Research: Arthroscopic knee surgery risks may outweigh benefits

Ross A. Hauser, MD. Caring Medical Florida
Danielle R. Steilen-Matias, MMS, PA-C. Caring Medical Florida
David N. Woznica, MD. Caring Medical Regenerative Medicine Clinics, Oak Park, IL

Arthroscopic knee surgery may not work and in fact, may be harmful

There are many people waiting for knee surgery. During their waiting time, they are being pain managed as best as possible. While some people may benefit from waiting for an arthroscopic knee surgery procedure, researchers have been questioning whether these surgeries provide any benefit at all for some patients and in fact, do these surgeries put the patient at risk.

Doctors and researchers are confirming arthroscopic knee surgeries for meniscus and cartilage “repair” do not heal, do not repair, and may accelerate knee instability and the degenerative collapse of the knee.

In this article, we will see research that questions the benefits of arthroscopic knee surgery in the long-term. We do realize that for a young athlete, many are presented with arthroscopic surgery as a means to get them playing quickly. Many do get back to sport within months, many do not. The same can be said for the older athlete who works hard to stay active. The same can be said for the patient with a physically demanding line of work. Later in this article, we will present evidence for non-surgical knee repair.

A study that challenges a surgical practice used for decades – debridement during arthroscopic meniscus surgery says it does not help patients

July 18, 2017. This is a portion of a press release from the University of Buffalo news center:

“A team of University at Buffalo medical doctors has published a study that challenges a surgical practice used for decades during arthroscopic knee surgery.”

What they questioned was debridement, the cleaning out, clipping, or smoothing of any dislodged cartilage they found in the knee with the belief it was helping patients. These bits of cartilage are usually found incidentally in arthroscopic meniscus surgery. Listen to the results of the study:

Patients who did not have dislodged cartilage removed, recovered faster

“the new study finds that practice does not benefit the patient. Patients who did not have dislodged cartilage removed, recovered faster, with less pain, and ended up a year later with identical results.”

Here are the highlight points of this research published in The Journal of Bone and Joint Surgery.(1)

• If you did not have debridement during arthroscopic meniscus surgery you:
  • recover faster
  • with less pain
  • and will likely have identical results to those who had the cartilage bits shaved away.

“Those with less surgery got better faster in comparison with the people we did more surgery on”

“Those with less surgery got better faster in comparison with the people we did more surgery on,” said Leslie J. Bisson, MD, professor and chair in the Department of Orthopaedics at the Jacobs School of Medicine and Biomedical Sciences at the University of Buffalo and lead author of the study.

The finding was so surprising that an editor at The Journal of Bone & Joint Surgery, which published the study, also published a commentary that said, “The conclusion that unstable cartilage lesions do not need debridement could have a dramatic impact on practice management, save health-care dollars, and improve early patient outcomes.” University of Buffalo news center.

As mentioned, these were surprising findings so other researchers set out to support or disclaim these results.

Microfracture or surgical debridement of cartilage damage with ACL rupture: Helpful? Not helpful?

An August 2018 study in the Orthopaedic Journal of Sports Medicine (2) examined the effect of microfracture or surgical debridement of full-thickness cartilage tears that were injured at the same time the patient suffered a ruptured ACL (anterior cruciate ligament). The researchers compared microfracture or surgical debridement with no surgical treatment on patient-reported outcomes five years after anterior cruciate ligament reconstruction (ACLR).

The illustration here is that an injury significant enough to rupture an ACL would provide significant damage to the meniscus to likely warrant a surgery. The results, surgery to fix the meniscus damaged in this way, probably not helpful. Here is what the researchers said:

Results: Compared with no surgical treatment, there were no unadjusted or adjusted effects of microfracture or surgical debridement of concomitant full-thickness cartilage lesions on KOOS scores at 5-year follow-up. (The Knee injury and Osteoarthritis Outcome Score (KOOS) is used to help evaluate short-term and long-term symptoms of knee injury and function.)

CONCLUSION: Compared with leaving concomitant full-thickness cartilage lesions untreated at the time of anterior cruciate ligament reconstruction, microfracture or surgical debridement showed no effect on patient-reported outcomes five years after surgery.

Simply the evidence that the surgery works or does not work or results in people being put on the fast track to knee replacement is uncertain.

Some researchers, however, claim that there is not enough of this evidence to suggest that arthroscopic knee surgery is all bad.

In July 2019, researchers at the University of Oxford (3) did a review of the medical studies published on the subject and came up with these findings. They may be confusing to you. Because they sound confusing:

• “There was low-quality evidence (evidence was no that strong) that there may be no evidence of a difference between arthroscopic partial meniscectomy surgery and a home exercise program for the treatment of this condition. (The researchers are saying that the evidence that home exercise works just as well as the surgery is not strong).
• Similarly, low-quality evidence from a few small trials indicates there may not be any benefit of arthroscopic surgery over other non-surgical treatments including saline irrigation and hyaluronic acid injection, or one type of surgery over another. (However, there is some evidence that the surgery does not work better than hyaluronic acid injections or saline injections).
• “We are uncertain of the risk of adverse events or of progressing to total knee replacement due to very small event rates.” (The researchers were not sure if arthroscopic surgery lead to knee replacement).
• Thus, there is uncertainty around the current evidence to support or oppose the use of surgery in mild to moderate knee osteoarthritis.

Simply the evidence that the surgery works or does not work or results in people being put on the fast track to knee replacement is uncertain.

Doctors issue warnings to Middle Age Patients – arthroscopic knee surgery accelerates osteoarthritis and NEED FOR KNEE REPLACEMENT

Published in the Annals of the rheumatic diseases, (4) doctors from medical universities in Finland combined their research to publish these findings on Arthroscopic partial meniscectomy. For much more research on knee surgery for meniscus tears please see our article Knee Surgery for Meniscus Tears | Complications and Outcomes.

Here are the findings of the Finnish study:

• Arthroscopic partial meniscectomy is one of the most common orthopedic operations with the number of procedures steadily increasing in the last three decades.
• Most are performed on middle-aged and older patients with knee symptoms and degenerative knee disease.
• Several recent meta-analyses based on randomized controlled trials have failed to show a treatment-benefit of Arthroscopic partial meniscectomy over conservative treatment or placebo surgery for these patients.

Here is the conclusion of the study, what you will find is all the reasons people tell us they NEED arthroscopic knee surgery, are NOT supported

• The widely held assertion that symptoms such as the sensation of knee catching or locking represent a valid indication for arthroscopic surgery.
• Resection of a torn meniscus has no added benefit over placebo surgery in relieving knee catching or occasional locking. (This was shown by this same research team in an earlier study that we will discuss below).

In conclusion, the results of this study showed Arthroscopic partial meniscectomy provides no significant benefit over placebo surgery in patients with a degenerative meniscal tear and no knee osteoarthritis.

Two studies demonstrate that arthroscopic surgery is no better than sham surgery

• The researchers concluded that these results support the evolving consensus that degenerative meniscus tear represents an (early) sign of knee osteoarthritis, rather than a clinical entity on its own, and accordingly, caution should be exercised in referring patients with knee pain and suspicion of a degenerative meniscal tear to MRI examination or Arthroscopic partial meniscectomy, even after a failed attempt of conservative treatment.

As noted above this same team of researchers followed up on a previous study. As part of the Finnish Degenerative Meniscal Lesion Study Group their study in the medical journal Annals of Internal Medicine (5) 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.

While these two studies demonstrate that arthroscopic surgery is no better than sham surgery, the same research team also published the landmark December 2013 study in The New England Journal of Medicine.(6)

The conclusion of this research which was heavily covered in the news media:

• “The results of this randomized, sham-controlled trial show that arthroscopic partial medial meniscectomy provides no significant benefit over sham surgery in patients with a degenerative meniscal tear and no knee osteoarthritis. These results argue against the current practice of performing arthroscopic partial meniscectomy in patients with a degenerative meniscal tear.”

Dr. Shaw-Ruey Lyu, a noted Taiwanese researcher with a specialty in problems of knee osteoarthritis noted in his paper published in the Annals of Translational Medicine that the above study since the number of Arthroscopic partial meniscectomy performed has been increasing, the information provided by this study should lead to a change in the clinical care of patients with a degenerative meniscus tear.(7) We are going to return to this study later in this article.

More research warning middle-aged and older patients to avoid arthroscopic knee surgery

Research in the British Medical Journal was scathing(8): Here are their bullet points:

• Arthroscopic knee surgery is frequently and increasingly used to treat middle-aged and older patients with persistent knee pain
• All but one published randomized trials have shown no added benefit for arthroscopic surgery over that of the control treatment, but many specialists are convinced of the benefits of the surgical intervention
• Interventions that include arthroscopy are associated with a small benefit and with harms; the small benefit is inconsequential and of short duration
• The benefit is markedly smaller than that seen from exercise therapy as a treatment for knee osteoarthritis
• These findings do not support the practice of arthroscopic surgery as a treatment for middle-aged or older patients with knee pain with or without signs of osteoarthritis.

In an accompanying press release from the British Medical Journal, the research team issued these statements:

• “Interventions that include arthroscopy are associated with a small benefit and with harms,” and the benefit is “markedly smaller than that seen from exercise therapy.”
• These findings “do not support the practice of arthroscopic surgery as a treatment for middle-aged or older patients with knee pain with or without signs of osteoarthritis.”
• “It is difficult to support or justify a procedure with the potential for serious harm, even if it is rare, when that procedure offers patients no more benefit than placebo,” argues Professor Andy Carr from Oxford University in an accompanying editorial.

Here is more damning evidence for patients to avoid arthroscopy knee surgery and comes from two (May 2017) multi-national team studies from surgeons in the British Medical Journal.

Here are the bulletin points from this research:

In the first study, a panel led by Canadian researchers from McMaster University, and supported by data from doctors at the University of Toronto; University researchers in Australia; University Hospitals of Geneva, Switzerland; the Netherlands; Chile; Norway; and the United States, published the study entitled: Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline and made these recommendations:

• “We make a strong recommendation against the use of arthroscopy in nearly all patients with degenerative knee disease, based on linked systematic reviews; further research is unlikely to alter this recommendation”
• “This recommendation applies to patients with or without imaging evidence of osteoarthritis, mechanical symptoms, or sudden symptom onset.”
  • Note: The doctors of this study say plainly: Even if your MRI shows knee osteoarthritis – don’t get an arthroscopic procedure.

Here is the summary given to surgeons:

• The panel is confident that arthroscopic knee surgery does not, on average, result in an improvement in long-term pain or function.
• Most patients will experience an important improvement in pain and function without arthroscopy.
• However, in less than 15% of participants, arthroscopic surgery resulted in a small or very small improvement in pain or function at three months after surgery—this benefit was not sustained at one year.
• In addition to the burden of undergoing knee arthroscopy there are rare but important harms (complication and side effect).(9)

The second study:
A new study that literally combed the world looking for the long-term benefits of knee arthroscopic surgery has been published in the British Medical Journal Open (on-line edition). In this research, an international team of doctors including lead researchers from McMaster University in Canada, the Universidad de Chile, Monash University in Australia, University Hospital Basel, Switzerland, Kerman University of Medical Sciences in Iran, and the University of Oslo, Norway, tried to determine the effects and complications of arthroscopic surgery compared with conservative management strategies in patients with degenerative knee disease.

Here are the highlights of this research:

• With respect to pain, the review identified high-certainty evidence that knee arthroscopy results in a very small reduction in pain up to 3 months and very small or no pain reduction up to 2 years when compared with conservative management.
• With respect to function, the review identified moderate-certainty evidence that knee arthroscopy results in a very small improvement in the short term and very small or no improved function for up to 2 years.
• Over the long term, patients who undergo knee arthroscopy versus those who receive conservative management strategies do not have important benefits in pain or function.(10)

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.
• Removal of inflamed synovial tissue that lines the joint capsules can lead to fluid accumulation in the knee.

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.

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?

Many past studies have concluded that surgery for osteoarthritis is not effective, not warranted, and basically should be avoided. So the idea is not new.

• In 2014 a  research team from McMaster University writing in the journal of the Canadian Medical Association says that evidence suggests that there is no benefit to arthroscopic meniscal debridement for degenerative meniscal tears.(11)
• Also in 2014, a study from Monash University in Australia researchers published in the Current opinion in rheumatology suggest that the use of arthroscopy to treat knee osteoarthritis has not declined despite strong evidence-based recommendations that do not sanction its use.(12)
• German researchers writing in the German language journal Sportverletz Sportschaden Sports injury Sports damage note that in the 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.”(13)
• As far back as 2002, doctors wrote in the New England Journal of Medicine that middle-aged or older patients with knee pain with or without signs of osteoarthritis should not be recommended for arthroscopic surgery. (14) This study, by the way, is from 2002. So the studies have been ongoing for some time.
• In 2007 doctors at the University of Colorado School of Medicine published in the journal Clinical Orthopaedics and Related Research.”Despite the lack of consensus guidelines and randomized control trials, the use of arthroscopy for the treatment of osteoarthritis of the knee has increased . . . Techniques used for the arthroscopic treatment of osteoarthritis of the knee include joint lavage, joint débridement, meniscectomy, abrasion arthroplasty, and microfracture.  We found limited evidence-based research to support the use of arthroscopy as a treatment method for osteoarthritis of the knee. Arthroscopic débridement of meniscus tears and knees with low-grade osteoarthritis may have some utility, but it should not be used as a routine treatment for all patients with knee osteoarthritis.”(15)

Arthroscopic knee surgery for osteoarthritis is not curative yet the numbers performed are increasing, is this the placebo effect?

Is arthroscopic knee surgery a placebo? In some of the studies referenced above and noted below, doctors are questioning whether the beneficial aspects of arthroscopic surgery reported in the literature were simply due to the placebo effect.

We are going back to the July 2017 published in the Annals of the Rheumatic Diseases from the Finnish university researchers:

“In this 2-year follow-up of 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 placebo surgery.”

In the study, the researchers did indeed perform placebo surgery. The doctors took 146 patients and randomized them into two groups.

• First group, 76 patients had an actual arthroscopic partial meniscectomy
• Second group, 70 patients had a placebo surgery. Incisions were made to make the patient believe they had a surgery

As stated above: “(they) found no statistically significant difference between the arthroscopic partial meniscectomy and placebo surgery for symptomatic patients with a degenerative meniscus tear and no osteoarthritis in any of the used outcome measures over the course of 24-month follow-up. No evidence could be found to support the prevailing ideas that patients with presence of mechanical symptoms or certain meniscus tear characteristics or those who failed initial conservative treatment are more likely to benefit from arthroscopic partial meniscectomy.”

The presence of mechanical symptoms – the justification of arthroscopic surgery – the loophole

All the research above has come to this conclusion, arthroscopic knee surgery for osteoarthritis is not curative. In summary, this agrees with the mounting level of evidence that arthroscopy doesn’t work any better than conservative care 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 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.

Let’s return to the study by Dr. Shaw-Ruey Lyu. In that research, Dr. Lyu asked:

• Why do we perform arthroscopy for a patient?
  • Is it for symptoms relief?
  • Prevention of cartilage degeneration?
  • Or just for the removal of the torn meniscus itself?
• Knee pain is usually the main reason that patients seek help.
• Arthroscopic partial meniscectomy is typically advocated for patients with knee pain in whom a tear is confirmed by MRI, particularly those without concomitant knee osteoarthritis.
• However, increasing evidence suggests that a degenerative meniscal tear may be an early sign of knee osteoarthritis rather than a separate clinical problem requiring meniscal intervention.
• This suggests that the current practice of performing Arthroscopic partial meniscectomy in patients with an accidentally found degenerative meniscal tear. More possibilities should be taken into consideration before making this decision.

MRIs can be misleading when diagnosing pain

The accidental finding of damage that is not causing the patient pain. Despite what a patient’s MRI will say, 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.(16)

• 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!

Non-Surgical Options

In this video Danielle R. Steilen-Matias, MMS, PA-C, gives an introduction to treatment.

We use non-surgical treatments for meniscus tears. We may use our Prolotherapy treatments and PRP. This is an in-office injection treatment.

• Dextrose Prolotherapy is a simple sugar injection into the knee that attracts you own healing repair cells into the area to fix the damaged meniscus
• In some patients, it may not be enough to attract your own cells to this damaged area with Prolotherapy, in this type case we may have to put cells there via injection. Our first option would be Platelet Rich Plasma (PRP) Prolotherapy. This would put the healing factors found in your blood platelets into the damaged joint.
  • WE DO NOT offer PRP as a stand-alone treatment or injection. While PRP brings healing cells into the joint, it acts to repair degenerative damage. In our experience, while PRP addresses damage deep in the such as a meniscus, we must still address the joint instability problem created around the knee. We do this with Prolotherapy. Here damaged or weakened ligaments that are simply “stretched,” can be strengthened with treatment to help restore and maintain normal joint mobility. We discuss the meniscus interaction with the MCL in a moment. Simple PRP on the inside, Prolotherapy on the outside of the joint.
  • PRP is injected at the meniscus with ultrasound guidance
• Most meniscal tears require four to six treatments although that could be less or more depending on the patient.
• What helps our success rate with meniscal tears is our treatment of the MCL or the medial collateral ligament at the same time.
• We will use of ultrasound machine to access the integrity of the MCL

Platelet Rich Plasma Therapy and Prolotherapy, which stimulates tendons, ligaments, and cartilage to heal, has many advantages over arthroscopy, which include:

• These treatments are considered 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

In this video, Ross Hauser, MD explains a Prolotherapy knee treatment as performed at our Caring Medical clinics. This is not typical of the way treatment may be performed in other doctor’s offices.

Video learning and demonstrated points:

• Prolotherapy is an injection technique that stimulates growth factor cells that work to repair damaged joints.
• Prolotherapy can be very helpful in patients with knee instability or hypermobility caused by damaged knee ligaments and tendons. Knee instability is a cause of knee osteoarthritis and degenerative wear and tear.
• In this video, Ross Hauser, MD is seen demonstrating intra-articular (inside the knee) as well as injections surrounding the outside of the knee.
• In addition to knee osteoarthritis, Prolotherapy injections can help patients with problems that will eventually lead to degenerative knee disease.
  • Patellofemoral pain syndrome and patellofemoral tracking problems.
  • Weakened and damaged ligaments and tendons and their attachments to the bones and muscles that make the knee work.
• In the video, you see that Dr. Hauser is injecting into the
  • The Knee’s medial joint line here where the medial collateral ligament is.
  • The pes anserine tendon
  • The medial patellar retinaculum tendon
  • The distal quadriceps attachments
  • The lateral joint line where the lateral collateral ligament is located.
  • The attachment of the iliotibial band
  • The capsular knee ligament attachments

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In this video, Ross Hauser, MD demonstrates an ultrasound examination of a patient’s knee with COMPLETE LOSS OF ARTICULAR CARTILAGE

• At 1:14 the patient’s knee instability caused COMPLETE LOSS OF ARTICULAR CARTILAGE
• In this patient, we would recommend Prolotherapy to the ligaments and stem cell treatment into the joint. Prolotherapy to address the knee instability and stem cell treatments to address the cartilage issue.
• We rarely offer stem cell treatments. In this case, the complete loss of cartilage in the knee calls for it.

These articles will provide more information about looking at options:

• PRP injections for meniscus tears
• Do stem cell injections for knee meniscus tears and post-meniscectomy work?
• Prolotherapy for Meniscus Tears
• Prolotherapy knee osteoarthritis injections
• Arthroscopic surgery and stem cells – the best of both worlds?

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