May 15, 2017

Expert panel: Arthroscopic surgery almost never helps degenerative knee problems

Daily Briefing

    For most patients with degenerative knee disease, arthroscopic surgery poses more harms than benefits and should be avoided, according to new practice guidelines released last week by an international panel of experts in BMJ.

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    In the United States, there are about 750,000 arthroscopic knee surgeries performed each year, at an annual cost of about $3 billion, the MinnPost reports. Overall, according to the new guidelines, the procedure is performed more than 2 million times per year worldwide.

    Current guidance

    Currently, most medical guidelines recommend against arthroscopic surgery for patients who have knee osteoarthritis that can be seen via x-ray, the MinnPost reports. However, many guidelines still recommend the procedure for subgroups of patients with meniscus tears, who have mild to moderate difficultly moving the knee, or who are dealing with a sudden onset of symptoms, such as swelling and pain.

    But the problem, according to the latest guidance, is that most patients with degenerative arthritis present at least one of those three subgroup characteristics.

    Review details

    The new guidance was released as part of BMJ's "Rapid Recommendation" initiative, which aims to more quickly implement strong evidence into practice recommendations. The guidance was spurred by a 2016 BMJ study that found that arthroscopic surgery is no better for treating meniscus tears than physical therapy.

    For the latest guidance, researchers reviewed 13 randomized trials involving 1,668 patients to compare knee arthroscopy and nonsurgical care for outcomes for pain, function, and quality of life. They also reviewed 12 observational studies—involving 1.8 million patients—to assess complications. In addition, a second team of researchers reviewed the evidence to determine what level of change on a given scale was important to patients.

    In the review, the researchers defined degenerative knee disease to include patients with knee pain, particularly those 35 years or older, who may or may not also have:

    • Osteoarthritis discernible via x-ray;
    • Meniscus tears;
    • Acute or subacute onset of symptoms; and
    • Locking, clicking, or other mechanical symptoms aside from persistent objective locked knee.

    Findings

    The researchers found that knee arthroscopy did not provide most patients with long-lasting pain relief or improved function.

    According to the researchers, fewer than 15 percent of patients reported an improvement in pain and function three months after surgery. Among those who reported such benefits, the effects largely vanished one year after surgery. Meanwhile, the surgery exposed patients to "rare but important harms," such as infection, the researchers said.

    Reed Siemieniuk, a physician in Canada and panel member, said the research shows that "on average, the pain relief that [a patient gets from the procedure] is not going to be important to [him or her] at all."

    New recommendations

    The researchers recommended against the use of arthroscopic knee surgery for all cases of degenerative knee disease except cases of recent trauma, ligament injuries, or for complications stemming from treatment.

    "Given that there is evidence of harm and no evidence of important lasting benefit in any subgroup, the panel believes that the burden of proof rests with those who suggest benefit for any other particular subgroups before arthroscopic surgery is routinely performed in any subgroup of patients," the researchers wrote.

    Reaction

    While physicians in the United States and Canada said current guidelines have helped to curb the procedure somewhat, rates are still high—and often driven by patient demand.

    "I try to talk patients out of [the surgery] on almost a daily basis," Peter MacDonald, president of the Canadian Orthopedic Association, said. But it can be difficult, he added, because "the patient comes into your office with a preconceived notion that he needs arthroscopy and then you discover there is arthritis in the knee. Trying to talk that patient out of surgery is not as easy as it sounds. Patients often demand it ... because for them it's better than having a knee replacement or better than just languishing in pain."

    Separately, David Johnson, an orthopedic surgeon with MedStar Orthopedic Institute, said while he will encourage other surgeons to read the report, he does not personally agree with the conclusions, stressing that decisions about knee arthroscopy must be made on a case-by-case basis. "You stratify your decision base to consider each and every one separately, and not [a] bunch [of] them all together and make a blanket statement that I'll never operate on anybody who has any kind of arthritis," he said (Heredia Rodriguez, Kaiser Health News/NPR's "Shots," 5/11; Perry, MinnPost, 5/11; Frellick, MedScape,  5/12; Frketich, Hamilton Spectator, 5/12).

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