Common knee surgery doesn’t help older adults

[March 10, 2018]   By Lisa Rapaport

(Reuters Health) – Many older adults are getting surgery to remove damaged cartilage in the knee even though these operations may not help ease pain or improve mobility in people over 65, a U.S. study suggests.

Researchers focused on a procedure known as arthroscopic partial meniscectomy, which involves shaving or cutting out damaged or torn tissue. Some previous research suggests younger patients with severely damaged cartilage may benefit from this operation, but it may not work any better than physical therapy for most people, especially when they’re over 65, researchers note in JAMA Surgery.

Despite the lack of benefit, more than 12,000 surgeons performed almost 122,000 of these procedures for patients insured by Medicare, the U.S. health program for people 65 and older, in 2015, the current study found.

“This study shows that it remains extremely common in older patients,” said senior study author Dr. Martin Makary, a surgery professor at Johns Hopkins School of Medicine in Baltimore.

“However, its benefit is limited to a small subset of patients who are usually younger,” Makary said by email.

In addition to the total number of partial meniscectomies, researchers also looked at how often operations involved just this procedure, and not additional work to repair damage to ligaments or cartilage.

Overall, about two-thirds of the operations involved this procedure alone, regardless of whether surgeons did a low or high volume of knee operations, the study found.

Among high-volume surgeons, 13 percent never did additional repair work when they performed arthroscopic partial meniscectomies, while 7 percent never performed this procedure on its own.

While researchers didn’t have data to explain why so many seniors are getting an operation that in all likelihood won’t help them, it’s possible that some doctors and patients aren’t yet aware of several randomized controlled experiments published in recent years showing a lack of benefit, researchers write.

Some surgeons and patients might be aware of this evidence, but disagree about the interpretation of the findings or think that their particular case might be an outlier where the procedure actually helps, the authors also write.

“Despite evidence, there is still a very strong belief by many surgeons and patients that the surgery is effective,” said Jonas Bloch Thorlund, a sports medicine researcher at the University of Southern Denmark who wasn’t involved in the study.

“Indeed, many patients do get better,” Thorlund said by email. “However, this is more likely due to placebo effect, natural remission, or a phenomenon called regression to mean (when people experiencing extreme pain before surgery report only average pain afterwards).”

The study wasn’t a controlled experiment designed to prove whether or how these operations might impact pain or mobility in older adults with knee problems.

Another limitation of the study includes the reliance on procedure codes in Medicare records, and the authors note in some cases patients might have other underlying issues or surgeons might be doing procedures for reasons not highlighted in the records.

Patients with degenerative meniscal tears, which can occur with osteoarthritis, may benefit from physical therapy, weight loss if needed and education on how to move to reduce pain, Thorlund said.

SOURCE: http://bit.ly/2Hkb5WF JAMA Surgery, online February 28, 2018.

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