Effectiveness of arthroscopic surgery compared with non-operative management of knee osteoarthritis

A new study from Western’s Bone and Joint Institute could save the health-care system millions of dollars while also preventing some of the more than 250 million knee osteoarthritis (OA) sufferers from going under the knife.

British Gymnastics at the 23rd European Championships in Trampoline Gymnastics for seniors, juniors and under-21’s in St. Petersburg, Russia April 2012

By Paul Mayne, Western News January 21, 2016

Previous Western-led research, published in 2008, showed arthroscopic knee surgery provided no extra benefit over non-operative care for sufferers of osteoarthritis (OA). Rates of that surgery have declined in the last seven years, however, it remains one of the most common orthopaedic surgeries internationally.

In response, Western researchers Jacquelyn Marsh, Trevor Birmingham and Robert Giffin conducted the first ever trial-based analysis on the cost-effectiveness of such surgeries. Their goal was to augment the previous study on effectiveness with economic data comparing both surgical and non-surgical options.

The study was recently published in the journal BMJ Open.

Western-led research by Trevor Birmingham, left, and Jacquelyn Marsh, right, along with Robert Giffin, conducted the first ever, trial-based analysis on the cost-effectiveness of arthroscopic knee surgery for knee osteoarthritis (OA) sufferers. Paul Mayne photo.

“We hope to influence all health-care providers – not just surgeons – and patients by further describing the value of our treatment choices for knee OA,” said Birmingham, Canada Research Chair in Musculoskeletal Rehabilitation in the Faculty of Health Sciences. “It’s not as easy as you think. Most people do feel better after knee arthroscopy. It’s hard for many (clinicians and patients) to grasp not doing something that obviously works.

“The catch is, randomized clinical trials show that similar patients also improve to a similar extent when they receive non-operative treatments. That’s partly why we decided to analyze the economic data, to add more information to help people make better decisions.”

Garnering data from the initial study by Dr. Sandy Kirkley, this recent study included 168 patients (88 in a arthroscopy group and 80 in a non-operative group). Patients who received the surgery followed the same physical and medical therapy program as those in the non-operative group, beginning within seven days following surgery. Direct costs of each surgery included equipment, operating room costs and laboratory or other medical tests done during the procedure.

For the non-operative care patients, the number of physical therapy sessions attended was recorded. Any medication used – including both over-the-counter and prescription pain or anti-inflammatory drugs, hyaluronic acid injections or other medical treatments for knee OA – were also recorded. Indirect costs, such as time off work, were also considered.

For researchers, the data showed arthroscopic surgery, when compared to non-operative treatments, cost more without offsetting other costs.

“Patients who received non-operative therapies showed similar improvements in pain, function and quality of life compared to those who also received surgery – at a significantly lower cost,” said Marsh, the lead author and a Postdoctoral Fellow at the Bone and Joint Institute. “In the end, the average cost was estimated to be more than $2,000 more for each patient who received the surgery, which, with millions suffering from knee OA, quickly adds up as the procedures continue.

“We know surgery costs more; the goal of an economic evaluation is to show how much extra benefit the surgery provides, to allow users of the information (clinicians, policy makers, patients) to decide if the extra cost is worth it. In our case, because the outcomes for patients in both groups were so similar, it would suggest arthroscopy is not cost effective, in other words to pay this extra money to get a very similar outcome is unlikely to represent good value,” Marsh added.

“Most people do feel better after knee arthroscopy,” Birmingham said, “however the catch is randomized clinical trials show that similar patients also improve to a similar extent when they receive non-operative treatments.”

“When that body of evidence is coupled with the present economic analysis, one has to question whether health-care funds would be better spent elsewhere,” said Birmingham, who has early signs of knee OA and won’t be having arthroscopy. “There still may be some individuals who benefit from arthroscopic surgery, and we do leave that to the surgeon to decide, which is likely the best thing. But, again, we have to educate the surgeons and other health- care providers about these types of results.

“As a consumer, and as someone with knee OA myself, I would want to know the treatment options.” Trevor Birmingham.

On the team’s growing research focus on health economics, Giffin, a Surgery professor, added, “There still may be some other individuals who benefit from arthroscopic surgery, and we do rightly leave that to the surgeon to decide. Science often tells us what we can do, clinical trials tell us what we should do, and economic evaluations tell us what we can afford to do in our publicly funded health-care system.”

Source Western University

Cost-effectiveness analysis of arthroscopic surgery compared with non-operative management for osteoarthritis of the knee, Marsh JD, Birmingham TB, Giffin JR, Isaranuwatchai W, Hoch JS, Feagan BG, Litchfield R, Willits K, Fowler P. BMJ Open. 2016 Jan 12;6(1):e009949. doi: 10.1136/bmjopen-2015-009949.

In-Hospital Cost Analysis of Total Hip Arthroplasty: Does Surgical Approach Matter? Petis SM, Howard JL, Lanting BA, Marsh JD, Vasarhelyi EM. J Arthroplasty. 2016 Jan;31(1):53-8. doi: 10.1016/j.arth.2015.08.034. Epub 2015 Aug 29.

Cost-Effectiveness of Treating Early to Moderate Stage Knee Osteoarthritis with Intra-articular Hyaluronic Acid Compared to Conservative Interventions, Rosen J, Niazi F, Dysart S. Adv Ther. 2020 Jan;37(1):344-352. doi: 10.1007/s12325-019-01142-x. Epub 2019 Nov 18. Full text

Health Economic Evaluations of Hip and Knee Interventions in Orthopaedic Sports Medicine: A Systematic Review and Quality Assessment, Primeau CA, Zomar BO, Somerville LE, Joshi I, Giffin JR, Marsh JD. Orthop J Sports Med. 2021 Mar 9;9(3):2325967120987241. doi: 10.1177/2325967120987241. Full text

A randomized trial of arthroscopic surgery for osteoarthritis of the knee, Kirkley A, Birmingham TB, Litchfield RB, Giffin JR, Willits KR, Wong CJ, Feagan BG, Donner A, Griffin SH, D’Ascanio LM, Pope JE, Fowler PJ. N Engl J Med. 2008 Sep 11;359(11):1097-107. doi: 10.1056/NEJMoa0708333. Erratum in: N Engl J Med. 2009 Nov 12;361(20):2004. Full text, PDF

Also see
New Western University study suggests arthroscopic knee surgery not cost-effective compared to other ‘non-operative’ treatments Medical News Today
Benefit of knee surgery for middle aged or older patients “inconsequential” say experts University of Oxford