Knee Arthroscopy for Pain: Do Harms Overshadow Benefits?
Surgeons in the US perform more than 700,000 knee arthroscopies annually, but a recent BMJ systematic review/meta-analysis suggests that the pain-relief efficacy of those procedures in middle aged and older adults with degenerative knee disease are inconsequential and short-lived.
In analyzing nine randomized trials that assessed the benefits of knee arthroscopy versus control treatments including exercise and sham surgery among almost 1300 patients, the Scandinavian authors found marginal improvements in pain at three and six months after surgery, but not thereafter (overall effect size of 0.14). The results were similar in subgroups with radiographically confirmed osteoarthritis.
In analyzing nine other studies (two randomized and seven observational) assessing possible harm from knee arthroscopy, authors found non-negligible rates of adverse effects, including deep vein thrombosis (4 events per 1000 surgeries), infection (2 events per 1000 surgeries), and pulmonary embolism and death (1 event each per 1000 surgeries).
The authors conclude that these findings “do not support the practise of arthroscopic surgery for middle aged or older patients with knee pain with or without signs of osteoarthritis.”
In an accompanying editorial, Andrew Carr, FRCS, from the UK’s Botnar Research Centre, notes that only two of the nine randomized trials analyzed to determine benefit were adequately blinded, but he basically agrees that “in robust and bias-free trials that use placebo controls, active treatment works no better than control treatment.” Considering the harm analysis the authors present, Dr. Carr concludes that “we may be close to a tipping point where the weight of evidence against arthroscopic knee surgery for pain is enough to overcome concerns about the quality of the studies, confirmation bias, and vested interests.”
OrthoBuzz readers, are we near that tipping point—or beyond it?