Arthroscopic knee surgery in a middle-age patient. Are there non-surgical options?

Ross Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C

At our center, we see a lot of patients who love to be active and play golf, tennis, and pickleball. We also see patients who have demanding lines of work. These included contractors, landscapers, and other jobs that require people to be on their feet all day. Many of these people are entering middle age and they are starting to have some degenerative breakdowns in their knees. Many have also reached a point where their knee braces, over-the-counter medications, ice packs, and heating pads are not helping anymore. Even so, the morning or pre-activity workout will still include pre-emptive NSAIDs to keep swelling at bay and the knee brace to hold the knee together. When the knee brace no longer fits under work clothes, then some type of sleeve or taping is used.

Arthroscopic knee surgery may not work and in fact, may be harmful

A story that many of the people we just described will tell goes something like this:

I have had three arthroscopic knee surgery cleanouts and repair and removal of tissue. I still have pain. Following the last surgery it was recommended to me that the next surgery should be a knee replacement but, because of my age, my surgeon will only perform the surgery if I get to the point where I cannot walk. To manage my pain I have had cortisone, hyaluronic acid gel injections, and Platelet Rich Plasma injections. I have a significant limp and have to deal with this, as I need to work and would like to play with my children.

There are many people waiting for knee surgery. During their waiting time, they are being pain managed as best as possible. While some people may benefit from waiting for an arthroscopic knee surgery procedure, researchers have been questioning whether these surgeries provide any benefit at all for some patients and in fact, do these surgeries put the patient at risk.

Doctors and researchers are confirming arthroscopic knee surgeries for meniscus and cartilage “repair” do not heal, do not repair, and may accelerate knee instability and the degenerative collapse of the knee.

In this article, we will see research that questions the benefits of arthroscopic knee surgery in the long term. We do realize that for young athletes, many are presented with arthroscopic surgery as a means to get them playing quickly. Many do get back to sport within months, but many do not. The same can be said for the older athlete who works hard to stay active. The same can be said for the patient with a physically demanding line of work. Later in this article, we will present evidence for non-surgical knee repair.

Article Summary

  • “When I entered into my 50’s my knees started to give out on me. There went my golf game.”
  • I am concerned that will I have to have surgery every year. Taking out bits and pieces of my knee until there is nothing left?
  • Research: For many patients who are over 50, arthroscopic meniscus surgery should not be offered. Instead, patients should continue with nonoperative management until total knee replacement is unavoidable.
  • Maybe arthroscopic meniscus surgery can be offered for some.
  • “Despite an abundance of literature exploring outcomes of arthroscopic partial meniscectomy for degenerative meniscus tears, there is little consensus among surgeons about the drivers of good outcomes following arthroscopic partial meniscectomy.”
  • Clinical trials recommend against arthroscopic partial meniscectomy as the first-line treatment for managing knee pain.
  • Do people have an over-expectation of what arthroscopic knee surgery can really do for their knee problem?
  • The middle-aged patient and meniscus surgery – surgeons cannot predict which patients will benefit and who will not benefit from meniscus surgery. Flipping a coin would work just as well.
  • Stem Cell Therapy, Platelet Rich Plasma Therapy, and Prolotherapy as a non-surgical alternative to arthroscopic knee surgery?
  • I have no meniscus; Will stem cell therapy grow one back? NO. Stem cell therapy, as an injection in the doctor’s office, will not grow a meniscus from nothing.
  • Research: Bone marrow-derived mesenchymal stem cells have the potential to help form meniscus tissue

This may be your story. You went to your doctor, got a referral for an orthopedist, had an x-ray, and an MRI, and some damage was seen, maybe it was an undescriptive type of damage, something was there and no one was really sure what it was, or to what extent. You were prescribed stronger doses of the medications that you were already taking to see if that helped. But you are starting to think the NSAIDs are making your problem worse. You were sent to physical therapy and massage therapy to see if that helped.

Now you are at the point where you have to decide to:

a) Live with it until you can’t anymore.

b) Seek a surgical option.

c) Seek something more on the alternative, non-surgical side of medicine. Here your orthopedist may have even discussed stem cell therapy and platelet-rich plasma therapy. We are going to discuss all these options below.

When I entered into my 50’s my knees started to give out on me. There went my golf game.

Arthroscopic knee surgery - walking the gold course

Here is a familiar story.

When I entered into my 50’s my knees started to give out on me. They started to become very painful and I had constant swelling. I was developing a bone-on-bone situation in my knees. I am an active guy, or I was. I used to play golf every second I could get myself out there. When I do play now, when my knees feel up to it, I have to use the cart because I can no longer walk the golf course. It is just not my knees anymore. It is also the weight I have been putting on. My doctors convinced me that if I had meniscus surgery, and I did, I had most of my meniscus removed last year. The benefit would be reduced pain and an increase in my activity, and it would be easier for me to lose weight. Maybe that is what happens to other people. That is not what happened to me.

After the meniscus removal, my knee hurt more, I became less active, I put on more weight and now my activity is reduced to whatever I can do in physical therapy as even everyday walking has become painful. Now I am being told to consider knee replacement. The knee replacement, so I am told, will reduce my pain and make me more active and I will be able to lose weight. Well, that is why I had the arthroscopic surgery and it did not work out. Now I am exploring other options.

In our almost three decades of helping people with knee pain, this is the type of confusion we see in patients. What will help me? What will not help me? The treatments I thought would help did not. The things I am doing to try to stay healthy may be making me unhealthy.

We have a number of articles on our website that discuss topics of staying healthy through knee pain. Here are some of them:

I am concerned that will I have to have surgery every year. Taking out bits and pieces of my knee until there is nothing left?

Many people have very successful surgeries. As research in this article and other articles highlighted here demonstrate, arthroscopic surgery with partial meniscectomy is fraught with many long-term problems including an increased risk of disabling osteoarthritis.

arthroscopic surgery with partial meniscectomy is fraught with many long-term problems including increased risk of disabling osteoarthritis

So how do we have healthy individuals, maintain weight, have no time to slow down, stay active but get frequent knee surgeries? Maybe here is how:

I am very active, golf, tennis, and out in the ocean a lot. Water and snow skiing. Two years ago I tore my meniscus. Silly injury, all I did was jump off a stair. That was in my left knee. My surgeon told me all the years of activity were beginning to take their toll. I had arthroscopic surgery, the doctor took out a piece of my meniscus that could not be repaired and everything felt fine. Then a few months later, I did the same exact thing to my right knee. A silly injury, believe it or not demonstrating to someone how I hurt my left knee. I was scheduled for another meniscus surgery.

Now I am concerned that will I have to have surgery every year. Taking out bits and pieces of my knee until there is nothing left? I am very healthy, almost 60 years old. I do not want to keep doing this until I need knee replacements.

The latest findings on the use of arthroscopic knee surgery for symptomatic knee osteoarthritis, including for degenerative meniscal tears.

A March 2022 study (1) from a multi-national team of orthopedist specialists led by Monash University in Melbourne, Australia updated the latest findings on the use of arthroscopic knee surgery for symptomatic knee osteoarthritis, including for degenerative meniscal tears.

In this study, the researchers compiled data from sixteen trials (2105 participants). The patients in this study had an average age of 46 to 65 years, and 56% of the participants were women.

  • Four studies (380 participants) compared arthroscopic surgery to placebo surgery.
  • Eight studies compared arthroscopic surgery to exercise (1371 participants)
  • One study compared arthroscopic surgery to a single intra-articular glucocorticoid injection (120 participants),
  • One study compared arthroscopic surgery to non-arthroscopic lavage (34 participants),
  • One study compared arthroscopic surgery to non-steroidal anti-inflammatory drugs (80 participants)
  • One study compared arthroscopic surgery to weekly hyaluronic acid injections for five weeks (120 participants).

“High-certainty evidence indicates arthroscopic surgery leads to little or no difference in pain or function at three months after surgery, moderate-certainty evidence indicates it is probably little or no improvement in knee-specific quality of life three months after surgery, and low-certainty evidence indicates arthroscopic surgery may lead to little or no difference in participant-reported success at up to five years, compared with placebo surgery.”

Authors’ conclusions: “Arthroscopic surgery provides little or no clinically important benefit in pain or function, probably does not provide clinically important benefits in knee-specific quality of life, and may not improve treatment success compared with a placebo procedure. It may lead to little or no difference, or a slight increase, in serious and total adverse events compared to control, but the evidence is of low certainty. Whether or not arthroscopic surgery results in slightly more subsequent knee surgery (replacement or osteotomy) compared to control remains unresolved.”

An August 2023 paper in the BioMed Central surgery (2) did find some success with a combination of surgical procedures including knee arthroscopic debridement and peripatellar denervation. The researchers noted that the combined procedures had a significant improvement in knee function in patients with knee osteoarthritis. However, their study has some limitations. The researchers noted their own findings: “For one thing, we cannot follow up with the patients, and the controllability of rehabilitation training and other aspects after discharge was slightly poor. Whether the final surgical method varies in the recovery of knee function in patients with different grades is still unclear. For another, the postoperative follow-up time was short, and the long-term results of postoperative patients are yet to be observed.” Simply, long-term results could not be offered and more research was necessary.”

Doctors Issue Warnings to Middle Age Patients

Published in the Annals of the Rheumatic Diseases, (3) doctors from medical universities in Finland combined their research to publish these findings on Arthroscopic partial meniscectomy. For much more research on knee surgery for meniscus tears please see our article Knee Surgery for Meniscus Tears | Complications and Outcomes.

Here are the findings of the Finnish study:

  • Arthroscopic partial meniscectomy is one of the most common orthopedic operations with the number of procedures steadily increasing in the last three decades.
  • Most are performed on middle-aged and older patients with knee symptoms and degenerative knee disease.
  • Several recent meta-analyses based on randomized controlled trials have failed to show a treatment benefit of Arthroscopic partial meniscectomy over conservative treatment or placebo surgery for these patients.

Here is the conclusion of the study, what you will find is all the reasons people tell us they NEED arthroscopic knee surgery, are NOT supported

  • The widely held assertion is that symptoms such as the sensation of knee catching or locking represent a valid indication for arthroscopic surgery.
  • Resection of a torn meniscus has no added benefit over placebo surgery in relieving knee catching or occasional locking. (This was shown by this same research team in an earlier study that we will discuss below).

In conclusion, the results of this study showed Arthroscopic partial meniscectomy provides no significant benefit over placebo surgery in patients with a degenerative meniscal tear and no knee osteoarthritis.

This study was noted in an August 2023 paper in the journal Clinical Rheumatology (4). In this study, 163 patients who had unilateral knee arthroscopy were compared to patients with knee osteoarthritis who did not. After 24 months analysis showed that the unilateral knee arthroscopy and non-unilateral knee arthroscopy groups showed no obvious difference in the three knee symptoms, but the probability of new-onset grinding or clicking, and frequent knee pain, aching, or stiffness symptoms in the unilateral knee arthroscopy group were respectively 5.82 and 5.65-fold higher than that in the non-unilateral knee arthroscopy group.

But arthroscopic partial meniscectomy can be performed in the right older patient

In August 2022, doctors writing in the journal Knee Surgery, Sports Traumatology, Arthroscopy (5) wanted to examine if patients were too old for arthroscopic partial meniscectomy and if the surgery hastened or delayed the need for knee replacement. The study group was divided into patients over 60 and less than 60. While the doctors noted a significant difference in the joint survival rates between the groups, it was not the age of the patient that was the factor why the patient’s knee did not survive. It had more to do with cartilage degeneration and meniscal tear pattern, rather than age itself. They write: “Advanced age should not be the only reason for precluding arthroscopic partial meniscectomy in treatment of degenerative medial meniscus tears. An arthroscopic partial meniscectomy is a viable option when treating degenerative medial meniscus tear in elderly patients if adopted with caution.”

Arthroscopic knee surgery for osteoarthritis is not curative yet the numbers performed are increasing, is this the placebo effect?

Is arthroscopic knee surgery a placebo? In some of the studies referenced above and noted below, doctors are questioning whether the beneficial aspects of arthroscopic surgery reported in the literature were simply due to the placebo effect.

We are going back to the above July 2017 published in the Annals of the Rheumatic Diseases from Finnish University researchers:

“In this 2-year follow-up of 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 placebo surgery.”

In the study, the researchers did indeed perform placebo surgery. The doctors took 146 patients and randomized them into two groups.

  • In the first group, 76 patients had an actual arthroscopic partial meniscectomy
  • In the second group, 70 patients had a placebo surgery. Incisions were made to make the patient believe they had surgery

As stated above: “(they) found no statistically significant difference between the arthroscopic partial meniscectomy and placebo surgery for symptomatic patients with a degenerative meniscus tear and no osteoarthritis in any of the used outcome measures over the course of 24-month follow-up. No evidence could be found to support the prevailing ideas that patients with the presence of mechanical symptoms or certain meniscus tear characteristics or those who failed initial conservative treatment are more likely to benefit from an arthroscopic partial meniscectomy.”

Many past studies have concluded that arthroscopic knee surgery for osteoarthritis is not effective, not warranted, and basically should be avoided. So the idea is not new.

Many past studies have concluded that arthroscopic knee surgery for osteoarthritis is not effective

As far back as 2002, doctors wrote in the New England Journal of Medicine that middle-aged or older patients with knee pain with or without signs of osteoarthritis should not be recommended for arthroscopic surgery. (6) So the studies have been ongoing for some time. Five years later in 2007 doctors at the University of Colorado School of Medicine published in the journal Clinical Orthopaedics and Related Research (7) these concerns: “Despite the lack of consensus guidelines and randomized control trials, the use of arthroscopy for the treatment of osteoarthritis of the knee has increased . . . Techniques used for the arthroscopic treatment of osteoarthritis of the knee include joint lavage, joint débridement, meniscectomy, abrasion arthroplasty, and microfracture.  We found limited evidence-based research to support the use of arthroscopy as a treatment method for osteoarthritis of the knee. Arthroscopic débridement of meniscus tears and knees with low-grade osteoarthritis may have some utility, but it should not be used as a routine treatment for all patients with knee osteoarthritis.” 

So why keep recommending the surgery? Is there a knee surgery placebo effect? Here we are 16 years later, in February 2023 doctors cited this research and published it in the Journal of Clinical Orthopaedics and Trauma (8) these observations: Patients between the ages 46-78 with degenerative meniscus tear and osteoarthritis felt they benefited from knee arthroscopy in an eight-year follow-up and would repeat the surgery. ” The defense of arthrsocopic knee surgery has been going on as long as the recommendations against the surgery have been published.

In 2014 a  research team from McMaster University writing in the journal of the Canadian Medical Association says that evidence suggests that there is no benefit to arthroscopic meniscal debridement for degenerative meniscal tears. (9)

The benefits of arthroscopy decrease over time

In 2013 German researchers writing in the German language journal Sportverletz Sportschaden Sports Injury Sports Damage note that in the middle stages of knee osteoarthritis, “arthroscopic joint debridement can effectively reduce subjective complaints. Because this treatment does not stop the process of osteoarthritis, the improvements decrease over time.”(10)

Updated: A 2023 paper cited this research. Here doctors writing in the journal Musculoskeletal surgery (11) said some surgery maybe beneficial. “Conservative treatment based on physical therapy should be the first-line management. However, most (studies) revealed subgroups of patients that fail to improve after conservative treatment and find relief when undergoing surgery.”

The number of arthroscopic surgeries continues to increase.

In 2014, a study from Monash University in Australia researchers published in the Current Opinion in Rheumatology suggests that the use of arthroscopy to treat knee osteoarthritis has not declined despite strong evidence-based recommendations that do not sanction its use. (12) Updated: A 2023 paper published in the journal Knee surgery, sports traumatology, arthroscopy agreed (13): “The benefits of arthroscopic partial meniscectomy in adults with degenerative and nonobstructive meniscal symptoms are limited. The current evidence reports similarity in the outcome between arthroscopic partial meniscectomy and physical therapy.”

Conflicting research and warnings to middle-aged and older patients to try to arthroscopic knee surgery

More research warning middle-aged and older patients to avoid arthroscopic knee surgery

In 2015, a landmark paper came out in the British Medical Journal and it was scathing (14): Here are the bullet points of this research.

  • Arthroscopic knee surgery is frequently and increasingly used to treat middle-aged and older patients with persistent knee pain
  • All but one published randomized trial have shown no added benefit for arthroscopic surgery over that of the control treatment, but many specialists are convinced of the benefits of the surgical intervention
  • Interventions that include arthroscopy are associated with a small benefit and with harms; the small benefit is inconsequential and of short duration
  • The benefit is markedly smaller than that seen from exercise therapy as a treatment for knee osteoarthritis
  • These findings do not support the practice of arthroscopic surgery as a treatment for middle-aged or older patients with knee pain with or without signs of osteoarthritis.

In an accompanying press release from the British Medical Journal, the research team issued these statements:

  • “Interventions that include arthroscopy are associated with a small benefit and with harms,” and the benefit is “markedly smaller than that seen from exercise therapy.”
  • These findings “do not support the practice of arthroscopic surgery as a treatment for middle-aged or older patients with knee pain with or without signs of osteoarthritis.”
  • “It is difficult to support or justify a procedure with the potential for serious harm, even if it is rare when that procedure offers patients no more benefit than placebo,” argues Professor Andy Carr from Oxford University in an accompanying editorial.

Here is more evidence for patients to avoid arthroscopy knee surgery and comes from two (May 2017) multi-national team studies from surgeons in the British Medical Journal.

Here are the bulletin points from this research:

In the first study, a panel led by Canadian researchers from McMaster University, (15) and supported by data from doctors at the University of Toronto; University researchers in Australia; University Hospitals of Geneva, Switzerland; the Netherlands; Chile; Norway; and the United States, published the study entitled: Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline and made these recommendations:

  • We make a strong recommendation against the use of arthroscopy in nearly all patients with degenerative knee disease, based on linked systematic reviews; further research is unlikely to alter this recommendation”
  • “This recommendation applies to patients with or without imaging evidence of osteoarthritis, mechanical symptoms, or sudden symptom onset.”

Here is the summary given to surgeons:

  • The panel is confident that arthroscopic knee surgery does not, on average, result in an improvement in long-term pain or function.
  • Most patients will experience an important improvement in pain and function without arthroscopy.
  • However, in less than 15% of participants, arthroscopic surgery resulted in a small or very small improvement in pain or function three months after surgery—this benefit was not sustained for one year.
  • In addition to the burden of undergoing knee arthroscopy, there are rare but important harms (complications and side effects).

The second study:
A study that literally combed the world looking for the long-term benefits of knee arthroscopic surgery has been published in the British Medical Journal Open (online edition) (14). In this research, an international team of doctors including lead researchers from McMaster University in Canada, the Universidad de Chile, Monash University in Australia, University Hospital Basel, Switzerland, Kerman University of Medical Sciences in Iran, and the University of Oslo, Norway, tried to determine the effects and complications of arthroscopic surgery compared with conservative management strategies in patients with degenerative knee disease.

Here are the highlights of this research:

  • With respect to pain, the review identified high-certainty evidence that knee arthroscopy results in a very small reduction in pain for up to 3 months and very small or no pain reduction for up to 2 years when compared with conservative management.
  • With respect to function, the review identified moderate-certainty evidence that knee arthroscopy results in a very small improvement in the short term and very small or no improved function for up to 2 years.
  • Over the long term, patients who undergo knee arthroscopy versus those who receive conservative management strategies do not have important benefits in pain or function.

Research: For many patients who are between 50 and 70, arthroscopic meniscus surgery should not be offered. Instead, patients should continue with nonoperative management until total knee replacement is unavoidable.

As we have seen from the above research there has been a decades long controversy as to whether arthroscopic knee surgery should be offered to middle age patients. In May 2021, surgeons published a paper in the medical journal Arthroscopy (16). In this paper, the doctors traced arthroscopic knee surgical outcomes over a 20 years period in patients who had knee surgery between the ages of 50 – 70. Part of the research was to see how many of these patients who had the arthroscopy, had to have a total knee replacement anyway.

Here are the learning points of this research:

  • The study included 289 patients aged at the surgery between 50 and 70 years old with a diagnosis of degenerative meniscal tear who underwent arthroscopic meniscectomy.
  • Patients with more advanced knee problems, women, and older patients were at higher risk to need a knee replacement after arthroscopic meniscus surgery
  • The doctors reported a 15.7% conversion rate at 20 years from the arthroscopic meniscus to total knee replacement and an average time between surgeries of seven years.
  • Further, patients over the age of 60 who had a lateral meniscectomy and concurrent ACL reconstruction were at higher risk for poor clinical outcomes at 20 years of follow-up.
  • Therefore, if patients present negative predictor factors, (more advanced knee osteoarthritis, being older) the arthroscopic meniscus surgery should not be offered, continuing with nonoperative management until total knee replacement is unavoidable.

In response to this research, Joan C. Monllau, M.D., Ph.D. wrote in the same issue of Arthroscopy🙁17)  “A painful knee with a degenerative meniscal tear is a quite common problem in the middle-aged patient. Arthroscopic partial meniscectomy is too often used to alleviate pain and seems to work in the short term. However, arthroscopic partial meniscectomy does not guarantee success, particularly in the long run, particularly in patients with greater grades of osteoarthritis, patients who are older than 60 years, female patients, patients with malalignment, and patients having lateral meniscectomy. There is a need for better science to recommend arthroscopic meniscectomy in those cases.”

There is a suspicion that patients with prior arthroscopic procedure for knee osteoarthritis have a greater risk of complications should they have to move onto a knee replacement.

A November 2022 study in the journal Archives of orthopaedic and trauma surgery (18) comes to us from a team of international orthopedic surgeons aimed at assessing and confirming that a total knee replacement surgery will have a higher complication rate if the patient had a previous arthroscopic procedure for knee osteoarthritis. The surgeons wrote of their study: “Our hypothesis was that a prior knee arthroscopy may be detrimental to the outcomes of knee arthroplasty (replacement) in the future.”

In this study the researchers reviewed seven retrospective studies, the total number of knee replacements without prior arthroscopies was 138,630, and the total knee replacements after a prior arthroscopy was 4372. Of the five studies that reported functional outcomes, three studies reported no difference, whereas two studies reported worse outcomes in patients with a prior knee arthroscopy. Higher rates of prosthetic joint infection and overall complications were seen in patients with a prior knee arthroscopy.

Conclusion: “Total knee arthroplasty (replacement), when preceded by knee arthroscopy for osteoarthritis may lead to an increase in complication rates like prosthetic joint infections, revision, and re-operations. However, no significant differences were observed in patient-reported functional outcomes and range of joint motion. An association with postoperative complications after subsequent total knee replacement should be a deterrent in advocating this procedure in an arthritic knee.”

So what are the researchers saying:

  • There is a suspicion that patients with prior arthroscopic procedure for knee osteoarthritis have a greater risk of complications should they have to move onto a knee replacement.
  • While the patients did not report problems with functional outcomes and range of joint motion higher rates of prosthetic joint infection and overall complications were seen in patients with a prior knee arthroscopy

Finally

  • An association with postoperative complications after subsequent total knee replacement should be a deterrent in advocating this procedure in an arthritic knee.”

Maybe arthroscopic meniscus surgery can be offered for some middle-aged patients

arthroscopic meniscus surgery can be offered for some middle-age patients

Simply the evidence that the surgery works or does not work is uncertain. More confusion.

Some researchers, however, claim that there is not enough of this evidence to suggest that arthroscopic knee surgery is all bad. Above we offered references in support of arthroscopic surgery, let’s further that discussion.

In July 2019, researchers at the University of Oxford (19) did a review of the medical studies published on the subject and came up with these findings. They may be confusing to you. Because they sound confusing:

  • “There was low-quality evidence (evidence was no that strong) that there may be no evidence of a difference between arthroscopic partial meniscectomy surgery and a home exercise program for the treatment of this condition. (The researchers are saying that the evidence that home exercise works just as well as the surgery is not strong).
  • Similarly, low-quality evidence from a few small trials indicates there may not be any benefit of arthroscopic surgery over other non-surgical treatments including saline irrigation and hyaluronic acid injection, or one type of surgery over another. (However, there is some evidence that the surgery does not work better than hyaluronic acid injections or saline injections).
  • “We are uncertain of the risk of adverse events or of progressing to total knee replacement due to very small event rates.” (The researchers were not sure if arthroscopic surgery lead to knee replacement).
  • Thus, there is uncertainty around the current evidence to support or oppose the use of surgery in mild to moderate knee osteoarthritis.

Simply the evidence that the surgery works or does not work or results in people being put on the fast track to knee replacement is uncertain. Sometimes we will get an email from someone who will tell us: “I went to (a well-known, leading medical center, one of the best in the world,) and they told me they would do a knee surgery, but they did not know what type to offer and once we will do the surgery we are not sure of the outcome, we will have to see if it helps.”

We do see many patients who were told that their meniscus surgery may or may not help. Ultimately the only way to know was to have the surgery and see how it turns out.

Predictors of dissatisfaction with arthroscopic partial meniscectomy were:

Here is a study that was in the August 2019 issue of The American Journal of Sports Medicine. (20)

Here are the learning points:

  • There is controversy about the benefit of arthroscopic partial meniscectomy for degenerative tears and damage in middle-aged patients.
  • The study wanted to determine outcome success in middle-aged patients with no or mild knee osteoarthritis who had either a degenerative meniscal tear or a traumatic tear.

Results: There were no meaningful differences in patient satisfaction or clinical outcomes between patients with traumatic and degenerative tears and no or mild osteoarthritis.

  • Predictors of dissatisfaction with arthroscopic partial meniscectomy were:
    • Being female,
    • obesity,
    • and lateral meniscal tears.

These findings suggested that arthroscopic partial meniscectomy was an effective medium-term option to relieve pain and recover function in middle-aged patients with degenerative meniscal tears, without obvious osteoarthritis, and with failed prior physical therapy.

In other words, if you do not have degenerative arthritis developing, were not obese, had a meniscus tear on the outside, and were a man, this surgery would be more successful for you as a “medium-term option.” That is until your knee started to deteriorate further and you needed an “end-term option.” Knee replacement.

Let us point out again, many people have very successful arthroscopic partial meniscectomy procedures. These are the people that we do not see at our center. We see that people will have less than successful outcomes.

“Despite an abundance of literature exploring outcomes of arthroscopic partial meniscectomy for degenerative meniscus tears, there is little consensus among surgeons about the drivers of good outcomes following arthroscopic partial meniscectomy.”

The above quotation comes from an October 2022 paper (21) from New York University Langone Health published in the journal Current Reviews in Musculoskeletal Medicine. In this research, the doctors say that “It is often difficult to determine if the presenting (knee pain) symptoms are secondary to the meniscus pathology or the degenerative disease in patients with concomitant osteoarthritis. A central tenet of managing meniscal pathology is to preserve tissue whenever possible. Most (studies) show that exercise therapy may be (just as good) as arthroscopic partial meniscectomy in degenerative tears if repair is not possible. Given this evidence, patients who fail nonoperative treatment should be counseled regarding the risks of arthroscopic partial meniscectomy before proceeding to surgical management.”

Clinical trials recommend against arthroscopic partial meniscectomy as the first-line treatment for managing knee pain in older patients

In January 2022, a team of Italian orthopedic surgeons wrote in the journal Acta Biomed (22): “Degenerative meniscal lesions typically occur in middle-aged or elderly patients without any history of significant acute trauma. Its prevalence increases with age and is associated with knee osteoarthritis. The most frequent orthopaedic treatment is arthroscopic partial meniscectomy (APM) to relieve pain and functional deficit associated with degenerative meniscal lesions. Nevertheless, several randomized controlled clinical trials recommend against arthroscopic partial meniscectomy as the first-line treatment for managing knee pain in patients affected by degenerative meniscal lesions, and no radiographic knee osteoarthritis that should be reserved for cases of failure after 3 months of conservative therapy or earlier in patients with significant knee mechanical symptoms.”

Do people have an over-expectation of what arthroscopic knee surgery can really do for their knee problem?

People in pain have a lot of wishes. They wish the pain will go away, they wish they can get back on with their lives, activity, and work. They wish the surgery, or any treatment including the ones we offer, will work.

In the image below the captions and explanations read:

MRI of the right knee without contrast: Noted changes in the medial meniscus, see how even the radiologist cannot determine whether this represents a recurrent meniscal tear or is just post-surgical changes.

Post-surgical changes are demonstrated in the medial meniscus with the smaller-than-expected size of the body of the medial meniscus, altered signal intensity in the body, and posterior horn of the medial meniscus extending to the inferior articular surface. This MRI demonstrates a similar appearance to the previous outside MRI. What does this report mean?

This either represents residual changes from prior surgery and meniscal tear or recurrent tears that are persistent from prior examination.

MRI Knee Meniscus

The middle-aged patient and meniscus surgery – surgeons cannot predict which patients will benefit and who will not benefit from meniscus surgery. Flipping a coin would work just as well.

In our companion article: Should I have meniscus surgery? Does arthroscopic meniscus surgery lead to knee replacement? We have more extensive discussions about realistic outcomes of arthroscopic knee surgery and non-surgical treatments for knee problems in older patients. Here is a summary of portions of that article.

The question trying to be answered here is: “Will this surgery work for me?”

A March 2020 study in the British Journal of Sports Medicine (23) 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: 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.

Here is a positive study on the benefits of meniscus surgery (24in middle-aged patients: In this study, doctors said that an arthroscopic partial meniscectomy is a good option for a medial meniscal tear in late middle-aged adults. For the best success, you need a proper diagnosis and excellent surgical technique. If you follow these two rules all the patients could get good clinical results, HOWEVER, “there are some patients with motion restrictions in the early stage after the operation.” 

In other words, even if a patient received “a proper diagnosis and excellent surgical technique,” problems with motion restrictions in the knee developed early. Motion restrictions are probably not what a middle-aged patient is expecting as a result of their meniscus surgery.

Two studies demonstrate that arthroscopic surgery is no better than sham surgery

  • The researchers concluded that these 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.

As noted above this same team of researchers followed up on a previous study. As part of the Finnish Degenerative Meniscal Lesion Study Group their study in the medical journal Annals of Internal Medicine (25) concludes:

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.

While these two studies demonstrate that arthroscopic surgery is no better than sham surgery, the same research team also published the landmark December 2013 study in The New England Journal of Medicine.(26)

The conclusion of this research which was heavily covered in the news media:

  • “The results of this randomized, sham-controlled trial show that arthroscopic partial medial meniscectomy provides no significant benefit over sham surgery in patients with a degenerative meniscal tear and no knee osteoarthritis. These results argue against the current practice of performing arthroscopic partial meniscectomy in patients with a degenerative meniscal tear.”

Dr. Shaw-Ruey Lyu, a noted Taiwanese researcher with a specialty in problems of knee osteoarthritis noted in his paper published in the Annals of Translational Medicine that the above study since the number of Arthroscopic partial meniscectomy performed has been increasing, the information provided by this study should lead to a change in the clinical care of patients with a degenerative meniscus tear.(27) We are going to return to this study later in this article.

Clearly, doctors are concerned that the wrong procedure was performed for these patients and made the patient’s condition worse.

But what were the circumstances that lead to this procedure?

  • Patients told their doctors what was going on in their knee, got a surgery that did not work and was not even appropriate to the patient’s concerns
  • So should patients be warned NOT TO TELL their doctors what’s wrong for fear of getting an inappropriate treatment?

Should the doctors not let what the patients are telling them help guide their treatments?

  • So concerning is this, is that doctors are warning doctors against using “self-reported” symptoms as a guide to treatments, i.e, surgery.

This is nonsensical because it is being speculated that the surgery did not work because doctors recommended a treatment  – arthroscopic procedure – based on

The presence of mechanical symptoms – the justification of arthroscopic surgery – the loophole

All the research above has come to this conclusion, arthroscopic knee surgery for osteoarthritis is not curative. In summary, this agrees with the mounting level of evidence that arthroscopy doesn’t work any better than conservative care for most knee conditions, including degenerative arthritis. This is based on thorough research published in some of the most prestigious medical journals in the world and has changed how insurance companies reimburse for this procedure.

  • Many insurance companies will not cover arthroscopic debridement of the knee for knee pain, but they will cover it for mechanical symptoms. This may sound reasonable until one really looks at the definition of mechanical symptoms of the knee: any type of locking, popping or giving way of the knee!

Almost every person with knee pain has some type of “popping” or crunching (also called crepitation) noise in these joints.

As we discussed above this could mean a patient could visit an orthopedist who documents mechanical symptoms in the patient’s knee and/or if the patient’s MRI shows any type of loose body or meniscal tear then arthroscopic surgery could be done and will be covered by insurance.

Let’s return to the study by Dr. Shaw-Ruey Lyu. In that research, Dr. Lyu asked:

  • Why do we perform arthroscopy for a patient?
    • Is it for symptoms relief?
    • Prevention of cartilage degeneration?
    • Or just for the removal of the torn meniscus itself?
  • Knee pain is usually the main reason that patients seek help.
  • Arthroscopic partial meniscectomy is typically advocated for patients with knee pain in whom a tear is confirmed by MRI, particularly those without concomitant knee osteoarthritis.
  • However, increasing evidence suggests that a degenerative meniscal tear may be an early sign of knee osteoarthritis rather than a separate clinical problem requiring meniscal intervention.
  • This suggests that the current practice of performing Arthroscopic partial meniscectomy in patients with an accidentally found degenerative meniscal tear. More possibilities should be taken into consideration before making this decision.

Injections as a non-surgical alternative to arthroscopic knee surgery?

In this section, we are going to discuss the realistic expectation of what these three regenerative medicine techniques can do to help you avoid surgery. These treatments will not benefit everyone. Our hope here is to present information to help understand the treatments.

For more information on the different types of injections for knee pain. Please see our article: What are the different types of knee injections for bone on bone knees

Is stem cell therapy a non-surgical alternative to arthroscopic knee surgery?

Perhaps nothing is as misunderstood in the world of regenerative medicine injections as is misunderstood when it comes to stem cell therapy. Our website is filled with articles on stem cell treatments. We are going to present some summarized information as it relates to you.

Stem cell therapy in the orthopedic office is mainly derived from bone marrow aspirate or adipose or fat cells. In recent years what was once called amniotic stem therapy or cord blood or Wharton’s jelly stem cell therapy has had the stem cell therapy description removed in favor of the more accurate “amniotic fluid allograft,” or “Wharton’s Jelly Injection,” because no evidence that stem cells existed in this tissue donor material could be definitely produced.

I have no meniscus, will stem cell therapy grow one back? NO. Stem cell therapy, as an injection in the doctor’s office, will not grow a meniscus from nothing.

NO. Stem cell therapy, as an injection in the doctor’s office, will not grow a meniscus from nothing. in our article Does stem cell therapy for knee meniscus tears and post-meniscectomy work? we offer a lot of research, patient stories, and clinical observations. To summarize that article here with learning points:

The reality of 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.

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 and cannot do. For some people, stem cell therapy cannot, in one simple injection, repair and reverse years of degenerative damage. Many treatments may be necessary.
  • If you have a meniscus tear, lesion, or hole in the articular 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.

October 2020 research: Bone marrow-derived mesenchymal stem cells have the potential to help form meniscus tissue

An October 2020 study (28) led by the University of Alberta in Edmonton, Canada offered this observation in the journal Tissue Engineering (Part A). “Bone marrow-derived mesenchymal stem cells have the potential to form the mechanically responsive matrices of joint tissues, including the menisci of the knee joint.” Matrices are the scaffold-like structures that are created in the body for things like fingernails and cartilage to grow on.

In this study a comparison was made: Do bone marrow stem cells taken from the iliac crest (the wing of the pelvis) create meniscus matrices? Further, if they do, how do they compare with stem cells taken from meniscus fibrochondrocytes cells (cartilage cells) taken from meniscus tissue removed during a partial meniscectomy of non-osteoarthritic knees? The general results? Bone marrow-derived mesenchymal stem cells from the iliac crest produced better meniscus building block tissue better than meniscus tissue did. Explanation and disclaimer. In this study, the stem cells taken from the patient were cultured and expanded in a laboratory setting. This is not an allowed medical procedure in the United States. There are many regulations including the prohibition of expanding and culturing stem cells. Typical in our office is the direct bone marrow aspirate injection or bone marrow concentrate injection. This involves no culturing of cells.

Bone marrow aspirate – stem cell therapy and Prolotherapy

In our office, “Bone marrow aspirate” or stem cell therapy is used in conjunction with dextrose Prolotherapy. Prolotherapy is a non-surgical regenerative treatment that can stimulate natural healing repair in the knee. The goal of the treatment is to rebuild tissue and provide stability to the knee. Stem cell therapy or Stem cell Prolotherapy is the combined use of your own harvested stem cells and dextrose Prolotherapy to treat the entire knee environment.

Not all meniscus tears and injuries (even those after meniscus surgery) require stem cell therapy to heal. We have documented in numerous studies that simple dextrose Prolotherapy has a 90% success rate in our office. However, for cases of the more advanced meniscus and related cartilage damage, our team of Prolotherapy practitioners may choose to use stem cell injections in combination with dextrose Prolotherapy to strengthen and stabilize the surrounding support structures of the knee.

Our published research on stem cell therapy combined with Prolotherapy

When we use bone marrow-derived stem cells and Prolotherapy together:

In our 2014 study in the journal Clinical Medicine Insights Arthritis and Musculoskeletal Disorders, (29) we examined 24 adult patients who had a diagnosis of radiographic osteoarthritis (this was degenerative knee disease which was seen and documented on an MRI) and had visited our chronic pain clinic in 2009 for Prolotherapy treatment to relieve their chronic pain. The results of our study have shown that a combined bone marrow stem cell Prolotherapy treatment regimen of injections to painful sites in and around the knee provided pain relief and improved joint function.

Paving the way for stem cell therapy success with Prolotherapy treatments

In the simplest terms, Prolotherapy is the injection of sugar water into a damaged joint. Prolotherapy injections work to heal damaged joints by stimulating nature’s healing and regenerative processes through inflammation. Prolotherapy does so by causing a controlled, specifically targeted inflammation that helps grow new ligament and tendon tissue.

Stem cell therapy is an injection of your own harvested stem cells. Stem cell therapy is typically utilized when we need to “patch” holes in cartilage and stimulate the bone. We explore this option in patients when there is more advanced osteoarthritis and a recommendation for a joint replacement has been made or suggested. Realistic expectations of treatment success should be made during discussions with the provider’s office prior to consultation.

Here are the case histories of this study: Case history I 69-year-old man

  • The patient is a 69-year-old male who presented with pain in both knees.
    • 4/10 on the left (30% frequency) and 7/10 on the right (90% frequency).
  • The pain had begun years earlier while playing rugby and had been more severe for the four years prior to the first office visit
  • Pain resulted in frequent sleep interruption and limitation of exercise. A slight flexion limitation was noted.
  • The patient was diagnosed with osteoarthritis and received five bone marrow/dextrose treatments at two-month intervals in both knees.
  • Two months after the final treatment, the patient reported that he was completely free of pain or stiffness in both knees, had regained full range of motion, no longer suffered sleep interruption, and was no longer limited in exercise or daily life activities.

Case history II 56-year-old man

  • The patient is a 56-year-old male who presented with pain in both knees.
  • The patient is a former competitive weightlifter who continues to do strength training exercises.
  • He complained of instability in both knees during exercise, as well as sleep interruption.
  • The patient received 29 bilateral dextrose prolotherapy treatments over five years to the knee. At the final prolotherapy visit, sleep interruption was still present, pain intensity was 4/10, and pain frequency was 100%.
  • Four months later, the patient was treated with platelet-rich plasma. Three months after plasma treatment, the patient began a series of three bone marrow stem cell injection treatments (without dextrose prolotherapy) at 2–3 month intervals. At the time of the second bone marrow stem cell injection treatment, stability was improved.
  • At the time of the third treatment, pain intensity was 2/10, and pain frequency was 30%. Sleep was no longer affected. These gains were maintained for nine months.

Case history III 69-year-old man

  • The patient is a 69-year-old female with pain in both knees.
  • She had been previously diagnosed with osteoarthritis, had arthroscopic surgery to both knees eight years earlier, and bilateral medial meniscus surgery 15 years earlier.
  • Pain occurred climbing or descending stairs and standing or walking for two hours. Pain interrupted sleep and limited participation in racquet sports and golf.
    • Pain intensity was 4/10 in the left knee and 5/10 in the right.
  • The patient received six bilateral treatments with dextrose prolotherapy over a ten-month period. After the first month of this period, the patient reported uninterrupted sleep, pain intensity of 2/10, resumption of limited golf, and an overall improvement of 50%–55%.
  • One year after the final prolotherapy, pain intensity had returned to 4/10 with a frequency of 20%, and sleep interruption had resumed. At this time, the patient received the first of two bone marrow stem cell injection treatments with dextrose Prolotherapy treatments, five months apart.
  • At the time of the second treatment, pain intensity was 1/10 with a frequency of 20%, sleep interruption was reduced by half, and patient-reported overall improvement was 90%. Eight months following the final treatment, the patient reported being free of pain and able to resume full participation in all of her usual athletic activities.

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.

  • 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 access 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.

Do you want to ask about your knees? Get help and information from our Caring Medical staff

References 

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