A Critique of “Surgery for Knee Pain May Not Provide Benefits”

Several weeks ago in the New York Times, the above-titled article by Nicholas Bakalar opened with the statement that “people in their 50’s and older often get arthroscopic surgery for their knee pain, but a new review of studies suggests that it has serious risks and no lasting benefits.”

As an arthroscopic surgeon and cartilage specialist with 25 years of experience, how do I react to such a statement?

Jonas Bloch, the lead author in the BMJ- (formerly British Medical Journal) published article, examined the results of 9 previous studies “with or without xray arthritis” in patients age 50-62 who underwent an assortment of surgical procedures, compared to medication, exercise and sham surgical “control” treatments. They found statistical evidence of “small but statistically significant” improvement from surgery that did not persist to 24 months. Interestingly, “exercise therapy” actually had a larger pain-relieving effect than arthroscopy.  Despite the catchy by-line, the described “harms” were very uncommon (much less than 1%).

Such claims are actually nothing new…

As long as 20 years ago, studies were published demonstrating that knee pain, in the presence of some arthritis and the absence of mechanical symptoms (catching, locking or  swelling/loss of smooth motion), may not benefit from surgery, compared to alternative treatment options. This is well-known, perhaps not always discussed with patients as thoroughly as it should be prior to considering arthroscopic treatment, a same-day surgery to alleviate joint symptoms.

This “study of studies” is tilted against surgical treatment, even going so far as to reference an at-best controversial article claiming that arthroscopy can lead to knee replacement “at a significantly younger age” ;  comparing it to a totally unrelated procedure (vertebroplasty);  summarizing that “…financial aspects and administrative policies may be factors more powerful than evidence…” . These are statements unsupported by any of presented data.

There are too many patient subsets (heterogeneity), frequent study biases (only 2 of the 7 selected groups met selection “control” criteria) , small sample sizes (especially on the surgical side) and several unsupported statements (cartilage “meniscus resection may also be associated with … harms”) for this study to be taken as clinically meaningful on the whole.

However, a thoughtful orthopedist must consider the facts in deciding what is best for his or her patient, including the reality that surgery is not right for everyone with knee (or joint) pain.

“Exercise therapy” is a real option for many conditions, with or without weight loss and medications.

Patients, especially athletically active ones  (including those in “middle age“) , want real pain relief. If such conservative measures don’t yield results, and surgery is clearly not the “go-to” option for everyone, what can we offer?

Austin Ortho+Biologics is a well-researched attempt to fill that gap with non-surgical but biologically active injectables to relieve joint and tissue pain. Platelet plasma (PRP) and stem cells, products carefully produced from a patient’s own body (“cell therapy“), and eventually allograft (placental and cord blood) cell products, may be the answer for less-invasive treatment of knee, shoulder and hip pain. These modalities are undergoing rigorous study and modification and are improving the lifestyle of many of my patients even as the treatment protocols evolve.

Point well-taken by articles such as this one that surgery is not always the best answer. As an orthopedic surgeon, I know there are times when arthroscopy is definitely warranted and provides superior results;  mild-to-moderate arthritic pain from activity may not be one of them.

Kelly Cunningham MD