Study Doubts Knee Surgery Benefits
By HILARY HYLTON Sun Sep 14, 7:30 PM ET
One of the most commonly used surgical procedures aimed at easing the pain of arthritis in the knee works no better than noninvasive therapy or drugs, according to a new study reported this week in the New England Journal of Medicine. At best, the study's authors say, the short-term relief reported by some surgery patients may simply be a placebo effect, and for millions of arthritis sufferers, surgery does not easy stiffness or pain any better than physical therapy or anti-inflmmatory drugs.
The same message went out to orthopedic surgeons in 2002, when a study of U.S. veterans found that patients who got arthroscopic knee surgery did not fare any better than patients who were given "sham surgery" but led to believe they had undergone a real procedure. That study, conducted by Department of Veterans Affairs (VA), prompted Medicare to drop coverage of the procedure for osteoarthritis patients. But whether it actually impacted the vast numbers of knee surgeries being done in the
The new study, conducted by Canadian researchers, reinforces the VA findings. About 20% of the 900,000 arthroscopic knee surgeries performed annually in North America are done as treatment for osteoarthritis, according to the study's co-author Dr. Bob Litchfield, the medical director of the Fowler Kennedy Sport Medicine Clinic at London Health Sciences Centre in
The Canadian study, which ran from 1999 to 2007 and included patients of orthopedic surgeons, rheumatologists and physiotherapists, sought to address some of the concerns raised about the 2002 report: The new study includes a better defined, but more diverse and representative, group of patients, and measured success using a carefully calibrated index that assessed patients' pain, stiffness and physical function. A group of 178 men and women from the
The two groups were carefully balanced for age, obesity and gender, Litchfield said, and their conditions were narrowly focused on osteoarthritis. In most cases of arthritis of the knee there is some evidence of damage to the miniscus, the cartilage that cushions the knee joint, says Litchfield, but some tears are too small to show up on X-rays or MRIs prior to surgery. The study eliminated all patients with discernible miniscal tears, on the assumption that they would clearly benefit from surgery. (A separate paper published in the same issue of the New England Journal of Medicine found, however, that meniscal tears may have no impact on arthritis pain: Two-thirds of middle-aged and elderly people in the study who had a damaged meniscus reported no pain or stiffness.)
Litchfield's study found that three months after arthroscopic surgery, patients appeared to enjoy no additional benefit compared with the nonsurgical group, suggesting that the operation initially may have had a placebo effect. Both groups experienced some improvement, which Litchfield credits in part to the structured regimen of physical therapy, home exercise and diligent follow up by nurses.
"Those who take some ownership for recovery, rather than just showing up at the surgeon's office and saying, 'Fix me'" have a better outcome, Litchfield says.
The study also suggests that the age of the patient, the cause of the injury and the origin of the pain should be taken into consideration when assessing whether surgery is necessary. The procedure is appropriate in patients with arthritis but only where the osteoarthritis is not the primary cause of pain. Even in those cases, patients whose X-rays already show arthritis have the least to gain, Litchfield says. Younger patients whose X-rays show minimal arthritic changes have the most to gain.
While knee surgery is a very safe operation, there are risks that patients should consider, Litchfield says. In about five percent of cases patients may develop infections or phlebitis. The bottom line, drawing on this study, is that in patients whose X-rays show that arthritis alone is the cause of their pain, arthroscopic surgery "should be used very judiciously," Litchfield says. It remains to be seen whether orthopedic surgeons and patients who want that quick fix will heed the advice. View this article on Time.com