Latest nail into what should already be a sealed coffin

Thursday, 21 Jul 2016

Experts have called for urgent measures to restrict the use of arthroscopic surgery for knee pain in light of yet more evidence that the procedure offers little benefit for most patients.

In a damning editorial in this week’s The BMJ Teppo Järvinen at the University of Helsinki and Gordon Guyatt at McMaster University in Canada were referring to new research published in the journal that they said was “the latest nail into what should be a sealing coffin”.

Published by orthopaedic surgeons and physiotherapists from Norway, Sweden and Denmark, the study randomised 140 adults with an average age of over 50 and degenerative meniscal tears confirmed by MRI to exercise therapy alone or arthroscopic partial meniscectomy alone (without any postoperative rehab).

Like many studies that have gone before it, the authors found no difference between the groups in patient reported knee function at the two-year follow-up, but greater muscle strength in the exercise group at three months.

How did this situation—widespread practice without supporting evidence of even moderate quality—come about?  the editorialists asked.

Good evidence has been widely ignored, and arthroscopic surgery for knee pain continues unabated, albeit under different procedure and billing codes, they said.

Possible reasons for reluctance in the orthopaedic community to stop performing the procedure included perverse financial incentives and an “understandable difficulty” in relinquishing cherished and long held beliefs.

“Because frontline practitioners and local commissioners have not responded appropriately to the evidence, it follows that system level measures that result in more appropriate use of scarce medical resources are necessary—and perhaps urgently required,” they wrote.

However, acting to severely limit procedures may be seen by advocates of arthroscopic partial meniscectomy as “precipitous” and “premature”.

If this line of argument was accepted then practical, real world trials embedded in the flow of practice should be undertaken to satisfy orthopaedic surgeons’ concerns about the current evidence.

“Which of these two options (or perhaps, to some degree, both) we should take is a matter requiring urgent societal debate and rapid resolution,” they said.

“In a world of increasing awareness of constrained resources and epidemic medical waste, what we should not do is allow the orthopaedic community, hospital administrators, healthcare providers, and funders to ignore the results of rigorous trials and continue widespread use of procedures for which there has never been compelling evidence,” they concluded.


Related stories:

Arthroscopy for degenerative knees doesn’t stand up

Close to a “tipping point” in knee arthroscopy

Australians are undergoing unnecessary surgery – here’s what we can do about it

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