Study questions benefits of knee surgery for a torn cartilage

Research published in New England Journal of Medicine is questioning the benefits of arthroscopic partial meniscectomy (cartilage surgery on the knee via an arthroscope). Wow, will this be a potential practice changer in the sports medicine world.

The Wall Street Journal reported that the study found that a sham procedure was as effective as the real procedure for reducing pain. For the study, 146 patients were randomly assigned to undergo either partial meniscectomy or the fake procedure rather than after a specific traumatic event like a sports injury. All participants were between the ages of 35 and 65 and had experienced tears in the meniscus that had gradually developed.

“The implications are fairly profound,” said Jeffrey Katz, a professor of medicine at Brigham and Women’s Hospital in Boston who wasn’t involved in the Finnish study. “There may be some relatively small advantages to meniscal surgery, but they’re short-lived.”

Meniscectomy is performed by inserting thin surgical instruments, including one called an arthroscope that is equipped with a video camera, through incisions in the knee. In a partial meniscectomy, the procedure evaluated in this study, surgeons trim and removes torn pieces rather than the entire meniscus so that they don’t interfere with the flexing of the knee joint.

The study is likely to stir controversy over the minimally invasive procedure, known as partial meniscectomy, which can cost between $3,000 and $6,000. The study’s authors estimated that it accounts for $4 billion in annual medical costs in the U.S.

The study’s relatively small sample size of 146 patients, however, makes it difficult to draw definitive conclusions about the procedure’s effectiveness, some physicians said.

“It’s hard to step back and say arthroscopy is overdone,” said Nicholas Giori, an associate professor of orthopedic surgery at Stanford University.

The New York Times reported that one “year later, most patients in both groups said their knees felt better, and the vast majority said they would choose the same method again, even if it was fake.”

The Finnish study does not indicate that surgery never helps; there is consensus that it should be performed in some circumstances, especially for younger patients and for tears from acute sports injuries. But about 80 percent of tears develop from wear and aging, and some researchers believe surgery in those cases should be significantly limited.

“Those who do research have been gradually showing that this popular operation is not of very much value,” said Dr. David Felson, a professor of medicine and epidemiology at Boston University. This study “provides information beautifully about whether the surgery that the orthopedist thinks he or she is doing is accomplishing anything. I think often the answer is no.”

The new research builds on a groundbreaking 2002 Texas study, showing that patients receiving arthroscopy for knee osteoarthritis fared no better than those receiving sham surgery. A 2008 Canadian study found that patients undergoing surgery for knee arthritisdid no better than those having physical therapy and taking medication. Now many surgeons have stopped operating on patients with only knee arthritis.

On its website, CBS News reports, “Two tests were given to measure pain and quality of life using scores between zero and 100, with zero indicating the most severe symptoms and 100 indicating symptom-free.” The investigators “found the scores between these two tests fluctuated between groups by about 1.5 to 2.5 points, differences that could have been due to chance.”

The NPR “Shots” blog reports that “the study included patients who had mechanical symptoms such as catching or locking of the knee, and they also showed no benefit from surgery.”

“This is a really well-done study,” says Dr. David Jevsevar, an orthopedic surgeon in St. George, Utah. “The only problem is how do you take this study and apply it to practice.”

It didn’t figure out who might actually benefit from meniscus surgery, Jevsevar tells Shots. More studies need to be done to find out, he says.

But the study included patients who had mechanical symptoms such as catching or locking of the knee, and they also showed no benefit from surgery. “That’s the harder one for me and my colleagues to swallow,” Jevsevar says. “I’m more likely to discuss surgery with you with that than if you have just pain.”

Also covering the story are CNNReuters, and HealthDay.

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