Clinicians Debate Use of Arthroscopy in Patients with Osteoarthritis

NEW YORK—September 11, 2008

In a study published in the New England Journal of Medicine (NEJM) issue of Sept. 11, 2008, investigators concluded that arthroscopic surgery for osteoarthritis of the knee provides no additional benefit to optimized physical and medical therapy. In an accompanying editorial, however, Robert G. Marx, M.D., an associate attending orthopedic surgeon at Hospital for Special Surgery (HSS) in New York, points out that the study has some weaknesses and argues strongly that arthroscopy does have a role in some patients with osteoarthritis.

“Arthroscopy is still valuable and you have to know when to use it,” said Dr. Marx, who is also director of the Foster Center for Clinical Outcome Research at HSS. “While I do not recommend arthroscopy as a treatment for an arthritic knee, it can be extremely helpful for people with arthritis who also have a co-existing knee problem such as a meniscal tear or a loose piece of cartilage that is causing the majority of their symptoms.”

In the study reported in the NEJM, investigators randomized 92 individuals to arthroscopic surgery and 86 to non-operative treatment for osteoarthritis of the knee. The non-operative treatments included one physical therapy session per week for twelve weeks with a home physical therapy program, patient education, and the step-wise use of acetaminophen, non-steroidal anti-inflammatory drugs, glucosamine and an injection of hyaluronic acid. The study did not identify any benefit in the group that received surgery.

Dr. Marx points out, however, that the study excluded patients who were believed to have a large meniscal tear based on clinical examination, or, in a small number of cases, identified through magnetic resonance imaging. “This study excluded people who the doctor thought needed arthroscopy for a meniscal tear. The doctor thought they would do well with surgery,” said Dr. Marx. “So, the only ones who are included are the ones who are not good candidates for the surgery because their symptoms were due only to arthritis and arthroscopy is not generally effective in that scenario.”

In other words, although the study showed a lack of efficacy of arthroscopy, it can be very useful in patients who may have osteoarthritis, but also another knee injury, such as a symptomatic meniscal tear. There are subtleties involved in clinical decision-making, commented Dr. Marx. Patients who are young, have mild osteoarthritis, a history of injury and clear meniscal pathology would be a good candidate for surgery and, in fact, would be unlikely to heal without the surgery. In contrast, patients who have symptoms that are only due to osteoarthritis are unlikely to benefit from arthroscopy.

Arthroscopic surgery is performed by orthopedic surgeons in many joints, most commonly the knee. The advantage of arthroscopy over traditional open surgery is that the joint does not have to be opened up fully. Instead, only two or three small incisions are made.

Dr. Marx, a member of the Sports Medicine Service at Hospital for Special Surgery, is also an associate professor of orthopedic surgery and associate professor of public health at Weill Cornell Medical College.