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How effective is arthoscopy for osteoarthritis of the knee? (Not very)

Posted Sep 16 2008 6:50am

Perhaps compared to many other doctors, I take the view that conventional medicine is less effective and more hazardous than we are generally led to believe. But I most certainly don’t dismiss it. There is no doubt in my mind that things can be done with conventional medicine that other forms of therapy cannot do. Things that can sometimes save lives or change them very much for the better.

A couple of the areas where conventional medicine excels and often comes into its own, I think, include acute and emergency medicine and surgery. Someone, for instance, who has been injured in a road traffic accident is going to be best served by the acute medical services paramedics, doctors and nurses can offer. It is usually highly beneficial for someone when an ophthalmic surgeon takes out their cloudy (cataract affected) lens in their eye and restores sight there with a synthetic lens.

One particular form of surgery which I feel generally has enormous merit is orthopaedic surgery. Within surgery, orthopaedic surgeons generally have a reputation for being rugby-playing DIY enthusiasts who have been let loose on the human body. I have enormous respect for them. If someone has, say, a very bad degenerative, painful hip joint, which is causing serious impairment to their quality of life, then the replacement of this joint can (and probably will) give them a whole new lease of life. Only yesterday I met two individuals who had ruptured a knee ligament (cruciate ligament) and had this repaired by an orthopaedic surgeon. Both of them started with quite useless knees, but as a result of the efforts of an orthopaedic surgeon have ended up with well-functioning ones. One of them has even returned to skiing (!). My experience is that orthopaedic surgery is one of conventional medicine’s most worthwhile endeavours.

However, not all things that orthopaedic surgeons do are equally effective. And I was interested to read a study published in the New England Journal of Medicine which assessed the effectiveness of arthroscopy for osteoarthritis (wear and tear) arthritis of the knee. Arthroscopy involves putting making usually two or three small incisions around the knee, and using a fibreoptic ‘telescope’ and tools to do things like tidy up damaged cartilage and remove things floating around in the knee joint that shouldn’t be there. Many individuals seem to feel better for having the procedure, but not uncommonly, the benefits can be short-lived.

In the NEJM study, the effectiveness of arthroscopy in individuals was compared with the results obtained from a mix of physical and medical (pharmaceutical medicine) alone [1]. Basically, after two years, the group who had had arthroscopy were no better off. The authors’ conclusions are that: “Arthroscopic surgery for osteoarthritis of the knee provides no additional benefit to optimized physical and medical therapy.”

Reading about this study reminded me of a very interesting study published in the NEJM back in 2002 [2]. Here, individuals with osteoarthritis of the knee were assigned to one of three ‘treatments’:

1. Arthroscopic débridement (surgical tidying up of the soft tissues in the knee)

2. Arthroscopic lavage (washing out of the knee)

3. Placebo surgery

In the last group, incisions were made in the knee as if for arthroscopy, but nothing was done. The participants in the study did not know what procedure they had had. They were assessed over a two-year period by practitioners who did not know what procedure they’d had either. At no point during the follow-up period did the individuals who had had joint débridement or lavage report less pain or better function than those who had undergone placebo surgery. The authors concluded that: “…the outcomes after arthroscopic lavage or arthroscopic débridement were no better than those after a placebo procedure.”

Whether someone ends up having arthroscopy or not, my advice for the management of osteoarthritis is generally centred on the use of the nutritional agent glucosamine. I have found this to be generally very effective in the treatment of osteoarthritis of not just the knee, but other joints including the hip. There is also some evidence that glucosamine is indeed generally effective for osteoarthritis. Some quite recent evidence also suggests that taking glucosamine can help keep individuals off the operating table. See here for more on this.

References:

1. Kirkley A, et al. A randomized trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2008;359:1097-1107

2. A controlled trial of arthroscopic surgery for osteoarthritis of the knee.
Moseley JB, et al. N Engl J Med. 2002;347(2):81-8

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