As a new study finds little value in arthroscopies in degenerative knee conditions (i.e. arthritis), is there ever a case for this keyhole procedure?
What is an arthroscopy?
An arthroscopy is a type of keyhole surgery in which a small tube attached to a camera is inserted into the knee to either aid diagnosis or to treat certain conditions. It has value in certain circumstances but not generally in relation to treating osteoarthritis.
This is confirmed by a recent paper which concludes: “Arthroscopic surgery provides little or no clinically important benefit in pain or function, probably does not provide clinically important benefits in knee-specific quality of life, and may not improve treatment success compared with a placebo procedure.”
It sounds quite damning. It is quite damning. But in truth, it’s not really news. We’ve known this for a long time. No Yorkshire Knee Clinic surgeon would ever recommend a knee arthroscopy simply to ‘wash out’ an arthritic knee. Why would we? Arthritis isn’t going to be fixed by a bit of a wash.
The only reason you might perform an arthroscopy on a patient with osteoarthritis of the knee might be to wash out any loose pieces that are floating around within the joint and which may cause the knee to catch and lock. But in these circumstances, you’re not attempting to ‘fix’ the osteoarthritis; you’re simply alleviating an issue resulting from it.
When is arthroscopy appropriate?
An arthroscopy isn’t a suitable treatment for resolving knee osteoarthritis. That’s clear. At the other end of the spectrum, we might have a young athlete who’s suffered a meniscal tear (the ‘shock absorbers’ that sit within the knee joint). Some tears can leave a portion of the meniscus free to interfere with the knee joint mechanism, and an arthroscopy to remove this would be a completely reasonable procedure.
The trickier cases – in terms of deciding ‘is an arthroscopy a suitable treatment?’ – are the ones that fall somewhere in the middle. What, for example, might you do with a patient who has a meniscal tear and who is displaying early signs of osteoarthritis? Often, where the meniscal tear is reasonably stable, you might manage it with physiotherapy and pain killers and expect it to settle down within six months. Only after this period, if problems remain, might you consider an arthroscopy.
But for patients with with an unstable tear – a loose piece of cartilage that keeps flicking in and out of the joint and causing problems, I would consider an arthroscopy quite quickly. Other patients might have a piece of tissue stuck between the shin bone and ligament on the side of the knee. These can be very painful, and I would recommend arthroscopic surgery here too.
A considered approach
You might wonder why the question of whether to carry out an arthroscopy is quite such a big deal. The answer is that arthroscopies have, in some instances, been a sort of ‘go to’ treatment for some private surgeons to demonstrate that a patient is getting something for their money – even if that particular treatment doesn’t offer any real advantage, as is the case with osteoarthritis.
Most of us, of course, would rather just do the things that make patients better – the things that work. Sometimes, that means not operating. Most surgeons, and certainly all Yorkshire Knee Clinic surgeons, would think carefully about doing any arthroscopy and only proceed if the benefit was clear and outweighed the (small) risk.
There can be value in an arthroscopy. But it won’t have any significant effect on your osteoarthritis.
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