Arthroscopy doesn't work????

Below is a letter to the editor from AANA that is being sent out to the national media this week. It sums the whole issue up nicely.
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A medical article published in the July 11, 2002 issue of the New England Journal of Medicine has captured the fantasy of the media. This study addressed the use of arthroscopic surgical techniques for the treatment of arthritis of the knee. The assumption made by the authors of the article as well as the media is that arthroscopic surgery is useless in the management of arthritis of the knee joint. Dozens of newspaper articles and television reports have focused on this study.

The casual reader of these articles might think that arthroscopic surgery is useless for any type of knee surgery involving arthritis. This is most unfortunate, particularly in view of the fact that arthroscopic surgery now has the well deserved reputation of being the gold standard for surgical care of the knee. For years those of us entrusted with the teaching of arthroscopic surgery to our peers have stressed the importance of a careful evaluation of our patients before considering surgery. When arthritis is a component of the problem in the knee, it is well recognized that arthroscopic techniques have limitations. When it is obvious by x-rays and physical examination that arthritis in the knee is advanced, arthroscopy should not be considered. If there is a narrowed joint space on x-ray, with no mechanical symptoms, arthroscopy offers the patient no chance of relief. This has been understood for years and has been taught to those learning the technique. In other words, patient selection is important. The authors of the article in the New England Journal of Medicine do not emphasize patient selection criteria, and actually had a pre-selection bias that was not fully discussed. With proper selection, patients with early degenerative arthritis and mechanical symptoms of locking or catching can derive significant benefit from arthroscopic surgery. Many well-controlled scientific studies have proven this point.

No responsible orthopaedic surgeon doing primarily arthroscopic surgery will claim that arthroscopic surgery is of benefit to all patients with arthritis of the knee. That would be clearly untrue and inappropriate. It is just as inappropriate to state that arthroscopic surgery is useless in any case of arthritis. It is shameful that responsible people would convey this impression to the public. Certainly, doctors should carefully evaluate their patients and select the most appropriate treatment plan based on established criteria that predict the best chance of relief. In many cases, this includes non-surgical management. In other cases, it may be the performance of a total knee replacement. There is however a sub-group of patients with knee arthritis that can be significantly helped with appropriate arthroscopic surgery.

Years of earned trust from the public regarding arthroscopic surgery can be threatened by incomplete or irresponsible reporting. This single article, while appropriate in some aspects of its scientific approach, is nonetheless flawed in several critical scientific respects.

The public – our patients – must be reassured that, in the hands of the conscientious orthopaedic surgeon familiar with the patient selection criteria for degenerative arthritis, arthroscopic surgery can be a dependable procedure, capable of producing long-lasting relief.



Stephen S. Burkhart, M.D., President
Arthroscopy Association of North America



J. Whit Ewing, M.D., Executive Vice President
Arthroscopy Association of North America

Who the --- used my name to post a reply to this topic, it sure as h$%& wasn't me?? :evilgrin:

Thanks OrthoDoc, the attending I was with today completely agreed. He said the study was based on old patients from a VA hospital. Of course they'd have poor results with such advanced disease.

This showed up on the front page of my newspaper today. I'm sure a few a my patients will clip it out and bring it in. It is interesting that the study was published in the NEJM and not in the orthopedic literature.
My suspicion even before looking it up was that there had to be an author on board from an internal medicine department and I was correct.

Maybe, it was denied in our literature b/c we already know that in advanced disease these patients do not benefit from an arthroscopic lavage.

The problem with it is they do not stratisfy the patients' disease level in the abstract which is what most people will read. It is just a blanket statement.

Scoping end stage disease is typically not a worth while procedure and we've known that for a long time, but if you scope mild and occasionally moderate DJD with a meniscus tear, most of those patients feel better. As I said above, it is usually related to meniscal flaps and not really the DJD.

Here is the link for the abstract. I'm going to dig up the article tommorrow in the library to see if they stratisfied their patients.

I myself did not know that arthroscopy was commonly performed for OA (I'm an intern). But if you read the editorial in the same issue of NEJM, it explains that "lavage removes debris such as microscopic or macroscopic fragments of cartilage that may induce synovitis, a likely source of pain. Lavage also removes calcium phosphate crystals that are detectable in most severely osteoarthritic knees and may be associated with synovitis. Debridement consists of smooting rough, fibrillatied articular and meniscal surfaces, shaving tibial-spine osteophytes that interfere with the motion of the joint, and removing inflamed synovium. "

The problem is that laypersons will interpret this study as "arthroscopy doesn't work", period. They don't realize that meniscal repair, ACL reconstructions, etc. are not included in this study.
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h well:

It's in the new england journal of medicine this week. The study (although I haven't had time to read it all) seems to address the two arthroscopic procedures of lavage (just washing tons of saline through the knee) and lavage with debridement of synovium. Apparently they took patients with osteoarthritis of the knee and did either of the two above surgeries or sham surgery and those with sham surgery did as well or better than the ones really treated. This doesn't really surprise me but I don't understand one thing. In my very brief orthopedic training osteoarthritis treatment entails NSAIDS, then steroid injections, possibly synvisc (hyaluronic acid) injections, and then ultimately total knee replacement. I have never seen arthroscopy done for OA. I have a very narrow experience and would love for an attending to comment. The laymen's news media is reporting that 650,000 people a year have arthroscopic lavage/debridement to treat osteoarthritis. I don't know where to find such statistics but that sounds ludicrous to me. If that were true, then in 10 years 20 percent of the US population would have had the procedure for OA. They further go on to point out that the surgery costs 5000 dollars. They make it sound like orthopods are doing three billion dollars a year in unnecessary and ineffective surgery. I have difficulty believing this. My gut feeling is that there are 650k arthroscopic knee procedures a year and a small percentage of these are for OA. Somebody tell me where the true data is and I'll send all the news outlets scathing letters about their gross misrepresentations.

I think you can read the study at

Yea I just caught the tail end of the NBC nightly news talking about this. Would be interesting to read the study they are talking about.

Gambit

What journal is the article in? From my clinical experience, if you pick the patient right, most will feel better following a scope. Usually, it is related to excision of unstable meniscal fragments that make them feel better and gets rid of their sharp catching pain. I always tell them that their dull achy arthritic pain will most likely persist