1. Relevance

Osteoarthritis (OA) is a heterogeneous disease in which articular cartilage, subchondral bone, ligaments, capsule, synovial membrane and periarticular muscles are involved in the pathological process. Such terminological definitions as "osteoarthrosis", "arthrosis", "osteoarthritis", "deforming arthrosis" are presented as synonyms in the X International Classification of Diseases (ICD 10) (Artroses: M15-M19) [3].

Degenerative-dystrophic diseases of the joints are one of the most common pathologies in the elderly. In the affected joints, the lubrication of the articular cartilage is deteriorated, their gliding and proper functioning are disrupted. Degenerative changes in articular tissues lead to defects in cartilage coating, especially in the loaded areas of articular surfaces [8].

Osteoarthritis occurs in 54.5% of patients with degenerative-dystrophic lesions of the joints. OA is one of the main causes of disablement, which in leads to disability 6.5% of cases. [1]

Their characteristic features are constant pain, changes in articular function, the reducing quality of life. The incidence of OA clearly correlates with age and reaches 50% in people over 65 years of age. [4,6,7,9] Treatment of osteoarthritis of the knee joint is one of the most problems in orthopedics of current interests. The last decades have been characterized by the introduction of arthroscopic techniques into the knee joint surgery, which greatly expanded the possibilities of diagnosing and treating of the osteoarthritis [2]. The importance of arthroscopy in the treatment of osteoarthritis of the knee is currently increasing. There is still no comprehensive clinical diagnostic algorithm that would have indications and contraindications in the treatment of osteoarthritis of the knee joint.

Objective: To improve the results of arthroscopic treatment of patients with osteoarthritis of the knee joint, through the introduction of a comprehensive clinical diagnostic algorithm.

2. Materials and Methods

218 patients treated in 2014–2019 from the Department of Sports Traumatology of Republican Spezialized Centre of Traumatology and Orthopedics, underwent arthroscopic treatment with osteoarthritis of the knee joint at various degrees. The age of patients was ranged from 40 to 80 years. 156 (71.6%) were women and 62 (28.4%) were men. In the diagnosis of osteoarthritis of the knee joint, clinical, radiographic, goniometric, MRI and X-ray densitometric studies were performed. Clinical studies included: clarifying complaints, collecting history, examination, palpation of the damaged area, determining the range of motion in the joint. We used the Kellgren and Lawrence classifications to determine the degree of osteoarthritis [7]. In this classification there were 5 degrees from 0 to IV degree. 0 and IV degree was not included in our study. We believe that with IV degree of osteoarthritis arthroscopy is not effective. In 0 degree of osteoarthritis, if no structural changes are identified, it can be treated conservatively. In our study, the following degrees of osteoarthritis were determined in patients: grade I - 19 patients (8.7%), grade II - 104 patients (47.7%), grade III - 95 patients (43.6%). In 158 (72.4%) patients, osteoarthritis was accompanied by synovitis. All 218 patients underwent arthroscopic diagnostic and simultaneous treatment. Knee arthroscopy was performed with a KARL STORZ arthroscope (Germany). 0.9% saline was used in the operating environment. The operations were performed under the general and spinal anesthesia. Arthroscopy was performed with standard antromedial and antrolateral approaches. If necessary, additional access was used. Arthroscopy was carried out using standard research methods. In the process of arthroscopic intervention, cruciate ligaments, the integrity and thickness of the capsule, the state of hyaline cartilage, damage of menisci, degenerative-dystrophic changes, the presence and amount of free fluid in the joint cavity and its character, the state of synovial folds were investigated. In synovitis, when the synovial membrane is hypertrophied, debridement is performed. If a free osteochondral fragment is detected in the chamber of the knee joint, it is removed from the joint with a special arthroscopic clamp. With limited movements in the joint, the patella is mobilized with arthroscopic scissors. A damaged or degeneratively altered posterior horn of the medial meniscus is resected. The edges of the meniscus are aligned by shavering. Foci of chondromalacia in the joints are treated with shivering. The chondramal lesion of the femur or tibia is tunneled through the articular surfaces towards the medullary canal with a drill, using Ø = 2 mm knitting needles. Moreover, the perforation of the tunnels on the femoral and tibial bones is performed at a distance of at least 5 mm from each other. Based on clinical complaints, goniometric, x-ray, MRI, x-ray densitometric analysis, we developed a clinical diagnostic algorithm for the treatment of OA of the knee joint. (1 table)

We have conducted 5 types of arthroscopic surgery in 218 patients with OA knee. The first type of operation — local debridement with meniscectomies was performed in 1– and 5 cases (on a table 1.) in 35 (16%) patients, the second type of operation — local debridement with subchondral tunneling was performed on 2,6,7 and 10 cases (on a table 1) in 41 ( 18.8%) patients, the third type of operation - partial debridement standard of subchondral tunneling was carried out 2,3,6,7,9 and 10 cases (according to the table 1) in 58 (26,6%) patients, the fourth type of operation is shown in table 3, 4,7,8 and 11, full debridement with standard subchondral tunneling in 53 (25.2%) patients, the fifth type of operation is given (in the table 1) 4,7,8,11 and 12, complete debridement with deep subchondral tunneling in 31 (13.4%) patients.

This operation allows to solve several problems simultaneously, including improving nutrition and remodeling of cartilage tissue, and reduces pressure in the subchondral zone, and increases bone density, improves the arthro-kinematics of the knee-femoral and femoral-tibial joint, normalizes the regulation of synovial fluid formation (1 – table).

Table 1. Clinical and diagnostic algorithm for arthroscopic treatment of osteoarthritis of the knee joint

3. Results and Its Discussion

The study included patients with osteoarthritis of the knee at various degrees. This disease is most common in elderly patients, and the presence of secondary diseases affects the outcome of the surgery. In all 5 types of performed operations excellent and good results were achieved. After operation, pain at rest has disappeared the next day. From the next day, a dose load on the operated leg, followed by a gradually increasing of the load were prescribed to patients. In for 3-5 days after surgery, the development of the joint has begun. After 10 days, full load was allowed on the operated limbs. Full flexion was allowed after 2 weeks. In all patients, the function of the knee joint was restored, the amplitude of movement increased, the discomfort in the joint decreased and disappeared. In all patients after surgery, no somatic changes were observed. The closest (from 3 to 6 months) and remote (from 6 months to 1 year) results were analyzed in all patients. In 194 patients, the pain at rest in the knee joint disappeared completely, in 24 patients pain remained with the load. After surgery, four patients had synovitis with arthralgia for up to 6 months. The condition of these patients has improved after the conservative treatment with active therapeutic exercise (exercise therapy). Effective results were obtained in 191 patients within 3-6 months, while 214 patients received good results from 6 months to 1 year. This is based on the long duration of treatment in some patients. During the period of rehabilitation treatment, walking with orthopedic unloading of the joint and subsequent, gradually increasing load to the leg is recommended. In the postoperative period, patients are recommended medication, early rehabilitation and physiotherapy.

According to our data, the department of Sports trauma at the Republican Centre of Traumatology and orthopaedics achieved 96.5% of the effect simultaneously from arthroscopic techniques of local, partial, extended debridement, standard and deep subchondral tunneling with osteoarthritis of the knee joint at different stages.

4. Conclusions

1. The introduction of a clinical diagnostic algorithm for the arthroscopic treatment of osteoarthritis of the knee joint has made it possible to obtain good results through selective intervention.

2. Arthroscopic treatment using the clinical diagnostic algorithm allows activating patients and starting the rune rehabilitation measures in the post-operative period.