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.
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“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.
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?”
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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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deannavzahablog
January 25, 2017
Hey Brian- me, again, still looking through all your posts. I’m a 22 year old female getting ACL reconstruction surgery along with either meniscus repair or shaving (not sure) this upcoming March in NJ. Here, you mentioned that if you knew then what you know now, you wouldn’t have gotten the surgery. What exactly do you mean by that?
I’ve had a torn ACL and meniscus for 3 years and have been getting around fine, with very little to no pain (to the point that I sometimes forget my knee is shredded up inside) but am sick of not being able to play any sports, jump, dance, play tag with kids in my scout troup, etc. It’s all become kind of depressing which is why I’ve chosen to finally do the surgery. After multiple continued injuries (reminiscent of when I first tore my ACL), and numerous episodes of instability, I feel that despite how everyone says it’s the worst operation ever, that I need to do this for me to be more active and in a sense feel somewhat “whole” and normal again (although I’m aware I will never be 100% again).
I know it’ll be tough trusting my knee again, since every time I try to do something semi-active it makes that popping sound and slides out to the side, but I still feel this is a better alternative than saying goodbye to my old active lifestyle and never being able to play a sport again. I used to play soccer and basketball competitively and ski recreationally, but tore my ACL playing football on Thanksgiving with my cousins by going up for a pass, colliding in air with one of my cousins, and landing completely wrong. Since then, at the fresh age of 19, I have been stuck to walking/running/biking and watching my friends and family from the sideline and I’m quite honestly over it lol. Any thoughts/advice/clarification would be greatly appreciated thanks!
reddyb
January 27, 2017
I know I’m being pedantic here but I remember writing those sentences purposely in the language I did- I didn’t quite say that. I said being older I wouldn’t have it, and if I knew what I knew now then, I probably wouldn’t back then. I go back and forth on this. I had ACL and meniscus surgery simultaneously. My ACL went very well. My meniscus did not, as the sutures tore open 18 months post-op.
Because of the meniscus retearing I essentially went three out of my four three years post-op no better than I was pre-op. I could e.g. run a 10k after my first surgery, but I could have done that before the ACL procedure. When I wrote this post, I was dealing with the retorn meniscus, although I didn’t know it at the time. So I will say that, for my case, biased me against the ACL surgery. Granted, many ACL surgeries involve the meniscus, but my issue wasn’t technically with the ACL surgery.
After I got the second surgery due to the meniscal tear getting locked in the knee, things were much better. If that’s how it was from the jump, I would feel more inclined to redo the whole thing, but the fact is this is a risk of ACL / meniscus surgery- the need to go in for another procedure.
Between that and my girlfriend and I taking up tennis this past year, which I maybe could have done but wouldn’t have (fear) pre ACL surgery, it ended up helping in that regard. However, I’m just about to have a baby nowadays. Would I do the ACL surgery during this time? No. My girlfriend and I could go hiking instead of tennis. I might then sigh at the inability to play tennis once in a while, but in the grand scheme my life wouldn’t be influenced.
There’s no clear answer on this, unfortunately. I did write way back when that the younger one is though, the more likely they should do the surgery. ( https://b-reddy.org/2011/11/29/reconstructive-acl-surgery-is-it-beneficial/ ) For reasons such as above e.g. not knowing if you’ll get want to get into a particular sport later in life. Options are nice.
That said, I do think people overestimate how likely getting into rec sports later in life is / how important it will be to them / how much ACL surgery will get them back to these activities / how much they’ll still want to do ACL risky activities once going through the entire rehab.
As you allude to, just knowing you have the option can be worth a lot. That’s been worth more to me than I thought it would. But every time I go back to a certain rec activity, I prove to myself I can do it, then I stop doing it. Because the more one does those types of things, the more likely injuries -not just knee- are going to happen. The paradox is post ACL rehab the more one can do an ACL demanding task, the less likely they may want to do it. I thought I’d be ecstatic to go back to things like basketball or dodgeball. All I found myself saying was “why am I doing this?”
What I can emphatically state is the *average* person would be better off modifying their lifestyle than doing the surgery. The average case simply is not ready for the surgery and does not do what’s necessary to make it worthwhile. The average person goes through everything only to end up having the same limitations as before, albeit possibly for different reasons. (Stability might be there, but range of motion is not.)
To use my situation again- my baby is due within a month. For me, I don’t want to risk being on crutches during, I don’t know, the next five years, because that’s going to significantly hamper my family. I’d feel like a dick if the mom was taking care of me and a kid at the same time. This is going to be a concern for many people around their upper 20s to early 30s, as that’s when many start having kids. That’s why I originally state 25 as a rough cutoff point. Trying to do this rehab with a young kid around is going to negatively influence the rehab, very likely to the point one shouldn’t bother with it at all. If you can’t do it right, don’t do it.
So not only is everybody’s situation important, but where somebody is in their own life can change the decision / how they feel about their original decision. (Talked about this more here: https://b-reddy.org/2013/06/12/timing-for-an-acl-surgery/ ) The further I get from the surgery the happier I am I did it. But I don’t know if I could do it all over again at this stage of life. I do think an active, early 20s person who does the rehab right, will likely be happy they did it.
Sorry if that was meandering some. I find this part of ACL surgery to be one of the hardest, as there is always a counterpoint, and it is by far the most individualized aspect of the whole thing.
deannavzahablog
March 16, 2017
Hi Brian!
Thanks so much for the response. I can totally understand your perspective being that I can hardly imagine getting my surgery done after I graduate college when I’ll be hopefully working (which is why I’m doing it during my last semester). Glad to know it was worth it though, many people I know who have gotten it done said the healing and the first few weeks after were a huge pain in the ass, but are so happy that they decided to get it done.
As for rec sports, I feel my situation will be similar to yours. Since I’ve had a torn ACL for about 3.5 years now, it’s going to be hard to convince myself that I can do things that I haven’t been able to do in (by the time I’m cleared) upwards of 4 years. Hopefully, PT will help convince me enough to at least try it.
I’ll be getting my surgery in a couple days and, despite knowing what I’m getting myself into, am excited at the prospect of having a knee with an ACL for once in my adult life (I tore it right after my 19th birthday). Congrats on the baby, and thanks again for taking the time to respond!
reddyb
March 17, 2017
You’re welcome!
Feeling good about your rationale is a great place to be when you go into things. Can really calm the nerves knowing you’re making the right decision for yourself.
For the getting back to activity, the PT / exercise will be crucial. A phrase I often throw out there is “Physical preparation will largely dictate mental preparation.” Building your way there physically will get the mind very far. Sometimes when coming back from an injury people can focus too much on trying to make it the other way around. Where they’ll think the reason they’re having trouble e.g. running is because mentally they have to get over a hurdle. In most cases, running hasn’t been properly built up to.
Good luck!
Jon Comins
September 23, 2019
so brian it’s been a few years since I chimed in – the only problem I have ever had and still have is the outcome measures – they are PROMs. And they do not correlate with physical measures – and are highly influenced by placebo. Mosely, Frobell, and Teppo have never used well-validated PROMs for their outcomes. What PT’s can be selling is an equally effective placebo effect as surgeons – but is there a true mechanical benefit from not operating? That is still unresolved. Although I do find it troubling that you, with your mindset of being ready also have had a rough experience with your ACL and meniscal surgery. I had a tough time with my meniscus surgery but that was because we discovered I had a 1″ x .5″ full thickness cartilage lesion on my lateral femoral chondyle that the MRI hadnt picked up. Anyway, good stuff you are writing – the debate needs to continue until absolutely resolved.
Best Jonathan Comins PT, MS, PhD
b-reddy
September 24, 2019
Good to hear from you Jon! Appreciate the extra detail.
I think if all we got from this kind of research was more humility from certain surgeons (or more pushback from insurance companies), that might be enough for me. I’ve come across plenty of surgeons who are all about physical therapy, etc, but I’ve also come across those scheduling to cut the moment an MRI isn’t perfect. Though there is a lot more going on there than the typical “god complex” explanation. Economic incentives being huge.
I actually think with back pain we seem to be on the right track. I only deal with this in a third hand manner, but in my experience, if nothing else, insurance won’t cover most back surgery without a fairly extended attempt at physical therapy. The only exception being you fit very specific criteria to be a candidate for surgery immediately.
With say, the meniscus, it seems we could largely do that right now? Your knee is mechanically blocked and you have impaired ROM? You’re a high level athlete with a torn ACL? Physical therapy probably isn’t going to be sufficient. In most other situations? Try exercise first; work from there.