Arthroscopic surgery for degenerative knee pain – A questionable practice without solid scientific supporting evidence?

Keyhole surgery to trim a torn meniscus of the knee (arthroscopic partial meniscectomy) is one of the most common surgical procedures. It is typically performed for middle aged to older adults with knee pain. Some 150 000 knee arthroscopies are performed in the United Kingdom each year. The volume is about five times higher in the United States. In the case of South Africa, the annual number of knee arthroscopies performed nationwide is unknown at the time of this writing, but the rate within the insured population is assumed to be comparable to the UK and US estimates.

Recently a group of Norwegian scientists published in the BMJ – one of the most prestigious medical journals — a comparison between exercise therapy alone and arthroscopic partial meniscectomy alone (without any postoperative rehabilitation) in adults with a degenerative meniscal tear of the knee. The authors found no differences between these two groups in self-reported knee function at the two year follow-up, but greater muscle strength in the exercise group at three months. The article was accompanied in the same issue of the journal with an editorial that questions the use of arthroscopic partial meniscectomy in the manner in which they are delivered today.

Considering the massive volume of arthroscopic partial meniscectomy, one would expect that there is conclusive scientific evidence for its benefits, but this is not the case. The publication of the first controlled trial comparing knee arthroscopy with placebo surgery as a comparator took place already a decade ago. Placebo surgery here means a faked/pretend surgical procedure that omits the step thought to be therapeutically relevant. Since then a series of scientific studies, summarised in two recent systematic reviews and meta-analyses, provide convincing evidence that arthroscopic knee surgery offers little benefit for most patients with degenerative knee disease (meniscus lesion) and knee pain.

How did this situation—widespread clinical practice without proper supporting scientific evidence—come about? For decades orthopaedic surgeons used to treat young people presenting after an injury with a “locked knee” by removing the torn meniscus in open surgery. Once knee arthroscopy evolved into a simple and safe procedure in the 1980’s, it could be done conveniently. This lead to a gradual broadening of the use the procedure, from locked knees in young patients to all patients of all ages with knee pain and meniscus tears of any sort. This “indication creep” had no support from scientific evidence. For example, recent evidence has convincingly shown that degenerative meniscus tears on magnetic resonance imaging are poorly associated with knee symptoms.

Arthroscopic surgery for knee pain seems to continue as before in clinical practice, despite the increasing scientific evidence against the current way of working. There are many likely reasons for a reluctance to change this practice in the orthopaedic community, including an understandable difficulty in letting go of long held beliefs and financial incentives. Orthopaedic surgeons are unlikely to endorse these explanations of their behaviour. What they offer as an alternative is to contend that the published studies do not reflect the real world: they are not “pragmatic”, rather “test-tube” experiments with little relevance to real-life. Many knee surgeons argue that “if only we tested the procedures in patients reflective of actual clinical practice in the settings in which arthroscopic partial meniscectomy is actually delivered, we would see that it works”.

This paradigm – adoption of procedures on the basis of assumed biological rationale on the putative grounds that randomized trials don’t reflect the real world, while the trials do not show benefit – is not unique in the orthopaedic community. Vertebroplasty or injecting bone cement to a collapsed vertebral body represents, for instance, another example of the same phenomenon.

What is the way forward?

We are at the point where any well-informed patient with knee pain who simultaneously considers the benefits and risks of arthroscopic partial meniscectomy would most likely primarily choose a non-surgical treatment option, like exercise therapy. On the other hand, well-informed public health administrators or officials of an insurance company would probably conclude that the huge volume of arthroscopic partial meniscectomies undertaken globally each year, at a high cost, is potentially worth very little in way of health benefits. Anyhow, we should not let the orthopaedic community, hospital administrators, healthcare providers, and funders to keep ignoring the results of carefully conducted scientific studies and continue the widespread use of procedures for which the evidence is missing.

References
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Thorlund JB, Juhl CB, Roos EM, Lohmander LS. Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms. BMJ 2015;350:h2747. doi:10.1136/bmj.h2747 pmid:26080045.
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