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Archive for the ‘Arthroscopy’ Category

meniscus1

The Journal of Bone and Joint Surgery (JBJS) published findings that most patients with a torn or damaged meniscus (under 50 years old) experienced less knee pain and an increase in knee function following meniscal transplant surgery. Although, many patients required additional surgery within 10 years.

The meniscus acts as a cushion between the femur and tibial plateau. It can be damaged in an injury or slowly as the body ages.  A meniscus transplant can be performed in younger patients (under 50) to stabilize the knee joint, decrease knee pain, increase function, and maintain a cushion between the two bones.  The surgery is performed arthroscopically.

38 meniscal transplant patients under 50 years old were followed for about 11 years.  Outcomes were based on radiographic, subjective, and clinical measures.

10 years in to the research Sixty-three percent of meniscal transplants were still good.  11 percent of patients had pain when engaging in daily activities after the transplant. Also, nearly seventy-five percent of patients were able to participate in low-impact sports like swimming.  In patients requiring additional surgery, the meniscal transplants made it about  7 to 8 years after the surgery depending which knee compartment was being transplanted.

“This data provides surgeons with reasonable percentages that encourage delaying additional major knee surgeries related to a damaged meniscus,” Frank R. Noyes, MD, said.  Dr. Noyes is the lead author of the study and founder of the Noyes Knee Institute at the Cincinnati Sports Medicine & Orthopaedic Center.

“However, the longer-term function of meniscus transplants remains questionable because the survivorship rate of the transplants decreases to between 40 and 15 percent at 15 years,” Dr. Noyes commented. “Patients should be advised that this procedure is not curative in the long-term and additional surgery will most likely be necessary.”

 



 

A recent study shows that smokers have a harder time with knee replacement surgery than non-smokers.  That’s not a surprise.  But what is surprising is that the research said there was no difference between current smokers and patients that had quit.

Dr. Michael Mont, director of the Center for Joint Preservation and Replacement said, “It could be that the damage was already done.  When you smoke and stop, you improve your health, but you still have build-up in your system. That may be why we didn’t see a difference.”

The study, which was presented at the annual Academy of Orthopedic Surgeons in San Francisco, examined 600 knee replacements in 60 – 65 year old patients.  About 20% of the patients were smokers.  Problems related to surgery like failing kidneys, blood clots, and abnormal heart rhythms affected 21% of the smokers compared to 12% of the non-smokers.  Smokers were ten times more likely to have a revision surgery to fix things that went wrong than non-smokers.

One of the last treatment options for osteoarthritis of the knee is knee replacement surgery.

 



arthroscopy

arthroscopy

In a recent policy article, health insurance giant Aetna considers arthroscopic debridement and lavage for osteoarthritis of the knee experimental and investigational because its effectiveness has not been established.

The only people Aetna considers arthroscopic debridement and lavage medically necessary are for those with mild to moderate osteoarthritis who have loose bodies or meniscal tears in their knees.

This means Aetna is reading the literature.  They based their policy on 40 different references from medical journals and scholarly articles.  Arthroscopic debridement and lavage is not an effective treatment option for many people with knee osteoarthritis.



Knee Arthroscopy

Knee Arthroscopy

Arthroscopy is a minimally invasive surgical procedure in which an examination and sometimes treatment of damage to the interior of a joint is performed using an arthroscope, a small camera.  The “scope” is inserted into the joint through a small incision.

The advantage of arthroscopy over traditional open surgery is that the joint does not have to be completely opened.   Instead, two small incisions are made – one for the arthroscope and one for the surgical instruments to be used in the knee cavity to fully remove the knee cap.

Though arthroscopic surgery is widely recommended by the orthopedic community to treat knee osteoarthritis, the usefulness of the surgery is doubtful. A study on arthroscopic surgery for osteoarthritis of the knee was published in the New England Journal of Medicine in 2002. In this three-group study, 180 military veterans with osteoarthritis of the knee were randomly assigned to receive arthroscopic debridement with lavage, just arthroscopic lavage, or a sham surgery, which made superficial incisions to the skin while pretending to do the surgery. The study reported, “At no point did either of the intervention groups report less pain or better function than the placebo group. Because there is no confirmed usefulness for these surgeries, many agencies are reconsidering paying for a surgery which seems to create risks with no benefit.”



Avoid Surgery

Avoid Surgery

Dr. David Hunter from New England Baptist Hospital in Boston and University of Sydney in Australia recently published a study in Arthritis Care & Research.  “Quality of Osteoarthritis Management and the Need for Reform in the US” is research aimed at drawing attention to the fact that health care professionals in the United States often treat the pain and try to increase function in arthritic knees, but seldom try to improve joint structure or try to work with patients on long-term solutions.

The authors of this study recommend conservative treatment options for knee OA, especially avoiding pharmacological solutions.  “Weight management and exercise programs tend to be overlooked by clinicians,” said Dr. Hunter.  “These conservative approaches are beneficial to patients who adhere to weight-loss and exercise programs.”

The study examined prior research on treating osteoarthritis of the knee and found that up to 30% of surgeries are inappropriate!  And as we discussed on this blog arthroscopy should be avoided as a treatment option for knee OA – it doesn’t work yet orthopedic surgeons still perform the operation – every day.

Weight loss and exercise are the best treatment options for knee OA – how many more studies have to be conducted on the subject?  Joint health supplements, and knee braces are conservative treatments that will help you get up and moving.



meniscectomy

meniscectomy

Recommendation 19 – Partial meniscectomy is an option for patients with knee osteoarthritis.  These patients must also have symptoms indicating a torn meniscus and / or a loose body in their knee joint.

There aren’t any published studies that confirm this recommendation but the expert opinion of the research team concludes that if you have a torn meniscus and knee osteoarthritis, it makes sense to have the tear or loose material removed by arthroscopy.



Knee Arthroscopy

Knee Arthroscopy

This post is one of a series of posts about the American Academy of Orthopedic Surgeons’ (AAOS) Knee Osteoarthritis TreatmentGuideline.

Recommendation 18 – The AAOS does not recommend arthroscopic debridement and lavage in patients with knee oa.

Since the North American Arthroscopy Association helped fund the AAOS Treatment Guideline, this recommendation is a big deal.  This is orthopedic surgeons telling other orthopedic surgeons that one of their bread-and-butter surgeries doesn’t work.

The research team concluded that arthroscopic debridement has no significant benefit for knee osteoarthritis.  Wow.




This is a continuation of our series on the Osteoarthritis Research Society International (OARSI) recommendations for the management of hip and knee osteoarthritis published in the Journal of Osteoarthritis and Cartilage.

knee surgery

arthroscopic knee surgery

Recommendation XXIV

Arthroscopic debridement and lavage for knee osteoarthritis is controversial.

3 out of 3 treatment guidelines recommend arthroscopic debridement and lavage as a treatment option for knee OA but some studies have demonstrated symptomatic pain relief can be attributed to a placebo effect.  Controversy regarding the efficacy and indications for this treatment option continues.

The research team gave this osteoarthritis treatment option a Strength of Recommendation score of 60%.

W. Zhang Ph.D., Moskowitz M.D., et al. OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis and Cartilage. (2008) 16, 137-162


knee painA study on arthroscopic surgery to treat knee OA was published in the New England Journal of Medicine.  The study reported “At no point did either of the intervention groups report less pain or better function than the placebo group.  Because there is no confirmed usefulness for these surgeries many agencies are reconsidering paying for a surgery which seems to create risks with no benefit”.

Further, the American Academy of Orthopedic Surgeons released in their 2008 Treatment Guideline for Knee Osteoarthritis that they could not recommend arthroscopic surgery as an effective treatment option.

The New England Journal of Medicine and the American Academy of Orthopedic Surgeons both agree that arthroscopic surgery may not be an effective treatment for your knee pain.

Have you ever considered trying a knee brace to treat your OA?  Bio-mechanical knee braces are clinically proven to decrease pain and increase function in arthritic knees.  They are commonly called Unloading Braces or Off-Loading braces.  Nobody has ever died from wearing knee braces.