Is the evidence-base for popular knee operations scandalously poor?
Orthopaedic surgeons and their patients will be disturbed to read that operations such as arthroscopic meniscal surgery and anterior cruciate ligament (ACL) reconstruction are of no proven benefit. (1)
In support of their argument, Lohmander and Roos present two studies published in the New England Journal of Medicine. (2, 3) These randomised controlled trials have been critically reviewed and their limitations highlighted. For example, from a cohort of patients avoiding ACL reconstruction, 39% defaulted and underwent surgery within only two years of incident injury. (4) And those deferring ACL reconstruction were also significantly more likely to need menisectomy over that period. (5)
Knee surgery is rarely mandatory for soft-tissue injury. Neither life nor limb is saved. The joint has evolved over millennia to survive trauma, albeit at the cost of the pain and dysfunction. Clinicians and patients have learned the hard way. Those returning to pivoting sport with unstable knees have a high risk of developing further meniscal injury, chondral damage and arthritis.(6)
In their article, Lohmander and Roos state that ‘clinical impressions can be deceiving’.
I believe it is good surgical practice to ask patients directly about outcome. ‘Was the operation worth it’?
Most usually say: ‘Yes doctor, my knee doesn’t hurt any more’ or ‘Yes, thanks, my knee is stable now’.
But the strongest endorsement for any surgeon is a patient returning with a symmetrical problem in the opposite knee, clearly satisfied with previous surgery. Such scenarios are common, often years after the first operation.
In an era obsessed with evidence-based practice, whose clinical impressions matter most, the doctor’s or the patient’s?
Jai Chitnavis MA MChir FRCS
Consultant Orthopaedic Surgeon
1. L Stefan Lohmander, Ewa M Roos. The evidence base for orthopaedics and sports medicine. Scandalously poor in parts. BMJ 2015;350:g7835.
2. Sihvonen R, Paavola M, Malmivaara A et al. Arthroscopic partial menisectomy versus sham surgery for a degenerative meniscal tear. N Engl J Med 2013;369:2515-2524.
3. Frobell RB, Roos EM, Roos HP, Ranstram J, Lohmader LS. A randomized trial of treatment for acute anterior cruciate ligament tears. N Engl J Med 2010;363:331-342.
4. Levy BA. Is early reconstruction necessary for all anterior cruciate ligament tears? N Engl J Med 2010;363;386-388.
5. Richmond JC, Lubowitz JH, Poehling GG. Prompt operative intervention reduces long-term osteoarthritis after knee anterior cruciate ligament tear. Arthroscopy 2011 Feb;27(2):149-152.
6. Sri-Ram K, Salmon LJ, Pinczewski LA, Roe JP. The incidence of secondary pathology after anterior cruciate ligament rupture in 5086 patients requiring ligament reconstruction. Bone Joint J 2013 Jan;95-B(1)59-64.
Competing interests: No competing interests