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Research disputes effectiveness of arthroscopic surgery for knee OA

Investigator suggests judicious use of arthroscopy in patients with X-ray evidence of degeneration.

A new study finds that arthroscopic surgery provides no additional benefit to physical therapy and medication for the treatment of knee osteoarthritis.

In a randomized trial, investigators from the University of Western Ontario studied 178 community-based patients who received physical therapy and medications for knee osteoarthritis (OA). In addition, 86 of the patients also underwent lavage and arthroscopic debridement. The study group had an average age of 60 years and included patients with Kellgren-Lawrence Grade II to IV OA, but did not have Grade IV OA in multiple compartments.

During the 2-year follow-up, the investigators found that both groups showed improvements in joint pain relief, function and stiffness at several time intervals. However, the study revealed no additional benefit in the surgically-treated group.

“The take-home message is for patients with X-ray evidence of moderate to severe arthritis of the knee, arthroscopy added no clinical benefit over and above best medical and physical therapy management,” study co-author, Robert B. Litchfield, MD, FRCSC, told Orthopedics Today.

Medication, therapy

“I would suggest that surgeons become a little more judicious in their use of arthroscopy when X-ray evidence of arthritis is present.”
— Robert B. Litchfield, MD, FRCSC

The study, which was published in the New England Journal of Medicine (NEJM), was conducted from 1999 to 2007, excluded patients with more than 5· of varus or valgus malalignment. Overall, 58 cases were excluded from the study, including: 18 cases of advanced disease, seven that had a recent arthroscopy, 13 meniscal tears, 10 with more than 5· of varus or valgus malalignment and 10 that were asymptomatic.

About 50% of patients received anti-inflammatories and over-the-counter analgesics, while the other half received intra-articular injections of either a corticosteroid or hyaluronic acid product. Both groups had 12 weeks of physiotherapy and were seen by a physiotherapist once a week. The patients were also given a home exercise program for the duration of the study.

The investigators found that the surgical group had a mean WOMAC score of 874±624 at 2 years, while the conservative group had a score of 897±583. The groups also showed mean SF-36 physical component summary scores of 37±11.4 and 37±10.6, respectively.

“I would suggest that surgeons become a little more judicious in their use of arthroscopy when X-ray evidence of arthritis is present, and they think about other options,” Litchfield said.

No co-existing lesions

“It is the intent of all arthroscopic surgeons to improve patient symptoms, not reap economic benefits by performing placebo surgery.”
— Jack M. Bert, MD

Robert G. Marx, MD, who wrote an NEJM editorial on the research, said that the study confirms that arthroscopy is not the ideal treatment for OA without a co-existing lesion.

“They essentially excluded patients who they believed had a large meniscal tear based on clinical or MRI findings (and therefore a good prognosis with surgery) and operated on them, leaving patients with inferior prognoses to be randomized to either surgery or no surgery,” he said.

In response to the NEJM article, Jack M. Bert, MD, president of the Arthroscopy Association of North America (AANA), said it is simply “old news.”

“Moseley’s article published in 2002 comparing sham operations to debridement, although widely criticized for violating multiple statistical requirements, led the Centers for Medicare & Medicaid Services (CMS) to disallow the index code for arthroscopic debridement in Medicare patients for pain alone or those with severe arthritis,” said Bert, who is also the section editor of Orthopedics Today’s The Business of Orthopedics section.

Citing years of research

He said a review he performed with Drogt of 102 articles dating back 50 years comparing the treatment of OA of the knee to various placebos, injections, application of electrical fields, topical creams, oral analgesics, vitamins, physical therapy and sham surgical procedures vs. joint lavage and debridement was presented at the American Academy of Orthopaedic Surgeons Annual Meeting in 2004.

Jack M. Bert, MD
Jack M. Bert

“In 72% of the articles, placebo treatment resulted in a minimum of 30% and up to 70% improvement in pain symptoms when measured by pre and post-treatment subjective pain evaluations,” he told Orthopedics Today. “Oral, parenteral, as well as surgical sham procedures all improved pain scores in the majority of patients with arthritic pain. Therefore, if placebo and conservative modalities for the treatment of OA of the knee are beneficial in a significant patient population, under what circumstances, if any, is arthroscopic intervention ever indicated in the elderly arthritic patient?”

Clinical proof for older patients

Bert said the literature confirms clinical improvement in the older patient or the patient with OA status post (S/P) knee arthroscopy when there is a torn meniscus with mechanical symptoms, loose bodies within the knee, or loose articular cartilage fragments.

In one 2002 study by Bohnsack there were symptoms at 5.4 years in 81% of patients with significant X-ray changes. Also, McGinley in 1999 reported that in patients with dramatic X-ray changes, 67% did not proceed to TKA at a mean of 10 years S/P debridement, with postop patients satisfaction scores recorded as 8.6 out of 10, Bert noted.

In other research, Ramappa at the 2005 AANA meeting presented that 83% of patients were able to postpone TKA more than 3 years S/P debridement. “Also, I reported on 16 published series from 1974 to 2007 ranging from 43 to 441 knees, success rates varied from 50% to 80% at the Metcalf Meeting in 2006,” he said.

Bert also said that in 2002 Hunt reported specific outcome predictors that caused poor results after debridement, which included significant malalignment, restricted range of motion, prior surgery and severe OA. Fond noted in 2002 that the predictors of improved outcomes S/P debridement are preoperative mechanical symptoms resulting from loose bodies or meniscal tears and X-ray evidence of mild articular degeneration.

‘Symptomatic meniscectomy’

“This article in no way condemns the dramatic benefits to knee arthroscopy in the vast majority of the things we do.”
— Robert B. Litchfield, MD, FRCSC

Meanwhile, in 2003, Pearse concluded that “symptomatic meniscectomy” in patients with associated severe degenerative disc disease resulted in improved symptoms initially and caused a prolongation of the need for further surgery, and did not hasten the progression of OA in these patients, according to Bert.

“The conclusions that one can draw from reviewing the literature, therefore, is that in joints without mechanical symptoms, repairing stable meniscal tears and debriding the arthritic joint is probably not indicated,” he said. “As Dervin noted in 2003, the three clinical variables significantly associated with improvement after arthroscopic debridement are medial joint line tenderness indicating a symptomatic torn meniscus, a positive Steinman test indicating a torn meniscus and finally the presence of an unstable meniscal tear at the time of arthroscopy.”

“Therefore, in joints with mechanical symptoms, including locking, catching or giving way, arthroscopic removal of loose bodies, chondral flaps and/or unstable meniscal tissue, debridement of the arthritic joint improves symptoms, prolongs the need for TKA and clearly is indicated,” Bert said.

Medicare patients

Finally, the number of Medicare patients requiring arthroscopic surgery of the knee is increasing simply because of the higher activity level of older patients and increasing numbers of patients over the age of 65 who develop symptoms of internal derangement, he said.

“It is the intent of all arthroscopic surgeons to improve patient symptoms, not reap economic benefits by performing placebo surgery,” Bert added. “In the elderly patient who has improved with arthroscopic surgery [to treat] preoperative symptoms indicative of internal derangement, we as orthopedic surgeons should feel proud that we have achieved that goal, and the published literature clearly supports this treatment approach.”

Litchfield countered that the NEJM research does not diminish the impact of knee arthroscopy.

“I’d like to emphasize that there is so much good with knee arthroscopy,” he said. “It’s revolutionized our ability to care for so many conditions. This article in no way condemns the dramatic benefits to knee arthroscopy in the vast majority of the things we do.”

For more information:

  • Robert B. Litchfield, MD, FRCSC, can be reached at the Fowler Kennedy Sport Medicine Clinic, 3M Centre, University of Western Ontario, London, ON N6A 3K7, Canada; 519-663-3033; e-mail: rlitchf@uwo.ca. He has indicated that The Canadian Institutes of Health Research provided study funding.
  • Jack M. Bert, MD, can be reached at Summit Orthopedics Ltd., 17 West Exchange St., Suite 307, St. Paul, MN 55102; 651-842-5220; e-mail: bertx001@tc.umn.edu.
  • Robert G. Marx, MD, can be reached at the Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021; 212-606-1645; email: MarxR@HSS.EDU. He has indicated that he receives research or institutional support form Arthrex and Smith&Nephew.

References:

  • Bohnsack M, Lipka W, Rühmann O, et al. The value of knee arthroscopy in patients with severe radiological osteoarthritis. Arch Orthop Trauma Surg. 2002;122(8):451-453.
  • 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(1):156-157.
  • Fond J, Rodin D, Ahmad S, Nirschl RP. Arthroscopic debridement for the treatment of osteoarthritis of the knee: 2- and 5-year results. Arthroscopy. 2002;(8):829-834.
  • Hunt SA, Jazrawi LM, Sherman OH. Arthroscopic management of osteoarthritis of the knee. J Am Acad Orthop Surg. 2002;10:356-363.
  • Kirkley A, Birmingham TB, Litchfield RB, et al. A randomized trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2008;359:1097-1107.
  • Marx RG. Arthroscopic surgery for osteoarthritis of the knee? N Engl J Med. 2008;359:1169-1170.
  • McGinley BJ, Cushner FD, Scott WN. Debridement arthroscopy. 10-year follow-up. Clin Orthop Relat Res. 1999;(367):190-194.
  • 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.
  • Pearse EO, Craig DM. Partial meniscectomy in the presence of severe osteoarthritis does not hasten the symptomatic progression of osteoarthritis. Arthroscopy. 2003;19(9):963-968.

A new study finds that arthroscopic surgery provides no additional benefit to physical therapy and medication for the treatment of knee osteoarthritis.

In a randomized trial, investigators from the University of Western Ontario studied 178 community-based patients who received physical therapy and medications for knee osteoarthritis (OA). In addition, 86 of the patients also underwent lavage and arthroscopic debridement. The study group had an average age of 60 years and included patients with Kellgren-Lawrence Grade II to IV OA, but did not have Grade IV OA in multiple compartments.

During the 2-year follow-up, the investigators found that both groups showed improvements in joint pain relief, function and stiffness at several time intervals. However, the study revealed no additional benefit in the surgically-treated group.

“The take-home message is for patients with X-ray evidence of moderate to severe arthritis of the knee, arthroscopy added no clinical benefit over and above best medical and physical therapy management,” study co-author, Robert B. Litchfield, MD, FRCSC, told Orthopedics Today.

Medication, therapy

“I would suggest that surgeons become a little more judicious in their use of arthroscopy when X-ray evidence of arthritis is present.”
— Robert B. Litchfield, MD, FRCSC

The study, which was published in the New England Journal of Medicine (NEJM), was conducted from 1999 to 2007, excluded patients with more than 5· of varus or valgus malalignment. Overall, 58 cases were excluded from the study, including: 18 cases of advanced disease, seven that had a recent arthroscopy, 13 meniscal tears, 10 with more than 5· of varus or valgus malalignment and 10 that were asymptomatic.

About 50% of patients received anti-inflammatories and over-the-counter analgesics, while the other half received intra-articular injections of either a corticosteroid or hyaluronic acid product. Both groups had 12 weeks of physiotherapy and were seen by a physiotherapist once a week. The patients were also given a home exercise program for the duration of the study.

The investigators found that the surgical group had a mean WOMAC score of 874±624 at 2 years, while the conservative group had a score of 897±583. The groups also showed mean SF-36 physical component summary scores of 37±11.4 and 37±10.6, respectively.

“I would suggest that surgeons become a little more judicious in their use of arthroscopy when X-ray evidence of arthritis is present, and they think about other options,” Litchfield said.

No co-existing lesions

“It is the intent of all arthroscopic surgeons to improve patient symptoms, not reap economic benefits by performing placebo surgery.”
— Jack M. Bert, MD

Robert G. Marx, MD, who wrote an NEJM editorial on the research, said that the study confirms that arthroscopy is not the ideal treatment for OA without a co-existing lesion.

“They essentially excluded patients who they believed had a large meniscal tear based on clinical or MRI findings (and therefore a good prognosis with surgery) and operated on them, leaving patients with inferior prognoses to be randomized to either surgery or no surgery,” he said.

In response to the NEJM article, Jack M. Bert, MD, president of the Arthroscopy Association of North America (AANA), said it is simply “old news.”

“Moseley’s article published in 2002 comparing sham operations to debridement, although widely criticized for violating multiple statistical requirements, led the Centers for Medicare & Medicaid Services (CMS) to disallow the index code for arthroscopic debridement in Medicare patients for pain alone or those with severe arthritis,” said Bert, who is also the section editor of Orthopedics Today’s The Business of Orthopedics section.

Citing years of research

He said a review he performed with Drogt of 102 articles dating back 50 years comparing the treatment of OA of the knee to various placebos, injections, application of electrical fields, topical creams, oral analgesics, vitamins, physical therapy and sham surgical procedures vs. joint lavage and debridement was presented at the American Academy of Orthopaedic Surgeons Annual Meeting in 2004.

Jack M. Bert, MD
Jack M. Bert

“In 72% of the articles, placebo treatment resulted in a minimum of 30% and up to 70% improvement in pain symptoms when measured by pre and post-treatment subjective pain evaluations,” he told Orthopedics Today. “Oral, parenteral, as well as surgical sham procedures all improved pain scores in the majority of patients with arthritic pain. Therefore, if placebo and conservative modalities for the treatment of OA of the knee are beneficial in a significant patient population, under what circumstances, if any, is arthroscopic intervention ever indicated in the elderly arthritic patient?”

Clinical proof for older patients

Bert said the literature confirms clinical improvement in the older patient or the patient with OA status post (S/P) knee arthroscopy when there is a torn meniscus with mechanical symptoms, loose bodies within the knee, or loose articular cartilage fragments.

In one 2002 study by Bohnsack there were symptoms at 5.4 years in 81% of patients with significant X-ray changes. Also, McGinley in 1999 reported that in patients with dramatic X-ray changes, 67% did not proceed to TKA at a mean of 10 years S/P debridement, with postop patients satisfaction scores recorded as 8.6 out of 10, Bert noted.

In other research, Ramappa at the 2005 AANA meeting presented that 83% of patients were able to postpone TKA more than 3 years S/P debridement. “Also, I reported on 16 published series from 1974 to 2007 ranging from 43 to 441 knees, success rates varied from 50% to 80% at the Metcalf Meeting in 2006,” he said.

Bert also said that in 2002 Hunt reported specific outcome predictors that caused poor results after debridement, which included significant malalignment, restricted range of motion, prior surgery and severe OA. Fond noted in 2002 that the predictors of improved outcomes S/P debridement are preoperative mechanical symptoms resulting from loose bodies or meniscal tears and X-ray evidence of mild articular degeneration.

‘Symptomatic meniscectomy’

“This article in no way condemns the dramatic benefits to knee arthroscopy in the vast majority of the things we do.”
— Robert B. Litchfield, MD, FRCSC

Meanwhile, in 2003, Pearse concluded that “symptomatic meniscectomy” in patients with associated severe degenerative disc disease resulted in improved symptoms initially and caused a prolongation of the need for further surgery, and did not hasten the progression of OA in these patients, according to Bert.

“The conclusions that one can draw from reviewing the literature, therefore, is that in joints without mechanical symptoms, repairing stable meniscal tears and debriding the arthritic joint is probably not indicated,” he said. “As Dervin noted in 2003, the three clinical variables significantly associated with improvement after arthroscopic debridement are medial joint line tenderness indicating a symptomatic torn meniscus, a positive Steinman test indicating a torn meniscus and finally the presence of an unstable meniscal tear at the time of arthroscopy.”

“Therefore, in joints with mechanical symptoms, including locking, catching or giving way, arthroscopic removal of loose bodies, chondral flaps and/or unstable meniscal tissue, debridement of the arthritic joint improves symptoms, prolongs the need for TKA and clearly is indicated,” Bert said.

Medicare patients

Finally, the number of Medicare patients requiring arthroscopic surgery of the knee is increasing simply because of the higher activity level of older patients and increasing numbers of patients over the age of 65 who develop symptoms of internal derangement, he said.

“It is the intent of all arthroscopic surgeons to improve patient symptoms, not reap economic benefits by performing placebo surgery,” Bert added. “In the elderly patient who has improved with arthroscopic surgery [to treat] preoperative symptoms indicative of internal derangement, we as orthopedic surgeons should feel proud that we have achieved that goal, and the published literature clearly supports this treatment approach.”

Litchfield countered that the NEJM research does not diminish the impact of knee arthroscopy.

“I’d like to emphasize that there is so much good with knee arthroscopy,” he said. “It’s revolutionized our ability to care for so many conditions. This article in no way condemns the dramatic benefits to knee arthroscopy in the vast majority of the things we do.”

For more information:

  • Robert B. Litchfield, MD, FRCSC, can be reached at the Fowler Kennedy Sport Medicine Clinic, 3M Centre, University of Western Ontario, London, ON N6A 3K7, Canada; 519-663-3033; e-mail: rlitchf@uwo.ca. He has indicated that The Canadian Institutes of Health Research provided study funding.
  • Jack M. Bert, MD, can be reached at Summit Orthopedics Ltd., 17 West Exchange St., Suite 307, St. Paul, MN 55102; 651-842-5220; e-mail: bertx001@tc.umn.edu.
  • Robert G. Marx, MD, can be reached at the Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021; 212-606-1645; email: MarxR@HSS.EDU. He has indicated that he receives research or institutional support form Arthrex and Smith&Nephew.

References:

  • Bohnsack M, Lipka W, Rühmann O, et al. The value of knee arthroscopy in patients with severe radiological osteoarthritis. Arch Orthop Trauma Surg. 2002;122(8):451-453.
  • 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(1):156-157.
  • Fond J, Rodin D, Ahmad S, Nirschl RP. Arthroscopic debridement for the treatment of osteoarthritis of the knee: 2- and 5-year results. Arthroscopy. 2002;(8):829-834.
  • Hunt SA, Jazrawi LM, Sherman OH. Arthroscopic management of osteoarthritis of the knee. J Am Acad Orthop Surg. 2002;10:356-363.
  • Kirkley A, Birmingham TB, Litchfield RB, et al. A randomized trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2008;359:1097-1107.
  • Marx RG. Arthroscopic surgery for osteoarthritis of the knee? N Engl J Med. 2008;359:1169-1170.
  • McGinley BJ, Cushner FD, Scott WN. Debridement arthroscopy. 10-year follow-up. Clin Orthop Relat Res. 1999;(367):190-194.
  • 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.
  • Pearse EO, Craig DM. Partial meniscectomy in the presence of severe osteoarthritis does not hasten the symptomatic progression of osteoarthritis. Arthroscopy. 2003;19(9):963-968.