A Randomized Trial of Arthroscopic Surgery for Osteoarthritis of the Knee

A Kirkley, TB Birmingham, RB Litchfield, JR Giffin et al.

ABSTRACT

Background – The efficacy of arthroscopic surgery for the treatment of osteoarthritis of the knee is unknown.

Methods – We conducted a single-center, randomized, controlled trial of arthroscopic surgery in patients with moderate-to-severe osteoarthritis of the knee. Patients were randomly assigned to surgical lavage and arthroscopic débridement together with optimized physical and medical therapy or to treatment with physical and medical therapy alone (for details please see “details of physical therapy provided” below) . The primary outcome was the total Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score (range, 0 to 2400; higher scores indicate more severe symptoms) at 2 years of follow-up. Secondary outcomes included the Short Form-36 (SF-36) Physical Component Summary score (range, 0 to 100; higher scores indicate better quality of life).

Results – Of the 92 patients assigned to surgery, 6 did not undergo surgery. Of the 86 patients assigned to control treatment, all received only physical and medical therapy. After 2 years, the mean (±SD) WOMAC score for the surgery group was 874±624, as compared with 897±583 for the control group (absolute difference [surgery-group score minus control-group score], –23±605; 95% confidence interval [CI], –208 to 161; P=0.22 after adjustment for baseline score and grade of severity). The SF-36 Physical Component Summary scores were 37.0±11.4 and 37.2±10.6, respectively (absolute difference, –0.2±11.1; 95% CI, –3.6 to 3.2; P=0.93). Analyses of WOMAC scores at interim visits and other secondary outcomes also failed to show superiority of surgery.

Conclusions – Arthroscopic surgery for osteoarthritis of the knee provides no additional benefit to optimized physical and medical therapy

the New England Journal of Medicine. 2008 Sep 11;359(11):1169-70.

Details of physical therapy provided: Optimized physical and medical therapy was initiated within 7 days after surgery and followed an identical program in both groups. Physical therapy was provided for 1 hour once a week for 12 consecutive weeks. The intervention was standardized and based on a review of the literature and a formal survey of university physical therapists.³¹ Information regarding a home exercise exercises program that emphasized range-of-motion and strengthening was provided to all patients. Individualized exercises were recommended on the basis of the severity of osteoarthritis, the patient’s age, and the patient’s specific needs. Instruction was also provided regarding activities of daily living, walking, use of stairs, and methods of treatment involving cold and heat. The patients were asked to perform the exercises twice daily and once on the day of a scheduled physical-therapy session. After the patients had completed 12 weeks of supervised activity, they continued an unsupervised exercise program at home for the duration of the study. The patients received additional education from attendance at local Arthritis Society workshops, from a copy of The Arthritis Helpbook³² that was provided to them, and from an educational videotape.

Filed under: Exercise therapy, Knee, Osteoarthritis, Patient education, Surgery

Incidental Meniscal Findings on Knee MRI in Middle-Aged and Elderly Persons

M Englund, A Guermazi, D Gale, DJ Hunter et al.

ABSTRACT

Background – Magnetic resonance imaging (MRI) of the knee is often performed in patients who have knee symptoms of unclear cause. When meniscal tears are found, it is commonly assumed that the symptoms are attributable to them. However, there is a paucity of data regarding the prevalence of meniscal damage in the general population and the association of meniscal tears with knee symptoms and with radiographic evidence of osteoarthritis.

Methods – We studied persons from Framingham, Massachusetts, who were drawn from census-tract data and random-digit telephone dialing. Subjects were 50 to 90 years of age and ambulatory; selection was not made on the basis of knee or other joint problems. We assessed the integrity of the menisci in the right knee on 1.5-tesla MRI scans obtained from 991 subjects (57% of whom were women). Symptoms involving the right knee were evaluated by questionnaire.

Results – The prevalence of a meniscal tear or of meniscal destruction in the right knee as detected on MRI ranged from 19% (95% confidence interval [CI], 15 to 24) among women 50 to 59 years of age to 56% (95% CI, 46 to 66) among men 70 to 90 years of age; prevalences were not materially lower when subjects who had had previous knee surgery were excluded. Among persons with radiographic evidence of osteoarthritis (Kellgren–Lawrence grade 2 or higher, on a scale of 0 to 4, with higher numbers indicating more definite signs of osteoarthritis), the prevalence of a meniscal tear was 63% among those with knee pain, aching, or stiffness on most days and 60% among those without these symptoms. The corresponding prevalences among persons without radiographic evidence of osteoarthritis were 32% and 23%. Sixty-one percent of the subjects who had meniscal tears in their knees had not had any pain, aching, or stiffness during the previous month.

Conclusions – Incidental meniscal findings on MRI of the knee are common in the general population and increase with increasing age

the New England Journal of  Medicine. 2008 Sep 11;359(11):1169-70.

Filed under: Imaging, Knee

A Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee

JB Moseley, K O’Malley, NJ Petersen, TJ Menke et al

Abstract

Background – Many patients report symptomatic relief after undergoing arthroscopy of the knee for osteoarthritis, but it is unclear how the procedure achieves this result. We conducted a randomized, placebo-controlled trial to evaluate the efficacy of arthroscopy for osteoarthritis of the knee.

Methods – A total of 180 patients with osteoarthritis of the knee were randomly assigned to receive arthroscopic débridement, arthroscopic lavage, or placebo surgery. Patients in the placebo group received skin incisions and underwent a simulated débridement without insertion of the arthroscope. Patients and assessors of outcome were blinded to the treatment-group assignment. Outcomes were assessed at multiple points over a 24-month period with the use of five self-reported scores — three on scales for pain and two on scales for function — and one objective test of walking and stair climbing. A total of 165 patients completed the trial.

Results – At no point did either of the intervention groups report less pain or better function than the placebo group. For example, mean (±SD) scores on the Knee-Specific Pain Scale (range, 0 to 100, with higher scores indicating more severe pain) were similar in the placebo, lavage, and débridement groups: 48.9±21.9, 54.8±19.8, and 51.7±22.4, respectively, at one year (P=0.14 for the comparison between placebo and lavage;P=0.51 for the comparison between placebo and débridement) and 51.6±23.7, 53.7±23.7, and 51.4± 23.2, respectively, at two years (P=0.64 and P=0.96, respectively). Furthermore, the 95 percent confidence intervals for the differences between the placebo group and the intervention groups exclude any clinicallymeaningful difference.

Conclusions – In this controlled trial involving patients with osteoarthritis of the knee, the outcomes after arthroscopic lavage or arthroscopic débridement were no better than those after a placebo procedure.

the New England Journal of Medicine Vol 347:81-88, July 11 2002, No 2

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Filed under: Knee, Osteoarthritis

EULAR Recommendations 2003: an evidence based approach to the management of knee osteoarthritis: Report of a Task Force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT)

Objectives: To update the EULAR recommendations for management of knee osteoarthritis (OA) by an evidence based medicine and expert opinion approach.

Methods: The literature search and guidelines were restricted to treatments for knee OA pertaining to clinical and/or radiological OA of any compartment of the knee. Papers for combined treatment of knee and other types of OA were excluded. Medline and Embase were searched using a combination of subject headings and key words. Searches for those treatments previously investigated were conducted for January 1999 to February 2002 and for those treatments not previously investigated for 1966 to February 2002. The level of evidence found for each treatment was documented. Quality scores were determined for each paper, an effect size comparing the treatment with placebo was calculated, where possible, and a toxicity profile was determined for each treatment modality.

Results: 497 new publications were identified by the search. Of these, 103 were intervention trials and included in the overall analysis, and 33 treatment modalities were identified. Previously identified publications which were not exclusively knee OA in the initial analysis were rejected. In total, 545 publications were included. Based on the results of the literature search and expert opinion, 10 recommendations for the treatment of knee OA were devised using a five stage Delphi technique. Based on expert opinion, a further set of 10 items was identified by a five stage Delphi technique as important for future research.

Conclusion: The updated recommendations support some of the previous propositions published in 2000 but also include modified statements and new propositions. Although a large number of treatment options for knee OA exist, the evidence based format of the EULAR Recommendations continues to identify key clinical questions that currently are unanswere

Final set of 10 recommendations based on both evidence and expert opinion    (table 6)
1.     The optimal management of knee OA requires a combination of non-pharmacological and pharmacological treatment modalities
2.     The treatment of knee OA should be tailored according to:
(a) Knee risk factors (obesity, adverse mechanical factors, physical activity)
(b) General risk factors (age, comorbidity, polypharmacy) (c) Level of pain intensity and disability
(d) Sign of inflammation—for example, effusion
(e) Location and degree of structural damage
3.     Non-pharmacological treatment of knee OA should include regular education, exercise, appliances (sticks, insoles, knee bracing), and weight reduction
4.     Paracetamol (acetaminophen) is the oral analgesic to try first and, if successful, the preferred long term oral analgesic
5.     Topical applications (NSAID, capsaicin) have clinical efficacy and are safe
6.     NSAIDs should be considered in patients unresponsive to paracetamol (acetaminophen). In patients with an increased gastrointestinal risk, non-selective
NSAIDs and effective gastroprotective agents, or selective COX 2 inhibitors should be used
7.     Opioid analgesics, with or without paracetamol (acetaminophen), are useful alternatives in patients in whom NSAIDs, including COX 2 selective inhibitors, are contraindicated, ineffective, and/or poorly tolerated
8.     SYSADOA (glucosamine sulphate, chondroitin sulphate, ASU, diacerein, hyaluronic acid) have symptomatic effects and may modify structure
9.     Intra-articular injection of long acting corticosteroid is indicated for flare of knee pain, especially if accompanied by effusion
10.     Joint replacement has to be considered in patients with radiographic evidence of knee OA who have refractory pain and disability

Annals of the Rheumatic Disease. 2003 December; 62(12): 1145–1155.

doi: 10.1136/ard.2003.011742.

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Filed under: Arthritis, Exercise therapy, Knee, Osteoarthritis, Patient education, Surgery

Non-surgical spinal decompression therapy: does the scientific literature support efficacy claims made in the advertising media?

Daniel DM

Background

Traction therapy has been utilized in the treatment of low back pain for decades. The most recent incarnation of traction therapy is non-surgical spinal decompression therapy which can cost over $100,000. This form of therapy has been heavily marketed to manual therapy professions and subsequently to the consumer. The purpose of this paper is to initiate a debate pertaining to the relationship between marketing claims and the scientific literature on non-surgical spinal decompression.

Discussion

Only one small randomized controlled trial and several lower level efficacy studies have been performed on spinal decompression therapy. In general the quality of these studies is questionable. Many of the studies were performed using the VAX-D^® unit which places the patient in a prone position. Often companies utilize this research for their marketing although their units place the patient in the supine position.

Summary

Only limited evidence is available to warrant the routine use of non-surgical spinal decompression, particularly when many other well investigated, less expensive alternatives are available.

Chiropractic & Osteopathy 2007, 15:7 doi:10.1186/1746-1340-15-7

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Filed under: Lumbar spine, Spine, Traction , decompression, Lumbar spine, Traction