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Understanding Placebo: Does knee surgery work?

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When patients feel better after a treatment, they naturally think it’s because the treatment they received is working.

They are en route to recovery.

This is simply not true. We could argue all day about this but I am not going to. The research on this is clear — feeling better (i.e. less pain, improve function) doesn’t mean you are recovering.

Having said that, it doesn’t mean the improvement is not real. It is. It is real. It just has no predictive value (i.e. doesn’t tell us you are getting better). 

The truth about knee surgery

There are tons of ineffective treatments available in Singapore and they are not always limited to what is considered as alternative medicine.

If we were to look at the research behind mainstream surgeries, you’ll find that not all surgeries work as well as you think!

Just because research says sham surgeries can work as well as fake ones that doesn’t mean orthopaedic surgeons have to stop doing it. Unfortunately arthroscopy is still one of the most commonly performed orthopaedic surgery in the world. Is this evidence-base practice? Screenshot: HC Orthopaedic Surgery

In 2002 — yes, almost two decades ago — Mosely and friends found that fake surgery works as well as real ones in patients with osteoarthritic knee pain.

In his experiment, 61 patients were assigned to the lavage group, 59 to the debridement group, and 60 to the fake surgery group.

In the lavage group, the joint was “flushed” with at least 10 litres of fluid to remove any loose tissue or debris. It should be noted for this group, no debridement — the removal of damage cartilage or bone — was performed.

In the debridement group, the rough cartilage on the surface of the bone was shaved and all torn or “degenerated” tissue at the meniscus was removed. The joint was also flushed with at least 10 litres of fluid.

The placebo group (my favourite), only had three 1-cm incisions made on their skin. Following which, the surgery was conducted as if it was happening but nothing beyond the incisions were performed. To ensure that the patients didn’t realise they had the fake surgery, the patients did not have total amnesia (i.e. they can still remember some details of the surgery).

Their findings?

“In this controlled trial involving patients with osteoarthritis of the knee, the outcomes after arthroscopic lavage or arthroscopic debridement were no better than those after a placebo procedure.”

So if you have osteoarthritis and you are considering knee surgery, I suggest you think twice!

What if I have a meniscus tear? Surely I need surgery to fix it right?
Even though research suggests that a meniscus repair surgery have no additional benefits over a placebo surgery, the procedure is still offer as a treatment option in all major hospitals around the world. In the Understanding Meniscal Injuries (PDF) brochure published by Changi General Hospital, no clinical trials or studies were cited to support their claims.

When we think of tears, we think of our body as broken. We need to fix the damage or torn bits to resume normal life.

Is this true?

In 2013, The New England Journal of Medicine, published that there’s no difference for both pain and function between those who had the real arthroscopic partial meniscectomy, a knee surgery for meniscus tears, vs those who had the sham surgery. For the sham surgery group:

“To mimic the sensations and sounds of a true arthroscopic partial meniscectomy, the surgeon asked for all instruments, manipulated the knee as if an arthroscopic partial meniscectomy was being performed, pushed a mechanized shaver (without the blade) firmly against the patella (outside the knee), and used suction. The patient was also kept in the operating room for the amount of time required to perform an actual arthroscopic partial meniscectomy.”

Guess what the study found?

There is no difference in both pain and function outcomes between real surgery vs fake surgery group after one week and 12 months.

What if I have a complete ACL tear? Surely I need surgery to fix it right?

Maybe meniscus and osteoarthritis are the outlier conditions. What about the anterior cruciate ligament? It holds our knees in place right?

Surely it needs to be “fixed”?

Again, no.

A 20-year study on ACL reconstruction surgery (vs no surgery) was published in 2018 to show:

No difference in functional outcomes between those who underwent anterior cruciate ligament surgery vs those who opted for conservative care
• Knee stability was better in patients who opted to undergo the orthopaedic surgery. However, this did not translate to any improvement in subjective or objective functional outcomes
80% of the surgery group had osteoarthritis and only 68% of nonoperative group had osteoarthritis

So not only does surgery not give you superior long-term outcomes. It also increases your risk for osteoarthritis.

Is surgery just a shamanistic ritual?

Now that we have talked about that real surgeries don’t really stand up against fake surgeries. Does that mean surgery is just some form of modern day shamanistic ritual?


No, not quite.

A commentary by Stuart Green was published in Clinical Orthopaedics and Related Research — an orthopaedic journal no less — discussed the parallels between traditional healers (i.e. shamans who are believe to be able to communicate with the gods and spirits to influence health and well being) and surgeons.

Green asserted that shamanistic practices and the modern surgical experiences have their similarities. They are both a series of events, each with its specific purpose, arranged in a specific order to achieve an outcome.

While he acknowledged that while every step in a surgical encounter is designed to maximise recovery outcomes, a shaman is also likely to point out that each step in their ritual is not without purpose.

You may think the comparison is overreaching.

However, Green was able to make some interesting comparisons:

Fasting: Both shamanistic and surgical practices promote fasting. This induces hypoglycemia, which in turns alters consciousness to increase susceptibility to the influence of suggestion.
Donning of Ritual Garb: In shamanistic practice, costumes play an important role in contributing to the trance state. In surgery, must strip of their old clothes to put on a loose-fitting gown. The social disorientation in both circumstances can contribute to suggestibility.
Ingestion of Psychotropic Substances: Psychedelic mushrooms are consumed in North American shamanistic practices as are premedication adminstered pre-surgery. Both substances also enhance suggestibility.
Anointment with Purifying Liquid: Shamanistic purification rituals may include spiritual cleansing using oil or animal grease. With preoperative skin preparation, applying a povidone-iodine solution leaves an orange-colored limb. The dissimilarity from ordinary experience, may also contribute to changes in suggestibility.

You may think Green totally lost it.

Here’s the surprise: He is in fact an orthopaedic surgeon and clinical professor with the Department of Orthopaedic Surgery at the University of California, Irvine.

Why do ineffective treatments seem helpful?

If you are suffering from knee pain and you are frustrated by the recommendations or poor treatments you have received, you may want to read into why ineffective treatments work.

Hartman shared about the various mechanisms to why people may seem to respond positively despite receiving ineffective therapies. Some of the concepts he explained include:

• Natural history of disease
• Regression to the mean
• Placebo effect
• Post hoc, ergo propter hoc fallacy
• Confirmation bias
• Cognitive dissonance

If you are considering knee surgery and you are not convinced it’s the right next step for you, I hope this post gives you something more to consider.

Please be mindful that none of the content I have shared conclusively determined that surgery doesn’t work. What the papers found was that some surgeries do not perform better than placebo (i.e. fake surgeries).

A systematic review of the content from government agencies and hospitals found that only 31% of the information were updated to the latest clinical guideline recommendations and only 43% was considered accurate. Source: Journal of Medical Internet Research

I hope this information finds you well.

When choosing your treatment option, it’s important to dig deep into the research papers and not rely on “credible” information sources alone.

As highlighted earlier, even hospital brochure are not obliged to include references to support their claims. In fact, the information they present may be skewed to not reflect the complete picture of what is understood about orthopaedic surgery.

In my previous post on knee osteoarthritis, I was unable to find a Singapore clinical guideline to help Singaporeans suffering from osteoarthritic knee pain navigate treatment options.

I know this leaves recovery to be a frustrating experience. If you are interested to talk to an evidence-based chiropractor about your conservative treatment options, book in an appointment with me via the form below to the discover the difference the right care can make.


Frustrated by the lack of results-driven and ethical chiropractic clinics in Singapore, Chiropractor Jesse Cai found Square One Active Recovery to deliver meaningful and sustainable pain solutions.

Our goal? To make our own services redundant to you.

*We do not offer temporary pain relief such as chiropractic adjustments, dry needling, or any form of soft tissue therapy.