Have you ever considered the potential pitfalls of common medical procedures? It's a thought-provoking question, especially when it comes to knee surgery, a procedure that thousands of Americans undergo each year. The conventional wisdom is that it provides relief, but recent research suggests otherwise.
The study, published in the New England Journal of Medicine, followed patients for a decade after they received either arthroscopic knee surgery or a mere skin incision. The results were eye-opening: the surgery provided little to no benefit and, alarmingly, was associated with accelerated osteoarthritis and higher rates of reoperation, often leading to total knee replacement.
One of the study's authors, Teppo Järvinen, an orthopedist and head of the Finnish Centre for Evidence-Based Orthopaedics, was blunt in his assessment: "I don't know how I would defend this procedure at all." The Finnish study was the first of its kind to demonstrate that the surgery could leave patients worse off.
What makes this particularly fascinating is the disparity between the study's findings and the current practice in the U.S. Arthroscopic rates in Finland have dropped by 90%, yet in the U.S., the decline has been far slower. A study of commercial claims found that the number of meniscus surgeries decreased by only about 4% each year from 2010 to 2020.
The study does not apply to cartilage tears resulting from acute injuries, but it does include subjects experiencing knee pain and whose MRIs show degenerative cartilage tears. Evidence has been mounting for over a decade that arthroscopic knee surgery to shave torn, degenerative cartilage is no more effective than physical therapy.
Robert Brophy, director of the Orthopaedic Clinical Research Center at Washington University in St. Louis, acknowledged that the evidence is growing for a more judicious use of this surgery, but noted that "many patients do benefit." However, he also admitted that current practice among his peers is inconsistent, with surgery for meniscus tears being far more common in the South than in the Northeast.
A massive study committee of orthopedic societies in Europe and the U.S. released a consensus statement last summer, noting that degenerative meniscus lesions can be treated with comparable results using either non-operative or surgical approaches. They recommended a trial of physical therapy before surgery, but still endorsed the operation.
The Save the Meniscus Society, a concerted campaign by orthopedic specialty societies, advocates for protecting and maintaining long-term knee health through nonsurgical treatments, surgical repair, and other therapies. This highlights an inherent issue in all medical specialties: appropriate treatment is often in the eye of the physician beholder.
Financial considerations also play a role. In the U.S., physician payments are decided by the Relative Value Scale Update Committee, a committee of the American Medical Association composed largely of specialists. The Department of Health and Human Services has reportedly looked into wresting control of this committee from the AMA, but the path forward is unclear, as the AMA owns the billing codes used to calculate patients' charges.
Arthroscopic knee surgery is not a minor procedure. It takes 30 to 60 minutes in the operating room, and patients spend a few hours recovering in a surgery center or hospital outpatient department. Medicare allots an average of $2,159 to $3,875 for the procedure, with patients paying 20% of the fee as coinsurance. Commercial insurers average well over twice that amount, and these figures do not include the fees of the surgeons and anesthesiologists.
The treatment of chronic knee pain has a varied history. Fifty years ago, the treatment for cartilage tears was to remove the entire piece of cartilage, viewing it as a useless, vestigial piece of tissue. Today, the first-line therapy for a painful knee with degenerative tears is physical therapy and weight loss, with arthroscopic surgery being a potential next step, depending on the surgeon's view of its utility.
There is also a range of injections, from scientifically-proven steroids to controversial stem cell and plasma-rich protein injections, which are not covered by most insurance due to inconclusive studies about their benefit. And as orthopedists move away from shaving meniscus tears, they are highlighting a newer procedure: sewing the torn cartilage back together. However, this is typically an option only for patients under 50 with acute injuries and clean tears, and it's unclear which patients might benefit.
When all else fails, there's knee replacement surgery, a big moneymaker for hospitals and doctors.
In my opinion, this research raises important questions about the balance between medical necessity and financial incentives in healthcare. It's a complex issue, but one that deserves careful consideration and further exploration.
