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Common knee surgery ineffective in study

By Gene Emery

NEW YORK (Reuters Health) - One of the most common types of knee surgery performed in the U.S. is no more effective than fake surgery, at least for the first year, according to a new study.

The new evidence should give doctors pause before they try to repair the meniscus, which cushions the bones of the knee, according to the Finnish doctors behind the research published in the New England Journal of Medicine.

The experiment involved 146 volunteers whose knee pain appeared to be caused by wear and tear of that cushion. None of the participants had a recognized injury or osteoarthritis, both situations for which the surgery is already known to be ineffective.

After 12 months, the average improvement among the people who received real surgery and those who got "sham" surgery was essentially the same, said the research team, led by Dr. Teppo Jarvinen of University of Helsinki.

There was no significant improvement in knee pain after exercise and no sizable improvement in the likelihood that a patient would require subsequent knee surgery.

But Dr. Craig Bennett, chief of sports medicine at the University of Maryland Medical Center, cautioned that the findings should not be over-generalized. One problem, he told Reuters Health in a telephone interview, is that such "sham" surgery is, in fact, a surgical procedure with potential benefit.

People with knee pain who seem to be candidates for meniscal repair may be suffering because of debris in a swollen knee joint. "If you scope the knee (without touching the cushion), that will often help even if you don't completely address the torn meniscus issue," he said.

During an arthroscopic examination, where fluid is injected to give doctors a good view, "you're taking out the junky, thick irritating fluid that can give a lot of people their pain," he said.

During both sham and regular surgery, small holes are poked through either side of the knee, so doctors can insert instruments to examine the joint. With the surgery, known as arthroscopic partial meniscectomy, damaged and loose pieces of the cushioning material that may be out of place and interfering with the motion of the knee are trimmed away.

Because about 700,000 such surgeries are done in the U.S. each year at a cost of $4 billion, the new findings "will not be welcomed with open arms," Jarvinen predicted in a phone interview.

The study was done at five medical centers in Finland. All the volunteers had experienced knee pain for at least three months and doctors believed the problem was a tear of the medial meniscus. Nonsurgical treatment had not helped them.

Patients did now know whether they had real surgery because of the way the researchers set up the experiment. Once a doctor had used arthroscopic techniques to examine the knee, if surgery seemed appropriate, the medical team opened an envelope - with the equipment still in place - to reveal whether the patient would receive fake surgery or real surgery.

For sham surgery, the microshaver that is typically used by the surgeon for meniscus removal didn't have a blade.

The patient was not told which option was randomly chosen and neither the orthopedic surgeon nor other operating room staff were involved in further care of the patient. The patients were unable to guess whether they had received real surgery or fake surgery.

On two scales objectively measuring symptoms, there was little difference in outcomes between sham and real surgery.

But patients regarded the treatment as a success whether they received real surgery or not. Surveys showed 89 percent in the actual surgery group and 83 percent in the sham group reported improvement.

Of those who got actual surgery, 77 percent said they were satisfied with the outcome, as did 70 percent of the sham surgery group. And 93 percent who got actual surgery and 96 percent who got the sham treatment said they would be willing to repeat the procedure.

Five patients in the sham-surgery group and two who actually had surgery had such persistent problems that further surgery was required, but that difference wasn't large enough to demonstrate that the operation worked better.

Jarvien said the lesson for patients is that if you have a sore knee that's not caused by an obvious injury, "it seems we really don't have a quick fix."

"Don't feel an obligation to seek help right away," he said. "You can just treat it with the conventional bag of tricks: painkillers, icing, losing weight, or slightly moderating your activities to make it a bit more tolerable."

"Try to ride a bike, swim, to get you back to what you used to do," he said.

Bennett, however, said the situation is more complicated. He predicted that if the patients were to be followed beyond one year, younger ones would eventually show a benefit from the surgery.

"If you have a 35-year old and I leave their torn piece of meniscus tissue alone, even though they're doing better at the one-year mark than the person in whom it was cleaned up, what's the story going to be 5, 6, 7, 8, or 9 years down the road?" Bennett said. "Is that piece in a highly-active 35-year-old person going to rough up and scuff up cartilage that was originally okay?"

"Not every meniscus tear warrants surgery," he said. "There's a lot of factors that go into determining whether someone should have surgery, and you can't get much of that from this paper."

SOURCE: http://bit.ly/1eD6oY5 New England Journal of Medicine, online December 25, 2013.

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