Should I Have Meniscus Surgery? No...
POSTED ON 2/21/2016 IN Regenerative Medicine Education BY Christopher Centeno
The most common orthopedic surgery in America had it's final epitaph written this month with a level-1 study showing that surgery for meniscus locking is no better than placebo. Given that this was the final indication for the surgery, based on the research, to use a party analogy, the booze has run out for this little soiree. So if you're asking yourself, "Should I have meniscus surgery?" the research on the topic has now spoken, and the answer is a resounding "NO!!!"
What Is a Meniscus Tear?
The meniscus is a natural shock absorber in the knee that provides some spring in your step and helps to protect cartilage. It can become torn with age or trauma, and greater than 90% of the surgeries on the structure are not repairs, as most patients believe, but are instead excisions, or cutting out, of the torn part of the meniscus.
Meniscus Tears in Middle Age Are like Wrinkles—Everybody Has Them
The big misconception that has been propagated like a "scandalous" rumor in a small town is that meniscus tears as seen on MRI after a middle-aged patient reports knee pain are significant. THEY ARE NOT. Just as many of your middle-aged friends who don't have any knee pain or problems have meniscus tears; hence, the fact that your MRI has one is as important as those new wrinkles on your forehead in need of a little Botox.
The Research Showing Meniscus-Tear Surgery Doesn't Work
The first canary in the meniscus surgery coal mine happened way back in 2002, when a study by a Baylor College of Medicine orthopedic surgeon showed that debridement (the cleaning up of a knee that has arthritis and degenerative meniscus tears) was no better than a placebo. After many surgeons published comments that in medical parlance equated to wanting to blow up the poor guy's car, the procedure over the last 15 years has slowly slipped into medical oblivion.
The next study came from an unlikely source; turns out the Framingham, Massachusetts, town that has given us such great heart data through the years also has a government-sponsored osteoarthritis study. This and other studies concluded that just as many middle-aged people without knee pain had meniscus tears as those with knee pain. Ouch...
In 2012 a large high-level research study published in the New England Journal of Medicine showed that on average, patients who had meniscus surgery didn't do any better than those who skipped the surgery and just had physical therapy. Many orthopedic surgeons criticized the study by saying that these patients had some arthritis and that there was still a justification for performing the procedure on patients with a meniscus tear without arthritis. That fantasy went "bye bye" in 2013 when a high-level study showed that meniscus surgery in patients without arthritis was no better than a fake surgical procedure. There was still one condition left where meniscus surgery might be helpful—a meniscus tear that was causing locking of the knee. However, a new study out this month just burst that bubble!
The New Study Puts the Final Nail in the Meniscus Surgery Coffin
The new study out of Finland looked at 146 patients who had "mechanical symptoms" (i.e., locking or catching thought to be caused by the meniscus). They randomized about one-half of the patients to meniscus surgery, and about half got a sham surgery. They found that the surgery provided no benefit to relieve knee catching or occasional locking, and they cautioned against patients getting the surgery.
Now, I know surgeons will argue that there still may be a justification for the surgery in patients with severe frequent locking of the knee or in patients who are younger and have an acute meniscus tear. In the first instance, they may be right, and in the second, given that studies have shown a rapid onset of arthritis and increased forces on the cartilage after a meniscus surgery, I would caution that the circumstantial evidence is that surgery should be avoided in those patients as well.
The upshot? It was a heck of a party while it lasted. However, not only has the booze run out, but someone has turned on the god-awful lights, and the after-party has been cancelled. Uber drivers have been called, and the hosts are showing us the door. In other words, there is little scientific justification at this point in patients 35 and older that operating on their torn meniscus will do any good, and it's only a matter of time until insurers and national healthcare systems begin relegating this procedure to the dustbin of medical history. So if you're asking yourself, "Should I have meniscus surgery?" answer yourself with a resounding "NO"!
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- knee meniscus