Good news about knees

Arthroscopy isn't effective against arthritis, but other procedures work well

Health & Fitness

September 01, 2002|By Jane E. Allen | By Jane E. Allen,Special to the Sun

When a recent study found that a popular knee operation was only as good as a placebo for arthritis, some sufferers misconstrued the results, assuming that no surgery would help them.

Doctors are now trying to reassure people that this isn't the case.

The research, published in July in the New England Journal of Medicine, found that arthroscopic knee surgery, in which a surgeon inserts small instruments into the knee to explore the damage and make repairs, provided only mild relief at most for arthritis sufferers. Patients undergoing the surgery, the study said, had the same degree of pain relief as those who had a simulated procedure, in which tiny incisions were made and nothing more was done.

"Patients that have arthritis read this as saying any knee surgery for arthritis doesn't work," said Dr. Larry Dorr, director of the Arthritis Institute at Centinela Hospital in Los Angeles.

Arthroscopy remains a good operation for those who have suffered knee trauma and acute injury, such as an athlete with torn cartilage or a weekend athlete who tears a meniscus or ligament, he said.

For those with painful, stiff, arthritic knees who can't get relief any other way, there are procedures to help.

"Total knee replacement is a highly successful operation, and it's shown to be one of the most effective treatments in terms of returning people to productivity," Dorr said. But knee replacements are painful, and rehabilitation can take up to a year.

Many doctors began offering the simpler arthroscopy, Dorr said, because patients were reluctant to endure the pain, cost and prolonged recuperation of knee replacement. But, he said, "There was no one overlooking it and saying, 'This isn't working and we should stop.' "

Up until the recent study, there hadn't been scientific comparisons of arthritis patients who underwent the surgery with those who got a dummy procedure. Two years after the procedures, about 35 percent of all the subjects thought they had improved; 65 percent felt worse or stayed the same. But the improvements were generally in perceived pain, not in any objective measure of whether they could function better, said Dr. Nelda P. Wray, the study's senior scientist.

Of the 650,000 annual arthroscopies, orthopedic surgeons report doing 35 percent to 50 percent of them for the wear-and-tear of arthritis, Wray said. With 250,000 to 300,000 such procedures performed for arthritis each year at a cost of $5,000 each, more than $1 billion is being spent only to get a placebo effect, said Wray, a researcher and internist at the Houston VA Medical Center and Baylor College of Medicine in Houston.

"We probably should be taking all the time and resources and money that we use to do this and be applying them in better, more effective ways," said Dr. Bruce Moseley, the Baylor orthopedic surgeon who performed the real and simulated surgeries for the study.

He and other orthopedic surgeons said patients have several options:

Nonsurgical management: Patients adapt their movements to what their knees will allow, while maintaining a healthy weight to alleviate extra stress on the joint. Pain relievers and anti-inflammatories can be used.

Heat before activity and ice afterward can reduce pain and swelling. Physical therapy and massage can help.

Osteotomy: Popular before the advent of arthroscopies, it's performed in a hospital on younger patients who want to reduce pain while preserving their knee joints. Because most people with arthritic knees become somewhat bow-legged or knock-kneed, doctors cut into either the leg bone (the tibia) or thigh bone (the femur) to realign the leg and knee and redistribute the load on the joint. Patients may return to work in three months; complete recuperation can take up to a year.

Knee replacement: Total knee replacement involves replacing worn or missing cartilage in all three knee compartments with a new lining consisting of metal on one side and plastic on the other. Recuperation can take six to 12 months. Doctors performed 299,000 total knee replacements in 2000. A 1998 study found that after 10 years, 90 percent of these procedures are successful.

Viscosupplementation: A relatively new therapy, involving injections of lubricant to replace knee fluid that has become less slippery because of arthritis. Although the injected hyaluronic acid eventually breaks down, some patients report years of relief.

Unispacer: The most recently developed knee procedure, it involves making a single incision and sliding a metal disk between the bones of the leg. Although FDA-approved, the procedure has been performed only 900 times to date.

Said Dorr: "It may be the next easy solution for arthritis in the knee, like arthroscopy was, but there's no good data yet that say it's going to work."

Jane E. Allen is a reporter for the Los Angeles Times, a Tribune Publishing newspaper.

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