Surgeons are doing fewer knee surgeries

Robert H. Shmerling, MD

Faculty Editor, Harvard Health Publishing

When knee arthroscopy became widely available in the 1980s, it represented a major advance. Today orthopedists evaluating and treating common knee problems often recommend arthroscopy, during which they insert an instrument into the joint and, with a light and camera on its tip, directly inspect the knee from the inside. While there, he or she can diagnose and treat common painful knee problems, such as arthritis or torn cartilage. The risks are much lower and recovery times much shorter than standard “open” knee operations.

As with any technology or other advance in medicine, years of research were required to understand when best to use it. Not surprisingly, arthroscopy turns out to be much more helpful for some conditions than others. For example, if you have a sports injury in which the medial meniscus (a crescent-shaped, shock absorbing wedge of cartilage) is torn and blocking the motion of the knee, arthroscopic surgery can provide dramatic relief in a short period of time.

But studies have demonstrated convincingly that for many other common causes of knee pain, including osteoarthritis and many instances of torn cartilage that do not block joint motion, medications and physical therapy may work just as well as arthroscopic surgery. Despite these recent data, some orthopedists continued to recommend arthroscopic surgery for these conditions. Now, that seems to be changing.

A new study says the number of knee arthroscopies is falling

Data recently published in JAMA Internal Medicine demonstrate that between 2002 and 2015, the rate of arthroscopic surgery in Florida

  • decreased from 449 to 345 per 100,000 people (a 23% decline)
  • dropped more among adults under age 65 (24% reduction) than among those over 65 (19% reduction)
  • fell most dramatically after 2008 (after a second important trial showed no benefit of arthroscopy for osteoarthritis of the knee).

Is this a good thing?

Reducing the number of unnecessary operations is certainly a good thing, especially for one that is so common. However, we don’t know if the reduction in arthroscopies occurred for the right reasons: while it’s possible that the reduction was because orthopedists are recommending them more selectively (and more appropriately), it’s also possible that people are not getting the surgery due to lack of insurance, trouble finding an orthopedist, or because they just prefer not to have surgery. We don’t know about patients’ health or outcomes: are some people suffering because they didn’t have an arthroscopy they needed? How many had arthroscopies they did not need and had complications, or simply didn’t improve?

We also don’t know whether rates are falling in other states. Still, it’s reasonable to assume that knee arthroscopies are being performed less often because we better understand when they are likely to help and when they are not.

Why does change take so long?

At the risk of gross over generalization, doctors tend to avoid change. That’s true of many — but certainly not all — of my colleagues. Who else is still using beepers and fax machines on a daily basis? So, some of the reluctance of orthopedists to change their practice in the face of studies questioning the usefulness of knee arthroscopy may be this tendency to resist change. Another reason might be financial considerations: surgical procedures tend to generate a large income stream for the doctor and the hospital or surgical center.

But it’s also true that a single study is rarely enough to change medical practice — doctors are, with good reason, a skeptical bunch. Subsequent research must verify and confirm a new finding. Perhaps that’s why the rate of knee arthroscopy dropped most significantly after the publication of a second trial regarding knee osteoarthritis.

What’s next?

You can expect to hear much more about studies that challenge standard practice, especially when that practice is invasive (including surgery) and expensive. My guess is that the number of knee arthroscopies will continue to fall for some time, until only the most appropriate ones are being done.

When it comes to standard but treatments being called into question, the big question is, indeed, “what’s next?” The answers will come once high-quality research is performed by skeptical researchers willing to question the status quo.

Follow me on Twitter @RobShmerling

Comments:

  1. S.P. Iyer

    Many people are not aware that Homoeopathy has a host of remedies to cure various knee problems. Ayurveda also has lots of medicines. Ayurveda has external applications and heat/cold therapy with natural ingredients that has given exceptional results. Generally the system of Homoeopathic, Ayurvedic or Siddha medicines are attempted only after a patient gets no relief for a considerable period under Allopathic medication. I will advise the patients to approach doctors who are well versed in these systems of medicines before going for a surgical option. Ayurveda has given me a new life from heart problems. I am fit and active at the age of 65, though I continue medicines prescribed as per my cardiologist advice, who admitted ayurvedic medicines have given me a surprisingly good result and has reduced the dose of allopathic drugs.

  2. OWEN H NEFF

    MY WIFE, WHO IS 8 3 YEAR OLD 102 POUNDS WHO HAS 2 KNEES THAT BUCKLE. ONE KNEE IS WORSE THAN THE OTHER- WHAT TYPE TREATMENT WOULD BE INDICATED FOR THIS SITUATION? THANKS ==OHN

    • Scott

      Owen, I would exhaust all conservative measures for symptomatic relief before considering surgical intervention. Your wife should be examined by a physical therapist. The literature indicates, in some cases, PT is equally as effective as arthroscopic surgery at relieving knee symptoms associated with osteoarthritis and.low grade meniscus tear. Keep in mind there are multiple pain generators around any joint that need to be ruled out as a cause and your spouse may have a joint dysfunction caused by hip weakness. Good luck

    • Bob

      One of the simplest things to look at first and you can do this yourself is to examine the tightness and soreness of the muscles just above the knee or the join between the start of the hard part of the knee and the muscles. Without touching or upsetting the patella see if the muscles are sore or tight by pressing with your thumb or elbow on the muscle only. If it is sore then relieving this soreness or tension here at the join may well be a start to rehabilitation. By using your elbow and resting on the tight muscle you may relieve that tightness and free the movement which you can then test to see if your knee improves. There may be another spot or 2 in that join area that may be tight and sore so do your own investigation. Rubbing magnesium oil or cream may also help to relax the area but I find the elbow does a good job if you can handle the tickle.

  3. Carole

    All I can tell you is that I was in such terrible pain I could get no sleep at all until I finally caved in and had arthroscopic knee surgery in 2005 and it made a MAJOR difference in my life to this day. Yes, I have occasional knee discomfort now, but NOTHING like what I experienced before that surgery.

  4. Dr Armando Sta.Ana(GP)

    In my futuristic ideas- I have thoughts of applying a shock absorber like
    device in the knee joints and a rubber like joint in between the knee head
    joint to absorb the friction of bone to bone in osteoarthritic knee joints.

    Maybe another idea is the the “Iron Man” like metal joint device that fits
    specifically to the knee joints.
    Medical science technology maybe can try inventing these futuristic ideas on mine for mankind use.

  5. laura anderson

    I have oesteoarthritis of the knee and my scope failed within 6 months. Shoulder lasted 2 1/2 years.

  6. Harvey L Harris

    Just wonder if here is a really competent Orthopedist in the Kansas City, Mo area with whom I may consult. If so How would I contact him/her.
    I am a 93 year old Male, somewhat over weight, with very good insurance, whose knees are in bad shape to the point I am unable to walk without frequently knees releasing and allowing me to fall. Only trauma to knees I am aware of was a bad parachute landing in 1943 but did not start having painful knees which was occasionally aleviated with injections until 2005 or so.Any suggestions?

  7. Nina Jordan

    I’d like to know if the same thinking applies. to hip surgery for osteoarthritis.

  8. JC Smith, MA, DC

    “What’s next?” you ask. Certainly the elephant in the OR of unnecessary procedures are spine fusion surgeries. Numerous studies from Boden to Mayo have determined “bad disks” are commonplace in asymptomatic patients, but spine PR such as the Laser Spine Institute continue to promote this misconception to a gullible public. Alf Nachemson has urged moratorium on fusions, but there is too much profit to stop.

    • Ethelyn Schaeffer

      Some need the stabilization due to systemic inflammation being so high that the body cannot heal chronic areas.
      Reduce both systemic inflammation and local. And not with drugs necessarily.
      Good comment, but just because some can go without doesn’t mean others can.

  9. Grace

    Several years ago I sustained a severe torn rotator cuff injury where tendon pulled away from bone! Very painful & caused neck pain & muscular pain in back! Shoulder replacement surgery was recommended. It had to be postponed! I researched online restorative medicine websites. Thought if I could encourage tissue to reattach to bone, I could avoid extensive surgery. Saw info about collagen benefits. Started taking extra collagen – 1000 mg on empty stomach daily. In 2 or 3 days, pain decreased. Kept taking until no more pain. Still take it occasionally. Still have full use of arm but am careful not to overdo. I consider collagen a miracle healer. It might prevent hip, knee & other joint injury surgeries. Also tissue injuries might benefit from extra collagen!

  10. Al Omar

    I had an open operation in 1981 to repair a torn ligament in my left knee from playing soccer. I followed it up with two arthroscopic fine-tuning procedures in 1992 and 2011 to remove some minor chipped cartilage. The ultimate outcome now is that I cannot bend my knee more than 90 degrees. The last consultation with my sports doctor in 2012 resulted in advising that there was no need for an arthroscopic procedure. They recommended that I do some exercises to strengthen the muscles around the knee and try to balance the body during my walks and exercises. So far so good as far as the general condition and prevention of further deterioration. However, I cannot recover the knee-bend beyond 90 degrees. A situation I have learned to live with without too much trouble. Currently, I do conditioning exercises at the gym, do a lot of gardening, ride my bike on weekends, and hike on trails. That is not bad at all.

    • Emm

      Hi Al Omar,

      I have a torn meniscus tear in my right knee. This was discovered after 18 months or so of informing my surgery that I had a problem (The UK NHS is variable in terms of service). I was informed that the best approach was to strengthen the muscles around the one. I am in the process of building up my hamstrings and my quads. I am wondering what rehab programme you have followed as you appear to have achieved some success.

      I have improved the stability of the knee but seem to have plateaued in my endeavours. Do you have any links to good articles or personal trainer programmes which focus on strengthening and stabilising the knee. Thanks in advance to you and anyone else who offers advice.

  11. Mary

    Maybe the people who where suffering has found an alternative pain relief method

  12. azure

    What’s missing from this article is a comparison w/data from other developed nations: France, Austria, Germany, the UK, Japan, Canada, Australia, etc.

    MDs, DOs in other developed nations seem, in general, to try less invasive treatment then US MDs have for the past 30 years or so. In addition, data from those nations might include consideration of some of the variables that are listed as lacking in the FL data–although lack of insurance is far far less likely to be an issue in those nations.

    Also, isn’t there reliable data from any other states in the US?

    • Francis Van Ausdal

      what are the complications from such surgeries?

    • Donald Spiderman Thomas

      Aloha,
      I was diagnosed with Osgood-Schlatter disease at age 19, many years ago, before arthroscopic surgery was in practice. Under “open knee” surgery 12 pieces of boney patella was discovered in each knee. I had the typical “bump” under the kneecap but the surgeon chose not to shave it down to maintain integrity. In my case, surgery was certainly warranted. Glad to see those unnecessary knee surgeries are on the decline. After surgery, I went on to establish a jump rope fitness program called New Jump Swing and served as the celebrity chairperson for the American Heart Association’s Jump Rope for Heart campaign in the state of Hawaii for several years. Thank you, Dr. Joel Teicher, MD

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