Fewer US adults getting unnecessary knee surgery

Arthroscopic knee surgery is being done less often in adults with torn cartilage or painful arthritis, as a growing body of evidence shows little benefit from these operations, a U.S. study suggests.

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By Lisa Rapaport, Reuters Health Information, Medscape September 26, 2018

Researchers examined data on all surgeries done on patients 18 and older in Florida from 2002 to 2015, including a total of 868,482 arthroscopic knee procedures. Overall, rates of these operations declined 23% during the study period, with sharper decreases after 2008.

“There was some evidence that use of arthroscopy was declining, but this study shows that the decline was large and has been sustained,” study author David Howard of Emory University in Atlanta said by email. “I think patients can be reassured that doctors reacted to the evidence.”

Multiple studies have shown that knee arthroscopy isn’t any better than non-operative treatments for conditions like arthritis, torn cartilage and knee pain, Howard noted September 24 online in JAMA Internal Medicine. But evidence to date hasn’t offered a clear picture of how much doctors and patients are avoiding the operations as a result.

Between 2002 and 2015, knee arthroscopy rates in Florida declined from 449 procedures for every 100,000 adults in the population to 345 procedures for every 100,000 adults, the current study found.

Declines were steeper after 2008, when a second major trial was published that failed to detect a difference between surgery and medical management.

These declines in surgery happened even as the prevalence of knee osteoarthritis among U.S. adults more than doubled from 6.6% in 1999 to 14.3% by 2014, Howard writes.

The study can’t show what factors might have influenced any declines in these surgeries or whether patients had different health outcomes as a result. And it only included data from Florida.

Still, the results suggest that doctors and patients are getting the message that these operations aren’t the best approach for wear and tear that contributes to knee pain as people age, said Andrew Carr, a researcher at the University of Oxford in the UK who wasn’t involved in the study.

“Rest and time are often very helpful,” Carr said by email. “If symptoms persist then other treatments including physiotherapy and the use of anti-inflammatory medication may be of benefit.”

There are still, however, far too many operations being done on patients who may not benefit and may be harmed instead, said Jonas Bloch Thorlund, a researcher at the University of Southern Denmark who wasn’t involved in the study.

“There is still room for improvement,” Thorlund said by email.

Source Medscape

Interview with Prof. David H. Howard PhD, Department of Health Policy and Management, Emory University, MedicalResearch.com September 25, 2018
MedicalResearch.com: What is the background for this study? What are the main findings?
David Howard: There is a lot of skepticism that physicians respond to evidence, especially when trials report that widely-used, separately-reimbursed procedures are not effective.

Physicians are reluctant to abandon treatments. This study shows that in the case of knee arthroscopy, evidence has made a difference. The use of knee arthroscopy declined by 23% in Florida between 2002 and 2015. This change occurred despite increases in the prevalence of osteoarthritis.

What should readers take away from your report?
Trials of established procedures are worthwhile. They can influence how doctors treat patients. In the case of knee arthroscopy, evidence may have had more of an impact because there were multiple trials that all reached the same conclusion.
What recommendations do you have for future research as a result of this work?
Knee arthroscopy has declined, but it is unclear if it is still overused. It would be interesting to know how treatment patterns vary between orthopedic surgeons in private practice versus those who are employed by hospitals and health systems. Also, what are the underlying changes in care that have contributed to the decline? Are patients less likely to pursue surgery? Are physicians counseling against immediate surgery.
Is there anything else you would like to add?
Many experts think physicians are slow to respond to evidence, but beliefs about the impact of evidence are not always evidenced-based. I have no disclosures/conflicts.

Source MedicalResearch.com

Trends in the Use of Knee Arthroscopy in Adults, Research Letter: Less Is More, David H. Howard PhD. JAMA Intern Med. Published online September 24, 2018. doi:10.1001/jamainternmed.2018.4175

  References
General health factors may be a barrier to effective non-surgical multidisciplinary rehabilitation of common orthopaedic conditions in tertiary care settings, Shaun O’Leary, Michelle Cottrell, Maree Raymer, David Smith and Asaduzzaman Khan. BMC Musculoskeletal Disorders 2018 19:348 https://doi.org/10.1186/s12891-018-2265-6

Deconstructing a popular myth: why knee arthroscopy is no better than placebo surgery for degenerative meniscal tears, Thorlund JB. Br J Sports Med. 2017 Nov;51(22):1630-1631. doi: 10.1136/bjsports-2017-097877. Epub 2017 Jun 14.

Risk factors, diagnosis and non-surgical treatment for meniscal tears: evidence and recommendations: a statement paper commissioned by the Danish Society of Sports Physical Therapy (DSSF), Thorlund JB, Juhl CB, Ingelsrud LH, Skou ST. Br J Sports Med. 2018 May;52(9):557-565. doi: 10.1136/bjsports-2017-098429. Epub 2018 Feb 2.

Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: randomised controlled trial with two year follow-up, Kise NJ, Risberg MA, Stensrud S, Ranstam J, Engebretsen L, Roos EM. BMJ. 2016 Jul 20;354:i3740. doi: 10.1136/bmj.i3740.

Arthroscopic partial meniscectomy for meniscal tears of the knee: a systematic review and meta-analysis, Simon GF Abram, Sally Hopewell, Andrew Paul Monk, Lee E Bayliss, David J Beard, Andrew J Price. British Journal of Sports Medicine. Published Online First: 22 February 2019. doi: 10.1136/bjsports-2018-100223

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