Our collection of research articles shows repeatedly that the research proves that non-surgical treatment for knees has the best long term results. In light of the following evidence, it is clear that our Functional Neurology treatment approach for the management of knee osteoarthritis is your superior choice.
The biomechanical base for human upright posture is the foot. Foot pronation or the presence of a Morton’s Toe does influence the biomechanical function and health of the ankle, knee, hip, pelvis and spine. Lower limb functional and/or biomechanical problems are known to impact the knee biomechanics and risks for development of osteoarthritis (1, 2).
Yvonne Golightly, PT, PhD, from the University Of North Carolina School Of Medicine notes that 6% of the US adult population suffer from knee osteoarthritis. She states:
“Osteoarthritis (OA) is one of the most common chronic conditions in the United States and a leading cause of disability among older adults.”
A recent (01/01/2014) search of the National Library of Medicine using the PubMed search engine with the words “arthroscopic knee surgery” locates 4,621 articles. Clearly arthroscopic surgery is the primary intervention for knee osteoarthritis in the United States, and it has been for decades.
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In 1996, orthopedic surgeon J Bruce Moseley, MD, and colleagues published the results of a small pilot study (n=10) pertaining to arthroscopic treatment of knee osteoarthritis (3).
Dr. Moseley is from the Houston Veterans Affairs Medical Center at Baylor College of Medicine. Their article was published in the American Journal of Sports Medicine, and titled:
Arthroscopic treatment of osteoarthritis of the knee: A prospective, randomized, placebo-controlled trial.
Results of a pilot study
The purpose of this study was to determine if a placebo effect might play a role in arthroscopic treatment of knee osteoarthritis. Five subjects were randomized to a placebo arthroscopy group, three subjects were randomized to an arthroscopic lavage group, and two subjects were randomized to a standard arthroscopic debridement group. The physicians performing the postoperative assessment and the patients remained blinded as to treatment.
Incredibly, patients who received the placebo surgery reported decreased frequency, intensity, and duration of knee pain. They also thought that the procedure was worthwhile and would recommend it to family and friends. The authors concluded, ‘there may be a significant placebo effect for arthroscopic treatment of osteoarthritis of the knee.” As a consequence of the small number of subjects in this study, little controversy was generated; that was soon to change.
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Seven years later, in 2002 Dr. Moseley and colleagues presented the results of a study in the New England Journal of Medicine, titled (4):
A Controlled trial of arthroscopic surgery for osteoarthritis of the knee
The authors conducted a randomized, placebo-controlled trial to evaluate the efficacy of arthroscopy for osteoarthritis of the knee. A total of 180 patients with osteoarthritis of the knee were randomly assigned to receive arthroscopic debridement, arthroscopic lavage, or placebo surgery. Patients in the placebo group received skin incisions and underwent a simulated debridement without insertion of the arthroscope.
Patients and assessors of outcome were blinded to the treatment-group assignment. Outcomes were assessed at multiple points (2 weeks, 6 weeks, 6 months, 12 months, 18 months, and 24 months) over a 2 year period with the use of five self-reported scores; three on scales for pain, and two on scales for function, and one objective test of walking and stair climbing. Incredibly, the authors found:
“At no point did either of the intervention groups report less pain or better function than the placebo group.”
“In this controlled trial involving patients with osteoarthritis of the knee, the outcomes after arthroscopic lavage or arthroscopic debridement were no better than those after a placebo procedure.”
These authors quantify arthroscopic knee surgery. They note that “more than 650,000 such procedures are performed each year at a cost of roughly $5,000 each.” Yet, there is no evidence that arthroscopy cures or arrests knee osteoarthritis. At no point did either the lavage group or the debridement group have greater pain relief than the placebo group. At no time did the lavage group or the debridement group have greater improvement in function than the placebo group. Objectively measured walking and stair climbing were poorer in the debridement group than in the placebo group at 2 weeks and 1 year and showed a trend toward worse functioning at 2 years.
This study provides strong evidence that arthroscopic lavage with or without debridement is not better than a placebo procedure in improving knee pain and function. The authors conclude:
“Indeed, at some points during follow-up, objective function was significantly worse in the debridement group than in the placebo group.”
“If the efficacy of arthroscopic lavage or debridement in patients with osteoarthritis of the knee is no greater than that of placebo surgery, the billions of dollars spent on such procedures annually might be put to better use.”
This study triggered multiple letters-to-the-editor, articles and an official editorial in the New England Journal of Medicine (5). Newspapers throughout the world wrote stories on the study’s results, including a front page article in the New York Times (6). The editorial from the New England Journal of Medicine makes the following points:
“Malaligned knees may not respond well to arthroscopic debridement.”
“Despite their current popularity, lavage and debridement are probably not efficacious as treatments for most persons with osteoarthritis of the knee.”
“Although the debris in osteoarthritic joints may be related to synovitis, the results of this trial suggest that the effects of this debris on clinical symptoms are negligible.”
“Although smoothing cartilage and meniscal irregularities may sound appealing, larger forces within and outside the joint environment, such as malalignment, muscle weakness, instability, and obesity, which are not addressed by this type of surgery, may have greater effects on the clinical outcomes of osteoarthritis of the knee.”
“Debridement and lavage may simply remove some of the evidence while the destructive forces of osteoarthritis continue to work.”
Importantly, these authors indicate that the primary factors in knee osteoarthritis pathophysiology, which arthroscopic surgery does not address, include mal-alignment, muscle weakness, instability, and obesity. These are problems commonly addressed in chiropractic clinical practice.
Joseph Bernstein, MD is an assistant professor of orthopedic surgery, University of Pennsylvania. In 2003, Dr. Bernstein and colleague do an extensive review of Moseley and colleagues, publishing in the Cleveland Clinic Journal of Medicine (7). They note:
“Arthroscopy for degenerative conditions of the knee is among the most commonly employed orthopedic procedures, but its effectiveness (like the effectiveness of many surgical operations) has never been proven in prospective trials.”
Dr. Bernstein notes that Moseley’s study has an important strength, the inclusion of a sham treatment — a rarity in surgical studies. He notes that the “challenge is now made for researchers to repeat the Moseley methodology. “As we will see below, this has been done.
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In January 2008, the Cochrane Database did an extensive review of the literature to identify the effectiveness of arthroscopic debridement in the management of knee osteoarthritis (8). Specifically, the authors evaluated the effectiveness of arthroscopic debridement on knee pain relief and improved knee function. The author’s conclusion was:
“There is “gold” level evidence that AD has no benefit for un-discriminated OA (mechanical or inflammatory causes).”
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In September of 2008, Alexandra Kirkley, M.D., and colleagues published an article in the New England Journal of Medicine, titled (9):
A Randomized Trial of Arthroscopic Surgery
for Osteoarthritis of the Knee
The purpose of this study was to determine the efficacy of arthroscopic surgery for the treatment of osteoarthritis of the knee. Patients were randomly assigned to surgical lavage and arthroscopic debridement together with optimized physical and medical therapy (n=86) or to treatment with physical and medical therapy alone (n+86). Each group was re-evaluated at 3, 6, 12, 18, and 24 months. The authors make these comments:
“Although arthroscopic surgery has been widely used for osteoarthritis of the knee, scientific evidence to support its efficacy is lacking.”
“Arthroscopic surgery for osteoarthritis of the knee provide no additional benefit to optimized physical and medical therapy.”
“This study failed to show a benefit of arthroscopic surgery for the treatment of osteoarthritis of the knee. At the end of 2 years, patients assigned to arthroscopic treatment in addition to optimized physical and medical therapy had no greater improvement in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores than did those who received only physical and medical therapy.”
“The results of this randomized, controlled trial show that arthroscopic surgery provides no additional benefit to optimized physical and medical therapy for the treatment of osteoarthritis of the knee.”
This study by Dr. Kirkley and colleagues generated a follow-up article that was published in NATURE: CLINICAL PRACTICE: Rheumatology, and titled (10):
Is arthroscopic surgery a beneficial treatment for knee osteoarthritis?
The author, Dr. Richard Nutton, from the Department of Orthopedics and Trauma at the University of Edinburgh, notes (from abstract):
“Considering the high prevalence of knee osteoarthritis and the relatively common use of arthroscopy to treat this condition, few well-designed studies have been published on the effectiveness of arthroscopy for treating knee osteoarthritis. The study by Kirkley et al. is a welcome addition to the literature as it addresses many of the criticisms of previous work by using appropriate exclusion criteria, standardizing treatment in the study groups, using well- validated clinical scores, and providing a period of follow-up exceeding 2 years. The authors conclude that although all patients benefited from active treatment for knee osteoarthritis, comprising rehabilitation and optimized medical treatment, the addition of arthroscopic debridement of the knee did not improve outcomes. These results underline the outcome of a previous prospective, randomized trial [Moseley Study Reference #4], which concluded that the placebo effect of performing knee arthroscopy for osteoarthritis accounted for the main therapeutic benefit observed at follow-up”
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Stephen Howell, MD, is a clinician, researcher, and innovator in the field of total knee replacement, anterior cruciate ligament reconstruction and meniscal injury. His clinical practice focuses on the treatment of degenerative processes and sports-related injuries to the knee. Dr. Howell performs over 350 total knee replacements and 100 ACL reconstructions per year. He is a Professor of Mechanical Engineering Department at the University California at Davis. He is President of the International ACL Study Group and he is on the editorial board of the American Journal of Sports Medicine and Knee Journal, In September 2010, Dr. Howell published an article in the Journal Orthopedics, Titled (11):
The Role of Arthroscopy in Treating Osteoarthritis
of the Knee in the Older Patient
Despite being one of the world’s best known and busiest knee surgeons, Dr. Howell notes (from abstract):
“Arthroscopy of the osteoarthritic knee is a common and costly practice with limited and specific indications.”
“The extent of osteoarthritis (OA) is determined by joint space narrowing, which is best measured on a weight-bearing radiograph of the knee in 30º or 45 º of flexion.”
“Randomized controlled trials of patients with joint space narrowing have shown that outcomes after arthroscopic lavage or debridement are no better than those after a sham procedure (placebo effect), and that arthroscopic surgery provides no additional benefit to physical and medical therapy.”
“The American Academy of Orthopedic Surgeons guideline on the Treatment of Osteoarthritis of the Knee (2008) recommended against performing arthroscopy with a primary diagnosis of OA of the knee.”
“There is no evidence that removal of loose debris, cartilage, flaps, torn meniscal fragments, and inflammatory enzymes have any pain relief or functional benefit in patients that have joint space narrowing on standing radiographs. Many patients with joint space narrowing are older with multiple medical comorbidities.”
“Consider the complications and consequences when recommending arthroscopy to treat the painful osteoarthritic without mechanical symptoms, as there is no proven clinical benefit.”
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A more recent article evaluating knee arthroscopic surgery (published 12/26/13)- Raine Sihvonen, MD, and colleagues from the Finnish Degenerative Meniscal Lesion Study (Fidelity) Group published their study in the New England Journal of Medicine, titled (12):
Arthroscopic Partial Meniscectomy versus Sham Surgery for a
Degenerative Meniscal Tear
The authors conducted a multicenter, randomized, double-blind, sham-controlled trial in 146 patients 35 to 65 years of age who had knee symptoms consistent with a degenerative medial meniscus tear and no knee osteoarthritis. Patients were randomly assigned to arthroscopic partial meniscectomy or sham surgery.
The authors noted that arthroscopic partial meniscectomy is one of the most common orthopedic procedures, yet rigorous evidence of its efficacy is lacking. These authors found that there were no significant between-group differences in the change from baseline to 12 months in any primary outcome. Likewise, there were no significant differences between groups in the number of patients who required subsequent knee surgery. Their conclusion was:
“In this trial involving patients without knee osteoarthritis but with symptoms of a degenerative medial meniscus tear, the outcomes after arthroscopic partial meniscectomy were no better than those after a sham surgical procedure.”
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On the same day that Dr. Sihvonen and colleagues published their study in the New England Journal of Medicine (12/26/13), Rachelle Buchbinder, PhD, and Colleagues published a study in the journal Current Opinion in Rheumatology, titled (13):
Knee Osteoarthritis and Role for Surgical Intervention:
Lessons Learned from Randomized Clinical Trials
and Population-based Cohorts
Dr. Buchbinder is an Australian Clinical Epidemiologist, and she has been the Director of the Monash Department of Clinical Epidemiology. The purpose of their study was to determine if the key findings from the best available studies pertaining to arthroscopic surgery to treat knee osteoarthritis has resulted in better evidence-based care. Their conclusions were:
“Use of arthroscopy to treat knee osteoarthritis has not declined despite strong evidence-based recommendations that do not sanction its use.”
“More efforts are needed to overcome significant evidence-practice gaps in the surgical management of knee osteoarthritis, particularly arthroscopy.”
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- Golightly YM, Tate JJ, Burns CB, Gross MT: Changes in Pain and Disability Secondary to Shoe Lift Intervention in Subjects With Limb Length Inequality and Chronic Low Back Pain; Journal of Orthopaedic & Sports Physical Therapy; Vol. 37, July 2007, pp. 380-388.
- Harvey WF, Yang M, Cooke TDV, Segal N, Lane N, Lewis CE, Felson DT; Associations of Leg Length Inequality With Prevalent, Incident, and Progressive Knee Osteoarthritis; Annals of Internal Medicine; March 2, 2010; 152(5): pp. 287-295.
- Moseley JB, Wray NP, Kuykendall D, Willis K, Landon G; Arthroscopic Treatment of Osteoarthritis of the Knee: A Prospective, Randomized, Placebo-controlled Trial. Results of a Pilot Study; Am J Sports Med. 1996 Jan-Feb; 24 (1): 28-34.
- Moseley JB, O’Malley K, Petersen NJ, Menke TJ, Brody BA, Kuykendall DH, Hollingsworth JC, Ashton CM, Wray NP; A Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee; N Engl J Med 2002 Jul 11; 347 (2): 81-8.
- Felson DT, Buckwalter J; Debridement and Lavage for Osteoarthritis of the Knee; N Engl J Med. 2002 Jul 11; 347 (2) 132-3.
- Wald ML; Arthritis Surgery in Ailing Knees is Cited as Sham. New York Times 2002 Jul 11; Sect. A:1 (col. 6).
- Bernstein K, Quach BS; A Perspective On the Study of Moselely Et Al: Questioning the Value of Arthroscopic Knee Surgery for Osteoarthritis; Cleveland Clinic Journal of Medicine; Vol. 70; No. 5; May 2003; pp. 401-410.
- Laupattarakasem W, Laopaiboon M, Laupattarakasem P, Sumananont C; Arthroscopic Debridement for Knee Osteoarthritis; Cochrane Database Syst Rev. 2008 Jan 23; (1).
- Kirkley A, Birmingham TB, Litchfield RB, Giffin JR, Willits KR, Wong CJ, Feagan BG, Donner A, Griffin SH, D’Ascanio LM, Pope JE, Fowler PJ; A Randomized Trial of Arthroscopic Surgery for Osteoarthritis of the Knee; September 11, 2008; Vol. 359; No. 11; pp. 1097-1107.
- Nutton RW; Is Arthroscopic Surgery a Beneficial Treatment for Knee Osteoarthritis?; Nat Clin Pract Rheumatol. 2009 Mar; 5(3): 122-3.
- Howell SM; The Role of Arthroscopy in Treating Osteoarthritis of the Knee in the Older Patient; Orthopedics; 2010 Sep 7; 33(9):652.
- Sihvonen R, Paavola M, Malmivaara A, Itälä A, Joukainen A, Nurmi H, Kalske J, Järvinen TNL; Arthroscopic Partial Meniscectomy Versus Sham Surgery for a Degenerative Meniscal Tear; New England Journal of Medicine; 2013 Dec 26; 369(26); 2515-24.
- Buchbinder R, Richards B, Harris I; Knee Osteoarthritis and Role for Surgical Intervention: Lessons Learned from Randomized Clinical Trials and Population-based Cohorts; Current Opinion in Rheumatology; 2013 Dec 26. [Epub ahead of print].