Debate on the use of arthroscopic surgery for osteoarthritis of the knee.

A recent article published in the New England Journal of Medicine by J. B. Moseley, an orthopaedic surgeon, and others, was entitled “A controlled trial of arthroscopic surgery for osteoarthritis of the knee” (1). The patients that they studied were all from the Veterans Affairs Medical Center in Houston. They recruited some 180 patients with osteoarthritis of the knee who agreed to be randomized into 1 of 3 groups: a) normal treatment, consisting of lavage and debridement, b) lavage (or saline irrigation) only, and c) a sham operation only, i.e., a nick in the skin but no arthroscopic procedure. Their results suggested that all 3 groups were improved slightly. However, as the placebo group also improved, their conclusion was somewhat damning and extremely far-reaching. They concluded that arthroscopic surgery was obviously of no value in the treatment of arthritis of the knee. The impact of this article on the public, the insurance industry, and the government has been significant and has raised a great deal of controversy. The conclusions reached by its authors are a good example of why research, particularly clinical research, should be subjected to peer review by experts in that specific field, and results validated, before such information is released to the public. Our own studies have also shown that arthroscopic surgery is of little value in the more advanced stages of arthritis but can be of significant value in relieving pain and swelling and improving function in the earlier stages of arthritis. A recent study that has been accepted for publication in the Journal of Arthroscopy has shown that such benefit can be obtained for at least 4 to 6 years in patients with early stages of arthritis. Dr. Nelda Wray, one of the authors of the Moseley study, was quoted as saying that “the fact that the effectiveness of arthroscopic lavage and debridement in patients with osteoarthritis of the knee is no greater than that of placebo surgery makes us question whether the $1 billion spent on these procedures might be put to better use.” Dr. Wray is also quoted as saying, “I believe the coffin lid is nailed shut on this procedure.” It is noted that Dr. Wray is an internist with a degree in public health and not an orthopaedic surgeon nor an expert in musculoskeletal disease. The fallout from these statements and others has been significant over the past few months. Patients are questioning their doctors' advice. The Department of Veterans Affairs (VA) in Washington issued a directive on August 23, 2002, recommending that without a review by a panel of experts, arthroscopic procedures for osteoarthritis should not be done in the VA system. If the VA as a government agency is telling surgeons what they can do and on whom they can operate, how soon will Medicare follow? United Healthcare, a private insurance company, has also written to surgeons that have conducted arthroscopic surgery on arthritic patients and suggested that they critically review the appropriateness of this procedure in this patient population. It is probable that insurers will soon stop paying for the procedure. The success for patients in this procedure is strongly dependent on selectivity, a factor that is missing from placebo surgery. Experienced surgeons are extremely thorough in selecting their patients with osteoarthritis for arthroscopic surgery and choose those that will benefit most. The implication of this article has been that patients with osteoarthritis of the knee should wait until their knee gets so bad that it requires a total knee replacement. Looking at the economic approach for the validity of such a concept, the cost of the total knee replacement is 5 times greater than that of an arthroscopic lavage and debridement. Also, since total knee replacements frequently have to be redone in several years because they tend to wear, one has to question whether the economics suggested in this article really stand up. This study was seriously flawed, first by the selection of patients with no clear indication as to how severe the arthritic state was in each case. Second, patients in the VA system do not represent the typical population, which consists of younger people and women (97% of study patients were men). Moreover, VA patients have a vested interest in getting continued benefits for a disability. Third, the statistics used in the paper have been strongly criticized by independent statisticians, as the authors changed their direction on 3 occasions, first using an established device to show superiority of one group over another (which it did not), then using another proven device to demonstrate “equivalence” (which it did not), and then finally using an unvalidated measurement device of their own making, which did prove equivalence of the 3 groups. The best one can say of this article was that it presented preliminary information from a limited study and did not prove or validate the concept of arthroscopic surgery in the treatment of arthritis as a whole. —Robert W. Jackson, OC, MD, FRCS(C)