Routine knee arthroscopic surgery for the painful knee in middle-aged and old patients—time to abandon ship

Routine knee arthroscopic surgery for the painful knee in middle-aged and old patients—time to abandon ship Knee arthroscopic surgery is one of the most common orthope-dic procedures. Introduced in Scandinavia in the late 1970s, it replaced and improved earlier open knee procedures, changed most of them from inpatient surgery to outpatient surgery, and drastically cut patient recovery time. Earlier case reports of open surgery had suggested that in the presence of " degenera-tive " changes in the joint at the time of meniscectomy, patients improved—but less so than in the absence of such changes (Jackson 1968, Appel 1970). Subsequent reports, now using arthroscopic surgery, again suggested poorer results in patients with cartilage changes (Lysholm and Gillquist 1981, Northmore-Ball and Dandy 1982, Gillquist and Oretorp 1982, Hamberg and Gillquist 1984). In spite of these early reports, middle-aged and older patients with a painful knee and suspected meniscus or cartilage lesion have become by far the most common patient group to be treated with arthroscopic knee surgery. Thus, 3 out of 4 patients who are treated arthroscopically for suspected meniscus rupture, cartilage lesion, or osteoarthritis of the knee are reported to be older than 35, the typical patient being between 35 and 65 years old and most often in their early fif-It took some 20 years after the general introduction of knee arthroscopic surgery, with millions of patients treated, before the first randomized controlled trial was published (Moseley et al. 2002). This pivotal, double-blind trial compared 3 interventions: lavage, debridement, and sham surgery in patients (mean age 52 years) with knee osteoarthritis. All 3 study groups improved, with no significant difference between the 3 in the 2-year outcomes. To date, at least 8 additional ran-domized trials investigating the effect of debridement and/ or arthroscopic partial meniscectomy have been published some, or none of the patients included (with a mean age of between 50 and 63) had a diagnosis of knee osteoarthritis. All but 1 of these 9 trials of arthroscopic surgery in middle-aged or older people with persistent knee pain failed to show any added benefit of interventions including arthroscopic surgery over a variety of control treatments. 7 of the 9 trials were not run with blinding, and part of the observed inconsequential benefit may be explained by the more marked placebo effect of surgery compared to non-surgical interventions (Zhang et al. 2008, Bannuru et al. 2015). 2 trials were double-blinded and …