Arthroscopy For Knee Arthritis Treatment Doesn't Work

Arthroscopy
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A new study in the New England Journal of Medicine shows that arthroscopic surgery with debridement to "clean up" an arthritic knee was of no more benefit than Advil or Tylenol and physical therapy in men and women with osteoarthritis. The same findings were reported in 2002 in a large study done by the Department of Veterans Affairs, but orthopedic surgeons have continued performing the surgery as a treatment for chronic knee pain in patients with osteoarthritis.

The following quote is from the abstract of A Randomized Trial of Arthroscopic Surgery for Osteoarthritis of the Knee published in NEJM.

"We conducted a single-center, randomized, controlled trial of arthroscopic surgery in patients with moderate-to-severe osteoarthritis of the knee. Patients were randomly assigned to surgical lavage and arthroscopic débridement together with optimized physical and medical therapy or to treatment with physical and medical therapy alone. The primary outcome was the total Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score (range, 0 to 2400; higher scores indicate more severe symptoms) at 2 years of follow-up. Secondary outcomes included the Short Form-36 (SF-36) Physical Component Summary score (range, 0 to 100; higher scores indicate better quality of life).

"Results Of the 92 patients assigned to surgery, 6 did not undergo surgery. Of the 86 patients assigned to control treatment, all received only physical and medical therapy. After 2 years, the mean (±SD) WOMAC score for the surgery group was 874±624, as compared with 897±583 for the control group (absolute difference [surgery-group score minus control-group score], –23±605; 95% confidence interval [CI], –208 to 161; P=0.22 after adjustment for baseline score and grade of severity). The SF-36 Physical Component Summary scores were 37.0±11.4 and 37.2±10.6, respectively (absolute difference, –0.2±11.1; 95% 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."

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Despite two prominent studies that have proven no benefit from arthroscopic surgery for knee osteoarthritis, it is doubtful that orthopedic surgeons will decrease the number of procedures. The clinical indications for arthroscopic knee surgery are numerous and patients with pain will almost always fit into one of them:

* Suspected ligament tear
* Damaged meniscus cartilage
* Evidence of bone fragments from a fracture
* Joint pain from an injury
* Unexplainable joint pain
* Lesions or other problems detected by x-rays
* Joint disease
* A need for joint surgery

Patients also often have unrealistic expectations of what surgery can do for them. Because arthroscopic surgery is often so helpful in athletes with injuries, patients with abnormalities on MRI scans believe they, too, can be relieved of chronic pain with surgery.

However, studies have shown that patients with osteoarthritis often have meniscus tears and other joint abnormalities that have nothing to do with their pain and they do not respond to surgery.

Treatment for arthritic knee pain can be challenging for both doctors and patients. Studies such as these should limit unnecessary and costly surgery when it will add no value.

Toni Brayer, MD

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Comments

The result is interesting in a negative sense (what may not be worth doing), but a constructive reference of some sort (what may be worth doing) for either the present or near future - would be more helpful.
Any chances that Dr. Brayer could explain the results of the study leading to the Dr's article: "Arthroscopy For Knee Arthritis Treatment Doesn't Work" Please explain the meaning of these to lay persons: "Results Of the 92 patients assigned to surgery, 6 did not undergo surgery. Of the 86 patients assigned to control treatment, all received only physical and medical therapy. After 2 years, the mean (±SD) WOMAC score for the surgery group was 874±624, as compared with 897±583 for the control group (absolute difference [surgery-group score minus control-group score], –23±605; 95% confidence interval [CI], –208 to 161; P=0.22 after adjustment for baseline score and grade of severity). The SF-36 Physical Component Summary scores were 37.0±11.4 and 37.2±10.6, respectively (absolute difference, –0.2±11.1; 95% 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."
I will attempt to put the study results into understandable terms. The researchers had a surgery group that underwent arthroscopy and a control group that did not have surgery but had physical and medical therapy for their knee arthritis. The WOMAC score is a group of pain and function evaluations that were used to see if there was any benefit to the patient. Researchers need a standardized way of comparing the results of the two groups of patients and WOMAC is a way of standardizing so the comparisons are accurate and real. They followed all of the patients for two years and assessed their ongoing function using the WOMAC scoring. The statistical analysis that is commonly used in all good research showed that there was no superiority in doing surgery compared to physical therapy as a treatment. Hope that helps. TB
Yes, what "works" is important but it is also important to know that treatments we commonly use have no scientific evidence to support them. That is why we are no longer doing "blood-letting" or using "arsenic" as treatments, even though that was considered good medicine at the turn of last century! Much of what we do today will also be proven wrong or expensive and unnecessary and medicine needs to continue to change as evidence comes forth. This was an important study to help Orthopedic doctors change behavior. So what works for osteoarthritis of the knee? Weight loss if overweight. Strengthening of the muscles around the knee (quadracepts, hamstrings and calves). Biking, swimming or other non impact exercise. NSAIDs or aspirin for inflammation. Physical therapy and ice when inflamed. Total knee replacement when knees are really bad. Evidence shows that doctors hold off too long on suggesting knee replacements and the benefit of being pain free and getting back to active life should be done sooner, rather than later. Hope that helps. TB