Long-term pain after meniscus surgery and acceleration of knee osteoarthritis

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

Clinical studies and patient outcomes show many people suffer from long-term pain and accelerated osteoarthritis after meniscectomy. A meniscectomy removes parts or all of the meniscus, the cartilage cushion that leads to bone-on-bone, knee instability, and stress on the knee joint.

Joint instability is a common result of meniscectomy and so is pain

Doctors at the Departments of Orthopedic Surgery and Biomedical Engineering at the University of California, Irvine teamed with the doctors at the Sports Medicine Institute, Hospital for Special Surgery, New York to assess what to do with the patient who had all or part of their meniscus removed. This is what they wrote in their November 2021 paper in the medical journal Cartilage. (1)

“Meniscus tissue deficiency resulting from primary meniscectomy or meniscectomy after the failed repair is a clinical challenge because the meniscus has little to no capacity for regeneration. Loss of meniscus tissue has been associated with early-onset knee osteoarthritis due to an increase in joint contact pressures in meniscectomized knees. Clinically available replacement strategies range from allograft transplantation to synthetic implants, including the collagen meniscus implant, ACTIfit (scaffold that is implanted in patients who have an intact meniscus rim), and NUSurface (an artificial meniscus). Although short-term efficacy has been demonstrated with some of these treatments, factors such as long-term durability, chondroprotective efficacy, and return to sports activities in young patients remain unpredictable. Investigations of cell-based and tissue-engineered strategies to treat meniscus tissue deficiency are ongoing.”

It has been suggested that the “quickest way for a person to get osteoarthritis is to have arthroscopic removal of their meniscus. There are many ways meniscectomy accelerates the osteoarthritis process through the structural wear of the articular cartilage.

Doctors at the Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, and The George Washington University School of Medicine and Health Sciences, Washington, DC., described the problem of degenerative joint disease after meniscectomy in a September 2021 paper published in the Sports Medicine and Arthroscopy Review. (2)

“The meniscus has an important role in stabilizing the knee joint and protecting the articular cartilage from shear forces. Meniscus tears are common injuries and can disrupt these protective properties, leading to an increased risk of articular cartilage damage and eventual osteoarthritis. Certain tear patterns are often treated with arthroscopic partial meniscectomy, which can effectively relieve symptoms. However, removal of meniscal tissue can also diminish the ability of the meniscus to dissipate hoop stresses, resulting in altered biomechanics of the knee joint including increased contact pressures.”

What are we seeing in this image? Even the radiologist cannot determine whether the image he/she is seeing represents a recurrent meniscus tear or is just post-surgical changes.

Post-surgical changes are demonstrated in the medial meniscus with a smaller-than-expected size of the body of the medial meniscus. (The meniscus is much smaller than anticipated).
Altered signal intensity (the signal; that has detected abnormalities) in the body and posterior horn of the medial meniscus extending to the inferior articular surface demonstrates a similar appearance to previously performed MRI. (The patient had a previous MRI that demonstrated similar degenerative changes).
This either represents residual changes from prior surgery and meniscus tear or recurrent tear persistent from the previous exam. (This damage may be from the previous surgery or a new injury, can’t tell.)

As mentioned above, the patient will be told that they will eventually develop knee problems. The long-term side effect of meniscus surgery is that meniscectomies can worsen knee joint instability by negatively influencing other supporting knee structures by increasing contact stress on the cartilage. The knee’s house of cards will crumble thereafter as increasing contact stress on the cartilage increases the risk and occurrences of chronic knee inflammation and accelerates the degenerative knee conditions that lead to knee joint erosion or irreversible joint damage to the knee.

Joint instability is a common result of meniscectomy, which is not surprising when considering that the meniscus is a primary stabilizing component of the knee. The knee meniscus provides maximum joint contact protection and thus, reduces the contact stresses on the load-bearing surface of the joint, much like a washer does to distribute the pressure of the nut or bolt evenly and to provide a smooth surface or a double rear wheel (four-wheel) truck distributes less pressure on each tire than a normal two rear wheeled truck.

Common physical symptoms of instability after meniscectomy are crepitation, such as cracking or popping and locking in the joint. On radiographic examination, this postoperative deterioration of the knee is evidenced by a narrowing of the joint space between the thigh and shin bones or a flattening of the tibiofemoral surfaces.

Biomechanically, the development of osteoarthritis can in part be explained by the increased stress placed on the tibia and femur post-meniscectomy. It is a known fact that reducing the size of the contact area on a surface increases pressure in the remaining area. Therefore, by removing part of or the entire meniscus from the knee, the area through which weight is transmitted in the joint is reduced, thus increasing the pressure on both the tibia and the femur and their articular cartilage.

Accelerated breakdown of the articular cartilage between the femur and tibia and the patella and femur bones

How does this happen? Meniscectomy increases friction dramatically during motion by depriving the joint of the ability to lubricate the articular cartilage properly. This accelerates the breakdown of the articular cartilage between the femur and tibia and the patella and femur bones. When these metabolically active articular cartilage cells degenerate faster than they can regenerate, the result is accelerated breakdown (degeneration) within the joint. This is not a recently discovered phenomenon.

In an effort to prevent rapid knee breakdown following meniscectomy surgery, many doctors offered their patients hyaluronic acid intra-articular injections. The thinking is that the “gel” shots would provide some cushion and help prevent the grinding of a “bone-on-bone situation.”

A November 2022 study in the journal Orthopaedic Surgery (3) assessed the effectiveness of Hyaluronic Acid intra-articular injection in helping patients with their recovery following arthroscopic knee surgery. The researchers acknowledge that while accepted hyaluronic acid injections after arthroscopic knee surgery have been widely offered, the injection’s effectiveness and safety remain controversial.

In reviewing previously published data, the researchers focused on fifteen studies involving 951 knees. The results showed no significant difference between the hyaluronic acid group and the control group in the reduction of pain or improvement of function. The researchers concluded: “Although hyaluronic acid injection after arthroscopic knee surgery is safe, the available evidence does not support its (effectiveness) in pain relief and functional recovery. Therefore, the application of hyaluronic acid injection after arthroscopic knee surgery is not recommended.”

When you remove the meniscus you remove vital knee lubrication

One of the most vital but lesser-known roles of the meniscus is to provide lubrication to the knee, which it accomplishes by diffusing (spreading out) synovial fluid across the joint. Synovial fluid provides nutrition and acts as a protective measure for articular cartilage in the knee. The femoral condyle of the thigh bone in the knee is covered in a thin layer of articular cartilage, which serves to reduce emotional friction and to withstand weight-bearing. This cartilage is very susceptible to injury both because of its lack of proximity to the blood supply and the high level of stress placed on it by excessive motion. The meniscus, therefore, is able to provide a much-needed source of nutrition to the femoral and tibial articular cartilage by spreading fluid to that avascular area.

Arthroscopic meniscus surgery leads to a three-fold increase in the need for knee replacement and supper accelerated osteoarthritis.

Here we present a brief review of many of the papers published in recent years suggesting that meniscus surgery causes more harm than good in many patients.

These are not new controversies. In November 2016: Research in the medical journal Orthopedics (4) examined the rate of patients needing knee replacement after an arthroscopic procedure.

Doctors examine the incidence of total knee arthroplasty (total knee replacement) in patients who have undergone knee arthroscopy for partial meniscectomy, chondroplasty, or arthroscopic debridement of the knee.
Reported rates of total knee replacement:
- One year: 10.1%
- Two years: 13.7%
- Three years: 15.6%
Obesity, depressive disorder, rheumatoid arthritis, diabetes, and being age 70 years and older were associated with the increased relative risk of conversion to total knee replacement at 2 years.
When obesity was combined individually with the top 5 other risk factors, no combination produced a higher relative risk than that of obesity alone.
Patients who were 50 to 54 years of age had the lowest incidence of conversion to total knee replacement.
Men had a lower incidence of conversion to total knee replacement (11.3%) than women (15.8%).

The study’s doctors suggested that this information can help surgeons counsel patients on the incidence of total knee replacement after knee arthroscopy and identify preoperative risk factors that increase risk.

In 2017, doctors in the Netherlands published their findings in the medical journal Osteoarthritis Cartilage: (5) “In patients with knee osteoarthritis, arthroscopic knee surgery with meniscectomy is associated with a three-fold increase in the risk for future knee replacement surgery.”

Citing this 2017 research is an August 2022 study led by doctors at Brigham and Women’s Hospital and Harvard Medical School and published in the journal Arthritis & rheumatology (6) examined the risk of the development of MRI-documented structural changes in knee osteoarthritis among individuals with meniscal tear and knee at baseline and 18 and 60 months after arthroscopic partial meniscectomy versus physical therapy.

The researchers found that for both treatment groups, arthroscopic partial meniscectomy and physical therapy, knee osteoarthritis changes were seen during the early observation intervals rather than during the later intervals. Analysis revealed that between baseline and the 18th-month assessment arthroscopic partial meniscectomy was significantly associated with an increased risk of having a worsening cartilage surface area score, involving both any worsening across all knee joint sub-regions (contact areas of the knee), and the number of sub-regions damaged, having a worsening effusion-synovitis score (more swelling), and having more than an additional subregion with develop boney overgrowth or bone spurs. Significant associations were detected between months 18 and 60 only for having any subregion with a worsening osteophyte score (the bone spurs got worse).

Conclusion: “These findings suggest that the association between arthroscopic partial meniscectomy and MRI-based structural changes in knee osteoarthritis is most apparent during the initial 18 months after surgery.” In other words, the osteoarthritis develops quickly.

Meniscus surgery causes super-accelerated knee arthritis

Do these findings present anything really new? No, research has been ongoing telling patients and doctors of the risks associated with arthroscopic meniscus repair.

It is remarkable that studies more than a decade and a half old have issued the same warnings. In 2005, doctors in Canada audited the effectiveness of certain medical procedures and found very poor quality evidence on the efficacy of arthroscopic debridement of the knee with partial meniscectomy. (7)

The summary of these studies is? If you have a meniscus surgery, chances are you will be disappointed in the outcome and then move on to an eventual knee replacement.

In research appearing in the medical journal Clinical Anatomy, doctors issued their report on a phenomenon of super-accelerated osteoarthritis in knees with meniscus tear damage and a history of surgical meniscus removal.

Coming out of Tufts Medical Center in Boston, the researchers noted that knee osteoarthritis is typically a slow, progressive problem; however, in some patients knees progressed to osteoarthritis with dramatic rapidity. However, clinicians cannot determine which patients may be at risk for accelerated knee osteoarthritis without knowing the incident structural damage that predisposes a knee to accelerated osteoarthritis. The Tuft researchers found that structural damage that is associated with accelerated knee osteoarthritis destabilizes and compromises the function of the meniscus or the subchondral bone. (8)

In an early study, researchers from the Department of Orthopaedic Surgery at Carolinas Medical Center found that a damaged meniscus is an active participant in the development of knee osteoarthritis. In the study above, the relationship to bone damage is discussed, in this cited study the Carolinas Medical team found a strong association between meniscus damage and cartilage loss. (9) The two combined studies help confirm missing meniscal tissue contributes to bone and cartilage degeneration.

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.

Doctors at the Hospital of Special Surgery found that meniscus removal, not only impacts the knee at the point of the surgery but throws the whole knee out of balance and leads to several points of cartilage deterioration. (10)

What is really remarkable is that researchers write paper after paper saying that the removal of meniscal tissue in surgery causes advanced osteoarthritis and the procedures continue.

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References

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