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Old 09-17-2008, 06:52 AM   #1
Darryl Shaw
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Default Arthroscopic Surgery May Not Be Helpful for Knee Osteoarthritis.

I spotted this story on dribriffa.com (Link) so I checked his references and it looks like bad news for those of us with bum knees.

http://content.nejm.org/cgi/content/full/347/2/81

Apologies for printing the whole medscape article but I couldn't get the link to work.

Quote:
Arthroscopic Surgery May Not Be Helpful for Knee Osteoarthritis CME
News Author: Laurie Barclay, MD
CME Author: Hien T. Nghiem, MD
Disclosures

Release Date: September 10, 2008; Valid for credit through September 10, 2009 Credits Available

Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s) for physicians

To participate in this internet activity: (1) review the target audience, learning objectives, and author disclosures; (2) study the education content; (3) take the post-test and/or complete the evaluation; (4) view/print certificate View details.



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

Describe arthroscopic surgery.
Compare optimized physical and medical therapy alone with arthroscopic treatment in addition to optimized physical and medical therapy.
Authors and Disclosures
Laurie Barclay, MD
Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.



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



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



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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Old 09-17-2008, 09:30 AM   #2
Steven Low
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Osteo is mostly wear and tear.

Not much you can do for that beyond regular PT (arthroscopic is kinda foolish) unless you're going to get a total joint replacement.

At least, that's what I've experienced...
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Old 09-18-2008, 08:13 AM   #3
Garrett Smith
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Calcinosis induced by the nightshades, combined with wear and tear, and often accompanied by injuries to the area (which don't heal correctly or quickly if nightshades are consumed in decent amounts) all too often leads to what most call OA.

All too often it is a systemic problem with a local focus. I've witnessed too many OA joints that once were excruciatingly painful go to pain-free within a month when people avoid the nightshades. Combined with laser therapy and prudent exercise, this stuff can improve rapidly.

Surgery my rear end (in most cases). Scar tissue is the biggest problem with surgery in my experience.
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Old 09-18-2008, 09:27 AM   #4
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Baby..bathwater all that. I had a pretty mixed experience.

In 1999-2000 I had to quit bike racing because of chronic patellae tracking issue and massive joint degradation, to the point I was walking with a pronounced limp and could not do a single BW squat. 400mile weeks on the bike were doable, but not much else.

I did PT for a year and a half and the full course of steroids, Celebrex and all that. Fianlly I broke down and got my knees scoped, scraped and buffed as well as both patellae relocated.....pretty invasive stuff. The rehab was horrible, it took another year to be able to walk right and a another year beyond that to be able to run or ride a bike pain free. In late 2005 I was able to return to weightlifting after a multi year hiatus. I am closing in (over the next few years) on some decent squat numbers. I'm able to compete in strongman and powelifting and can do about 90% of the stuff I want to. That's not bad for a pair of f'ed up knees.

For me, the scope was a life saver. If I hadn't bit the bullet and done it I'd likely still be in pain and a sedentary alcoholic. I was lucky and had some good ortho's and got second opinions from some even better ones. At the end of the day, I wouldn't counsel anyone to just start cutting but in my experience, much of the success of surgery is based entirely on whether you are willing to be patient through the rehab…mine took Years. This is not the NFL..they don’t give the average patient a full course of good drugs and a full time PT, nor does the average patient have that kind of focus. I certainly didn't.


These decision should of course be based on the individual pathology but if I had to guess where a lot of these scopes go sideways it's in that people don't realize how long and hard the rehab is and living in chronic movement restricting pain is a life suck. The question is whether the pain now is so bad that you are willing to endure at least another year of worse pain and maybe less function in order to have a chance for it to get about 65% better. For me that decision was easy.
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Old 09-19-2008, 08:01 AM   #5
Craig Snyder
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With my experience as a PT, many knee scopes that are done in my area don't get PT after wards. The orthos seem to have a chip on their shoulders (some of them...not all) and all they need is their fancy surgery and the body will heal the rest. Sometimes that works. But there is always (big word there) something that a PT can help with.

People don't just get OA for no reason. Poor mechanics, muscle imbalances, previous injuries, etc that can be worked out either pre/post surgery. I believe that OA can be reversed. If the mechanics that caused it can be corrected and proper movement patterns and loading restored, why wouldn't the OA go away? If there is joint derrangement, ie menical tear or ligament destruction, you are in trouble. But insidious onset OA from muscle imbalances, gait abnormalities or other movement impairments (Sarhman stuff). Unfortunately, with the way our reimbursement system is set up, I don't have the ability to follow patients for the possible year it would take for this to happen.

The average Joe doesn't know crap about how to strengthen/rehab after an injury. They don't even know when to switch from ice to heat for pete's sake. So how are they going to recover from an invasive procedure and expect any type of favorable outcome.

On a side note, I would rather have a doc cut me open and do a surgery than scope me. Many of my patient's have much more post op pain from a scope from all the work that is done through the small incisions than what would have been done though a larger incision. And the doc is less likely to miss something, which does happen (occasionally) despite the fancy cameras.

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Old 09-19-2008, 08:23 AM   #6
Garrett Smith
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Craig,
I also have several patients who have had both open and arthroscopic surgery who have said they prefer the open surgery.

I have this theory that an open surgery is more like a "wound" that would occur naturally (and thus the body is better adapted to heal it with fewer sequelae) than super-deep puncture wound(s), as in arthroscopy, where the wound is actually "bigger" at the deep end of the cut than at the shallow/surface end. Athroscopy also creates scar tissue that is harder for me to treat with scar therapy injections than a large open surgical scar. FWIW.
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Old 09-23-2008, 06:32 AM   #7
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Makes sense. After the scopes I spend a lot of time trying to do scar mobs over the VERY tender scope entry ports, and that is just not usually necessary with the open surgeries.

Thanks for your opinion.

Craig
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