Orthopedists are overusing arthroscopic knee procedures, performing them on patients for whom the benefits are questionable and the potential harms are serious, according to a new BMJ study.
The benefits of knee repair procedures in older adults for painful arthritic knee or torn meniscus are short-lived and “inconsequential” compared with the potential harms, according to a study published online Tuesday. Older patients who have knee pain but do not have osteoarthritis- a chronic disease of the joint cartilage and bone- should not be recommended the procedure, the researchers said.
It's not the first study to suggest that the increasingly popular knee arthroscopies are overused, or to recommend clarification for which patients are most appropriate for surgery. The steadily rising numbers of patients undergoing the procedure paired with the high associated costs are raising eyebrows among both researchers and insurers.
The number of knee arthroscopies performed in the U.S. is rising, now totaling 700,000 a year. In the U.K., there are about 150,000 done each year.
But it may take more than just mounting evidence of questionable value to change physician behavior, the authors suggested. Financial benefits and the tendency of many to stick to what they already know “may be factors more powerful than evidence,” they wrote. “Disinvestment of commonly used procedures remains a challenge.”
Arthroscopic knee repair is intended for those with severe knee damage, often caused by arthritis in the joint that makes it painful or difficult to walk, according to the National Institutes of Health. The best candidates are generally considered to be adults with severe levels of pain, functional loss and knee osteoarthritis. Yet recent studies have found a third of patients who had the surgery did not meet those criteria.
The new BMJ study is part of the journal's “Too Much Medicine” campaign, which focuses on wasted resources caused by unnecessary care. The meta-analysis looked at nine randomized trials in the U.S. and the United Kingdom for older patients who either had partial or total surgery on the meniscus or had a non-surgical option such as exercise.
Although reductions in pain were statistically significant in the first six months after surgery, the benefit diminished beyond that point and were gone within two years. In terms of physical function, there was no significant difference between those who underwent knee arthroscopy and those who did not. Still, adverse events such as clots in the veins and/or lungs, infections and death, were reported in the studies evaluated.
Many specialists are convinced of the benefits of the surgery. But the overall additional benefit is comparable to the effect of taking an over-the-counter pain reliever, the authors said. “Middle aged patients with knee pain and meniscal tears should be considered as having early stage osteoarthritis and be treated according to clinical guidelines for knee osteoarthritis, starting with information, exercise, and often weight loss.”
