Knee Surgery for a Meniscus Tear? Not if You're Middle Aged...
POSTED ON 12/14/2015 IN Archive BY Christopher Centeno
Should you get knee surgery for a meniscus tear? According to recent research, not if you're middle aged or older, since it's likely that the tear seen on MRI has nothing to do with your knee pain.
This may come as a surprise, but let me explain. This has been a rough time for orthopedic surgery. As the calls for more research-based care ramp up, the results on common orthopedic knee surgeries like "cleaning up the knee" and "repairing or trimming a meniscus" have been dismal, basically showing that these surgeries don't work. While many surgeons keep defending these cash cows and somehow the general public has missed the memo that these surgeries are ineffective, the academics are busy publishing papers shouting that it's time to give them up. Case in point is a recent editorial in the prestigious journal Acta Orthopedica.
The Most Common Orthopedic Surgery in America is Ineffective
Knee arthroscopy is by far the most common orthopedic surgery performed today and most of these are for painful middle aged knee meniscus tears or debridement for arthritis. This is despite the fact that high level research has shown that these two procedures are ineffective for relieving pain. So why are patients allowing these surgeries to be performed? Most have no idea that the surgeries have little therapeutic value.
The fact that patients don't know that these procedures don't work isn't from lack of mass media coverage. The New York Times
has a nice piece explaining that a fake surgery or physical therapy is often just as good as the invasive surgery. I've also blogged on a slew of high quality studies showing that knee surgery is ineffective
Yet Another Call to Abandon Ship
In a very cheeky U.K. way, the British Medical Journal had an editorial citing the "Scandalously Poor" evidence behind many common orthopedic surgery procedures like knee arthroscopy
. Now the newest call for orthopedic surgeons to throw in the towel
on treating middle aged knee pain with surgery is entitled, "Routine knee arthroscopic surgery for the painful knee in middle-aged and old patients—time to abandon ship". Based on how bad the outcome data is for surgery for knee pain, all of the Titanic references are indeed warranted.
Some great quotes from this newest paper:
"In spite of these early reports, middle-aged and older patients with a painful knee and suspected meniscus or cartilage lesion have become by far the most common patient group to be treated with arthroscopic knee surgery. Thus, 3 out of 4 patients who are treated arthroscopically for suspected meniscus rupture, cartilage lesion, or osteoarthritis of the knee are reported to be older than 35, the typical patient being between 35 and 65 years old and most often in their early fifties (Roos and Lohmander 2009, Cullen et al. 2009, Bohensky et al. 2012, Dearing and Brenkel 2010, Thorlund et al. 2014)."
Translation? If the patient is older with any signs of arthritis, we've known since the 80s that surgery was unlikely to be helpful.
The Beginning of the End for Surgery for Middle Aged Knee Pain
"It took some 20 years after the general introduction of knee arthroscopic surgery, with millions of patients treated, before the first randomized controlled trial was published (Moseley et al. 2002)."
The Mosely study being referenced was the beginning of the end for knee arthroscopy for middle aged knee pain
, showing that a fake placebo surgery had the same results as the real deal. Despite years of protestations from surgeons that these surgeries really were effective, rates for this type of debridement surgery (a.k.a. "clean-up surgery") for knee arthritis have fallen since 2002, with most surgeons increasingly unwilling to perform the procedure.
The editorial continues:
"To date, at least 8 additional randomized trials investigating the effect of debridement and/ or arthroscopic partial meniscectomy have been published...All but 1 of these 9 trials of arthroscopic surgery in middle-aged or older people with persistent knee pain failed to show any added benefit of interventions including arthroscopic surgery over a variety of control treatments."
Translation: Based on the research we have, operating on a painful knee, regardless of the MRI findings of a "torn meniscus
", is a pretty silly idea as several studies now show that the surgery is no better than a placebo.
Why Are We Still Operating on Middle Aged Knee Pain?
The editorial really hits the nail on the head by concluding:
"There are other possible contributory factors to a lack of implementation of high-level evidence contrary to unquestioned routine. One example is the influence of the organization of the care pathway on procedure rates, where systems can create perverse incentives, with success and remuneration being dependent on volume rather than patient outcome (Hamilton and Howie 2015). Another example is the MR examination early in the care pathway of the middle-aged or older patient with a painful knee showing a meniscus lesion. Demonstrating the presence of such a lesion is bound to increase the likelihood of an arthroscopic procedure, irrespective of the clinical relevance of the lesion."
The translation? Surgery is a huge multi-billion dollar business with multiple stakeholders that benefit including doctors, hospitals, outpatient surgery centers, device manufacturers, etc... Stopping that financial train is not something that surgeons are likely to do willingly. In addition, middle aged patients have been taught incorrectly that a meniscus tear seen on MRI is a problem causing pain that needs to be fixed surgically, despite years of research showing that a mythical evil unicorn living inside their knee is about as likely to be the cause of their knee pain as the meniscus tear. We have said before that meniscus tears in middle aged and older patients are as common as wrinkles and about as significant
, so that tear seen in the knee meniscus of a painful knee likely has nothing to do with why the knee hurts.
"Available evidence supports the reversal of a common medical practice. It is time to abandon ship."
That sentence needs no translation.
The upshot? While there are a few circumstances where you can make the argument that these surgeries are needed (i.e. a locking knee due to a torn meniscus), those surgeries constitute just a small fraction of the total procedures performed. In the meantime, the public continues to get hoodwinked into believing that knee arthroscopy is needed when the knee hurts and an MRI shows a random meniscus tear. Hopefully, the public and surgeons will begin getting the memo that the academics are now shouting from the roof tops!