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 The test found that while 85 percent of patients who underwent
surgery showed clinically-significant improvement after one year, so
did 67 percent assigned to a combination of supervised exercise, use
of insoles, pain medication, education and dietary advice.
"It won't do any harm trying the nonsurgical treatment," chief
author, Dr. Soren Skou of the University of Southern Denmark in
Odense, told Reuters Health. "I hope this will give a more balanced
discussion of whether or not to have the surgery."
There's little debate that knee replacement helps many people, and
the new test of 100 patients - the first randomized controlled trial
ever done on the technique - confirms it. Surgery patients didn't
show just some improvement. They registered far less pain and
disability than those assigned to the non-surgery group.
Yet the study was needed because as many as 1 percent of surgery
patients die within 90 days of their operation and about 1 in 5 have
residual pain at least six months after the procedure, said Dr.
Jeffrey Katz of Harvard Medical School in Cambridge, Massachusetts,
in an accompanying editorial in the New England Journal of Medicine.
"Until now, we have lacked rigorously controlled comparisons between
total knee replacement and its alternatives."
"People need to understand and respect that knee replacement is not
without complication. Knee replacement is a big surgical procedure
and there are risks associated with it," Dr. Andrew Pollak, chairman
of orthopedics at the University of Maryland School of Medicine in
Baltimore, told Reuters Health.
The study "really emphasizes what we suspected all along - total
knee replacement works. It will be obvious to many of us who take
care of patients. But for patients with significant symptoms and
evidence of arthritis, total knee replacement is a very effective
way of improving quality of life," said Pollak, who was not
associated with the research. "Therapy alone has a role. It does
help certain patients. It can certainly prolong the time to when
knee replacement is necessary."
More than 670,000 total knee replacements are done in the U.S. each
year at a cost of $36.1 billion.
All of the patients in the study had moderate-to-severe knee
osteoarthritis. The team measured symptoms, pain and quality of life
over a one year period.
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Volunteers in the surgery group gained an average of 32.5 points
versus 16.0 points for people who received nonsurgical therapy. All
started off with a score of about 48 on a 101-point assessment
scale.
Individual measures of pain, symptoms, activities of daily living,
quality of life, and sports and recreation all showed significant
improvement with surgery.
But while there were just six instances of serious adverse events in
the 50 patients who didn't receive surgery, there were four times as
many among the 50 assigned to have a knee replaced. One third of the
problems involved the replaced knee, including three cases each of
unacceptable stiffness and deep vein thrombosis requiring
anticoagulation, and one case each of deep infection and leg
fracture.
Thirteen of the 50 patients assigned to the no-surgery group ended
up having their knee replaced anyway during the 12-month follow-up
period.
"We've had some patients who had the surgery who did not improve in
pain and, in some cases, had worse pain," Skou said. They may
improve with longer followup, but, he said, "what struck me is, if
you do not go through surgery, you could always have the surgery
later."
SOURCE: http://bit.ly/1GjqUv3 New England Journal of Medicine,
online October 21, 2015.
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