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.
Disclaimer:
As always, my advice to readers is to seek the advice of your physician
before making any significant changes in
medications, diet, or level of physical activity.
