Over 40 and Considering Meniscus Surgery? Think Again
Despite multiple high-level studies showing that meniscus surgery is no better than placebo, this procedure is still the most commonly performed elective orthopedic surgery in the U.S. Today we'll explore that a bit amidst a new study that again shows the procedure doesn't work. Let's dig in.
Understanding Your Knee Meniscus
The meniscus is a fibrocartilaginous, spacer-type structure that lives in the knee and protects the hyaline cartilage lining the ends of the bones by providing cushioning. It forms a figure-8 shape and is located in the space between the long leg bones where they form the knee joint. Meniscus tears can form due to wear and tear, which are the most common tears, or they can occur when there is an injury, such as some type of sports trauma.
Though mounds of research exist showing the lack of efficacy for meniscus surgery, hundreds of thousands of these procedures are still performed every year in the U.S. And the surgery known as a meniscectomy accounts for over 95% of these surgeries. So what exactly is a meniscectomy? Your surgeon might also refer to it as a meniscus repair, but it is far from being a repair; meniscectomy (-ectomy means to excise) actually involves cutting out parts of the meniscus.
During surgery, the knee joint is accessed through open incisions, or in this case portals, or tunnels, to the joint. An arthroscope (an instrument connected to a camera for visualization) is inserted through one portal and into the joint, and surgical instruments are inserted through another portal that will allow the surgeon to slice out, or excise, the piece or pieces of the meniscus that are torn.
Keep in mind, the purpose of the meniscus is to provide a protective cushion for the cartilage, and when you remove some of that cushion, what do you think happens? Besides putting more wear and tear force on other parts of the meniscus, the cartilage also loses some protection. What happens when the cartilage becomes vulnerable? Rapid cartilage degeneration, or knee arthritis. So meniscus surgery, as studies have shown, likely puts you at a greater risk for knee arthritis.
Now, a new study confirms what many other studies have also shown—that meniscus surgery is no better than no surgery for pain or function outcomes in those age 40 and older (though the risks aren’t limited to this age group—more on that later). While this isn’t a new finding by any means, it certainly adds more confirmation that meniscus surgery is a bad idea.
40 and Over Patients No Better with Meniscus Surgery than Without
The new study was a meta-analysis of nine different but similar randomized controlled trials. A meta-analysis is a king amongst studies in that it pools data from many investigations. Hence, these are the largest studies out there with regard to the number of patients.
The focus was on comparing arthroscopic surgery and nonsurgical conservative care in patients 40 and older who had meniscus injuries. Specific outcomes measured included both pain and function. The result? There was no significant difference in pain or function outcomes between arthroscopic surgery and conservative care. What does this mean? It means surgery was no better than no surgery in the 40-and-over age group for meniscus injuries!
This isn’t the first study suggesting knee meniscus surgery is a bad idea in middle age and beyond. In fact, we can go all the way back to 2002, when a much earlier study also found that meniscus surgery was no better for middle-aged knee pain than a fake, or placebo, surgery. I’ve shared before that meniscus tears are as common as gray hair or wrinkles in middle age and beyond. Middle-aged people without knee pain also have the normal wear-and-tear meniscus tears that occur with aging, so assuming a causal relationship between knee pain and meniscus tears seen on MRI in middle age and later is careless at best. Learn more about how to read your knee meniscus MRI by watching my video below:
Does this mean you’re free and clear for arthroscopic meniscus surgery if you’re under age 40? No way! Let’s review.
Meniscus Surgery Is Bad News No Matter Your Age
One study looked at participants as young as 35 and also found that meniscus surgery for wear-and-tear meniscus tears also was no better than a sham surgery, specifically as it related to mechanical issues (catching or locking symptoms in this case), in the knee. Another study on patients aged 16–44 who underwent stitching of the meniscus tears rather than excision found that while this seemed to be a better option for the younger group, those over 30 had deterioration of function, and 20% went on to have meniscectomy. We’ve also seen studies showing that performing surgeries on our young athletes, such as those with traumatic meniscus tears suffered during play, may only be setting them up for early-onset arthritis in their young-adult years.
Why Hasn't this Procedure Gone Away?
With all of this research showing that meniscus surgery in patients over 35 doesn't work, why is it still being done? Money. Most large hospitals and orthopedic surgery groups wouldn't be able to make payroll without this income stream. While the universities should be leading the charge to get rid of the procedure, most patients don't realize that they're businesses no different from the local for-profit hospital. For example, I showed convincingly using their own data that the Cleveland Clinic, despite research showing that this meniscus procedure shouldn't be performed, was actually doing more and not fewer meniscus surgeries.
The upshot? We really shouldn't be offering meniscus surgery in patients over 35 on a routine basis. In fact, on the rare occasion it is offered, it should be clearly explained to patients that the procedure doesn't work based on the research, but it may or may not work in their knee. Is that routinely happening? Not that I see…