July 2012

Arthroscopy attrition: 2002 study changes practice patterns

In the moment: Knee OA

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By Samantha Rosenblum

The number of knee arthroscopy proce­dures performed in patients with osteo­arthritis (OA) has greatly decreased since the 2002 publication of a high profile New England Journal of Medicine study that questioned the procedure’s effectiveness, according to research from the Cleveland Clinic in Cleveland, OH.

The Cleveland Clinic investigators explored the American Board of Orthopaedic Surgery database of six-month case logs for examinees sitting for Part II of the board examination between 1999 and 2009. They found a decline in the overall number of knee arthroscopies as well as a decline in the number of procedures performed for OA following publication of the 2002 study. The findings were published in the June issue of the American Journal of Sports Medicine.

“We thought that most orthopedic surgeons would be aware of this study’s results because of the broad and sustained media coverage that it received, so this was a best-case scenario for being able to see an impact on practice patterns,” said Morgan Jones, MD, MPH, an author of the current study and a staff physician at the Cleveland Clinic’s Center for Sports Health.

The 2002 study, conducted at the Houston Veterans Affairs Medical Center, was notable for its randomized placebo-controlled design utilizing a sham procedure in the control group.

“If a procedure is done primarily to improve a patient’s subjective symptoms, then to know whether that improvement is greater than the placebo effect or is simply due to a place­bo effect, one must do a placebo-controlled study,” said Nelda Wray, MD, MPH, an author of the study and senior member of the Methodist Hospital Research Institute in Houston.

Wray said the researchers did not expect such a rapid response from orthopedic surgeons when the study was first published; however, they were not entirely surprised that clinicians appreciated the high level of evidence.

“Our study was a very methodologically correct study,” Wray said. “Anyone who understands study design has to be concerned that the findings are solid.”

The Cleveland Clinic study data were limited to surgeons preparing for their board exams and whose practice patterns may not necessarily reflect those of more experienced surgeons.

“The surgeons submitting their case lists know that their behavior will be scrutinized during the oral board examinations, so we expected them to be more likely to limit the number of arthroscopic procedures that they performed on patients with arthritic knees,” Jones said. “In addition to not needing to worry about the board exams, more seasoned orthopedic surgeons probably have decided that the procedure is effective based on their anecdotal personal experiences.”

Even the board examinees are still performing arthroscopy in some OA patients, however. According to the research, knee arthroscopy as a percentage of total cases decreased to a low of 6.7% by 2009, while knee arthroscopy cases with an associated OA diagnosis settled around 16.3% of all total cases.

The procedure might still be relevant in certain situations, Jones said.

“For example, a patient with a locked knee that won’t fully straighten because of the entrapment of meniscus or cartilage tissue or a loose body,” he said.

Wray maintained that, based on the 2002 findings, knee arthroscopy should not be done on patients with knee OA. She noted that since her study excluded patients with evidence of meniscal tear on magnetic resonance imaging, such patients could still be candidates for the procedure.

“However,” she clarified, “I of course believe, with the strong evidence of a placebo effect from this procedure, that instead of just performing arthroscopic surgery on these [menis­cal tear] patients, we should enter them into a randomized trial to determine if in fact the benefit is any greater than the placebo.”

Sources:

Potts A, Harrast J, Harner C, et al. Practice patterns for arthroscopy of osteoarthritis of the knee in the United States. Am J Sports Med 2012;40(6): 1247-1251.

Moseley J, O’Malley K, Petersen N, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med 2002;347(2):81-88.

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