Arthroscopic surgery has revolutionized operative treatment of the knee over the past thirty years. This technique allows the surgeon to visualize the inside of the knee through incisions as small as one centimeter in length - a dramatic contrast to the large incisions required with open surgery.
Owing to the magnification achieved with fiber optics used in modern arthroscopy, and a television screen that is viewed in the operating room, the surgeon can also view the inside of the knee in far greater detail than is allowed in open surgery. He or she can then insert instruments through a separate small portal to perform therapeutic procedures through arthroscopic surgery.
Arthroscopic surgery has been documented to be extremely valuable for dealing with conditions such as meniscal tears or loose bodies in the joint, and for performing reconstructive procedures such as anterior cruciate ligament reconstruction. The value of arthroscopy in patients with osteoarthritis of the knee, however, is somewhat controversial.
A study published in 2008 by Kirkley, et al, in the New England Journal of Medicine entitled "A Randomized, Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee" attempted to determine whether arthroscopic surgery was a useful treatment for people with advanced arthritis. This study involved a comparison of arthroscopic surgery (debridement or removal of tissue or fragments that may cause pain or impede movement) for knee osteoarthritis to nonoperative treatment. In this case, the nonoperative treatment included physical therapy, patient education, and the administration of acetaminophen, NSAIDs, glucosamine, and injected hyaluronic acid.
The merit of this study is that it was a randomized trial in which patients were randomly allocated to one treatment group or another. This is the most valid form of scientific clinical research, as it allows the treatment groups to be as similar as possible, aside from the intervention (in this case surgery) they receive. Also, the severity of participants' arthritis was well-defined, as the researchers studied the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, which assesses pain, stiffness, and physical function.
Overall, the investigators found that arthroscopic surgery was not effective therapy for advanced osteoarthritis of the knee. All patients experienced some benefit over time, but there were no major differences between the groups in a wide variety of outcome measures including pain, function, and walking ability.
Although this study demonstrates that arthroscopic surgery for degenerative knee arthritis remains of questionable value, it is important to note that the lack of efficacy of arthroscopic surgery in this trial does not imply that it has no role in the treatment of patients who may have osteoarthritis and also another knee condition, such as a symptomatic meniscal tear, which is causing mechanical symptoms. In cases where additional knee conditions are present in conjunction with osteoarthritis, the benefits of arthroscopy may greatly exceed those of nonsurgical treatments.
Nonsurgical treatments are also effective options for some patients with osteoarthritis of the knee. These include physical therapy, anti-inflammatory medication, chondroitin and glucosamine supplements, use of a cane and steroid injection. In cases where osteoarthritis of the knee cannot be controlled with these measures and the patient is experiencing severe pain and/or disability, surgery such as osteotomy or knee replacement may be recommended.
For more information on Dr. Marx’s comment on the Kirkley study, read his editorial, “Arthroscopic Surgery for Osteoarthritis of the Knee?,” on the New England Journal of Medicine webpage (Registration is required; free trials are available to new users) or Clinicians Debate Use of Arthroscopy in Patients with Osteoarthritis, a Hospital for Special Surgery release.