A study just published in the New England Journal of Medicine found that arthroscopy was no more effective than placebo surgery for treating osteoarthritis of the knee.1 The study assigned 180 patients to receive arthroscopic debridement, arthroscopic lavage, or placebo surgery. All of the groups showed improvement, and neither of the surgical groups reported less pain or better function than the placebo group. The study didn’t examine knee arthroscopy for acute injury, such as partial tear of the ligaments.
"We’re talking about old people with wear-and-tear’ arthritis," says Nelda P. Wray, MD, MPH, chief of general medicine at the Houston Veteran Affairs Medical Center and one of the authors of the study. Painful knees are one of the most common reasons patients see orthopedists for osteoarthritis of the knees, she says.
Arthroscopic surgery is performed approximately 200,000 times annually on osteoarthritic knees. The results of the study are apparent, Wray says. "We’re saying, people who have had the procedure who are better, are better solely because of the placebo effect." Which raises a significant question, she says: Should we continue to do this procedure if it only has placebo effect? Her answer is clear. An emphatic no.
Some media have picked up on the report and are labeling the procedure "sham surgery," says John Bergfeld, MD, director of the Cleveland Clinic Sports Health. "The surgery itself is not a sham," he maintains. "If surgeons didn’t present the possibilities of cure faithfully to the patient, that would be a sham." One strength of the study is that it points out that this surgery is not going to completely relive the pain of arthritis, Bergfeld says. "I say, It can be improved, but not cured.’"
One issue that remains is whether the study’s finding would be true for women, because the current study was conducted at a Veteran’s Affairs facility and included mostly men. Also, can these results of such a small study be applied to the entire population? Wray contends that they can. She says that the difference between the placebo patients and the surgery patients was so exceedingly small, that even if more and more patients had been entered in the study, there would not have been a benefit found in the surgical patients.
Wray acknowledges that some surgeons are likely to argue with the results. For example, some may say that the procedure is better if patients have mild arthritis. "We’ve done a subgroups analysis, and our results don’t vary by degree of arthritis," she says. Some surgeons may say that patients who have worse alignment, such as those who have bowed knees or knock-knees, won’t do as well with this procedure. "We did a subgroup analysis, and alignment did not determine results," Wray says.
Most surgeons tell potential patients that they can improve their knees, particularly if they have mechanical symptoms, Bergfeld says. "I tell them there’s a real possibility that they could get worse [with or without the surgery]," he says. "It’s not realistic to tell them that."
Wray says that 176 of the 180 patients in the study had mechanical symptoms, such as locking, popping, catching, or giving way of the knee, and they did no better with surgery. "Our statement is: Our study provides strong evidence in the population of patients who present for this condition, with osteoarthritis of the knee, when it’s gradually gotten worse and there’s no trauma, these procedures provide no benefit," she says. Wray isn’t going as far as saying that no patients will do well with surgery. But her position is that if the procedure continues to be done, "there should be a placebo-controlled trial."
This is the first such placebo-controlled study on arthroscopy for osteoarthritis, so it isn’t certain how surgeons or insurers will respond. However, Hartford, CT-based Aetna already has indicated in media reports that it plans to have its medical directors review the information. Wray recommends that the insurers form an expert panel to decide the future of the surgery. "I would hope we would have some policy discussion about how we should discuss surgical procedures before they are allowed to disseminate widely," she says.
Reference
1. Moseley JB, O’Malley K, Petersen NJ, et al. A con-trolled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med 2002; 347:81-88.
Source
For more information on the knee study, contact: Nelda P. Wray, MD, MPH, Chief of General Medicine, Houston Veteran Affairs Medical Center. E-mail: [email protected].
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