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:

• 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.

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:

• 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.
• While the patients did not report problems with functional outcomes and range of joint motion higher rates of prosthetic joint infection and overall complications were seen in patients with a prior knee arthroscopy

Finally

• An association with postoperative complications after subsequent total knee replacement should be a deterrent in advocating this procedure in an arthritic knee.”

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.

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.

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

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

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?

3314

• Surgery
• NSAIDs
• Cortisone Shots
• R.I.C.E.