A man at the boatyard is booked for surgery

THE 30-SECOND VERSION

For a worn knee, keyhole surgery has matched a fake operation in trials. Exercise did just as well, without the knife. There are real exceptions, so talk to your surgeon.

FEEL-GOOD FRIDAY

The operation that matched a sham

We close knee week with one of the most surprising findings in orthopedics, and what it does not mean.

A man at the boatyard told me last week that he is booked for keyhole surgery on his knee in October. Sixty-one years old, sore knee for two years, a scan showing a torn meniscus. The surgeon will go in with a small camera and tidy up the tear. He seemed relieved to have a date.

I did not say much, because it is not my knee and I am not his doctor. But I went home and read the trials again, because this particular operation has one of the strangest evidence stories in medicine.

Researchers did something bold. They compared the real operation against a pretend one. What they found is worth knowing before anyone books a date. Let me tell you.

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Real keyhole knee surgery was tested against a pretend operation. What happened?

Tap your guess. A ready-to-send reply opens. Just press send and we’ll tell you if you got it right.

Both groups did about the same

The real surgery did much better

The pretend group got worse

THE MYTH

A torn meniscus does not always mean surgery

First, the parts. The meniscus is a pad of tough cartilage that sits inside the knee as a cushion. Keyhole surgery, which doctors call arthroscopy, means going in through small cuts with a camera and trimming the ragged edges of a torn one.

The logic is easy to follow. Something inside the knee is torn, so tidy it up and the knee should feel better. For years this was one of the most common operations performed anywhere.

Then Finnish researchers ran the test that settles arguments. They took 146 people with a worn meniscal tear into the operating room. Everyone had the camera put in. Then half had the tear trimmed, and half had nothing done at all, while the surgeon went through the motions. Nobody knew which they had received.

A year later, the two groups were the same. Same pain, same function, same quality of life. And this year the ten-year results came out. Still no difference. A decade on, the people who had a pretend operation were doing just as well as the people who had a real one.

And exercise held its own

Other trials compared the operation against a course of exercise therapy instead. Same story. No meaningful gap. After pooling 16 trials and more than 2,000 patients, reviewers concluded there is little or no benefit from the surgery over either a placebo or exercise. In 2017 a BMJ panel issued a strong recommendation against it for nearly all people with wear-related knee trouble.

Now the important part

This applies to wear-related tears, the kind that come with age. It does not apply to a young athlete who twisted a knee, or to a knee locked in a bent position that will not straighten, or to injuries from a real accident. Those are different problems, and surgery can be exactly right for them. Please do not cancel anything on the strength of a newsletter. Take these findings to your surgeon and ask what applies to your knee.

Where the week lands

Here is the part that pleases me. The thing that matched the operation, over and over, was exercise. On Monday we built the thigh with step-ups. On Wednesday we found a way to keep working when land hurts too much. That is not a consolation prize. In these trials it was the equal of surgery, and it is entirely in your hands.

⚠ WHEN SURGERY IS A DIFFERENT QUESTION

This is a conversation for your surgeon

The findings above are about wear-related tears. See a doctor promptly, and do not assume they apply, if:

● Your knee locks or catches so it will not straighten, or it gives way under you.

● The trouble began with a fall, a twist, or an accident rather than creeping up over months.

● The knee is hot, red, and swollen, or you have a fever alongside the pain.

When in doubt, get it checked. PainFree adds to your doctor’s care. It never replaces it.

THIS WEEK’S QUICK WINS

Three ways to carry knee week forward

❓ Ask two questions before any operation

What happens if I do nothing for three months? And what would a course of exercise therapy give me instead? Any good surgeon will welcome both questions.

Two questions • Ask before you book

🦵 Keep the step-ups going

Monday’s slow step-up on the bottom stair is the sort of thing that matched surgery in the trials. Five each leg, most days, lowering over a count of three.

2 minutes • The proven half of the deal

📜 Do not fear the words on the scan

A worn meniscal tear on a report is common with age, much like the disc changes we covered in back week. Finding one does not automatically mean it is the cause, nor that it needs cutting.

Anytime • Ask what it means for you

RESEARCH BRIEF

Ten years on, still no difference

The Finnish trial, published in the New England Journal of Medicine, randomly assigned 146 people with a worn meniscal tear to either a real trimming operation or a sham one. Neither the patients nor the assessors knew who got which. At one year, the groups matched on pain, on function, and on quality of life. The ten-year follow-up appeared this year, and the results had still not separated. Alongside it, a Cochrane review pooling 16 trials and 2,105 patients found little or no benefit over placebo or over exercise programs, and a BMJ expert panel recommended strongly against the surgery for nearly all wear-related knee problems. All of this concerns degenerative tears, not fresh injuries.

146

patients randomly given a real or a pretend operation

2,105

patients across 16 trials, showing little or no benefit

Strong

the BMJ panel’s recommendation against it for wear-related knees

For an ordinary worn knee, the operation did not beat pretending. Exercise did as well, and you can start it today.

WORTH KNOWING

10 years

That is how long the Finnish researchers followed their patients. A full decade after the day in the operating room, the people who had received a pretend procedure were doing as well as those who had the real thing. Few findings in medicine are that clean, or that humbling.

From the ten-year follow-up published this year.

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