No Extra Benefit Found from Surgery for Chronic Knee Pain

[Guest guest]

The following article should be of interest to

trainers.

However note:

Action Points

Explain to interested patients that this study did not

rule out a potential benefit from knee surgery for

chronic patellofemoral pain syndrome for some

subgroups of patients.

Also point out that the results are only valid for

patients ages 18 to 40 who do not participate in

competitive sports

Ralph Giarnella MD

Southington Ct USA

No Extra Benefit Found from Surgery for Chronic Knee

Pain

By Todd Neale, Staff Writer, MedPage Today

Reviewed by Zalman S. Agus, MD; Emeritus Professor

University of Pennsylvania School of Medicine.

HELSINKI, Finland, Dec. 13 -- For relief of chronic

patellofemoral pain syndrome, eight weeks of home

exercise was just as effective as arthroscopic surgery

plus the exercise, researchers found in a randomized

trial here.

Explain that this study does not necessarily indicate

that the home exercise program was beneficial as there

was no control group.

In a 56-patient randomized controlled trial, both the

arthroscopic surgery-exercise group and the

exercise-only group showed similar improvements at

nine months, with no significant differences, Jyrki

Kettunen, Ph.D., of the ORTON Research Institute in

Helsinki, and colleagues, reported online in BMC

Medicine.

The improvements were measured by an increased Kujala

score on patellofemoral pain and function, assessed on

a questionnaire-based 100-point scale.

For the arthroscopy-exercise group, the mean

improvement from baseline was 12.9 points (69.0 versus

81.9, 95% CI: 8.2 to 17.6) and for the exercise-only

group, the mean improvement was 11.4 (71.1 versus

82.5, 95% CI: 6.9 to 15.8). An increase of about eight

to 10 points reflects a clinically significant

improvement, according to the researchers.

" There is some evidence that exercise therapy reduces

anterior knee pain in patients with [patellofemoral

pain syndrome], " the authors wrote. Although many

physicians prefer conservative therapies, they

continued, " in chronic cases and after the failure of

conservative treatment, arthroscopy is often carried

out. "

Citing a lack of evidence for a benefit from surgery,

the investigators selected 56 patients ages 18 to 40

with chronic patellofemoral pain symptoms for at least

six months. All participants had been admitted from

May 2003 through February 2005. Competitive athletes

or those who had previous knee surgery were excluded.

If the patients had pain in both knees, the knee with

the more severe symptoms was included in the study.

Twenty-eight participants were placed in the

arthroscopy-exercise group (one dropped out prior to

the exercise) and 28 received only the eight-week

exercise program. The home exercise program consisted

of lower-body strengthening and stretching.

During arthroscopic surgery, which was done one week

following randomization, there was resection of

inflamed/scarred medial plicae, abrasion of chondral

lesions and shaving of excessive and inflamed

synovium, minor corrections of the patellofemoral

articulation, and treatment of minor meniscal tears.

A physiotherapist instructed patients on how to do the

daily exercises, which began three weeks after

randomization in both groups. The first four weeks of

the program focused on lower-limb muscle strengthening

and stretching. For the last half of the program,

participants were given a rubber sling to be placed

around the ankle for resistance exercises.

All participants kept a daily exercise diary. The

questionnaires measuring Kujala scores were

administered before randomization, following the

exercise program, and at nine months.

One patient in the arthroscopic surgery group and

three in the exercise-only group were lost to

follow-up at nine months.

Three in the exercise-only group insisted on having

arthroscopic surgery following the exercise program,

and their responses were analyzed according to their

original group assignment; they did not have greater

improvement than any of the other controls.

Compliance with the exercise program was similar in

both groups. The mean weekly exercise frequency was

5.0 in the surgery group and 5.2 in the exercise-only

group (P=0.52).

A second questionnaire was mailed at 24 months

following randomization, yielding a response rate of

89% in the surgery group and 82% in the exercise-only

group. The mean improvement in Kujala score was

maintained in both groups.

The authors pointed out that in the absence of a

control group, this study could not demonstrate the

efficacy of exercise. " It should be emphasized that

the primary aim was not to investigate the

effectiveness of exercise therapy in patients with

patellofemoral pain syndrome, " they wrote. " In fact,

we found no association between frequency of weekly

exercise and improvement. "

" In conclusion, on the basis of our randomized study,

which was planned using available knowledge on the

diagnosis and methods of treating patellofemoral pain

syndrome, " Dr. Kettunen and colleagues wrote,

" arthroscopy cannot be recommended for patients with

chronic patellofemoral pain syndrome. "

Action Points

Explain to interested patients that this study did not

rule out a potential benefit from knee surgery for

chronic patellofemoral pain syndrome for some

subgroups of patients.

Also point out that the results are only valid for

patients ages 18 to 40 who do not participate in

competitive sports.

The study was supported by a grant from the Social

Insurance Institution of Finland.

The authors declared that they had no financial

conflicts.

Primary source: BMC Medicine

Source reference:

Kettunen J, " Knee arthroscopy and exercise versus

exercise only for chronic patellofemoral pain

syndrome: a randomized controlled trial " BMC Medicine

2007; DOI:10.1186/1741-7015-5-38.