The Value of Arthroscopy in Knee Osteoarthritis

Summarized by Robert W. Griffith, MD
January 24, 2003 (Reviewed: January 21, 2005)

Introduction

Osteoarthritis of the knee is a painful condition, and medication is not always successful in providing relief. Many patients turn to arthroscopic lavage and/or debridement, which have been reported (in uncontrolled studies) to be helpful in about half the cases. As the physiological basis for the procedure is unclear, a group of surgeons in Houston, Texas, decided to conduct a randomized placebo-controlled study of knee joint arthroscopy in subjects with osteoarthritis.

Method

Patients under 75 years of age with osteoarthritis of the knee (as defined by the American College of Rheumatology criteria) were recruited; they had to have moderate pain (>/= 4 on a visual analog scale of 0 to 10) despite maximal medical treatment for 6 months or more, and not to have had a previous arthroscopy within 2 years. The severity of their disease was graded radiographically, with a scale of 0 to 12.

Of 324 suitable patients, 144 (44%) refused to participate when they learned of their chances of receiving placebo surgery. Patients were stratified into 3 levels of severity, and each group was randomly assigned to arthroscopic lavage, arthroscopic debridement with lavage, or the placebo procedure; those having arthroscopy received general anesthesia, while those in the placebo group had an i.v. tranquillizer, an opioid, and oxygen-enriched air.

Lavage and debridement procedures were standard. The placebo group patients had 3 1-cm skin incisions made, and their postoperative care was the same as for the arthroscopy groups.

Postoperative outcome measures were made at 2 weeks, 6 weeks, and 3, 6, 12, 18 and 24 months. Three different, well-recognized pain scales, along with two scales assessing function, were used at each visit. An objective measure of function - the time taken to walk 100 ft (30 m) and to climb up and down a flight of stairs - was also done.

Results

A total of 180 patients were enrolled, i.e. 59-61 in each group; 165 patients completed the trial, i.e. were present at all follow-up evaluations. The groups had similar characteristics at baseline. The mean age was 52, and 92% were male. About 29% had mild, 46% moderate, and 25% severe osteoarthritis, with 20% of them on prescription analgesics.

At none of the time points did either of the arthroscopy groups report greater pain relief or improved function, compared with those reported by the placebo group. And the objective assessment of function (walking and stair climbing) failed to show any advantages of arthroscopy; indeed, the debridement group had statistically-significant inferior time scores to the placebo group, at 2 weeks and 2 years.

Comment

This study shows that arthroscopic lavage, with or without debridement, offers no benefits regarding pain relief or improved joint function in patients with osteoarthritis of the knee. In the USA over 650,000 such procedures are conducted annually, at a cost of about $5,000 each. Clearly there is a lot of money to be saved in abandoning this apparently useless procedure.

Source

• A controlled trial of arthroscopic surgery for osteoarthritis of the knee. JB. Moseley, K. O'Malley, NJ. Petersen,  et al., N Engl J Med, 2002, vol. 347, pp. 81--88

Related Links
Viscosupplementation in the Osteoarthritic Knee
A Placebo-Controlled 3-Year Study of Glucosamine Sulfate in Osteoarthritis
Total Knee Replacement Surgery in Osteoarthritis

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