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CME

Arthroscopic Surgery May Not Be Helpful for Knee Osteoarthritis

  • Authors: News Author: Laurie Barclay, MD
    CME Author: Hien T. Nghiem, MD
  • CME Released: 9/10/2008
  • THIS ACTIVITY HAS EXPIRED FOR CREDIT
  • Valid for credit through: 9/10/2009
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Target Audience and Goal Statement

This article is intended for primary care clinicians, orthopaedic specialists, and any other specialist who cares for patients with osteoarthritis of the knee.

The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

Upon completion of this activity, participants will be able to:

  1. Describe arthroscopic surgery.
  2. Compare optimized physical and medical therapy alone with arthroscopic treatment in addition to optimized physical and medical therapy.


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Author(s)

  • Laurie Barclay, MD

    Laurie Barclay, MD, is a freelance reviewer and writer for Medscape.

    Disclosures

    Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.

Editor(s)

  • Brande Nicole Martin

    Brande Nicole Martin is the News CME editor for Medscape Medical News.

    Disclosures

    Disclosure: Brande Nicole Martin has disclosed no relevant financial information.

CME Author(s)

  • Hien T Nghiem, MD

    Writer for Medscape Medical News

    Disclosures

    Disclosure: Hien T. Nghiem, MD, has disclosed no relevant financial relationships.


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CME

Arthroscopic Surgery May Not Be Helpful for Knee Osteoarthritis

Authors: News Author: Laurie Barclay, MD CME Author: Hien T. Nghiem, MDFaculty and Disclosures
THIS ACTIVITY HAS EXPIRED FOR CREDIT

CME Released: 9/10/2008

Valid for credit through: 9/10/2009

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September 10, 2008 — Arthroscopic surgery for knee osteoarthritis offers no added benefit to optimized physical and medical therapy, according to the results of a single-center, randomized controlled trial reported in the September 11 issue of the New England Journal of Medicine.

"The efficacy of arthroscopic surgery for the treatment of osteoarthritis of the knee is unknown," write Alexandra Kirkley, MD, from the University of Western Ontario in London, Canada, and colleagues. "Arthroscopic surgery, in which an arthroscope is inserted into the knee joint, allows for lavage, a procedure that removes particulate material such as cartilage fragments and calcium crystals. It also allows for debridement, whereby articular surfaces and osteophytes can be surgically smoothed."

Patients with moderate to severe osteoarthritis of the knee were randomly assigned to receive either surgical lavage and arthroscopic debridement, together with optimized physical and medical therapy, or treatment with physical and medical therapy alone. The main endpoint was the total Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score (range, 0 - 2400, with higher scores indicating greater symptom severity) at 2 years of follow-up. Secondary endpoints included the Short Form 36 (SF-36) Physical Component Summary score (range, 0 - 100, with higher scores indicating better quality of life).

Six of the 92 patients randomly assigned to surgery did not undergo surgery, but all 86 patients randomly assigned to the control group received physical and medical therapy alone. Mean WOMAC score after 2 years was 874 ± 624 for the surgery group and 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 = .22 after adjustment for baseline score and grade of severity).

The SF-36 Physical Component Summary scores also did not differ significantly between groups (37.0 ± 11.4 vs 37.2 ± 10.6; absolute difference, −0.2 ± 11.1; 95% CI, −3.6 to 3.2; P = .93). Analyses of WOMAC scores at interim visits and other secondary endpoints also did not demonstrate that surgery plus physical and medical therapy was superior to physical and medical therapy alone.

"Arthroscopic surgery for osteoarthritis of the knee provides no additional benefit to optimized physical and medical therapy," the study authors write.

Limitations of this study include possible bias because of the lack of a sham-surgery control and that only 68% of patients who were evaluated for participation were deemed eligible and assigned to treatment.

In an accompanying editorial, Robert G. Marx, MD, from Weill Medical College of Cornell University in New York City, warns that the lack of efficacy of arthroscopic surgery in this trial does not imply that it has no role in the treatment of patients who may have osteoarthritis and also another knee condition, such as a symptomatic meniscal tear.

"The study by Kirkley et al., combined with other evidence, indicates that osteoarthritis of the knee (in the absence of a history and physical examination suggesting meniscal or other findings) is not an indication for arthroscopic surgery and indeed has been associated with inferior outcomes after arthroscopic knee surgery," Dr. Marx writes. "However, osteoarthritis is not a contraindication to arthroscopic surgery, and arthroscopic surgery remains appropriate in patients with arthritis in specific situations in which osteoarthritis is not believed to be the primary cause of pain. Surgeons must practice evidence-based care and use sound clinical judgment to make the best decisions for individual patients."

The Canadian Institutes of Health Research supported this study. The authors have disclosed no relevant financial relationships.

N Engl J Med. 2008;359:1097-1107, 1169-1170.

Clinical Context

Osteoarthritis of the knee is a degenerative disease that causes joint pain, stiffness, and decreased function. Arthroscopic surgery has been widely used to treat this disease. It involves inserting an arthroscope into the knee joint, which allows for lavage, a procedure that removes particulate material such as cartilage fragments and calcium crystals. In addition, debridement occurs, allowing for articular surfaces and osteophytes to be surgically smoothed. Arthroscopic surgery results in reduced synovitis and eliminates mechanical interference with joint motion. At present, there is a lack of evidence to support arthroscopic surgery. No benefit of surgery has been demonstrated in a large-scale, randomized controlled trial.

The aim of this study was to evaluate the efficacy of arthroscopic surgery for the treatment of osteoarthritis.

Study Highlights

  • In this single-center, controlled trial, patients were randomly assigned to either surgical lavage and arthroscopic debridement together with optimized physical and medical therapy or to treatment with physical and medical therapy alone between January 1999 and August 2007.
  • Eligible patients were aged 18 years or older with idiopathic or secondary osteoarthritis of the knee with grade 2, 3, or 4 radiographic severity, as defined by the modified Kellgren-Lawrence classification.
  • Arthroscopic treatment was performed within 6 weeks after randomization, and physical and medical therapy followed 7 days after surgery.
  • For both groups, identical programs of physical therapy were provided for 1 hour once a week for 12 consecutive weeks. In addition, stepwise use of acetaminophen and nonsteroidal anti-inflammatory drugs and intraarticular injection of hyaluronic acid were advised.
  • The primary outcome was the total WOMAC score (range, 0 - 2400; higher scores indicate more severe symptoms) at 2 years of follow-up. A 20% improvement in the total WOMAC score was considered clinically important.
  • Secondary outcomes included the SF-36 Physical Component Summary score (range, 0 - 100; higher scores indicate better quality of life).
  • 92 patients were assigned to surgery; however, 6 did not undergo surgery. 86 patients were assigned to the control treatment of only physical and medical therapy.
  • Although the baseline characteristics of the groups were similar, patients assigned to surgery had slightly higher total WOMAC scores.
  • At 3 months, scores in the surgery group had improved to a greater extent than those in the control group, but there were no significant differences between the groups at any visits thereafter.
  • After 2 years, the mean WOMAC score for the surgery group was 874 ± 624 vs 897 ± 583 for the control group (absolute difference, −23 ± 605; 95% CI, −208 to 161; P = .22 after adjustment for baseline score and radiographic grade of disease severity).
  • No significant differences were observed between the treatment groups for any of the secondary outcome measures.
  • Specifically, patients assigned to arthroscopic surgery were no more likely to improve with respect to physical function, pain, or health-related quality of life than were those assigned to the control group.
  • 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 = .93).

Pearls for Practice

  • Arthroscopic surgery involves inserting an arthroscope into the knee joint to lavage particulate material such as cartilage fragments and calcium crystals and to debride articular surfaces and osteophytes. The goal is to reduce synovitis and eliminate mechanical interference with joint motion.
  • Arthroscopic surgery for osteoarthritis of the knee provides no additional benefits to optimized physical and medical therapy.

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