The Orthopedic Civil War over Meniscus Surgery Begins
POSTED ON 4/27/2017 IN Research BY Christopher Centeno
A new editorial in the journal Clinical Orthopaedics and Related Research hints at war brewing inside the orthopedic community. You see, we have enough evidence right now to end insurance and other coverage for all common knee meniscus surgeries performed in anyone over 35. However, despite many surgeons proclaiming that they are following evidence-based guidelines, these surgeries continue. Why? The author posits that one reason may be that the American Academy of Orthopedic Surgeons (AAOS) has yet to change its guidelines.
How We Got Here
Research results on surgery for meniscus tears has been dismal, despite this being one of the most common surgical procedures in America and worldwide. The first indication of serious trouble for the procedure was noted in 2002 when a study authored by the Baylor College of Medicine orthopedic department demonstrated that debridement (the surgical "cleaning up" of a knee that has arthritis and degenerative meniscus tears) was no better than a fake, sham, or placebo surgery. While there was an initial pushback, that particular surgery (debridement) over the last 15 years has mostly slipped into the dustbin of medical history.
The next blow for meniscus surgery came from the Framingham Osteoarthritis Study and Osteoarthritis Initiative. Both are government-funded research studies that track patients with knee arthritis over time. They have both concluded that just as many middle-aged people without knee pain have meniscus tears as those with knee pain. You see the problem? If meniscus tears are as common as wrinkles and about as meaningful for predicting why someone's knee hurts, what are we doing operating on them?
Then came a 2012 study published in the prestigious New England Journal of Medicine which showed that patients who chose meniscus surgery did no better than those who just underwent physical therapy. Many orthopedic surgeons noted that many patients in this study had some degree of arthritis and that meniscus surgery still made sense for patients with a meniscus tear, but without arthritis. That bubble burst the next year in 2013 when a randomized controlled trial demonstrated that meniscus surgery in patients with no arthritis couldn't beat a fake surgery. Finally, the most recent blow to the meniscus surgical empire came with a new study out of Finland. This research was focused on patients with “mechanical symptoms” (i.e. their knee periodically locked up and this was thought to be caused by a torn piece of meniscus). This research also concluded that meniscus surgery provided no benefit to relieve pain or locking.
Academics Aren't Listening
I blogged last year that despite the research showing that we should abandon routine meniscus surgeries, the very surgeons who should be leading the way were ignoring the research. This was based on data put out by the Cleveland Clinic showing that despite the evidence that meniscus surgery didn't work, it was still one of the most common procedures being performed in their hospital. In fact, the number of meniscus procedures had actually increased since the negative research was published!
The Most Recent Editorial
Hence, given that even academic surgeons are ignoring the research, it's not surprising that some within the orthopedic community would be crying foul and saying enough is enough. This happened recently in an editorial that used strong words in saying that it's time to stop operating on middle-aged people with meniscus tears. In particular, the author noted that despite all of the evidence described above, the AAOS online tool still recommended meniscus surgery be performed for many indications for which it has shown to be ineffective.
An excerpt from that piece follows:
"Surgeons must either demonstrate that our interventions are effective, or stop using them. Where this particular intervention is concerned, we can no longer suggest that the many high-quality studies showing inefficacy somehow don't apply. It is time to start digesting the available high-quality evidence on this topic and practicing as though it matters."
Are you listening, Cleveland Clinic? In fact, most of the academic medical centers from the Mayo Clinic to Stanford to Harvard are guilty of the same hypocrisy, so no need to just single out the folks in Ohio.
The upshot? Read the editorial; it has lots of tough love for orthopedic surgeons who ignore the research and continue operating on meniscus tears. In particular, you have to ask yourself, at what point will smart malpractice attorneys smell blood in the water and go after surgeons who have complications? With editorials like this one and the mounting evidence that meniscus surgery is ineffective, it won't be long before the malpractice sharks start to circle.
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