A Study Revives a Debate on Arthritis Knee Surgery

The New York Times—September 10, 2008

A study has found that surgery is no better than more conservative treatment to relieve knee pain caused by arthritis.

In the study, being published Thursday in The New England Journal of Medicine, 86 patients who had the operation fared no better over two years than 86 who had physical therapy and took medications to dampen inflammation.

The results of the study are in line with those from a study published in 2002. But experts are divided about what effects the two studies will have.

Some say the new study just confirms what they already knew. Others say they hope that doctors who did not believe the 2002 study will be persuaded by this one to stop doing the operations.

The 2002 study, by the Department of Veterans Affairs, had a different design: instead of assigning patients to surgery or medical treatment, it assigned them to real surgery or a sham operation. The real surgery was found to be no better than the sham one.

That study was denounced by many orthopedic surgeons, but Medicare decided in 2003 to stop paying for the operation. Still, because doctors can be reimbursed for the procedure by modifying what they say is the patient's problem, it is not clear whether most doctors stopped doing the operation, or how many such operations are being done. There is no national system for keeping track.

The surgery involves making small incisions in the knee, inserting an arthroscope to see the joint, and then flushing debris from the knee or shaving rough areas of cartilage and cleansing the joint.

It seemed to make sense that the debris and rough areas were contributing to knee pain, and when the department's study said the operation was useless, many simply did not believe it.

But the federal Centers for Medicare and Medicaid Services were convinced.

Another study, also published Thursday in The New England Journal of Medicine, found that even when an M.R.I. scan of an arthritis patient's knee showed damaged cartilage, that injury might have nothing to do with knee pain.

Dr. Robert G. Marx, an orthopedist at Hospital for Special Surgery in Manhattan, who wrote an editorial accompanying the papers, cautions that there are different sorts of meniscal tears and that the decision on surgery can require clinical judgment.

"It can be very effective for patients who have osteoarthritis but are complaining from other problems in the knee, most commonly a large meniscal tear or a loose flap of cartilage," Dr. Marx said. "The challenge for the surgeon is to pick the patients appropriately." But others said they hoped the studies would persuade many orthopedists to be more judicious in their use of the surgery for arthritis.

Read the full story at nytimes.com.