Common osteoarthritis treatment questioned
■ Studies suggest that surgical intervention for osteoarthritis has limited benefit, and that activity modification and NSAIDs should be considered first-line therapy.
By Victoria Stagg Elliott — Posted Oct. 13, 2008
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Nearly half the population will develop osteoarthritis in their lifetimes, and hospitalizations for this problem are increasing. A common surgical intervention, however, is often not the best answer, according to a several recently published papers.
With regard to prevalence, a study in the Sept. 15 Arthritis Care & Research analyzed data on 3,068 participants in the Johnston County Osteoarthritis Project in North Carolina. Researchers found that 45% would experience the symptoms of osteoarthritis in at least one knee by age 85. For some, that risk was higher. Nearly 57% of those with a history of injury to this joint and 61% of those who are obese also were destined to develop this problem.
"People are living longer, and symptomatic osteoarthritis is a common and often disabling problem that [physicians] can anticipate seeing," said Chad Helmick, MD, one of the paper's authors and a medical epidemiologist with the Centers for Disease Control and Prevention's arthritis program.
Experts are particularly concerned about these numbers because the population is getting older and becoming more overweight. These factors already have led to increases in hospitalization rates, primarily for joint replacement. According to data released Sept. 3 by the Agency for Healthcare Research and Quality, the number of hospital stays with osteoarthritis as the primary diagnosis increased from 322,200 in 1993 to 735,100 in 2006.
While it is clear that the prevalence is accelerating, evidence also is emerging that one of the procedures commonly used to treat it is not effective. A study in the Sept. 11 New England Journal of Medicine found that, for those with moderate to severe arthritis in the knee, surgical lavage and arthroscopic debridement provided no added benefit to physical and pharmaceutical therapy.
"The practice of performing the surgery has evolved over the years, but, like many surgical procedures, it's an experimental procedure that went into practice without rigorous evaluation and controlled trials," said Dr. Brian Feagan, one of the paper's authors and clinical trials group director at the Robarts Research Institute at the University of Western Ontario in Canada.
"It's a very widely performed procedure, but we did not find either a clinical or statistical difference in outcomes," he added.
Researchers randomized 178 patients to receive an hour of physical therapy once a week for three months and medical management with or without arthroscopic surgery. Patients with large meniscal tears were excluded. Those who got the surgery were more improved at the three-month mark than were those who did not undergo this procedure. But no difference in outcomes was evident at the end of two years.
The authors consider differences in recovery three months after arthroscopy to be a placebo effect, citing a previous randomized trial that also suggested that the procedure had no benefit for this condition. Those results were reported in the July 11, 2002, NEJM.
Investigators randomized 180 people to receive either this procedure or a placebo surgery. They, too, concluded that the surgery had no benefit, although participants in both arms experienced some relief after either receiving the surgery or believing they had.
Some physicians praised these studies for providing guidance as to who might benefit the most from this procedure and what should be said to patients to make their expectations more realistic.
"We need to be cautious about arthroscopic surgery for intermediate arthritis that is not severe enough to warrant a knee replacement," said Nathan Hitzeman, MD, a family physician at Sutter Health in Sacramento, Calif. "We might be giving false hope to patients."
Experts stressed, though, that this surgery continues to be appropriate for certain patients.
"You have to know when to use it," said Dr. Robert G. Marx, who wrote the accompanying editorial and is an associate orthopedic surgeon at the Hospital for Special Surgery in New York. "While I do not recommend arthroscopy as a treatment for an arthritic knee, it can be extremely helpful for people with arthritis who also have a co-existing knee problem, such as a meniscal tear or a loose piece of cartilage, that is causing the majority of their symptoms."
A recent paper in the Sept. 11 issue of NEJM, suggested that even if a co-existing problem is found, it may not be the source of the pain.
Researchers asked 991 participants in the Framingham Heart Study about arthritic symptoms in their right knees and assessed MRI joint scans. About 63% of those with pain, aching and stiffness, and radiographic evidence of osteoarthritis had a meniscal tear. The numbers, though, also were similar for those without symptoms. Approximately 60% of those with osteoarthritis and a meniscal tear did not experience these symptoms within the past month.
"Damage was very common even in the absence of any symptoms," said Dr. Martin Englund, lead author on that paper and a research associate at Boston University School of Medicine. "When a meniscal tear is found on an MRI examination of the knee, normally we blame that, but it may have nothing to do with the symptoms. We need to think a little bit harder about how we treat patients. Surgery should not be the first option we think of or even the second. Surgery has a place, but in a very few selected cases."
American Academy of Orthopaedic Surgeons guidelines say initial treatment of knee osteoarthritis involves modifying activities and non-steroidal anti-inflammatory medications. Surgical interventions should be considered only when more conservative strategies haven't worked.
"If these measures are not effective, think about surgery," said E. Anthony Rankin, MD, AAOS president.
He added that the findings of these studies were in line with this organization's guidelines, which also state that debridement may be indicated if degenerative arthritis is accompanied by locking, catching or giving way of the joint. It is not indicated for those without these symptoms.