Posted January 7th, 2010 at 10:02 pm

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Surgery, therapy both prove good for knee repair.

Published March 19, 2013

Associated Press

  • 660_KneeSurgery.jpg

    (Associated Press)

You might not want to rush into knee surgery. Physical therapy can be just as good for a common injury and at far less cost and risk, the most rigorous study to compare these treatments concludes.

Therapy didn’t always help and some people wound up having surgery for the problem, called a torn meniscus. But those who stuck with therapy had improved as much six months and one year later as those who were given arthroscopic surgery right away, researchers found.

“Both are very good choices. It would be quite reasonable to try physical therapy first because the chances are quite good that you’ll do quite well,” said one study leader, Dr. Jeffrey Katz, a joint specialist at Brigham and Women’s Hospital and Harvard Medical School.

He was to discuss the study Tuesday at an American Academy of Orthopaedic Surgeons conference in Chicago. Results were published online by the New England Journal of Medicine.

A meniscus is one of the crescent-shaped cartilage discs that cushion the knee. About one-third of people over 50 have a tear in one, and arthritis makes this more likely. Usually the tear doesn’t cause symptoms but it can be painful.

When that happens, it’s tough to tell if the pain is from the tear or the arthritis – or whether surgery is needed or will help. Nearly half a million knee surgeries for a torn meniscus are done each year in the U.S.

The new federally funded study compared surgery with a less drastic option. Researchers at seven major universities and orthopedic surgery centers around the U.S. assigned 351 people with arthritis and meniscus tears to get either surgery or physical therapy. The therapy was nine sessions on average plus exercises to do at home, which experts say is key to success.

After six months, both groups had similar rates of functional improvement. Pain scores also were similar.

Thirty percent of patients assigned to physical therapy wound up having surgery before the six months was up, often because they felt therapy wasn’t helping them. Yet they ended up the same as those who got surgery right away, as well as the rest of the physical therapy group who stuck with it and avoided having an operation.

“There are patients who would like to get better in a `fix me’ approach” and surgery may be best for them, said Elena Losina, another study leader from Brigham and Women’s Hospital.

However, an Australian preventive medicine expert contends that the study’s results should change practice. Therapy “is a reasonable first strategy, with surgery reserved for the minority who don’t have improvement,” Rachelle Buchbinder of Monash University in Melbourne wrote in a commentary in the medical journal.

As it is now, “millions of people are being exposed to potential risks associated with a treatment that may or may not offer specific benefit, and the costs are substantial,” she wrote.

Surgery costs about $5,000, compared with $1,000 to $2,000 for a typical course of physical therapy, Katz said.

One study participant – Bob O’Keefe, 68, of suburban Boston – was glad to avoid surgery for his meniscus injury three years ago.

“I felt better within two weeks” on physical therapy, he said. “My knee is virtually normal today” and he still does the recommended exercises several times a week.

Robert Dvorkin had both treatments for injuries on each knee several years apart. Dvorkin, 56, director of operations at the Coalition for the Homeless in New York City, had surgery followed by physical therapy for a tear in his right knee and said it was months before he felt no pain.

Then several years ago he hurt his left knee while exercising. “I had been doing some stretching and doing some push-ups and I just felt it go `pop.’” he recalls. “I was limping, it was extremely painful.”

An imaging test showed a less severe tear and a different surgeon recommended physical therapy. Dvorkin said it worked like a charm – he avoided surgery and recovered faster than from his first injury. The treatment involved two to three hour-long sessions a week, including strengthening exercises, balancing and massage. He said the sessions weren’t that painful and his knee felt better after each one.

“Within a month I was healed,” Dvorkin said. “I was completely back to normal.”

 

Rehabilitation Within A Day of Knee Replacement Pays Off.

Article Date: 6 March 2011 – 16:00pst

Starting rehabilitation sooner following knee arthroplasty surgery could pay dividends – for both patients and hospitals. Commecing physical therapy within 24 hours of surgery can improve pain, range of motion and muscle strength as well as cut hospital stays, according to new research in the journal Clinical Rehabilitation, published by SAGE.

Mindful of the trend towards discharging patients from hospital more rapidly after surgery in recent years, physical therapy and public health researchers from Almeria, Malaga and Granada in Spain set out to investigate whether an early start to physical therapy would improve recovery from knee arthroplasty surgery. They compared patients who began treatment within 24 hours of surgery with those who began 48-72 hours after their operation in a random, controlled clinical trial. Each group comprised over 150 patients aged 50-75.

The post-operative treatment began with a series of leg exercises, breathing exercises, and tips on posture. By the second day walking short distances with walking aids was added, and in subsequent days this was built up towards adapting to daily life activities, such as beginning to climb stairs on day four.

On average, those beginning treatment earlier stayed in hospital two days less than the control group and had five fewer rehabilitation sessions before they were discharged. An early start also lead to less pain, a greater range of joint motion both in leg flexion and extension, improved muscle strength and higher scores in tests for gait and balance.

Health systems are currently subjected to strong economic pressures, and a cutting the length of hospital stays has become a priority. Other benefits of early mobilization after this surgery are fewer complications such as deep vein thrombosis, pulmonary embolism, chest infection, and urinary retention. With hospital-acquired infections such as MRSA also a serious concern, a shorter hospital stay might also lower the risk to patients of contracting this type of secondary infection.

“Orthopaedics, especially knee replacement surgery, is one area that may lend itself to accelerated discharge,” says author Adelaida Mª Castro Sánchez, from the University of Almeria. “We therefore postulated that early rehabilitation after total knee arthroplasty could accelerate the capacity of patients for daily life activities, and reduce their hospital stay.”

Osteoarthritis is estimated to affect around three quarters of over 65s in developed countries, and when it affects the knees it can be intensely painful, affecting the gait and leading to deformity. As a result, replacing the knee joint with a surgical implant has now become a routine, but major, surgical procedure.

Source: Medical News Today

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