Uh-oh. More woo?

[pnwmom]

http://www.nytimes.com/2013/12/26/health/common-knee-surgery-does-very-little-for-some-study-suggests.html?hp

A popular surgical procedure worked no better than fake operations in helping people with one type of common knee problem, suggesting that thousands of people may be undergoing unnecessary surgery, a new study in The New England Journal of Medicine reports.

The unusual study involved people with a torn meniscus, crescent-shaped cartilage that helps cushion and stabilize knees. Arthroscopic surgery on the meniscus is the most common orthopedic procedure in the United States, performed, the study said, about 700,000 times a year at an estimated cost of $4 billion.

The study, conducted in Finland, involved a small subset of meniscal tears. But experts, including some orthopedic surgeons, said the study added to other recent research suggesting that meniscal surgery should be aimed at a narrower group of patients; that for many, options like physical therapy may be as good.

SNIP

The Finnish study does not indicate that surgery never helps; there is consensus that it should be performed in some circumstances, especially for younger patients and for tears from acute sports injuries. But about 80 percent of tears develop from wear and aging, and some researchers believe surgery in those cases should be significantly limited.

SNIP

_______________________________

This very commonly practiced knee surgery has been performed, without scientific evidence showing that it works for most people, for almost one hundred years.

http://en.wikipedia.org/wiki/Arthroscopic

Professor Kenji Takagi in Tokyo has traditionally been credited for performing the first arthroscopic examination of the knee joint of a patient in 1919. He used a 7.3 mm cystoscope for his first arthroscopies. Recently it has been discovered that the Danish physician Severin Nordentoft reported on arthroscopies of the knee joint as early as 1912 at the Proceedings of the 4lst Congress of the German Society of Surgeons at Berlin.[1] He baptized the procedure (in Latin) arthroscopia genu. Nordentoft used sterile saline or boric acid solution as his optic media and entered the joint by a portal on the outer border of the patella. However, it is not clear if these examinations were anatomic studies of deceased or of living patients.

Pioneering work in the field of arthroscopy began as early as the 1920s with the work of Eugen Bircher.[2] Bircher published several papers in the 1920s about his use of arthroscopy of the knee for diagnostic purposes.[2] After diagnosing torn tissue through arthroscopy, Bircher used open surgery to remove or repair the damaged tissue. Initially, he used an electric Jacobaeus thoracolaparoscope for his diagnostic procedures, which produced a dim view of the joint. Later, he developed a double-contrast approach to improve visibility.[3] Bircher gave up endoscopy in 1930, and his work was largely neglected for several decades.

While Bircher is often considered the inventor of arthroscopy of the knee,[4] the Japanese surgeon Masaki Watanabe, MD, receives primary credit for using arthroscopy for interventional surgery.[5][6] Watanabe was inspired by the work and teaching of Dr Richard O'Connor. Later, Dr. Heshmat Shahriaree began experimenting with ways to excise fragments of menisci.[7]

The first operating arthroscope was jointly designed by these men, and they worked together to produce the first high-quality color intraarticular photography.[8] The field benefited significantly from technological advances, particularly advances in flexible fiber optics during the 1970s and 1980s.

[BlueStreak]

1. That becomes a catch-all diagnosis

like "autism" or "ADD".

I developed a looseness in one of my knee joints a few years ago and it was causing pain. I saw an orthopedic Doc. He felt it for about 15 seconds and said "Hmmm, looks like you have a torn meniscus. We'll probably need to operate."

I was shocked that he was so quick to make such a judgment without even taking any X-rays or MRIs and not really even asking me how I did it and what the symptoms were like.

I thought this was bogus. I was pretty sure the problem was looseness, not turn cartilage. I'm no doctor, but I would have thought the looseness was more likely a stretched tendon or something. He asked me to get an MRI before deciding on surgery. I would have insisted on nothing less anyway. But I decided that this sounded like a medical scam, so I gave it a two week rest and another 3 weeks with a good support brace, then worked on strengthening exercises. This solved the problem.

[hootinholler]

2. More evidence as to why it's called a practice n/t

[nadinbrzezinski]

3. From personal experience, possible

I got therapy not surgery, the last time. The reason is another story, but it worked.

[KT2000]

4. How could it be wooooo?

I bet there are a ton of journal articles about the need for surgery on a torn meniscus. That means it is science, right?

Thanks for the woo catch

[Barack_America]

5. Woo? This is medical science checking itself via evidence-based medicine.

Pretty much the exact opposite of woo.

[pnwmom]

7. Took them long enough. They've been doing this for more than 11 years

since the first 2002 study showed that it didn't seem to help.

And doctors had actually begun to do the procedure much earlier; that's why they finally decided to study it.

From the link at the OP:

"The new research builds on a groundbreaking 2002 Texas study, showing that patients receiving arthroscopy for knee osteoarthritis fared no better than those receiving sham surgery. A 2008 Canadian study found that patients undergoing surgery for knee arthritis did no better than those having physical therapy and taking medication. Now many surgeons have stopped operating on patients with only knee arthritis."

[Humanist_Activist]

8. You do realize that more than one study was required? Why do you require science...

to work literal miracles, or for the theories and practices that result to be infallible?

[pnwmom]

11. There have been multiple studies, done years apart. They certainly weren't in

any hurry to confirm the results.

Based on the 2002 study Medicare stopped paying for the procedure in 2003 but doctors continue to do it, despite the confirming study in 2008. So much for "evidence based medicine."

From the link in the OP:

"A popular surgical procedure worked no better than fake operations in helping people with one type of common knee problem, suggesting that thousands of people may be undergoing unnecessary surgery, a new study in The New England Journal of Medicine reports."

"Arthroscopic surgery on the meniscus is the most common orthopedic procedure in the United States, performed, the study said, about 700,000 times a year at an estimated cost of $4 billion."

From an article 5 years ago:

http://www.nytimes.com/2008/09/11/health/research/11knee.html

The results of the study are in line with those from a study published in 2002. But experts are divided about what effects the two studies will have.

Some say the new study just confirms what they already knew. Others say they hope that doctors who did not believe the 2002 study will be persuaded by this one to stop doing the operations.

The 2002 study, by the Department of Veterans Affairs, had a different design: instead of assigning patients to surgery or medical treatment, it assigned them to real surgery or a sham operation. The real surgery was found to be no better than the sham one.

SNIP

“If it doesn’t change care, it speaks poorly for the medical community’s willingness to take evidence into account,” Dr. Felson said.

[Humanist_Activist]

35. Again, you expect results practically instantly, instant consensus, and instant change...

of practice of every doctor on the planet, apparently, yet you trust alternative "medicine" based on nothing but faith, so my question, again, is why the different standards?

[pnwmom]

36. When a procedure has been done for almost 100 years without any proof

that it works for most people, I don't know how anyone can call it an example of evidence-based medicine. And when studies showing it doesn't work for most were done 11 years ago and 5 years ago, I don't see why expecting a response to these studies means I expect "instant" change.

Concerning alternative medicine, I don't trust alternative medicine in general; but I have linked to Bastyr University, where they conduct research along with M.D.'s and MPH people from the University of Washington and the Fred Hutchinson Cancer Research Center, among other institutions. I don't trust everything they do either, preferring to consider specific research and researchers, as I usually do with medical research

http://en.wikipedia.org/wiki/Arthroscopic

Professor Kenji Takagi in Tokyo has traditionally been credited for performing the first arthroscopic examination of the knee joint of a patient in 1919. He used a 7.3 mm cystoscope for his first arthroscopies. Recently it has been discovered that the Danish physician Severin Nordentoft reported on arthroscopies of the knee joint as early as 1912 at the Proceedings of the 4lst Congress of the German Society of Surgeons at Berlin.[1] He baptized the procedure (in Latin) arthroscopia genu. Nordentoft used sterile saline or boric acid solution as his optic media and entered the joint by a portal on the outer border of the patella. However, it is not clear if these examinations were anatomic studies of deceased or of living patients.

Pioneering work in the field of arthroscopy began as early as the 1920s with the work of Eugen Bircher.[2] Bircher published several papers in the 1920s about his use of arthroscopy of the knee for diagnostic purposes.[2] After diagnosing torn tissue through arthroscopy, Bircher used open surgery to remove or repair the damaged tissue. Initially, he used an electric Jacobaeus thoracolaparoscope for his diagnostic procedures, which produced a dim view of the joint. Later, he developed a double-contrast approach to improve visibility.[3] Bircher gave up endoscopy in 1930, and his work was largely neglected for several decades.
While Bircher is often considered the inventor of arthroscopy of the knee,[4] the Japanese surgeon Masaki Watanabe, MD, receives primary credit for using arthroscopy for interventional surgery.[5][6] Watanabe was inspired by the work and teaching of Dr Richard O'Connor. Later, Dr. Heshmat Shahriaree began experimenting with ways to excise fragments of menisci.[7]

The first operating arthroscope was jointly designed by these men, and they worked together to produce the first high-quality color intraarticular photography.[8] The field benefited significantly from technological advances, particularly advances in flexible fiber optics during the 1970s and 1980s.
.

[Nevernose]

49. Coincidentally, the fact that something has been practiced for a long time

Is frequently cited as one of the ways we know that woo "works." Traditional Chinese Medicine, acupuncture, sweat lodges, most herb lore: all stuff that people claim works because it has been practiced for a long time, yet despite thousands of studies has been shown not to work.

[pnwmom]

50. That's not true with regard to acupuncture. Unless Harvard researchers

and the Archives of Internal Medicine are guilty of woo, too.

http://www.health.harvard.edu/blog/acupuncture-is-worth-a-try-for-chronic-pain-201304016042

Over the years there has been substantial debate about whether acupuncture really works for chronic pain. Research from an international team of experts adds to the evidence that it does provide real relief from common forms of pain. The team pooled the results of 29 studies involving nearly 18,000 participants. Some had acupuncture, some had “sham” acupuncture, and some didn’t have acupuncture at all. Overall, acupuncture relieved pain by about 50%. The results were published in Archives of Internal Medicine.

The study isn’t the last word on the issue, but it is one of the best quality studies to date and has made an impression.

“I think the benefit of acupuncture is clear, and the complications and potential adverse effects of acupuncture are low compared with medication,” says Dr. Lucy Chen, a board-certified anesthesiologist, specialist in pain medicine, and practicing acupuncturist at Harvard-affiliated Massachusetts General Hospital.

[Barack_America]

26. Entrenched procedures are the hardest to convince physicians and patients about.

Been keeping tabs on the furor regarding yearly Pap smears and mammograms? Recent studies clearly demonstrate we had been doing them too frequently, but there has been a downright mutiny by some physicians and patients about giving them up. So the studies continue, and continue...

For arthroscopy, there are tons of physicians trained to do the procedure and tons of patients demanding it. I will tell you right now that even this current study won't be the end of arthroscopy for meniscal tears.

[RandiFan1290]

9. They just like to type the word 'woo'

[bluesbassman]

6. That's not woo, it's malpractice.

If one really has a torn meniscus, physical therapy is not going to make it go away. OTH, cutting into an injured knee that only requirers physical therapy is not woo, it's malpractice, aided and abetted by the insurance companies.

[hobbit709]

10. It certainly worked for one of my best friends. She's back to dancing when before she could

hardly walk.

[pnwmom]

12. The question is what kind of tear she had and whether

physical therapy could have been enough.

Some people -- a small minority -- do benefit more from the surgery.

[hobbit709]

13. She had TWO torn meniscus and she did physical therapy for 3 months and it got worse

One month after the surgery, she was back to dancing.

[pnwmom]

15. That's great for her. But the research shows that about 80% of the time

the problem is due to normal wear and tear, and that's less likely to benefit from the procedure.

[hobbit709]

17. So citing one study(with narrowly defined limits) and referring to a noncited source is science.

[pnwmom]

18. I gave links to articles about 2 studies, ones in 2002 and 2008.

And the 2002 study was considered significant enough that Medicare stopped paying for the procedure in 2003.

So why are doctors still doing so many of the procedures? If it's a question of not enough studies, then why haven't more studies been done? Are they reluctant to have the results confirmed yet again?

[adirondacker]

14. I had meniscus surgery after over a year of PT and chronic pain.

My physician and orthopedic surgeon were very conservative with diagnosis and treatment. I finally gave in to my surgeon's request to have it scoped after I fell in to a bunch of cholla cactus hiking down a slope in Death Valley. I was awake for the surgery and my meniscus was frayed into about 30 pieces. Once removed, I was mountain biking three days later. I have a bit of arthritis in it now (15 years later) but I don't regret having had the surgery.

I'm Still waiting for them to culture the cartilage for a replacement, like they've already done for race horses two decades ago, but I'm not holding my breath. Probably too busy developing new drugs like Viox.

[pnwmom]

16. My sister also benefited from the procedure. But my husband

decided to wait, and his knee got better with physical therapy. And that was about 12 years ago.

[adirondacker]

21. I injured my knee while doing commercial floor tiling during college.

The work was extremely strenuous considering we were doing schools, banks and your Capitol's floor. It was a two man show with constant heavy lifting and kneeling (we did everything from mud work to finish). The repetitiveness is what more than likely wore it out, along with a high pronation to start with.

I can believe that a "simple" tear could heal itself over caution and time, but after seeing what mine looked like, there was no question I wanted it out. It may have dissolved in a matter of another year, but the surgery was quick and easy to go through. The large problem with dx is that Xrays and MRI's can't detect the cartilage very well, and in my case, neither indicated a problem. That was why I was reluctant to undergo an orthoscopy early on, against the surgeon's advice.

I was thankful that my ex girlfriend convinced me to get medical insurance through the WA state program at the time for the whopping cost of $10.00/ month (what happened?), since I wasn't about to claim a workman's comp case on a private individual.

I tend to be conservative on the necessity of surgery, but it does reach a point when holistic and "natural" treatment doesn't do much good, and prolonging agony isn't a wise choice in the long run. I have a bigger problem with the woo of pharmaceuticals and "there's a pill for that" attitude of some practitioners like my Mom's geriatric physician. I've had constant arguments with him pushing drugs on her. Specifically Nemenda and Aricept which are Nothing But woo and are costly as all getout. He also prescribed antidepressants which only made her more anxious. She's now drug free with the exception of occasional aspirin, and is in a pleasant, and fairly happy state.

[MannyGoldstein]

19. Orthopedic surgeons make big, big, big money

Huge.

This procedure will not be stopped.

[adirondacker]

23. I blame Boomers and their lust for ings!

Hiking, Biking, Skiing, Snowboarding, Surfing. And Roofing and Tiling for us poor suckers.

There was an article I read on this a while back. I'll try and locate it later.

[Orrex]

20. This is how science works, and it's a great strength.

If a technique or a theory of actual medicine is found to be in error, it is revised or abandoned. Contrast that with alternative medicine, wherein a debunked practice is defended with cries of suppression and Big Pharma conspiracy.

Proponents of alternative medicine suddenly become amazing critical thinkers when they hear about a faulty practice of actual medicine. They would do well to cast that same critical gaze upon the dubious treatments for which they advocate so passionately.

[msanthrope]

22. And....this. nt

[PasadenaTrudy]

24. Like this crap...

http://sanctuaryofwellness.com/wellness_topics/c_744_wellness_store.html

I knew this guy when we were teens. He was a dancer with the Alvin Ailey Dance Co. He went on to become a chiropractor. Too funny--he's black, Jewish, a chiro., and a Republican...voted for Bush and McCain...and he's into this new age crap. All about the $$$..

[pnwmom]

30. But it has NOT been "revised or abandoned." Quite the opposite.

So how is this a great strength again? Or scientific? As long as the studies are done, it doesn't matter if anyone actually pays attention to them?

The procedure was found not to be helpful for most patients eleven years ago and Medicare stopped paying for it, but doctors kept doing it; and another study showed the same thing five years ago; and yet there's no indication that even the current study will stop doctors from performing the most popular knee surgery there is.

[Orrex]

31. What are you suggesting? That they should turn on a dime?

Should an entire procedure be abandoned because of a small study that "involved a small subset of meniscal tears?"

Further study is merited. If this further study demonstrates that the procedure should not be undertaken, then the consensus will adapt to reflect this. That's entirely consistent with what I wrote, and the point stands.



For comparison, please provide us a list of alternative medicine treatments that have been abandonded because of advances in the field of alternative medicine. Go ahead, I'll wait.

[pnwmom]

32. This is the third study. Since it's such a popular procedure,

why haven't there been others, if they are necessary? I'm not suggesting they "turn on a dime," but it has been eleven years since the first study. And the procedure was performed for years without the benefit of any study showing that it worked at all.

[Orrex]

33. So that makes it woo, in your estimation?

Still waiting for that list.

[pnwmom]

37. If you will read the OP, you will note

the question mark.

The knee surgery has been performed by surgeons -- without science-based evidence -- for almost a hundred years, so I'm sure there have been plenty of special "tonics" discarded by the alternative medicine people in that time frame, although I'm not going to bother looking for their names.

But some, for instance, were said to include what are now illegal or highly regulated drugs in their recipes. I'm sure you've heard about that.

And then there are others, like aspirin, that were used in alternative medicine preparations and then developed by the conventional medical community.

There wasn't such a bright line between alternative and conventional medicine in the past as there is now.

[Orrex]

38. About that list...

Were those alternative medicines rejected because of advances in alternative medicine, or because actual science and actual law stepped in to outlaw their toxic ingredients and/or fraudulent claims? If the latter, then you really need to admit that alternative medicine has no actual interest in advancing knowledge or understanding.

There wasn't such a bright line between alternative and conventional medicine in the past as there is now.

That's all the argument one needs to conclude that we are, indeed, advancing. The more we stamp out those superstitious quack practices, the better.

That's true of both failed actual medicine and failed alternative medicine. The difference is that actual medicine acknowledges its failures, as much as you like to think/pretend otherwise.

[pnwmom]

39. The knee surgeons haven't acknowledged anything, although Medicare

called for them to drop the procedure in 2003, and other researchers called for this in 2008. There is no assurance at all that the latest study will cause any surgeon to drop the procedure, much less "acknowledge its failure."

[Orrex]

40. In that case, those surgeons are in the wrong.

And their continued use of the procedure is likely unethical at the very least.

See how that works? Science (and an advocate for science) criticize faulty practitioners of science and do so on the basis of science. Find me all of the alternative medicine practitioners who criticize faulty practitioners of alternative medicine and who do so on the basis of the tenets of alternative medicine.

[pnwmom]

41. The tenets of Bastyr University call for evidenced-based medicine,

which is why they have had a research program since the late 1980's, a research program that is conducted along with conventional practitioners and supported in part by NIH funds.

http://www.bastyr.edu/research/studies

[Orrex]

42. Great. And when the results are peer reviewed and confirmed, they'll be accepted.

That's how science works, see?

The reason that so much of alt med is bullshit is that it relies on utterly non-verifiable, mystical thinking (reiki & other "energy healing," for example.

If a practice/procedure can be tested and shown to be effective, then it graduates from the hocus pocus of alt med into the world of actual science and actual medicine.

[pnwmom]

43. Cute. So when naturopaths prove the value of a therapy through research,

then it is automatically deemed to be part of conventional medicine as opposed to alternative -- so you can always and forever discount anything naturopaths do that is proven effective, because then it is part of "actual medicine," not naturopathy. Very clever, but I'm not buying.

No, when their practices are proven effective through research they will not "graduate" anywhere. They will be remain/become (depending on the situation) part of the tools naturopaths use, which may then be adopted by some conventional practitioners.

[Orrex]

45. It's great praise, in fact. Why would you wish otherwise?

Would you prefer that your favored technique or practice stay in the same heap as ear candling and therapeutic urine-drinking? Why wouldn't you want a procedure to be recognized for its value?


The reason, it seems, is that you want it both ways; you want alternative medicine to be accepted as true and viable. Well, there's already a term for medical principles that are found to be true and viable: they call it conventional medicine.

You might even prefer to call it by one of the (slightly?) pejorative dogwhistle terms "western medicine" or "non-traditional medicine" or, I don't know, "allopathic medicine," so you don't want to lose the mystique of whatever practice you're celebrating. It might even leave a bad taste in your mouth because you've decided that conventional medicine is closed-minded, unlike the egalitarian majesty of alternative medicine that accepts all self-described experts.

Adopting a technique as part of conventional medicine is much higher praise than slapping an ad for it on a flash banner next to Andrew Weil's grinning face. Why would you not want that acceptance? Or do you prefer the outlaw cachet that the "alternative" label implies among the faithful?

[pnwmom]

46. That's only because you view alternative medicine as a slur

and I don't. I don't agree that conventional western medicine is superior in every manifestation, and that every proven medical treatment needs to be falsely labeled as the product of conventional medicine.

[Orrex]

47. I view medicine that works as superior to "medicine" that does not

Since, on balance, alternative medicine is more strongly represented by the latter, I do indeed consider it a slur.

It's just like people who consider "rational" to be an insult.

[pnwmom]

54. I consider rational to be a compliment, and I don't find

alternative medicine to be a slur.

[Barack_America]

53. They're obviously still working out which subsets it works for.

This is how science works. A study is done and published. The limitations of the study are discussed. Additional studies that address those limitations are done. Eventually a consensus is reached.

[SidDithers]

25. No, that's science...nt

Sid

[djean111]

27. Thank goodness, then, that I got surgery in 1997!!!

I had a torn meniscus that would lock up my knee and when I could not relax enough to unlock it, the muscles would seize and the pain was such that I would rather have had the leg taken off above the knee than endure the pain.
I had Cigna at the time. They sent me to a surgeon who did an MRI and could see the tear, he fixed it, and I have never had a problem since. And that knee had been locking up for 45 years or so.

[truebluegreen]

28. Cool.

Vindicates my decision to not Have Surgery As Soon As Possible! after a tear last spring. Feels fine now...and I've had knee surgery before and will no doubt need replacements in the future. But not today.

[tridim]

29. A few years ago I had a locked shoulder...

The doctor said I needed surgery, I decided to do research on my own and rehab myself.
About 30 days later my shoulder was 100% and has been perfect ever since. No surgery.

IMO the most dangerous woo comes from doctors who go by the book, the OBSOLETE, INCORRECT, CAPITALIST book.

[AngryOldDem]

55. You're lucky.

I know someone who has that. He underwent the surgery a few years ago (after going through PT) and was pain free for awhile, but now it's back and in BOTH shoulders. The doctor warned him that it would most likely occur. I doubt he'll go through the surgery again, unless it gets to be too much.

I understand the pain that causes is beyond excruciating.

[mr blur]

34. >

[csziggy]

44. When the torn meniscus folds over it is agonizing

That happened with both my knees - I'd had a lot of pain for several years but could still function. In 2001 the left knee got much worse, then one night I moved wrong and it felt as though a sword was stuck through my leg. I couldn't put weight on it at all without excruciating pain. My regular doctor got me in to see the best knee orthopedic surgeon in the area and he scheduled the surgery to remove the torn and folded meniscus.

After I recovered from the surgery, that knee was back to being about the same pain level as before the meniscus folded. Six years later I went through the same thing with the right knee - but when the surgeon got into the joint he found even more damage than just the folded meniscus.

Without those surgeries, I would not have been able to do anything. I couldn't stand or walk, even with a cane. I had to use crutches to get around because putting weight on those knees was so painful.

With the surgeries to remove the medial meniscus from each knee, I got years more useful time from my knees. But without the meniscus and with no sheath around the bones, the ends of the bones ground together in my knee joints. I knew this would happen - the surgeon warned me before the surgeries. Last year the pain had gotten so bad, I was as incapacitated as when the meniscus folded. I had both knees replaced and the relief from pain is tremendous.

I hope insurance companies don't use this study to deny arthroscopy to patients who are in the kind of pain I was in. I can see not doing it for the pain I had been in before the meniscus folded - but not once there is that level of damage!

[pnwmom]

52. It's clear that this procedure does benefit some people --

that is, more than physical therapy or other non-surgical treatments -- but unfortunately, it's a small minority of people. They need to more effectively target the patients who need this.

The same issue has come up with a common surgery for lower back pain.

I'm glad it worked for you!

[Nye Bevan]

48. When people are charging thousands of dollars for such operations,

with a small fraction of this paid by the patient, it is highly likely that too many of these procedures are being performed, as opposed to too few.

This kind of study is invaluable.

[Jesus Malverde]

51. Worked there, it's called the health care INDUSTRY..where if your healthy we don't get paid!..NT