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Sham Knee Surgery Just As Good As The Real Thing

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It will come as a huge shock to both orthopedic surgeons and their patients to learn that a pretend surgical procedure was just as good as "arthroscopic partial meniscectomy" for meniscal tears. The results of the study were published in the New England Journal of Medicine (Dec. 26, 2013) and will no doubt create controversy and confusion.

This is not rare surgery. Roughly 700,000 people have this kind of arthroscopic knee surgery each year in the U.S. to repair tears in their meniscus. The cost is estimated to be around $4 billion annually.

When the meniscus is injured, it can produce pain, stiffness and reduced range of motion in the knee. Surgery is also intended to clear away debris and fragments of cartilage that are thought to contribute to degenerative knee discomfort.

The Finnish researchers who conducted this rigorous knee surgery study pointed out, however, that "rigorous evidence of its efficacy is lacking." The surgeons recruited patients between 2007 and 2013. They were fully informed that they might be randomized to either sham surgery or the real thing and all granted their approval. A total of 146 patients participated (70 received the real surgery and 76 were assigned to the sham surgery). During the fake surgery the patients were treated exactly the same as if they had the real thing without actually having their meniscus trimmed or having cartilage fragments removed.

The results were astounding. The authors concluded:

"This multicenter, randomized, sham-controlled trial involving patients with a degenerative medial meniscus tear showed that arthroscopic partial meniscectomy was not superior to sham surgery, with regard to outcomes assessed during a 12-month follow-up period. Although both groups had significant improvement in all primary outcomes, the patients assigned to arthroscopic partial meniscectomy had no greater improvement than those assigned to sham surgery."

There will no doubt be a great hue and cry from the orthopedic medical community and from patients who have undergone this procedure. After all, $4 billion is a lot of money. But optimized physical and medical therapy has been shown in other trials to be just as good as surgical interventions

Surgeons are not used to placebo-controlled trials. The idea of fake surgery seems seriously unethical. Nevertheless, it is the only way to tell whether a particular procedure is better than nothing at all. Perhaps the most famous sham surgery of all time was reported in the New England Journal of Medicine in 1959 by cardiologist Leonard Cobb, MD and colleagues.

The story actually got its start in 1939 when an Italian surgeon named David Fieschi began treating patients with heart disease and chest pain using a technique called mammary artery ligation. He created a hole in the chest wall and tied off an important artery now called the internal thoracic artery (previously the internal mammary artery). Dr. Fieschi thought that by tying a knot in this artery he could create collateral circulation that would improve blood flow to the heart and reduce chest pain (angina). His results were spectacular! He reported that about 75% of his patients improved and one third were actually cured of their heart disease.

Not surprisingly, heart surgeons around the world quickly adopted Dr. Fieschi's technique. Within 20 years tying a knot in the internal mammary artery was a mainstream procedure for dealing with the pain of angina and doctors reported success in up to 85% of patients.

This surgical approach crashed and burned on May 28, 1959. That's when surgeons in Seattle and Kansas City reported the results of their sham surgery. Two groups of angina patients were divvied up. All received general anesthesia and an incision in the chest wall. One group got the standard knots in their arteries while the other group was sewn shut without any actual procedure being performed. To everyone's shock, the sham surgery produced better results than the real surgery. Some patients reported "striking improvement in exercise tolerance" after the fake surgery. Even more amazing were the long-lasting benefits of the sham surgery for some patients:

"The degree of improvement in some cases was extraordinary. One patient (Case 4), who had been unable to work because of his heart disease, was almost immediately rehabilitated and was able to return to his former occupation. He reported a 100 percent improvement at six months and 75 percent improvement after a year. His arteries were not ligated [tied off]."

http://www.nejm.org/doi/full/10.1056/NEJM195905282602204

What is the Take Home Message?

The power of the human mind to help heal the body is poorly understood and has barely been tapped. Physicians often scoff at home remedies as placebos. And yet we have no idea how many prescribed medications and surgical procedures are working in part through a similar mechanism. It is apparent from the research just published in the New England Journal of Medicine that arthroscopic knee surgery for a torn meniscus may need to be reevaluated for many patients. The authors of the current study noted,

"In conclusion, the results of this randomized, sham-controlled trial show that arthroscopic partial medial meniscectomy provides no significant benefit over sham surgery in patients with a degenerative meniscal tear and no knee osteoarthritis. These results argue against the current practice of performing arthroscopic partial meniscectomy in patients with a degenerative meniscal tear."

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Knee braces work very well for some knee injuries. I have used them a few times, until my painful knees healed.

I had a Menicus tear and was treated with approx 6 weeks of PT at a facility and continued at home... all at the suggestion of a Orthopedic surgeon because of my age... and his mother got along fine with out surgery and he advised this... I will always be grateful as I did better than a friend that had the surgery.

In 2001, I tore the menisci of both knees. Arthroscopic surgery was performed on both sides of my left knee. The lateral meniscus on my right knee was also torn, but not repaired.

After 12 years, the results are the same: bone on bone for both
knees, so the repair (and expense) accomplished nothing.

The medial on left knee tore again last year. I am able to walk due to exercises (from the PT) and Voltaren. I am avoiding knee replacement as long as I can.

Had two types of surgery for torn ligament. The first for a minor tear was arthroscopy. Cost of out patient surgery $6000 (that was without anesthesia bill, as a relative did the anesthesia). Took weeks and weeks to get back to normal. Second was a horrible tear that I had to hold treatment/surgery off on due to moving, but was unable to walk (and only on one leg) without crutches and swelling of knee and lower leg did not abate. Went to a naturopath, had prolotherapy done for $95, was walking the next day, and walking normally the day after that. Never again will I have arthroscopy for a torn ligament, prolotherapy it is.

I had acupuncture for the severe pain caused by my torn meniscus. It was very successful within a number of weeks.

I had acupuncture for the severe pain caused by my torn meniscus. It was very successful within a number of weeks.

well i guess i will leave my 'baby' tear alone...

i had the real surgery for a tear about 4 years ago after 6 weeks of therapy did not provide relief. i wear a knee brace on the 'bad' days but can no longer run so i walk and bike instead.

I know that there are a lot of confusion regarding our health care and medicines, etc. I had arthroscopy surgery years ago and walked out of the hospital that same day.

I've had no problems. I guess what I am trying to say is that we must be careful and weigh all options before any surgical procedure. Then when I developed shoulder discomfort my surgeon sent me to PT versus surgery. I guess I was lucky that I found a good orthopedic surgeon.

there is also prolotherapy available for other types of knee disorders that in the past required the patients to have a knee replacement. It's not for every case and varies with the condition of the knee-but many people have had great success-your orthopedic doctors do not do this procedure-it is mostly very specialized D.O.'s

4 years ago I suffered excruciating acute pain after putting sudden strain on my knee which was somewhat swollen and hurting after a bad bump several days previous. I was sent to an orthopedist who diagnosed me as having torn the meniscus and he recommended arthroscopic surgery, immediately. I demurred, having heard that sometimes these tears can best be treated with PT. The doctor reluctantly agreed to prescribe 6 weeks of PT, along with the warning that I'd be back for surgery.

Well… no. The Physical Therapist, unlike the doctor, told me that no harm would be done by waiting on surgery and he immediately started me on a full restorative program, including getting me on a stationary bike and other knee supportive exercises to strengthen the supporting muscles. Within a week I was walking without crutches, by the end of the 6 weeks, I was biking a dozen miles a session and had almost no pain. Needless to say, on my follow up visit to the orthopedist, I told him no thanks, I would not have the surgery unless my knee function deteriorated.

Today, I can bike and walk totally pain or knee weakness free, without ever having any surgery. I often bike up to 40 miles a trip. I am 70. I thank the PT for sparing me the expense and trouble of un-necessary surgery. He, not the surgeon, was concerned with my well being and recovery.

After a knee injury, I was told I needed surgery for a torn medial meniscus. I asked for an MRI to confirm this. His answer, "You don't need an MRI, I know the symptoms." He scheduled me for surgery in two weeks, and put me in a long leg brace; groin to ankle, which relieved the pain.

I wanted a second opinion. A Dr. who no longer did surgery was recommended. Saw her two days later, she did the MRI, the radiologist read it and: No sign of torn medial meniscus. I wore the brace for a month at new Dr.'s suggestion. Swelling and pain totally gone. That was 8 years ago. I'm 73 now and the knee has never given me any more trouble. When I asked her what the first orthopedist would have done to me if I had had the surgery he scheduled me for. She replied, "He would have scraped around in there and you would have been worse off then you were"! Wasn't I lucky to get the second opinion from such a nice Dr.?

I have had MANY injuries to both knees, including breaking each of them across the ball and socket joint, which did necessitate surgery. I've also had many soft-tissue injuries, like tearing various ligaments, sinews and tendons. After the latest one, my knee would intermittently swell up to nearly the size of a basketball (with much pain!) and stay that way for a couple of days, then finally go down again as I treated it very aggressively with anti-inflammatories both topical and oral, and wrapped it tightly. I've never had health insurance so I have treated most injuries myself without consulting a dr.

I've always assumed everything will turn out OK so it did! But just to be safe I've also taken lots of hyaluronic acid and krill oil to lubricate the joints from the inside, and also started speedwalking about 3 miles most days. NOW, my knees are better than ever! And, at 66yo, I'm skiing the double-diamonds quite aggressively. ALSO, the grape juice n' Certo and the gin-soaked raisins have really helped too. Don't get that surgery! It isn't worth it. Harness the power of your mind and natural remedies and the knees will come around.

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