Arthroscopic Surgery for Knee Arthritis
By Scott Stubbs, M.D.
Arthroscopy (minimally invasive telescopic surgery through small incisions) for degenerative knee arthritis is controversial. In some cases, severe arthritis has progressed to a point where such a procedure is unlikely to be beneficial. In fact, a highly publicized study in the New England Journal of Medicine a few years ago concluded that this type of procedure was no better than other non-operative options for pain relief. Many patients and physicians at the time were heavily influenced by the report. This study has since been heavily scrutinized and found to have many flaws and significant bias. Since then other studies have been published supporting arthroscopic surgery for some arthritic conditions.
One of the better studies to look at this recently included 593 patients in a private practice who opted for arthroscopic debridement over total knee replacement to relieve arthritis symptoms. All of the patients had knee arthritis classified as "severe". The researchers found that just over half of the patients improved at an average of five years after surgery. Many of these patients wanted to avoid knee replacement and never got one. They were referred to as "copers" meaning they had the personality and persuasion to cope with their condition.
So what is one to do? How do you decide if a minimally invasive procedure with a relatively quick recovery will help or not? How do you decide when it is time for a knee replacement that requires assuming more risk and a longer recovery phase? The short answer — consult with an experienced orthopedic surgeon. He or she should be able to help you come to an informed decision.
Many factors such as age, severity of arthritis, location of changes in the knee, mechanical symptoms, loose cartilage, swelling, lifestyle, expectations and many others must be taken into account. A patient's expectations may be one of the most important factors in deciding whether a procedure is right for them or not. The role of the orthopedist is to educate and answer questions to let the patient make an informed decision with realistic expectations.
For example, a 50 year old male with post-traumatic arthritis from old athletic injuriesmay suddenly develop new locking and swelling in his knee. This may indicate a loose piece of cartilage or tear on top of his preexisting degenerative changes. Arthroscopic surgery may be helpful to treat the new problem understanding that the patient will still have some future discomfort and limitations. Such a procedure could return them to their previous functional level, possibly delaying the need for more extensive surgery or even knee replacement. The expectation that an arthroscopic surgery would "cure" or make the patients knee "normal" again would be unrealistic.
Bottom line — arthroscopic surgery can be helpful for some patients with knee arthritis. It is certainly not a panacea for all. Be wary of any study or report of a procedure that claims it will always or never be beneficial. Rarely are there any such absolutes in medicine or life in general. Take time to understand your individual problem and level of arthritic changes. Review your x-rays with the physician. Ask lots of questions and rely on your orthopedic surgeon to educate you to make an informed decision on the right path to take.
