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evidence based medicine, pain, Surgery

The burden of unnecessary surgery: partial meniscectomy for degenerative tears no better than placebo

Meniscus, image from the American Academy of Orthopedic Surgeons

Meniscus, image from the American Academy of Orthopedic Surgeons

Arthroscopic knee surgery is big business in the United States. Arthroscopic partial meniscectomies alone cost $4 billion/year. Yes, billion. But do they work?

I’ve written previously about arthroscopic surgery for a torn meniscus and how it adds nothing above and beyond physical therapy for people with arthritis. We also know that arthroscopic knee surgery for arthritis isn’t effective either. Given the poor performance of these arthroscopic surgeries for knee pain looking at other arthroscopic procedures, such as partial meniscectomies for a symptomatic degenerative tear, is crucial.

Interestingly, as the authors of a new study looking at partial meniscectomy for degenerative meniscal tears point out, arthroscopic knee surgeries for arthritis have decreased since the studies showing their lack of efficacy were published, however, there has been a 50% increase in surgeries for meniscal tears. I suppose that could be attributed to the overuse of MRIs for knee pain (when did the clinical exam become obsolete?) and the fact that meniscal tears are very common (35% of people over the age of 50 will have a meniscus tear on MRI). However, the cynic in me wonders how many times another “diagnosis” was identified so some kind of surgery could be offered, either because the surgeon couldn’t think of something else to offer, the surgeon wanted to fill their time on that day, or the patient pressed so much for and operation that the surgeon gave in.

But I digress.

This new study is a wonderful prospective randomized double-blinded trial with an elegant sham procedure with the data fully evaluated and analyzed before the investigators were unblinded. Also, the surgeons did not participate in the post operative care so there was no way patients could be accidentally informed about their procedure, true meniscal surgery or simply a diagnostic arthroscopy.

The results? Arthroscopic surgery offers nothing for patients with a partial degenerative meniscal tear who do not have  arthritis. Patients with traumatic tears were excluded from the study, so the outcome is only applicable to degenerative tears.

Why does this matter? Considering the prevalence of chronic knee pain and the sensitivity of of MRI at identifying meniscal tears, it matters a lot. And the $4 billion we are spending on direct medical costs for this unnecessary surgery. Surely that money could be used elsewhere? There are also the indirect costs of missed work and disability payments, raised health care premiums to pay for the unnecessary surgery, and of course the risk of surgical complications. (Don’t even get me started on how much we could save by preventing unnecessary hysterectomies).

As a chronic pain medicine physician I appreciate the desire to get better as quickly as possible, but for most painful conditions the path to wellness doesn’t involve a scalpel and a surgery that will not produce the desired outcome is a worse option than no surgery. To invest the time, effort, risk, and great expense of surgery there must be proof that it offers a chance to help. Given the solid lack of evidence for pain attributed to a degenerative meniscal tear, Medicaid, Medicare, and insurance companies should stop reimbursing for partial meniscectomy.

We accept so little of surgery from an efficacy and safety standpoint compared with medications. At least you can stop a medication, but you can’t undo a surgery. What if every procedure were required to have the same type of efficacy and safety data for approval as the FDA requires of medications?

Unnecessary surgeries are a huge driver of both health care costs and false expectations and if we don’t do something about it we will never be able to provide universal cost effective care. It’s simply a burden that we can’t afford in so many ways

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Discussion

One thought on “The burden of unnecessary surgery: partial meniscectomy for degenerative tears no better than placebo

  1. I somehow twisted my left knee last April; it became very swollen and painful. I saw my old colleague, the orthopod, who examined it and thought I’d torn the medial meniscus. I had an MRI, and at review a tear was confirmed on the scan. My friend said that I’d not be any off with a laparoscopic procedure. It’s still uncomfy at times, and feels a bit peculiar. But I was glad to avoid surgery. This, of course, was in the UK.

    Posted by korhomme | December 28, 2013, 6:23 am

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