By Bert Mandelbaum, MD
A Comprehensive Approach to Knee Osteoarthritis
To be a good surgeon these days, you can’t just focus on what you do with your knife.
I thought of that when reading the recent editorial in the British Journal of Medicine against performing knee arthroscopy for degenerative joint disease in middle-aged and older patients.[1]Based on a meta-analysis of nine studies,[2] the editorial combines statistics on patients in different stages and circumstances of knee degeneration and concludes that surgery for knee pain provides hardly any benefit. 
The study makes an important point. For those older adults who never plan to return to vigorous activity, knee arthroscopy as an isolated intervention may not have significant benefit.
But many of the studies on which its findings are based are dated, and the study oversimplifies complex questions. In the real world, knee problems come in all shapes and sizes. Patients range from young to old, from within their proper weight range to obese, and from out of shape to well-trained, and they have different levels of arthritis.
In addition, the study disregards a wide variety of interventions, including exercise and weight loss, and a spectrum of biologic treatments.
As part of a comprehensive approach to degenerative diseases of the knee, sports medicine specialists must play an active role before injuries take place. Randomized controlled trials have shown that systematic neuromuscular training programs, such as the FIFA 11+,[3] can reduce the risk for knee injury by 50% or more.
But no regimen can completely eliminate knee injuries. And we know that meniscus and anterior cruciate ligament (ACL) injuries substantially increase the risk for long-term osteoarthritis.[4,5]
We are beginning to understand that these injuries cause a catabolic cascade of matrix metalloproteinases and cytokines that contribute to the development of osteoarthritis.