About 20% of the 900,000 arthroscopic knee surgeries performed annually in North America are done as treatment for osteoarthritis (Time, 2008). A knee arthroscopy is a procedure where a small telescope is inserted into a joint and debris is removed. The vast majority are done by orthopedic surgeons.

It turns out that knee arthroscopy may be no more effective over two years than non-surgical treatment using physical therapy and medications, according to a recent study published in the New England Journal of Medicine (Kirkley A, et al. A Randomized Trial of Arthroscopic Surgery for Osteoarthritis of the Knee. NEJM. 2008; 359:1097-1107).

The researchers examined 178 patients who had an average age of 60. All patients received standard non-surgical treatment, including physical therapy, anti-inflammatory drugs or analgesics such as acetaminophen and ibuprofen, glucosamine supplements, and injections to lubricate the joint.

Eighty-six of the patients also underwent arthroscopic surgery. Patients were evaluated over two years using a scoring system that measured pain, stiffness and physical function. After three months, the surgery group initially showed more improvement, but two years after the procedure, there was no significant difference between the groups.

The results paralleled the findings of a 2002 Department of Veteran Affairs study conducted at the Houston VA (Moseley JB, et al. A Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee. NEJM. 2002; 347: 81-88).

In response to the most recent study, E. Anthony Rankin, MD, president of the American Academy of Orthopedic Surgeons, said, "As a tool for treating arthritis alone, it probably isn't a good tool".

In an accompanying editorial, Robert Marx, an orthopedic surgeon at the Cornell University Medical College of Cornell University, wrote that the study provides "strong support" for the conclusion that "arthroscopic surgery is not effective therapy for advanced osteoarthritis of the knee." Marx added that the procedure could offer benefits for patients experiencing additional knee problems.

Both orthopedic surgeons added that "knee replacement surgery is an option for those with serious arthritis."

Approximately 555,000 total knee replacement procedures, also called total knee arthroplasty (TKA), are performed each year (Saletan W. Washington Post September 14, 2008).

Primary total knee replacement is most commonly performed for osteoarthritis (OA).

So... orthopedic surgeons win no matter what. Surgeons perform surgery.

If they can't 'scope a patient, they can replace the knee.

So what are the options for a patient if they don't want a knee replacement?

The big question is this: can cartilage- the gristle that caps the ends of long bones, and which wears away during the process of arthritis, re-grow? Some physicians like K. Dean Reeves, a physical medicine and rehabilitation specialist, in Kansas City, Kansas are studying the effects of prolotherapy in inducing cartilage growth.

Prolotherapy is a procedure where cartilage is purposefully injured to stimulate the formation of chondroblasts, early cartilage cells that have the ability to regenerate. He has just completed a double-blind study on knee arthritis using prolotherapy techniques.

In the knee arthritis study, after one year, there was a 44 percent improvement in pain, 63 percent improvement in swelling, and a 14-degree improvement in flexibility. There was an 85 percent reduction in knee buckling episodes. Improvement in joint space was also noted.

Other physicians are studying the effects of growth hormone.

Finally, the most promising approach appears to be the use of a combination of cartilage irritation and stem cells.

Dr. Nathan Wei, a rheumatologist in Frederick, Maryland, states, "We are studying the effect of a prolotherapy-like procedure in combination with autologous stem cells and growth factors for osteoarthritis of the knee. Autologous stem cells are stem cells obtained directly from the bone marrow of the patient. These stem cells are then concentrated using a special technique. Once they are reintroduced into the knee capsule along with other growth factors using ultrasound guidance, they have the capacity to differentiate into cartilage cells. Growth factors are used to send the healing phase into 'warp speed.'

The early results are very encouraging and parallel the findings of others. In the final analysis, if we can demonstrate significant improvements in clinical measures along with cartilage regeneration, we can reduce the tremendous number of knee surgeries performed every year."

He goes on to say, "Obviously, if a patient has severe arthritis -"bone on bone" with no cartilage left, then this procedure is not going to help him. That patient then will need a knee replacement. We would like to get to the patient before that stage."