Needless procedures: knee arthroscopy is one of the most common but least effective surgeriesIan Harris, UNSW; Denise O'Connor, Monash University, and Rachelle Buchbinder
From time to time, we hear or read about medical procedures that can be ineffective and needlessly drive up the nation’s health-care costs. This occasional series will explore such procedures individually and explain why they could cause more harm than good in particular circumstances.
More than 70,000 knee arthroscopies were performed in 2011 in Australia and, though rates of the surgical procedure are now falling, it still remains one of the most common surgical procedures.
The word arthroscopy means to look inside a joint, in this case the knee. But newer imaging techniques, such as magnetic resonance imaging (MRI) scans, mean performing a knee arthroscopy simply to look inside the knee joint is rare.
Knee arthroscopies are most commonly performed to treat osteoarthritis (wear and tear in the joint) or problems with the menisci (the two rubbery discs between the bone ends). An arthroscopy involves making a small incision in the skin and inserting a kind of camera on a stick. Another incision is made to insert other instruments to cut and remove tissue.
In the case of osteoarthitis or meniscal problems, arthroscopy can be used to clear debris from the joint or to trim loose cartilage or torn parts of the menisci. The procedure can also be used to perform ligament reconstructions, help with treating fractures or infections in the knee, or simply to take a sample of tissue from the joint.
The camera can see structures such as the cartilage that covers the end of the bones, the lining (synovium), the menisci and ligaments. Knee arthroscopy requires admission to hospital and an anaesthetic. It carries some risk of harm such as infection or further damage in the joint.
It’s rarely effective
Most knee arthroscopies are done in older people for degenerative conditions such as osteoarthritis. The prevalence of knee osteoarthritis, which can involve wear and tear of the menisci as well as the cartilage that lines the bone, increases with age. Most people aged 50 years and over have some osteoarthritis in the joint and roughly one-quarter will have some wear and tear in the menisci.
Many people with osteoarthritis or a torn meniscus also have knee pain. This has led to the belief that the osteoarthritis changes or the meniscus tear cause the pain. But these changes are also common in those who have no pain at all. And menisci mostly don’t have nerves, so they can’t be felt unless there is a large tear, often resulting from a major injury. In fact, most people with a torn meniscus don’t have knee pain.
Many studies have now shown the outcomes from arthroscopic surgery for osteoarthritis and degenerative meniscal tears are no better than the outcomes from placebo (fake) surgery or other treatments (such as exercise therapy).
A recent summary of these studies made “a strong recommendation against the use of arthroscopy in nearly all patients with degenerative knee disease” (osteoarthritis and degenerative tears of the menisci) and concluded “further research is unlikely to alter this recommendation”.
Many surgeons believe the presence of mechanical symptoms – a concept that is not clearly defined but involves pain and abnormal feelings (such as catching, clicking and locking) when moving the joint – can be treated with arthroscopy. However, studies have also shown having arthroscopy does not provide better results than fake surgery for the treatment of mechanical symptoms.
Sometimes, a meniscus can be so badly torn it folds over on itself, jamming the knee and restricting the ability to straighten the knee. This is a relatively uncommon type of meniscus tear and if the symptoms don’t improve on their own, the torn part of the meniscus can be removed arthroscopically.
Why do surgeons still recommend it?
Doctors tend to overestimate how good their treatments are and underestimate the harms that come from them. Surgeons are often faced with patients in pain and, other than surgery, have little else to offer except continued non-operative treatment, reassurance and time.
Patients may want a quick fix or may have failed to improve with other treatments, but unfortunately the failure of other treatments doesn’t make knee arthroscopy any more successful.
Knee pain due to osteoarthritis often fluctuates in severity and patients tend to present for treatment when their pain is most severe. This means any treatment given at this time will appear more effective than it truly is. This is why comparative studies, particularly placebo studies, are important, as these show the true effects of treatments.
Though some surgeons may believe they can predict which patients will do well from surgery, this belief has not been validated. Despite the desire for this procedure to work, arthroscopy for degenerative knee conditions puts patients at risk of harm, including death, for no important benefits.
How can we stop it?
Changing practice in response to evidence is often slow. The first high-quality trial to demonstrate knee arthroscopy was no better than placebo surgery was published in 2002, yet overuse of knee arthroscopy has persisted.
The rates of knee arthroscopy in Australia are starting to fall, particularly in New South Wales, where the rate of knee arthroscopies in people aged 50 and over has nearly halved since 2011. More action is needed. All surgeons, particularly in high-volume states such as Western Australia, South Australia and Victoria, need to take a good hard look at the evidence, question their practice, and take action to reduce this overuse.
A key metric on whether or not I am a good physio is: "Do my patients get better?"...
Most patients do get better (unfortunately not all***), and I'll ask them at the end, what made the difference? Was it the hands-on treatment?, taping?, ice?, heat?, tablets?, stretching? strength exercises?, or natural recovery? It's not always obvious to the patient what made the biggest difference to recovery and patients will tell me all sorts of things. However, I'm very confident the most important component of whether or not they get better is "Do they do the rehab exercises I give them?".
So I think, whether or not I am a good physio, comes down to:
There are some very good physios around who prescribe very thorough rehab programs, working on this-or-that stabiliser, or this-or-that kinetic chain. 20 exercises, head to toe. Gold plated. Which is great, except I'm just never going to get 20 exercises done. "Doing" the one most important exercise is always going to be more effective than "not doing" 20 thorough exercises.
So my recommendations are always:
So you've got one job to do. You'd think that would work?...
It's really hard to get something done. One exercise - it should be easy, but it's not.
And it's not that it takes too long, or it's inconvenient. You can do it anywhere, anytime.
The problem is remembering to do it. You remember to do the exercise when you're in the middle of something else, you think "I'll do it later", and you just don't remember. You crawl into bed at the end of the day: "Bugger. Didn't get that exercise done. I'll do it tomorrow".
Then you've missed a day. Maybe you've missed a whole week.
So how do you remember to do the exercise?
Set an alarm? - The alarm goes off when you're in the middle of doing something else. "I'll do it later."
I think the best way is to "marry" the exercise to something that happens regularly in your day already. I've heard people recommend doing their exercises when they brush their teeth. Your doing it twice a day already.
But quite often you're running late for work in the morning and don't have time, or you're too tired before going to bed...
"I'll do it later."
I suffer with a tendinopathy from time to time. I reckon I'm good for one a year. Sore Achilles, or a tennis elbow. It's a peroneal tendinopathy at the moment. I've got a pretty good routine for them to settle in a week or two if I do isometrics. I try and get 10 reps/day of a 30 second contraction. It works well for me. But how do I remember to get them done through the day when it's not constantly sore and pain isn't reminding me?
I marry the exercise to having a drink. I know I'll have about 10 drinks through the day; a couple of coffees in the morning, glasses of water through the day, a couple of cups of tea in the afternoon, and maybe a beer at night on the weekends.
Having a drink reminds me to do the stupid exercise. And I'm only going to have a drink when I've got a minute spare, so it's also the opportunity to get the exercise done.
Memory aid, opportunity, and hydration, wrapped into one.
Cheers to that.
*** Not all patients get better...
Is it my fault or their fault? I'd like to blame them, but I have to acknowledge it's probably my fault. Some disappear and are never heard from again. I can only presume they've (1) gotten better, or (2) didn't like me. I do try and give them all a call to find out. Some people don't get better and I think it's often a failure of mine to find the explanation of their problem that resonates with them enough, so that they do the rehab exercises I recommend. I don't find the "hook" for them and It ends up frustrating for both of us.