Millions wasted on useless surgery: researcher

Knee arthroscopy still a common procedure worldwide, done two million times a year

Ontario is wasting almost $35 million a year on a knee surgery that doesn’t work, says a McMaster University researcher.

Internist and PhD student Dr. Reed Siemieniuk led a group of doctors, patients and health-care workers to create a guideline published in medical journal The BMJ Wednesday that strongly recommends against the use of knee arthroscopy in nearly all patients with degenerative disease.

Despite growing evidence that the minimally invasive procedure doesn’t result in an improvement in long-term pain or function, it remains the most common orthopedic procedure worldwide performed more than two million times each year.

In Ontario alone, there were 27,542 arthroscopic knee surgeries in 2013 costing an average of $1,358 each, says Siemieniuk, citing data from Health Quality Ontario. About 92.5 per cent of those were for degenerative knee disease.

“It’s a big burden for the healthcare system, it’s very common and frankly it doesn’t work,” he said. “It’s quite clear in this disease arthroscopy doesn’t help.”

Doctors with the American and Canadian orthopedic associations say part of the reason the procedure is still so widespread is patient demand.

“I try to talk patients out of it on almost a daily basis,” said Dr. Peter MacDonald, president of the Canadian Orthopaedic Association.

“The patient comes into your office with a preconceived notion that he needs arthroscopy and then you discover there is arthritis in the knee. Trying to talk that patient out of surgery is not as easy as it sounds. Patients often demand it … because for them it’s better than having a knee replacement or better than just languishing in pain.”

He says it’s a tough ethical dilemma to deny surgery to patients who know the odds are against them.

“You’re left with less and less in terms of treatment options for people who are fairly significantly disabled and hobbling into your office,” he said. “It becomes hard.”

The American and Canadian associations have their own guidelines that have had some success in curbing the number of procedures.

“It is decreasing,” said Dr. David Jevsevar, chair of the council of research and quality at the American Association of Orthopaedic Surgeons. “There’s been a significant drop.”

But enough surgeries are still being done to warrant a “rapid recommendation,” which is a project between The BMJ and an international group of researchers, including McMaster, to get strong evidence into practice faster.

The trigger was a trial published in The BMJ in June that concluded knee arthroscopy was no better than exercise therapy for patients with a degenerative medial meniscus tear.

An expert panel was convened and before it came up with a recommendation the result was compared to a systematic review of 13 randomized trials and 12 observational studies.

The review, led by a group of McMaster researchers, found patients undergoing arthroscopy did not end up with less pain or more knee function compared to those treated with exercise therapy, injections, medication or sham surgery.

The resulting guidelines go much further than the recommendations of the associations, suggesting only those with recent trauma, ligament injures and treatment/device complications get the surgery. In Ontario, that would account for just 7.5 per cent of procedures in 2013.

“Our guideline is much broader than the current professional guidelines,” said Siemieniuk. “We hope people will adopt these guidelines right away.”

During the surgery, small cuts are made to insert a camera and small surgical tools to diagnose knee issues and fix problems such as trimming torn floating cartilage, removing cartilage or bone that has broken off or cysts, reconstructing a ligament or washing out infection.

The guidelines are significant considering one in four people over the age of 50 have knee pain from degenerative disease.