Study Finds Popular Knee Surgery
Not Worth It
In a surprising new review published in BMJ, researchers have found that arthroscopic knee surgery to alleviate pain in middle-aged and older patients, despite its wide use, is not more beneficial than standard non-surgical care—and is associated with certain significant harms.
Arthroscopic knee surgery is frequently, even increasingly, used to treat middle aged and older patients with persistent knee pain or degenerative knee disease.
The new review
The new comprehensive meta-analysis looked at nine studies involving nearly 1,300 patients, extending the existing knowledge of surgical outcomes by incorporating the most up-to-date data, including more patients, and by presenting outcomes on pain, function, and harms in patients, “ranging from those with degenerative meniscal tears and no radiographic signs of osteoarthritis to those with degenerative meniscal tears and more severe signs of osteoarthritis.”
The patients were randomized to partial meniscectomy and/or debridement, which is the medical removal of damaged tissue to improve the healing of healthy tissue.
These were compared with control treatments such as placebo surgery and exercise, with the main outcome measures being pain level and physical function. When analyzed over time of follow-up, interventions including arthroscopy showed a small benefit for pain at three and six months, but not later up to 24 months. No significant benefit on physical function was found.
The overall benefit on pain from arthroscopic surgery was comparable to the small pain relieving effect on knee pain seen from paracetamol and less than that of NSAID use. It was also “markedly smaller” than the moderate to large pain-relieving effect seen from exercise therapy.
The authors quite starkly write, “The small inconsequential benefit seen from interventions that include arthroscopy for the degenerative knee is limited in time and absent at one to two years after surgery. Knee arthroscopy is associated with harms. Taken together, these findings do not support the practise of arthroscopic surgery for middle aged or older patients with knee pain with or without signs of osteoarthritis.”
In the two randomized and seven observational studies examined for harms, the adverse effects of surgery were not negligible: deep vein thrombosis occurred in four per 1,000 surgeries; infection in two; and pulmonary embolism and death in one each.
Beyond noting a lack of evidence for the surgery’s efficacy, the authors go so far as to call for a reversal of the practice: “Available evidence supports the reversal of a common medical practice.”
Why is arthroscopic knee surgery with meniscus resection so common for middle aged or older people with persistent knee pain? One factor muddying the waters is that the knees of these patients often show “degenerative” lesions of cartilage, meniscus, and other tissues, suggestive of osteoarthritis. However, population based studies using magnetic resonance imaging show that incidental findings of such lesions are also very common among people without knee symptoms and among those without plain radiographic signs of osteoarthritis, suggesting that the clinical significance of such findings is unclear.
Yet the authors even found that previously, all but one published randomized trials had shown no added benefit for arthroscopic surgery over that of the control treatment. We now learn that interventions that include arthroscopy are associated with a small benefit and with harms—and the small benefit is inconsequential and of short duration.
However, desisting commonly used procedures remains a challenge. As the authors write, “[M]any specialists are convinced of the benefits of the procedure from their own experience, and several recent reports show an increase, or no decrease, in the incidence of arthroscopic knee surgery with meniscus resection during the past decade.”
It seems clear that this is a trend worth changing.