Arthroscopic Knee Surgery Little Help for Arthritis
Studies finds common procedure may not help painful knees.
Arthroscopic knee surgery, the most commonly performed orthopaedic procedure in the United States, may only be effective for a narrow group of people with chronic knee pain according to the results of a study published in the December 26, 2013 issue of the New England Journal of Medicine (NEJM). The study was done in Finland and adds to earlier research that suggests the procedure may be unnecessary for most people with knee osteoarthritis.
What is Arthroscopy?
A surgeon inserts a narrow tube through a very small incision. The fiber-optic video camera attached to the tube allows to surgeon to see inside the joint and repair some types of joint damage with pencil-thin surgical instruments. This is done with small additional incisions rather than a large incision.
“The joint [with arthritis] can become full of all kinds of junk – cartilage, degrading materials and little strands of stuff and tiny tears in the meniscus and shards of things that are sometimes attached to the tissue," said David T. Felson, MD, MPH, a rheumatologist with the Boston University School of Medicine. "And the thinking was that if you cleaned that up, it would help the pain," he added.
According to the National Center for Health Statistics, more than 650,000 arthroscopic lavage and debridement (cleaning and smoothing) procedures are performed for knee pain each year in the United States, at an average cost of $5,000 each.
Studies Question Effectiveness of Procedure
Researchers at the University of Western Ontario randomly assigned 178 people with moderate to severe osteoarthritis of the knee to either arthroscopic surgery or to a combination of medications, supplements and physical therapy. After two years, both groups reported nearly the same levels of pain, stiffness and disability. The study was published in the September 11 2008 issue of the NEJM.
A 2008 review published by the Cochran Collaboration, a group of scientists based in the U.K. that reviews the evidence behind medical treatments, found that arthroscopic debridement was not an effective remedy for osteoarthritis of the knee.
Researchers at the Houston Veterans Affairs Medical Center reported the results of a study in which 180 patients with osteoarthritis were randomly assigned to one of three groups: treatment with arthroscopic surgery with lavage; treatment with arthroscopic debridement; or to placebo surgery, where doctors cut into the skin but perform a fake procedure.
The VA team found no difference in pain or function between the study participants who had arthroscopic procedures and those that had the sham surgery. Their study was published in the July 11, 2002 issue of the NEJM.
"They all show the same thing," said Claude T. Moorman III, MD, an orthopedic surgeon and sports medicine director at the Duke University Medical Center in Durham, NC. "If your outcomes measure is whether you cure arthritis or help pain, arthroscopy is not going to be your tool."
In cases where people with osteoarthritis experience certain functional problems, like a knee that suddenly locks up, or a joint that clicks and pops when they try to play sports – "not the grinding and crunching of chronic arthritis" – Dr. Moorman said, then arthroscopic knee surgery may be indicated to repair injured tissue.
But Dr. Moorman was quick to add that people with arthritis and their doctors should think very carefully about arthroscopic procedures because there is emerging evidence that they may make the condition worse.
"If you're really scoping a knee in a patient with significant arthritis," Dr. Mooman said," I think you have a 1 in 20 chance of making them worse."