Ross Hauser, MD; Danielle Matias, PA-C; Demi Foster, APRN

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Arthroscopic meniscus surgery.

• Getting in there, the arthroscopic meniscus and knee clean-up surgery.
• Red zone tear, white zone tear. When non-surgical options can work and when surgery will be the maybe the only choice.
• Partial-thickness tears or full-thickness tears: The other classification of the meniscus tear is related to the depth of the tear.
• Arthroscopic surgery with partial meniscectomy.

Arthroscopic meniscus surgery in the middle-aged patient.

• Athletes can return to sport faster with a partial meniscectomy. But at what cost?
• Getting in there, the arthroscopic meniscus and knee clean-up surgery.
• Is it a meniscus problem or osteoarthritis? A look at patients over 50.
• Patients are too optimistic about the success of a meniscus repair – Failure of meniscal repair occurs in up to 25% of patients.
• Surgeons suggest the reason people come in for meniscus surgery is over expectation of what the surgery can really do for their knee problem.
• The surgical realities of meniscus tear surgery – the research.
• Research 2013-2023 Arthroscopic Partial Meniscectomy versus Sham Surgery.
• Arthroscopic Partial Meniscectomy versus Sham Surgery for a Degenerative Meniscus Tear – Surgery does not alleviate knee catching or knee locking after surgery.
• In other words, avoid the rush of a meniscus surgery that may not fix the patient’s reported problems.
• Results also showed that meniscectomy did not provide better functional improvement than the nonoperative group.
• Study: The answer is better patient selection, not better surgery.
• Surgeons strongly argue that there is validity to meniscectomy.
• Another procedure – knee microfracture surgery and cartilage implant surgery.
• Summary of this section: Why do we still perform meniscectomy?
• Why do we ignore a mountain of clinical and scientific evidence against meniscectomy?

Pain after meniscus surgery

• What happens when all or part of the meniscus is removed? Joint instability is a common result of meniscectomy and so is pain after meniscectomy.
• Accelerated breakdown of the articular cartilage between the femur and tibia and the patella and femur bones.
• Hyaluronic Acid Intra‐articular Injection after Arthroscopic Knee Surgery.
• When you remove the meniscus you remove vital knee lubrication.
• Arthroscopic meniscus surgery leads to a three-fold increase in the need for knee replacement and supper accelerated osteoarthritis.
• Meniscus surgery causes super-accelerated knee arthritis.
• Meniscus removal throws the whole knee out of balance and damages other structures – the best way to prevent cartilage breakdown and knee osteoarthritis caused by meniscal surgery is to AVOID the surgery.

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In this section, we will focus on meniscus surgery and for those who already had the surgery, post-meniscus recovery. We will explore why some patients may have continued or worsening knee problems after meniscus surgery and subsequent treatment recommendations. Many people have successful meniscus surgeries. These are typically not the people we hear from. We hear from the people whose surgery did not meet hoped-for results.

Getting in there, the arthroscopic meniscus and knee clean-up surgery.

Many times we will hear from people that when the doctor gets into his/her knee, they will “clean things up” and get these people back on their way. The clean-up procedure is usually recommended to someone who in the past has “fought through” knee pain, had past injuries without standardized treatments including surgery, and has recently done something to aggravate their knee. Many of these people will likely require some type of surgical procedure if they can no longer bend their knees or walk without significant pain. However, many people are not recommended for surgery because their knee is already in a wear-and-tear degenerative state and the surgical procedure may accelerate the person’s knee osteoarthritis. The patient can in some instances be stuck in the “rock and a hard place scenario.” Get the surgery and accelerate the knee osteoarthritis, don’t get the surgery, and figure out some other types of treatments. All during this time the person figures out clever ways to get in and out of chairs, beds, and cars without significant pain while doing so. At some point, for many people, something needs to be done, and that something is surgery.

Meniscus injury – three surgical recommendations.

• An Arthroscopic meniscus repair. In this procedure, there is a small tear that the suture can sew up. In some instances, surgeons are taking bone marrow from the iliac crest and using stem cell therapy to accelerate this repair.
• An Arthroscopic partial meniscectomy. In this procedure, there is a piece of a meniscus that is more badly torn or macerated (all chewed up) and considered non-repairable. There is basically nothing to stitch up. This piece of the meniscus is recommended for removal because of its condition.
• An Arthroscopic total meniscectomy. The whole meniscus is considered damaged beyond repair and the entire meniscus will be recommended for removal.

One of the primary reasons for a meniscal operation is to improve joint stability, yet meniscectomy often appears to have the opposite effect, as it elicits even more instability, crepitation, and degeneration than the meniscus injury produced prior to operation. This is why reoperation rates after meniscectomy can be as high as documented in the research below.

Red zone tear, white zone tear. When non-surgical options can work and when surgery will be the maybe the only choice.

This illustration demonstrates the reasoning often given to patients that meniscus surgery is the only way.  Menisci has two zones. The red zone is the meniscus’ outside zone the white zone is the inside zone. A red zone tear lies within the blood-rich portion of the meniscus. Where there is a blood supply to the meniscus, there is the opportunity to stimulate healing or repair. The white zone meniscal tear is thought to be non-healing because there is no direct blood supply.  Many doctors do not believe the white zone meniscus tear can be repaired because of this. This is typically the part of the meniscus removed in meniscus surgery.

Partial-thickness tears or full-thickness tears: The other classification of the meniscus tear is related to the depth of the tear.

What are we seeing in this image?

Meniscus tears can be considered to either be partial-thickness tears or full-thickness tears. Partial-thickness tears are tears that only extend partway across the meniscus, while full-thickness tears extend fully across. So, if you have a full-thickness flap tear, then it is a tear that cuts across the meniscus completely.

Arthroscopic surgery with partial meniscectomy

In the research below you will see that this surgery is fraught with many long-term problems including an increased risk of disabling osteoarthritis. However, many people do have successful procedures. The image below shows arthroscopic surgery with partial meniscectomy.

The middle-aged patient with meniscus tears

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Is it a meniscus problem or osteoarthritis? A look at patients over 50

Much of the controversies surrounding meniscus surgery revolve around middle-aged patients and whether or not this surgery is helpful or harmful.

An October 2022 paper in the journal Current Reviews in Musculoskeletal Medicine (1) summarizes the controversies surrounding the surgical treatment of meniscus tears. “In patients with symptomatic meniscal tears, the location and tear pattern play a vital role in clinical management. Tears in the central white-white zone are less amenable to repair due to poor vascularity. Patients may be indicated for arthroscopic partial meniscus surgery or non-surgical intervention depending on the tear pattern and symptoms… There have been several landmark multicenter randomized controlled trials (RCTs) studying the outcomes of arthroscopic partial meniscus compared to physical therapy or sham surgery in symptomatic degenerative meniscal tears… Despite an abundance of literature exploring outcomes of the arthroscopic partial meniscus for degenerative meniscus tears, there is little consensus among surgeons about the drivers of good outcomes following arthroscopic partial meniscus. It is often difficult to determine if the presenting symptoms are secondary to the meniscus pathology or the degenerative disease in patients with concomitant osteoarthritis.”

The middle-aged patient and meniscus surgery – surgeons cannot predict which patients will benefit and who will not benefit from meniscus surgery. Research Results: Surgeons making a prediction on who would have a successful meniscus surgery was equal to predicting a coin toss.

A March 2020 study in the British Journal of Sports Medicine (2) questioned whether experienced orthopedic surgeons could predict who would benefit from surgery for degenerative meniscus tears and who would not.

The researchers set up an experiment. Surgeons participating in this study were given 20 cases to examine. In each case, the surgeon was asked to predict the outcome of treatment for meniscal tears by arthroscopic partial meniscectomy and exercise therapy in middle-aged patients. The surgeons were also asked to predict the beneficial change in knee function in those patients they would recommend surgery and those patients they would send to physical therapy or an exercise program.

The surgeons combined to examine and predict outcomes in 3880 knees. The results?

• Overall, 50.0% of the predictions turned out to be correct, the surgeons were able to predict 50% of the time which treatment would be of most benefit before treatment. The researchers of this study however noted – 50% correct would be no better than flipping a coin as it equals the proportion expected by chance.
• Experienced knee surgeons were not better at predicting outcomes than other orthopaedic surgeons.
• Conclusions: The surgeons’ criteria for deciding that surgery was indicated did not pass the statistical examination. This was true regardless of a surgeon’s experience. These results suggest that non-surgical management is appropriate as first-line therapy in middle-aged patients with symptomatic non-obstructive meniscal tears.

Typically when patients decide whether to have surgery or not they typically do not toss a coin. Probably some do because they do not have enough information to make a more educated assessment of their chances of having a successful surgery or having equal success with non-surgical options.

So here are the results of this study. Remember a surgeon was asked to look at 20 patient profiles and make a recommendation for surgery or no surgery. The 20 patients had already had surgery or exercise therapy and the successful results of their treatment had already been recorded. How did the surgeons do? They may as well have flipped a coin.

Here is what the study said:

• Overall, 50.0% of the (surgeon’s) predictions were correct, which equals the proportion expected by chance.
• Experienced knee surgeons were not better at predicting outcomes than other orthopaedic surgeons.
• In general, bucket handle tears, knee locking, and failed non-operative treatment directed the surgeons’ choice towards arthroscopic partial meniscectomy, while a higher level of osteoarthritis, degenerative (problems), and the absence of locking complaints directed the surgeons’ choice towards exercise therapy.

Conclusions: The surgeons’ criteria for deciding that surgery was indicated did not pass the statistical examination. This was true regardless of a surgeon’s experience. These results suggest that non-surgical management is appropriate as first-line therapy in middle-aged patients with symptomatic non-obstructive meniscal tears.

More reading on meniscus surgery

The use of PRP during arthroscopic meniscus surgery remains controversial : Research surrounding the use of Platelet-Rich Plasma (PRP), a healing compound made from concentrating a patient’s own blood platelets and injecting them (in the case of this subject at the surgical site) to hopefully stimulate a better, faster more complete healing following arthroscopic repair.

Arthroscopic partial meniscectomy or physical therapy in the middle-aged patient?

Given the choice, most patients would rather see if physical therapy can alleviate their knee pain and improve function. However, as research points out, when physical therapy fails, the next step is usually surgery. Yet, the evidence suggests that the surgery will work just as well or not work just as well as the physical therapy. When then are people going to surgery?

Arthroscopic partial meniscectomy versus physical therapy for traumatic meniscal tears in patients aged under 45 years old

A November 2023 study in The Bone & Joint Journal (3) from Dutch researchers led by the Department of Orthopaedics and Sports Medicine, Erasmus MC University Medical Centre compared patient outcomes of arthroscopic partial meniscectomy versus physical therapy for traumatic meniscal tears in patients aged under 45 years old.

This study was conducted on one hundred patients, 18 – 45 years old, who had a recent traumatic isolated meniscal tear injury. Patients were randomized to arthroscopic partial meniscectomy or standardized physical therapy with an optional delayed arthroscopic partial meniscectomy after three months of follow-up.

• 49 were randomized to arthroscopic partial meniscectomy.
• 51 to physical therapy. In the physical therapy group, 21 patients (41%) had an arthroscopic partial meniscectomy within three months.
• Over 24 months, patients in the arthroscopic partial meniscectomy group had a lower quality of life. They also incurred more health costs (meaning more doctor visits) “indicating that arthroscopic partial meniscectomy incurs additional costs without any added health benefit.”

The researchers concluded that arthroscopic partial meniscectomy is unlikely to be more effective than physical therapy in treating young patients with isolated traumatic meniscal tears.

Researchers could not determine if arthroscopic partial meniscectomy or physical therapy offered superior results.

A July 2022 paper writes (4): “It is unclear whether the results of arthroscopic partial meniscectomy are comparable to a structured physical therapy.” The researchers of this review study then investigated the efficacy of arthroscopic partial meniscectomy in the management of symptomatic meniscal damage in middle-aged patients. Using current available randomized controlled trials that compared arthroscopic partial meniscectomy performed in isolation or combined with physical therapy versus sham arthroscopy or isolated physical therapy, the researchers found: “The benefits of arthroscopic partial meniscectomy in adults with degenerative and nonobstructive meniscal symptoms are limited.” Further, they could not determine if arthroscopic partial meniscectomy or physical therapy offered superior results.

A June 2022 paper in the journal Osteoarthritis and cartilage open (5) from doctors at Brigham and Women’s Hospital, Harvard Medical School, and Boston University School of Public Health suggests that physical therapy can be a “reasonable initial treatment.” However, it is unclear what the best treatment would be for those for whom physical therapy did not offer substantial benefit. “The evidence also demonstrates that arthroscopic partial meniscectomy may be associated with greater risk of radiographic osteoarthritic changes, though more research and the addition of enhanced quantitative MRI-assessments are needed to further detail any compositional changes in the knee.” Simply, arthroscopic partial meniscectomy may be associated with a more rapidly developing osteoarthritis which should be explored further. Researchers have explored this further and we will discuss this below.

Surgical results vs. early exercise intervention in 30-year-olds

A January 2022 paper published in the New England Journal of Medicine (57) enrolled 121 young adults (average age, 29.7 years; 28% were female), who were randomly assigned to surgery (partial meniscectomy or meniscal repair) or 12-week supervised exercise therapy and education with the option of surgery later if needed. In total, 107 participants (88%) completed the 12-month follow-up. What happened at 12 months when surgery was compared to exercise?

The researchers suggested that among young, active adults with meniscal tears, patients who had early or quicker meniscal surgery did not achieve any better results than patients who had a strategy of exercise and education with the option of later surgery.

Both groups experienced clinically relevant improvements in pain, function, and quality of life at 12 months.

Although 26% of patients randomly assigned to exercise and education chose the option of later surgery during the 1-year follow-up, nearly three of four did not undergo surgery. 

In six reviews of randomized controlled trials, arthroscopic partial meniscectomy did not show clinically important benefit over conservative treatment for knee function and pain.

A July 2021 paper (17) published in the British Medical Journal (BMJ) by the United Kingdom’s National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust, and the University of Bristol examined the clinical effectiveness of common elective orthopedic procedures compared with no treatment, placebo, or non-operative care and assess the impact on clinical guidelines. Among these elective procedures was arthroscopic partial meniscectomy.

In this examination of effectiveness, the doctors explored previously published research including review articles. A review article is a study where previous research is accumulated into one set of findings. Here is what these doctors found.

• In six reviews of randomized controlled trials, arthroscopic partial meniscectomy did not show clinically important benefit over conservative treatment for knee function and pain.
• In the most recent review, which was based on 10 randomized controlled trials, arthroscopic partial meniscectomy did not provide a clinically meaningful improvement in knee pain, function, or quality of life.
• However, small benefits of arthroscopic partial meniscectomy were reported for patients without osteoarthritis.
• The authors indicated that surgical treatment should not be considered the first-line intervention for patients with knee pain and meniscal tears.

Researchers in Spain writing in the Archives of Orthopaedic and Trauma Surgery (18) compared the effectiveness of exercise versus arthroscopic partial meniscectomy in August 2022 research. They also explored exercise alone for degenerative meniscal tears in the knee function of patients at a 5-year follow-up. In examining the data from previously published studies, the researchers suggested no significant between-group differences existed. Exercise vs exercise and arthroscopic partial meniscectomy resulted in similar outcomes in activities of daily living and quality of life.

Short-term follow-up of meniscectomy has generated some positive results

Short-term follow-up of meniscectomy has generated some positive results; for example, a meniscectomy can provide temporary pain relief in the early stages following the operation, especially when an acute tear has caused excessive pain or popping preoperatively. Another immediate result may be a greater feeling of stability if the tear had previously been a source of instability or knee locking by catching between the tibia and femur. On long-term follow-up, however, these initial improvements have rarely been shown to last. Complete pain relief from meniscectomy is nearly unheard of after more than ten years and, at that point, more complex issues including a limited range of motion, radiographic degeneration, crepitation, and severe functional impairment have usually begun to surface. In many cases, a simple meniscus tear, if operated on, can become a career-ending injury.

Meniscus surgery that resulted years later in the patient’s need for further surgical treatment in the form of knee replacement or is considered failure

Surgeons at the Glasgow Royal Infirmary, University Hospital Llandough, and the University Hospital Wishaw in the United Kingdom published a February 2020 paper (19) recommending to their fellow surgeons which patients with meniscus damage and osteoarthritis would be considered as good candidates for surgery. Here is what they said:

“Clinical practice is moving away from treating meniscal tears in patients with osteoarthritis unless there are mechanical symptoms. (Knee function is significantly compromised) This study assessed the risk of needing further surgery for osteoarthritis in the five years following partial meniscectomy in different age groups and different grades of knee osteoarthritis.”

What these doctors did was look at partial meniscectomies that were performed by the paper’s senior author during a 31-month period.  The range of follow-up was 3 to 5 years.

• Knees that needed further surgical treatment in the form of joint replacement or osteotomy were considered failures.
• The study population was split into three groups according to their age (35-54, 55-64, and 65+).

Results:

• 207 knees were included.
• In the 35-54 age group, patients with no/mild osteoarthritis had a survival rate of 97.59% and the severe osteoarthritis group had a survival rate of 73.5%. (25.5% of the patients moved on to further surgery in the 3 – 5 year follow-up).
• In the 55-64 age group, these figures were no/mild osteoarthritis 100% and 73.6%, respectively. (26.4% of the patients moved on to further surgery in the 3 – 5 year follow-up).
• In the older than 65 age group, the survival rates were 100% and 65%, respectively. (35% of the patients moved on to further surgery in the 3 – 5 year follow-up).

Conclusion: “(This) study shows that patients with no/mild osteoarthritis should be considered for  Arthroscopic Partial Meniscectomy. Patients with meniscal tears and severe osteoarthritis should be counseled on the outcomes and risks of further surgery after an Arthroscopic Partial Meniscectomy.

Meniscus repair surgery

Recently doctors have been debating the types of meniscus surgery. More recently, as opposed to removing the meniscus, suture repair has been recommended in cases where it can be performed. It cannot be performed in all cases.

Dr. Kavyansh Bhan of the Department of Trauma and Orthopaedics, Whipps Cross University Hospital, London published this June 2020 review of surgical treatment in the medical journal Cureus. (20) “Arthroscopic partial meniscectomy (APM) is currently the most performed orthopedic procedure around the globe. However,  recent studies have conclusively shown that outcomes after an Arthroscopic partial meniscectomy are no better than the outcomes after a sham/placebo surgery. Meniscal repair is now being touted as a viable and effective alternative. Meniscal repair aims to achieve meniscal healing while completely avoiding the adverse effects of partial meniscectomy.  It is now increasingly recommended to attempt a meniscal repair in all repairable tears, especially in young and physically active patients. Partial Meniscal implants have also shown excellent outcomes in long-term studies, but their efficacy in acute settings still requires further research. Research performed on various techniques of meniscal regeneration looks promising, and regenerative medicine appears to be the way forward.”

When is it that suture repair can be recommended? Mostly when the tear falls within the well-blood-supplied meniscus red-red zone.

A February 2024 study in the Journal of Orthopaedics (21) compared the number of and risk factors of the need for knee replacement after a primary meniscus repair or primary meniscectomy.

• 8125 patients had meniscus repair, while 240,209 had meniscectomy.
• 5-year conversion rates: repair 1.7% of patients went on to knee replacement, following meniscectomy 8.4% went on to knee replacement.
• In both surgeries, the younger the patient (comparing ages 40 to 70+) the less likely knee replacement will be needed. Obesity, smoking, and general poorer health were risk factors for knee replacement needs.

Meniscus surgery recovery times: Patients, average age 50, undergoing arthroscopic meniscus surgery were too optimistic regarding their recovery time

We will now see why people get meniscus surgery. For many, there is an over-expectation of what the surgery will do for them. This is why there is a lure to surgery. We see it every day in our offices. The long-standing belief is that surgery will fix everything. A recent paper from the University of Southern Denmark (22) wrote:

• “In general, patients undergoing arthroscopic meniscus surgery were too optimistic regarding their recovery time and postoperative participation in leisure activities. This highlights the need for shared decision making which should include giving the patient information on realistic expectations. . . “

What is the recovery time after arthroscopic meniscus surgery?

Some of the questions patients want to be answered when they compare non-surgical to surgical treatment of meniscus tears are:

• What is the recovery time after meniscus surgery?
  • For many in regenerative medicine, this is a trick question because as the independent research cited in this article makes clear your meniscus will never recover and your knee will be made that much weaker.
  • Follow the timeline after surgery
    • Most patients can stand and put weight on their knee somewhat immediately with the help of a knee brace
    • Typically a patient can walk without crutches for a few days to 6 weeks after meniscus surgery. Depending on narcotic pain medication doses
    • Range of motion restored in 1 – 6 weeks depending on the surgical procedure
    • Return to sports 4 weeks to 6 months

While these numbers sound reasonable they are not for the patients in the long run. Non-surgical treatments such as comprehensive Prolotherapy typically and for a realistic expectation of treatment success are offered at about 6-week intervals and on average see results at the third treatment – anywhere from 12 – 18 weeks after the first treatment.

The difference is that while meniscus surgery can offer short-term goals the knee is in a downward spiral of joint instability from osteoarthritis to degenerative joint disease.

Athletes can return to sport faster with a partial meniscectomy. But at what cost?

Let’s start talking surgery and let’s start with athletes as they represent a group of patients who are most aggressive in getting treatment to get them back to their sport. For many athletes, surgery is a strong consideration. However which surgery is best at getting them back to sport fastest?

In November 2022, a multi-national team of doctors writing in the journal Knee Surgery, Sports Traumatology, Arthroscopy (23) evaluated outcomes and compared:

• the time required to return to sports after surgery,
• the rate of revision surgery that may be needed following surgery and,
• the time required for return to sports after revision surgery in elite athletes undergoing meniscal repair or partial meniscectomy.

The doctors hypothesized that both procedures would return similar, high rates of return to sports, with lateral (outside knee) meniscus procedures exhibiting higher potential healing compared to the medial (inside) meniscus.

• In this study, 421 patients (415 men and 6 women) with an average age of 23 years old, were elite athletes in wrestling, baseball, soccer, rugby, or handball.
• While 327 (77.7%) patients received partial meniscectomy, 94 (22.3%) patients received meniscal repair.
  • After partial meniscectomy, 277 patients (84.7%) returned to their competitive sports activity and 256 (78.3%) returned to their pre-injury activity levels.
  • A total of 12 (3.7%) patients required revision surgery because of persistent pain

Learning points:

• Athletes required more time to return to sports after meniscal repair and exhibited an increased rate of revision surgery associated with a reduced rate of return to sports after the subsequent surgery.
• For lateral meniscus tears, meniscectomy was associated with a high rate of revision surgery and risk of chondrolysis (progressive loss of articular cartilage).
• Partial medial meniscectomy allowed for rapid return to sports but with the potential risk of developing knee osteoarthritis over the years.

Patients are too optimistic about the success of a meniscus repair – Failure of meniscal repair occurs in up to 25% of patients.

A January 2020 paper published in The Archives of Bone and Joint Surgery (24) offers this assessment of meniscus repair:

“Meniscus repair is not a small surgery without complication. It is technically challenging and has a steep learning curve. General complications of arthroscopy such as venous thromboembolism, infection, and vascular injury could occur. Specific complications including nerve injuries, ligamentous injury, iatrogenic cartilage lesions, and poor suture techniques can happen during the meniscal repair. The surgeon should depict and accept the eventual complications and address them as rapidly as possible. It is also important to inform patients about potential complications. Failure of meniscal repair occurs in up to 25 % of patients.”

Surgeons suggest the reason people come in for meniscus surgery is over expectation of what the surgery can really do for their knee problem.

Doctors writing in The Journal of the American Academy of Orthopaedic Surgeons (25) offer a very good rationale for why people still have meniscus surgery. Here are some talking points of the research:

• For older patients or those more active patients with developing arthritis, the use of partial meniscectomy to manage degenerative meniscus tears and mechanical symptoms may be beneficial; however, its routine use in the degenerative knee over physical therapy alone is not supported. (Physical therapy has been found to be just as good as surgery in a paper published in the New England Journal of Medicine) (26).
• In younger populations (sports-minded), partial meniscectomy (removal of meniscus tissue) may provide an earlier return to play, and a lower revision surgery rate compared with meniscal repair.  However, partial meniscectomy may result in the earlier development of osteoarthritis.

Evaluating this data, one could imply that:

• Younger patients get the meniscus partial removal surgery because they need to get back to work or back to the game quicker and surgery, despite its drawbacks, gets them there faster. As we will see in the research below this is not grounded in fact, for many people getting this surgery, the situation becomes worse.
• Younger patients may not find repair surgery appealing because of
  • Longer rehabilitation times
  • Risk of needing a second surgery because the first surgery did not fix everything
  • Long-term development of osteoarthritis is seen as something that will happen “eventually,” not any time soon.

The surgical realities of meniscus tear surgery – the research

Between 2013 and 2016 – research began appearing to question not only the value of meniscus surgery but whether or not the surgery caused more harm than good. Let’s start with a New York Times piece in 2016. The summary is below.

• Dr. Gordon H. Guyatt, a professor of medicine and epidemiology at McMaster University in Hamilton, Ontario, wrote (an) editorial in The British Medical Journal, in which he called arthroscopic meniscal surgery “A highly questionable practice without supporting evidence of even moderate quality.”
• Dr. Guyatt was quoted in the Times “I personally think the operation should not be mentioned (to the patient as an option),” he says, adding that in his opinion the studies indicate the pain relief after surgery is a placebo effect. But if a doctor says anything, Dr. Guyatt suggests saying this:
• “We have randomized clinical trials that produce the highest quality of evidence. They strongly suggest that the procedure is next to useless. If there is any benefit, it is very small and there are downsides, expense, and potential complications.”
• Hearing that, he says, “I cannot imagine that anybody would say, ‘Go ahead. I will go for it.”

Research 2013-2024 Arthroscopic Partial Meniscectomy versus Sham Surgery

We are going to take a ten-year journey through the medical research calling into question meniscus surgery. We are going to start with a January 2023 paper published in the journal Osteoarthritis Cartilage (27). In this paper, researchers examined comparison studies between arthroscopic partial meniscectomy versus non-surgical or sham treatment in patients with MRI-confirmed degenerative meniscus tears. This was a systematic review and meta-analysis with individual participant data from 605 randomized patients performed by a team of Dutch, Norwegian, and Danish medical researchers.

In this study, the researchers combined data from four previously published studies. The patients in these studies averaged about 55 years old and were about evenly split between men and women. A data comparison was made between the patients who had an actual arthroscopic partial meniscectomy against those who had a sham or fake knee surgery.

Primary outcomes were knee pain, overall knee function, and health-related quality of life, at 24 months follow-up.

Results: The arthroscopic partial meniscectomy group showed a small improvement over the non-surgical or sham group on knee pain at 24 months follow-up. Overall knee function and health-related quality of life did not differ between the two groups. Across all outcomes, no relevant subgroup of patients who benefitted more so from the arthroscopic partial meniscectomy vs. the sham surgery was detected. The researchers recommend “a restrained policy regarding meniscectomy in patients with degenerative meniscus tears.”

Arthroscopic Partial Meniscectomy versus Sham Surgery for a Degenerative Meniscus Tear – Surgery does not alleviate knee catching or knee locking after surgery.

The research mentioned above and reported by the New York Times was not the first time the meniscus surgery controversy was reported in the international media. On December 24, 2013, the New England Journal of Medicine published an article entitled “Arthroscopic Partial Meniscectomy versus Sham Surgery for a Degenerative Meniscal Tear.”(28)

• This was the work of Finnish researchers who recognized that arthroscopic partial meniscectomy is one of the most common orthopedic procedures, yet rigorous evidence of its efficacy is lacking.
• What they did was to conduct a multicenter, randomized, double-blind, sham-controlled trial in 146 patients 35 to 65 years of age who had knee symptoms consistent with a degenerative medial meniscus tear and no knee osteoarthritis.

Patients were randomly assigned to arthroscopic partial meniscectomy or sham surgery. Then a scoring system was designed to measure pain, symptom severity, and knee pain after exercise at 12 months after the procedure.

What they found was “In this trial involving patients without knee osteoarthritis but with symptoms of a degenerative medial meniscus tear, the outcomes after arthroscopic partial meniscectomy were no better than those after a sham surgical procedure.”

In other words, avoid the rush of a meniscus surgery that may not fix the patient’s reported problems.

Continuing forward, the lead researcher of this study Raine Sihvonen, MD published more papers on the problems of meniscus surgery.

In February 2018, in the Annals of the Rheumatic Diseases (29) Dr. Sihvoven and his fellow researchers noted that degenerative meniscus tear can be the result of knee osteoarthritis and not vice-versa: “(Our) results support the evolving consensus that degenerative meniscus tear represents an (early) sign of knee osteoarthritis, rather than a clinical entity on its own, and accordingly, caution should be exercised in referring patients with knee pain and suspicion of a degenerative meniscal tear to MRI examination or Arthroscopic partial meniscectomy, even after a failed attempt of conservative treatment.“

In other words, the meniscus tear is the result of knee osteoarthritis development. If you remove the meniscus you accelerate knee osteoarthritis. We will discuss this further below.

In April 2016, Dr. Sihvonen and colleagues wrote in the Annals of Internal Medicine (30) that removing parts of the meniscus did not appear to relieve the symptoms of knee pain and knee locking in surgical patients. “Resection of a torn meniscus (cutting away tissue that cannot be sutured) has no added benefit over sham surgery to relieve knee catching or occasional locking. These findings question whether (these) mechanical symptoms are caused by a degenerative meniscus tear and prompt caution in using patients’ self-report of these symptoms as an indication for Arthroscopic Partial Meniscectomy.” In other words, avoid the rush to surgery that may not fix the patient’s reported problems.

Many orthopedic surgeries in my opinion have a far worse outcome than patients anticipate primarily because they cannot return to the activities they love, such as running. When people have arthroscopy surgery I try to go over their surgical reports with them because often what they perceived as what was done with the surgery was not done and other things were done that were detrimental and they had no idea they were done.  I have never as far as seen an orthopedic operative report that showed a real meniscus repair, where the meniscus was sewn together and that was it.  The typical report shows partial meniscectomy and no repair yet the patient believes it was a repair. Every arthroscopy report I have ever seen has findings that reveal osteochondral lesions, chondromalacia, meniscus degeneration, articular cartilage lesions ligament injury, and many others. Remember anyone can have decreased pain by doing less, and unfortunately, many people who receive orthopedic surgeries end up doing less.

Results also showed that meniscectomy did not provide better functional improvement than the nonoperative group.

Earlier in 2013 research published in the American Journal of Sports Medicine showed what little value meniscectomy has. Researchers compared meniscectomy to nonoperative treatment for meniscus tears. (31)

• They specifically studied degenerative horizontal tears of the medial meniscus and hypothesized that surgical treatment would produce better outcomes than nonoperative strengthening exercises.
• The study had 102 patients with medial meniscus tears – 81 women and 21 men with an average age of 53.8.
• Fifty patients underwent arthroscopic meniscectomy while 52 participated in nonoperative strengthening exercises. The results did not match up with the researchers’ hypothesis.

At the two-year follow-up, there was no difference in pain relief, improved knee function, or patient satisfaction. Results also showed that meniscectomy did not provide better functional improvement than the nonoperative group.

But what was the difference between these two groups? One group of patients underwent invasive surgery, had tissue removed, and will likely experience long-term meniscus degeneration.

In fact, most surgical meniscus treatments have, “have a high long-term failure rate with the recurrence of symptoms including pain, instability, locking, and re-injury. The most serious of the long-term consequences is an acceleration of joint degeneration.”

In research from May 2016, (32) doctors warned that the role of arthroscopic partial meniscectomy in reducing pain and improving function in patients with meniscal tears continues to remain controversial and that studies show no difference between arthroscopic partial meniscectomy and non-surgical treatment. 

Study: The answer is better patient selection, not better surgery

Now let’s jump to April 2024 which continues this line of research. Publishing in the Orthopaedic Journal of Sports Medicine (33) doctors suggest that “surgeons who wish to improve patient outcomes after arthroscopic partial meniscectomy should focus on improving patient selection rather than improving the surgical technique.”

Surgeons strongly argue that there is validity to meniscectomy

Doctors in Germany (34) say that many of the studies critical of arthroscopic meniscus surgery are not 100% reflective of the patients they see. Medical research is broken up into levels of evidence. Level 1 is based on evidence which means a researcher took existing research and combined it into a review of the literature. Doctors and researchers grade this at the lowest level of accredited research.

The German doctors say too much level 1 evidence is being offered as a generalization of meniscus surgery. The complaint is some surgeries will help some patients and that every meniscus surgery is not a bad surgery and this research is not reflective of that.

• They also cite that according to the consensus statement of ESSKA the European Society of Sports Traumatology, Knee Surgery, and Arthroscopy, meniscus surgery is still recommended.
• So European surgeons have not yet embraced the idea of totally moving away from meniscectomies.

“The treatment of degenerative meniscal lesions should start with conservative management.”

The ESSKA guidelines also say the treatment of degenerative meniscal lesions should start with conservative management. In the case of persistent symptoms, surgery should be considered after 3 months. In the case of mechanical symptoms, arthroscopy might be indicated earlier.

They do say arthroscopy in advanced osteoarthritic knees is not indicated due to inferior clinical outcomes.

• So there is a window of who the surgery can help. Unfortunately, this small window is usually left wide open to include patients who do not need the surgery.

A July 2024 study in The American journal of sports medicine (59) however suggested partial meniscectomy did benefit some middle-aged patients: “Knee arthroscopic surgery, in most cases consisting of partial meniscectomy or diagnostic arthroscopy, in addition to exercise therapy in middle-aged patients with meniscal symptoms, did not increase the rates of radiographic or symptomatic osteoarthritis and resulted in similar patient-reported outcomes at the 10-year follow-up compared with exercise therapy alone.” The surgery performed as well as exercise alone and in the patient group did not significantly increase osteoarthritis risk.

Another procedure – knee microfracture surgery and cartilage implant surgery.

The notion that replacing dead meniscus tissue, with a dead person’s meniscus (human allograft) or with synthetic meniscus (really meniscus replacement) is going to prevent osteoarthritis, as discussed in our article Alternatives to knee microfracture surgery and cartilage implant surgery is not realistic. By the time a person has a damaged meniscus, many other tissues in their joints are also affected including ligaments and tendons that provide stability when strong or provide instability when compromised. The whole knee joint needs to be treated not just the meniscus tear. The human meniscus is mobile, movable, stretchable, and made up of fibrocartilage, and has many functions including joint stabilization and the manufacturing of specific mediators of healing that go into the synovial fluid. None of these functions can truly be reproduced by any other type of meniscus besides the person’s own meniscus.

Although there is some short-term improvement after these surgeries in aspects such as pain control, the long-term effects of meniscectomy, meniscal repair, and meniscal allograft transplantation reveal that symptoms, such as pain and instability, will persist for years afterward.

A November 2022 paper (35) in The American Journal of Sports Medicine looked at meniscal allograft transplant (MAT), following a previous meniscectomy. In this study of 324 consecutive patients, the survivorship of arthroscopic Meniscal allograft transplant (MAT) using the soft tissue technique (the transplant is held in place by soft tissue as opposed to screwing it into the bone) was examined. Further, factors that could potentially influence failures and outcomes were investigated.

Study highlights:

• A total of 324 consecutive patients were evaluated at a mean follow-up of 5.7 years.
• Of these, 189 (58%) underwent an associated surgical procedure.
• A total of 22 patients (6.8%) were considered to have experienced surgical failure
• 70 (21.6%) patients were considered to have experienced clinical failure
  • the need for concurrent cartilage procedures and anterior cruciate ligament (ACL) reconstruction were predictors of failure.
• Finally, a lower survival rate was reported in female patients compared with male patients and in patients who required cartilage surgery.

Summary of this section: Why do we still perform meniscectomy?

Army physicians from the William Beaumont Army Medical Center and doctors from Rush University Medical Center published a March 2018 study in the Journal of Knee Surgery. (36)

It reports on how military surgeons dealt with meniscal injuries. The report reveals findings on nearly 30,000 meniscus surgeries.

• In 81.3% of patients, a partial meniscectomy was performed.
• In 20.3% a meniscal repair was performed. This is typically limited to the red zone of the meniscus where ample blood supply allows for suturing and healing.
• Very rarely a meniscus allograft transplantation (cadaver donor) in 0.7% of patients was performed.
• Older patients were more likely to get a meniscectomy and less likely to get a repair.

What are we to make of this?

• In 4 out of 5 patients, meniscus tissue had to be removed.
• In 1 out of 5 patients, the injury was fixable because of location and size.
• Meniscus transplant has lost much of its appeal.
• The meniscus is hard to save.

The goal of meniscectomy was to reduce pain, restore knee function, and prevent the development of osteoarthritis. As surgeons had long believed that the meniscus was a “remnant” tissue and that it was not needed, it could be removed if damaged without a negative effect.

However, as medical research studied the long-term effects of this procedure, it became apparent in the medical community that meniscectomy was a primary cause of the sudden onset of knee osteoarthritis. The meniscus was, in fact, an important component of the knee.

The meniscus provides several vital functions including mechanical support, localized pressure distribution, and lubrication to the knee joint. They are made of thick fibrous cartilage that allows them to function as a shock absorber between the upper and the lower leg bones.

Doctors in France writing in the medical journal Orthopaedics & Traumatology, Surgery & Research, (37) joined the growing list of doctors rallying under the banner “Save the Meniscus!”

This research asks the same question we do, Why do we still perform meniscectomy?

• The French researchers acknowledge that even in late 2017, meniscectomy remains one of the most frequent orthopedic procedures, despite meniscus-sparing techniques having been advocated for several decades now.

Why do we ignore a mountain of clinical and scientific evidence against meniscectomy?

• The French team says the number of meniscectomies is excessive in the light of scientifically robust studies demonstrating the interest in meniscal repair or of non-operative treatment for traumatic tears and of non-operative treatment for degenerative meniscal lesions.
• Meniscectomy was long considered the treatment of choice. All but 1 of the 8 recent randomized studies reported non-superiority of arthroscopy over non-operative treatment, which should thus be the first-line choice, with arthroscopic meniscectomy reserved for cases of failure, or earlier in case of “considerable” mechanical symptoms.

They, like us, agree that it is high time that the paradigm shifted, in favor of meniscal preservation.

Long-term pain after meniscus surgery and accelerated osteoarthritis

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Non-surgical and injection treatment options for the different types of Meniscus tears

• Intra-articular injection of corticosteroids or hyaluronic acid may help in providing temporary symptomatic relief, but no influence should be expected on the quality of the meniscal tissue.
• Are there risks of using cortisone before meniscus surgery?
• Corticosteroid short-term success and long-term problems in meniscus injuries.
• Cortisone can thin out the meniscus.
• Cortisone during the surgery.
• Platelet-rich plasma therapy, is commonly referred to as PRP.
• Prolotherapy
• The reality of stem cell therapy

Are there risks of using cortisone before meniscus surgery?

A December 2021 paper published in the medical journal Cartilage (48) describes the challenges of treatment for a symptomatic painful knee with or without loss of function. About surgery, the paper notes: “arthroscopic surgery provides unpredictable results: recent evidence has shown that partial meniscectomy is not better than conservative management up to two years of follow-up, and the removal of meniscal tissue may accelerate osteoarthritis progression. . . ”

About injections, the paper describes: “Intra-articular injection of corticosteroids or hyaluronic acid may help in providing temporary symptomatic relief, but no influence should be expected on the quality of the meniscal tissue.” In other words, these injections will not help repair a damaged meniscus. Then the authors describe. the use of platelet-derived growth factors. “Preclinical studies have documented that platelet-derived growth factors may play a beneficial role in stimulating meniscal repair and regeneration by triggering anabolic pathways and stimulating local mesenchymal stem cells from synovium (the fluid of the knee). Furthermore, also mechanical stimulation (e.g., arthroscopic trephination (punching holes in the meniscus to try to stimulate healing) or percutaneous needling) in the red-red or red-white zone may further promote tissue healing.”

A December 2021 paper published in the Journal of Experimental Orthopaedics (49) revealed the thoughts of the attending members of the 2021 5th International Conference on Meniscus Science and Surgery “for furthering the state of meniscus science in 2021.”

The most important findings of this survey were that the highest ranked future research and development focus areas should include meniscus repair, biologics, osteotomy procedures, addressing meniscus extrusion (your meniscus is sticking out beyond the shin bone and has its causes in root tear), and the development of new therapies for the prevention of Post-traumatic osteoarthritis. Currently, the reported most ‘valuable’ type of biologic for meniscus treatment was PRP injections, while amniotic fluid was reported as least ‘valuable’.

So what are we reading here? The doctors thought that the features of meniscus tear treatment should be:

• Repairing not removing meniscus tissue
• Biologics. These are sometimes referred to as “cellular” treatments or “platelet” treatments./ More commonly Platelet-rich Plasma Therapy and Stem Cell Therapy.

 

Platelet-rich plasma therapy, commonly referred to as PRP

One of the treatment options the patient may have researched is platelet-rich plasma therapy, commonly referred to as PRP. PRP is an injection treatment that re-introduces your own concentrated blood platelets into areas of chronic joint deterioration. We have an extensive article online that covers:

• “Patients treated with PRP injections demonstrated an improving knee function and symptoms over the duration of the study.”
• Medical reviews of PRP meniscus injections.
• Platelet Rich Plasma injections have the ability to regenerate tissue.
• Ten patients with degenerative meniscal tears were treated with PRP injections.
• Five Platelet Rich Plasma Prolotherapy meniscus treatment cases are presented in the medical literature.
• Ross Hauser, MD explains how one injection of PRP will likely not work.
• PRP injections into the meniscus and around the cartilage.

You can find that article here: PRP for meniscus tears

In Comprehensive Prolotherapy, the knee joint instability is restored by repairing and regenerating tissue

We use non-surgical treatments for meniscus tears. We may use our Prolotherapy treatments and PRP. This is an in-office injection treatment. This video and the summary below are an introduction to our non-surgical treatments. It is presented by Danielle R. Steilen-Matias, MMS, PA-C of Caring Medical Florida.

• Dextrose Prolotherapy is a simple sugar injection into the knee that attracts your own healing repair cells into the area to fix the damaged meniscus
• In some patients, it may not be enough to attract your own cells to this damaged area with Prolotherapy, in this type of case, we may have to put cells there via injection. Our first option would be Platelet Rich Plasma (PRP) Prolotherapy. This would put the healing factors found in your blood platelets into the damaged joint.
  • WE DO NOT offer PRP as a stand-alone treatment or injection. While PRP brings healing cells into the joint, it acts to repair degenerative damage. In our experience, while PRP addresses damage deep in the such as a meniscus, we must still address the joint instability problem created around the knee. We do this with Prolotherapy. Here damaged or weakened ligaments that are simply “stretched,” can be strengthened with treatment to help restore and maintain normal joint mobility. We discuss the meniscus interaction with the MCL in a moment. Simple PRP on the inside, Prolotherapy on the outside of the joint.
  • PRP is injected at the meniscus with ultrasound guidance
• Most meniscal tears require four to six treatments although that could be less or more depending on the patient.
• What helps our success rate with meniscal tears is our treatment of the MCL or the medial collateral ligament at the same time.
• We will use of ultrasound machine to assess the integrity of the MCL

Platelet Rich Plasma Therapy and Prolotherapy, which stimulates tendons, ligaments, and cartilage to heal, have many advantages over arthroscopy, which include:

• These treatments are considered a much safer and more conservative treatment
• the procedure does not take long to administer; an individual is usually in and out of the doctor’s office in less than an hour
• it stimulates the body to help repair the painful area; for example, the new collagen tissue formed is actually stronger than it was before the injury
• it reduces the chance of long-term arthritis; with arthroscopy, the chance of long-term arthritis increases
• in the case of athletes, it increases their chances of being able to play their sports for the rest of their lives; arthroscopy significantly decreases those chances
• exercise is encouraged while getting Prolotherapy treatments; one must be very cautious with exercise after arthroscopy
• the procedure is much less invasive; remember that arthroscopy requires the knee to be blown up with about 100 ml of fluid to fit all the scopes into the knee.

The reality of stem cell therapy

• Stem cell therapy can be an effective treatment for meniscus damage. We have seen excellent results in many patients. However, stem cell therapy needs to be understood within the reality of what this treatment can and cannot do and how this treatment should be used.

We don’t treat everyone with stem cell therapy

• It is important to note that we do not use stem cell therapy on every patient. In fact, we use stem cell therapy in very few of our patients. We find that other simpler and less costly regenerative medicine injection treatments can work just as well. This is explained below.

If you do not have a meniscus, stem cell therapy as an injection will not make a new one

Expectations of what stem cell therapy can do may lead to patient disappointment

• In many people who reach out to our office, we find that they have an unrealistic expectation of what stem cell therapy can offer them. For some people, stem cell therapy cannot, in one simple injection, repair, and reverse years of degenerative damage. Many treatments may be necessary. Patients should be aware of what stem cell therapy can really do.
• For example, stem cell therapy cannot generate a meniscus from nothing. If you do not have a meniscus, stem cell therapy as an injection will not make a new one. If you have a meniscus tear, lesion, or hole in cartilage, stem cell therapy may help create a natural healing patch, but, the treatment, like any medical treatment, has its limitations. Stem cell therapy can patch a hole, but without supportive treatments to address what caused the degenerative knee condition and what caused the hole in the cartilage in the first place, (knee instability and degenerative wear and tear motion from damaged and weakened knee ligaments), stem cell therapy will not be the single-shot cure a patient will hope for.

Summary: Should I have another meniscus surgery?

We offer a non-surgical option for meniscus repair and that is why people reach out to us. It is probably the reason you arrived at this article now. To see if our non-surgical option may be an option for your meniscus surgery recommendation. We do understand that there are instances where someone will consider that they have no choice but to have surgery. They are active people whose knees lock up and are acutely painful on movements. The meniscus problem is interfering with their ability to work, participate in sports, or simply have a decent quality of life. For some people, meniscus surgery will be successful. The point of this article however is what is the long-term cost of meniscus surgery in terms of knee function and pain? Secondly, if non-surgical options can deliver success equal to or better than surgical intervention.

Another of the most common calls our office receives involves patients who have had part or all of their meniscus removed and are now suffering from continued pain or arthritis as a consequence of the meniscus or multiple meniscus surgeries they had.

• What is concerning the most to these patients is that their knee problems came upon them much more quickly, in some cases almost immediately after surgery. This was seemingly against their surgeon’s admission that they (the patient) would “eventually” develop osteoarthritis.

This is reflected in the types of emails that we get from people looking for help. They go something like this:

I have severe osteoarthritis in both knees. I have had meniscus surgery on both knees. Every day I live with severe pain and swelling in both of my knees. I am told only knee replacements will help me now. I do not want any more surgery. I feel that it is the meniscus surgeries that put me in this position.

I have had meniscus surgery on each knee. X-rays and MRIs show major arthritis in each knee. I can’t walk for longer than an hour without my knees swelling and being so painful I can’t walk anymore. I just turned 50, I do not want to even consider knee replacement without trying everything first

Again, some people do benefit from meniscus surgery in the short term and near future. It is these recent surgical success patients that we do not see in our clinic. Who we see are the people, who already had meniscus surgery and their knee is causing them problems, or people who do not want a meniscus surgery at this time because of upcoming sports seasons, competitions, or simply because they need to work and there is a waiting list to get the surgery.

The meniscus can have a 90% tear and it will still figure out how to function

The meniscus has a very difficult time healing its own injuries because of a lack of vascularization to the entire meniscus. That is the blood that carries healing elements does not reach the entire meniscus. Because of this, the meniscus is a composite of different types of cells, superficially, those that can heal, and those that can’t.

However, researchers at the University of Pennsylvania examining the meniscus’ complex mesh of fibers that run criss-cross to each other discovered that the two types of meniscus fibers, whose jobs are to absorb knee impact, the circumferential fibers and the radial tie fibers have a unique understanding of maintaining knee integrity in the event of meniscus injury.

They write: The meniscus is comprised of circumferentially aligned fibers (basically a mesh) that resist the tensile forces within the meniscus that develop during loading of the knee. Although these circumferential fibers are severed by radial meniscal tears, tibial contact stresses (the impact on the shin bone) do not increase until the tear reaches about 90% of the meniscus width, suggesting that the severed circumferential fibers still bear the load and maintain the mechanical functionality of the meniscus.

Note: The meniscus can have a 90% tear and it will still figure out how to function.

How it does this, is that the radial tie fibers, the perpendicular mesh network of the meniscus are helping to redistribute the knee load back to the severed but still functioning circumferential fibers.

Note: What does all this mean?

The study conclusion spells it out. “This finding supports the notion that radial tie fibers may similarly promote tear tolerance in the knee meniscus, and will direct changes in clinical practice and provide guidance for tissue engineering strategies.”(56)

Meet some of our knee patients who avoided further knee surgeries!

Contact

Controversy over the accuracy of knee MRI for meniscus tears

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