Knee ail­ments don’t al­ways re­quire surgery

Less in­va­sive treat­ments work for com­mon arthri­tis, say Eric Bohm and Ivan Wong.

Vancouver Sun - - OPINION -

Nearly half of Cana­di­ans aged 65 and over ex­pe­ri­ence os­teoarthri­tis in their knees. Os­teoarthri­tis is the most com­mon form of arthri­tis and oc­curs when the pro­tec­tive car­ti­lage on the ends of bones wears down over time, lead­ing to pain, stiff­ness and de­creased mo­bil­ity. It fre­quently oc­curs in the hips and knees.

To help im­prove mo­bil­ity and treat joint pain, it has been com­mon in the past for older adults with os­teoarthri­tis of the knee to be re­ferred to or­tho­pe­dic sur­geons, like us, for knee arthroscopy.

As or­tho­pe­dic sur­geons, we want to en­sure that our sur­gi­cal pro­ce­dures pro­vide high-value care to pa­tients and do more good than harm. Un­for­tu­nately, this is of­ten not the case for knee arthroscopy in older adults with arthri­tis.

Arthroscopy of the knee for arthri­tis in­volves mak­ing sev­eral small cuts to in­sert a small cam­era and in­stru­ments to view the joint and trim loose car­ti­lage and wash the joint out.

Now there’s a grow­ing body of re­search show­ing that this pro­ce­dure may not be nec­es­sary for most older adults, since it usu­ally has the same long-term out­comes as non-oper­a­tive and less in­va­sive treat­ments.

Al­ter­na­tive treat­ments can in­clude weight loss, phys­io­ther­apy, ex­er­cise, over-the-counter pain medicines such as Tylenol, anti-in­flam­ma­to­ries and pain-re­liev­ing joint in­jec­tions.

Knee arthroscopy, on the other hand, is a sur­gi­cal pro­ce­dure that typ­i­cally re­quires spinal or gen­eral anes­thetic. It’s not risk-free be­cause there’s al­ways a risk of in­fec­tions or struc­tural dam­age to the joint.

Does this mean that no arthroscopy should be per­formed? No.

Rather, arthroscopy needs to be done for the right con­di­tions and on the right pa­tients. For ex­am­ple, menis­cus-re­pair surgery for a younger per­son with a knee in­jury can help im­prove func­tion, treat pain and in­crease mo­bil­ity.

What’s at stake?

Arthroscopy needs to be done for the right con­di­tions and on the right pa­tients.

Un­nec­es­sary surg­eries mean that our time as sur­geons, as well as health-care sys­tem re­sources, such as op­er­at­ing rooms and staff, are tied up do­ing surg­eries that don’t add much value to pa­tients.

These re­sources could be di­rected to­ward other or­tho­pe­dic pro­ce­dures that pro­vide pain re­lief and im­proved func­tion, yet have long wait­ing lists, such as spine surgery and hip and knee re­place­ments.

For older pa­tients with os­teoarthri­tis in the knee, arthroscopy is more of­ten than not the wrong choice.

As sur­geons, we ad­vise our pa­tients on al­ter­na­tives to surgery and re­flect on our own prac­tice habits. We are also cham­pi­oning the Choos­ing Wisely Canada cam­paign to our col­leagues and pa­tients far and wide. Re­cently, the Cana­dian Or­thopaedic As­so­ci­a­tion, the Cana­dian Arthro­plasty So­ci­ety and the Arthroscopy As­so­ci­a­tion of Canada joined to­gether to re­lease a set of rec­om­men­da­tions on best prac­tices.

The first rec­om­men­da­tion is against arthroscopy for ini­tial treat­ment and man­age­ment of os­teoarthri­tis in the knee.

It is well es­tab­lished that physi­cians tend to over­es­ti­mate the ben­e­fits of our pro­ce­dures and of­ten un­der­es­ti­mate harms. Re­cent re­search shows that the same mis­con­cep­tions about harms and ben­e­fits of com­mon pro­ce­dures are held by pa­tients.

A cul­ture shift is needed for sur­geons, pa­tients and the pub­lic on treat­ment ex­pec­ta­tions for knee os­teoarthri­tis.

Say­ing no to arthro­scopic surgery, and in­stead un­der­tak­ing non-oper­a­tive man­age­ment is a chal­lenge for both clin­i­cians and pa­tients alike.

Thought­ful, ev­i­dence-based uti­liza­tion of our health-care sys­tem re­sources will help to im­prove ap­pro­pri­ate care for all Cana­di­ans.

Dr. Eric Bohm is a pro­fes­sor at the Univer­sity of Man­i­toba, an or­tho­pe­dic sur­geon with the Con­cor­dia Joint Re­place­ment Group in Win­nipeg and a con­trib­u­tor with Ev­i­denceNet­; Dr. Ivan Wong is an as­so­ciate pro­fes­sor at Dal­housie Univer­sity, an or­tho­pe­dic sur­geon at the QEII Health Sci­ences Cen­tre in Hal­i­fax, and pres­i­dent of the Arthroscopy As­so­ci­a­tion of Canada.

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