More evidence against knee surgery

Posted on March 5, 2014

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A few years ago I wrote a post called Should you have surgery for arthritis in your knees? I discussed a type of study rare in the research world. One where a “sham surgery” is used to give a placebo group. A sham surgery is where doctors do everything involved in a regular procedure, but don’t actually do anything to the inside of your body. So, if you were to get your knee “scoped,” you’d be dressed for surgery, anesthetized, have incisions in your knee, and then randomly either have work done inside your knee or be left alone. In the sham / fake case, as much as possible would be done so the patient didn’t know what happened to their knee.

This is the gold standard for surgical research. Placebos matter, and this is how you give surgical research a placebo group. As you can imagine, due to a myriad of reasons, performing fake surgery on people is hard to pull off. So, these types of studies aren’t done often. As far as I can tell, in orthopedic surgery, three of these have been performed. Two on the knee, one on the spine.

In the arthritis study I discussed, it was found the fake surgery group had just as good an outcome as the real surgery group. Trying to surgically get rid of knee osteoarthritis is a futile endeavor.

Later on that year I extensively discussed ACL surgery. In Reconstructive ACL Surgery: Is it beneficial? and Is it worth it? The short version of those is: It’s very, very hard to justify ACL surgery unless you are 1) Quite young (25 or younger I’d say) and or 2) A high level athlete (rec sports don’t count). As someone who had the surgery at 25 years old and is now 27, and knowing first hand what the recovery process is like, I can tell you at 27 there is just about no way in hell I would have that surgery. If I were 25 again, knowing what I know now, I probably wouldn’t have it. What you get from it is not commensurate with what you give. (Worth mentioning no ACL research has used a sham group either.)

So, two of the most common knee operations -a less invasive arthritis procedure and a quite invasive ACL procedure- respectively make zero and little argument for their endorsement. There is a procedure between those two extremes we haven’t examined yet.

That sham surgery for arthritis paper was from 2002. At the time I found it, 2011, I remember thinking “I wouldn’t be surprised if this is never done again.” Firstly, due to how bent out of shape people get with the “ethics” and whatever. (Is it ethical to perform a procedure you have no evidence for?!) Second, doctors and surgeons carry out these types of studies. Just performing the study puts them at risk for looking bad. With that one study, we’re talking, at a minimum, hundreds of thousands of operations where a majority, if not all, were useless, yet extremely profitable. You can easily see how hard it would be for a group of doctors to sack up and find out if other things they are doing fit into the same category. Amazingly, they did.

From December 2013, enter Arthroscopic Partial Meniscectomy versus Sham Surgery for a Degenerative Meniscal Tear.

This is our “middle group” of knee surgery. More involved than a simple debridement; less involved than a reconstruction. In a partial menisectomy the person has some type of meniscal tear, in this study a “degenerative tear,” where because a repair isn’t feasible, part of the meniscus is excised. The idea is when the meniscus is torn, the tear can flap around inside the knee, causing irritation. Cut out that part of the tear => Less irritation => Less pain.

This is the most common knee surgery in the United States. 700,000 are performed every year, at an estimated cost of four billion dollars. Roughly $5,700 per surgery. If anything, that’s on the low end. The impetus for the study, according to the authors,

“Arthroscopic partial meniscectomy is one of the most common orthopedic procedures, yet rigorous evidence of its efficacy is lacking.”

Does that sentence not alarm anyone? This is not only the most common knee operation in the United States, it’s the most common orthopedic operation! A procedure done seven hundred THOUSAND times per year doesn’t have strong evidence for its use?!?!

“The number of arthroscopic surgical procedures performed to treat established knee osteoarthritis, with or without a concomitant meniscal lesion, has decreased dramatically in the past 15 years. This trend has been attributed to two controlled trials showing a lack of efficacy of arthroscopic surgery.”

The two controlled trials they’re referencing are the one I discussed from 2002, and another I haven’t discussed from 2008. (The 2002 study used a sham group, the 2008 didn’t.) I find it odd to say surgical procedures for knee OA have decreased in the past 15 years due to two studies, neither of which date 15 years back. Anyways…

When I discussed the 2002 study, I wrote even though the authors mentioned their results should cause extreme hesitance, and a decrease in performing arthroscopic knee OA procedures, that didn’t seem to be happening. Apparently it actually has, which is great.

“However, the number of arthroscopic partial meniscectomies performed has concurrently increased by 50%.”

Sooo, we’ve performed less of one surgery in favor of performing more of another. One where “RIGOROUS EVIDENCE OF ITS EFFICACY IS LACKING.” Ugh. This provides me one of my “Seriously, humans can do some amazing things, but none of us are actually that smart” moments. For Christ’s sake, these are the most educated people in the world doing these things.

“A recent randomized trial showed that arthroscopic partial meniscectomy combined with physical therapy provides no better relief of symptoms than physical therapy alone in patients with a meniscal tear and knee osteoarthritis.”

This is the 2008 study that didn’t use a sham group. If anything, the odds were in favor of surgery, yet the results still didn’t show that. The efficacy of those 700,000 operations a year isn’t looking good.

Rather than quote the methods section, I want it to be clear this study was very well controlled. The steps to insure lack of bias, randomization, etc. were extensive. If you look up this study and read reports from the New York Times, NPR, Wall Street Journal, you’ll find nothing but positive comments on the study’s design. Not only from reporters, but from fellow physicians and researchers.

After the patients had surgery, fake or real, all took part in a graded exercise program. Both groups then had a multitude of follow ups for 12 months.

“Although marked improvement from baseline to 12 months was seen in the three primary outcomes in both study groups, there were no significant between-group differences in the change from baseline to 12 months in any of these measures.”

And that nail is in the coffin.

I want to bring up how this study looked at degenerative meniscal tears. The authors clearly state their results should not be extrapolated to other types of tears. Such as a traumatic tear, like from playing sports or slipping in the bathroom. This was brought up in much of the media who covered the study. Doctors quoted to the effect of, “Alright, ok, this is definitely surprising. And we’ll have to reassess how we do things. But for others, like a traumatic tear, or those with mechanical issues, like clicking and catching, I feel confident we’re doing good there.”If you look at the baseline characteristics of the patients in this study, their symptoms are not indicative of a strictly “degenerative tear.”

The participants were 35-65 with a median age of 52 -half the patients were between 35 and 52; it’s not like everyone was older. Nearly 50% of the patients HAD “symptoms of catching or locking.” A good amount had pain with twisting (14-18%), pain after exercise (17-18%), pain provoked by forced knee flexion (71-78%), medial joint line tenderness (90-97%), none had arthritis as that was the purpose of this study (meniscus issue without arthritis)…I mean, these are classic meniscal patients. Nothing about them screams “degenerative tear” only. Nothing even speaks quietly to you. I have a hard time NOT extrapolating this to other patients. Not to mention the authors go (bolding mine),

“Our results are directly applicable only to patients with nontraumatic degenerative medial meniscus tears, because a traumatic onset of the condition was an exclusion criterion. However, results of a post hoc subgroup analysis limited to patients who had a sudden onset of symptoms likewise showed no significant benefit of arthroscopic partial meniscectomy over sham surgery, although the sample for this analysis was small. “

Make no mistake about it, this study is a brutal indictment on the most common orthopedic procedure we do. I’m not ready to say the surgery is useless for everybody. But, I’m ready to say take 1% of 700,000, perform that many partial menisectomies every year, and I bet our society’s knees are no worse off, and we’ll have nearly four billion dollars which can go to something more useful. You know, as long as we don’t lessen the amount of partial menisectomies and concurrently increase the amount of some other, lacking-efficacy, surgery.

“Well, that’s just great…”

From reading others accounts of this study, and based off interactions with people, I feel a common response to these types of things is, “Wonderful. What a waste of money. We haven’t figured anything out.” Everyone is focused on the negative. Nobody focuses on the upside: We can simply move and think our way out of our pain.

People forget to mention while yes, the sham groups and surgical groups have no differences, they both improve on every measure! Pain at rest, pain after exercise, function, satisfaction, you name it, these people all get better. I referenced the one study where a sham group wasn’t even done, only physical therapy was, yet the people still got better. So, it’s not even like you need the placebo effect of surgery to feel better. Then, in the study which did use a sham group, I mentioned the commonality in partaking in a graded exercise program. Which brings us to our overarching theme: Those who exercise, get better.

Is that not empowering? Doesn’t it give you solace? That if you have a tear or some other “abnormality” in your knee, you don’t need some amazing advent of technology to help you? (This is the “thinking” and understanding your way out of pain aspect.) All you need is to exercise, and maybe get whatever associated mental benefit there is from exercising. (I’ll add, in my opinion, it’s not just exercising; it’s how you exercise too.)

Maybe even the exercise is a placebo. Based on how much evidence we have for exercise in pretty much every ailment we’ve ever discovered, I doubt it’s strictly a placebo. But for the sake of argument, let’s say with knee pain, it is.

One of my favorite TED talks is by Chris Bliss, called “Comedy is translation.” In it he brings up climate change. A hurdle in getting anywhere with global warming is the debate over whether the science is “complete.” Or if it’s true. Is it just theory, are we sure about this, yada yada. Bliss’ colleague, Joel Pett, came up with a cartoon to answer these questions:

By Joel Pett of USA Today.

By Joel Pett of USA Today.

In other words, who gives a shit? Debating whether climate change is real, whether it’s man made…When you reframe the question, “What if we create a better world for nothing?” the answer is obvious. It’s a worthwhile thing to work on regardless.

Some benefits from exercise:

  • Improves your chances of living longer and living healthier
  • Helps protect you from developing heart disease and stroke or its precursors, high blood pressure and undesirable blood lipid patterns
  • Helps protect you from developing certain cancers, including colon and breast cancer, and possibly lung and endometrial (uterine lining) cancer
  • Helps prevent type 2 diabetes (what was once called adult-onset diabetes) and metabolic syndrome (a constellation of risk factors that increases the chances of developing heart disease and diabetes; read more about simple steps to prevent diabetes)
  • Helps prevent the insidious loss of bone known as osteoporosis
  • Reduces the risk of falling and improves cognitive function among older adults
  • Relieves symptoms of depression and anxiety and improves mood
  • Prevents weight gain, promotes weight loss (when combined with a lower-calorie diet), and helps keep weight off after weight loss
  • Improves heart-lung and muscle fitness
  • Improves sleep
  • Helps with dementia
  • Helps with parkinson’s disease
  • Benefits fibromyalgia patients
  • Improves self-esteem
  • Strengthens immune system
  • Reduces inflammation
  • Impacts basic cognitive function, such as learning and memory.
  • Decrease macular degeneration (helps with eyesight)

The list goes on forever. Say surgery and exercise are both placebos. Which placebo would you rather have? The one with the laundry list of risks, or the one with the laundry list of benefits? We keep looking for a panacea to health, but, to an extensive degree, we already have one. It’s called get off your ass, move, and move well. If we could get a surgery to do that, or put that in a pill, it’d be the most amazing creation of modern medicine.

When it comes to exercise for knee pain, “What if it’s a placebo and you make your body healthier for nothing?”

If you want an exercise program aimed at helping knee issues, you can check out mine in 6 exercises to loosen the IT band.

Here’s the TED talk:

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