From Jonathan Cluett, M.D.,
Your Guide to Orthopedics.
FREE Newsletter. Sign Up Now!

About.com Health's Disease and Condition content is reviewed by Kate Grossman, MD

Arthroscopic surgery of the knee has come under public scrutiny after a report in the New England Journal of Medicine published in July, 2002, seemed to say that surgical treatment was no better than a "sham" surgery.

But that's not the whole story.

The presentation of this study by the media has been misleading to patients, and caused a general misunderstanding about treatments available for arthritis of the knee.

What did the study report?
The article presented in the New England Journal of Medicine presented the results of a study that evaluated the treatment of arthritis of the knee joint in patients at a VA hospital in Houston, Texas. The study separated 180 patients into one of three groups. One group received an arthroscopic debridement, where the knee was 'cleaned up'; another group received a knee wash-out, or lavage, with saline; and the final group had no procedure--a 'sham' surgery. The results showed that there was no difference in outcome between these groups.

Does that mean arthroscopic surgery does not work?
Absolutely not! In fact, many surgeons have thought for decades that arthritis was not a good reason to perform arthroscopic surgery. The benefit of knee arthroscopy in treating cartilage tears, ACL injuries, and other specific conditions has been shown repeatedly to be outstanding. Surgical decisions must take into account careful consideration of so-called operative indications. When surgery is done for the right reasons, it is usually effective.

So what are the 'right' reasons to scope a knee?
There are quite a few, but most commonly knees respond best to "mechanical" symptoms. Mechanical symptoms are problems such as a catching sensation, a giving way, or painful popping. These symptoms can be due to mechanical impediments to normal knee function. Knee arthroscopy to treat isolated pain, with no other symptoms, can be beneficial, but other treatments need to be considered as well.

What is the problem with the study?
Essentially, the study looks at a group of patients who had a specific surgery, without the proper indications for that procedure. Many orthopedic surgeons would not perform this surgery in these cases, and therefore, you might expect these patients would do no better than the patients who had the 'sham' surgery.

Did the study offer any other insight?
Most interestingly, and not reported by the media, was that ALL of the patient groups were "better" after their treatment-- even the 'sham' surgery group. The placebo effect is not a new concept, but it certainly raises some ethical eyebrows when just the idea of having surgery is known to benefit a patient.

What options do I have for knee arthritis?
Unfortunately, arthritis treatment is most beneficial in the earliest and latest stages of the condition. Anti-inflammatory medications, physical therapy, glucosamine, steroid injections, Synvisc, are all viable options for early stages of the condition, and total knee replacement is an excellent treatment for late stage arthritis. The problem is treatment of people in the middle ground. Working with the aforementioned treatment options, to find a treatment regimen best suited to the individual is an important job of an orthopedic surgeon.