Meniscus Injuries. Surgery or Rehab?
- June 26, 2017
- Posted by: Pieter Kroon
- Category: Research
Hello, in today’s blog post I want to talk about meniscus injuries. Some very compelling research has come out recently that surgery might not be as good of a treatment option as we thought it was.
As a runner, leg injuries happen. A systematic review by van Gent et al. showed that the most common site of injury in a runner was the knee, with up to 50% of runners reporting knee problems at one time in their running career.
Let’s say for example, you are running on the trail at 5.30 AM, it is dark, you inadvertently step in a pothole, and you jam your knee. Rings a bell? Of course it does. Your knee pops and clicks, and you also noticed it locks up on you. You see your favorite orthopedist and a subsequent MRI shows that you have a tear in your meniscus. The verdict is that you are going to need arthroscopic surgery to repair the torn meniscus. This seems to make inherent sense. Something is torn in the knee, it causes symptoms, you fix what is torn and your knee gets better with 6 weeks of good rehab.
However, the most current research in this area doesn’t seem to back up this commonly accepted and seemingly prudent clinical practice. A randomized controlled trial by Jarvinen proved that partial removal of a degenerative torn meniscus does not alleviate mechanical symptoms when compared to sham surgery (3).
In a 2-year follow up study of these patients who did not have knee osteoarthritis but had symptoms of a degenerative medial meniscus tear, the outcomes after arthroscopic partial meniscectomy were no better than those after sham surgery (4). No evidence could be found to support the prevailing ideas that patients with presence of mechanical symptoms or certain meniscus tear characteristics or those who have failed initial conservative treatment are more likely to benefit from arthroscopic partial meniscectomy than no surgery at all.
Before these studies, orthopedic surgeons were confident of the benefits of arthroscopic surgery on patients suffering from mechanical symptoms. However, scientific proof of the benefits has been based entirely on uncontrolled follow up studies. In addition, a study by Mosely in 2002 showed that arthroscopy was no more helpful than sham surgery in older people (1). The fact is that the use of MRI is a great diagnostic tool to determine if there is tissue damage or not, but it is just not a good predictor of who will actually benefit from knee arthroscopy.
To top that off, a study by Roos in 2016 showed that a conservative approach (physical therapy and exercise) provides just as good results as arthroscopic meniscectomy (2). It furthermore showed that patients who fail conservative rehab also end up failing subsequent surgery. We need to look for other solutions, not surgery, to cure that patient.
So the take away message is that you should not rush into having your torn meniscus surgically repaired, even if the MRI shows that there is indeed a tear.
See you all next time
1. Mosely et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. NEJM. 2002;347(2)
2. Roos E et al. Exercise therapy versus arthroscopic partial meniscectomy
for degenerative meniscal tear in middle aged patients. BMJ.2016;(354):3740
randomised controlled trial with two year follow-up
3. Sihvonen R et al. Arthroscopic partial meniscectomy versus placebo surgery for a degenerative meniscus tear. NEJM. 2013:2515-24
4. Sihvonen R et al. Arthroscopic partial meniscectomy versus placebo surgery for a degenerative meniscus tear: a 2- year follow up of the randomised controlled trial. Ann Rheum Dis 2017. DOI: 10.1136/annrheumdis-2017-211172
5. Van Gent et al. Incidence and determinants of lower extremity running injuries in long distance runners: a systematic review. Br J Sports Med. 2007;41(8):469-480