Knee surgery for cartilage damage does not benefit patients, study suggests | Medical research
A common knee surgery for cartilage damage does not benefit patients and may lead to worse outcomes, a 10-year study suggests.
The study tracked the outcomes of patients who were treated for meniscus tears and underwent partial meniscectomy, one of the most common orthopedic surgeries. Their trajectories were compared with patients randomly assigned to receive “sham surgery,” in which no procedure was performed.
Patients who underwent surgery that involved cutting away worn meniscus tissue did not benefit and scored worse on a battery of measures designed to measure knee function, pain and progression of symptoms.
Prof Teppo Järvinen, an orthopedic surgeon and researcher at the University of Helsinki who led the study, said: “Our findings suggest that this may be an example of what is known as medical flashback, where commonly used treatment is ineffective or even harmful.”
The meniscus is a C-shaped, rubbery cartilage pad that acts as a shock absorber between the femur and tibia in the knee joint. There are two on each knee.
A meniscus tear may occur when the tissue edges are worn away as a result of sudden bending of the knee while doing sports. Damage can also occur gradually over time, and MRI scans often reveal meniscus tears in healthy people with no symptoms.
“We now know that these meniscus tears are found very frequently in patients with no symptoms,” Järvinen said. “Over the last 20 years, evidence has accumulated to show that many of these findings on MRI are completely coincidental.”
Symptoms associated with a meniscus tear include knee pain, stiffness, difficulty bending the knee, or a cracking or clicking sensation when the knee moves.
The study included 146 patients aged between 35 and 65 from five hospitals in Finland. Approximately one-third were diagnosed with a meniscus tear following an acute sports-related injury or knee sprain, while two-thirds gradually began to develop symptoms. Patients were randomly assigned to meniscus surgery or sham surgery, in which incisions were made but no surgery was performed.
After 10 years of follow-up, the group that had meniscus surgery had poorer knee function, more advanced osteoarthritis, and was more likely to have subsequent knee surgery.
Mark Bowditch, consultant knee surgeon and former president of the British Orthopedic Association, said best practice guidelines had changed in recent years to reflect emerging concerns about the limited benefits of surgery. This included extending the recommended waiting period from three months to six months to see if symptoms resolve spontaneously or with physiotherapy.
“In the past, three-quarters of patients might have had surgery, but now this [closer to a quarter]”We have a ‘think before you attack’ approach. Surgery should not be the first step.”
But based on his clinical experience, he said there are still subgroups of patients who may benefit. “If you’re doing surgery to treat pain, it’s very unpredictable,” he said. “But there is a group that feels that something is mechanically interesting; this group has a more predictable benefit.”
Many independent, non-orthopedic organizations that provide clinical guidelines have recommended discontinuing the procedure, Järvinen said. “For example, the American Academy of Orthopedic Surgeons (AAOS) and the British Association of Knee Surgeons (BASK) nevertheless continue to support the surgery,” he added. “This effectively demonstrates how difficult it is to give up ineffective treatments.”
The findings are published at: New England Journal of Medicine.
