Should I have knee surgery for meniscus tear?
Is surgery necessary for torn meniscus?
One of the most common calls our office receives involves patients who have had part or all of their meniscus removed and are suffering with continued pain or arthritis that was accelerated due to the surgery. What happens when all or part of the meniscus is removed? The long-term side effects of meniscus surgery is that Meniscectomies worsen knee joint instability by negatively influencing other supporting knee structures, increasing contact stress, and leads to arthritis.
When deciding on surgery or non-surgical approaches to their meniscus problem, the first two usual questions patients in our office ask are:
- Should I have knee surgery for meniscus tear?
- Can a meniscus injury heal without surgery?
The idea behind a meniscus surgery is to improve joint stability by removing pain causing damaged tissue, yet as we will see in the research below, meniscectomy often appears to have the opposite effect, as it creates greater instability, crepitation, and degeneration than the initial injury produced prior to operation. Usually a pteint in our office will say the regret the surgery, it certainly was not worth it,
To save the knee, you must save the meniscus
Doctors in France writing in the medical journal Orthopaedics & traumatology, surgery & research, September 2017 are the latest to join the growing list of doctors rallying under the banner “Save the Meniscus!”
This research asks the same question we do, Why do we still perform meniscectomy?
- The French researchers acknowledge that even in late 2017, meniscectomy remains one of the most frequent orthopedic procedures, despite meniscal sparing techniques having been advocated for several decades now.
Why do we ignore a mountain of clinical and scientific evidence against meniscectomy?
- The French team says the number of meniscectomy is excessive in the light of scientifically robust studies demonstrating the interest of meniscal repair or of non-operative treatment for traumatic tear and of non-operative treatment for degenerative meniscal lesions.
- Meniscectomy was long considered the treatment of choice. All but 1 of the 8 recent randomized studies reported non-superiority of arthroscopy over non-operative treatment, which should thus be the first-line choice, with arthroscopic meniscectomy reserved for cases of failure, or earlier in case of “considerable” mechanical symptoms.
They like us agree, it is high time that the paradigm shifted, in favor of meniscal preservation.(1)
Now, let’s get back to the reasons why you may still be recommended to meniscus surgery
Doctors in Germany also publishing in September 2017 says that many of the studies saying that arthroscopic surgery for meniscus is no good are not 100% reflective of the patients they see. Research is broken up into levels of evidence. Level 1 being base evidence which means a researcher took existing research and combined it into a review of the literature. Doctors and researchers grade this the lowest level of accredited research.
The German doctors say too much level 1 evidence is being offered as a generalization of meniscus surgery. The complaint is some surgeries will help some patients and that every meniscus surgery is not a bad surgery and this research is not reflective of that.
- They also cite that according to the consensus statement of ESSKA the European Society of Sports Traumatology, Knee Surgery and Arthroscopy, meniscus surgery is still be recommended.
- So European surgeons have not yet embraced the idea of totally moving away from meniscectomy.
The ESSKA guidelines also say the treatment of degenerative meniscal lesions should start with conservative management. In the case of persistent symptoms, surgery should be considered after 3 months. In the case of mechanical symptoms, arthroscopy might be indicated earlier.
- So there is a window of who the surgery can help. Unfortunately, this small window is usually left wide open to include patients who do not need the surgery.
The other unfortunate thing is the constant and confusing term “conservative treatments.” Our idea of conservative treatments for meniscus tears is not the same as a surgeons view of what conservative care is.
For us conservative care means regenerative medicine, for surgeons conservative care means treatments such as rest, ice, immobilization, anti-inflammatories, painkillers, Hyaluronic Acid Injections for knee osteoarthritis etc, treatments we already have dismissed as ineffective. This is discussed below.
Patients can avoid meniscus surgery, there are alternatives
For many athletes, the appeal of meniscus surgery is very alluring. The belief that the surgery will be a “quick fix,” and provide fast pain relief and mobility and range of knee motion are still the main reasons patients get the surgery. However very few patients are seemingly informed that all meniscus tears are not all surgically repairable and further for many, as stated in vast amounts of medical research, the surgery does more damage than good.
As I write below: if you have a meniscus surgery, chances are you will be disappointed in the outcome and then move onto knee replacement.
Before we discuss the research on meniscus surgery, let’s look at a fascinating new study from the University of Pennsylvania.
The meniscus can have a 90% tear and it will still figure out how to function
The meniscus has a very difficult time healing its own injuries because of a lack of vascularization to the entire meniscus. That is the blood which carries healing elements do not reach all of the meniscus. Because of this, the meniscus is a composite of different types of cells, superficially, those that can heal, those that can’t. This subject is discussed at length in my articles on our alternative to surgery procedures:
- Stem cells for meniscus tears,
- Prolotherapy for meniscus tears.
- Platelet Rich Plasma Therapy for meniscus repair
- The many types of meniscus tears
However, researchers at the University of Pennsylvania examining the meniscus’ complex mesh of fibers that run criss-cross to each other discovered that the two types of meniscus fibers, who jobs are to absorb knee impact, the circumferential fibers and the radial tie fibers have a unique understanding of maintaining knee integrity in the event of meniscus injury.
They write: The meniscus is comprised of circumferentially aligned fibers (basically a mesh) that resist the tensile forces within the meniscus that develop during loading of the knee. Although these circumferential fibers are severed by radial meniscal tears, tibial contact stresses (the impact on the shin bone) do not increase until the tear reaches about 90% of the meniscus width, suggesting that the severed circumferential fibers still bear the load and maintain the mechanical functionality of the meniscus.
Note: The meniscus can have a 90% tear and it will still figure out how to function.
How it does this, is that the radial tie fibers, the perpendicular mesh network of the meniscus is helping to redistribute the knee load back to the severed but still functioning circumferential fibers.
Note: What does all this mean?
The study conclusion spells it out. “This finding supports the notion that radial tie fibers may similarly promote tear tolerance in the knee meniscus, and will direct changes in clinical practice and provide guidance for tissue engineering strategies.”(3)
Meniscus injury may be treated better with non-surgical regenerative medicine.
Now let’s look at the research surrounding meniscus surgery.
Arthroscopic meniscus surgery leads to a three-fold increase in the need for knee replacement
Earlier this year, doctors in the Netherlands published their findings in the medical journal Osteoarthritis Cartilage:
- “In patients with knee osteoarthritis, arthroscopic knee surgery with meniscectomy is associated with a three-fold increase in the risk for future knee replacement surgery.”(4)
November 2016: Research in the medical journal Orthopedics:
- Doctors examine the incidence of total knee arthroplasty (total knee replacement) in patients who have undergone knee arthroscopy for partial meniscectomy, chondroplasty, or arthroscopic debridement of the knee.
- Reported rates of total knee replacement:
- One year: 10.1%
- Two years: 13.7%
- Three years: 15.6%
- Obesity, depressive disorder, rheumatoid arthritis, diabetes, and being age 70 years and older were associated with increased relative risk of conversion to total knee replacement at 2 years.
- When obesity was combined individually with the top 5 other risk factors, no combination produced a higher relative risk than that of obesity alone.
- Patients who were 50 to 54 years of age had the lowest incidence of conversion to total knee replacement.
- Men had a lower incidence of conversion to total knee replacement (11.3%) than women (15.8%).
The study’s doctors suggested that this information can help surgeons to counsel patients on the incidence of total knee replacement after knee arthroscopy and identify preoperative risk factors that increase risk.(5)
Patients undergoing arthroscopic meniscus surgery were too optimistic regarding their recovery time
December 2016: Doctors in Denmark publish these findings:
- “In general, patients undergoing arthroscopic meniscus surgery were too optimistic regarding their recovery time and postoperative participation in leisure activities. This highlights the need for shared decision making which should include giving the patient information on realistic expectations. . . “(6)
Doctors at New York University’s Langone Medical Center investigated the failure rate for surgically repaired bucket-handle meniscus tears at a minimum 2-year follow-up interval. Reporting in the medical journal the Physician and Sports Medicine in May 2017, the doctors looked at 51 patients who experienced bucket-handle meniscus tears that were isolated or occurred with an ACL injury.
- Of the 51 patients that had a bucket-handle meniscal repair, 12 (23.5%) were defined as failures (return of symptoms alongside re-tear in the same zone of the repaired meniscus within two years of surgery). According to the researchers, this is the first study to report outcome scores solely for bucket-handle meniscus repairs, shedding light on the postoperative quality of life of patients with repair success or failure.(7)
Meniscus surgery causes super accelerated knee arthritis.
Do these findings present anything really new? No, research has been ongoing telling patients and doctors of the risks associated with arthroscopic meniscus repair.
It is remarkable that studies more than a decade old have issued the same warnings. In 2005, doctors in Canada audited the effectiveness of certain medical procedures found very poor quality evidence on the effectiveness of arthroscopic debridement of the knee with partial meniscectomy.(8)
The summary of these studies? If you have a meniscus surgery, chances are you will be disappointed in the outcome and then move onto eventual knee replacement.
In research appearing in the medical journal Clinical Anatomy, doctors issued their report on a phenomenon of super-accelerated osteoarthritis in knees with meniscus tear damage and history of surgical meniscus removal.
Coming out of Tufts Medical Center in Boston, the researchers noted that knee osteoarthritis is typically a slow, progressive problem; however, in some patients knees progressed to osteoarthritis with dramatic rapidity. However, clinicians cannot determine which patients may be at risk for accelerated knee osteoarthritis without knowing the incident structural damage that predisposes a knee to accelerated osteoarthritis. The Tuft researchers found that structural damage that is associated with accelerated knee osteoarthritis destabilizes and compromises the function of the meniscus or compromises the subchondral bone.(9) More commonly known as Knee Instability.
In an early study researchers from the Department of Orthopaedic Surgery at Carolinas Medical Center found that a damaged meniscus is the active participant in the development of knee osteoarthritis. In the study above, the relationship to bone damage is discussed, in this cited study the Carolinas Medical team found a strong association between meniscus damage and cartilage loss.(10) The two combined studies help confirm missing meniscal tissue contributes to bone and cartilage degeneration.
Meniscus repair failure – Arthroscopic meniscus surgery
Doctors at the Hospital of Special Surgery found that meniscus removal, not only impacts the knee at the point of the surgery but throws the whole knee out of balance and leads to several points of cartilage deterioration.(11)
What is really remarkable is that researchers write paper after paper saying that removal of meniscal tissue in surgery causes advanced osteoarthritis and the procedures continue.
Clearly, the best way to prevent cartilage breakdown and knee osteoarthritis caused by meniscal surgery is to AVOID the surgery.
Dr. Gordon H. Guyatt, a professor of medicine and epidemiology at McMaster University in Hamilton, Ontario, who wrote (an) editorial in The British Medical Journal, which he called arthroscopic meniscal surgery “A highly questionable practice without supporting evidence of even moderate quality.”
Dr. Guyatt was quoted in the Times “I personally think the operation should not be mentioned (to the patient as an option),” he says, adding that in his opinion the studies indicate the pain relief after surgery is a placebo effect. But if a doctor says anything, Dr. Guyatt suggests saying this:
“We have randomized clinical trials that produce the highest quality of evidence. They strongly suggest that the procedure is next to useless. If there is any benefit, it is very small and there are downsides, expense, and potential complications.”
Hearing that, he says, “I cannot imagine that anybody would say, ‘Go ahead. I will go for it.’”
Nearly twenty years ago in the first edition of our book Prolo Your Pain Away – we told patients that if the surgeon removes the meniscus, arthritis is the end result. Further, since the meniscus aids in the stability of the knee, if removed the knee is left with too much motion and becomes unstable.
Arthroscopic Partial Meniscectomy versus Sham Surgery for a Degenerative Meniscus Tear – Surgery does not alleviate knee catching or knee locking after surgery
The research mentioned above and reported by the New York Times was not the first time the meniscus surgery controversy was reported in the mainstream media. On December 24, 2013, the New England Journal of Medicine published an article entitled “Arthroscopic Partial Meniscectomy versus Sham Surgery for a Degenerative Meniscal Tear.”
This was the work of Finnish researchers who recognized that arthroscopic partial meniscectomy is one of the most common orthopedic procedures, yet rigorous evidence of its efficacy is lacking.
So what they did was to conduct a multicenter, randomized, double-blind, sham-controlled trial in 146 patients 35 to 65 years of age who had knee symptoms consistent with a degenerative medial meniscus tear and no knee osteoarthritis.
Patients were randomly assigned to arthroscopic partial meniscectomy or sham surgery. Then a scoring system was designed to measure pain, symptom severity, and knee pain after exercise at 12 months after the procedure.
What they found was “In this trial involving 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 a sham surgical procedure.”
Earlier in 2013 research published in the American Journal of Sports Medicine showed what little value meniscectomy has. Researchers compared meniscectomy to nonoperative treatment for meniscus tears.(12)
They specifically studied degenerative horizontal tears of the medial meniscus and hypothesized that surgical treatment would produce better outcomes than nonoperative strengthening exercises.
This study was a randomized controlled trial with the highest level of evidence (level 1). The study had 102 patients with medial meniscus tears – 81 women and 21 men with the average age of 53.8.
Fifty patients underwent arthroscopic meniscectomy while 52 participated in nonoperative strengthening exercises. The results did not match up the to researchers hypothesis.
At the two year follow-up, there was no difference in pain relief, improved knee function or patient satisfaction. Results also showed that meniscectomy did not provide better functional improvement than the nonoperative group.
But what was the difference between these two groups? One group of patients underwent invasive surgery, had tissue remove, and will likely experience long-term meniscus degeneration.
In fact, most surgical meniscus treatments have, “all have a high long-term failure rate with the recurrence of symptoms including pain, instability, locking, and re-injury. The most serious of the long-term consequences is an acceleration of joint degeneration.”
So, even if the knee is stabilized, removing the meniscus causes osteoarthritis. Consider this conclusion from a medical paper published in late 2014:
In this study from China, doctors said that an arthroscopic partial meniscectomy is a good option for a medial meniscal tear in late middle-aged adults. For best success, you need a proper diagnosis and excellent surgical technique. If you follow these two rules all the patients could get good clinical results, HOWEVER, “there are some patients with motion restrictions in the early stage after the operation.” (13)
In research from May 2016, doctors warned that the role of arthroscopic partial meniscectomy in reducing pain and improving function in patients with meniscal tears continues to remain controversial and that studies show no difference between arthroscopic partial meniscectomy and non-surgical treatment. (14)
In July 2017 doctors from medical universities in Finland combined their research to publish these findings on Arthroscopic partial meniscectomy in the Annals of the Rheumatic Diseases.
- Arthroscopic partial meniscectomy is one of the most common orthopaedic 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 randomised 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 represents 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.
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
- 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.(15)
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 concluded:
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. (16)
Why was the primary treatment for a meniscus tear a complete meniscectomy?
Why was the primary treatment for a meniscal tear a complete meniscectomy, a surgery that removed the entire meniscus from the knee? Why in the patient base that seemed the most likely to need a meniscus?
A typical patient profile for this procedure was a younger, active, athletic patient who through their lifestyle accelerated knee overuse, and, the older patient who suffered from degenerative osteoarthritis.
The goal of complete meniscectomy was to reduce pain, restore knee function, and prevent the development of osteoarthritis. As surgeons had long believed that the meniscus was a “remnant” tissue and that it was not needed, it could be removed if damaged without a negative effect.
However, as medical research studied the long-term effects of this procedure, it became apparent in the medical community that complete meniscectomy was a primary cause of the sudden onset of knee osteoarthritis. The meniscus was, in fact, an important component of the knee.
The meniscus provides several vital functions including mechanical support, localized pressure distribution, and lubrication to the knee joint. They are made of thick fibrous cartilage that allows it to function as a shock absorber between the upper and the lower leg bones.
Even the American Academy of Orthopedic Surgeons was unable to come up with evidence to support the use of partial meniscectomy.
They looked at a study comparing arthroscopic partial meniscectomy to a conservative exercise program.(18)
- The authors reported no significant treatment benefits of meniscectomy and at the 6 month follow up there was no difference noted between the two groups, “in terms of reduced knee pain, improved knee function and improved quality of life.” Not only was there no benefit, but it is important to note that surgical treatment for meniscal injuries can result in an acceleration of cartilage degeneration and an increased rate of osteoarthritis.
Is there recovery after an arthroscopic meniscus surgery?
Some of the questions patients want to be answered when they compare non-surgical to surgical treatment of meniscus tears are:
- What is the recovery time after meniscus surgery?
- For many in regenerative medicine, this is a trick question because as the independent research cited in this article makes clear your meniscus will never recover and your knee will be made that much weaker.
- Follow the timeline after surgery
- Most patients can stand and put weight on their knee somewhat immediately with help of a knee brace
- Typically a patient can walk without crutches a few days to 6 weeks after meniscus surgery. Depending on narcotic pain medication doses
- Range of motion restored 1 – 6 weeks depending on surgical procedure
- Return to sports 4 weeks to 6 months
While these numbers sound reasonable they are not for the patients in the long-run. Non-surgical treatments such as comprehensive Prolotherapy typically and for a realistic expectation of treatment success are offered at about 6-week intervals and on average see results at the third treatment – anywhere from 12 – 18 weeks after first treatment.
The difference is: While meniscus surgery can offer short-term goals the knee is in a downward spiral of joint instability to osteoarthritis to degenerative joint disease. In Comprehensive Prolotherapy, the knee joint instability is restored by repairing and regenerating tissue.
Danielle Steilen-Matias, PA-C | Katherine Worsnick, PA-C | Ross Hauser, MD | David Woznica, MD
1 Beaufils P, Pujol N. Management of traumatic meniscal tear and degenerative meniscal lesions. Save the meniscus. Orthop Traumatol Surg Res. 2017 Sep 2. pii: S1877-0568(17)30231-1 [Google Scholar]
2 Becker R, Bernard M, Scheffler S, Kopf S. Treatment of degenerative meniscal lesions : From eminence to evidence-based medicine. Orthopade. 2017 Sep 5. doi: 10.1007/s00132-017-3465-8. [Google Scholar]
3 Bansal S, Mandalapu S, Aeppli C, Qu F, Szczesny SE, Mauck RL, Zgonis MH. Mechanical function near defects in an aligned nanofiber composite is preserved by inclusion of disorganized layers: Insight into meniscus structure and function. Acta Biomaterialia. 2017 Feb 1. [Google Scholar]
4 Rongen JJ, Rovers MM, van Tienen TG, Buma P, Hannink G. Increased risk for knee replacement surgery after arthroscopic surgery for degenerative meniscal tears: a multi-center longitudinal observational study using data from the osteoarthritis initiative. Osteoarthritis Cartilage. 2017 Jan;25(1):23-29. [Google Scholar]
5 Boyd JA, Gradisar IM. Total Knee Arthroplasty After Knee Arthroscopy in Patients Older Than 50 Years. Orthopedics. 2016 Nov 1;39(6):e1041-e1044. doi: 10.3928/01477447-20160719-01. Epub 2016 Jul 27. [Google Scholar]
6 Pihl K, Roos EM, Nissen N, JøRgensen U, Schjerning J, Thorlund JB. Over-optimistic patient expectations of recovery and leisure activities after arthroscopic meniscus surgery: A prospective cohort study of 478 patients. Acta Orthopaedica. 2016;87(6):615-621. [Google Scholar]
7. Moses MJ, Wang DE, Weinberg M, Strauss EJ. Clinical outcomes following surgically repaired bucket-handle meniscus tears. Phys Sportsmed. 2017 May 16. [Google Scholar]
8. Health Quality Ontario. Arthroscopic lavage and debridement for osteoarthritis of the knee: an evidence-based analysis. Ontario health technology assessment series. 2005;5(12):1. [Google Scholar]
9 Driban JB, Ward RJ, Eaton CB, Lo GH Lyn Price, Lu B8, McAlindon TE. Meniscal extrusion or subchondral damage characterize incident accelerated osteoarthritis: Data from the Osteoarthritis Initiative. Clin Anat. 2015 Jul 6. [Google Scholar]
10. Sun Y, Mauerhan DR, Honeycutt PR, Kneisl JS, Norton JH, Hanley EN Jr, Gruber HE. Analysis of meniscal degeneration and meniscal gene expression. BMC Musculoskelet Disord. 2010 Jan 28;11:19. doi: 10.1186/1471-2474-11-19. [Google Scholar]
11. Maher S, Wang H, Koff MF, Belkin N, Potter HG, Rodeo S. A clinical platform for understanding the relationship between joint contact mechanics & articular cartilage changes after meniscal surgery. J Orthop Res. 2016 Jul 13. [Google Scholar]
12. Yim JH, Seon JK, Song EK, Choi JI, Kim MC, Lee KB, Seo HY. A comparative study of meniscectomy and nonoperative treatment for degenerative horizontal tears of the medial meniscus. The American journal of sports medicine. 2013 Jul;41(7):1565-70. [Google Scholar]
13. Liu JS, Li ZY. Arthroscopic partial meniscectomy for medial meniscal tear in late middle-aged adults. Zhongguo gu shang= China journal of orthopaedics and traumatology. 2014 Aug;27(8):631-4. [Google Scholar]
14. Ha AY, Shalvoy RM, Voisinet A, Racine J, Aaron RK. Controversial role of arthroscopic meniscectomy of the knee: A review. World Journal of Orthopedics. 2016;7(5):287-292. [Google Scholar]
15 Sihvonen R, Paavola M, Malmivaara A, Itälä A, Joukainen A, Nurmi H, Kalske J, Ikonen A, Järvelä T, Järvinen TA, Kanto K. Arthroscopic partial meniscectomy versus placebo surgery for a degenerative meniscus tear: a 2-year follow-up of the randomised controlled trial. Annals of the Rheumatic Diseases. 2017 May 18:annrheumdis-2017. [Google Scholar]
16 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]
17. Herrlin S, Hållander M, Wange P, Weidenhielm L, Werner S. Arthroscopic or conservative treatment of degenerative medial meniscal tears: a prospective randomised trial. Arthroscopic or conservative treatment of degenerative medial meniscal tears: a prospective randomised trial. Knee Surg Sports Traumatol Arthrosc. 2007;15(4):393-401. [Google Scholar]