Originally written for The Dragontree

Knees are cranky joints. They’re complicated, prone to injury, and often difficult to treat since they bear most of our weight. Whereas I used to see more LONG scars running vertically over the knee – evidence of an old knee surgery – they’re rare these days. More often I see just a couple little dots – evidence of arthroscopic surgery, which went through big developments in the 1960s and took off in the 1990s.

In arthroscopic surgery, a tiny camera or arthroscope (“arth” means joint, and scope, well, you know what that part means) is inserted into a little hole in the knee, and, while viewing the interior of the joint on a video screen, the surgeon can use tiny surgical instruments (inserted through additional small holes) to make repairs. Minimally invasive camera-assisted procedures revolutionized surgery. They’ve been especially profound for abdominal and chest repairs (called laparoscopic and thoracoscopic surgery, respectively), since these areas involve many layers of delicate tissue and are quite prone to scarring through conventional scalpel surgery.

When it comes to knee repairs, however, arthroscopic surgery almost got too easy. Such a quick and easy procedure that many doctors – orthopedic surgeons in particular – recommend it before really giving other options a try. And, more importantly, before considering the likelihood that it will actually make a lasting difference.

For certain conditions, such as a complete ligament tear, it can be useful. But for others, such as arthritis of the knee or a tear of the meniscus (two pads of cartilage that sit on the top of the larger of the two lower leg bones – the tibia), arthroscopic surgery has been shown in numerous studies to be close to worthless.

In knee pain without a clear cause, many surgeons will guess that the cause is a meniscal tear, and upon arriving at this diagnosis, the recommendation is surgery. The arthroscopic removal of part of a meniscus is the most common surgery performed by orthopedists in the United States. However, a 2008 study in the New England Journal of Medicine, “Incidental Meniscal Findings on Knee MRI in Middle-Aged and Elderly Persons,”  showed a huge number of people have meniscal tears, and most of the time, they’re not associated with pain or stiffness of the knee. In fact, this study revealed that 56% of men between the ages of 70 and 90 have meniscal damage and “the majority of meniscal tears were found in persons who did not have knee pain, aching, or stiffness.” This study thus greatly undermines the validity of “torn meniscus” as an explanation for knee pain or a reason to do surgery.

A study in May 2013 in the same journal, “Surgery versus Physical Therapy for a Meniscal Tear and Osteoarthritis,” compared the outcomes of two groups with knee pain. One group had surgery and the other received only physical therapy. They were evaluated after six months and the researchers concluded, “We did not find significant differences between the study groups in functional improvement.” I think it would be worth telling anyone considering surgery if the study had even found that surgery was only slightly better than physical therapy, but no significant difference? For a cost of thousands of dollars and weeks or months of rehabilitation?

A third article in the same prestigious journal, “Meniscectomy in Patients with Knee Osteoarthritis and a Meniscal Tear?” notes, “Persuasive evidence from randomized, controlled trials indicates that arthroscopic [surgery is] no more effective than sham surgery and nonoperative alternatives for symptomatic knee osteoarthritis.”

Finally, a 2002 study, also in the NEJM, “A Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee,” looked at the use of arthroscopic surgery in the treatment of garden variety knee arthritis (“osteoarthritis”). Increasingly, when arthritis fails to respond to less invasive treatments, arthroscopic surgery is recommended (specifically “lavage” [rinsing out the joint] and debridement [removing damaged cartilage, bone, or other tissue]). This article begins by stating, “More than 650,000 such procedures are performed each year at a cost of roughly $5,000 each,” – and remember, that was more than ten years ago. Researchers performed lavage and/or debridement to some of the participants while those in the placebo group got “sham surgery.”

The researchers report, “At no point did either arthroscopic-intervention group have greater pain relief than the placebo group.” One year later, “there was no difference in knee pain between the placebo group and either the lavage group or the débridement group.” Do we need to say it again? In their conclusion, they state, “This study provides strong evidence that arthroscopic lavage with or without débridement is not better than and appears to be equivalent to a placebo procedure in improving knee pain and self-reported function. Indeed, at some points during follow-up, objective function was significantly worse in the débridement group than in the placebo group.”

So, if you have knee pain and it’s presumed to be due to arthritis or a torn meniscus, and your doctor is recommending surgery, ask them why, in light of these studies, they think it’s going to be worth it. Previously, I wrote a twelve part series of articles on ways to manage joint pain without drugs or surgery. You can read it HERE.

Be well,

Dr. Peter Borten