Research suggests that surgery may not be the best answer for knee pain caused by ragged cartilage. A patient’s age and the nature of the injury are key factors in determining the best course of treatment. Thousands of Americans who undergo a common knee surgery may be making their problems worse rather than better.
According to the report, arthroscopic knee surgery to trim degenerative cartilage tears provides little or no benefit and is associated with accelerated osteoarthritis and higher rates of reoperation. The study followed patients for 10 years after they received either the actual procedure or “sham surgery” — a skin incision — for knee pain.
The first-line therapy for a painful knee with degenerative tears is physical therapy and, for some people, weight loss. Then there is arthroscopic surgery, depending on the view of the surgeon about its utility. However, evidence has been accumulating steadily for over a decade that arthroscopic knee surgery to shave torn, degenerative cartilage does not help more than physical therapy.
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Teppo Järvinen, an orthopedist and the head of the Finnish Centre for Evidence-Based Orthopaedics, said, “I don’t know how I would defend this procedure at all.” He added, “What has been shown dramatically is that patients who have this procedure have more pain — they do worse. All the scores pointed in the same direction.”
There is also a menu of injections, including steroids, which have proved scientifically valuable in the short term. Injections of stem cells and plasma-rich protein are widely offered but are controversial — and not covered by most insurance — because studies have been at best inconclusive about their benefit.
Robert Brophy, director of the Orthopaedic Clinical Research Center at Washington University in St. Louis, said that “evidence is growing for judicious use of this surgery in this population.” However, he noted that “many patients do benefit.”
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One inherent issue in all medical specialties is that appropriate treatment is often in the eye of the physician beholder, meaning that specialists create the guidelines for when a treatment is in order. And financial considerations may influence that decision, Järvinen said.
The trend of moving away from arthroscopic knee surgery will continue, and more patients will be encouraged to try physical therapy and other non-surgical treatments first. This could lead to better outcomes for patients and reduced healthcare costs in the long run.
Current practice among orthopedic surgeons is “all over the map,” according to Brophy. Data shows that surgery for meniscus tears in the Medicare population is far more common in the South than in the Northeast. A massive study committee of orthopedic societies in Europe and the U.S. released a consensus statement noting that “degenerative meniscus lesions can be treated with comparable results with either non-operative or surgical approach.”
