Key hole surgery of the knee has long been a popular choice for knee surgeons and patients alike as a staging post for those suffering with arthritic knee pains (pain with clicking, grinding, and cracking noises) but were either too young or not yet bad enough to consider a half or full knee replacement.
It has been long thought that cleaning out of any floating debris (Debridement) and trimming up of any frayed edges to the degenerating cartilages (Meniscectomy) in the joint improved the pain and disability by a meaningful amount.
However a recent review of all the available evidence for key hole surgery to help and improve degenerative/osteoarthritic knees published last week shows:-
- The potential for key hole surgery to cause harm outweighs the procedures small pain relief benefits,
- The benefits of key hole surgery will last no more than 1 to 2 years after the procedure.
Commenting on the study Mr Andy from the Oxford University Institute of Musculoskeletal Sciences said, “Supporting or justifying a procedure with the potential for serious harm, even if this is rare, is difficult when that procedure offers patients no more benefit than a placebo. A substantial number of lives could be saved and deep venous thromboses prevented each year if this treatment were to be discontinued or diminished”.
Surgeons perform more than 700,000 knee arthroscopies in the United States, and more than 150,000 in the United Kingdom. Yet the MRI imaging abnormalities often used to justify these procedures are common in the general population – meaning that in many instances the changes of the MRI which leads to the keyhole surgery can be red herrings and not responsible for the pain the patient is feeling.
What did the researchers do?
The researchers identified all randomized controlled trials that appeared in five online databases in August 2014 and assessed the benefits of arthroscopic surgery for patients, regardless of whether they had X-ray evidence of osteoarthritis. The studies had to include surgery with partial Meniscectomy, debridement, or both, and the researchers included additional studies from 2000 onward to determine harm.
• The nine trials they found included 1270 patients,
• Ages from 49.7 to 62.8 years and follow-ups ranging from 3 to 24 months.
The studies used a pain scale rating tool 0-100 to assess improvement.
The analysis revealed only a 2.4% improvement in pain for keyhole compared with control treatments (exercise and sham surgery). This was about the same as paracetamol but less than that seen from nonsteroidal anti-inflammatory drugs and exercise therapy. The pain relief seen at 3 and 6 months, did not last to 24 months and the analysis revealed no improved physical functioning (i.e. the ability to do day to day tasks better).
The most common harm as a result of surgery was was:-
- DVT (Deep Vein Thrombosis) occurring at a rate of 4 per 1000 procedures.
- PE pulmonary embolism 1.5 per 1000 procedures.
- Infection 2 per 1000 procedures.
- Death 1 per 1000 procedures.
Mr Carr commented that we are at a tipping point where there is a weight of evidence against arthroscopic knee surgery and when that point is reached we should anticipate a swift reversal of established practice.
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