August 2002 Bulletin

AAOS responds to NEJM study

In its July 11, 2002 edition, The New England Journal of Medicine (NEJM) published a report on a randomized, placebo-controlled trial involving use of arthroscopy in treatment of patients with osteoarthritis of the knee. (See the abstract at: content/short/347/2/81) This article was widely reported in the press and has generated some controversy within the orthopaedic profession. AAOS responded to the study with a statement to AAOS members and through a letter to the editors of major city newspapers across the country. The texts of those responses follow.

Statement to members

William W. Tipton, Jr., MD, AAOS executive vice president, issued the following response to members regarding publication of the study through "Headline News" and on the AAOS Web site:

"In the recent study on the role of arthroscopy in osteoarthritis of the knee, we applaud the authors and the patients who participated in this placebo controlled investigation. Evidence-based medicine should be a guiding light in today’s health care delivery and this study confirms the conventional orthopaedic wisdom on the limited value of arthroscopic cleansing of arthritic knees.

"The strengths of the study include the large size of the patient groups, an excellent control group, and the long-term patient assessment. The weaknesses include a potential selection bias caused by the number of patients who decided not to participate and the nonspecific indications for arthroscopy. Additionally, data were not stratified for body weight, mal alignment and mechanical symptoms. Arthroscopic surgery may relieve mechanical symptoms (buckling, locking, etc.) thus delaying the need for more aggressive surgery such as total knee replacement.

"As regard the ethics of this study and the use of a placebo group, the study seems to meet specific criteria such as an informed patient, and the use (or non-use) of a procedure (placebo), which had little potential for harm to the patient.

"We would recommend attempts to reproduce the findings in subsequent studies in other practice settings with selection for pre-existing mal-alignment, mechanical symptoms, body weight etc.

"We would also agree with the authors that an expert panel be convened to review the findings of this study and make recommendations as to the selective use of arthroscopy in the treatment of osteoarthritis of the knee."

Letter to the editor

The AAOS partnered with the American Orthopaedic Society for Sports Medicine (AOSSM) to send a letter to the editors of major city newspapers throughout the U.S. responding to the conclusions of the study as reported in NEJM. That letter, which was signed by AAOS President Vernon T. Tolo, MD, and by Peter Fowler, MD, President of AOSSM, was published in a number of papers including the New York Times and Chicago Tribune. The letter stated:

"It is a mistake to use a research publication that is focused on osteoarthritis or degenerative arthritis of the knee to suggest that knee arthroscopy is ineffective for treating knee pain caused by torn cartilage or ligaments, conditions far more likely to have arthroscopic treatment than is osteoarthritis.

"Over the past 25 years, thousands of clinical research publications have confirmed the effectiveness of arthroscopic knee surgery in relieving knee pain for millions of Americans.

"Osteoarthritis of the knee constitutes only a small segment of those who have arthroscopic knee surgery, and for the much larger group with torn cartilage and ligaments, arthroscopic surgery remains effective, less invasive and more cost-effective treatment than was available before its advent".

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