Question: In patients with osteoarthritis (OA) of the knee, does arthroscopic surgery confer any added benefit to optimized physical and medical therapy?
Design: Randomized (allocation concealed), blinded (outcome assessors) controlled trial with mean 24-month follow-up.
Setting: A sports medicine clinic in London, Ontario, Canada.
Patients: 188 patients who were =18 years of age and had idiopathic or secondary OA of the knee with grade 2, 3, or 4 radiographic severity (as defined by the modified Kellgren-Lawrence [K-L] classification). Exclusion criteria included large meniscal tears, inflammatory or postinfectious arthritis, previous arthroscopic treatment for knee OA, >5° of varus or valgus deformity, previous major knee trauma, K-L grade 4 OA in 2 compartments in persons >60 years of age, an intra-articular corticosteroid injection within the previous 3 months, a major neurological deficit, serious medical illness, and pregnancy. 10 patients withdrew consent after randomization, leaving 178 patients (mean age 59 y, 63% women). 168 patients (89%) completed the study.
Intervention: Patients were allocated to and received optimal physical and medical therapy plus arthroscopic surgery (n = 86) or physical and medical therapy alone (n = 86). Arthroscopic surgery was done within 6 weeks after randomization and involved synovectomy; débridement; or excision of degenerative tears of the menisci, fragments of articular cartilage, or chondral flaps and osteophytes that prevented full extension. Physical and medical therapy began within 7 days after surgery. Physical therapy was provided 1 hour per week for 12 weeks. Patients also received a home exercise program emphasizing range of motion and strengthening exercises and instruction on activities of daily living, walking, use of stairs, and cold and heat treatments. Medical treatments were optimized according to an evidence-based algorithm that recommended stepwise use of acetaminophen, nonsteroidal anti-inflammatory drugs, and intra-articular injection of hyaluronic acid.
Main outcome measures: The primary outcome measure was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score (range, 0 to 2400; higher scores indicate worse symptoms). A 20% improvement (a decrease of approximately 200 points) was considered clinically important. Secondary outcome measures were the physical component summary of the Short Form-36 (SF-36) (range, 0 to 100; higher scores indicate better quality of life), the McMaster-Toronto Arthritis Patient Preference Disability Questionnaire (MACTAR) (range, 0 to 500; higher scores indicate greater disability), and the Arthritis Self-Efficacy Scale (ASES) (range, 10 to 100; higher scores indicate greater self-efficacy).
Main results: WOMAC scores were better in patients receiving arthroscopy plus physical and medical therapy than in patients receiving physical and medical therapy alone at 3 months, but no significant differences existed between the groups at any later follow-up point (Table). No significant differences were seen in any secondary outcome measures at any time point (Table).
Conclusions: In patients with osteoarthritis of the knee, arthroscopic surgery did not confer any additional benefit to optimized physical and medical therapy.
In 2002, we published the results of a randomized, placebo-controlled trial evaluating the efficacy of arthroscopy for treating OA of the knee1. In spite of our conclusion that all of the benefit of arthroscopy for OA of the knee was from a placebo effect, the use of arthroscopy for this purpose was not substantially affected by our study.
It is in this context that Kirkley et al. designed another randomized controlled trial of OA of the knee, comparing arthroscopy, physical therapy, and medical treatment with physical therapy and medical therapy alone. The methods were carefully planned in an effort to address some of the perceived flaws in our study, and they appear to have performed a textbook example of how to execute a randomized clinical trial in orthopaedic surgery. I see no major flaws in the design or execution of the study.
Kirkley et al. found no benefit of arthroscopy over physical therapy and medical therapy in the treatment of OA of the knee. These results are consistent with the conclusions of our previous study. On the basis of these 2 studies, it is clear that orthopaedic surgeons should no longer use arthroscopy to treat OA of the knee, even if the patient has mechanical symptoms. This is in agreement with the recently published guidelines on treatment for OA of the knee from the American Academy of Orthopaedic Surgeons2.
Moseley JB, O'Malley K, Petersen NJ, Menke TJ, Brody BA, Kuykendall DH, Hollingsworth JC, Ashton CM, Wray NP. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med.2002;347:81-8.34781
2002
[PubMed][CrossRef]