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CME Released: 9/10/2008
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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.
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.
