Knee Pain: Surgery Might Not Be Best OptionJan 9, 2014
Dr. Tom Miller: If you've been diagnosed with a meniscal tear of the knee, surgery might not be your only option. I'm Dr. Tom Miller, and that's coming up next on The Scope.
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Dr. Tom Miller: Today I'm here with Dr. Chris Pelt. He's an assistant professor of orthopedic surgery here at the University of Utah. Chris, I wanted to get your take on a recent study published in the New England Journal. This study that came out last month says that a common knee surgery known as arthroscopy is overused and perhaps of limited value in the treatment of knee pain due to meniscal tears.
Dr. Chris Pelt: Yeah, Tom. The arthroscopic surgery for the meniscus is done very commonly in the United States. About 700,000 surgeries are performed yearly at a cost of roughly $4 billion. The study was looking at whether or not surgery for knee pain related to meniscal tear offered significant benefit.
They looked at whether or not doing a "sham surgery," which is a surgery wherein not all of the procedure is performed, versus a partial meniscectomy, or removal of the meniscus, led to benefit. What they found was there was no difference. Both groups actually improved, but there was no difference in their outcomes.
Dr. Tom Miller: Let's back up for just a second and talk about what is the meniscus for our audience. What's the meniscus? What does it do in the knee?
Dr. Chris Pelt: The meniscus plays an important role in our knee joint. The knee joint is composed of three primary bones: the femur or the thigh bone, the tibia or the shin bone, and the patella. All of those bones are lined with a very smooth surface called the articular cartilage. The articular cartilage is what allows all of our joints to move freely in our body. It has a smoothness that's akin to a piece of ice floating on another piece of ice. It's incredibly smooth. In fact, it's smoother than that.
The meniscus is a shock absorbing cushion that lives in the knee joints, one of the unique joints that has a meniscus. It's a cushion that helps protect that articular cartilage. When we lose the articular cartilage in our joint we develop a condition known as arthritis or wear and tear of that cartilage. The meniscus plays an important role in our joints and in preventing that undue stress and damage to the cartilage.
Dr. Tom Miller: One of the points of the study was that folks with meniscal tears might not benefit from arthroscopy. How do you get a meniscal tear typically? What is a meniscal tear?
Dr. Chris Pelt: Meniscal tears can occur in a variety of ways. Some of them are related to acute injuries or trauma. Often, they may occur in coordination with other injuries like an ACL injury of the knee. They also may occur as part of a wear and tear process or degenerative process. The study that we're talking about today actually was looking specifically at degenerative meniscal tears which may be altogether entirely different than an acute injury to the meniscus.
Dr. Tom Miller: Are those the most common types of tear?
Dr. Chris Pelt: Yeah. The surgeries that are performed for meniscal tears actually may be more often performed for the acute injuries or the traumatic injuries. Degenerative tears are probably more along the lines of an osteoarthritic process that's already started to develop in the knee.
Dr. Tom Miller: How does somebody know, or what are the symptoms that they might have a tear?
Dr. Chris Pelt: The symptoms can be different for different people. Acute injuries and traumatic tears may often present with mechanical symptoms. Degenerative tears may also present with mechanical symptoms.
Mechanical symptoms are things like locking of the knee where the knee is in motion and can't move to either a flexed or extended position because of mechanical block, almost like having a pebble in your shoe, so to speak. It could also be clicking, popping, catching, or buckling or giving way of the knee joint.
Other symptoms of meniscal tears may be more along the lines of pain. Again, this study was looking at painful knees related to degenerative tears instead of these mechanical symptoms.
Dr. Tom Miller: Do you agree essentially with the findings of the study, or is there a limited group that would benefit from arthroscopy? Maybe you could discuss a little bit about what arthroscopy is.
Dr. Chris Pelt: Arthroscopy is when we use a small camera inserted into the knee joint. We use some fluid to help distend the knee so we can see clearly. Various procedures can be performed along with the use of the camera. Instruments can be placed into the knee joint through very small incisions to perform procedure as such as removal or partial removal of the meniscus, which this study was looking at.
The sham group in this trial put the camera in and actually irrigated the joint out, but they did not remove part of the meniscus. They simulated the motion and the sounds, because the patient was awake and able to perceive these things underneath a spinal anesthetic.
That's what an arthroscopic surgery is. The findings of this study may not be generalizable to all meniscal tears, however. Again, I think it's an important distinction that these patients were being operated on for pain and for degenerative tears of the meniscus, not necessarily these acute or traumatic injuries.
In addition, all of these patients had no preceding diagnosis of osteoarthritis, so in theory they had an early process, a degenerative meniscus. The results showing that there's no difference, both groups actually showed improvement but no difference between the groups, may be only generalizable to those specific types of meniscal tears.
Dr. Tom Miller: It sounds like it's okay for a patient to request physical therapy as one modality to treat a meniscal tear or pain due to a meniscal tear.
Dr. Chris Pelt: I think that's right. Often, doctors will recommend non- operative treatments before they go directly to the operating room. There may be certain instances in certain patients with specific types of conditions or meniscal tears that would necessitate more urgent surgical procedures, but more often than not, especially in these degenerative tears, I think conservative treatments are going to be the go to first.
Dr. Tom Miller: So, the bottom line is that patients who have knee pain might have a meniscal tear, and if they have knee pain they could be evaluated, but they don't need to have surgery necessarily as a treatment. Is that...
Dr. Chris Pelt: That's right. Not all meniscal tears may require treatment. I think that's the take home message from this study.
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