Arthroscopic surgery provides no additional benefit over physiotherapy and medication for the treatment of knee osteoarthritis

Question

What is the effect of the addition of arthroscopy to physiotherapy and medication in patients with osteoarthritis (OA) of the knee?

Design

Randomised, controlled trial with blinded outcome assessment and intention-to-treat analysis.

Setting

A university sports medicine clinic in Ontario, Canada.

Participants

Adults with idiopathic or secondary moderate-to-severe OA of the knee (Grade 2, 3, or 4 radiographic severity on the modified Kellgren-Lawrence classification). Key exclusion criteria were large meniscal tears, inflammatory arthritis, previous arthroscopic treatment for knee OA and more than 5 degrees of lateral deformity. Randomisation of 188 participants allotted 94 to an intervention group and 94 to a control group.

Interventions

The intervention group underwent arthroscopy within 6 weeks after randomisation and a standard physiotherapy and medication regimen was initiated within 7 days after surgery. The control group initiated the same physiotherapy and medication regimen at an equivalent time. Physiotherapy was provided for 1 hour once a week for 12 weeks. It included range-of-motion and strengthening exercises to be performed at home twice daily, information about activities of daily living, instruction in the use of heat and cold, and an educational video. Exercises were individualised according to the severity of OA and age. After the 12-week period, participants were advised to continue the exercise program. Medications (potentially including paracetamol, non-steroidal anti-inflammatory drugs, hyaluronic acid, and glucosamine) were prescribed according to standard guidelines.

Outcome measures

The primary outcome was the WOMAC score at 2 years follow up. The WOMAC is scored from 0 (worst) to 2400, with subscales for pain, stiffness, and physical function. Secondary outcomes included the Physical Component Summary Score of the Short Form-36 (0 to 100); the McMaster Toronto Arthritis patient preference (MACTAR) questionnaire (0 to 500); and the Arthritis Self- Efficacy Scale (ASES) (10 to 100).

Results

168 participants completed the study. After 2 years, the mean (SD) WOMAC scores were 874 (624) in the intervention group and 897 (583) in the control group, mean difference 23 (95% CI –208 to 161). The groups differed on the SF-36 by only 0.2 (95% CI –3.2 to 3.6), on the MACTAR questionnaire by only 6 (95% CI –37 to 49), and on each of the ASES subscales by less than 6 (all non-significant).

Conclusion: The addition of arthroscopy to a regimen of physiotherapy and medication does not improve physical function, pain, or health-related quality of life in patients with moderate-to-severe OA of the knee.