage defects secondary to injury and are not addressed in this policy.

Regulatory Status
Although devices used during arthroscopic lavage and cartilage débridement are subject to regulation by FDA, operative procedures are not.

Policy
Except as noted below, arthroscopic debridement and/or lavage are considered not medically necessary for treatment of osteoarthritis of the knee.

Note: Arthroscopic debridement may be considered medically necessary when preoperative imaging indicates that specific anatomic lesions other than osteoarthritis, e.g., large meniscal tears, loose bodies, are the cause of the patient’s symptoms, regardless of the presence of osteoarthritis.

Rationale
Arthroscopic débridement and lavage have been used extensively for the treatment of osteoarthritis (OA) of the knee. Because lavage and débridement are often performed at the same time, it is difficult to attribute the success or failure of arthroscopy to a specific procedure.¹

Evidence of efficacy had for many years consisted of reports of case series or controlled trials with methodologic problems. In 2002, Moseley et al. published a randomized placebo-controlled trial that found limited efficacy of arthroscopy for OA of the knee.² A total of 180 patients were randomly assigned to débridement (without abrasion or microfracture), lavage or placebo surgery. Placebo surgery involved a skin incision and simulated débridement without insertion of the arthroscope. Patients and assessors were blinded to treatment group. Neither treatment group reported less pain or better function than the placebo group at any time point during the 2-year follow-up. A systematic review produced in 2007 for the Agency for Healthcare Research and Quality by the Blue Cross and Blue Shield Association Technology Evaluation Center Evidence-based Practice Center noted that generalizability of these study results was limited by the lack of detail provided regarding the patient sample, use of a single surgeon and enrollment of patients at a single Veterans Affairs Medical Center.¹ The report concluded that "the existing evidence does not definitively show that arthroscopic lavage with or without debridement is more effective than placebo. However, additional placebo-controlled RCTs (randomized controlled trials) showing clinically significant advantage for arthroscopy would be necessary to refute the Moseley results, which show equivalence between placebo and arthroscopy."

A 2008 Cochrane review of arthroscopic débridement for knee OA assessed 3 RCTs, including the study by Moseley et al. and concluded that there is criterion-level evidence that arthroscopic débridement has no benefit for undiscriminated OA (mechanical or inflammatory causes).³ The other 2 studies included in the Cochrane review were of lower methodologic quality and compared arthroscopy with lavage. In one of the reviewed studies, Chang et al. compared arthroscopy with closed needle lavage and found no significant between-group differences in pain, self-reported and observed functional status and patient and physician global assessments.⁴ This study was small (32 subjects), with only 3 months of follow-up. The second study was a randomized trial of 76 knees, 40 laparoscopic débridement and 36 washout, with mean follow-up time of 4.5 years and 4.3 years, respectively.⁵ At 1 year, 32 of the débridement group and 5 of the washout group were pain-free. At 5 years, 19 of the survivors in the débridement group and 3 of the 26 in the washout group were pain-free. This study was noted by the Cochrane review to be at high risk of bias; specifically, outcome assessors were neither independent nor blinded, and pain was measured as success when absent and failure when present.

An updated systematic review of the evidence for joint lavage for OA of the knee was published by the Cochrane Musculoskeletal Group in May 2010 and was based on the literature to April 2009.⁶ This review included 7 trials with 567 patients. The Cochrane review did not include the study described next by Kirkley et al.⁷ because that trial focused on débridement. The authors concluded that joint lavage does not result in a benefit for patients with knee OA for pain relief or improvement in function.

In 2008, Kirkley et al.⁷ published a single-center RCT comparing surgical lavage and/or arthroscopic débridement (without abrasion or microfracture) together with optimized physical and medical therapy, or physical and medical therapy alone. Patients with more than 5° of misalignment were excluded. Both men and women were enrolled. Seven experienced arthroscopists performed lavage, débridement or both, at their discretion. Between January 1999 and August 2005, 277 patients were assessed for eligibility; 58 were not eligible (most [38 percent] because of substantial misalignment) and 31 declined participation. Ninety-two patients were randomly assigned to the surgery arm, and 86 were assigned to physical and medical therapy alone. Ten withdrew consent (2 in the surgery group, 8 in the control group). Six in the surgery group did not undergo surgery. Data from these patients were included in the intention-to-treat analysis. The primary outcome was total Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score. Secondary outcomes included the 36-Item Short-Form Health Survey (SF-36) Physical Component Summary (PCS) score. After 2 years, the mean (SD) WOMAC score for the surgery group was 874 (624), compared with 897 (583) for the control group (absolute difference [surgery-group score minus control-group score], -23 [605]; 95 percent confidence interval [CI], -208 to 161; p = 0.22). The SF-36 PCS scores were 37.0 and 37.2, respectively (absolute difference, -0.2; 95 percent CI, -3.6 to 3.2; p = 0.93). Analyses of WOMAC scores at interim visits and other secondary outcomes also failed to show superiority of surgery. Prespecified analyses of subgroups were performed for patients with less severe disease (Kellgren-Lawrence grade 2) at baseline and patients with mechanical symptoms of catching or locking, and no significant difference between treatment groups was found. A post hoc analysis of patients with more severe radiographic disease (Kellgren-Lawrence grade 3 or 4) also found no benefit of surgery.

A 2013 meta-analysis found no additional randomized trials on arthroscopic joint débridement for knee osteoarthritis.⁸ Meta-analysis of studies with follow-up of 2 years or more found a conversion rate to joint replacement of 6.1 percent at 1 year, 16.8 percent at 2 years, 21.7 percent at 3 years and 34.1 percent at 4 years. Data were not available on conversion to joint replacement in patients treated conservatively. This systematic review is limited by the inclusion of poor quality studies (level IV, uncontrolled and retrospective) and heterogeneity in study results. In addition, the definition of joint débridement in this meta-analysis included smoothing of cartilage lesions, removal of loose bodies, meniscectomy, synovectomy and ligament release. The débridement could be combined with other types of treatment, including osteotomies or cartilage-restoring techniques (drilling, abrasion, microfracturing, autologous chondrocyte implantation), making it difficult to isolate the specific impact of débridement on outcomes. Thus, interpretation of this meta-analysis is limited.

In an editorial, Marx comments that OA is not a contraindication to arthroscopic surgery and that it "remains appropriate in patients with arthritis in which osteoarthritis is not believed to be the primary cause of pain."⁹

Clinical Input Received From Physician Specialty Societies and Academic Medical Centers
While the various physician specialty societies and academic medical centers may collaborate with and make recommendations during this process through the provision of appropriate reviewers, input received does not represent an endorsement or position statement by the physician specialty societies or academic medical centers, unless otherwise noted.

In response to requests, input was received from 2 physician specialty societies and 3 academic medical centers while this policy was under review for April 2009. Most of the 5 reviewers providing input supported the conclusions of this policy that arthroscopic débridement and/or lavage are considered not medically necessary for treatment of osteoarthritis of the knee.

Summary of Evidence
Arthroscopic lavage and cartilage débridement are operative treatments for osteoarthritis (OA) that may be performed separately or at the same time. The evidence base includes 2 large well-designed controlled trials, one comparing arthroscopic débridement with lavage and placebo and the other comparing arthroscopy and lavage along with medical and physical therapy to medical and physical therapy alone. These studies provide sufficient evidence to conclude that arthroscopic débridement and lavage, separately or together, do not improve symptoms of OA of the knee and, therefore, are considered not medically necessary.

Practice Guidelines and Position Statements
A systematic review of recommendations and guidelines for the management of OA was published in 2014 by the U.S. Bone and Joint Initiative.¹⁰ Sixteen guidelines from the United States, Canada, Europe and Asia were reviewed. Needle lavage and arthroscopy with debridement were not recommended for symptomatic knee OA by the American Academy of Orthopaedic Surgeons (AAOS, see next) or the U.K.’s National Collaborating Centre for Chronic Conditions. Osteoarthritis Research Society International (OARSI) guidelines from 2008 found limited support for these procedures. Overall, arthroscopy with debridement was not recommended.

Guidelines from the AAOS in 2013 provide a strong recommendation against performing arthroscopic débridement and lavage: "We cannot recommend performing arthroscopy with lavage and/or debridement in patients with a primary diagnosis of symptomatic osteoarthritis of the knee."¹¹A strong recommendation means that the quality of the supporting evidence is high and that practitioners should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present. Based on moderate evidence, AAOS "cannot suggest that the practitioner use needle lavage for patients with symptomatic osteoarthritis of the knee."

In 2008, OARSI convened 16 experts from primary care, rheumatology, orthopedics and evidence-based medicine from 6 countries, including the United States, to develop consensus recommendations for management of hip and knee OA.¹² OARSI concluded that "the roles of joint lavage and arthroscopic debridement are controversial and that, although some studies have demonstrated short-term symptom relief, others suggest that improvement in symptoms could be attributable to a placebo effect."

U.S. Preventive Services Task Force Recommendations
The U.S. Preventive Services Task Force has not addressed arthroscopic debridement and lavage as a treatment for OA of the knee.

References:

1. Samson DJ, Grant MD, Ratko TA, et al.. Treatment of Primary and Secondary Osteoarthritis of the Knee. Evidence Report/Technology Assessment No. 157 (Prepared by Blue Cross and Blue Shield Association Technology Evaluation Center Evidence-based Practice Center under Contract No. 290-02-0026). AHRQ Publication No. 07-E012. Rockville, MD: Agency for Healthcare Research and Quality. September 2007. http://archive.ahrq.gov/clinic/tp/oakneetp.htm. Accessed November 7, 2014.
2. Moseley JB, O'Malley K, Petersen NJ, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. Jul 11 2002;347(2):81-88. PMID 12110735
3. Laupattarakasem W, Laopaiboon M, Laupattarakasem P, et al. Arthroscopic debridement for knee osteoarthritis. Cochrane Database Syst Rev. 2008(1):CD005118. PMID 18254069
4. Chang RW, Falconer J, Stulberg SD, et al. A randomized, controlled trial of arthroscopic surgery versus closed-needle joint lavage for patients with osteoarthritis of the knee. Arthritis Rheum. Mar 1993;36(3):289-296. PMID 8452573
5. Hubbard MJ. Articular debridement versus washout for degeneration of the medial femoral condyle. A five-year study. J Bone Joint Surg Br. Mar 1996;78(2):217-219. PMID 8666628
6. Reichenbach S, Rutjes AW, Nuesch E, et al. Joint lavage for osteoarthritis of the knee. Cochrane Database Syst Rev. 2010(5):CD007320. PMID 20464751
7. Kirkley A, Birmingham TB, Litchfield RB, et al. A randomized trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. Sep 11 2008;359(11):1097-1107. PMID 18784099
8. Spahn G, Hofmann GO, Klinger HM. The effects of arthroscopic joint debridement in the knee osteoarthritis: results of a meta-analysis. Knee Surg Sports Traumatol Arthrosc. Jul 2013;21(7):1553-1561. PMID 22893268
9. Marx RG. Arthroscopic surgery for osteoarthritis of the knee? N Engl J Med. Sep 11 2008;359(11):1169-1170. PMID 18784107
10. Nelson AE, Allen KD, Golightly YM, et al. A systematic review of recommendations and guidelines for the management of osteoarthritis: The Chronic Osteoarthritis Management Initiative of the U.S. Bone and Joint Initiative. Semin Arthritis Rheum. Jun 2014;43(6):701-712. PMID 24387819
11. American Academy of Orthopaedic Surgeons. Treatment of osteoarthritis of the knee - 2nd edition. 2013; http://www.aaos.org/research/guidelines/GuidelineOAKnee.asp. Accessed November 7, 2014.
12. Zhang W, Moskowitz RW, Nuki G, et al. OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis Cartilage. Feb 2008;16(2):137-162. PMID 18279766

Coding Section

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each Policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines

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