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Arthroscopic surgery added no benefit to optimized physical and medical therapy in knee osteoarthritis

Question How does arthroscopic surgery plus optimized physical and medical therapy (OPMT) compare with OPMT alone for moderate-to-severe knee osteoarthritis (OA)? Methods Design Randomized controlled trial (RCT). ClinicalTrials.gov NCT00158431. Allocation {Concealed}.* Blinding Blinded (nurses, outcome assessors, {data collectors, and data analysts}).* Follow-up period 2 years. Setting Fowler Kennedy Sport Medicine Clinic, London, Ontario, Canada. Patients 188 patients 18 years of age (mean age 60 y, 37% men, based on 178 patients) who had idiopathic or secondary knee OA with modified Kellgren-Lawrence (KL) grades 2 to 4 radiographic severity. Exclusion criteria included large meniscal tears, inflammatory or postinfectious arthritis, previous arthroscopic treatment for knee OA, >5 degrees of varus or valgus deformity, previous major knee trauma, KL grade 4 OA in 2 compartments (if >60 y of age), intraarticular corticosteroid injection in the past 3 months, and major neurologic deficit. Intervention Arthroscopic surgery plus OPMT (n =94) or OPMT alone (n =94). OPMT consisted of supervised physical therapy emphasizing range-of-motion and strengthening exercises, 1 h/wk for 12 weeks, followed by unsupervised exercise for the rest of the study. Individual medical treatment plans were optimized using an evidence-based algorithm. Outcomes Scores on the Western Ontario and McMaster Universities OA Index (WOMAC), SF-36 physical function survey, McMaster-Toronto Arthritis Patient Preference Disability Questionnaire, Arthritis Self-Efficacy Scale, and standard-gamble utility. Patient follow-up 89% (intention-to-treat analysis). Main results At 2 years, surgery plus OPMT did not differ from OPMT alone for WOMAC scores or any other outcome (Table). Conclusion Arthroscopic surgery plus optimized physical and medical therapy did not differ from optimized physical and medical therapy alone in moderate-to-severe knee osteoarthritis. Arthroscopic surgery plus optimized physical and medical therapy (OPMT) vs OPMT alone in knee osteoarthritis Outcomes at 2 y Surgery + OPMT OPMT Absolute difference (95% CI) Total WOMAC score 874 897 23 (208 to 161) SF-36 physical function 37.0 37.2 0.2 (3.6 to 3.2) MACTAR 238 244 6 (37 to 49) Arthritis Self-Efficacy Scale (pain)** 69 64 5 (0.8 to 11) Arthritis Self-Efficacy Scale (function)** 83.5 81.9 1.6 (4 to 7) Standard-gamble utility 0.87 0.86 0.01 (0.04 to 0.06) MACTAR = McMaster-Toronto Arthritis Patient Preference Disability Questionnaire; WOMAC = Western Ontario and McMaster Universities Osteoarthritis Index; CI defined in Glossary. Absolute difference adjusted for baseline score and disease severity. Score range 0 to 2400, higher score = more severe symptoms. Score range 0 to 100, higher score = better quality of life. Score range 0 to 500, higher score = greater disability. **Score range 10 to 100, higher score = greater self-efficacy. Score range 0 (death) to 1 (perfect health). Commentary Arthroscopic debridement and lavage for knee OA continues in practice despite persuasive negative findings from a sham-surgery controlled RCT (1). The RCT by Moseley and colleagues was criticized as nongeneralizable and perhaps invalid because it included mostly men at a veterans hospital, was carried out by 1 surgeon whose practice may not have been representative, and used an unusual outcome measure. Also, treatment effects for patients with catching or locking symptoms, which could have improved with debridement of meniscal tears, were not evaluated. The RCT by Kirkley and colleagues should put the matter to rest. Although sham or placebo surgery was not done, this RCT found that arthroscopic debridement and lavage by 8 surgeons did not add benefit to no surgery at 2 years. The RCT included women, used a validated outcome, and showed no benefit in the subgroup of patients with catching and locking. Another study showed that incidental meniscal tears are common in middle-aged and older adults, so that tears identified on magnetic resonance imaging do not necessarily require surgery (2). Incidentally, the RCT by Kirkley and colleagues provides indirect evidence that OA is driven by aberrant mechanical loading across the knee, which is not addressed by washing and debriding the inside of the joint. Would any patients with knee OA benefit from arthroscopic surgery? An accompanying editorial (3) noted that sudden twisting injuries or knee trauma can cause an acute meniscal tear requiring surgery, even in persons with OA. On a background of activity-related pain, such patients have sudden severe acute and continuous pain and/or new onset of knee catching or locking. If the joint is not ready for a knee replacement, then arthroscopic meniscectomy may be indicated.