Friday, December 27, 2013

"Sham" surgery yields improvement - the surgical placebo?

Arthroscopic Partial Meniscectomy versus Sham Surgery for a Degenerative Meniscal Tear

How does one know what part of a surgical procure is responsible for improvement? For example, in rotator cuff repair surgery we've seen many articles demonstrating functional improvement even though the repair doesn't work (i.e. it does not result in a durable reattachment of the cuff to the humeral tuberosity). So we may not always understand how surgery helps.

These authors conducted a multicenter, randomized, double-blind trial in 146 patients 35 to 65 years of age who had knee symptoms consistent with a degenerative medial meniscus tear and no knee osteoarthritis. After diagnostic arthroscopy patients were randomly assigned to arthroscopic partial meniscectomy or a sham surgery. Only the orthopedic surgeon and other staff in the operating room were made aware of the group assignment, and they did not participate in further treatment or follow-up of the patient. For patients having arthroscopic partial meniscectomy, the damaged and loose parts of the meniscus were removed until solid meniscal tissue was reached.

For the sham surgery, the patient was kept in the OR for the same length of time as for the arthroscopic partial meniscectomy during which time the sensations and sounds of a true arthroscopic partial meniscectomy were imitated without actually performing the procedure.

Importantly, both groups improved with no significant between-group differences in the change from baseline to 12 months.
The Lysholm score improved 21.7 points in the partial-meniscectomy group as compared with 23.3 points in the sham-surgery group.
The WOMET score improved 24.6 and 27.1 points, respectively.
The score for knee pain after exercise, 3.1 and 3.3 points, respectively.

So the point here is that both groups were improved after the diagnostic arthroscopy, but there was no incremental benefit of the partial menisectomy. One might wonder what the results of a similar study of cuff repair vs sham might show.


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