Scimex: A Danish and Swedish study has found knee surgery performed on middle aged or older patients is only marginally beneficial, and could even cause harm. The study brought together 18 trials of knee surgery, and the researchers say the potential harms identified, which include deep vein thrombosis and blocked arteries, outweigh the small benefits seen in terms of pain relief in some studies.
The benefit of surgery for middle aged or older patients with
persistent knee pain is inconsequential and such surgery is potentially
harmful, say researchers in a study published in The BMJ this week.
findings do not support arthroscopic surgery as a treatment for the
middle aged or older person with a painful arthritic knee or torn
meniscus (the shock absorbing cartilage between the knee bones).
The article is part of The BMJ's Too Much Medicine campaign - to highlight the threat to human health and the waste of resources caused by unnecessary care.
700,000 knee arthroscopies (a type of keyhole surgery) are carried out
in the USA and 150,000 in the UK each year on middle aged and older
adults with persistent knee pain. Yet the evidence for arthroscopic
surgery is known to be weak, with all but one published trials showing
no added benefit for surgery over control treatment.
Despite this, many specialists are convinced of the benefits of surgery.
researchers based in Denmark and Sweden reviewed the results of 18
studies on the benefits and harms of arthroscopic surgery compared with a
variety of control treatments (ranging from placebo surgery to
exercise) for middle aged and older people with persistent knee pain.
Most studies on benefits lacked blinding (placebo-control) and studies on harms were generally of poor quality.
randomised trials involving 1,270 patients reported benefits of
surgery. The average age of patients ranged from 48 to 63 years and
follow-up time varied between three and 24 months.
surgery was associated with a small but significant effect on pain at
three and six months (but no longer) compared with control treatments.
No significant benefit on physical function was found.
nine studies reporting on harms found that, although rare, deep vein
thrombosis (DVT) was the most frequently reported adverse event,
followed by infection, pulmonary embolism (a blockage of the main artery
of the lung), and death.
"Interventions that include arthroscopy
are associated with a small benefit and with harms," say the authors,
and the benefit is "markedly smaller than that seen from exercise
therapy." These findings "do not support the practice of arthroscopic
surgery as treatment for middle aged or older patients with knee pain
with or without signs of osteoarthritis," they conclude.
difficult to support or justify a procedure with the potential for
serious harm, even if it is rare, when that procedure offers patients no
more benefit than placebo," argues Professor Andy Carr from Oxford
University in an accompanying editorial. With rates of surgery at their
current level, a substantial number of lives could be saved and DVTs
prevented each year if this treatment were to be discontinued or
diminished, he adds.
He believes "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 studies,
bias and vested interests.
When that point is reached, he concludes, "we should expect a swift reversal of established practice."