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.

For patients over the age of 50, please refer to our article Arthroscopic knee surgery when over 50. Are there non-surgical options?

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.

There is a suspicion that patients with prior arthroscopic procedure for knee osteoarthritis have a greater risk of complications should they have to move onto a knee replacement.

A November 2022 study in the journal Archives of orthopaedic and trauma surgery (1) comes to us from a team of international orthopedic surgeons aimed at assessing and confirming that a total knee replacement surgery will have a higher complication rate if the patient had a previous arthroscopic procedure for knee osteoarthritis. The surgeons wrote of their study: “Our hypothesis was that a prior knee arthroscopy may be detrimental to the outcomes of knee arthroplasty (replacement) in the future.”

In this study the researchers reviewed seven retrospective studies, the total number of knee replacements without prior arthroscopies was 138,630, and the total knee replacements after a prior arthroscopy was 4372. Of the five studies that reported functional outcomes, three studies reported no difference, whereas two studies reported worse outcomes in patients with a prior knee arthroscopy. Higher rates of prosthetic joint infection and overall complications were seen in patients with a prior knee arthroscopy.

Conclusion: “Total knee arthroplasty (replacement), when preceded by knee arthroscopy for osteoarthritis may lead to an increase in complication rates like prosthetic joint infections, revision, and re-operations. However, no significant differences were observed in patient-reported functional outcomes and range of joint motion. An association with postoperative complications after subsequent total knee replacement should be a deterrent in advocating this procedure in an arthritic knee.”

So what are the researchers saying:

Finally

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.

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.

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

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 Goyal T, Tripathy SK, Schuh A, Paul S. Total knee arthroplasty after a prior knee arthroscopy has higher complication rates: a systematic review. Archives of Orthopaedic and Trauma Surgery. 2021 Sep 20:1-1. [Google Scholar]

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]
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]
6 Sihvonen R, Paavola M, Malmivaara A, Itälä A, Joukainen A, Nurmi H, Kalske J, Järvinen TL. Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. New England Journal of Medicine. 2013 Dec 26;369(26):2515-24.[Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear] [Google Scholar]
7. Lyu SR. Why arthroscopic partial meniscectomy? Ann Transl Med. 2015 Sep;3(15):217. doi: 10.3978/j.issn.2305-5839.2015.07.04.[Google Scholar]
8. Thorlund JB, Juhl CB, Roos EM, Lohmander LS. Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms. bmj. 2015 Jun 16;350:h2747.[Google Scholar]
16. Englund M, Guermazi A, Gale D, Hunter DJ, Aliabadi P, Clancy M, Felson DT. Incidental meniscal findings on knee MRI in middle-aged and elderly persons. New England Journal of Medicine. 2008 Sep 11;359(11):1108-15. [Google Scholar]

3314

 

Make an Appointment |

Subscribe to E-Newsletter |

Print Friendly, PDF & Email
SEARCH
for your symptoms
Prolotherapy, an alternative to surgery
Were you recommended SURGERY?
Get a 2nd opinion now!
WHY TO AVOID:
★ ★ ★ ★ ★We pride ourselves on 5-Star Patient Service!See why patients travel from all
over the world to visit our center.
Current Patients
Become a New Patient

Caring Medical Florida
9738 Commerce Center Ct.
Fort Myers, FL 33908
(239) 308-4701 Phone
(855) 779-1950 Fax

Hauser Neck Center
9734 Commerce Center Ct.
Fort Myers, FL 33908
(239) 308-4701 Phone
(855) 779-1950 Fax
We are an out-of-network provider. Treatments discussed on this site may or may not work for your specific condition.
© 2022 | All Rights Reserved | Disclaimer