Knee Surgery for a Meniscus Tear? Not if You're Middle Aged.

Knee Surgery for a Meniscus Tear? Not if You’re Middle Aged…

 

knee surgery for a meniscus tear

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.

In conclusion:

“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!

 

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Read 37 Comments
  1. Unfortunately, the news has not reached The Orthopedic Institute (TOI), Gainesville, Florida of some 20 orthopedic docs.
    I plan to print and mail the above article to one of them as they do not allow access to their office email for patients, for direct emailing!

    1. M Downie,
      Sounds like a great plan…hope they read it! It might be what begins what eventually changes everything! Doctors in general are truly dedicated to helping people. It’s that they have been trained by a paradigm which treats things surgically, and unfortunately the information that those surgeries so often do more harm than good and that there are regenerative procedures that would be better for the patients, while clearly out there, have not filtered down into the system in which they operate.

        1. Dennis,
          The first step is determining what the problem is. We’d need to see a current MRI and medical history, which you can upload by submitting the Candidate form. If you are local to a Regenexx provider we can see what’s going on and handle the Candidacy Evaluation in person. Once we know what the problem is, we can discuss treatment options. Here is the list of Regenexx providers: https://www.regenexx.com/find-a-physician/

  2. If you have had ortho in one kneww no mini in 22ndknee. Numerous steri shots in both knees. The slang term: blue chicken comb gel; in both knees. Much worse in lft. With some minic syoll thetr. Would it be sage , in your opinion to shoot steriod shot in both knees fue yo severe pain? I have yo mske a chg.

    1. Louise,
      “Blue Chicken Comb Gel” sounds like hyaluronic acid, a Symvist type product which attempts to replace your own lubrication in the knee joint. It can help, but needs to be done repeatedly and has no repair potential, so like squirting WD40 into a hinge that actually needs repair. It will help the squeak, but not the problem. It is, however, a very much better option than repetitive steroid shots, as they literally kill the local stem cells and therefore make the situation worse over time. Stopping steroid shots, adding in the right supplements (http://www.regenexx.com/knee-replacement-questions/ 4th paragraph) and getting some type of regenerative procedure like platelet or stem cells is what would change to repair rather than damage to avoid knee replacement. http://www.regenexx.com/the-regenexx-procedures/knee-surgery-alternative/

  3. Hi Dr Centeno,
    I began educating myself for alternative ways to avoid knee replacement and contacted Dr Mayo Friedlis who treated me in April for advanced osteoarthritis of my left knee. Fortunately I never let anyone ” clean up my knee” . I’m so grateful that you are committed to providing a better way to heal the human body and are fervently proclaimly this to your peers and through the Regenexx Network of providers.
    Since my stem cell procedure in April my knee pain is gone! I trusted your databased evidence and daily blog to guide me for treatment and I’m so grateful that I did!
    Living Life more Fully in Charlotte,
    Jeanmarie

    1. Jeanmarie,

      Such wonderful news! Thank you so much for sharing it! I forwarded your letter to Dr. Centeno…
      “So great to hear about your success!” ~ Dr. Centeno

  4. As a 52 year old male with recently torn meniscus evident on a MRI, what are the recommendations here in light of your post that a knee arthroscopy would be ineffective ?
    Thanks

    1. John,
      Depends on the type of tear. Small meniscus tears caused by wear and tear are unlikely to be the cause of pain and can be found on the MRI’s of most middle-aged and older people http://www.regenexx.com/why-middle-aged-people-should-ignore-cartilage-loss-and-meniscus-tears/ . http://www.regenexx.com/osteoarthritis-pain-not-related-to-structure-again/ A meniscus tear caused by specific traumatic injury is a different.http://www.regenexx.com/can-you-treat-a-meniscus-tear-without-surgery/ So the most important thing is an evaluation and exam by someone who can figure out what’s causing the pain; whether there are unstable tendons or ligaments, or nerve issues in the back altering the biomechanics of the knee, etc. And treating those issues with regenerative therapies like your own platelets and stem cells that can correct and repair those problems before they create bigger ones. http://www.regenexx.com/the-regenexx-procedures/knee-surgery-alternative/

  5. I am a 66 year old female and 1 1/2 years ago had surgery to remove a meniscus tear and clean up the knee. The pain did subside for a few months, and when steroid shots quit working, I had the series of supartz shots. They have helped alleviate some pain, but the knee, even after PT, is still very unstable and I am becoming knock-kneed. I am bone on bone, and Dr. is recommending a total knee replacement, so I sought a second opinion…same outcome. Since my knee seems to be so far gone, would the stem cell treatment be effective now and in the long term.

    1. Linda,
      Unfortunately the instability is likely coming from the missing meniscus, as it acts as both shock absorber and spacer. The Supartz shots are a much better idea than the steroid shots as while they don’t have regenerative potential at least they don’t kill the stem cells in the knee like steroid shots do. It sounds like your knee has advanced arthritis which is a very common complication of meniscus surgery, but knee replacement is irreversible, and trying all less invasive options first is always the best plan. The instability can be helped by strengthening and tightening the lax ligaments which result from the missing meniscus altering the biomechanics of the knee, and getting stem cells into the knee could at best sort things, at worse, at least delay the knee replacement for a few years. Joint replacements in real life don’t last as long as they’re advertised to, and, joint replacement is a huge surgery with risks and complications. http://www.regenexx.com/knee-replacement-questions/ http://www.regenexx.com/the-regenexx-procedures/knee-surgery-alternative/

  6. I am a 40 year old female with degenerative meniscus and my knee locks. I would prefer not to have surgery, but I just read on this site that a locking knee would be improved by surgery. What do you recommend?

    1. Jenry,

      What your doctor must be referring to is cutting away the torn pieces of meniscus, as removing cartilage would be highly unusual. Both are made of similar type tissue. Stem cells would definitely be the better option as healing what’s torn in place rather than removing it has much better long-term results for your knee. The meniscus is a shock absorber, and when pieces of it are removed, it creates instability in the knee and the actual cartilage begins to wear down, which all sets the stage for severe arthritis. Here is how we treat meniscus tears: http://www.regenexx.com/meniscus-tears/

    1. Bob,
      Great to hear! Consider yourself one of the lucky few! Just be on the lookout for instability issues going forward, and deal with them quickly if they come up.

    1. Teresa,
      We have 31 locations. This link allows you to put in your city and state and will show you the closest to you: http://www.regenexx.com/find-a-physician/ This link will give you information about how we treat knees with stem cells: http://www.regenexx.com/knee-replacement-questions/ These are medical procedures based on exam. Some situations require platelets rather than stem cells, and platelet procedures are in the $1K range. If stem cells are needed, those procedures are in the $4-6K range.

  7. I have discussed stem cell option for knee osteoporosis (having had a series of steroid injections, followed by meniscus arthroscopy, followed by orthovisc injections- none of them effective), with two orthopedic surgeons, who are prepared to do total knee replacement at The Orthopedic Institute, Gainesville, but they say SC is for young people only, and of course warn that insurance does not cover it.

    1. M Downie,
      They are correct that insurance does not cover it. However, they are wrong that it is for young people. Our research and outcome data shows that age has nothing to do with outcome:http://www.regenexx.com/regenexx-research-review/. Important to avoid steroid injections though, as they are lethal to the stem cells in your knee and can only make the situation worse. http://www.regenexx.com/new-research-steroids-hammer-stem-cells/ Here is what we do: http://www.regenexx.com/the-regenexx-procedures/knee-surgery-alternative/ This is a very important read, as it goes over questions that need to be answered before even considering a knee replacement. There are also good suggestions for supplements that can help: http://www.regenexx.com/knee-replacement-questions/

  8. It is strange that insurance covers arthroscopic surgery and not the stem cell procedure. Where’s the research that justifies the arthroscopic approach?

  9. I am also concerned as to why insurance will not cover the procedures. Had total knee on the left knee one year after having a meniscus surgery that didn’t help relieve the pain. also had steroids and rooster comb. now the right knee has a meniscus tear. Had one steroid shot, with no relief. You have me concerned about having it scoped. The high cost of your treatment is a barrier to me having your procedure.

    1. Bart,
      The procedures are not covered simply because it takes the insurance industry a good amount of time to catch up. Years ago, most heart issues were treated surgically. Someone figured out that those same issues could be more safely addressed through a catheter (angiogram, angioplasty, stents) and today issues that previously required cutting through the breastbone and stopping the heart, are now done that way. This is where we are with Interventional Orthopedics; in time, orthopedic surgery will be used for only those cases where no options exist…no more menisectomies, ACL surgeries, etc.
      The problem with arthroscopy for a meniscus tear is that rather than sewing the meniscus back together, the torn sections are removed, which ultimately leaves the joint unstable and exposes the articular cartilage to wear and tear. It’s simply a better and safer option to treat the injury which, since it hasn’t healed on its own means the local stem cells are not up to the job, by sending in the troops so to say with your own stem cells. You might consider beginning with a platelet procedure like Regenexx SCP, (which is more powerful than PRP and significantly less expensive than stem cells) to get things going in the direction of repair rather than breakdown. Steroid shots really should be avoided, as they kill the local stem cells making the situation worse, not better. http://www.regenexx.com/meniscus-tears/

  10. I have just floated across this information.
    I had two meniscus tears in my left knee which bought instant pain ehilst at the Mall. I could barely get back to the car. Could hardly walk with such pain.
    Three weeks later I had Arthroscopic surgery to clean the floaty bits of meniscus and two tears.
    Almost three years to the day and still all ss well with my knee.
    I’m happy with my result and feel I should share this with you.
    My Ortho did an excellent job on this older than middle aged lady. ☺

    1. Jill,
      Really glad it helped! There most important indication for meniscus surgery is a locked meniscus which makes walking incredibly painful and sometimes not possible. The issue is meniscus surgery when the knee hurts and a tear to the meniscus is found on MRI, without establishing that meniscus tear as the source of pain, as most do not cause pain. There are always going to be people a procedure that does generally not help, helps; and a procedure that generally helps, does not help.

  11. I have three degenerative tears in my right knee. The lateral is not bothering me at all but the two medial tears are causing significant swelling all the way down to my foot. The pain is not so bad when walking but descending stairs is very painful. What are my best options? I’m 59 years old

    1. Cindy,
      You age is average for Regenexx knee procedures. Your best option would be to avoid meniscus surgery (!) and have one of our physicians see what’s actually going on, and why for instance you have these degenerative changes in that particular knee. Here is the list of Physicians who can do that kind of exam. You can also submit the candidate form to upload a recent MRI and get started that way. Please see: https://www.regenexx.com/find-a-physician/

  12. Hi Doctor,

    I’m 33, male and just found out from a MRI that I had torn my meniscus. I’m terrified of having surgery and I almost refused to. I can still walk and put weight without pain. The only time I experience a sharp pain on my medial meniscus is when I accidentally flick my feet when walking (bring the foot in front) causing a twisting motion. This is what the impression was from the doctor.

    Impression
    Complex flap tear of posterior horn of medial meniscus, extending into the posterior meniscal root attachment. Anterior horn, body, and posterior horn lateral meniscus are intact.

    Mild superficial fibrillation of medial femoral condyle articular cartilage.

    Mild joint effusion and synovitis.

    Intact cruciate and collateral ligaments.

    May I pleaseif stem cell would be effective in my case? If so, how much this would cost? Would it be a crazy amount that the average person cannot afford?

  13. OMG. I was 59 in pain for 3 months with my right knee. My doctor sent me to orthopedic doctor. He took MRI. Said No tear it was age, weight and arthritis. I was still in pain for 6 more months, difficulty to teach 1st graders. Went back to my own doctor AGAIN who happened to be knowledgeable in sports medicine as well. He thought I had a tear so he referred me to a different (older) orthopedic doctor. This orthopedic doctor looked at same MRI that had been done. He manipulated by knee back and forth while in his office, yes it hurt. He said he would go in for an exploratory since he could not see anything on the MRI but arthritis. GUESS WHAT… I had a big tear that he repaired. In two weeks I was a new person. SO DON’T TELL ME THAT OLDER PEOPLE DON’T NEED SURGERY!!!!

    1. Candy,
      Great news that it helped in your case, and hope it continues to! We weren’t saying older people don’t need surgery, we were saying in the majority of cases meniscus surgery isn’t needed because most meniscus tears can be actually repaired, instead of trimmed, or pieces of it cut out, or removed, which leave sections of the knee unprotected and lead to longterm instability. And importantly, the meniscus tear is often not the cause of pain and there are other issues that need to be addressed. The older we get, the more surgery using general anesthesia should be avoided when possible. Please see: https://www.regenexx.com/meniscus-treatment-without-surgery/ and https://www.regenexx.com/surgery-dementia-risk/ and https://www.regenexx.com/memory-decline-and-dementia-from-surgery/ and https://www.regenexx.com/memory-decline-and-dementia-from-surgery/

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