People are still getting arthroscopic knee surgery? Do they not watch Healthcare Triage? This is Healthcare Triage News.   (Intro)   OK, so back in our episode on surgical placebos, I discussed the use of sham (or fake) surgery, to test whether procedures actually make a difference in outcomes. One of the examples, and my all-time favorite, is arthroscopic surgery for osteoarthritis of the knee. Years ago, researchers randomized people with the condition to one of three arms. The first got arthroscopic surgery, the second got lavage, which is really sort of washing it out, and the third got sham surgery. There were NO significant differences between the three groups. Arthroscopic surgery performed no better than fake surgery.   A recent paper in the BMJ (British Medical Journal) goes a step further, it looks at ALL the research: “Arthroscopic surgery for degenerative knee systematic review and meta-analysis of benefits and harms.” The researchers looked at all randomized controlled trials published since 2000 that looked at arthroscopic knee surgery, including procedures that involved partial meniscectomy or debridement. They also included cases with and without radiographic signs of osteoarthritis. They found nine trials involving 1270 patients. The first outcome, overall pain, showed a statistically significant difference from three months to two years after surgery. But the actual difference was really small. Imagine if you asked people to rate their pain on a 100-point scale. The difference between the two groups was equivalent to a 2.4 difference on that scale. It’s hard to argue that’s a meaningful enough difference to justify surgery.   But that was only looking at people after the procedures. If you looked at the differences between people themselves before and after the real or fake surgery, then there were only statistically significant differences at three and six months. Yes, still barely clinically meaningful, but they weren’t even statistically significant by one year. If you looked at physical functioning, there were no differences period. None. Not at any point in time from three months to two years.   And of course there are harms! These included, for instance, symptomatic deep venous thrombosis, or clots following surgery, which occurred in about 4 times in every 1000 procedures. Less common, but still real, were pulmonary embolism, infection, and death, which occurs in about 1 per 1000 procedures.   So this meta-analysis tells us that there are small and likely inconsequential benefits from arthroscopic knee surgery. AND significant and real potential harms. So, who gets this surgery? Lots and lots of people. The accompanying editorial reports that more than 700,000 of these are done in the United States each year. Another 150,000 of them are done in the UK.   Surgeons swear by them. The editors of the journal “Arthroscopy” said, and I’m quoting, “The New England Journal of Medicine is biased against knee surgery.” Others said that patients who take part in placebo-controlled trials, and again I’m quoting them, “may not be of entirely sound mind,” and that “ethically, sham surgery is a questionable research method, which may be harmful.” The editorial also contains this quote from Leo Tolstoy, who was on point in 1899:   “I know that most men, not only those considered clever, but even those who are very clever, and capable of understanding most difficult scientific, mathematical, or philosophic problems can very seldom discern even the simplest and most obvious truth if it be such as to oblige them to admit the falsity of conclusions they have formed, perhaps with much difficulty conclusions of which they are proud, which they have taught to others, and on which they have built their lives.”   It’s not just that there’s money to be made here, and there is. It’s not just that they see patients getting better after arthroscopic surgery, ‘cause they do. It’s also that many might be unable to see the results of the trials for what they are, because they go against everything that many surgeons believe, have been proud of, and have taught to others.   Healthcare triage is supported in part by viewers like you through P, a service that allows you to support the show through a monthly donation. We’d like to thank all our Patreon supporters in general, and thank our honorary research associate Cameron Alexander, specifically. Thanks Cameron! Learn how you can become a patron at patreon.com/healthcaretriage.