Clinical trials have shown that keyhole surgery doesn’t help people suffering from arthritis of the knees any more than mild painkillers, physical therapy or weight loss, said lead author Dr. Reed Siemieniuk. He is a health researcher with McMaster University in Toronto, Canada.
“You can make a pretty strong statement saying that from a long-term perspective, it really doesn’t help at all,” Siemieniuk said. “If they knew all the evidence, almost nobody would choose to have this surgery.”
Keyhole surgery is one of the most common surgical procedures in the world, with more than 2 million performed each year, Siemieniuk said. The United States alone spends about $3 billion a year on the procedure.
The new guidelines – published online May 10 in the BMJ – were issued as part of the journal’s initiative to provide up-to-date recommendations based on the latest evidence. The guidelines make a strong recommendation against arthroscopy for nearly all cases of degenerative knee disease.
This includes osteoarthritis as well as tears of the meniscus, the padding between the two leg bones in the knee, Siemieniuk said. “With age and use, the grinding of the two bones together can break down that padding,” he said. “It’s very common to see little rips and tears in that padding in patients with arthritis.” Siemieniuk and his colleagues noted that a trial published in 2016 showed that surgery was no better than exercise therapy in patients with a meniscus tear.
Despite this and other medical evidence, most guidelines still recommend keyhole surgery for people with meniscus tears, sudden onset symptoms like pain or swelling, or mild to moderate difficulties with knee movement.
Arthroscopic surgery relies on small incisions through which a tiny camera and miniature instruments are inserted. Doctors can remove or repair damaged tissue without having to cut the knee open.
The American Academy of Orthopaedic Surgeons currently advises against performing arthroscopic surgery in patients with full-fledged knee osteoarthritis, said Dr. Kevin Shea, an academy spokesman.
There is a financial incentive for doctors and hospitals to perform unnecessary keyhole surgeries, but Siemieniuk said these surgeries also might be prompted by the desire to treat a painful medical condition. Inertia might also play a role. “It’s a lot easier to introduce a new treatment into clinical care than to de-implement one that we later find out doesn’t work,” Siemieniuk said. “That’s what we’re seeing here.”
The surgery still can be useful to fix torn ligaments or repair damage caused by severe trauma, Siemieniuk said. But in most cases, he said, given the evidence, insurers “may choose not to fund it, which I think would be appropriate.”
Once the insurance companies stop paying for the procedure, it will disappear.
There have been three previous “sham-studies” on arthroscopic knee surgery. In all three studies, patients who thought they had knee surgery (but didn’t, they were shammed) fared much better than patients having the actual surgery when both were followed with physical therapy.
The Bottom Line:
Avoid arthroscopic knee surgery unless you have a well-defined ligament tear with no evidence of osteoarthritis.
Source: May 10, 2017 National Institutes of Health