An international panel of experts has strongly recommended against arthroscopic surgery for nearly everyone with ‘degenerative knee disease.’
The Center for Disease Control and Prevention reports that more than 5.7 million visits to the doctor each year are due to knee pain. Arthroscopic knee surgery for osteoarthritis is the most common orthopedic procedure performed. Per the American Orthopedic Society for Sports Medicine, more than 4 million knee arthroscopy procedures are done worldwide each year; 700,000 in the United States alone.
Patients understandably become frustrated with persistent symptoms after trying less invasive management options that failed.
The side effects, such as infection and blood clots, are not worth the few months that pain is reduced. Jonas Bloch Thorlund of the University of Southern Demark wrote this: “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.”
The British Medical Journal (BMJ) composed a panel of doctors, orthopedic surgeons, physical therapists and three patients with OA. They reviewed 13 studies involving nearly 1,700 patients that compared knee arthroscopy to non-surgical injections (such as hyaluronic acid), exercise therapy and placebo surgeries. The review showed that most patients received no benefit from the surgery. A small percentage saw an improvement in pain and function three months following arthroscopy, but those benefits disappeared within a year.
The reviewers also looked at 12 studies that involved almost 2 million patients concerning the possible complications from knee arthroscopy. Although rare, complications can be serious. They acknowledge that the evidence for serious harm is slim, it is focused more on practical matters, including recovery time (2-6 weeks) and limited mobility after surgery.
When formulating their recommendation, the panel placed a high value on surgical outcomes that are important to patients, particularly pain relief. While the patient panelists identified pain, function and quality of life as the most important outcomes for patients considering surgery, they said a small improvement in function wouldn’t matter to them without a corresponding improvement in pain. Yet the studies showed that knee arthroscopy usually didn’t relieve pain, and any pain relief was short-lived. So, given the cost, the small potential for serious complications and the relatively long recovery for no (or very short-lived) measurable benefit, the panel concluded the surgery should not be performed for OA or related meniscus tears and mechanical knee problems.
The panel’s one possible exception to this recommendation is patients who have a fully locked knee and can’t completely straighten it.
In a randomized trial, Finnish researchers registered 146 patients between the ages of 35 and 65 who had knee pain for at least three months to either undergo an arthroscopic partial meniscectomy or a “fake” procedure that mimics an arthroscopy. The “fake” group was held in the operating and recovery rooms for the same amount of times as the surgical group, and all patients received the same walking aids and instructions for exercises, taking over-the-counter painkillers as required.
Participants were given questionnaires before surgery, and at 2, 6 and 12 months after the procedures, to measure pain and quality of life.
Though both groups showed improvements in symptoms from their baseline questionnaires to the 12-month follow-up, there were no significant differences between the real surgery group and the sham group.
Patients in the “fake” surgical group were not significantly more likely than patients in the partial-meniscectomy group to guess that they had undergone a fake procedure either.
“Although both groups had significant improvement in all primary outcomes, the patients assigned to arthroscopic partial meniscectomy had no greater improvement than those assigned to sham surgery,” wrote the study’s authors. They did note their study can’t be generalized to people who experienced traumatic tears to the meniscus, since the study focused on people who had wear and tear injuries.
Lead study author Dr. Teppo Jarvinen, a surgeon at the University of Helsinki in Finland, told Reuters that people “shouldn’t feel an obligation to seek help right away. 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.”
How Does Arthroscopy Work?
The surgeon will make three or four small incisions around the knee, insert a camera in one and instruments in the others, mainly to remove loose debris and/or repair or remove part of a damaged meniscus – the C-shaped cartilage pad between the thighbone and shinbone, which can become ragged as OA attacks the joint tissues. The intent is to improve arthritis pain and function.
Potential risks for this surgery include swelling, scarring, bleeding, blood clots, pulmonary embolism, infections and death.
When is Surgery Appropriate?
Dr. David Jevseva, chair of the committee on evidence-based quality and value at the American Academy of Orthopedic Surgeons, told the New York Times that “We still think there is benefit in arthroscopic meniscectomy in appropriate patients. What we need to define in the future is what’s the definition of an appropriate patient.”
There are situations when surgery is appropriate. Pain in a healthy knee with a tear resulting from acute injury in likely to respond to arthroscopy while pain associated with a tear in an arthritic knee is not. When a knee has some degenerative change of the cartilage and some tearing of the meniscus, the benefits of surgery become more difficult to predict. For these patients, options include physical therapy, weight loss, off-loading knee braces, joint fluid therapy and platelet rich plasma therapy.
It is very important for patients and their surgeon to be clear about the possible benefits and risks of the surgery prior to going to the operating room.
At Reflex, we believe in patient empowerment through education and discussion of the various treatments. We highly recommend that patients explore non-surgical treatments before committing to surgery.