This is part II of Is “real” surgery any better than a “sham” surgery? To read part I, click HERE. In that blog post, we talked about how researchers are looking at sham surgeries and we looked at a few examples using back pain surgeries. Here in part II, we’re looking at a few recent studies involving knee and shoulder surgeries.
Arthroscopic partial meniscectomy for degenerative meniscal tears [i]
The meniscus is a fibrous cartilage located in the knee joint. I’m sure you’ve heard of somebody that has had a torn meniscus. It’s very common in athletic injuries and also in the general population. This study had 146 patients with a degenerative medial meniscus tear without knee osteoarthritis. Basically, each patient in this study had a worn-out medial meniscus in a knee joint without any other issue in the knee. The meniscus slowly tore over time; none had any kind of sudden injury causing the tear. Surgery involves going in and cutting out the torn part of the meniscus. The idea is that the torn part of the meniscus is irritating the joint and causing the patient’s pain. In this study, one group had the real surgery (cutting and removal of the torn meniscal tissue) while the shame surgery group only received insertion of the arthroscope but with no cutting. After a 12 month follow-up, the groups showed no difference. This group was actually studied again for a 2 year follow up, and the results were still the same[ii].
Arthroscopic subacromial decompression for subacromial shoulder pain[iii]
On the very top outside of your shoulder you can feel a bony prominence. This is the acromion process, which is part of your shoulder blade. Underneath the acromion (subacromial space) sits the tendon from the long head of the biceps, parts of rotator cuff musculature and a subacromial bursa. That’s a lot of tissues in a small space. So when people have pain in that area, it is thought that those tissues are getting compressed. The theory then is that relief can be found by surgically opening up or “decompressing” that space by removing tissue and/or bone.
This study had 313 patients with sub-acromial pain that were randomly assigned to three groups. One received the full treatment: arthroscopy with bone and soft tissue removal (decompression). The second group only received arthroscopy, where the scope was placed in their shoulder but no tissue was removed. The third group received no treatment other than a follow-up appointment at three months.
At 6 months, the decompression group and the placebo surgical group both had small improvements in shoulder pain and function compared to no treatment. However, the authors noted that these differences were “not clinically important.” The authors also noted that these findings “question the value of this operation for these indications.”
Type II SLAP tears for shoulder pain[iv]
The labrum is a fibrocartilaginous rim on part of your scapula (shoulder blade) that makes your shoulder joint larger and more stable. There is also a labrum in your hip joint. For the shoulder, the tendon of the long head of the biceps brachii attaches to the superior part of the labrum. SLAP stands for Superior Labral tear from Anterior to Posterior. Basically, the top part of the labrum is damaged from front to back. A type II labral tear is characterized by the detachment of the superior part of the labrum and the origin of the long head of the biceps brachii.
Surgeons have two common methods to treat these injuries. One method is a biceps tenodesis, where the bicep tendon is cut from the labrum and reattached to the humerus (upper arm). The other method is a labral repair, where the labrum is re-attached to the scapula (shoulder blade).
In this study, 118 patients were randomly assigned to one of three groups. One group received biceps tenodesis, one received labral repair and the third group received a sham surgery. The sham surgery involved a skin incision and placement of a shoulder arthroscope into the shoulder joint.
A two-year follow-up found no differences between any of the three groups.
Again, I want to emphasize that not all surgeries are useless. Our clinic has sent many patients for successful surgeries that did not improve with a trial of our care. But this research is starting to question many of the commonly used procedures today. Hopefully, we’ll eventually get to the point where almost every surgery is compared to a sham surgery to find out which surgeries are more effective than a placebo. If you’re interested in learning more about these sham surgeries, I highly recommend Surgery: The Ultimate Placebo written by Dr. Ian Harris, an orthopedic surgeon.
[i] N Engl J Med. 2013 Dec 26;369(26):2515-24
[ii] Annals of the Rheumatic Diseases 2018;77:188-195.
[iii] Lancet.2018 Jan 27;391(10118):329-338
[iv] Br J Sports Med. 2017 Dec;51(24):1759-1766
Jeff Remsburg DC, MS, DACBR, Cert MDT