This document addresses the use of arthroscopic lavage and arthroscopic debridement procedures for the treatment of individuals with osteoarthritis of the knee.

Medically Necessary: 

The use of arthroscopic lavage and arthroscopic debridement is considered medically necessary when used to treat painful osteoarthritis of the knee only when the presence of a concomitant surgically correctable lesion is confirmed by physical examination, MRI, x-ray, or at the time of arthroscopy. (Examples of such surgically correctable lesions include, but are not limited to chondral or meniscal defects or intrarticular loose body.)

Not Medically Necessary:  

The use of arthroscopic lavage and arthroscopic debridement for the treatment of individuals with osteoarthritis of the knee is considered not medically necessary when the presence of a surgically correctable lesion is not documented.

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

Future ICD-10 coding (effective 10/01/2013)
A draft of ICD-10 Coding related to this document, as it might look today, is available for reference and comments at: Appendix 1: Future ICD-10 coding

Despite the presence of only weak evidence based upon case series studies, the use of arthroscopic lavage and arthroscopic debridement for the treatment of osteoarthritis of the knee has become widespread.  Only after this procedure became widely used have the results of more rigorous randomized controlled trials focusing on the efficacy of these procedures been reported.

The first of several multicenter, randomized, controlled studies was published in 1999 (Ravaud, 1999).  This study assessed the effectiveness of joint lavage and intra-articular steroid injection, alone and in combination, in the treatment of individuals with symptomatic knee osteoarthritis (OA) compared to placebo.  This study included 91 subjects who were randomized to one of four treatment groups: (1) intra-articular placebo injection, (2) intra-articular corticosteroids, (3) joint lavage and placebo injection, and (4) joint lavage and corticosteroid injection.  This study had a 6 month follow-up period. The authors reported no interaction between steroid injection and joint lavage; and joint lavage significantly improved pain scores. Interestingly, corticosteroid injection had no long-term effects.  Based upon Lequesne's functional index, no significant improvement in function was identified at week 4 for any of the 4 groups.

Another multicenter, randomized trial published by Kalunian and colleagues in 2000 examined arthroscopic lavage for individuals with early OA of the knee.  In this double-blind study, 90 individuals were randomized to receive either arthroscopic lavage with 3000 ml of normal saline or lavage with only 250 ml, the minimum volume needed to perform arthroscopy.  The latter group acted as the control group.  The findings of the study indicated that there were no significant differences in arthritis severity between treatment groups based upon Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores at 12 months.

In what is probably the most well known study on this topic, a paper published in the New England Journal of Medicine by Moseley and colleagues in 2002 described a randomized, double blind, placebo-controlled trial addressing the effectiveness of arthroscopy for OA of the knee.  This trial consisted of 180 subjects with OA of the knee who were randomly assigned to receive arthroscopic debridement, arthroscopic lavage, or placebo surgery. The placebo group involved skin incisions and a simulated debridement procedure without insertion of an arthroscope into the joint space.  At the end of the 2 year follow-up period, 165 individuals completed the trial. Throughout the trial, no significant differences were detected between the groups in regard to pain or function. These authors concluded that neither arthroscopic lavage nor arthroscopic debridement were significantly better than placebo for the treatment of OA of the knee.

Another study published in 2002 reported the results of a sham-controlled, randomized, double-blinded study of the effectiveness of arthroscopic lavage vs. sham lavage for OA of the knee in 180 people.  At the end of the 12 month follow-up period the author reported finding no differences between the effects of lavage and sham lavage procedures (Bradley, 2002).

As a result of the findings in 2002 and earlier, the Centers for Medicare and Medicaid Services (CMS) convened an analysis group of medical experts in the field to discuss the medical evidence and to determine the potential benefits of arthroscopic lavage and arthroscopic debridement. This analysis group included representatives from many well known and respected knee-related medical specialty societies including: American Academy of Orthopaedic Surgeons (AAOS), American Association of Hip and Knee Surgeons (AAHKS), Arthroscopy Association of North America (AANA), American Orthopaedic Society of Sports Medicine (AOSSM), and the Knee Society.  As a result of the discussions of this analysis group, CMS issued a national non-coverage determination for arthroscopic lavage and for specific applications of arthroscopic debridement. The determination states that arthroscopic lavage alone is not reasonable and necessary for people with OA of the knee; and that arthroscopic debridement is not reasonable and necessary for individuals presenting with knee pain only or with severe OA (Outerbridge classification III or IV).

More recent evidence from Kirkley and colleagues continues to support this position (2008).  This group published the results of a randomized clinical trial of 172 subjects with OA.  The authors reported that at the two year follow-up, as well as at interim measurements, there were no significant differences detected in terms of WOMAC score or quality of life measure (SF-36) between the group that received arthroscopic Debridement and Lavage combined with optimized medical care when compared to the group who received optimized medical care alone.

Finally, in their 2009 guideline for the treatment of osteoarthritis of the knee (non-arthroplasty), the American Academy of Orthopedic Surgeons (AAOS) states: "We recommend against performing arthroscopy with débridement or lavage in patients with a primary diagnosis of symptomatic OA of the knee."  The text accompanying this recommendation adds that "none of the evidence we examined specifically included patients who had a primary diagnosis of meniscal tear, loose body, or other mechanical derangement and who also had concomitant diagnosis of OA of the knee, and the present recommendation does not apply to such patients." This recommendation is supported with level I and II evidence and a Grade Recommendation of "A".

Peer Reviewed Publications:

1. Bradley JD, Heilman DK, Katz BP, et al. Tidal irrigation as treatment for knee osteoarthritis: a sham-controlled, randomized, double-blinded evaluation. Arthritis Rheum. 2002; 46(1):100-108.
2. Dervin GF, Stiell IG, Rody K, Grabowski J. Effect of arthroscopic debridement for osteoarthritis of the knee on health-related quality of life. J Bone Joint Surg Am. 2003; 85-A(1):10-19.
3. Jackson RW, Dieterichs C. The results of arthroscopic lavage and debridement of osteoarthritic knees based on the severity of degeneration: a 4- to 6-year symptomatic follow-up. Arthroscopy. 2003; 19(1):13-20.
4. Kalunian KC, Moreland LW, Klashman DJ, et al. Visually-guided irrigation in patients with early knee osteoarthritis: a multicenter randomized, controlled trial. Osteoarthritis Cartilage. 2000; 8(6):412-418.
5. Kirkley A, Birmingham TB, Litchfield RB, et al. A randomized trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2008; 359(11):1097-1107
6. Marx RG.  Arthroscopic surgery for osteoarthritis of the knee? N Engl J Med. 2008; 359(11):1169-1170.
7. Moseley JB, O'Malley K, Petersen NJ, et al.  A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2002; 347(2):81-88.
8. Ravaud P, Moulinier L, Giraudeau B, et al. Effects of joint lavage and steroid injection in patients with osteoarthritis of the knee: results of a multicenter, randomized, controlled trial. Arthritis Rheum. 1999; 42(3):475-482.
9. Wai EK, Kreder HJ, Williams JI.  Arthroscopic debridement of the knee for osteoarthritis in patients fifty years of age or older: utilization and outcomes in the Province of Ontario.  J Bone Joint Surg Am. 2002; 84-A(1):17-22.

Government Agency; Medical Society; and other Authoritative Publications:

1. Centers for Medicare and Medicaid Services. Arthroscopic Surgery and Osteoarthritis of the Knee. A report for the Centers for Medicare and Medicaid Services, Coverage Analysis group. December 2002. Available at: http://www.cms.hhs.gov/determinationprocess/downloads/id7a.pdf. Accessed on June 15, 2011.
2. Centers for Medicare and Medicaid Services. National Coverage Determination: Arthroscopic Lavage and Arthroscopic Debridement for the Osteoarthritic Knee. NCD #150.9. Effective June 11, 2004. Available at: http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=150.9&ncd_version=1&basket=ncd%3A150%2E9%3A1%3AArthroscopic+Lavage+and+Arthroscopic+Debridement+for+the+Osteoarthritic+Knee. Accessed on June 15, 2011.
3. Laupattarakasem W, Laopaiboon M, Laupattarakasem P, Sumananont C. Arthroscopic debridement for knee osteoarthritis. Cochrane Database Syst Rev. 2008; (1]: CD005118.
4. Richmond J, Hunter D, Irrgang J, et al; American Academy of Orthopedic Surgeons. Treatment of osteoarthritis of the knee (non-arthroplasty). J Am Acad Orthop Surg. 2009; 17(9):591-600.
5. Reichenbach S, Rutjes AWS, Nüesch E, et al. Joint lavage for osteoarthritis of the knee. Cochrane Database Syst Rev. 2010; [5]: CD007320.

Debridement
Knee
Lavage
Osteoarthritis