News and Perspective
Skip Arthroscopy for Degenerative Knee Disease, Report Says
Knee
arthroscopy is not cost-effective and is strongly discouraged for
patients with degenerative knee disease, say authors of a
meta-analysis-based practice guideline published May 10 in the BMJ.
The authors include in the definition of degenerative knee disease patients with knee pain, especially those more than 35 years old, with or without X-rays showing osteoarthritis, meniscus tears, locking or catching of the knee, and acute or subacute onset of symptoms.
However, some experts disagree with the report's conclusions. David C. Johnson, MD, an orthopedic surgeon with MedStar Orthopaedic Institute at MedStar Washington Hospital Center in Washington, DC, who says he has completed about 5000 of the surgeries since 1978, said the report will not change his practice.
The report was prompted most recently by a randomized controlled trial published in the BMJ in June 2016, which concluded that, among patients with a degenerative medial meniscus tear, knee arthroscopy was not more beneficial than physical therapy.
The current report is based on two systematic reviews: one
on the benefit of knee arthroscopy compared with nonsurgical care,
which included data from 13 randomized trials for benefit outcomes (1668
patients) and 12 more observational studies for complications (more
than 1.8 million patients.)
A second team did a systematic review to address what level of change on a given scale is important to individual patients.
"[F]urther research is unlikely to alter this recommendation," they write.
Lead author Reed A. C. Siemieniuk, MD, from the Department of Health Research Methods,
Evidence, and Impact at McMaster University in Hamilton, Ontario, Canada, told Medscape Medical News the recommendation is strong enough that insurers should consider withholding payment for the surgeries, and that there should be financial incentives for not performing them, as they cost $3 billion a year in the United States alone.
The authors include in the definition of degenerative knee disease patients with knee pain, especially those more than 35 years old, with or without X-rays showing osteoarthritis, meniscus tears, locking or catching of the knee, and acute or subacute onset of symptoms.
However, some experts disagree with the report's conclusions. David C. Johnson, MD, an orthopedic surgeon with MedStar Orthopaedic Institute at MedStar Washington Hospital Center in Washington, DC, who says he has completed about 5000 of the surgeries since 1978, said the report will not change his practice.
The report was prompted most recently by a randomized controlled trial published in the BMJ in June 2016, which concluded that, among patients with a degenerative medial meniscus tear, knee arthroscopy was not more beneficial than physical therapy.
A second team did a systematic review to address what level of change on a given scale is important to individual patients.
"[F]urther research is unlikely to alter this recommendation," they write.
Lead author Reed A. C. Siemieniuk, MD, from the Department of Health Research Methods,
Evidence, and Impact at McMaster University in Hamilton, Ontario, Canada, told Medscape Medical News the recommendation is strong enough that insurers should consider withholding payment for the surgeries, and that there should be financial incentives for not performing them, as they cost $3 billion a year in the United States alone.
He said the procedure is
ingrained in medical school education and is commonly done for many
reasons, "and financial incentives are certainly one of them."
The report notes that knee arthroscopy is performed more than 2 million times a year worldwide. And most guidelines continue to support arthroscopy for groups including those with torn meniscus, sudden onset of pain or swelling, or mild to moderate difficulties with knee movement.
The problem, Dr Siemieniuk says, is that most people affected would fit into those 3 categories.
"We think the burden of proof rests squarely on the shoulders of people who would suggest that this does help anybody in the long term," Dr Siemieniuk said.
Among reasons the report is trustworthy, he says, are that
authors did not have financial conflicts of interest, the literature
was rigorously studied, and patients were consulted, including those who
did and did not have the surgery.
"Really, there's almost no long-term benefit at all and there are risks with [the surgery]. We weren't able to find any evidence to support its use," he said.
Surgeons Evaluate Cases Individually
Although Dr Johnson encourages his colleagues to read the report and take it to heart, he says he does not agree with the conclusions.
"Doctors in the trenches," he said, know that risks and kinds of tears must be stratified, and some people will not do well with arthroscopy, but others will, and those decisions must be made individually.
He offered an example: "If you have a knee that doesn't have any arthritis, X-rays are normal, and there is a clear vertical tear which is an acute tear or a complex tear...those people will do better."
Good candidates are also those with a complex tear, with vertical and horizontal tears, and when the meniscus has been degenerating for a period of time and now with a twisting injury a fragment has broken off and that fragment is giving the patient difficulty when they did not have difficulty before.
"Those
people will do well in the vast majority cases," he said. "And it may
last 3 years. But 3 years is a long time for somebody who's having knee
pain. They get a reprieve."
The report notes that knee arthroscopy is performed more than 2 million times a year worldwide. And most guidelines continue to support arthroscopy for groups including those with torn meniscus, sudden onset of pain or swelling, or mild to moderate difficulties with knee movement.
The problem, Dr Siemieniuk says, is that most people affected would fit into those 3 categories.
"We think the burden of proof rests squarely on the shoulders of people who would suggest that this does help anybody in the long term," Dr Siemieniuk said.
"Really, there's almost no long-term benefit at all and there are risks with [the surgery]. We weren't able to find any evidence to support its use," he said.
Surgeons Evaluate Cases Individually
Although Dr Johnson encourages his colleagues to read the report and take it to heart, he says he does not agree with the conclusions.
"Doctors in the trenches," he said, know that risks and kinds of tears must be stratified, and some people will not do well with arthroscopy, but others will, and those decisions must be made individually.
He offered an example: "If you have a knee that doesn't have any arthritis, X-rays are normal, and there is a clear vertical tear which is an acute tear or a complex tear...those people will do better."
Good candidates are also those with a complex tear, with vertical and horizontal tears, and when the meniscus has been degenerating for a period of time and now with a twisting injury a fragment has broken off and that fragment is giving the patient difficulty when they did not have difficulty before.
He
points out the report targets people older than 35 years and adds,
"people over 35 are still very active, and in my book are young, and it
would be bad to withhold a treatment that would benefit them even if the
chance of benefit is 75% or 65%. Most patients would choose that."
Physicians need to examine each patient to see what is causing the problem, Dr Johnson explains.
"You stratify your decision base to consider each and every one separately, and not bunch them all together and make a blanket statement that I'll never operate on anybody who has any kind of arthritis," he said.
The authors also point out risks associated with the surgery; Dr Johnson says those are "overblown."
"In 5000 cases, I have had zero infections. I've never had to go back into a knee to wash out an infection."
He said he has had five deep-vein thrombosis (DVT) cases that needed treatment, all of whom came in with clotting disorders.
"If you count five DVTs, that's about the rate of DVTs in the general population even without surgery, so when I hear that you shouldn't do something because of risk of infection or DVTs, I find that overblown, at least in my population."
He points out, and the report confirms, that the American Academy of Orthopaedic Surgeons is against doing arthroscopy for patients with osteoarthritis, "but if you have a degenerative knee with meniscus tear, they're going to support doing arthroscopy. They're going to support doing arthroscopy for patients who have mechanical symptoms, and they're going to support patients with evidence of osteoarthritis with a meniscal tear that is symptomatic, and they'll support patients without evidence of osteoarthritis who had a meniscal tear that was symptomatic.
Physicians need to examine each patient to see what is causing the problem, Dr Johnson explains.
"You stratify your decision base to consider each and every one separately, and not bunch them all together and make a blanket statement that I'll never operate on anybody who has any kind of arthritis," he said.
The authors also point out risks associated with the surgery; Dr Johnson says those are "overblown."
"In 5000 cases, I have had zero infections. I've never had to go back into a knee to wash out an infection."
"If you count five DVTs, that's about the rate of DVTs in the general population even without surgery, so when I hear that you shouldn't do something because of risk of infection or DVTs, I find that overblown, at least in my population."
He points out, and the report confirms, that the American Academy of Orthopaedic Surgeons is against doing arthroscopy for patients with osteoarthritis, "but if you have a degenerative knee with meniscus tear, they're going to support doing arthroscopy. They're going to support doing arthroscopy for patients who have mechanical symptoms, and they're going to support patients with evidence of osteoarthritis with a meniscal tear that is symptomatic, and they'll support patients without evidence of osteoarthritis who had a meniscal tear that was symptomatic.
"All of these were denied by the BMJ."
The authors have disclosed no relevant financial relationships.
BMJ. 2017;357:j1982. Full text
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Source: http://www.medscape.com/viewarticle/879922#vp_2
The authors have disclosed no relevant financial relationships.
BMJ. 2017;357:j1982. Full text
For more news, join us on Facebook and Twitter
Source: http://www.medscape.com/viewarticle/879922#vp_2
