Canadian Institutes of Health Research
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Think Twice Before You Cut
A group of Ontario orthopedic surgeons asked the unorthodox question: what if surgery didn't make arthritis of the knee any better?
At a Glance
Who - Bob Litchfield is the medical director at the Fowler Kennedy Sport Medicine Clinic and an orthopedic surgeon.
Issue - Arthroscopic knee surgery sends a small endoscope through a hole in the knee to smooth rough edges and pull out flecks of floating cartilage. But, does this really improve osteoarthritis?
Solution - Following a large group of patients for up to two years, Litchfield and his colleagues found that there was no difference between those patients who received surgery and those who just underwent normal rehabilitative therapy and lifestyle changes.
Impact - While the group believes there are still instances where surgery is justified, they are also hoping to encourage orthopedic surgeons to consider non-operative therapies before cutting in.
About half of all Canadians will deal with arthritis of the knee whether because of age or injury, and arthroscopic knee surgery to remove small torn bits of cartilage or smooth rough edges of the joint surface have been the standard treatment for osteoarthritis. However, research at the University of Western Ontario has produced evidence that has completely altered traditional treatment strategies for this condition.
Based on preliminary research done on veterans undergoing knee surgery, UWO's Fowler Kennedy Sport Medicine Clinic decided to launch a major investigation. "A lot of what we do in medicine and certainly surgery are really techniques and thought processes that are handed down over the years, and when you look back you realize there isn't great evidence to support some of the operations we do," said Dr. Bob Litchfield, medical director at the Fowler Kennedy Clinic and an orthopedic surgeon.
The group did a randomized controlled trial where 200 patients received therapy and education, but only half the patients received surgery first. Then they followed the patients' recovery over a two-year period.
At three months time, the normal point for a follow up visit with a surgeon, the surgery group appeared to have a greater recovery. However, Litchfield suspected that this initial response to surgery was likely explained by a placebo effect.
"It's sort of an intuitive thing if there's areas of flaps of cartilage or pieces floating around by removing those pieces we maybe change some of the mechanical symptoms where people complain of catching and locking," said Litchfield. "Every orthopedic surgeon felt strongly that we were helping patients, but one of the problems with busy surgeons is we would probably follow a patient for only about 3 months. When you put it to the scientific test and follow these patients longer, you realize you really could have achieved the same result with an optimized non-operative program."
Every time they measured patient health and response to treatment up to two years later, they could find no difference between those who received surgery and those who didn't. The fact that surgery did not provide major benefits was shocking, and when the results of the study were published in the New England Journal of Medicine in September 2008 it prompted huge debate.
"Sometimes with surgeons it's easier to operate than to guide patientsthrough a non-operative program. It's what we do and we like doing it and we believe in it, but sometimes some of the non-operative modalities get forgotten. So hopefully this study will encourage people to think about those options again," said Litchfield.
For his part, Litchfield has been practicing what the research evidence has taught him. In cases where he would have done surgery before, now he says he is much more likely to discuss this study with the patient and try other treatments first. And, if he does need to perform surgery, it is not just to remove debris, but to actually realign the ligament or replace cartilage.
