Arthroscopic surgery not the only answer for knees

by Jeannine Stein ,  Los Angeles Times | 2008-09-22

The prognosis for people with knee osteoarthritis isn't so bleak as it might seem in the wake of a study finding that arthroscopic surgery, once hailed as promising, may not be the best option.

That study, released in the Sept. 11 issue of the New England Journal of Medicine, suggested that those who underwent the surgery didn't fare any better in the long run than their counterparts who received physical therapy. During the surgery, small incisions are made through which a small camera and surgical instruments are inserted. Physicians can then repair or remove cartilage, or flush the knee to remove debris -- or do both procedures.

The trick is to find one or more treatments -- amid the array that includes medication and physical therapy -- that can ease the pain of worn cartilage. It can take some work.

"When patients come into my office," says Dr. Ronald Grelsamer, a knee surgeon in the orthopaedics department at Mount Sinai School of Medicine in New York, "I give them a list of 17 options to help them manage their condition. At the very bottom is arthroscopy. It works for a little while, but it's not going to cure it. . . . What I've found is that nothing works for everybody, and everything works for somebody."

Oral nonsteroidal anti-inflammatories, such as Celebrex, can reduce inflammation and pain, as can cortisone injections. Hyaluronic acid injections can replace some of the viscous synovial fluids that lubricate the joints but that sometimes decrease with age. Acupuncture and massage may also alleviate pain. But as people get older and knees become more worn, the ultimate remedy could be a total knee replacement.

And although a New England Journal of Medicine study in 2006 found that glucosamine and chondroitin supplements fared no better than a placebo among 1,583 people in reducing knee pain by 20%, some doctors still recommend it. "The average effect is quite small," says Dr. John FitzGerald, assistant professor of rheumatology at the David Geffen School of Medicine at UCLA, "and it can be slow-acting. That study is open to interpretation; I think on average it works a little bit for some people."

But much can be said for consistent exercise, which can also tamp down pain and improve mobility, according to health experts. One study published in the Annals of Internal Medicine compared a physical therapy program of manual therapy and exercise with a placebo program of subtherapeutic ultrasound, and it found that exercise improved walking distance and function, pain and stiffness scores far greater than the placebo.



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