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Monday, February 17, 2014

Knee surgery ineffective for many cases of torn cartilage

With minor variation, the following is an extremely common sequence of events. A man notices slowly worsening nagging knee pain that persists over months. He sees an orthopedist, who examines him and orders an MRI. The MRI shows a tear in the medial meniscus. (The lateral and medial menisci are the cartilage pads that cushion the knee joint.) Pain medicine and physical therapy are prescribed but the pain persists. So the orthopedist recommends surgery and performs an arthroscopic partial meniscectomy. That’s the technical way of saying that with tiny instruments inserted into the joint through small incisions the doctor visualizes the cartilage tear and shaves away the loose and torn portion, leaving behind only solid intact cartilage. After the surgery more physical therapy is prescribed and over the subsequent months, the patient feels much better. Both he and his doctor agree that the surgery was a success.

This story repeats itself about 700,000 times annually in the U.S., amounting to direct costs of $4 billion. Partial mensicectomies are one of the most common orthopedic procedures. I certainly have never given it a second thought, and have sent patients to orthopedists expecting exactly this treatment. The assumption that the pain is caused by the cartilage tear is so compelling we don’t even notice it.

Previous studies have already shown that arthroscopic knee surgery is ineffective for arthritis. In patients with a cartilage tear and arthritis a study demonstrated that physical therapy and surgery was no better than surgery alone. But for cartilage tears without arthritis the belief remained that the problem was mechanical, the cartilage was torn, and therefore had a mechanical solution, cut away the torn fragment.

The New England Journal of Medicine (NEJM) published an ingeniously designed trial which tested that assumption. Researchers in Finland enrolled 146 patients with medial meniscus tears and no arthritis. Cartilage tears due to trauma, such as sports injuries, were excluded. Only degenerative tears, those due to chronic use, wear and tear, were enrolled. The researchers knew that surgery itself can have a very powerful placebo effect so they designed a trial that would not reveal to the patients whether or not they had their cartilage repaired.

All the patients underwent arthroscopy, the placing of the scopes into the joint so that the surgeon can visualize the cartilage. If a cartilage tear was confirmed the patients were randomized to one of two groups during the surgery by opening a sealed envelope. One group had the standard surgery, the partial meniscectomy. The other group had sham surgery. The surgeon still asked for all the implements he would normally ask for and in the same order. (Many of the patients had regional anesthesia and couldn’t feel their leg but were awake.) During the part of the sham surgery in which the cartilage was to be shaved the surgeon held a shaver without the blade against the patients knee cap so that his body would experience the vibration and sound of the shaver. The sham surgery patients were kept in the operating room as long as the patients undergoing real surgery. Afterwards the surgical team, the only people who knew the patient’s group allocation, never saw the patient again. All follow up care and evaluation was performed by a different team who were unaware of which groups the patients were in.

The complex blinding scheme worked. Equal proportions of both groups thought they had the real surgery. The patients continued physical therapy and underwent standardized evaluation of their knee symptoms at 2, 6 and 12 months after the surgery. Both groups showed significant improvement, and there was no difference between the groups. About half of both groups reported being satisfied with the procedure, and two-thirds of both groups said they would be willing to repeat it.

So it seems that, at least for degenerative tears, the torn cartilage is not the cause of the pain. The torn cartilage is simply a marker of the chronic wear and tear that is causing pain through some other mechanism. The treatment, which appears to be quite effective, is physical therapy and time.

So if this study spared you from an unnecessary surgery, raise a toast to the intrepid Finnish patients who were willing to have surgeons put instruments in their knees and do absolutely nothing for the sake of discovery.

Learn more:
Common Knee Surgery Does Very Little for Some, Study Suggests (New York Times)
Fake Knee Surgery as Good as Real Procedure, Study Finds (Wall Street Journal)
You may not be better off after knee surgery (CNN)
Arthroscopic Partial Meniscectomy versus Sham Surgery for a Degenerative Meniscal Tear (NEJM article)

Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000. Holding privileges at Cedars-Sinai Medical Center, he is also an assistant clinical professor at UCLA's Department of Medicine. This post originally appeared at his blog.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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