Arthroscopic knee surgery for osteoarthritis
Doctors and researchers are confirming arthroscopic knee surgeries for meniscus and cartilage “repair” do not heal, do not repair, and accelerate knee instability and the degenerative collapse of the knee.
You can’t fight the evidence – arthroscopic knee surgery is only a stop gap, and to many researchers, not even a good one to total knee replacement.
But why take my word for it?
- Below we are going to review some revealing studies. In this article I explain why many patients seek regenerative injection therapies like Prolotherapy, Stem Cells and Platelet Rich Plasma Therapy (treatments discussed below) not only as an option to knee surgery, but following a problem knee surgery as well.
According to the American Orthopaedic Society for Sports Medicine
Arthroscopy for the knee is most commonly used for:
- Removal or repair of torn meniscal cartilage
- Reconstruction of a torn anterior cruciate ligament
- Trimming of torn pieces of articular cartilage
- Removal of loose fragments of bone or cartilage (please see our companion article Arthroscopy for middle-aged or older patients)
- Removal of inflamed synovial tissue which lines the joint capsules and can lead to fluid accumulation in the joint.
As you will see in the research below – when meniscus and the articular cartilage, both of which are needed to help the femur bone glide smoothly over the tibia is removed, the bones do not glide properly.
February 2016: Listen to how research appearing in the medical journal Annals of Internal Medicine concludes:
Resection of a torn meniscus (cutting away tissue that cannot be sutured) has no added benefit over sham surgery to relieve knee catching or occasional locking. These findings question whether (these) mechanical symptoms are caused by a degenerative meniscus tear and prompt caution in using patients’ self-report of these symptoms as an indication for Arthroscopic Partial Meniscectomy.1
Clearly doctors are concerned that the wrong procedure was performed for these patients and made the patient’s condition worse.
But what were the circumstances that lead to this procedure?
Patients told their doctors what was going on in their knee, got a surgery that did not work and was not even appropriate to the patient’s concerns
So should patients be warned NOT TO TELL their doctors what’s wrong for fear of getting an inappropriate treatment?
Should the doctors not let what the patients are telling them help guide their treatments?
So concerning is this, is that doctors are warning doctors against using “self-reported” symptoms as a guide to treatments, i.e, surgery.
This is nonsensical because it is being speculated that the surgery did not work because doctors recommended a treatment – arthroscopic procedure – based on what the patients told them about their symptoms? Will doctors now dismiss what patients are telling them about their knee?
Other doctors have also tried to make sense of the proper usage for arthroscopic knee surgery in patients with osteoarthritis. They had difficulty finding it.
Publishing in the medical journal Arthroscopy, researchers noted that “arthroscopy is not a “cure” for osteoarthritis, but they go on to say that arthroscopic and related surgery is of significant benefit to many patients with osteoarthritis and articular cartilage disease. So maybe cartilage surgery is okay but not meniscus surgery.
BUT THEY CONTINUE, arthroscopy alone is insufficient, and arthroscopic treatment of patients with arthritis is a salvage procedure requiring an approach where arthroscopy must be combined with additional procedures. 2 So you have to get the surgery PLUS other treatments for it to work – but not for the meniscus – arthroscopic procedures are not effective.
At this point other research has issued these findings:
- Many studies have concluded that surgery for osteoarthritis is not effective, not warranted, and basically should be avoided.
- Researchers say that evidence suggests that there is no benefit to arthroscopic meniscal debridement for degenerative meniscal tears.3
- Use of arthroscopy to treat knee osteoarthritis have not declined despite strong evidence-based recommendations that do not sanction its use.4
- In middle stages of knee osteoarthritis, “arthroscopic joint debridement can effectively reduce subjective complaints.Because this treatment does not stop the process of osteoarthritis, the improvements decrease over time.”5
- Finally doctors write that middle aged or older patients with knee pain with or without signs of osteoarthritis should not be recommended to arthroscopic surgery.6
Arthroscopic knee surgery for osteoarthritis is not curative yet the numbers performed are increasing
Arthroscopic knee surgery for osteoarthritis is not curative. This agrees with the mounting level of evidence that arthroscopy doesn’t work any better than conservative care (non-surgical) for most knee conditions, including degenerative arthritis. This is based on thorough research published in some of the most prestigious medical journals in the world 7-11 and has changed how insurance companies reimburse for this procedure.
- Many insurance companies will not cover arthroscopic debridement of the knee for knee pain, but they will cover it for mechanical symptoms. This may sound reasonable until one really looks at the definition of mechanical symptoms of the knee: any type of locking, popping or giving way of the knee!
Almost every person with knee pain has some type of “popping” or crunching (also called crepitation) noise in these joints.
As we discussed above this could mean a patient could visit an orthopedist who documents mechanical symptoms in the patient’s knee and/or if the patient’s MRI shows any type of loose body or meniscal tear then arthroscopic surgery could be done and will be covered by insurance.
Dr. SR Lyu, a noted Taiwanese researcher with specialty in problems of knee osteoarthritis noted that: “Arthroscopic Partial Meniscectomy versus Sham Surgery for a Degenerative Meniscal Tear” published in the New England Journal of Medicine on December 26, 2013 draws the conclusion that arthroscopic partial medial meniscectomy provides no significant benefit over sham surgery in patients with a degenerative meniscal tear and no knee osteoarthritis.
This result argues against the current practice of performing arthroscopic partial meniscectomy (APM) in patients with a degenerative meniscal tear. Since the number of arthroscopic partial meniscectomy performed has been increasing, the information provided by this study should lead to a change in clinical care of patients with a degenerative meniscus tear.12 But they are still increasing.
MRIs can be misleading when diagnosing pain
One problem with the above scenario of MRI inaccuracy is that MRIs cannot always reveal the cause of the patient’s Knee Pain. Among persons with radiographic evidence of osteoarthritis, the prevalence of a meniscal tear was 63% among those with knee pain, catching, or stiffness on most days, and 60% among those without symptoms.13
- A full 60% of people who have no pain will show a meniscal tear on MRI! The net result is that the number of knee arthroscopies continues to rise because everyone with a knee problem qualifies for it!
Knee arthroscopy – A dilution of healing
RESEARCH UPDATE: Here is a troubling study with implications for healing after arthroscopic surgery. Doctors hypothesized that agents injected into the knee after knee arthroscopy will be significantly diluted by residual arthroscopic fluid by 27%. 14
- This may be why pain surgical painkiller injectables do not work as well and higher doses are clearly needed
- This is why we typically recommend to post-arthroscopi patients that we want them to do a follow-up visit with their orthopedist-which usually is one month after the surgery then they can get Prolotherapy. We do not want a dilution of healing.
Pain after Knee arthroscopy
Have you ever read the written report from an orthopedic surgery procedure? The surgical report gives a detailed description of the step-by-step techniques utilized during surgery as well as the anatomical positioning of the patient throughout the surgery.
Many people do not realize that one of the main risks of orthopedic surgery relates to patient positioning. The amount of force applied to the joint and the length of time it remains in certain positions can damage the joint structure. For the purpose of this discussion, we analyzed the surgical report of a seventeen-year-old boy who underwent arthroscopy for right-sided hip pain. The report begins by describing the positioning of the patient:
“The patient was placed supine [face up] on a traction table, all bony prominences were well padded, and prophylactic antibiotics were given. The right extremity was secured in a traction boot and positioned in adduction and internal rotation. Traction was applied until adequate distraction of the hip was confirmed with fluoroscopy.”
“Traction” and “distraction” are common terms found in orthopedic surgery reports. Traction is defined as the pulling force exerted on a skeletal structure by means of a special device. Traction is necessary during hip arthroscopy in order to gain access to the confined joint space during surgery.
Distraction is defined as the separation of the joint surfaces without rupture of their binding ligaments and without joint displacement. Distraction is achieved through traction during arthroscopic surgery (Knee joint distraction (KJD) surgery) and allows for placement of surgical instruments within the joint space. The amount of force necessary to distract or open the hip joint varies from person to person. Because this process is not an “exact science”, it is easy to see how injury can occur.
Pain after Surgery:
Prolotherapists frequently see patients that have continued pain after surgery or even new pain that arises from joint surgery. Injury may not only result from the tension applied to the joint during traction, but the surgical instruments themselves. These instruments used to perform arthroscopy can inadvertently damage the delicate articular cartilage of the joint surfaces. Both the force applied and length of time in traction during surgery can synergistically or independently cause damage to joint structures. Muscle and soft tissue pain are common side effects of surgery and when this pain does not resolve, it is usually because the patient is left with a ligament injury. The ligament injury is a result of the ligaments being pulled or overstretched for prolonged periods of time during traction. Ligament injury causes joint instability and subsequent pain.
Comprehensive Prolotherapy, PRP and Stem Cells
Platelet Rich Plasma Therapy and Prolotherapy, which stimulates tendons, ligaments and cartilage to heal, has many advantages over arthroscopy, which include:
- These treatments are a much safer and conservative treatment
- the procedure does not take long to administer; an individual is usually in and out of the doctor’s office in less than an hour
- it stimulates the body to help repair the painful area; for example, the new collagen tissue formed is actually stronger than it was before the injury
- it reduces the chance of long-term arthritis; with arthroscopy, the chance of long-term arthritis increases
- in the case of athletes, it increases their chances of being able to play their sports for the rest of their lives; arthroscopy significantly decreases those chances
- exercise is encouraged while getting Prolotherapy treatments; one must be very cautious with exercise after arthroscopy
- the procedure is much less invasive; remember that arthroscopy requires the knee to be blown up with about 100 ml of fluid to fit all the scopes into the knee
Stem Cell Therapy represents the latest and most innovative injection therapy under the Prolotherapy umbrella – the details of this procedure are discussed in our companion article Stem Cell Therapy for knee osteaorthritis and cartilage repair.
References for this article Arthroscopic knee surgery for osteoarthritis
1. Sihvonen R, Englund M, Turkiewicz A, Järvinen TL, Mechanical Symptoms and Arthroscopic Partial Meniscectomy in Patients With Degenerative Meniscus Tear: A Secondary Analysis of a Randomized Trial. Ann Intern Med. [Epub ahead of print 9 February 2016] doi:10.7326/M15-0899
2. Lubowitz JH, Provencher MT, Brand JC, Rossi MJ. Arthroscopic arthritis options are on the horizon. Arthroscopy. 2015 Mar;31(3):389-92. doi: 10.1016/j.arthro.2015.01.003.
3. Khan M, Evaniew N, Bedi A, Ayeni OR, Bhandari M. Arthroscopic surgery for degenerative tears of the meniscus: a systematic review and meta-analysis. CMAJ. 2014 Aug 25. pii: cmaj.140433. [Epub ahead of print]
4. Buchbinder R, Richards B, Harris I. Knee osteoarthritis and role for surgical intervention: lessons learned from randomized clinical trials and population-based cohorts.Curr Opin Rheumatol. 2013 Dec 26. [Epub ahead of print]
5. Spahn G, Klinger HM, Hofmann GO. The Effect of Arthroscopic Debridement and Conservative Treatment in Knee Osteoarthritis Sportverletz Sportschaden. 2013 Nov 6.
6. Moseley JB, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. NEJM. 2002;347:137-139.
Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms BMJ
8. Dervin G, et al. Effect of arthroscopic debridement for osteoarthritis of the knee on health-related quality of life. Journal of Bone and Joint Surgery American. 2003;85-A(1):10-19.
9. Kirkley A, et al. A randomized trial of arthroscopic surgery for osteoarthritis of the knee. NEJM. 2008;359:1097-1107.
10. Siparksky P, et al. Arthroscopic treatment of osteoarthritis of the knee: are there any evidence-based indications? Clinical Orthopaedics and Related Research. 2007;455:107-112.
11. Petty CA, Lubowitz JH. Does arthroscopic partial meniscectomy always cause arthritis? Sports Med Arthrosc. 2012 Jun;20(2):58-61. doi: 10.1097/JSA.0b013e31824fbf3a.
12. Lyu SR. Why arthroscopic partial meniscectomy? Ann Transl Med. 2015 Sep;3(15):217. doi: 10.3978/j.issn.2305-5839.2015.07.04.
13. Englund M, et al. Incidental meniscal findings on knee MRI in middle-aged and elderly persons. New England Journal of Medicine. 2008;359:1108-1115.
14. Stopka SS, Wilson GL, Pearsall AW. Dilution Effect of Intra-articular Injection Administered After Knee Arthroscopy. Dilution Effect of Intra-articular Injection Administered After Knee Arthroscopy.
This article was updated on February 16, 2016 – BW