A landmark study conducted in London, Canada at The University of Western Ontario and Lawson Health Research Institute shows that a routinely practiced knee surgery is ineffective at reducing joint pain or improving joint function for sufferers of osteoarthritis. The study appears in the September 11th New England Journal of Medicine.
"This study provides definitive evidence that arthroscopic surgery provides no additional therapeutic value when added to physical therapy and medication for patients with moderate osteoarthritis of the knee," says study co-author Dr. Brian Feagan, Clinical Trials Director at the Robarts Research Institute at Western. Feagan is also a professor of Medicine, and Epidemiology and Biostatistics at Western's Schulich School of Medicine & Dentistry.
Arthroscopic surgery is widely accepted as an effective treatment for osteoarthritis of the knee. It's a minimally invasive surgical procedure involving insertion of an arthroscope and other instruments into the joint through small incisions in order to remove cartilage fragments and smooth the joint surfaces. Osteoarthritis is the most common form of arthritis affecting one in ten Canadians and 27 million Americans.
The study was designed by the late Sandy Kirkley, an orthopedic surgeon specializing in arthroscopic surgery. It was coordinated by the Clinical Trials Group at Robarts Research Institute and conducted by orthopedic surgeons at the Fowler Kennedy Sport Medicine Clinic at London Health Sciences Centre (LHSC). The research team also included rheumatologists and physiotherapists.
Running from 1999 to 2007, the study treated 178 London-area men and women with an average age of 60. All study participants received physical therapy as well as medications such as ibuprofen or acetaminophen, but 86 of the patients also received surgery consisting of lavage and arthroscopic debridement at LHSC. At several time intervals post-treatment, the researchers found both patient groups experienced comparable improvements in joint pain, stiffness, and function, but surgery provided no additional benefit.
Orthopedic surgeon and study co-author Dr. Bob Litchfield emphasizes this study addresses only arthritis-related knee problems. "Although this study did not show a significant therapeutic benefit of arthroscopic debridement in this patient population, knee arthroscopy is still beneficial in many other conditions affecting the knee, such as meniscal repair and resection, and ligament reconstruction." Litchfield is the Medical Director of the Fowler Kennedy Sport Medicine Clinic. He's also a professor In the Department of Surgery at Western's Schulich School of Medicine & Dentistry and a scientist with the Lawson Health Research Institute. "As surgeons, we need to know when things are working and when they're not. If this particular technique is not working for this subgroup of patients, we better come up with something else that does."
A 2002 study demonstrating similar results to this study was broadly dismissed by the medical community, and arthroscopic surgery of the knee remains a common treatment for joint pain and stiffness. But in this latest study the researchers conclude "based on the available evidence, we believe that the resources currently allocated towards arthroscopic surgery for osteoarthritis would be better directed elsewhere."
Funding for this study was provided by the Canadian Institutes of Health Research.
Interviews with the co-authors and study patient Steve Studenny who had surgery, and video of arthroscopic surgery and physiotherapy can be downloaded off the internet at:
Doubleclick at home@FOM
You will find folders with b-roll and clips from Dr. Feagan and Dr. Litchfield and Steve Studenny, a study participant as well as a zip file with all of the video and a pdf of the NEJM study.
Dr. Brian Feagan, Clinical Trials Director, Robarts Research Institute, The University of Western Ontario:
B-Roll: -walking, looking at NEJM paper
B-Roll: arthroscopic debridement being performed on a knee with osteoarthritis.
Clip #1 "The study enrolled patients with moderate to severe osteoarthritis of the knee. The patients were randomly assigned to either receive surgery plus best medical therapy, or best medical therapy alone. They were followed for two years and during that time they were assessed using a standardized measure for the severity of osteoarthritis. And the primary end point of the study was the score on this measure at the end of two years and what the trial found was no effect of surgery that was superior to medical therapy alone."
Clip #2 "We think this study really provides definitive evidence that the procedure is ineffective. The Moseley study was published in the New England Journal of Medicine in 2002. Many orthopedic surgeons did not accept the result and there were many criticisms of the methodology used in that trial, specifically the study was conducted by a single surgeon in a Veterans administration hospital in Houston Texas, so naturally patients were older male veterans as opposed to the more generalized patient population that we studied in our study. So the patient population that we evaluated included both men and women and the average age of 60 and they're more representative of the typical patient with osteoarthritis that would have this procedure."
Clip #3 "Well I think this is a procedure many people felt was effective and we now know isn't effective and I think the resources that are being directly towards arthroscopic surgery for osteoarthritis should be directly elsewhere. And I want to make the distinction, that this study is not saying arthroscopic surgery isn't a useful treatment. It's a very good treatment for many conditions, but it seems osteoarthritis of the knee is not one of them."
Dr. Bob Litchfield, Medical Director, Fowler Kennedy Sport Medicine Clinic, London Health Sciences Centre
B-Roll - looking at knee x-rays
Clip # 1 "This is a study of community-based patients. These are patients that would present to a clinic such as ours in orthopedics, sport medicine with complaints of knee pain. And inclusion criteria: they had to meet radiographic grades of arthritis. So this is grade 2 to grade 4 of arthritis, not involving grade 4 in more than one compartment. So these are patients that are typically arthritic but not at the end of the scale where they need a knee replacement, so moderate and approaching severe arthritis."
Clip #2 "I think as surgeons we like to think we're helping everyone and we tend to be very optimistic about our procedures. We have seen, I think over the years, disappointment that we thought we were doing appropriate surgery on these types of knees arthroscopically, and yet these patients would do well for a couple of months but suddenly they would be back with ongoing symptoms sometimes worst than what they started with in the first place. Unfortunately there was a small group of patients we were making even worst and a number of patients we clearly were not making better with these procedures and this led to this trial."
Clip # 3 "I would hope that evidence-based medicine is embraced by everyone, particularly health care providers. We need to know when things are working and when they're not. Health care dollars are precious, we need to spend them wisely and we need to do things that work, and we need to be very honest and open about our results, and that's what this study is all about. If this particular technique is not working for this subgroup of patients, we better come up with something else that does. The other thing I think we learned a lot about was providing very good non-operative care is an excellent way of helping patients. Both our patient groups did get better overall with scores and I think that's because they did get a lot of these extra things we tend to forget about. Maximizing all the medical management for arthritis is very important and I think as surgeons we sometimes jump to operations. It's sometimes easier to explain an operation than to educate a patient and to provide all the other things they might need."
Steve Studenny, Study Participant (had surgery):
B-Roll shows Physiotherapist Steve DiCiacca working with Steve Studenny at the Fowler Kennedy Sport Medicine Clinic
Clip #1 "Unfortunately my knees starting hurting both at the same time so I was referred to the Fowler Clinic and we started working on both of them. One of them improved, the other we had to go and have some surgery and some cleanout and some physiotherapy, and it's still aching but you manage."
Clip #2 "You talk to so many people and everyone's having surgery and everybody's having cleanout and to find out it really doesn't, it's not effective, that was a bit of a shock."