Knee Pain Not Helped by Surgery, Study Shows

By GINA KOLATA
11 sept 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.
“What happened after our study was that organized orthopedics rallied the troops to try and discredit our study as much as possible,” said Dr. Bruce Moseley, the 2002 study’s principal investigator, who is now at the Richmond Bone and Joint Clinic in Texas. “People continued to practice the way they practiced.”
But the federal Centers for Medicare and Medicaid Services were convinced.
“It was one of the very rare occasions that C.M.S. actually narrowed coverage from its existing policy,” said Dr. Sean Tunis, the centers’ chief medical officer at the time. “The V.A. trial showing no benefit was very influential.”
Since then, said Dr. Barry Straube, the current chief medical officer, the number of operations may have declined.
Medicare pays for the surgery under several cost codes. For one, arthroscopies that involved shaving knee cartilage, Medicare paid for 27,697 arthroscopies in 2002. In 2006, the number was 6,466, Dr. Straube said.
Dr. E. Anthony Rankin, president of the American Academy of Orthopaedic Surgeons, said most orthopedists appreciated the surgery’s limitations. “As a tool for treating arthritis alone, it probably isn’t a good tool,” he said.
But others say the operation remains popular.
In fact, said Dr. David T. Felson, a professor of medicine and epidemiology at Boston University School of Medicine, the operation seems to have “become even more popular.”
Dr. Brian G. Feagan, head of the clinical trials unit at the Fowler Kennedy Sport Medicine Clinic in London, Ontario, and an author of the new study, said Canadian doctors, too, were not much affected by the department’s study.
“It really didn’t change practice,” Dr. Feagan said. Surgeons continued to believe in arthroscopy for arthritis pain, he added, and “they are doing a lot of it.”
Now, with the new study, “I think practice will change,” he said, adding, “It’s pretty hard to ignore two studies that say the same thing.”
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.
The study, led by Dr. Felson, involved 991 middle-age and elderly people in Framingham, Mass. Sixty-three percent of participants with knee pain from arthritis had a torn or destroyed meniscus, the wedge-shaped piece of cartilage that helps stabilize the knee. But 60 percent of those with arthritis but without knee pain also had a damaged meniscus.
“In patients with arthritis, almost everybody has meniscal tears,” said Dr. Martin Englund of Boston University, the study’s lead author. “We are so drilled to think, ‘Oh, a meniscal tear — that must be painful,’ or ‘That’s the cause of the pain.’ But it may be involved in the disease process itself. There are many, many other reasons for pain in knee, but the meniscus is the structure we focus on and see.”
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.
“If it doesn’t change care, it speaks poorly for the medical community’s willingness to take evidence into account,” Dr. Felson said.

Osteoarthritis Singled Out as Cause of Meniscal Damage and Knee Pain

BOSTON, Nov. 29 -- In older patients, osteoarthritis causes both knee pain and damage to the meniscus, according to researchers here.
Action Points
Explain to patients that knee stiffness and pain in older individuals are probably caused by osteoarthritis rather than by damage to the meniscus.
Explain that meniscus damage may also be caused by osteoarthritis.
Meniscal damage is not directly linked to knee pain, aching, and stiffness but, rather, both are related to osteoarthritis, Martin Englund, M.D., Ph.D., of Boston University, and colleagues reported in the December issue of Arthritis & Rheumatism.
In the U.S., 11% to 15% of men and women 65 and older have osteoarthritis of the knee manifesting in pain, aching, and stiffness.
Associated with aging, obesity, and sport injuries, tears to the menisci are a common MRI finding, especially in an osteoarthritic knee. However, whether meniscal damage foreshadows knee pain from another source or directly causes it has not been known, the researchers said.
To help improve the early detection of osteoarthritis, researchers with the Multicenter Osteoarthritis Study set out to evaluate the effect of meniscal damage on the development of knee pain, aching, and stiffness in a randomized prospective study of 3,026 individuals ages 50 to 79 who had a high risk of developing osteoarthritis of the knee.
Participants included men and women and white and ethnic minorities recruited from Alabama and Iowa. Knees were studied at baseline and at 15 months.
Case knees (110) were drawn randomly from patients with no frequent symptoms on most days at baseline but who developed frequent pain and stiffness in one or both knees at 15 months.
Control knees (220) were drawn randomly from patients with no frequent symptoms at baseline or at 15 months.
After MRI studies at baseline and 15 months, two musculoskeletal radiologists blinded to the individuals' status assessed meniscal damage using the following scale: 0=intact, 1=minor tear, 2=nondisplaced tear or prior surgical repair, and 3=displaced tear, resection, maceration, or destruction.
Finally, the effect of meniscal damage on the development of frequent knee pain was studied with contingency table and logistic regression analysis.
At baseline, meniscal damage was common in both case knees (38%) and in control knees (29%), with a higher frequency among women.
There was a modest association between the meniscal damage score (range 0-3) and the development of frequent knee pain, aching, or stiffness (odds ratio: 1.21, 95% CI: 0.96 to 1.51), adjusted for age, sex, and body mass index.
However, meniscal damage was present mostly in knees with radiographic evidence of osteoarthritis as measured by Kellgren/Lawrence grade.
For K/L grade 3 or greater, meniscal damage was present in 82%, for grade K/L grade 2, in 39%, and for grade 1, in 26%. Osteoarthritis was considered to be present for grade 2 or greater.
In a stratified analysis, the researchers found no independent association between meniscal damage and the development of frequent knee symptoms.
Meniscal damage in older adults is highly associated with osteoarthritis of the knee, Dr. Englund wrote. However, he added, meniscal damage often seems not to be directly responsible for later pain and stiffness symptoms. Other features of osteoarthritis may be responsible.
It is conceivable, he said, that certain types of meniscal lesion may be directly responsible for knee pain, particularly during the early stages of certain types of tears. Still, he noted, the high prevalence of meniscal damage in the older adult knee and the weak association with knee symptoms suggest that any such discomfort may be self-limited and can be treated conservatively.
The study had certain important limitations, the investigators said, including its limited sample size and the need to collapse various types of meniscal damage into a few categories for statistical analysis.
Also, they said, the relationship between site of damage or type of lesion and knee symptoms requires further study.
Stressing the importance of treating osteoarthritis as a whole-joint disorder, Dr. England said that this study calls attention to the risk of misinterpreting meniscal damage as the direct cause of knee pain.
However, he added, basic prevalence data of meniscal lesions and their association with knee symptoms in the general population of older adults remain to be explained.
This study was supported by grants from the National Institute on Aging. Dr. Englund's work was supported by the Arthritis Foundation.
Primary source: Arthritis & RheumatismSource reference: Englund M, et al "Effect of meniscal damage on the development of frequent knee pain, aching, or stiffness" Arthritis & Rheumatism 2007; 56: 4048-4054.