Saturday, December 28, 2013

Popular Knee Surgery Works No Better Than a Placebo

Couldn’t resist writing this one up. The results of the following study have been making the rounds lately, in publications from the Wall Street Journal to the New York Times:
A popular surgical procedure worked no better than fake operations in helping people with one type of common knee problem, suggesting that thousands of people may be undergoing unnecessary surgery, a new study in The New England Journal of Medicine reports.
Specifically, researchers wanted to know about the effectiveness of arthroscopic surgery for patients with a torn meniscus, a crescent-shaped wad of cartilage in the knee. The operations are very common. About 700,000 are performed in the U.S. yearly, at a total cost of $4 billion.

But how much do they help?

A Finnish study set out to find the answer: 146 patients, from age 35 to 65, who had wear-induced tears of the meniscus and knee pain (but apparently not arthritis) took part. About half had mechanical issues such as locking or clicking in their joints.

The last-minute way that subjects were directed into one of the two groups was kind of cool:
Most patients received spinal anesthesia, remaining awake (one hospital used general anesthesia). Surgeons used arthroscopes to assess the knee. If it matched study criteria, nurses opened envelopes containing random assignments to actual or sham surgery. In real surgery, shaver tools trimmed torn meniscus; for fake surgery, bladeless shavers were rubbed against the outside of the kneecap to simulate that sensation. Nobody evaluating the patients later knew which procedure had been received.
Then, after a year ...

Each group reported a similar improvement. (That sound you just heard was billions of dollars flushing down the U.S. health care toilet.)

Of course the New York Times quotes surgeons defending the procedure for certain patients. And of course the surgeons have a point: for certain people, especially those who are young and in much pain from a major tear in the tissue, surgery is no doubt the best option -- maybe the only option.

But always remember: Surgeons are part of their own SIG (special interest group). They have been trained in, and have acquired expertise in, the act of performing surgery. They make their money doing so (not exclusively, true, but still, the honest, thoughtful ones realize the conflict this leads to).

It’s like when a member of the Avocado Growers Association says more Americans should be eating avocados -- for their health, of course.

So Frederick Azar, first vice president of the orthopedic surgeons academy, not surprisingly finds grounds to dismiss the study's results. He tells us he operates mostly on patients outside the study's purview, who have mild to moderate arthritis and meniscal tears that appear to be painful.

He might be wise to take a glance upstory at Dr. Kenneth Fine, an orthopedic surgeon also quoted. Of 100 people with knee pain, Fine says, a “very high percentage” will also have a tear in their meniscus. He goes on:
People love concreteness: ‘There’s a tear, you know. You have to take care of the tear.’ I tell them, ‘No. 1, I’m not so sure the meniscal tear is causing your pain, and No. 2, even if it is, I’m not sure the surgery’s going to take care of it.'
That’s the kind of wisdom we need more often.

Oh, did this news seem kind of, well, familiar to regular readers here?

If so, you may be remembering this post from May in which I reported another study showing that this kind of surgery was ineffective. For that study, the patients did have arthritis.

Now that we’ve covered the arthritis and non-arthritis sufferers, casting doubts about the usefulness of the procedure generally, maybe we can finally shave a billion or two off that annual $4 billion medical bill.


  1. 700,000 procedures totaling $4 billion. Compare that to 600,000 knee replacements at however many billions more.

    I'm in the previous group. Those diagnosed with meniscus tears, but who have arthritis too. My surgeon decided to chondral shave the crap out of my knee (and perform a lateral release) when he "discovered" grade 3 degeneration while I was under and he was scoping. It has been 2 years and it does not appear that my knee will ever be as good as it was before surgery.

    I am still uncertain about the operating OS' motives, but have narrowed them down: ignorance (the healer), arrogance, malice or greed, or some combination of all of the above.

    One path that lends insight into the reasons and potential motives of my operating OS, lie buried in documents that used to be on his website (they were apparently removed shortly after I suggested them as reading to several people who had consulted with the good doctor and who also have arthritis), that clearly stated chondral shaving almost always leads to knee replacement with middle aged and older patients and is only meant as a stopgap procedure. I would have liked to have known that before I "consented" to the procedure. I assume most people would. If you have a vested interest or know some that does, go research it yourself.

    Maybe some OS' think that cutting legs in two and placing exotic (and not nearly as good as the OEM stuff) materials, is a viable and no big deal option and solution for arthritis? I guess you have to "think" like an OS, inside the paradigm of the "SIG," in order to follow that logic.

    Or is that in order to follow that paper trial, all the way to the bank?

    At some point in time, if what Richard (and Doug K. in his blog this week) are saying about certain orthopaedic procedures is true... That they are no better (are they, worse? In my case, clearly, yes) than placebo and if some OS' continue to perform them, then it seems to me, at some point those OS' will be violating their oaths and maybe the law too.

    To chondral shave someone to prepare them for TKR without informing them of the long-term consequences seems to me to clearly be a breach of both and because of the invasiveness of TKR's, clearly more needs to be done to save cartilage before "electing" for one: Surgeons and PT's both need to better inform their patients of the consequences of not trying to "save their knees" and TKR must be saved as a last resort.

    Last time I wrote it "like I see it" here, an anon, responded by writing that this site was full of "liars and miscreants." No sir (a shadow OS?), just a lot of "degenerates."


    1. "Malice" is too strong and an ill advised word. Incompetence, for whatever reasons: Too busy, tired, lack of skill, etc., is probably more accurate.

      Limping around on a post-surg angry knee for 2 years is no fun for sure, particularly for the super-fit (ex) looking for the fix for a patella catch.


  2. I am empathetic to your chondral shave situation. I hope it improves.

    We as patients need to start demanding better treatment. Hopefully orthopedics will pick up on new regenerartive procedures.

    I am going to ask a lot of questions if I go under but I just feel they are mis-taught. Like you mentioned above, I just don't know what they are thinking.

    I have a bunch of bone marrow edemas and stress fractures is slow to heal bones of the foot (cuboid, etc.). If you look up any academic articles on this, you will see they take like 3 months at fastest to heal (maybe less for the stress fractures), and up to a year or more.

    This doctor said I was fully healed after my feeling my foot after 4 weeks. I am young, 26 and male but that is total BS. I have no idea what he was thinking.

    He's 40 and obviously "intelligent". Like you said, I would like to meet a doctor who has some idea what the hell they are doing.

    Well good luck to all of us.

    Happy New Year.

    BTW, I don't think malice is too far off. These idiots need to learn from observation like the rest of us, they are supposed to f*ing geniuses. It's not in the textbook, hey what happens with your patients? They're 99% ignorant megalomaniacs.

  3. OS's are one of the best paid specialities ...why? They perform expensive TKR's, THR's, etc. There's an inherant COI (conflict of interest).

    The status quo and science is so regressive in orthopedics that people just go with the flow. The rivers pretty strong.

    Done ranting now.

  4. R-X, so did you know you were going to get the chondral shave or did he just do because it's part of his "armoire" of procedures?

    I have a bunch of scar tissue, I want/need removed eventually but I hope to hell they just leave my articular cartilage alone! 8|


  5. The bottom line, knee surgery is a lottery. My menisectomy went well - eliminated my knee locking, reduced pain by 90%. But I believe it also triggered bilateral knee pain from existing patella cartilage damage which was previously causing minimal pain - though that was an unforseeable outcome. My symptoms are identical to Richards. My surgery was done by the only OS in our small city in Oz & thankfully he did not also shave etc when he was in there (actually, he said the rest of my knee looked good for a 48yo).

    Many people here prefer to go to Sydney for knee surgery to the 'big city experts' (including the OS's wife, as he can't operate on family) and many have a bad outcome (including his wife). I reiterate - knee surgery is a lottery and should be a last resort. And surgeons doing extra stuff once you are under without informing you of the possibility & consequences beforehand is negligent....and playing God IMO.

    I believe our local guy is competent and honest - he told me before surgery menisectomy predisposes you to OA later in life, and later that I should avoid surgery to fix my current patella pain like the plague as it will likely make it worse. I've talked to him about Richards book (we know him socially) and he agrees - conservative treatment is always the first option.

    But I also agree with the posts above - too many OSs have a vested interest in cutting and scraping. And some of the big city guys think they are Gods.

    Like R-X, I was super-fit and coming to terms with my current situation is devastating. It's like I lost my identity. I'm hoping with patience (which I lack in spades) I can recover something of my sporting life.


  6. Don't want to hog the thread here so will keep it brief at the peril of being painfully simple. Guess I am one messenger for bad results. Seems like orthopaedia is on the threshold of changing their protocol and the indications for certain procedures: Meniscus tears and chondral shaving, particular for middle aged folks. Partly because of the OS SIG, change is slow. Learning hospitals (here in California) have different protocols than "knee corporations" in the private sector. My message is that the orthopaedic industry on the whole needs to formally acknowledge these changes in protocols.

    Am not sure what scenario scares me more: The uninformed OS who continues to give away lateral releases and chondral shaves like candy to the middle aged as a curative for arthritis/chondromalacia, or the OS who knows that the procedures are at best a wash, not to mention OS' who know that chondral shaving can exacerbate the degeneration of cartilage (see Dr Dye's articles on tissue homeostasis, some written a painfully longtime ago)?

    These are just my opinions. I know I have a snowballs chance of affecting change in that system. I am trying to make sense and peace and heal as best as I can from my "bad result."

    Good luck to everyone healing their knees. R-X

  7. R-X, if you need some hope have a look at: - post #35 & #65

    two guys who won the battle - albeit one took 5yrs! Going back through all their posts is an eye-opener and an overview of the type of journey you & I are in for, though Terry42 was a lot more patient then me. He basically avoided all aggravating activities for years. Quinkin's was more of an active approach guided by some good medicos.

    this is the stuff I cling to.

    cheers. TriAgain

    1. Thanks for the link TriAgain. Have read some of those threads, but will revisit them in detail. Coming up on 2 years (this Tuesday) since my bad result surgery and you're right, need a little hope sometimes.

      At 2 years "reality" has started to sink it's teeth into me. Guess I could choose to give up or shift gears again and get ready for the longer haul. Like you say, sometimes it takes 5 years to heal your knees, so thanks for the reminder and perspective. It takes a lot less time to blow knees up by doing the wrong things, even if it seems like we can't be sure what all those things are .


  8. Spot on with your last sentence R-X. After thinking I was nearly out of the woods, I blew mine up big-time when we had to move house = lots of heavy carrying over 2-3 days (but what can you do - can't let the wife do it all?). I've gone back a long way - perhaps 12mths or so, back to the sharp constant burning, whereas before I'd got it down to a vague tingling sensation.


  9. Wow, this info is soooo awesome.

    I was an ortho nurse. Now I am a holistic nurse. When having knee pain, my surgeon and the same guy I worked for in the hospital, said that I was too young to get cut. Thankfully, it got better with oral treatments.

    Then, on getting into holistic health care, I found that there is not a pain so far that I cannot help reduce or eliminate, simply with foods and, I am assuming, what you have on the sides of this page. The white crystals on the sides....are they quartz of salt?

    It is unprocessed sea salt that does the trick to not only eliminate knee pain and clicking, it helps heal the knee. This is because the sea salt has essential minerals that act like buffers and the sodium chloride helps get the water inside the tissues of the knee where there is no circulation.

    Its called the Water Cures Protocol.

    The Water Cures is preparing to do a study to see if it is possible to reproduce the same results in a clinical setting. That is, healing a knee with proper hydration and electrolyte intake.

    This is so simple, easy and basically free (most people already have the unprocessed sea salt).‎