The content on or accessible through Medpedia.com is for informational purposes only. Medpedia is not a substitute for professional advice or expert medical services from a qualified health professional.
Read more
Medpedia Answers
(Sports Medicine)Medpedia Answers is a platform for asking and answering questions about health and medicine. Read more.
Is there any evidence (prospective studies) that arthoscopy of the knee to scrape "torn cartilidge" is superior to physical therapy in the setting of knee pain?
In the treatment of knee pain, what is the evidence that supports arthoscopic cartildge scraping (of torn miniscus) is superior to physical therapy alone? I'm baffled since it is common for orthopedists to prescribe PT after miniscul procedures. It seems that this is basically saying, "I have no idea if what I just did to you is going to help any more than PT alone, so i'm going to game it by also prescribe PT so you'll get your result one way or the other".
Where are the head-to-head clinical trials to evaluate? Seems to me like these procedures could be largely over performed.......
Where are the head-to-head clinical trials to evaluate? Seems to me like these procedures could be largely over performed.......
asked Mar 03, 2010 at 08:48AM in Sports Medicine
-
1Votes
answered Mar 03, 2010 at 12:59PMDear collegue,
There has been a famous study, comparing real arthroscopy with (placebo) fake arthroscopy. I recall, that in the latter, patients were anesthesized inidentical ways, and only minor incisions were made, suggestive for arthroscopic wounds. During the fake procedure, the surgeon did say the same sort of things that are being said during normal arthroscopy, like 'Oh, we're now in the knee cavity, we 're cleaning the surface, things go nice and well etc'. During follow up, as far as I remember, both groups, the one with real cleaning procedure and the one with fake procedures, showed similar improvement, something like 50% faring better in both groups. Some say, that just the flushing of the joint with saline, takes out inflammatory substances and thus accounts for such relief. That would change your question: Is flushing superior to PT?-
Yes, I'm familiar with the sham studies that you have mentioned. But, they don't address the question whether standard PT is inferior to arthoscopic removal of torn cartilage (or better yet, if arthoscopy is superior to PT).Jonathan Williams MD, MMSc commented Mar 03, 2010 at 02:55PM
-
-
0Votes
answered Mar 03, 2010 at 04:29PMAll I know is that the procedure I underwent was painful and expensive... and while it led to temporary improvement, after a couple of years I had returned to pre-surgery baseline.
MUCH better would have been simply to stop some of the activities I'd stubbornly insisted on doing... meanwhile I should have started doing yoga, which (when done properly) is *fantastic* at aligning joints, particularly knees, thus reducing friction. -
1Votes
answered Mar 03, 2010 at 04:55PMI believe you may be referring to: A Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee, NEJM Volume 347:81-88 July 11, 2002.
Of course Osteoarthritis (OA) is quite a bit different form meniscal tears.
I am unaware of any strides that have compared menesectomy to physical therapy head to head. However, NIH is currently recruiting participants for just such a study: Comparing Knee Cartilage Surgery Versus Standard Physical Therapy in Treating People With a Meniscal Tear and Osteoarthritis. There may also be a subset of patients with tears that are responders to PT while others are not. Research should also look to develop clinical prediction rules to determine in advance who would likely benefit form PT and who should go directly to surgery. Until we get more evidence on meniscal tears we must rely on our clinical judgments alone.
There is already evidence that PT is successful at reducing pain and restoring function in people with knee OA.
Post surgery most, but not all, knee arthroscopy pts should have a period of PT. First to insure that full ROM is achieved, second to restore normal activation of the knee extensors, third to improve hamstring strength and co-contraction around the knee and most importantly, to insure safe and normal function for all activities, if possible.-
Thanks Arthur. Yep, I know John Wright an Ortho at Brigham and Women's is one of the PI's on this NIH funded study. Spoke with him last week and he mentioned the study and how he feels that it is likely that more than half of the 250,000 arthoscopies for this issue are probably netting nothing other than costs. He mentioned the frustration of not knowing whether it does anything and that in fact a signficant percentage actually do worse after surgery (because the surgery just amps up the inflammatory process and OA, etc. I'm going to guess that the trial will show no difference in outcomes.Jonathan Williams MD, MMSc commented Mar 03, 2010 at 08:38PM
-
Yes, I'm specifically talking about meniscal tears in the absence of OA. Although OA is important in this setting, I think it introduces overwhelming confounding and should really be excluded from the comparison for now.Jonathan Williams MD, MMSc commented Mar 04, 2010 at 10:16AM
-
I would be interested to know what the inclusion criteria is for the study. Are they looking at any disruption of the menisci or some specific classification. I would also like to know what is being provided as PT. While the research suggests best practices for knee rehab there is a lot of variation among therapists.
The thought of 125,000 possibly unnecessary arthroscopes with all the sequela is not all that unsurprising, yet still makes me agape. So where is it that health care savings can be found?Arthur Veilleux PT commented Mar 04, 2010 at 06:39PM -
It's registered with ClinicalTrials.gov, which lists the inclusion/exclusion criteria. NIH-funded. 4 sites. Even Wright says there are way too many of these procedures going on unnecessarily. I suspect just as there are with cardiac cath.Jonathan Williams MD, MMSc commented Mar 04, 2010 at 08:23PM
-
Sign-in
to post an answer to this question.
Related Questions
- Is there a treatment for bad knees other than surgery or replacement?
- What is the best over-the-counter medicine for knee pain?
- What are some common causes of knee pain?
- What can I do about chronic joint pain in hips, knees and feet?
- What could cause sharp pain from the knee to ankle?
- What are some possible causes of swelling on the knee joint?
- Is there any evidence that acupuncture can relieve lower back pain that seems to be muscular pain?
- What could this knee pain be caused by?
- What are suggestions for relieving knee pain?
- Will a torn rotator cuff, detached deltoid and torn labrum get worse over time, or heal themselves?
- »» See All
The content on or accessible through Medpedia.com is for informational purposes only. Medpedia is not a substitute for professional advice or expert medical services from a qualified health professional.
Read more