Researchers today pitched strike two to arthroscopic surgery for osteoarthritis, a popular choice for many boomers struggling with knee pain. The first strike came in 2002 when a surprising study in the New England Journal of Medicine found that, for many patients, the minimally invasive procedure was no more beneficial than sham surgery. Many orthopedic surgeons, however, immediately howled that that study's methodology was flawed, and few backed away from knee arthroscopy. According to the Arthroscopy Association of North America, more than 1 million of the procedures, which cost an estimated $5,000 each, are still performed each year, making it one of the highest-volume orthopedic procedures in the United States.
Now another landmark study, this one with a broader population of patients and a more reliable study design, has come to a similar conclusion. The research, which was published in the same journal, compared a group of knee patients who underwent physical therapy and took common medications such as ibuprofen or acetaminophen with a similar group who received arthroscopic surgery as well. The study's authors found that surgery offered no additional benefits for most types of arthritic knee problems. (They emphasize, however, that for certain uses, such as meniscal repair and ligament reconstruction, arthroscopic surgery remains a highly effective treatment.)
The findings underscore the importance of alternatives to treatment. "Surgeons need to think about other ways of treating patients rather than jumping immediately to surgery," says Robert Litchfield, an orthopedic surgeon at Fowler Kennedy Sport Medicine Clinic in Canada and one of the study's coauthors. Here are six such alternatives:
1. Exercise and weight loss. Keeping a healthy weight is key, explains Suzanne Moore, a physical therapist practicing in Maryland, because the extra weight increases the stress on the joint. A study released this week showed that obese people had a 65 percent lifetime risk of developing osteoarthritis in comparison with the 35 percent risk for people of normal weight. One study showed that people who lost an average of about 10 pounds significantly reduced pain and improved mobility in comparison with those who didn't. Other research has proved that strength training, as well as low-impact exercise such as bicycling or swimming, lessens pain.
2. Physical therapy. The amount of pain people with knee arthritis feel is directly related to muscle weakness. That's why a comprehensive physical therapy program that strengthens quadriceps can go a long way, experts say, especially for people that have difficulty motivating themselves to exercise on their own. Physical therapists can also correct misaligned knees, a problem that can worsen pain, using wedged insoles and other orthotic devices.
3. Medications. There are a variety of medications that can help, but they do come with the risk of side effects. Research has shown that nonsteroidal anti-inflammatory drugs, or NSAIDs, such as aspirin (Bayer is a common brand), ibuprofen (Motrin), and naproxen (Aleve) are slightly more effective than acetaminophen (Tylenol), though acetaminophen has a lower risk of side effects such as stomach bleeding, which affects about 90 out of 10,000 people over age 75 who take an NSAID. Capsaicin skin cream (such as Theragen), which is derived from hot peppers, is a popular option that has fewer risks than other medications. COX-2 inhibitors have also been shown to be effective, but they carry a cardiovascular risk.
4. Glucosamine and chondroitin sulfate. These two dietary supplements are widely used to reduce the pain of osteoarthritis. Most rigorous studies have found they provide greater pain relief than a placebo, though it isn't clear how the supplements work or whether they can delay the progression of the disease. "They seem to work especially well during the earlier stages," says Robert Marx, an orthopedic surgeon at the Weill Medical College of Cornell University. A fact sheet from the American Academy of Orthopedic Surgeons warns consumers that quality can vary significantly among brands, since dietary supplements such as these are not heavily regulated.
5. Viscosupplementation. If traditional painkillers fail, this procedure, which involves injecting hyaluronic acid into the knee, may help. Hyaluronic acid is a substance that's normally found in the knee and helps lubricate joints and absorb shock. The procedure is relatively new; it was approved in 1997. So far, the evidence suggesting it helps is somewhat underwhelming, some experts say. Some studies show the expensive treatment offers a small benefit, while others suggest no benefit at all. Typically, treatment requires three to five $100 to $200 injections each week.