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Common Knee Surgery Called Unnecessary

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By Rob Stein
Washington Post Staff Writer
Thursday, September 11, 2008

One of the most common surgical procedures performed in the United States -- arthroscopy to treat arthritis in the knee -- is useless, researchers reported yesterday.

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A study involving 178 men and women found that those who underwent the surgery fared no better than those who received medication and physical therapy only.

"I think we have definitive evidence that that procedure is ineffective," said Brian Feagan of the University of Western Ontario, whose findings are being published in today's issue of the New England Journal of Medicine. "If it isn't effective, patients should not be undergoing it."

The study marks the second time a major study has questioned the operations, which can cost about $5,000 and are done on hundreds of thousands of Americans each year. In 2002, a study found the operations were no better than a sham procedure for arthritis. A year later, based on that and other studies, Medicare stopped paying for the operations for severe arthritis of the knee, and the number of claims for the procedure plunged.

But the 2002 study was criticized as flawed: All the operations were done by one surgeon, and the subjects, who were all men, tended to be older than the typical patient. As a result, many surgeons continued to perform the procedures. Feagan says that as many as a third of the estimated 950,000 arthroscopic knee surgeries performed each year in the United States are probably still being done for arthritis, which affects about 27 million Americans.

"Not much really changed," Feagan said. "I don't think they were willing to respond to a single study."

Feagan and others said the new study was designed to avoid the shortcomings of the earlier research; it involved men and women with an average age of 60, which is more typical. All patients received standard nonsurgical treatment, including physical therapy, painkillers such as acetaminophen and ibuprofen, glucosamine supplements and injections to lubricate the joint. Eighty-six of the patients also underwent arthroscopic surgery, which involves inserting instruments through tiny incisions to clean out any loose debris and smooth out the joint.

Tests done every six months for the next two years showed that both groups improved, reporting less pain and stiffness and more mobility. But the patients who did not have the surgery fared just as well as those who did.

"For garden-variety osteoarthritis of the knee, this isn't very effective surgery," Feagan said.

Feagan and others stressed that surgery can help people who have problems other than arthritis, such as a badly torn ligament or cartilage. But they say that they hope the new research will encourage surgeons to be much more selective in offering the operations, and that patients will be less aggressive about demanding it.

"The bottom line is: If it isn't very good, we shouldn't be doing it," said J. Bruce Moseley, a Houston area orthopedic surgeon who conducted the 2002 study.

Although complications are rare, they can occur, Moseley and others said, noting that dangerous blood clots can form afterward.

"You have this baby boomer population driving a lot of this. They really think that they can turn the clocks back and surgery can fix everything," said Nicholas DiNubile, a spokesman for the American Academy of Orthopedic Surgeons. "But if arthritis is the primary problem and it's moderate to severe, this shows those patients aren't going to do very well. I think that word needs to get out there."

Whether the new study will settle the debate remains unclear. In an editorial accompanying the study, Robert Marx of the Hospital for Special Surgery in New York argued that the new study also has weaknesses, and that there might be patients with knee arthritis who might benefit, such as those who also have torn cartilage.

Feagan said that argument could result in continued overuse of the surgery. A second study involving 991 patients in the same issue of the journal found that many patients with arthritis in their knees also have small cartilage tears but that the tears are not the source of their pain.

"I'm very disappointed by the editorial," Feagan said. "I'm not sure who he is advocating we should treat."

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