03.06.2016

Patients with arthroscopy were 30% more likely to have joint replacement

by Nancy Walsh
Senior Staff Writer, MedPage Today

ORLANDO — Among patients who have meniscal damage complicated by knee osteoarthritis (OA), arthroscopy did not decrease or delay the likelihood of eventually having knee replacement, a researcher reported here.

In a large cohort of patients with knee OA and meniscal damage, 4,883 had knee arthroscopy and 2,143 had physical therapy alone. Over the course of more than 10 years, almost 1,400 patients in the arthroscopy group underwent knee replacement surgery compared with 488 in the physical therapy group (HR 1.30, 95% CI 1.16-1.46), according to Ronald A. Navarro, MD, of Kaiser Permanente in Rolling Hills, Calif.

“Over time, patients who had knee arthroscopy were 30% more likely to undergo knee replacement than those who had physical therapy alone,” Navarro said.

And although the physical therapy group were slightly more likely to utilize outpatient services for knee pain, there was no significant difference between the two groups in use of narcotic medications or knee injections.

“A lot of orthopedists tell patients that arthroscopy will buy you time, staving off the need for total knee replacement, but we found that was not the case,” he said.

“Our data show that knee arthroscopy in the milieu of knee OA with a meniscal tear did not stave off knee arthroplasty or buy patients time,” he said at the annual meeting of the American Academy of Orthopaedic Surgeons.

“The American Board of Internal Medicine recently put forth a campaign called Choosing Wisely to encourage physicians and patients to engage in conversations about reducing the overuse of tests and procedures. The American Academy of Orthopaedic Surgeons initially suggested limiting patient use of over the counter nutraceuticals such as glucosamine, which are often recommended for knee pain,” he said.

“In our organization, we think there might be a more clinically relevant opportunity to address Choosing Wisely, especially in the setting of knee OA and meniscus tears, both of which are very common and demand a lot of resources from our system,” Navarro said.

Patients presenting with knee pain typically are evaluated for both OA and meniscal damage, and to relieve pain and delay the need for more invasive knee surgery, the meniscal damage is often treated with arthroscopy even in mild or moderate OA is present. However, recent randomized studies found no greater pain relief or functional improvement with arthroscopy compared with physical therapy alone.

To further examine this in a larger population, he and his colleagues identified 7,026 patients who were at least 45, had no prior knee surgery, and had a recent diagnosis of OA at the time of meniscal tear. All patients were treated from 2003 through 2006.

Patients were followed from the date of arthroscopy or first physical therapy session until partial or total knee replacement surgery, death, disenrollment from the healthcare system, or end of study in 2013.

A total of 69% of the patients had knee arthroscopy, and 31% had physical therapy only. Among the entire cohort, 27% had partial or total knee replacement during follow-up.

Those who had physical therapy only were older, more likely to be female, have higher comorbidity scores, and more frequent healthcare utilization.

“Considering initiatives like Choosing Wisely and organizational goals, reduction in knee arthroplasty procedures performed for these patients may be warranted,” he concluded.