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  • More Evidence Questions Benefits of Arthroscopic Knee Surgery

    The case continues to mount around the lack of evidence to support arthroscopic surgery for degenerative knees—this time, by way of research that calls for a "reversal of a common medical practice," even among patients with knee osteoarthritis. Authors of the article write that the procedure produces "small inconsequential" benefits in pain and that surgery produced no benefit in function.

    In an article published in BMJ, researchers share the results of a systematic review and meta-analysis of 9 trials, involving 1,270 individuals, that looked at the benefits of knee arthroscopic surgery in middle-aged and older patients with knee pain and degenerative knee disease. Patient data were analyzed in several different ways, including in terms of those with no knee osteoarthritis (OA) found by radiography, those with knee OA confirmed through radiography, and a mixed OA and no-OA group.

    Researchers tracked pain, function, and adverse events through the trials' follow-up times, which ranged from 3 to 24 months.

    Authors found that although small statistically significant improvements in pain were present among the intervention (surgery) group, those differences disappeared after 6 months—and even when they were present were no better than the benefits provided by the use of acetaminophen, and a little less effective than nonsteroidal anti-inflammatory drugs. There were no differences found in terms of function between the surgery group and any control (some of which included exercise) at any point postsurgery.

    Although evidence to assess adverse events was harder to come by, researchers estimated that deep venous thrombosis was reported most, followed by infection, pulmonary embolism, and death. They estimated the risk of deep venous thrombosis at 4.13 per 1,000 knee arthroscopy procedures.

    Authors write that their study is one of the first to look at the benefits and harms of arthroscopic surgery across "the whole continuum" of degenerative knee diseases," ranging from patients with meniscal tears but no radiographic changes to those with tears "and other joint changes combined with more severe radiographic changes."

    Exercise was a fairly common element in the various control groups analyzed, but authors write that in many cases "was … of inadequate dose for optimal efficacy," speculating that the deficiencies could point to a bias in favor of surgery.

    It's not that patients who receive arthroscopic surgery don't improve, authors write, it's just that "improvements in control groups were similarly impressive, with no clinically relevant between-group differences at any time point," something they say is in line with recent studies on improvements noted in placebo control groups.

    The most recent findings echo earlier research, including a 2008 study that questioned the benefits of arthroscopic surgery, and a more recent study that found no differences in outcomes among patients who received the procedure and others who received sham surgery.

    Even with the mounting evidence, authors predict an uphill battle in countering the prevalence of arthroscopic surgery for degenerative knees.

    "Disinvestment of commonly used procedures remains a challenge," authors write. "Surgeon confirmation bias in combination with financial aspects and administrative policies may be factors more powerful than evidence in driving practice patterns."

    Learn more about approaches to knee disorders: check out continuing education on manual therapy for disorders of the knee available through the APTA Learning Center.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Comments

    • I have had several orthoscopic surgeries with great results for my DJD/osteoarthritis. The results lasted 6-10 years for decreased pain and increased activities. Grant it, I was no longer able to participate in aggressive sports - tennis, softball/running but I could still work out in the gym. I'm currently doing bikram yoga to help the flexibility/strength. So the surgery definitely helped me.

      Posted by L boone on 6/24/2015 11:35 PM

    • This is some really good information about arthroscopy. It is good to know with surgery you can get rid of the pain after about six months. It is good to know that it would be smart to talk to a doctor about that.

      Posted by Penelope Smith on 8/15/2018 11:10 PM

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