Placebo-surgery controlled trials

FIDELITY was considered the key evidence by the Council for Choices in Health Care in Finland (COHERE, a permanent body appointed by the Government that works in conjunction with the Ministry of Social Affairs and Health) in making a rare restrictive funding decision: in 2017, COHERE declared that knee arthroscopy for degenerative knee disease would no longer be included in the range of public health services available in Finland.

Possibly even more noteworthy, in the same year, the BMJ RapidRec panel issued a guideline strongly recommending against the use of arthroscopy in nearly all patients with degenerative knee disease. The panel went further to recommend that healthcare administrators and funders may use the number of arthroscopies performed in this context as an indicator of poor quality care. Knee arthroscopy has thus become one of the starkest examples of modern medical reversal.

While these policy decisions and guidelines were landmark events, they came after years of mounting evidence and a broader cultural shift. As we described in an editorial published in the flagship journal of sports medicine, the British Journal of Sports Medicine, such reversals are rarely triggered by a single study or policy.
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Instead, they unfold gradually, driven by a combination of rigorous clinical trials, growing awareness among general practitioners and patients, media coverage highlighting “useless surgery,” and finally, individual clinicians stepping up to change their practices despite professional and financial inertia. This slow but decisive transition underscores how hard it is to abandon ineffective procedures, even in the face of compelling evidence.

Perhaps even more emblematic is what Jonathan Scott originally described as Scott’s parabola—the rise and fall of medical techniques that are rapidly embraced, then just as rapidly abandoned.

In our CORR article, we demonstrated how the utilization of knee and shoulder arthroscopy in Finland traced exactly this parabolic trajectory.

What began as an exciting, bioplausible innovation became routine practice before high-quality studies revealed that the benefits had been overestimated.

Where are we now?

Funders are increasingly responding to the accumulating evidence that many common procedures deliver marginal or no benefit—so-called low-value care. Subacromial decompression and knee arthroscopies for arthritis are among the first 17 operations NHS England plans to discontinue completely or heavily restrict:
https://www.bbc.com/news/health-44665560
https://www.theguardian.com/society/2018/jun/29/nhs-wields-the-axe-on-17-unnecessary-procedures‍

One way to look at this is that in less than 50 years, arthroscopic surgery for knee and shoulder pain has moved from promising new techniques to widespread practice—only to be ultimately rejected. These developments vividly illustrate Scott’s parabola in action and offer a cautionary example of how easily medicine can fall in love with plausible but unproven treatments.