Is arthroscopic surgery for a partial meniscal tear unnecessary?

Arthroscopic knee surgery is big business in the United States. Arthroscopic partial meniscectomies alone cost $4 billion per year. Yes, billion. But do they work?

I’ve written previously about arthroscopic surgery for a torn meniscus and how it adds nothing above and beyond physical therapy for people with arthritis. We also know that arthroscopic knee surgery for arthritis isn’t effective either. Given the poor performance of these other arthroscopic surgeries, answering the question of whether partial meniscectomies are effective is crucial.

Interestingly, as the authors of a new study looking at partial meniscectomy for meniscal tears point out, arthroscopic knee surgeries for arthritis have decreased since the studies showing their lack of efficacy were published, however, there has been a 50% increase in surgeries for meniscal tears. I suppose that could be attributed to the overuse of MRIs for knee pain (when did the clinical exam become obsolete?) and the fact that meniscal tears are very common (35% of people over the age of 50 will have a meniscus tear on MRI). However, the cynic in me wonders how many times another “diagnosis” was identified so some kind of surgery could be offered, either because the surgeon couldn’t think of something else to offer, the surgeon wanted to fill their time on that day, or the patient pressed so much for and operation that the surgeon gave in.

But I digress.

This new study is a wonderful prospective randomized double-blinded trial with an elegant sham procedure with the data fully evaluated and analyzed before the investigators were unblinded. Also, the surgeons did not participate in the post operative care so there was no way patients could be accidentally informed about their procedure, true meniscal surgery or simply a diagnostic arthroscopy.

The results? Arthroscopic surgery offers nothing for patients with a partial meniscal tear who do not have  arthritis.

Why does this matter? Well, there’s the $4 billion we are spending on direct medical costs for this unnecessary surgery. Surely that money could be used elsewhere? There are also the indirect costs of missed work and disability payments, raised health care premiums to pay for the unnecessary surgery, and of course the risk of surgical complications. (Don’t even get me started on how much we could save by preventing unnecessary hysterectomies).

As a pain medicine physician I appreciate the desire to get better as quickly as possible, but for most painful conditions the path to wellness doesn’t involve a scalpel and a surgery that will not produce the desired outcome is a worse option than no surgery. To invest the time, effort, risk, and great expense of surgery there must be proof that it offers a chance to help. Given the solid lack of evidence for partial meniscectomy Medicaid, Medicare, and insurance companies should stop reimbursing for it.

We accept so little of surgery from an efficacy and safety standpoint compared with medications. At least you can stop a medication, but you can’t undo a surgery. What if every procedure were required to have the same type of efficacy and safety data for approval as the FDA requires of medications?

Unnecessary surgeries are a huge driver of both health care costs and false expectations and if we don’t do something about it we will never be able to provide universal cost effective care. It’s simply a burden that we can’t afford in so many ways.

Jennifer Gunter is an obstetrician-gynecologist and author of The Preemie Primer. She blogs at her self-titled site, Dr. Jen Gunter.

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  • Thomas D Guastavino

    With all due respect, Dr Gunter, you are in no position to pass judjment on whether or not arthroscopic surgery is necessary. If I may, For many years we have known that arthroscopic surgery for arthritis alone has limited value. However, if a patient has pain along with mechanical symptoms (painful popping, locking, giving way) then it has great value. I explain to my patients that the principal reason for the surgery is to remove any loose tissue (meniscus, loose bodies, broken off cartilage) that may be catching in the knee. Conservative management is always offered first and surgery offered if that fails. This protocol is followed as well for the younger, non-arthritic patient who has a traumatic meniscal tear.

    With this protocol my satisfaction and success rate has been over 95%.I will not tell you how to treat cervical cancer, dont tell me how to treat partial meniscal tears.

    • Jen

      So only orthopedic surgeons can comment on articles about orthopedic surgery? When presented with such a wonderful study I feel I have a duty to comment. Everyone should, it might help improve medical care.

      The outcomes from this study are clear: arthroscopic partial meniscectomy for someone between the ages of 35 to 65 with a symptomatic degenerative meniscal tear is no more effective than a scope. Surgeries, whether they are for cancer or pain, need to be studied. Surely, you cannot find fault in needing to study surgical outcomes?

      If you are not doing partial mesicectomies for degenerative tears, they you are ahead of the curve and bravo. However, many surgeons must be, otherwise why do the study and why would the NEJM publish it?

      Surgery for any condition isn’t indicated simply because conservative management fails, it is indicated if it is indicated. This study tells us that partial meniscectomy for degenerative tears is no better than a sham procedure and patients deserve better than that.

      • Thomas D Guastavino

        How exactly did you determine that this was a “wonderful study” ? What is the difference between an “arthroscopic partial menisectomy ” and a “scope”? As stated, doing arthroscopic menisectomies for degenerative meniscal with mechanical symptoms is good medicine, not simply being “ahead of the curve”
        Finally, if I have for years done a procedure with a high rate of success both in terms of clinical outcome and patient satisfaction I am supposed to abandon it on the basis of a supposed clinical study? I am sure you could think of similar studies in ob-gyn whose conclusions did not jive with your clinical experience.

  • Jen

    Thanks. Some how Instead of replying to you I commented. And thanks for your clarification.

    Anyway, see above.

    Cheers.

  • Shirie Leng, MD

    Thanks Kim. Just because we can doesn’t mean we should. People with pain want the pain to go away by DOING SOMETHING. I would only caution that these big studies are good for population guidance, but the decision for each individual patient is made in the office between the patient and the doctor.

  • Suzi Q 38

    Timing is everything.
    I wish I had read your story before I had my arthroscopic knee surgery in August. I have the CD of the surgery itself, and I can see that my surgeon had a lot to “clean up.”

    The last knee surgery I had was back in 1992 on my left knee. I healed well from that one, and it definitely was an improvement.

    In both cases, I feel that the years of sports and other physical activity took its toll.

    It has been about 4 months, and while my recent knee surgery improved my walking ability, it is still a bit swollen with fluid and I am still in a pain.
    Time to go back to physical therapy, as I don’t want a total knee replacement.

  • Suzi Q 38

    “….The sad thing is I have seen many patients who were told the surgery probably wouldn’t help, but the doctor still did it and they still signed the consent form. Sigh….”

    The problem is that we are told that the surgery probably will help. This information, coupled with daily pain and limited mobility push us to have the surgery.

    I have learned that a hope for a positive outcome and an actual positive outcome are two different things.

    I have also learned: “Never ask a barber if you need a haircut.”

  • doc99

    David Stern, Please call your office.
    http://search.espn.go.com/arthroscopic-knee-surgery/nba/46

  • http://www.howardluksmd.com/blog Howard Luks MD

    Jen..
    The appropriate treatment for degenerative meniscus tears has been bantered about for years now. Earlier studies came to the same conclusion as the paper you quoted. Arthroscopic management of degenerative meniscus tears, in the absence of mechanical symptoms should likely be avoided. I have 2 or 3 posts on my blog with the same take home message. http://www.howardluksmd.com/orthopedic-social-media/common-knee-surgery-unnecessary/

    Meniscus tears are one of the most over-indicated and over-treated issues in Orthopedic Surgery. Over-utilization of MRI technology is certainly playing a role. The art of physical exam and history taking may be taking a back seat to technology. MRIs can be useful in certain situations.. but certainly not in all patients with a few days of knee pain, absent an injury or significant mechanical issues.

    Having these articles discussed in social circles might go a long way in educating the public about many issues in medicine and surgery where the potential benefit of an intervention may not outweigh the potential risks, or the results of no treatment at all.