Arthroscopy scrutinized as treatment for patients with degenerative knees

An arthroscopic surgery performed to treat the osteoarthritic knee is one of the most common medical treatments done worldwide with more than 700,000 such procedures performed annually in the United States, according to the National Center for Health Statistics. However, some studies and physicians question the benefits this procedure provides to patients with degenerative knees.

Recently, evidence has shown that arthroscopic surgery to treat a knee with osteoarthritis (OA) has little benefit. The small benefits patients gained from the procedure tend to be short-lived, Andrew Carr, ChM, DSc FRCS, FMedSci, of the Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, in Oxford, United Kingdom, said in a 2015 editorial in the British Medical Journal. He noted evidence for the procedure is weak and lacks high-quality, multicenter, randomized control trials in its favor.

Carr wrote, “Researchers have already reported that trials of arthroscopic surgery find no benefit over control interventions ranging from exercises to placebo surgery.”

Biased for arthroscopy

According to Carr, many orthopaedic surgeons have fallen prey to their biases and ignored the “robust and high-quality evidence” against the procedure. Instead, he noted, they lean on their entrenched attitudes toward the benefit of arthroscopic surgery to treat osteoarthritic knees.

The benefits of arthroscopic surgery over control interventions can often be short-lived and may typically last 6 months or less. Patients can receive a similar degree of added benefit simply from taking analgesics, Stefan L. Lohmander, MD, PhD, of the Department of Clinical Sciences at Lund University, in Lund, Sweden, said.

A study by Thorlund, Lohmander and colleagues published this year compared different treatments for patients with osteoarthritic knees.

“The result of our meta-analysis was the benefit of arthroscopic surgery, as compared to the overall effect of any of the comparators, was trivial and short-lived. The benefit would be compared to just taking a simple analgesic, like acetaminophen, essentially. It was short-lived, so that by 6 months there was no benefit at all compared to the study or treatments that formed the comparative treatment of these studies,” he told Orthopaedics Today Europe.

Complications of arthroscopy

In addition, arthroscopic surgery can produce adverse events, including deep venous thrombosis, pulmonary embolism, infection and possibly death in extremely rare cases, according to Lohmander.

Therefore, instead of looking to arthroscopy to treat OA, Lohmander said patients should first be referred to a physiotherapist who is familiar with managing painful knees in the patients’ age group.

“The patients should be given a structured exercise program, lasting a few months, with regular visits to a physiotherapist to make sure they progress as expected. The majority of the patients who undergo this find it to be beneficial. The harms of this type of intervention are essentially zero,” Lohmander said.

Funded by health care

Arthroscopy for degenerative knees is currently funded by the Swedish National Health Care system, but that may change, Lohmander said.

“National guidelines clearly advise that arthroscopic surgery for the painful knee in the middle-aged and older patient is not the primary treatment to be considered, but rather [they] recommend an exercise program under guidance of a physiotherapist. The latter is also paid for by the national health insurance system,” he said.

Lohmander agreed with points Carr raised in his editorial and said it is difficult to recommend an expensive and possibly risky surgery, such as knee arthroscopy, that achieves improvements no greater than placebo.

Although many orthopaedists report their patients with osteoarthritic knees experience positive outcomes following arthroscopy, Lohmander said a landmark study by Moseley and colleagues showed sham surgery offered similar outcomes for these types of patients.

Sham surgery vs arthroscopy

The study was a randomized, placebo-controlled trial published in 2002, which was controversial at the time. It analyzed results of 180 patients with osteoarthritic knees who underwent either an arthroscopic lavage procedure, debridement or a placebo procedure. The results showed arthroscopic lavage or debridement in patients with knee OA was associated with no better outcomes than placebo surgery.

“This study provides strong evidence arthroscopic lavage with or without debridement is not better than and appears to be equivalent to a placebo procedure in improving knee pain and self-reported function. Indeed, at some points during follow-up, objective function was significantly worse in the debridement group than in the placebo group,” Moseley and colleagues wrote.

Benefits of arthroscopy available

According to Freddie H. Fu, MD, DSc(Hon), DPs(Hon), of the University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, in Pittsburgh, a percentage of the population can benefit from knee arthroscopy to treat OA.

However, the procedure should be “individualized, but not generalized,” Fu told Orthopaedics Today Europe.

“If pain is the only complaint from a patient, this procedure may not work. You need to diagnose the patient clearly. If you have pain and bad arthritic changes, it will not do well. But, if you have mechanical symptoms, such as catching of the knee, catching pieces and loose pieces, it may help. This is the key. There are misconceptions because there are papers coming out that say it does not work, but the key is that the patient has to be more scrutinized by the surgeon,” he said.

Mechanical symptoms may improve

An arthroscopic procedure can often improve mechanical issues, such as a meniscus flap or loose particles, in the knee, but it will often not provide a longtime improvement in a patient’s pain, Fu, a member of the Orthopaedics Today Europe Editorial Board, said.

Lifestyle changes, such as losing weight or participating in a rehabilitation program, may prove more effective than arthroscopy, but many patients push back when a physician suggests they change their lives in such a way. Perhaps the best option for patients who exhibit mechanical and pain symptoms is to do nothing until they need a total knee arthroplasty (TKA), he said.

“You need to spend time with the patient and explain to them they need to change their lifestyle, [try] weight reduction, diet — all of those things come into play if they want to feel better,” Fu said.

He also noted that doing nothing is cost-effective.

Increased use worldwide

Despite evidence that supports the notion that arthroscopic surgery for the degenerative knee may not be beneficial, Carr noted the procedure seems to be used more today than ever before in Europe and North America.

Martin Lind, MD, PhD, of Aarhus University Hospital, in Denmark, told Orthopaedics Today Europe he believes the procedure is overused for this indication.

“I agree with the editorial, and that the main cause for reluctance is practice change, despite strong evidence of limited effects of knee arthroscopy. Some cannot get away from the long-term tradition of giving patients hope for improvement by a small procedure that makes sense, with the concept of cleaning and smoothing of a worn joint,” Lind said.

All arthroscopic surgery is paid for by the Danish health care system as specific indications for procedures are not controlled by authorities. Therefore, surgeons are not individually reimbursed for treatments performed within in the public health care system, according to Lind.

Not proven to improve pain

Arthroscopic debridement will not improve the pain of an osteoarthritic knee, Lind noted.

The procedure is nearly always a precursor to TKA. Its indications should be rethought, Lind said, and if the indication is pain alone, then arthroscopy will not be effective for that patient.

He agreed with Fu and said arthroscopy may sometimes be effective for patients with mechanical issues and can help improve their quality of life.

“It is a physician’s responsibility to tell patients what they can expect from a procedure. It should only be used to relieve mechanical symptoms, not pain symptoms, and certainly not to postpone total knee arthroplasty,” Lind said.

Rehab, exercise is best

At present, training, physiotherapy and physical rehabilitation programs done correctly is the most efficient way to approach osteoarthritic knee symptoms. These strategies are more efficient than pain medication and certainly more efficient than arthroscopy, according to Lind.

The science and the evidence concerning arthroscopy for the degenerative knee suggests physicians should not waste their patients’ time and resources if the procedure is done solely to relieve pain, Lind said.

This controversy demands worldwide attention, Matteo Denti, MD, who is president of the European Society of Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA), said.

Denti is a member of the ESSKA steering committee that is developing guidelines about arthroscopy to address the procedure’s worth in patients with osteoarthritic knees.

“We do not have to perform an arthroscopy in an osteoarthritic knee. This is a borderline procedure. It is completely different if you have an older patient, 70 [years] to 80 years old with no arthritis, but has a meniscus tear and wants to continue playing golf. A debridement procedure is appropriate. But otherwise, if you have an arthritic knee, it is not an effective procedure,” Denti told Orthopaedics Today Europe.

Because complications, such as osteonecrosis, can occur after arthroscopy of an osteoarthritic knee, conservative treatment should be used whenever possible. Stationary bicycling and freestyle swimming are both perfect exercises for patients who want to alleviate the pain in their knees without resorting to surgery, Denti said.

He agreed with a point Carr raised in his article that any harm or complications due to physical exercise programs are rare and, if they occur, they are often minor.

According to Denti, the ESSKA steering committee findings on knee arthroscopy are scheduled to be presented in 2016 at the ESSKA Congress in Barcelona. – by Robert Linnehan

• References:
• Carr A. BMJ. 2015;doi:10.1136/bmj.h2983.
• Mosely JB, et al. N Engl J Med. 2002;doi:10.1056/NEJMoa013259.
• Thorlund JB, et al. BMJ. 2015;doi:10.1136/bmj.h2747.

• For more information:
• Matteo Denti, MD, can be reached at Clinica Luganese, Via Moncucco 10, 6900 Lugano, Switzerland; email: matteo@denti.ch.it.
• Freddie H. Fu, MD, DSc(Hon), DPs(Hon), can be reached at 200 Lothrop St., Pittsburgh, PA 15213 USA; email: ffu@upmc.edu.
• Martin Lind, MD, PhD, can be reached at Aarhus University, Nordre Ringgade 1, 8000 Aarhus C, Denmark; email: martinlind@dadlnet.dk.
• Stefan L. Lohmander, MD, PhD, can be reached at Orthopaedic Surgery, Department of Clinical Sciences at Lund University, Box 117, 221 00 Lund, Sweden; email: stefan.lohmander@med.lu.se.

Disclosures: Denti, Fu, Lind and Lohmander report no relevant financial disclosures.

 

Will more trials help determine the efficacy of arthroscopy for the treatment of the degenerative knee?

No place for this treatment

The article by Moseley and colleagues in the New England Journal of Medicine created much dispute in 2002. In patients with established knee OA, arthroscopic lavage or debridement did not result in better outcomes than a sham procedure.

Many orthopaedic surgeons did not want to believe the good results they obtained by these procedures were just caused by placebo effects and/or the natural course of the disease. However, in 2008 Kirkley and colleagues showed similar results and concluded “arthroscopic surgery for osteoarthritis of the knee provides no additional benefit to optimized physical and medical therapy.” After that article appeared, however, there remained doubt about the role of arthroscopic meniscectomy of degenerative meniscal ruptures.

The results of the Finnish Degenerative Meniscal Lesion Study published in 2013 showed “arthroscopic partial medial meniscectomy provides no significant benefit over sham surgery in patients with a degenerative meniscal tear and no knee osteoarthritis.”

These three studies, all published in the New England Journal of Medicine, which illustrates their high scientific quality, should have revolutionized orthopaedics. However, each of the articles induced sentiments and letters to the editor with a significant change in orthopaedic treatment approach. Writers of the letters to the editor indeed suggested more research was needed.

There is always a place for more detailed and high-quality science, but there is hardly an area of orthopaedics that has been analyzed with a better scientific approach and more rigorous methods. For that reason, I think the orthopaedic community should start implementing this knowledge and not wait for further scientific proof. There is hardly any place for arthroscopic treatment of OA of the knee if the available robust scientific evidence is considered.

• References:
• Kirkley A, et al. N Engl J Med. 2008;doi:10.1056/NEJMoa0708333.
• Moseley JB, et al. N Engl J Med. 2002;doi:10.1056/NEJMoa013259.
• Sihvonen R, et al. N Engl J Med. 2013;doi:10.1056/NEJMoa1305189.

Jan Verhaar, MD, PhD, is an Orthopaedics Today Europe Editorial Board member. He is at Erasmus University Medical Centre, in Rotterdam, The Netherlands.
Disclosure: Verhaar reports no relevant financial disclosures.

More evidence may not help

Arthroscopic procedures are the most commonly performed orthopaedic operations. Most of them are carried out in middle-aged and older patients to treat knee symptoms attributed to degenerative knee disease with arthroscopic partial meniscectomy (APM) being performed most often.

However, several randomized controlled trials (RCTs) have failed to show a treatment-benefit of knee arthroscopy (including APM) over conservative treatment, coupled with conservative treatment over conservative treatment alone, or even over placebo surgery for patients with degenerative knee disease.

Is it a possibility that, this evidence aside, someone would still benefit from this surgery? In life, and in medicine, there always exists a possibility some individuals may benefit from any treatment. However, there is no scientific evidence supporting the assumption and, furthermore, there is not the slightest evidence of who these patients would be. These RCTs have included patients with mild to moderate knee OA and also those with no knee OA, patients without and with a variety of meniscus tears, as well as those with so-called mechanical symptoms. These RCTs studied a variety of interventions — debridement, chondral procedures and partial meniscectomy — without finding any beneficial effect, but with harms.

This topic — the treatment of patients with knee pain and degenerative knee disease — is second to none in the orthopaedic literature with respect to the number of high quality RCTs performed. It is time to stop doing procedures which are repeatedly proven to be ineffective. It is time to abandon the ship. We need no more evidence.

Raine Sihvonen, MD, PhD, is in the Department of Orthopedics and Traumatology at Hatanpää City Hospital, in Tampere, Finland.
Disclosure: Sihvonen reports he receives scientific grants from non-profit institutions and support from DePuy Synthes for travel to the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine Congress.