LONDON, Ontario, Canada—New research in the September 11 issue of the New England Journal of Medicine¹ shows that arthroscopy is not effective for the treatment of knee osteoarthritis (OA), but an editorialist² urges clinicians not to throw out the baby with the bathwater as arthroscopy can—and does—help knee OA patients in whom a coexisting knee problem such as a meniscal tear or a loose piece of cartilage is causing the majority of their symptoms.

“The study provides definitive evidence that arthroscopic surgery provides no additional therapeutic value when added to physical therapy and medication for patients with moderate osteoarthritis of the knee,” said study coauthor Brian Feagan, MD, the clinical trials director at the Robarts Research Institute at the University of Western Ontario and a professor of medicine, epidemiology, and biostatistics at Western’s Schulich School of Medicine & Dentistry in London, Ontario, Canada.

The new study included 178 adults with an average age of 60 who had moderate knee OA and received physical therapy as well as medications such as ibuprofen or acetaminophen. Of these patients, 86 also received lavage and arthroscopic debridement. The nonoperative treatments included one physical therapy session per week for 12 weeks with a home physical therapy program, patient education, and the stepwise use of acetaminophen, NSAIDs, glucosamine, and an injection of hyaluronic acid.

Knee arthroscopy provided no additional benefit over physical therapy and medication, the study showed.

“Based on the available evidence, we believe that the resources currently allocated towards arthroscopic surgery for osteoarthritis would be better directed elsewhere,” the study authors concluded.

Arthroscopy still has uses in the arthritic knee joint

Not so fast, argues Robert G. Marx, MD, an associate attending orthopaedic surgeon the director of the Foster Center for Clinical Outcome Research at the Hospital for Special Surgery in New York City.  

“Arthroscopy has many uses in the knee including the removal of a torn meniscus tissue, removing loose cartilage and bone, and removing inflamed synovium,” he told MSKreport.com. “This study offers further confirmation that arthroscopy for pure knee OA is probably not the appropriate thing to do, however, there may be a patient with known arthritis who has a change in symptoms following an injury who can benefit from arthroscopy.”

The physical examination is key when deciding whether arthroscopy is a good call, he noted. “The surgeon should take a history, physical exam, and [order] imaging studies to conclude what is causing the problem—knee OA or a torn meniscus, for example. We must counsel the patient that there is a good chance the arthroscopy will fix the torn meniscus, but there is a decent chance [the patient will] still have arthritis symptoms,” he said. “You can have satisfied patients if they understand the difference.”

References

1. Kirkley A, Birningham TB, Litchfiekd RB, et al. A randomized trial of arthroscopy surgery for osteoarthritis of the knee. New Engl J Med. 2008;359:1097-1107.
2. Marx RG. Arthroscopic surgery for osteoarthritis of the knee? New Engl J Med.2008;359:1169-1170.