Popular Knee Surgery May Be Useless

Experts Say Arthroscopy for Arthritis Is a Waste of Time and Money

July 10, 2002 -- Each year, hundreds of thousands of Americans have knee surgery to relieve arthritis pain. But a highly unusual study suggests the arthroscopic approach is not effective.

Arthroscopic knee surgery is done through tiny incisions without having to completely open up the knee.

"As appealing as arthroscopy might be, patients shouldn't waste their time or their money," lead researcher J. Bruce Moseley, MD, tells WebMD. "There are going to be surgeons out there who will continue to do it, because they will rationalize that the study isn't applicable to their patient population. But I would hope that most surgeons would not do it anymore."

In the Baylor College of Medicine study, people with osteoarthritis were treated with one of two types of arthroscopic surgery -- to either clean or wash out the knee joint. Results of these surgeries were compared to people who unknowingly underwent a "placebo" surgery, in which incisions were made in the knee but nothing else was actually done.

After one year, all three groups reported equal amounts of improvement in pain and function -- and the same held true two years after surgery.

The findings, published July 11 in TheNew England Journal of Medicine, call into question the value of a procedure that is performed in roughly 200,000 arthritis patients in the U.S. each year, at a total cost of over a billion dollars.

The results show that when people thought they were getting surgery yet nothing was actually done, their symptoms still improved -- called the placebo effect.

"This research indicates that there is an enormous placebo effect for this surgery, but that is the only value in the vast majority of osteoarthritis patients," says Nelda P. Wray, MD, who helped design the study. "We should certainly rethink doing this operation, and policymakers should definitely rethink paying for it."

Osteoarthritis is the most common form of joint disease. It is caused by wear and tear on the joints due to age or injury, and patients are routinely treated with painkillers and anti-inflammatory drugs. But arthroscopic surgery is one of the few treatment options short of total knee replacement when pain cannot be controlled with drugs.

The surgery involves the insertion of an arthroscope into the knee and either flushing the joint with a saline solution or flushing and scraping the knee joint. Both procedures are done to remove debris and inflammatory enzymes, but there is no indication that they slow the progression of arthritis.

In this study, 180 osteoarthritis patients treated at the Houston VA Medical Center were randomly assigned to receive the flushing procedure alone, the flushing plus scraping procedure, or the placebo surgery. All the patients understood at the outset that there was a one-in-three chance that they would receive the placebo surgery, and none knew which procedure they had gotten.

Medical observers who were also unaware of which procedure the patients received assessed their ability to perform various functions such as walking and climbing stairs.

Lead researcher J. Bruce Moseley, MD, who performed all 180 surgeries, tells WebMD that he has long questioned the value of using arthroscopic surgery to treat people with osteoarthritis. This study, he says, is the best evidence yet that the procedure is not useful. Moseley is a clinical associate professor of orthopaedic surgery at Baylor and is team surgeon for the Houston Rockets and the Houston Comets.

Osteoarthritis expert and rheumatologist David T. Felson, MD, says the study offers very strong evidence that that the surgery is of little value in this group of patients. He agrees that persuading orthopaedic surgeons not to do it may be difficult.

"There is a large community of surgeons who do this operation, and what this study is telling them is that what they are doing is worthless," Felson tells WebMD. "What I have seen when I refer patients is that surgeons tend to use this as a way to delay total knee replacement. But I don't think that is in the patient's best interest."