Research: Arthroscopic knee surgery risks may outweigh benefits

Ross A. Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C

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

A story we hear goes something like this:

I have had three arthroscopic knee surgery cleanouts and repair and removal of tissue. I still have pain. Following the last surgery it was recommended to me that the next surgery should be a knee replacement but, because of my age, my surgeon will only perform the surgery if I get to the point where I cannot walk. To manage my pain I have had cortisone, hyaluronic acid gel injections, and Platelet Rich Plasma injections. I have a significant limp and have to deal with this, as I need to work and would like to play with my children.

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)

“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:

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:

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

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

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:

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:

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

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:

Here is the summary given to surgeons:

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:

According to the  American Orthopaedic Society for Sports Medicine:
Arthroscopy for the knee is most commonly used for:

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?

Should the doctors not let what the patients are telling them help guide their treatments?

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.

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.

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.

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:

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)

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.

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

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:

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

These articles will provide more information about looking at options:

Do you have a question about Arthroscopic knee surgery for osteoarthritis? Get help and information from our Caring Medical staff

References for this article Arthroscopic knee surgery for osteoarthritis

1 Bisson LJ, Kluczynski MA, Wind WM, Fineberg MS, Bernas GA, Rauh MA, Marzo JM, Zhou Z, Zhao J. Patient Outcomes After Observation Versus Debridement of Unstable Chondral Lesions During Partial Meniscectomy: The Chondral Lesions And Meniscus Procedures (ChAMP) Randomized Controlled Trial. JBJS. 2017 Jul 5;99(13):1078-85. [Google Scholar]
2 Ulstein S, Årøen A, Engebretsen L, Forssblad M, Lygre SH, Røtterud JH. A Controlled Comparison of Microfracture, Debridement, and No Treatment of Concomitant Full-Thickness Cartilage Lesions in Anterior Cruciate Ligament–Reconstructed Knees: A Nationwide Prospective Cohort Study From Norway and Sweden of 368 Patients With 5-Year Follow-up. Orthopaedic journal of sports medicine. 2018 Jul 30;6(8):2325967118787767. [Google Scholar]
3 Palmer JS, Monk AP, Hopewell S, Bayliss LE, Jackson W, Beard DJ, Price AJ. Surgical interventions for symptomatic mild to moderate knee osteoarthritis. Cochrane Database of Systematic Reviews. 2019(7). [Google Scholar]
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5 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 Mechanical Symptoms and Arthroscopic Partial Meniscectomy. Annals of internal medicine. 2016 Apr 5;164(7):449-55. [Google Scholar]
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