I saw a middle-aged patient yesterday who injured his knee two weeks ago. He had an immediate MRI that showed a meniscus tear and some arthritis. He’s an established patient, so when a prestigious orthopedic clinic told him he needed surgery, he knew enough to check back with me. He, like many other patients, was surprised to learn that this invasive procedure is no better than a sham surgery. So if we have these high-level studies answering the question, “Does meniscus repair work?” again and again, why are my patients still getting offered this surgery? Why is their insurance company still covering it?
The Research That Answers the Question, “Does Meniscus Repair Work?”
Believe it or not, meniscus surgery is one of the best-studied procedures on earth. We have at least five different high-quality, large randomized controlled trials that show it’s next to useless. The newest one that added a few more nails to the proverbial coffin was just published a few weeks back. It compared physical therapy (PT) alone to meniscus surgery alone to treat a degenerative meniscus tear (the ones that show up in middle-aged people on MRIs after the knee is injured or hurts). Only one in five patients in the exercise group had continued pain after three months of PT. More interesting was that when that 19% of patients who failed PT chose surgery, it provided no additional benefit. Ouch!
This study gets added to others that show that acute meniscus-tear surgery is no better than physical therapy, that debridement is no better than placebo surgery, that surgery for a locking meniscus is no better than no surgery, and others. You get the picture. Meniscus surgery has been studied from every possible angle, and every time we see a large, high-level study performed, it fails like a hastily constructed balsa-wood bridge trying to hold a Sherman tank.
Why Are My Patients Still Getting This Procedure?
There’s a very nice article in the NY Times this week on why patients still get offered surgeries like low-back fusion, disc surgery, and meniscus surgery when the high-level research shows these procedures don’t work. The bottom line is there only seems to be one thing that we know causes surgeons to stop offering these procedures—killing reimbursement. Given that it’s been established that meniscus surgery is a sham, how much longer could meniscus surgery survive before insurance-company medical directors begin pulling reimbursement?
That’s a complex question. One of the issues is that there is a literal army of financial stakeholders making money off operating on the meniscus who will all oppose the retirement of this sham procedure. Hospitals and surgery centers make money—after all, this is still the most common elective orthopedic procedure in the U.S. So if no meniscus surgeries were performed beginning in 2017, 400,000 fewer orthopedic surgeries would be performed, reducing hospital revenues by about a billion USDs. Obviously, surgical revenues for many orthopedic surgery practices would be decimated. Finally, there are no less than 100 companies that sell devices, implants, and instruments that support meniscus surgery, so the medical-device industry would take a huge hit.
So how much longer does meniscus surgery have? My guess is that we’ll see the first changes in reimbursement begin by next year. In addition, some European National Health Systems are considering eliminating coverage.
The upshot? The answer to the proverbial question, “Does meniscus repair work?”is a resounding No! Meniscus surgery is a sham. It has failed to produce results either better than placebo or physical therapy now in many high-level studies. So as a memo to my orthopedic colleagues, please stop offering this useless procedure to my patients!