Our interest was piqued by a couple of studies – one from the US, one here in the UK – which indicate that some traditional methods for knee arthritis treatments may be slipping out of vogue.
The first report comes from the British Medical Journal, where a panel of international experts claim that knee arthroscopy – keyhole surgery which attempts to relieve pain and improve movement – should not be performed in all but a few instances, based on new evidence that it doesn’t result in a lasting improvement in pain relief or function.
Knee arthritis treatments: one slice doesn’t fit all
The panel – made of bone surgeons, physiotherapists, clinicians and patients with a record of degenerative knee disease – came to the conclusion that surgery was no more effective than exercise therapy. To quote one of the panel members; “Knee arthroscopy has been oversold as a cure-all for knee pain.”
We agree with this article’s opinion that keyhole surgery in patients with wear and tear changes is often of no value. However, in a tailored or individualised approach, there are situations where specific pieces of cartilage or meniscus are causing very specific or mechanical symptoms, and by targeting these with an arthroscopy there can be some benefit obtained.
In other words, this often comes down to understanding the condition and understanding what the arthroscopy is able to achieve. It can certainly never cure arthritis in a knee, but it can certainly make some other symptoms more bearable.
The drugs don’t work – they just make you worse
The second article – from the Journal of the American Medical Association – addresses the use of steroid injections in order to treat patients with symptomatic knee osteoarthritis. A two-year study conducted by the Tufts Medical Center in Boston tracked the progress of 70 patients suffering from symptomatic knee OA – half of whom received a course of corticosteroid injections, while the other half received a course of placebos.
The results? Compared with the group who received placebos (who experienced an average cartilage thickness loss of 0.1mm), the group on steroids experienced an average thickness loss of 0.21mm – over twice as much degeneration2.
My response to this is very much along the same lines as the keyhole surgery report. We use steroids from time to time with patients, but we also take great pains to explain that it doesn’t cure the problem: what steroids can do is make a very swollen, painful knee more comfortable for a period of time afterwards.
The long-term future of the knee is much less affected: we certainly wouldn’t give steroids to a patient every three months over a two-year period, because of my concern about the longer-term function of the knee – something that seems supported by their evidence.
What both these studies spell out is that the viewpoint on how best to treat knee arthritis is always shifting, and it’s crucial for practitioners to keep up with and react to these developments. It’s also hugely important that sufferers of knee arthritis are kept in the loop and are under no illusions to the fact that there isn’t a magic solution to their ailment. There are advantages of a more conservative management regime such as exercise therapy over arthroscopic surgery: no need for an operation, no recovery time, no surgical pain and inconvenience. Yet, for the right patient, surgery or steroids can work.