Controlled Trials for Arthroscopic Surgery
for
Osteoarthritis of the Knee
Surgery to Trim Cartilage in the Knee
osteoarthrits,arthroscopic surrgery,reseach,study,clinical,Knee condition,knee pain,trial controlled,
J. Bruce Moseley, M.D., Kimberly O'Malley, Ph.D., Nancy J.
Petersen, Ph.D., Terri J. Menke, Ph.D., Baruch A. Brody, Ph.D., David H. Kuykendall,
Ph.D., John C. Hollingsworth, Dr.P.H., Carol M. Ashton, M.D., M.P.H., and Nelda P. Wray,
M.D., M.P.H.
ABSTRACT
Background Many patients report symptomatic
relief after undergoing arthroscopy of the knee for osteoarthritis, but it is
unclear how the procedure achieves this result. We conducted a randomized,
placebo-controlled trial to evaluate the efficacy of arthroscopy for
osteoarthritis of the knee.
Methods
A total of 180 patients with osteoarthritis of the knee were randomly
assigned to receive arthroscopic débridement, arthroscopic lavage, or placebo
surgery. Patients in the placebo group received skin incisions and underwent a
simulated débridement without insertion of the arthroscope. Patients and
assessors of outcome were blinded to the treatment-group assignment. Outcomes
were assessed at multiple points over a 24-month period with the use of
five self-reported scores — three on scales for pain and two on scales for
function — and one objective test of walking and stair climbing. A total
of 165 patients completed the trial.
Results
At no point did either of the intervention groups report less pain or
better function than the placebo group. For example, mean (±SD) scores on the
Knee-Specific Pain Scale (range, 0 to 100, with higher scores indicating more
severe pain) were similar in the placebo, lavage, and débridement groups:
48.9±21.9, 54.8±19.8, and 51.7±22.4, respectively, at one year (P=0.14
for the comparison between placebo and lavage; P=0.51 for the comparison
between placebo and débridement) and 51.6±23.7, 53.7±23.7, and 51.4±23.2,
respectively, at two years (P=0.64 and P=0.96, respectively). Furthermore,
the 95 percent confidence intervals for the differences between the placebo
group and the intervention groups exclude any clinically meaningful difference.
Conclusions In this controlled trial
involving patients with osteoarthritis of the knee, the outcomes after
arthroscopic lavage or arthroscopic débridement were no better than those
after a placebo procedure.
Source Information
From the Houston Veterans Affairs Medical Center
(J.B.M., K.O., N.J.P., T.J.M., D.H.K., C.M.A., N.P.W.); the Department of Orthopedic
Surgery (J.B.M.), the Department of Medicine, Section of Health Services Research (K.O.,
N.J.P., T.J.M., C.M.A., N.P.W.), and the Center for Medical Ethics and Health Policy
(B.A.B.), Baylor College of Medicine; and International Survey Research (D.H.K.) —
all in Houston; and the Laguna Honda Hospital, San Francisco (J.C.H.).
Address reprint requests to Dr. Wray at the Section of
Health Services Research, Baylor College of Medicine, 2002 Holcombe Blvd. (M.R. 152),
Houston, TX 77030, or at nwray@bcm.tmc.edu.
1259 -- 7/11/02
ARTHROSCOPIC KNEE SURGERY IS USUALLY USELESS
I have said repeatedly that surgery to trim cartilage in the knee is worthless. I have seen many patients who have had cartilage removed by surgeons for an average charge of $5000 and then they must have a knee replacement several years later. The surgeon must know about the harm he is doing because he has to see his patients for followup, when many of them require knee replacement surgery.
Now a report in the New England Journal of Medicine shows that knee surgery to remove cartilage is worse than doing nothing. The headline from Baylor Medical School, where the landmark study was performed, is that "Study Finds Common Knee Surgery No Better Than Placebo." Patients with osteoarthritis of the knee who underwent placebo arthroscopic surgery were just as likely to report pain relief as those who received the real procedure. The researchers say their results challenge the usefulness of one of the most common surgical procedures performed for osteoarthritis of the knee. Lead investigator Dr. Elda P. Way states, "The fact that the effectiveness of arthroscopic lavage or debridement in patients with osteoarthritis of the knee is no greater than that of placebo surgery makes us question whether the one billion plus dollars spent on these procedures might not be put to better use,"
In the study, 180 patients with knee pain were randomized into three groups. One group received debridement, in which worn, torn, or loose cartilage is cut away and removed with the aid of a pencil-thin viewing tube called an arthroscope. The second group underwent arthroscopic lavage, in which loose cartilage is flushed out. The third group underwent simulated arthroscopic surgery; small incisions were made, but no instruments were inserted and no cartilage removed. The people who did not have surgery on their cartilage did better than the people who had some of their cartilage removed.
In the United States, more than 650,000 arthroscopic debridement or lavage procedures are performed each year, at a cost of about $5,000 each. The knee is just two sticks held together by four bands called ligaments. Bones are soft, so the ends of bones are covered with a hard gristle called cartilage. Cartilage serves as a padding to protect the ends of bones. Once cartilage is broken, it can never heal. And once you break a small amount of cartilage in your knee, your knee cartilage can never fit together properly, and every time you put force on the knee, you break off more cartilage.
When surgeons remove cartilage, they leave less cartilage than the person had before the surgery. Eventually the knee joint runs out of cartilage and when bone rubs on bone, it hurts all the time and a peson must have a knee replacement just to be able to sleep at night. Surgery to remove cartilage just hastens knee replacement. On the other hand, doctors can replace torn ligaments, which stabilizes the knee joint. They can remove a loose piece that is blocking the movement of the joint. People with loose cartilage have sudden locking of the knee when they walk or the cannot fully straighten or bend their knees.
As a result of this study and my own impression from treating hundreds of damaged knees, I recommend that you do not get knee surgery unless you have a torn ligament that needs to be repaired or you have sudden locking of the knee during walking or you cannot fully straighten or bend you knee. Otherwise surgery is likely to hasten your need for another surgery, knee replacement.
NEJM July 11, 2002
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