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Why a rheumatologist should be interested in arthroscopy.

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ARTHRITIS & RHEUMATISM Volume 37
Number 1I , November 1994, pp 157S1576
0 1994, American College of Rheumatology
1573
EDITORIAL
WHY A RHEUMATOLOGIST SHOULD BE INTERESTED IN
ARTHROSCOPY
ROWLAND W. CHANG and LEENA SHARMA
Arthroscopy has stimulated much discussion in
the rheumatologic community. While the prospect of
‘‘interventional rheumatology” with its therapeutic
and financial rewards has interested some, others feel
that the conservative, cognitive approach for which
rheumatology is noted is incompatible with this technical and potentially costly procedure. Our purpose
here is to discuss why arthroscopy might be helpful to
rheumatologists and their patients and why those in
the rheumatology community should support current
research and educational arthroscopy endeavors
whether they intend to use the procedure in their own
practices or not.
The rationale for pursuing arthroscopy as an
alternative diagnostic and therapeutic procedure stems
from the inadequacy of current diagnostic and therapeutic strategies for many patients who have chronic
rheumatic diseases. It is likely that pathoanatomy
plays a major role in many musculoskeletal conditions,
even in those known to be immunologically triggered,
such as rheumatoid arthritis. We are realizing that
while cures for rheumatic diseases require extensive
knowledge in the fields of molecular biology, genetics,
immunology, inflammation, and biochemistry, once
certain pathobiological processes have been set in
motion, symptoms from structural damage and altered
biomechanics contribute significantly to a patient’s
pain and disability. Arthroscopy can potentially give
rheumatologists the ability to understand the pathoanatomic correlates of the patient’s symptoms and to
intervene appropriately.
Supported by grants from the Robert Wood Johnson Foundation (no. WO), the NIH (NIAMS), MAMDC (AR-30692), and
from the Arthritis Foundation, Illinois Chapter.
Rowland W. Chang, MD, MPH: Northwestern University
Multipurpose Arthritis Center and Center for Health Services and
Policy Research, Northwestern University Medical School, Chicago, Illinois; Leena Sharma, MD: Northwestern University Multipurpose Arthritis Center and Medical School.
Address reprint requests to Rowland W. Chang, MD,
MPH, Northwestern University Multipurpose Arthritis Center, 303
East Chicago Avenue, W121, Chicago, IL 60611.
The reluctance of the majority of rheumatologists to engage in arthroscopy stems from several
factors. Some relate it to our biological rather than
mechanical orientation, others to our reluctance to
perform procedures. Perhaps the most compelling
reason is skepticism about whether the procedure is
diagnostically andfor therapeutically useful in terms of
patient outcome. Finally, there are significant concerns about the costs of the procedure.
From a diagnostic perspective, arthroscopy is
useful in identifying intraarticular anatomic abnormalities that may cause the patient’s joint symptoms. The
technology most commonly used to assess intraarticular pathology is magnetic resonance imaging (MRI).
The accuracy of MRI is purported to exceed 90% in
the diagnosis of meniscal abnormalities (1-3). However, when a double-blind design is used (i.e., arthroscopist and radiologist are unaware of each other’s
findings), MRI appears to be less accurate if the
arthroscopic findings are considered the gold standard.
Raunest and colleagues (4)reported that the overall
accuracy of MRI for detecting degeneration of the
meniscus was no better than 78%. In another doubleblind study done by Glashow and colleagues (9,MRI
was found to have a positive predictive value of 75%, a
negative predictive value of 90%, a sensitivity of 83%,
and a specificity of 84% for any meniscal pathology.
While unblinded studies estimate MRI’s accuracy in diagnosing anterior cruciate ligament (ACL)
tears to be about 95% and the negative predictive
value to be 100% for this condition (6,7), the doubleblind study by Glashow and colleagues estimated
sensitivity and specificity of MRI for complete tears of
the ACL to be only 61% and 82%, respectively (5).
Although the use of certain contrast agents may improve visualization of synovium and articular cartilage, there are few data on the accuracy of enhanced
MRI as compared with arthroscopy (8). Thus, given
the limitations of MRI in the assessment of intraarticular pathology, there are circumstances in which ar-
1574
throscopy might be preferred as a diagnostic tool.
Risk-benefit and cost-effectiveness studies are needed
to further assess the relative advantages and disadvantages of MRI and arthroscopy in any given diagnostic
situation.
Another potential diagnostic use for arthroscopy relates to the sampling of synovial tissue. Some
have advocated that synovial biopsies obtained
through the arthroscope may be more useful than
those obtained using the closed-needle technique (9).
While it is controversial how often assessment of
synovial pathology proves useful in the management
of rheumatic disease patients (10,l l), arthroscopic
synovial biopsies offer several potential advantages.
First, the procedure ensures that the most severely
affected area is sampled (9,12). With closed biopsy,
there is a risk of missing significant abnormalities,
since synovitis is not uniform either in intensity or in
mass. The study by Lindblad and Hedfors (9) suggests
a strong correlation between gross or macroscopic
synovitis and microscopic synovitis. Second, arthroscopy allows multiple samples to be obtained. Blind
biopsy provides less tissue, sometimes insufficient for
any analysis. Rooney and colleagues (13) found that
out of 36 patients who underwent blind closed-needle
synovial biopsy, 7 samples had to be excluded because
of inadequate tissue. Also, the arthroscope allows
assessment of the extent of synovitis (i.e., proportion
of joint involved). Finally, there is the added diagnostic utility of visualizing the joint. One could argue that
to examine the synovium and ignore other factors
(e.g., meniscal pathology) is incomplete. Thus, if
examining synovial pathology is found to be useful in
the management of rheumatic disease patients, arthroscopy may be a superior method of obtaining
synovial tissue. Again, further studies are needed
before precise indications for these procedures can be
formulated.
Related literature does little to quell the skepticism that arthroscopy is useful therapeutically. The
orthopedic surgery literature has several uncontrolled
case series of arthroscopic surgery in symptomatic
knee osteoarthritis (OA) which describe good-toexcellent short-term outcome in 60-95% of patients
(14-30) and improvement at longer followup in 5 0 4 5 %
(3 1-34). While advanced OA and malalignment are
associated with worse outcome, shorter symptom duration, bucket handle tear, and mechanical symptoms
may be positive prognostic factors (17,20,24,25,27,3236). Firm conclusions about the procedure’s effectiveness cannot be made from these studies, however,
CHANG AND SHARMA
because of several universal methodologic flaws: retrospective design with incomplete data provided on
selected cases, physician-assigned outcomes not explicitly defined and not functionally oriented, noncomparable outcome measures used in different studies,
comorbidity and potential confounding variables not
considered, variable followup, and, most importantly,
no control or comparison group.
The randomized, controlled trial performed at
our institution did not show any convincing evidence
that arthroscopic surgery was beneficial with regard to
pain or functional status when compared with tidal
irrigation of the knee (37). This study was small and
highlighted the need for larger and more anatomically
informed trials to allow for subgroup analyses. A
larger study could better define a possible subset of
patients with OA of the knee who would benefit from
operative arthroscopy (e.g., those with mobile meniscal tears). A larger, randomized trial evaluating operative arthroscopy, irrigation using a needle arthroscope, and conservative management is underway at
our center as a followup of our original observations.
Costs associated with arthroscopy are high.
Operative arthroscopy at our institution costs -49,000
($5,000 hospital charge for supplies, operating room,
and recovery room time, etc.; $1,000 for the anesthesiologist, and $3,000 for the surgeon). An informal
survey revealed that outpatient needle arthroscopy
costs between $600 and $2,000, -$300 of which is for
supplies. In comparison, MRI of the knee at our
institution costs more than $1,250 ($960 hospital
charge for the procedure and $306 radiologist charge).
Despite the uncertainty of the practical diagnostic and therapeutic utility of operative and/or needle
arthroscopy from the perspective of rheumatologists
and their patients, we strongly feel that the procedure
is important for broadening and strengthening rheumatology’s academic endeavors. Typically, rheumatologists have been involved only in research and teaching
of the pathophysiology of joint diseases. In general,
the anatomy of the joint is taught by anatomists, the
normal physiology of the joint is commonly ignored,
and the pathoanatomy of the joint is taught exclusively
by orthopedic surgeons. This apparent lack of interest
and expertise in these nonpathophysiologic subjects
relevant to the joint is unusual when one surveys other
subspecialties in internal medicine. The subspecialist
internist is normally familiar with, and intellectually
engaged in, the normal anatomy and physiology as
well as pathoanatomy of the subspecialty’s primary
organ (c.f., cardiologists, pulmonologists, gastroenter-
1575
EDITORIAL
ologists, etc.). Commonly this interest is as intense as
that of the related surgical specialist. No other subspecialty of internal medicine has renounced its intellectual ownership of its organ’s anatomy, physiology, and
pathoanatomy as has rheumatology with respect to its
primary organ, the joint. Participating in arthroscopy
is a direct way of improving our knowledge of the
anatomy and pathoanatomy of joints and can only
improve our capabilities of understanding the relationship between joint symptoms and signs and underlying
pathoanatomic as well as pathophysiologic concepts.
There is great potential for arthroscopy to help
us judge the efficacy of potential pharmacologic treatments of chronic arthropathies and to better understand these treatments’ biological effect on the disease
process. Commonly cited deficiencies of currently
measured parameters in rheumatic disease clinical
trials are lack of precision (c.f., the unreliability of
joint counts) and lack of sensitivity (e.g., radiographic
erosions). Arthroscopy allows the investigator to examine directly the effect of the pharmacologic agent on
the relevant tissue. Additionally, it can enhance the
understanding of the biology of those diseases which
have traditionally interested rheumatologists. For instance, in an assessment of a pharmacologic agent for
RA, it would be more direct to measure synovial bulk
and cartilage degeneration through an arthroscope
than to rely on joint counts and radiographic erosions.
Furthermore, longitudinal histologic assessment of the
synovium using samples obtained via arthroscopy may
be an efficient way of assessing the pharmacologic
agent’s biological effect on the disease process. Given
the technological advances that have led to the continued miniaturization of the arthroscope, repeated
synovial tissue sampling is now both feasible and
relatively affordable.
Finally, arthroscopy itself should be a focus of
intense health services research, given that it is the
most commonly performed orthopedic procedure.
Over 1.2 million knee arthroscopies are performed
yearly (38), many of which are performed on patients
with knee OA. While orthopedic surgeons are just
beginning to participate in the outcome research
movement (39,40), rheumatologists have a tradition of
health services research that is developed in terms of
research instruments and knowledgeable researchers
skilled in carrying out responsible empirical studies.
Indeed, the American College of Rheumatology has
gone on record insisting that rigorous evaluations of
arthroscopy be done before the procedure is recom-
mended for use by a larger proportion of the rheumatologic community (41).
Thus, arthroscopy can be thought of as an
opportunity for the field of rheumatology , especially
academic rheumatology. It can be a tool to enhance
our understanding of the pathophysiology of chronic
joint diseases, but it can also stretch the intellectual
horizons of our specialty, which could potentially lead
to improved diagnosis and treatment of our patients.
The appropriate rheumatologic use of the arthroscope
awaits rigorous outcome and cost studies. Meanwhile,
the availability of the needle arthroscope poses a more
fundamental and immediate question: Do rheumatologists affirm that intraarticular anatomy and pathoanatomy are important to our understanding of chronic
arthropathies, or will we abdicate these intellectual
disciplines to others?
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