Should I have meniscus surgery? Should I have another meniscus surgery?
Ross A. Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C.
Many people who contact our office are in a decision-making process. The decision is to get a meniscus surgery, or, get some type of non-surgical treatment. Many times when we initially discuss meniscus surgery options with people interested in treatment, we ask them if they know what type of surgery are they going to get, total meniscectomy, partial meniscectomy, or suture repair? Many times they do not know because the surgeon told them they themselves do not know what they are going to have to do until they “get in there.”
In this article we will focus on post-meniscus recovery. Why some patients may have continued or worsening knee problems after meniscus surgery and subsequent treatment recommendations.
Many people have successful meniscus surgeries. These are typically not the people we hear from. We hear from the people whose surgery did not meet hoped for results.
Getting in there, the clean-up surgery
Many times we will hear from people that when the doctor gets into his/her knee, they will “clean things up” and get these people back on their way. The clean up procedure is ususally recommended to someone who in the past has “fought through” knee pain, had past injuries without standardized treatments including surgery and has recently done something to aggravate their knee. Many of these people will likely require some type of surgical procedure if they can no longer bend their knee or walk without significant pain. However, many people are nolt recommended to surgery because their knee is already in a wear and tear degenerative state and the surgical procedure may accelerate the person’s knee osteoarthritis. The patient can in some instances be stuck in the “rock and a hard place scenario.” Get the surgery and accelerate the knee osteoarthritis, don’t get the surgery and figure out some other types of treatments. All during this time the person figures out clever ways to get in and out of chairs, beds, and cars without significant pain while doing so. At some point, for many people, something needs to be done and that something is surgery.
Waiting until the arthroscopic procedure to figure out what type of surgery I am getting. My MRI was not helpful.
Why do your doctors want to “get in there” and see what is going on? Because your MRI may be leading you down a poor treatment choice path. An April 2021 paper in the Australian and New Zealand Journal of Surgery (1) suggested while “Magnetic resonance imaging (MRI) is commonly used for diagnosis and as a research tool, but its accuracy is questionable.” They further wrote that the goal of their study was to compare the accuracy of knee MRI with clinical (in surgery) assessment for diagnosing meniscal tears and to determine the accuracy of MRI for grading chondral lesions. What did they find? “MRI has relatively poor correlation with arthroscopic findings for grading the chondral damage and was less accurate than clinical assessment for the diagnosis of lateral meniscal tears.”
The controversy over the value of knee MRI in meniscus diagnosis has been ongoing. Taking the other side of the argument a 2018 (2) study suggested that “MRI could effectively demonstrate imaging features of medial and lateral meniscal root tear and its accompanying signs. It could provide the basis for preoperative diagnosis of clinicians, and be worthy to be popularized.”
Should I have another meniscus surgery?
We offer a non-surgical option for meniscus repair and that is why people reach out to us. It is probably the reason you arrived at this article now. To see if our non-surgical option may be an option to your meniscus surgery recommendation. We do understand that there are instances where someone will consider that they have no choice but to have surgery. They are active people whose knees lock up and are acutely painful on movements. The meniscus problem is interfering with their ability to work, participate in sports or simply have a decent quality of life. For some people, meniscus surgery will be successful. The point of this article however is what is the long-term cost of meniscus surgery in terms of knee function and pain? Secondly, if non-surgical options can deliver success equal to or better than surgical intervention.
Another of the most common calls our office receives involves patients who have had part or all of their meniscus removed and are now suffering from continued pain or arthritis as a consequence of the meniscus or multiple meniscus surgeries they had.
- What is concerning the most to these patients is that their knee problems came upon them much more quickly, in some cases almost immediately after surgery. This was seemingly against their surgeon’s admission that they (the patient) would “eventually” develop osteoarthritis.
This is reflected in the types of emails that we get from people looking for help. They go something like this:
I have severe osteoarthritis in both knees. I have had meniscus surgery on both knees. Every day I live with severe pain and swelling in both of my knees. I am told only knee replacements will help me now. I do not want any more surgery. I feel that it is the meniscus surgeries that put me in this position.
I have had meniscus surgery on each knee. X-rays and MRIs show major arthritis in each knee. I can’t walk for longer than an hour without my knees swelling and being so painful I can’t walk anymore. I just turned 50, I do not want to even consider knee replacement without trying everything first
Again, some people do benefit from meniscus surgery in the short-term and near future. It is these recent surgical success patients that we do not see in our clinic. Who we see are the people, who already had meniscus surgery and their knee is causing them problems, or people who do not want a meniscus surgery at this time because of upcoming sports seasons, competitions, or simply, they need to work and there is a waiting list to get the surgery.
This article will focus on the research surround meniscus surgery. If you would like to focus on treatment plans please visit our articles
- Does Stem cell therapy work for meniscus tears?
- Prolotherapy for meniscus tears
- Platelet Rich Plasma Therapy for meniscus repair
If you have been given the meniscus injury surgical recommendation, you have been told that you will get one of these three procedures.
- An Arthroscopic meniscus repair. In this procedure, there is a small tear that the suture can sew up. In some instances, surgeons are taking bone marrow from the iliac crest and are using stem cell therapy to accelerate this repair.
- An Arthroscopic partial meniscectomy. In this procedure, there is a piece of a meniscus that is more badly torn or macerated (all chewed up) and considered non-repairable. There is basically nothing to stitch up. This piece of the meniscus is recommended for removal because of its condition.
- An Arthroscopic total meniscectomy. The whole meniscus is considered damaged beyond repair and the entire meniscus will be recommended for removal.
One of the primary reasons for a meniscal operation is to improve joint stability, yet meniscectomy often appears to have the opposite effect, as it elicits even more instability, crepitation, and degeneration than the meniscus injury produced prior to operation. This is why reoperation rates after meniscectomy can be as high as documented in the research below.
The fourth procedure – knee microfracture surgery and cartilage implant surgery
The notion that replacing dead meniscus tissue, with a dead person’s meniscus (human allograft) or with synthetic meniscus (really meniscus replacement) is going to prevent osteoarthritis, as discussed in our article Alternatives to knee microfracture surgery and cartilage implant surgery is not realistic. By the time a person has a damaged meniscus, many other tissues in their joint are also affected included ligaments and tendons that provide stability when strong or provide instability when compromised. The whole knee joint needs to be treated not just the meniscus tear. The human meniscus is mobile, movable, stretchable and made up of fibrocartilage and has many functions including joint stabilization and the manufacturing of specific mediators of healing that go into the synovial fluid. None of these functions can truly be reproduced by any other type of meniscus besides the persons own meniscus.
Although there is some short term improvement after these surgeries in aspects such as pain control, the long term effects of meniscectomy, meniscal repair, and meniscal allograft transplantation reveal that symptoms, such as pain and instability, will persist for years afterward.
What happens when all or part of the meniscus is removed? Joint instability is a common result of meniscectomy and so is pain after meniscectomy
It has been suggested that the “quickest way for a person to get osteoarthritis is to have arthroscopic removal of their meniscus. There are many ways meniscectomy accelerates the osteoarthritis process through the structural wear of the articular cartilage.
Doctors at the Department of Orthopaedic Surgery, Walter Reed National Military Medical Center and The George Washington University School of Medicine and Health Sciences, Washington, DC., described the problem of degenerative joint disease after meniscectomy in a September 2021 paper published in the Sports medicine and arthroscopy review.(3)
“The meniscus has an important role in stabilizing the knee joint and protecting the articular cartilage from shear forces. Meniscus tears are common injuries and can disrupt these protective properties, leading to an increased risk of articular cartilage damage and eventual osteoarthritis. Certain tear patterns are often treated with arthroscopic partial meniscectomy, which can effectively relieve symptoms. However, removal of meniscal tissue can also diminish the ability of the meniscus to dissipate hoop stresses, resulting in altered biomechanics of the knee joint including increased contact pressures.”
What are we seeing in this image? Even the radiologist cannot determine whether the image he/she is seeing represent a recurrent meniscus tear or is just post surgical changes.
- Post surgical changes are demonstrated in the medial meniscus with smaller than expected size of body of the medical meniscus. (The meniscus is much smaller than anticipated).
- Altered signal intensity (the signal; has detected abnormalities) in the body and posterior horn of the medical meniscus extending to inferior articular surface demonstrates similar appearance to previous performed MRI. (The patient had a previous MRI that demonstrated similar degenative changes).
- This either represents residual changes from prior surgery and mensicus tear or recurrent tear persistent from previous exam. (This damage may be from the previous surgery or a new injury, can’t tell.)
As mentioned above, the patient will be told that they will eventually develop knee problems. The long-term side effect of meniscus surgery is that meniscectomies can worsen knee joint instability by negatively influencing other supporting knee structures by increasing contact stress on the cartilage. The knee’s house of cards will crumble thereafter as increasing contact stress on the cartilage, increases the risk and occurrences of chronic knee inflammation and accelerates the degenerative knee conditions that lead to knee joint erosion or irreversible joint damage to the knee.
Joint instability is a common result of meniscectomy, which is not surprising when considering that the meniscus is a primary stabilizing component of the knee. The knee mensicus provide maximum joint contact protection and thus, reduce the contact stresses on the load-bearing surface of the joint, much like a washer does to distribute the pressure of the nut or bolt evenly and to provide a smooth surface or a double rear wheel (four wheel) truck distributes less pressure on each tire than a normal two rear wheeled truck.
Common physical symptoms of instability after meniscectomy are crepitation, such as cracking or popping, and locking in the joint. On radiographic examination, this postoperative deterioration of the knee is evidenced by narrowing of the joint space between the thigh and shin bones or a flattening of the tibiofemoral surfaces.
Biomechanically, the development of osteoarthritis can in part be explained by the increased stress placed on the tibia and femur post meniscectomy. It is a known fact that reducing the size of contact area on a surface increases pressure in the remaining area. Therefore, by removing part of or the entire meniscus from the knee, the area through which weight is transmitted in the joint is reduced, thus increasing the pressure on both the tibia and the femur and their articular cartilage.
In six reviews of randomized controlled trials, arthroscopic partial meniscectomy did not show clinically important benefit over conservative treatment for knee function and pain.
A July 2021 paper (4) published in the British Medical Journal (BMJ) by the United Kingdom’s National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol examined the clinical effectiveness of common elective orthopedic procedures compared with no treatment, placebo, or non-operative care and assess the impact on clinical guidelines. Among these elective procedures were arthroscopic partial meniscectomy.
In this examination of effectiveness the doctors explored previously published research including review articles. A review article is a study where previous research is accumulated into one set of findings. Here is what these doctors found.
- In six reviews of randomized controlled trials, arthroscopic partial meniscectomy did not show clinically important benefit over conservative treatment for knee function and pain.
- In the most recent review, which was based on 10 randomized controlled trials, arthroscopic partial meniscectomy did not provide a clinically meaningful improvement in knee pain, function, or quality of life.
- However, small benefits of arthroscopic partial meniscectomy were reported for patients without osteoarthritis.
- The authors indicated that surgical treatment should not be considered the first line intervention for patients with knee pain and meniscal tear.
Accelerated breakdown of the articular cartilage between the femur and tibia and the patella and femur bones
How does this happen? Menisectomy increases friction dramatically during motion by depriving the joint of the ability to lubricate the articular cartilage properly. This accelerates the breakdown of the articular cartilage between the femur and tibia and the patella and femur bones. When these metabolically active articular cartilage cells degenerate faster than they can regenerate, the result is accelerated breakdown (degeneration) within the joint. This is not a recently discovered phenomena.
But why did these people have the surgery in the first place? Especially if they were told meniscus surgery could accelerate and cause irreversible knee damage?
It is the patient’s belief that the surgical removal of the whole or part of the meniscus will restore function and lessen their pain.
It can be difficult to tell a patient to have patience when their knee hurts. Most of the time when someone comes into our clinic for the first time they will report on the characteristic symptoms of meniscus related knee problems:
- Knee catches at seemingly random times. When this happens, the patient reports that they simply “shake it out,” by lifting that foot and shaking it.
- Knee locks causing significant pain.
It is also difficult to convince an athlete that meniscus surgery may prevent them from returning to sports altogether. At this point, we will introduce the research from surgeons as a second opinion to our statements.
When you remove the meniscus you remove vital knee lubrication
One of the most vital but lessor known roles of the meniscus is to provide lubrication to the knee, which it accomplishes through diffusing (spreading out) synovial fluid across the joint. Synovial fluid provides nutrition and acts as a protective measure for articular cartilages in the knee. The femoral condyle of the thigh bone in the knee is covered in a thin layer of articular cartilage, which serves to reduce motional friction and to withstand weight bearing. This cartilage is very susceptible to injury both because of its lack of proximity to blood supply and the high level of stress placed on it by excessive motion. The meniscus, therefore, is able to provide a much-needed source of nutrition to the femoral and tibial articular cartilage by spreading fluid to that avascular area.
This illustration demonstrates the reasoning often given to patients that meniscus surgery is the only way.
This illustration demonstrates the reasoning often given to patients that meniscus surgery is the only way. Menisci have two zones. The red zone is the meniscus’ outside zone the white zone is the inside zone. A red zone tear lies within the blood-rich portion of the meniscus. Where there is a blood supply there is healing as blood brings the healing and growth factors needed for wound repair. The white zone meniscal tear is thought to be non-healing because there is no direct blood supply. Many doctors do not believe the white zone meniscus tear can be repaired because of this. This is typically the part of the meniscus removed in meniscus surgery.
Surgeons suggest the reasons people come in for meniscus surgery is over expectation of what the surgery can really do for their knee problem
Doctors writing in The Journal of the American Academy of Orthopaedic Surgeons (5) offer a very good rationale for why people still have meniscus surgery. Here are some talking points of the research:
- For older patients or those more active patients with developing arthritis, the use of partial meniscectomy to manage degenerative meniscus tears and mechanical symptoms may be beneficial; however, its routine use in the degenerative knee over physical therapy alone is not supported. (Physical therapy has been found to be just as good as the surgery in a paper published in the New England Journal of Medicine) (6).
- In younger populations (sports-minded), partial meniscectomy (removal of meniscus tissue) may provide an earlier return to play, and a lower revision surgery rate compared with meniscal repair. However, partial meniscectomy may result in the earlier development of osteoarthritis.
Evaluating this data, one could imply that:
- Younger patients get the meniscus partial removal surgery because they need to get back to work or back to the game quicker and surgery, despite its drawbacks, gets them there faster. As we will see in the research below this is not grounded in fact, for many people getting this surgery, the situation becomes worse.
- Younger patients may not find repair surgery appealing because of
- Longer rehabilitation times
- Risk of needing a second surgery because the first surgery did not fix everything
- Long-term development of osteoarthritis is seen as something that will happen “eventually,” not any time soon.
The risks of cortisone use pre-surgery
Most people that contact us already have a good understanding the frequent or long-term cortisone use has its challenges and risks.
In March 2021, research lead by Rush University Medical Center and published in the journal Arthroscopy (7) found that patients who received knee injections within one month prior to knee arthroscopic surgery developed postoperative infections at twice the rate of those who did not receive an injection.
This of course relates to an injection increasing the risk for surgical infection. But what about the overall impact of corticosteroids on the meniscus?
Corticosteroid short-term success and long-term problems.
It is well understood by most medical professionals and their patients that prolonged and long-term corticosteroid injections for knee pain can break down cartilage including the meniscus. In 2017, doctors from Tufts Medical Center in Boston asked, “What are the effects of intra-articular injection of 40 mg of triamcinolone acetonide every 3 months on the progression of cartilage loss and knee pain in patients with osteoarthritis?”
Writing in the Journal of the American Medical Association, (JAMA) (8) they published their answer:
“Among patients with symptomatic knee osteoarthritis, 2 years of intra-articular triamcinolone, compared with intra-articular saline, resulted in significantly greater cartilage volume loss and no significant difference in knee pain. These findings do not support this treatment for patients with symptomatic knee osteoarthritis.”
In February of 2020 a review study with the title “Medical Reversals in Family Practice: A Review,” (9) published in the journal Current Therapeutic Research, Clinical and Experimental offered these points:
Cortisone can thin out the meniscus.
In August of 2020 in the journal Scientific Reports (10) doctors expressed concerns about damaging the meniscus tissue with cortisone injections. It should be noted that this research’s main findings were that it was okay to get one cortisone injection. For many people, one injection would be considered safe. Here are the learning points of that research:
- “In conclusion, a single intra-articular corticosteroid injection for the treatment of osteoarthritis-related knee pain was shown to be safe with no negative impact on structural changes, but there was a transient meniscal thickness reduction, a phenomenon for which the clinical relevance is at present unknown.”
Patients undergoing arthroscopic meniscus surgery were too optimistic regarding their recovery time
There is a lure to surgery. We see it every day in our offices. The long-standing belief that surgery will fix everything. A recent paper from the University of Southern Denmark (11) wrote:
- “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. . . “
Patients are too optimistic about the success of a meniscus repair – Failure of meniscal repair occur in up to 25% of patients.
A January 2020 paper published in The archives of bone and joint surgery (12) offers this assessment of meniscus repair:
“Meniscus repair is not a small surgery without complication. It is technically challenging and has a steep learning curve. General complications of arthroscopy such as venous thromboembolism, infection and vascular injury could occur. Specific complication including nerve injuries, ligamentous injury, iatrogenic cartilage lesions, and poor suture techniques can happen during meniscal repair. The surgeon should depict and accept the eventual complications and address them as rapidly as possible. It is also important to form patients about potential complications. Failure of meniscal repair occur in up to 25 % of patients.”
The surgical realities of meniscus tear surgery – the research
Between 2013 and 2016 – research began appearing questioning not only the value of meniscus surgery but whether or not the surgery caused more harm than good. Let’s start with a New York Times piece in 2016. The summary is below.
- Dr. Gordon H. Guyatt, a professor of medicine and epidemiology at McMaster University in Hamilton, Ontario, 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.’”
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 international 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.”(13)
- 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.
- 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.”
In other words, avoid the rush to a surgery that may not fix the patient’s reported problems.
Continuing forward, the lead researcher of this study Raine Sihvonen, MD published more papers on the problems of meniscus surgery.
In February 2018, in the Annals of the Rheumatic Diseases (14) Dr. Sihvoven and his fellow researchers noted that degenerative meniscus tear can be the result of knee osteoarthritis and not vice-versa: “(Our) 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.“
In other words, the meniscus tear is the result of knee osteoarthritis development. If you remove the meniscus you accelerate the knee osteoarthritis. We will discuss this further below.
In April 2016, Dr. Sihvonen and colleagues wrote in the Annals of Internal Medicine (15) that removing parts of the meniscus did not appear to relieve the symptoms of knee pain and knee locking in surgical patients. “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.” In other words, avoid the rush to a surgery that may not fix the patient’s reported problems.
Many orthopedic surgeries in my opinion have a far worse outcome then patients anticipate primarily because they cannot return to the activities they love, such as running. When people have arthroscopy surgery I try to go over their surgical reports with them because often what they perceived what was done with the surgery was not done and other things were done that were detrimental and they had no idea they were done. I have never as far as know seen an orthopedic operative report that showed a real meniscus repair, where the meniscus was sewn together and that was it. The typical report shows partial meniscectomy and no repair yet the patient believes it was a repair. Every arthroscopy report I have ever seen, has findings that reveal osteochondral lesions, chondromalacia, meniscus degeneration, articular cartilage lesions ligament injury and many others. Remember anyone can have decreased pain by doing less, and unfortunately, many people who receive orthopedic surgeries end up doing less.
Results also showed that meniscectomy did not provide better functional improvement than the nonoperative group
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. (16)
- 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 an average age of 53.8.
- Fifty patients underwent arthroscopic meniscectomy while 52 participated in nonoperative strengthening exercises. The results did not match up with the 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.”
In research from May 2016, (17) 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.
Meniscus surgery outcomes in American soldiers
Army physicians from the William Beaumont Army Medical Center and doctors from Rush University Medical Center published a March 2018 study in the Journal of Knee Surgery. (18)
It reports on how military surgeons dealt with meniscal injury. The report reveals findings on nearly 30,000 meniscus surgeries.
- In 81.3% of patients, a partial meniscectomy was performed.
- In 20.3% a meniscal repair was performed. This is typically limited to the red zone of the meniscus where ample blood supply allows for suturing and healing.
- Very rarely a meniscus allograft transplantation (cadaver donor) in 0.7% of patients was performed.
- Older patients were more likely to get a meniscectomy and less likely to get a repair.
What are we to make of this?
- In 4 out of 5 patients, meniscus tissue had to be removed.
- In 1 out of 5 patients the injury was fixable because of location and size.
- Meniscus transplant has lost much of its appeal.
- The meniscus is hard to save.
Does meniscus surgery lead to knee replacement?
To save the knee, you must save the meniscus. A shift is occurring in meniscus surgery but it is just starting
In the July/August 2018 edition of the medical journal Sports Health,(19) surgeons at UCLA talked about the younger patient and why taking out meniscus tissue is really not optimal.
Here are the talking points:
- “With the rise in sports participation and increased athleticism in the adolescent population, there is an ever-growing need to better understand adolescent meniscus pathology and treatment.”
- “A shift in the management of isolated adolescent meniscal tears is reflected in the literature, with a recent increase in operative repair. This is likely secondary to poor outcomes after meniscectomy reflected in long-term follow-up studies.” (In other words, surgeons need to offer different options because taking out a piece of the meniscus does not offer good outcomes).
- “The current literature highlights the need for an improved description of tear patterns, standardized reporting of outcome measures, and improved study methodologies to help guide orthopedic surgeons on the operative treatment of meniscal tears in adolescent patients.”
Basically, surgeons need to repair and save the meniscus. They also need to figure out how to do it.
Why do we still perform meniscectomy?
The goal of 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 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 them to function as a shock absorber between the upper and the lower leg bones.
Doctors in France writing in the medical journal Orthopaedics & Traumatology, Surgery & Research, (20) joined 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 meniscus 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 meniscectomies is excessive in the light of scientifically robust studies demonstrating the interest in 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 that it is high time that the paradigm shifted, in favor of meniscal preservation.
Now, let’s get back to the reasons why you may still be recommended for meniscus surgery. Surgeons strongly argue that there is validity to meniscectomy
Doctors in Germany (21) say that many of the studies critical of arthroscopic meniscus surgery are not 100% reflective of the patients they see. Medical 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 recommended.
- So European surgeons have not yet embraced the idea of totally moving away from meniscectomies.
“The treatment of degenerative meniscal lesions should start with conservative management.”
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.
They do say arthroscopy in advanced osteoarthritic knees is not indicated due to inferior clinical outcomes.
- 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 complaint surgeons have is that some surgeries will help some patients and that every meniscus surgery is not a bad surgery and research is not reflective of this benefit.
In March 2020, (22) researchers announced a new study to answer this question. They write of their study:
“Arthroscopic partial meniscectomy after degenerative meniscus tears is one of the most frequently performed surgeries in orthopedics. Although several randomized controlled trials have been published that showed no clear benefit compared with sham treatment or non-surgical treatment, the incidence (numbers performed) of Arthroscopic partial meniscectomy remains high. The common perception by most orthopedic surgeons is that there are subgroups of patients that do need Arthroscopic partial meniscectomy to improve, and they argue that each study sample of the existing trials is not representative of the day-to-day patients in the clinic.”
The researchers of this study announced that they will seek to find “whether there are subgroups of patients with degenerative meniscus lesions who benefit from Arthroscopic partial meniscectomy in comparison with non-surgical or sham treatment.”
Short-term follow-up of meniscectomy has generated some positive results
Short-term follow-up of meniscectomy has generated some positive results; for example, a meniscectomy can provide temporary pain relief in early stages following operation, especially when an acute tear had caused excessive pain or popping preoperatively. Another immediate result may be a greater feeling of stability, if the tear had previously been a source of instability or knee locking by catching between the tibia and femur. On long-term follow-up, however, these initial improvements have rarely been shown to last. Complete pain relief from meniscectomy is nearly unheard of after more than ten years and, at that point, more complex issues including limited range of motion, radiographic degeneration, crepitation, and severe functional impairment have usually begun to surface. In many cases, a simple meniscus tear, if operated on, can become a career-ending injury.
Arthroscopic meniscus surgery leads to a three-fold increase in the need for knee replacement and supper accelerated osteoarthritis.
Here we present a brief review of many of the papers published in recent years suggesting that meniscus surgery causes more harm than good in many patients.
- In 2017, doctors in the Netherlands published their findings in the medical journal Osteoarthritis Cartilage: (23) “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.”
November 2016: Research in the medical journal Orthopedics:(24)
- 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 the 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.
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 and a half 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. (25)
The summary of these studies? If you have a meniscus surgery, chances are you will be disappointed in the outcome and then move onto an 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 a 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. (26)
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. (27) The two combined studies help confirm missing meniscal tissue contributes to bone and cartilage degeneration.
Even the American Academy of Orthopedic Surgeons was unable to come up with evidence to support the use of partial meniscectomy.
Meniscus removal throws the whole knee out of balance and damages other structures – the best way to prevent cartilage breakdown and knee osteoarthritis caused by meniscal surgery is to AVOID the 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. (287)
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 meniscus surgery is to AVOID the surgery.
The middle-aged patient and meniscus surgery – surgeons cannot predict which patients will benefit and who will not benefit from meniscus surgery. Flipping a coin would work just as well.
A March 2020 study in the British Journal of Sports Medicine (29) questioned whether experienced orthopedic surgeons could predict who would benefit from surgery for degenerative meniscus tears and who would not.
The researchers set up an experiment. Surgeons participating in this study were given 20 cases to examine. In each case, the surgeon was asked to predict the outcome of treatment for meniscal tears by arthroscopic partial meniscectomy and exercise therapy in middle-aged patients. The surgeons were also asked to predict the beneficial change in knee function in those patients they would recommend to surgery and those patients they would send to physical therapy or an exercise program.
The surgeons combined to examine and predict outcomes in 3880 knees. The results?
- Overall, 50.0% of the predictions turned out to be correct, the surgeons were able to predict 50% of the time which treatment would be of most benefit before treatment. The researchers of this study however noted – 50% correct would be no better than flipping a coin as it equals the proportion expected by chance.
- Experienced knee surgeons were not better at predicting outcomes than other orthopaedic surgeons.
- Conclusions: Surgeons’ criteria for deciding that surgery was indicated did not pass the statistical examination. This was true regardless of a surgeon’s experience. These results suggest that non-surgical management is appropriate as first-line therapy in middle-aged patients with symptomatic non-obstructive meniscal tears.
Clinical practice is moving away from treating meniscal tears in patients with osteoarthritis
Surgeons at the Glasgow Royal Infirmary, University Hospital Llandough and the University Hospital Wishaw in the United Kingdom published a February 2020 paper (30) in recommending to their fellow surgeons which patients with meniscus damage and osteoarthritis would be considered as good candidates for surgery. Here is what they said:
“Clinical practice is moving away from treating meniscal tears in patients with osteoarthritis unless there are mechanical symptoms. This study assessed the risk of needing further surgery for osteoarthritis in the five years following partial meniscectomy in different age groups and different grades of knee osteoarthritis.”
What these doctors did was to look at partial meniscectomies that were performed by the paper’s senior author during a 31-month period. Range of follow-up was 3 to 5 years.
- Knees that needed further surgical treatment in the form of joint replacement or osteotomy were considered as failures.
- The study population was split into three groups according to their age (35-54, 55-64 and 65+).
- 207 knees were included.
- In the 35-54 age group, patients with no/mild osteoarthritis had a survival rate of 97.59% and the severe osteoarthritis group had a survival rate of 73.5%. (25.5% of the patients moved onto to further surgery in the 3 – 5 year follow up).
- In the 55-64 age group, these figures were no/mild osteoarthritis 100% and 73.6%, respectively. (26.4% of the patients moved onto to further surgery in the 3 – 5 year follow up).
- In the older than 65 age group, the survival rates were 100% and 65%, respectively. (35% of the patients moved onto to further surgery in the 3 – 5 year follow up).
Conclusion: “(This) study shows that patients with no/mild osteoarthritis should be considered for Arthroscopic Partial Meniscectomy. Patient’s with meniscal tears and severe osteoarthritis should be counseled on the outcomes and risks of further surgery after an Arthroscopic Partial Meniscectomy.
Here is a positive study on the benefits of meniscus surgery (31) in middle-aged patients: In this study, doctors said that an arthroscopic partial meniscectomy is a good option for a medial meniscal tear in late middle-aged adults. For the 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.”
In other words, even if a patient received “a proper diagnosis and excellent surgical technique,” problems with motion restrictions in the knee developed early. Motion restrictions are probably not what a middle-aged patient is expecting as a result of their meniscus surgery.
In the above research we cited from Raine Sihvonen, MD in February 2018, in the Annals of the Rheumatic Diseases (14), it is noted that:
- Most arthroscopic partial meniscectomies are performed on middle-aged and older patients with knee symptoms and degenerative knee disease.
- In conclusion, the results of this study showed Arthroscopic partial meniscectomy provides no significant benefit over placebo surgery in patients with a degenerative meniscus tear and no knee osteoarthritis.
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 that carries healing elements do not reach the entire meniscus. Because of this, the meniscus is a composite of different types of cells, superficially, those that can heal, those that can’t.
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, whose 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 are 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.”(32)
Is there recovery time after 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 the 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 the 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 the 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
We use non-surgical treatments for meniscus tears. We may use our Prolotherapy treatments and PRP. This is an in-office injection treatment. This video and the summary below is an introduction to our non-surgical treatments. It is presented by Danielle R. Steilen-Matias, MMS, PA-C of Caring Medical Florida.
- Dextrose Prolotherapy is a simple sugar injection into the knee that attracts your 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 of 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.
Do you have a question about meniscus surgery or need help?
Get help and information from our Caring Medical staff
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This article was updated September 29, 2021