Putting Placebo Knee Surgery Study into Perspective
It's no surprise that knee arthroscopy for arthritis worked no better than a sham procedure in which patients were sedated while surgeons pretended to operate, say a panel of orthopedic surgeons polled by
Outpatient Surgery magazine. Just look at the patients included in the study reported in last month's
The New England Journal of Medicine: arthritis patients who did not have mechanical symptoms- patients whose knees catch, lock or give way- that arthroscopy can fix fairly easily. The study patients were not going to get better with an operation, so it stands to reason that the results of the operative group would be the same as that of the placebo group.
Unless insurance providers decide not to pay for this procedure, experts say this study will not the change the way orthopods practice medicine. Orthopods have long doubted the efficacy of knee arthroscopy for arthritis, and only perform it on a few patients in a last-ditch effort to provide pain relief - however temporary.
"All I do is knee surgery, and only a very small number of arthritis patients receive arthroscopy," says Douglas Jackson, MD, former president of the American Academy of Orthopaedic Surgeons (AAOS) and an orthopedist in Long Beach, Calif. "We try to buy them two to five years of reduced symptoms. We know that arthroscopy does not work for advanced cases."
"The findings...are important tools for examining the role of arthroscopy in treating knee osteoarthritis. However, it's a mistake to use the study to suggest that knee arthroscopy as a whole is ineffective. Knee arthroscopy has been proven effective in treating knee pain caused by torn cartilage or ligaments, conditions far more likely to have arthroscopic treatment than osteoarthritis." Vernon Tolo, MD
President, American Academy of Orthopaedic Surgeons (AAOS) |
"The study has value both in giving insight into the placebo effect of surgery and in giving scientific evidence about the efficacy of the procedure with a specific group of patients. The larger meaning of the research, however, should not be construed as saying that knee arthroscopy is an ineffective treatment. Clearly, for the large majority of knee arthroscopy candidates, the procedure is beneficial." Peter Fowler, MD
President, American Orthopaedic Society for Sports Medicine (AOSSM) |
"This should serve as a wakeup call to doctors still doing washouts for arthritis. The study has merit in confirming what the orthopedics community at large already knew: knee arthroscopy doesn't do a lot of good for treating arthritis, unless there are corresponding mechanical problems with the knee. On a broader level, we're going to have to start from the beginning explaining knee arthroscopy to patients." S. Terry Canale, MD
Germantown, Tenn.
Past President, AAOS | |
The indications for patients with osteoarthritis that would make them candidates for arthroscopic knee surgery are pain, swelling and the mechanical symptoms of catching, locking or giving way. Once the arthritis becomes too advanced and the leg becomes deformed or bowed, arthroscopic procedures have little benefit. James Tibone, MD, of the University of Southern California Department of Orthopaedics, routinely dissuades arthritis patients from having knee arthroscopy. "Well before this article ever came out, it was my practice to talk people out of this procedure," says Dr. Tibone. "It only gives temporary relief to arthritis symptoms. Sometimes we're stuck with doing it, but only on patients who have already tried everything else and failed, and are too young for a knee replacement."
This is not to say that arthritis is not amenable to arthroscopic surgery, only that there are a couple of different spectrums that you don't operate on:
- those patients who have pain alone and can be managed conservatively;
- those patients whose osteoarthritis is too severe to surgically manage.
The
NEJM study titled "A Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee" reports on 180 Veterans Administration hospital patients with osteoarthritis of the knee who were randomly assigned to receive arthroscopic debridement, arthroscopic lavage or placebo surgery. Outcomes assessed over a two-year period show that patients who had arthroscopy did not benefit any more than patients who underwent the placebo.
"The findings are no surprise to the medical community, which knows how to interpret the results. The problem is that the lay press has sensationalized the study and...made a crisis where there really does not have to be one. For one, by implication, the study overstates the number of these procedures that are done for osteoarthritis patients. Secondly, some patients medically should still be considered candidates for this treatment option because other methods have failed but they are not ready for a total knee replacement. This is especially true for patients with mechanical problems in their knees. The study does not indicate this." Abbott "Bo" Kagan, MD
Fort Meyers, Fla.
President Florida Orthopaedics Society |
"Knee arthroscopy remains a valid and important treatment modality for a large number of arthritis patients, particularly early in the disease process. Unfortunately, those participating in this study really needed total knee arthroplasty, not arthroscopy. Definitive care, not placebo surgery, is what all arthritis patients deserve, and is, hopefully, what they will continue to receive." W. Wayne Malone, RN
Director, Surgical Services
Texas Orthopedic Hospital
Houston, Tex. | |
The study broke patients down into three categories:
- the traditional arthroscopic debridement group, a clean-up of the joint;
- a group who had saline fluid flushed through the joint;
- the placebo or "sham" arm of the study who had a knife stuck in their skin to create three superficial incisions in the knee. An assistant sloshed water in a bucket to make the sound of a knee being flushed clean.
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