Arthroscopic Knee Surgery- No Better than Placebo?; A Healthy Lifestyle Prevents Stroke

The information in this column is intended for informational purposes only, and does not constitute medical advice or recommendations by the author.  Please consult with your physician before making any lifestyle or medication changes, or if you have any other concerns regarding your health.

ARTHROSCOPIC KNEE SURGERY- NO BETTER THAN PLACEBO?

As most everyone knows, our population is aging, and our lifespan is gradually increasing.  According to the Centers for Disease Control (CDC), nearly 50 million Americans (1 in 5 adults) have been diagnosed with one or more forms of arthritis.  The most common type of arthritis, osteoarthritis, is generally caused by wear-and-tear on the joints as we age, and afflicts at least 21 million Americans.  Among those 65 years of age and older, at least 50% will have been diagnosed with arthritis. 

In addition to advancing age and prior injuries, obesity is also a risk factor for osteoarthritis.  Increasing degrees of weight add further stress to the weight-bearing joints that are involved in standing and walking, and being obese essentially double’s one’s risk of developing osteoarthritis.

Living a sedentary lifestyle also increases the risk of arthritis, as well as increasing the likelihood of disability caused by arthritis.   

The human knee joint, which is one of the most complex joints in the body, is especially prone to osteoarthritis.  The knee joint’s stabilizing ligaments and protective joint cushions are easily torn by injuries, and are progressively stretched and worn (respectively) by normal physical activities over the years.  For most patients with arthritis of the knee, lifestyle modifications, physical therapy, applications of heat or cold, knee braces, and, if needed, anti-inflammatory medications will bring considerable relief of the pain, stiffness and swelling that often accompany degenerative changes of the knee joint. 

Arthroscopic surgery, which involves the placement of small instruments and a video camera into the joint, through small incisions, has become the most commonly performed orthopedic surgery in the United States.  Using the arthroscopic approach, the surgeon is able to directly view the internal structures of the knee joint, including the ligaments that stabilize the joint, and the cartilaginous cushions (menisci) that line the surfaces of the bones within the joints.  Bits of degenerated cartilage that are floating within the joint can be irrigated out of the joint, and torn or eroded cartilage can be trimmed and remodeled. 

Two new clinical research studies, just published in the prestigious New England Journal of Medicine, have now called into question some of the fundamental assumptions that have made arthroscopic knee surgery such a common procedure.

This prospective, randomized clinical study was performed in Ontario, Canada.  A total of 84 patients with moderate-to-severe osteoarthritis of the knee were assigned to receive both arthroscopic surgery and maximal medical treatment, while 86 patients with moderate-to-severe osteoarthritis received only maximal medical therapy.  Two years after completing treatment, both groups of patients were re-evaluated.  Using previously validated osteoarthritis and physical disability scoring tools, the authors of this study determined that the addition of arthroscopic surgery to maximal medical treatment was not associated with any measurable improvement in osteoarthritis symptoms or arthritis-related physical disability. 

This is now the second prospective clinical research trial that has shown absolutely no apparent benefit from arthroscopic surgery for osteoarthritis of the knee in patients who have otherwise been treated with optimal physical therapy and medical treatment.  Given that much of the previous clinical data supporting arthroscopic knee surgery as a useful procedure was derived from retrospective data (i.e., a review of patient medical records after the fact), this prospective clinical trial’s finding (as with its predecessor prospective randomized trial) that arthroscopic knee surgery adds nothing to primary medical treatment and physical therapy should really lead to a thoughtful reassessment of the procedure.  As with all surgical procedures, there are risks inherent in undergoing arthroscopic surgery.  If, as two randomized, prospective clinical research trials now suggest, there is no benefit from arthroscopic knee surgery, then patients undergoing the procedure may be taking on all of the risk of the procedure without any likelihood of benefit.  Unless compelling prospective clinical data comes along that disproves the identical findings of these two separate prospective clinical trials, then it might be prudent to defer arthroscopic surgery of the knee for osteoarthritis for now.

A second companion clinical study in the New England Journal of Medicine provides additional insight as to why arthroscopic knee surgery may not provide any benefit to patients with osteoarthritis of the knee.

Magnetic resonance imaging, or MRI, has become the standard imaging test used to evaluate the ligaments and cartilage of painful knee joints.  MRI scans easily demonstrate tears and erosions of the cartilage (menisci) lining the knee joint, and because knee pain is often attributed to these types of meniscal injuries, patients with meniscal injuries are often advised to undergo arthroscopic surgery to trim and remodel these damaged cartilages.

This study, which was performed at Boston University, performed MRI scans of the right knees of 991 volunteers between the ages of 50 and 90.  All of these volunteers were randomly selected in Framingham, Massachusetts.  Additionally, all of these volunteers were asked to complete a questionnaire regarding the presence or absence of osteoarthritis symptoms in their right knees. 

Among women between the ages of 50 and 59 years, 19% were found to have tears or erosions of the meniscal cartilage by MRI scanning.  Among men between the ages of 70 and 90 ages, 56% had MRI evidence of significant meniscal cartilage tears or erosions.  In patients with x-ray evidence of bone erosion (osteoarthritis) within the knee, meniscal abnormalities were twice as commonly observed by MRI when compared to patients without additional signs of osteoarthritis.  More importantly, among those patients with radiographic signs of bone erosion (osteoarthritis) within the knee joint and knee symptoms, 63% had meniscal abnormalities identified by MRI.  However, a statistically identical 60% of patients with radiographic evidence of osteoarthritis, but without any knee symptoms, had similar meniscal cartilage tears and erosions.    

The results of this study strongly suggest that most meniscal tears and erosions, by themselves, probably do not cause significant knee symptoms in most patients.  Since meniscal tears and erosions are the most commonly repaired abnormalities within the knee joint during arthroscopic surgery, the findings of this study offer the most likely explanation for the lack of benefit from arthroscopic surgery that was observed in the previous study.

Once again, it is time to reappraise the role (if any) of arthroscopic knee surgery.

 

A HEALTHY LIFESTYLE PREVENTS STROKE

We all know that a healthy lifestyle can significantly reduce the risk of heart disease, peripheral vascular disease, diabetes and high blood pressure.  Up until now, however, there has been little clinical data available supporting the benefit of a healthy lifestyle in the prevention of stroke.

Stroke is the third most common cause of death in the United States (behind cardiovascular disease and cancer).  Each year, nearly 800,000 Americans will experience a stroke, and more than 150,000 will die as a result (there are an estimated 6 million stroke survivors alive in the United States at this time).  Strokes are also a major cause of long-term disability.

A new prospective clinical research study from Harvard University, recently published in the journal Circulation, evaluated nearly 44,000 men and more than 71,000 women who had previously participated in two large public health studies (the Health Professionals Follow-up Study and the Nurses’ Health Study). 

A healthy lifestyle was defined, within this study, by the following factors: abstinence from smoking, normal weight, at least 30 minutes of moderate physical activity per day, modest alcohol consumption, and a healthy diet. 

During the course of this study, 1,559 of the women in the Nurses’ Health Study experienced a stroke, while 994 of the men in the Health Professionals Follow-up Study experienced a stroke.  Among the women who followed all 5 healthy lifestyle factors, the risk of stroke was 79% lower than what was observed in women who followed none of these lifestyle factors.  Similarly, among the men who followed all 5 healthy lifestyle factors, the risk of stroke was 69% lower than what was observed among the men who did not follow any of the 5 healthy lifestyle factors. 

Thus, this clinical research study, which used data from two very large and well-controlled public health studies, strongly suggests that the same healthy lifestyle factors that are known to reduce the risk of cardiovascular disease, hypertension, and diabetes can also significantly reduce the risk of stroke as well.

 

Dr. Wascher is an oncologic surgeon, professor of surgery, a widely published author, and the Director of the Division of Surgical Oncology at Newark Beth Israel Medical Center:

http://www.sbhcs.com/hospitals/newark_beth_israel/mservices/oncology/surgical.html

Send your feedback to Dr. Wascher at:  rwascher@doctorwascher.net
 

http://www.doctorwascher.com

Copyright 2008.  Robert A. Wascher, MD, FACS.  

All rights reserved.

 

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Cancer surgeon, professor of surgery & author. Webmaster: http://doctorwascher.com | More from Robert A. Wascher, MD, FACS