Mil­lions wasted on use­less surgery: re­searcher

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

The Hamilton Spectator - - LOCAL - JOANNA FRKETICH jfr­ketich@thes­pec.com 905-526-3349 | @Jfr­ketich

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.

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