Although knee arthroscopy, a type of keyhole surgery used to treat arthritis, is the world’s most common orthopaedic procedure, it is not recommended in almost all patients with degenerative knee disease, an international panel concluded in a new guideline.

According to the panel, while knee arthroscopy is performed two million times every year worldwide, it achieves almost nothing and does not show a lasting improvement in pain or function for those with degenerative knee disease. The new guideline is not restricted to only arthritis but also patients with meniscus tears, sudden onset of pain and mechanical symptoms, such as clicking or catching of the knee.

“We make a strong recommendation against the use of arthroscopy in nearly all patients with degenerative knee disease, based on linked systematic reviews. Further research is unlikely to alter this recommendation,” the study wrote.

Studies prove keyhole operation has been oversold

The experts of the study were made up of bone surgeons, physiotherapists and clinicians who analysed the data of more than 1.8 million patients with experience of degenerative knee disease. The researchers carried out a detailed review on 13 random control trials and 12 observational studies to find out about the advisability of arthroscopic knee surgery.

Corresponding with the findings of a 2016 study, the review indicated that patients with a degenerative medial meniscus tear fared no better two years after the surgery than patients who underwent conservative management, including exercise therapy or medication.

Meanwhile, a previous study in 2013 also found that removing part of the meniscus through surgery did not offer discernible benefits. However, arthroscopic surgery is still commonly performed on patients with symptoms of degenerative knee disease until today.

“The United States alone spends about USD3 billion a year on the procedure,” said the lead author Dr Reed Siemieniuk, a health researcher with McMaster University in Toronto, Canada.

Reasons behind surgery’s persistence

As the panel noted, several factors may be linked to the high volume of such surgeries. Siemieniuk said the overuse of knee arthroscopy is common in many industrialised countries where healthcare is mainly funded by the government.

However, it may not just be financial incentives, Siemieniuk added, as the extent of the overuse may also indicate that it could simply be failure to apply new evidence into clinical practice.

In the meantime, Dr David Jevsevar, chair of the organisation’s council on research and quality said most surgeons are also driven by the desire to help their patients. “I don’t think the majority of surgeons are doing things because they think they can make money,” he said. “They are doing them because they think they work.”

Siemieniuk shared the view and said, “And there's an expectation from patients that by the time they see a surgeon, the surgeon is going to have something to be able to offer them.”

In addition, patients’ frustration with conservative approaches and delays in incorporating new evidence into clinical practice could lead to unnecessary procedures.

“After new practice-changing evidence, it takes years for that evidence to be implemented,” Siemieniuk said. “We think that takes way too long. In the medical community, we should be doing better.”

Guideline not applicable 100% of the time

Despite the strong objection against the use of knee arthroscopy, a physician with the American Academy of Orthopaedic Surgeons said there are exceptions to every guideline though the organisation broadly agrees with the findings.

“Patients would be wrong if they took this as, 100% of the time this intervention is inappropriate,” said Jevsevar. “There will be certain scenarios where it is entirely appropriate.”

Dr Kevin Shea, a spokesman from the academy and professor of orthopaedic surgery at the University of Connecticut, said arthroscopic surgery could still provide help for people with joint movement problems caused by meniscus tears that have not developed moderate or severe knee osteoarthritis.

“Those patients should first be treated with mild painkillers and exercise therapy, but keyhole surgery should remain an option for them,” Shea added. Therefore, patients are advised to go through a shared decision-making process with the surgeons to confirm the need of a knee arthroscopy. MIMS

Read more:
Hospital-based doctors more likely to order unnecessary tests or referrals
Industry funding may be contradicting the purpose of infection-control studies
Unnecessary medical tests a threat to the viability of healthcare