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Orthopaedic papers

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A controlled trial of arthroscopic surgery for osteoarthritis of the knee.  Moseley J B, O'Malley K, Petersen N J et al.  N Eng J Med 2002;  347:  81-88.

When medical therapy fails to relieve the pain of osteoarthritis of the knee, arthroscopic lavage or debridement is often recommended.  In uncontrolled studies of knee arthroscopy for osteoarthritis, about half of the patients report a reduction in symptoms.  However, the physiological basis of this pain relief is unclear.  There is no evidence that arthroscopy cures or arrests the arthritic process.  The aim of this study was to perform a randomised, placebo-controlled trial to assess the efficacy of arthroscopic surgery of the knee in relieving pain and improving function in patients with osteoarthritis.  Both patients and assessors were blinded to the treatment assignments.  Overall, 180 patients with osteoarthritis of the knee were randomly assigned to receive either arthroscopic debridement, arthroscopic lavage or placebo surgery.  Patients in the placebo group received skin incisions and underwent a simulated debridement without insertion of the arthroscope.  Outcomes were assessed at multiple points over a 24-month period with use of five self-reported scores ( 3 on scales for pain and 2 on scales for function) and one objective test of walking and stair climbing.  A total of 165 patients completed the trial.  At no point did patients in either of the intervention groups report less pain or better function than the placebo group.  Furthermore, the 95% confidence intervals for the difference between the placebo group and the intervention group excluded any clinically meaningful difference.  It was concluded that in this controlled trial involving patients with osteoarthritis of the knee, the outcomes after arthroscopic lavage or arthroscopic debridement were no better than those after a placebo procedure.

Outcomes of endoscopic surgery compared with open surgery for carpel tunnel syndrome among employed patients:  randomised controlled trial.  Atroshi I,  Larsson G-U,  Ornstein E et al.  BMJ 2006;  332:  1473-1481.

Surgery for carpel tunnel syndrome is one of the most performed surgical procedures.  The largest proportion are done in working working people.  Open carpel tunnel release may result in prolonged pain at the scar and in the proximal palm.  Endoscopic procedures have been introduced with the proposed benefit of reduced postoperative pain and a quicker return to work.  The aim of this study was to compare endoscopic and open carpel tunnel release in employed patients with carpel tunnel syndrome.  A randomised controlled trial was conducted in a single orthopaedic department,  Overall, 128 employed patients aged 25-60 years with clinically diagnoses and electrophysiologically confirmed idiopathic carpel tunnel syndrome.  The primary outcome measure was the severity of postoperative pain in the scar or proximal palm and the degree to which pain or tenderness limited activity.  The secondary outcome measures were length of postoperative work absence, severity of symptoms of carpel tunnel syndrome and functional status scores.  63 patients were allocated to endoscopic surgery and 65 patients to open surgery.  Pain in the scar or proximal palm was less severe after after endoscopic surgery but the differences were generally small.  At three months, pain was reported by 33 patients (52%) in the endoscopic group and 53 patients (82%) in the open group (number needed to treat = 3.4, 95% CI 2.3-7.7).  No differences between the groups were found in other outcome measures.  The median length of work absence was 28 days in both groups.  It was concluded that in carpel tunnel syndrome, endoscopic surgery was associated with less postoperative pain then open surgery, but the small size of the benefit and the similarity in other outcomes makes its cost effectiveness uncertain.

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