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 Every year, more than two million people with degenerative knee
problems have arthroscopic surgery, in which a surgeon inserts a
tiny camera into the knee and uses small instruments to try to fix
what’s wrong.
But guidelines published Wednesday in the British Medical Journal
recommend against the procedure for just about everyone with knee
arthritis.
“It does more harm than good,” Dr. Reed Siemieniuk, chair of the
guideline panel, told Reuters Health by email. “Most patients
experience improvement after arthroscopy, but in many cases, this is
probably wrongly attributed to the surgery itself rather than to the
natural course of the disease, a placebo effect, or (other)
interventions like painkillers and exercise.”
In addition, the procedure is costly - up to $3 billion annually in
the U.S. alone - and there’s a risk of rare but serious adverse
effects such as blood clots or infection, said Siemieniuk, who works
in the department of Health Research Methods, Evidence and Impact at
McMaster University in Hamilton, Ontario, Canada.
The panel, made up of surgeons, physical therapists, clinicians and
patients, analyzed data from 13 randomized controlled trials - the
gold standard way to test medical procedures - involving a total of
1,668 patients. The trials compared knee arthroscopy to conservative
treatments such as exercise and painkillers.
The panelists also reviewed 12 less-rigorous studies of close to two
million patients that looked at complications from the procedure.
After considering the balance of benefits, harms and burdens of knee
arthroscopy, as well as the quality of the evidence for each
outcome, the panel made a “strong recommendation against
arthroscopy.”
The evidence shows a less than 15 percent probability of “small or
very small improvement in short-term pain and function” from the
procedure, and improvements would likely last less than a year, the
panelists noted.
They thought it was more important to avoid postoperative
limitations such as pain, swelling and restricted activity, and the
risk of adverse effects.
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“Chronic knee pain can be incredibly frustrating to live with - both
for the person experiencing the pain and for their doctors,”
Siemieniuk said. “The problem is that none of the current options
cure the pain. Most people will continue to live with some pain even
with weight loss, physical therapy, and painkillers. Knee
replacement surgery also has important limitations and should be
delayed as long as possible. So it's no surprise that many placed
their hopes in arthroscopic knee surgery.”
Still, he said, “We believe that no one or almost no one would want
this surgery if they understand the evidence.”
If you have chronic knee pain, “double down on efforts for things we
know work - for example, weight loss and physical therapy,” he
advised.
“Also, talk to your healthcare provider (doctor, physical therapist)
about strategies to reduce the physical stress on the knee that
exacerbates the pain,” he added.
Dr. Joseph Bosco, vice-chair at NYU Langone Orthopedics in New York
City, told Reuters Health, “In general I agree with the findings and
support most of the conclusions.”
“The only issue is that in the study with the strongest evidence,
the operative group did not do physical therapy,” he said by email.
“That is not consistent with how we treat our patients. Almost all
patients get physical therapy following knee arthroscopies.”
“Cortisone injections, physical therapy and anti-inflammatory
medications work as well or better than surgery for most
degenerative meniscal tears,” said Bosco, who was not involved in
developing the guidelines.
However, he added, a small group of people “who (also) have
mechanical symptoms, localized pain, and acute onset of pain will
benefit, so a blanket recommendation against all surgery for
degenerative meniscal tears is not appropriate.”
SOURCE: http://bit.ly/2qdSd4d BMJ, online May 10, 2017.
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