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Joint lavage for osteoarthritis of the knee

  • Review
  • Intervention

Authors

  • Stephan Reichenbach,

    Corresponding author
    1. University Hospital, Department for Rheumatology, Clinical Immunology, and Allergology, Bern, Switzerland
    • Stephan Reichenbach, Department for Rheumatology, Clinical Immunology, and Allergology, University Hospital, Inselspital, Bern, Switzerland. rbach@ispm.unibe.ch.

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  • Anne WS Rutjes,

    1. University of Bern, Division of Clinical Epidemiology and Biostatistics, Institute of Social and Preventive Medicine, Bern, Switzerland
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  • Eveline Nüesch,

    1. University of Bern, Division of Clinical Epidemiology and Biostatistics, Institute of Social and Preventive Medicine, Bern, Switzerland
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  • Sven Trelle,

    1. University of Bern, Institute of Social and Preventive Medicine, Bern, Switzerland
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  • Peter Jüni

    1. University of Bern, Division of Clinical Epidemiology and Biostatistics, Institute of Social and Preventive Medicine, Bern, Switzerland
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Abstract

Background

Osteoarthritis is the most common form of joint disorder and a leading cause of pain and physical disability. Observational studies suggested a benefit for joint lavage, but recent, sham-controlled trials yielded conflicting results, suggesting joint lavage not to be effective.

Objectives

To compare joint lavage with sham intervention, placebo or non-intervention control in terms of effects on pain, function and safety outcomes in patients with knee osteoarthritis.

Search methods

We searched CENTRAL, MEDLINE, EMBASE, and CINAHL up to 3 August 2009, checked conference proceedings, reference lists, and contacted authors.

Selection criteria

We included studies if they were randomised or quasi-randomised trials that compared arthroscopic and non-arthroscopic joint lavage with a control intervention in patients with osteoarthritis of the knee. We did not apply any language restrictions.

Data collection and analysis

Two independent review authors extracted data using standardised forms. We contacted investigators to obtain missing outcome information. We calculated standardised mean differences (SMDs) for pain and function, and risk ratios for safety outcomes. We combined trials using inverse-variance random-effects meta-analysis.

Main results

We included seven trials with 567 patients. Three trials examined arthroscopic joint lavage, two non-arthroscopic joint lavage and two tidal irrigation. The methodological quality and the quality of reporting was poor and we identified a moderate to large degree of heterogeneity among the trials (I2 = 65%). We found little evidence for a benefit of joint lavage in terms of pain relief at three months (SMD -0.11, 95% CI -0.42 to 0.21), corresponding to a difference in pain scores between joint lavage and control of 0.3 cm on a 10-cm visual analogue scale (VAS). Results for improvement in function at three months were similar (SMD -0.10, 95% CI -0.30 to 0.11), corresponding to a difference in function scores between joint lavage and control of 0.2 cm on a WOMAC disability sub-scale from 0 to 10. For pain, estimates of effect sizes varied to some degree depending on the type of lavage, but this variation was likely to be explained by differences in the credibility of control interventions: trials using sham interventions to closely mimic the process of joint lavage showed a null-effect. Reporting on adverse events and drop out rates was unsatisfactory, and we were unable to draw conclusions for these secondary outcomes.

Authors' conclusions

Joint lavage does not result in a relevant benefit for patients with knee osteoarthritis in terms of pain relief or improvement of function.

摘要

背景

膝蓋退化性關節炎的關節灌洗

退化性關節炎是最常見的關節病變,而且是造成疼痛和生理障礙的主要原因。觀察性研究認為關節灌洗是有利的,但最近的一些模擬對照試驗有相反的結果,認為關節灌洗是沒有用的。

目標

以膝蓋退化性關節炎病患為樣本,比較關節灌洗和模擬介入、安慰劑或無介入對於疼痛、生理功能的療效及安全性。

搜尋策略

我們搜尋了CENTRAL、MEDLINE、EMBASE及CINAHL直到2009年8月3日,檢視會議摘要、參考資料並和研究作者連絡。

選擇標準

我們收錄有以膝蓋退化性關節炎病患為樣本,比較關節鏡和非關節鏡關節灌洗跟對照介入的隨機或半隨機試驗。沒有語言上的限制。

資料收集與分析

2位作者分別利用標準格式擷取數據。我們和研究者連絡以取得遺失的結果資料。計算疼痛和生理功能的標準平均差 (SMDs) ,以及安全性結果的風險率。我們利用變異數倒數的隨機效果統合分析合併試驗。

主要結論

我們收錄了7個試驗,總共包含567位病患。3個試驗討論關節鏡關節灌洗,2個討論非關節鏡關節灌洗,另外2個使用固定班次灌洗。試驗的方法品質及結果品質皆差,而且我們發現這些試驗有中度到高度的異質性 (I2 = 65%) 。針對關節灌洗對3個月後的疼痛緩解,我們找到的證據很少 (SMD −0.11, 95% CI −0.42 to 0.21) ,而使用膝蓋灌洗的組別和對照組在10cm visual analogue scale (VAS) 的疼痛分數上有0.3cm的差異。3個月後功能改善的結果差不多 (SMD −0.10, 95% CI −0.30 to 0.11) ,而使用關節灌洗的組別和對找組在WOMAC disability subscale的0到10的功能評分上,有0.2的差異。針對疼痛,根據灌洗的種類在效果量上有些許不同,但這可能是因為對照組的可信度不同而造成的;使用模擬介入模仿關節灌洗的試驗則呈現零效應。不良反應和退出試驗比率的回報不足,因此我們無法針對次要結果提出結論。

作者結論

關節灌洗對膝蓋退化性關節炎病患的疼痛緩解或功能改善,並沒有相關的好處。

翻譯人

本摘要由朱奕蓁翻譯。

此翻譯計畫由臺灣國家衛生研究院 (National Health Research Institutes, Taiwan) 統籌。

總結

針對膝蓋退化性關節炎的關節灌洗:這篇Cochrane評論的整理,呈現了我們從研究中取得關於膝蓋退化性關節炎 (OA) 關節灌洗的資訊。這篇評論顯示,和模擬治療或不治療比較,對於退化性關節炎病患而言,膝蓋灌洗可能無法改善疼痛和功能。我們通常沒有關於副作用或併發症的精確資訊。這對於罕見但嚴重的副作用是很重要的。甚麼是退化性關節炎?又甚麼是關節灌洗呢?退化性關節炎 (OA) 是最常見的關節炎,它可能會影響到手、髖部和膝蓋。在退化性關節炎中,軟骨會被破壞,且可能會導致腫脹及持續性的疼痛。退化性關節炎可能在膝蓋的不同區域,甚至整個膝蓋發生。當軟骨被破壞,部分組織被遺留在膝關節附近,就可能導致發炎,並影響膝蓋正常運作。關節灌洗就是要將遺留的組織或殘骸從關節腔洗出。須將導管經由1個或多個開孔,暫時的置入膝蓋。這篇系統性評論討論到3種關節灌洗的方式。固定班次灌洗只需要1個開口,交替注入液體後接著將其抽出。非關節鏡關節灌洗需要2個開口,1個注入液體,另1個抽出液體,但無肉眼膝關節檢視。關節鏡關節灌洗是比較正式的方式,在完成後需要做膝關節結構檢視。

Plain language summary

Joint lavage for osteoarthritis of the knee

This summary of a Cochrane review presents what we know from research about the effect of joint lavage for osteoarthritis (OA) of the knee.  The review shows that in people with OA, joint lavage;

- may not improve pain and function compared to a sham treatment or no treatment.

We often do not have precise information about side effects and complications. This is particularly true for rare but serious side effects. 

What is osteoarthritis and what is joint lavage

Osteoarthritis (OA) is the most common form of arthritis that can affect the hands, hips, and knees. In OA, the cartilage breaks down and may cause swelling and consecutive pain. OA can occur in different areas of the knee or the whole knee. When the cartilage breaks down, bits of tissue are left around the knee joint, which can add to the inflammation and prevent the joint from working properly. 
Joint lavage means to wash out any loose tissue or debris from inside the joint space. It involves temporally inserting small tubes into 1 or more entry points into the knee.

This systematic review discusses three types of joint lavage. Tidal irrigation joint lavage uses only one entry point to alternately inject fluid, and then draw it out.   Non-arthroscopic joint lavage uses two entry points, one to inject the fluid and a separate one for the withdrawal of the fluid, but no visual inspection of the knee is performed.  Arthroscopic joint lavage is a formal joint lavage in addition to a visually inspection of the knee joints structures as this is done.

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