Almost half of all U.S. adults and nearly two-thirds of obese adults will develop painful osteoarthritis of the knee by age 85.
Osteoarthritis of the knee is more frequent after the age of 50, but can occur at any age. On occasion, it is precipitated by an injury, but more commonly it occurs as a result of a lifetime of wear and tear. It can lead to a great deal of disability, interfering with mobility, increasing the risk of falls, contributing to deconditioning of the muscles and markedly impairing quality of life.
For most adults, the presenting symptom is pain, which is made worse by movement. As the disease progresses, the knee can swell and become deformed. This condition can be very painful and difficult to manage, prompting many patients to look to arthroscopic surgery as a solution. However, new research indicates that the minimally invasive procedure may not be as beneficial as once thought.
Thanks to magnetic resonance imaging, a detailed evaluation of the abnormal knee is possible. In many cases the knee exhibits loose fragments, the cartilage is irregular and a torn meniscus is frequently found.
In patients who continue to have pain despite treatment with analgesics, arthroscopic surgery may be recommended. The procedure involves inserting a flexible fiber-optic scope and other small instruments through a tiny incision in order to remove loose material in the knee, to smooth out irregular and damaged cartilage and to remove bone spurs. Often a torn meniscus is repaired.
Although arthroscopy’s efficacy is controversial, there is a general feeling that arthroscopy greatly relieves symptoms and reduces the need for a total knee replacement.
In the past few years, this conventional wisdom has come into question. Two research studies published in the New England Journal of Medicine indicate that the value of arthroscopic surgery is questionable.
In the first paper, a group of Canadian orthopedic surgeons, rheumatologists and physical therapists treated 178 patients with an average age of 60, who had moderate to severe osteoarthritis. All received appropriate pain management and physical therapy. Eighty-six of the patients also received arthroscopic surgery. After two years, the two groups experienced equal improvements in pain, mobility and stiffness. Based on these results, the researchers maintain that arthroscopic knee surgery adds no value to the treatment of patients with moderate to severe osteoarthritis.
The second study raised questions about the effectiveness of arthroscopic surgery in repairing a torn or damaged meniscus. Researchers performed an MRI of the right knee of 1,000 subjects between the ages of 50 and 90. Thirty-five percent of participants had significant meniscal tears that increased to more than 50 percent between the ages of 60 and 70. The tears were more common in men. Remarkably, 61 percent of those with significant tears reported no pain at all, even when clear evidence of osteoarthritis was present. Simply put, the tear in the meniscus may not be related to any arthritic pain and therefore, arthroscopic surgery will likely be of little value in treatment.
Based on this information, it seems clear that for patients with osteoarthritis of the knee, pain management should involve medications, physical therapy and exercise. Initial treatment involves the use of analgesics, particularly acetaminophen (Tylenol) and nonsteroidal anti-inflammatory drugs (NSAID’s — Motrin, Aleve, Mobic, Celebrex). Ideally, analgesics should be taken on schedule, as it is much easier to prevent pain than to relieve it. Medications must be combined with physical therapy and later with exercise (walking and strength training). For older adults with knee osteoarthritis, engaging in moderate physical activity at least three times per week can reduce the risk of arthritis-related disability by 47 percent.
Osteoarthritis is more common in overweight adults. Weight loss of as little as 11 pounds reduces the risk of developing knee osteoarthritis among women by 50 percent.
While there is little need for arthroscopic surgery, partial or total knee replacement remains a mainstay of therapy for those patients in whom pain is continually present and unrelieved by pain management, movement is very difficult and quality of life is poor. There is no question that this operation, done under the right circumstances, can be very successful. Remember, though, that appropriate medical care combined with exercise and weight loss may prevent the need for a major surgical procedure.
Dr. David Lipschitz is the director of the Dr. David Health and Wellness Center in Little Rock. To find out more about Dr. David Lipschitz, visit www.drdavidhealth.com