January 2017: Doctors in the Netherlands publish their findings in the medical journal Osteoarthritis Cartilage:
- “In patients with knee osteoarthritis arthroscopic knee surgery with meniscectomy is associated with a three fold increase in the risk for future knee replacement surgery.”1
November 2016: Research in the medical journal Orthopedics:
- Doctors examine the incidence of total knee arthroplasty (total knee replacement) in patients who have undergone knee arthroscopy for partial meniscectomy, chondroplasty, or arthroscopic debridement of the knee.
- Reported rates of total knee replacement:
- One year: 10.1%
- Two years: 13.7%
- Three years: 15.6%
- Obesity, depressive disorder, rheumatoid arthritis, diabetes, and being age 70 years and older were associated with increased relative risk of conversion to total knee replacement at 2 years.
- When obesity was combined individually with the top 5 other risk factors, no combination produced a higher relative risk than that of obesity alone.
- Patients who were 50 to 54 years of age had the lowest incidence of conversion to total knee replacement.
- Men had a lower incidence of conversion to total knee replacement (11.3%) than women (15.8%).
The study’s doctors suggested that this information can help surgeons to counsel patients on the incidence of total knee replacement after knee arthroscopy and identify preoperative risk factors that increase risk.10
December 2016: Doctors in Denmark publish these findings:
- “In general, patients undergoing arthroscopic meniscus surgery were too optimistic regarding their recovery time and postoperative participation in leisure activities. This highlights the need for shared decision making which should include giving the patient information on realistic expectations…”2
Do these findings present anything really new? No, research has been ongoing telling patients and doctors of the risks associated with arthroscopic meniscus repair. Meniscus surgery causes super accelerated knee arthritis.
It is remarkable is that studies more than a decade old have issued the same warnings. In 2005 doctors in Canada in auditing the effectiveness of certain medical procedures found very poor quality evidence on the effectiveness of arthroscopic debridement of the knee with partial meniscectomy.12
The summary of these studies? If you have a meniscus surgery, chances are you will be disappointed in the outcome and then move onto knee replacement.
In research appearing in the medical journal Clinical Anatomy, doctors issued their report on a phenomena of super accelerated osteoarthritis in knees with meniscus tear damage and history of surgical meniscus removal.
Coming out of Tufts Medical Center in Boston, the researchers noted that knee osteoarthritis is typically a slow progressive problem; however, in some patients knees progressed to osteoarthritis with dramatic rapidity. However, clinicians cannot determine which patients may be at risk for accelerated knee osteoarthritis without knowing the incident structural damage that predisposes a knee to accelerated osteoarthritis. The Tuft researchers found that structural damage that is associated with accelerated knee osteoarthritis destabilizes and compromises the function of the meniscus or compromises the subchondral bone.3 More commonly known as Knee Instability.
In an early study researchers from the Department of Orthopaedic Surgery at Carolinas Medical Center found that a damaged meniscus is the active participant in the development of knee osteoarthritis. In the study above, the relationship to bone damage is discussed, in this cited study the Carolinas Medical team found a strong association between meniscus damage and cartilage loss.4 The two combined studies help confirm missing meniscal tissue contributes to bone and cartilage degeneration.
Meniscus repair failure – Arthroscopic meniscus surgery
Doctors at the Hospital of Special Surgery found that meniscus removal, not only impacts the knee at the point of the surgery, but throws the whole knee out of balance and leads to several points of cartilage deterioration.5
What is really remarkable is that researchers write paper after paper saying that removal of meniscal tissue in surgery causes advanced osteoarthritis and the procedures continue.
Clearly the best way to prevent cartilage breakdown and knee osteoarthritis caused by meniscal surgery is AVOID the surgery.
As reported in the New York Times August 3, 2016, arthroscopic knee surgery, especially meniscal tears, is a “useless” procedure.
Dr. Gordon H. Guyatt, a professor of medicine and epidemiology at McMaster University in Hamilton, Ontario, who wrote (an) editorial in The British Medical Journal, which he called arthroscopic meniscal surgery “A highly questionable practice without supporting evidence of even moderate quality.”
Dr Guyatt was quoted in the Times “I personally think the operation should not be mentioned (to the patient as an option),” he says, adding that in his opinion the studies indicate the pain relief after surgery is a placebo effect. But if a doctor says anything, Dr. Guyatt suggests saying this:
“We have randomized clinical trials that produce the highest quality of evidence. They strongly suggest that the procedure is next to useless. If there is any benefit, it is very small and there are downsides, expense and potential complications.”
Hearing that, he says, “I cannot imagine that anybody would say, ‘Go ahead. I will go for it.’”
Arthroscopic Partial Meniscectomy versus Sham Surgery for a Degenerative Meniscus Tear – Surgery does not alleviate knee catching or knee locking after surgery
The research mentioned above and reported by the New York Times was not the first time the meniscus surgery controversy was reported in the mainstream media. On December 24, 2013, the New England Journal of Medicine published an article entitled “Arthroscopic Partial Meniscectomy versus Sham Surgery for a Degenerative Meniscal Tear.”
This was the work of Finnish researchers who recognized that arthroscopic partial meniscectomy is one of the most common orthopedic procedures, yet rigorous evidence of its efficacy is lacking.
So what they did was to conducted a multicenter, randomized, double-blind, sham-controlled 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.
Patients were randomly assigned to arthroscopic partial meniscectomy or sham surgery. Then a scoring system was designed to measure pain, symptom severity and knee pain after exercise at 12 months after the procedure.
What they found was “In this trial involving patients without knee osteoarthritis but with symptoms of a degenerative medial meniscus tear, the outcomes after arthroscopic partial meniscectomy were no better than those after a sham surgical procedure.”
Earlier in 2013 research published in the American Journal of Sports Medicine showed what little value meniscectomy has. Researchers compared meniscectomy to nonoperative treatment for meniscus tears.6
They specifically studied degenerative horizontal tears of the medial meniscus and hypothesized that surgical treatment would produce better outcomes that nonoperative strengthening exercises.
This study was a randomized controlled trial with the highest level of evidence (level 1). The study had 102 patients with medial meniscus tears – 81 women and 21 men with the average age of 53.8.
Fifty patients underwent arthroscopic menisicectomy while 52 participated in nonoperative strengthening exercises. The results did not match up the to researchers hypothesis.
At the two year follow-up there was no difference in pain relief, improved knee function or patient satisfaction. Results also showed that meniscectomy did not provide better functional improvement than the nonoperative group.
But what was the difference between these two groups? One group of patients underwent invasive surgery, had tissue remove, and will likely experience long-term meniscus degeneration.
In fact, most surgical meniscus treatments have, “all have a high long-term failure rate with the recurrence of symptoms including pain, instability, locking, and re-injury. The most serious of the long-term consequences is an acceleration of joint degeneration.”
So, even if the knee is stabilized, removing the meniscus causes osteoarthritis. Consider this conclusion from a medical paper published in late 2014:
In this study from China, doctors said that arthroscopic partial meniscectomy is a good option for medial meniscal tear in late middle-aged adults. For best success you need a proper diagnosis and excellent surgical technique. If you follow these two rules all the patients could get good clinical results, HOWEVER, “there are some patients with motion restrictions in the early stage after operation.” 7
In research from May 2016, doctors warned that the role of arthroscopic partial meniscectomy in reducing pain and improving function in patients with meniscal tears continues to remain controversial and that studies show no difference between arthroscopic partial meniscectomy and non-surgical treatment.8
April 2016: Doctors writing in the Annals of Internal Medicine examined evidence that arthroscopic partial meniscectomy offers no benefit over conservative treatment of patients with a degenerative meniscus tear. Patients were divided into two groups. Those who received a sham or fake surgery and those who received arthroscopic partial meniscectomy.
- The findings? Resection of a torn meniscus has no added benefit over sham surgery to relieve knee catching or occasional locking.11
Why was the primary treatment for a meniscus tear a complete meniscectomy?
Why was the primary treatment for a meniscal tear a complete meniscectomy, a surgery that removed the entire meniscus from the knee? Why in the patient base that seemed the most likely to need a meniscus?
A typical patient profile for this procedure was a younger, active, athletic patient who through their lifestyle accelerated knee overuse, and, the older patient who suffered from degenerative osteoarthritis.
The goal of complete meniscectomy was to reduce pain, restore knee function, and prevent the development of osteoarthritis. As surgeons had long believed that the meniscus was a “remnant” tissue and that it was not needed, it could be removed if damaged without a negative effect.
However, as medical research studied the long-term effects of this procedure, it became apparent in the medical community that complete meniscectomy was a primary cause of the sudden onset of knee osteoarthritis. The meniscus was in fact an important component of the knee.
The meniscus provides several vital functions including mechanical support, localized pressure distribution, and lubrication to the knee joint. They are made of thick fibrous cartilage that allows it to function as a shock absorber between the upper and the lower leg bones.
Even the American Academy of Orthopedic Surgeons was unable to come up with evidence to support the use of partial meniscectomy.
They looked at a study comparing arthroscopic partial meniscectomy to a conservative exercise program.9
- The authors reported no significant treatment benefits of meniscectomy and at the 6 month follow up there was no difference noted between the two groups, “in terms of reduced knee pain, improved knee function and improved quality of life.” Not only was there no benefit, but it is important to note that surgical treatment for meniscal injuries can result in an acceleration of cartilage degeneration and an increased rate of osteoarthritis.
1 Rongen JJ, Rovers MM, van Tienen TG, Buma P, Hannink G. Increased risk for knee replacement surgery after arthroscopic surgery for degenerative meniscal tears: a multi-center longitudinal observational study using data from the osteoarthritis initiative. Osteoarthritis Cartilage. 2017 Jan;25(1):23-29. doi: 10.1016/j.joca.2016.09.013. Epub 2016 Oct 3. [Pubmed]
2 Pihl K, Roos EM, Nissen N, JøRgensen U, Schjerning J, Thorlund JB. Over-optimistic patient expectations of recovery and leisure activities after arthroscopic meniscus surgery: A prospective cohort study of 478 patients. Acta Orthopaedica. 2016;87(6):615-621. [Pubmed]
3. Driban JB, Ward RJ, Eaton CB, Lo GH Lyn Price, Lu B8, McAlindon TE. Meniscal extrusion or subchondral damage characterize incident accelerated osteoarthritis: Data from the Osteoarthritis Initiative. Clin Anat. 2015 Jul 6. [Pubmed]
4. Sun Y, Mauerhan DR, Honeycutt PR, Kneisl JS, Norton JH, Hanley EN Jr, Gruber HE. Analysis of meniscal degeneration and meniscal gene expression. BMC Musculoskelet Disord. 2010 Jan 28;11:19. doi: 10.1186/1471-2474-11-19. [Pubmed]
5. Maher S, Wang H, Koff MF, Belkin N, Potter HG, Rodeo S. A clinical platform for understanding the relationship between joint contact mechanics & articular cartilage changes after meniscal surgery. J Orthop Res. 2016 Jul 13. [Pubmed]
6. A Comparative Study of Meniscectomy and Nonoperative Treatment for Degenerative Horizontal Tears of the Medial Meniscus Am J Sports Med May 23, 2013 ; published online before print May 23, 2013. [Pubmed]
7. Zhongguo Gu Shang Arthroscopic partial meniscectomy for medial meniscal tear in late middle-aged adults. 2014 Aug;27(8):631-4. [Pubmed]
8. Ha AY, Shalvoy RM, Voisinet A, Racine J, Aaron RK. Controversial role of arthroscopic meniscectomy of the knee: A review. World Journal of Orthopedics. 2016;7(5):287-292. [Pubmed]
9. Herrlin S, et al. Arthroscopic or conservative treatment of degenerative medial meniscal tears: a prospective randomised trial. Knee Surg Sports Traumatol Arthrosc. 2007;15(4):393-401. [Pubmed]
10. Boyd JA, Gradisar IM. Total Knee Arthroplasty After Knee Arthroscopy in Patients Older Than 50 Years. Orthopedics. 2016 Nov 1;39(6):e1041-e1044. doi: 10.3928/01477447-20160719-01. Epub 2016 Jul 27. [Pubmed]
11. Sihvonen R, Englund M, Turkiewicz A, Järvinen TL; Finnish Degenerative Meniscal Lesion Study Group. Mechanical Symptoms and Arthroscopic Partial Meniscectomy in Patients With Degenerative Meniscus Tear: A Secondary Analysis of a Randomized Trial. Ann Intern Med. 2016 Apr 5;164(7):449-55. doi: 10.7326/M15-0899. Epub 2016 Feb 9. [Pubmed]
12. Health Quality Ontario. Arthroscopic Lavage and Debridement for Osteoarthritis of the Knee: An Evidence-Based Analysis. Ontario Health Technology Assessment Series. 2005;5(12):1-37. [Pubmed]
This article was originally published by Ross Hauser MD in Knee Surgery for Meniscus Tears | Complications and Outcomes