Knee surgery for cartilage damage does not benefit patients, study suggests | Medical research

Routine knee surgery for cartilage damage does not benefit patients and may lead to worse outcomes, a 10-year trial suggests.

The study tracked the outcomes of patients treated for a torn meniscus who underwent a partial meniscectomy, one of the most common orthopedic surgeries. Their trajectories were compared to those of patients randomized to undergo “sham surgery,” in which no procedures were performed.

Patients who had the surgery, which involves cutting away frayed tissue from the meniscus, did not appear to benefit and performed worse on a series of measures designed to measure knee function, pain and symptom progression.

Professor Teppo Järvinen, an orthopedic surgeon and researcher at the University of Helsinki who led the study, said: “Our results suggest that this could be an example of what is known as a medical reversal, where a widely used therapy turns out to be ineffective or even harmful. »

The meniscus is a rubbery, C-shaped pad of cartilage located in the knee joint that acts as a shock absorber between the femur and the tibia. There are two in each knee.

A meniscus tear, in which the edges of the tissue fray, can occur due to a sudden twisting of the knee while playing sports. Damage can also occur gradually over time, and MRI scans often reveal meniscal tears in healthy people without symptoms.

“We now know that these meniscal tears are very common in patients without symptoms,” Järvinen said. “Over the past 20 years, evidence has accumulated suggesting that most of these MRI findings are purely incidental.”

Symptoms related to a meniscus tear include knee pain, stiffness, difficulty bending the knee, or a cracking or clicking sensation when the knee moves.

The study recruited 146 patients, aged 35 to 65, from five Finnish hospitals. About a third had been diagnosed with a meniscus tear after an acute sports-related injury or twisted knee, while two-thirds had gradually started to experience symptoms. Patients were randomly assigned to undergo either meniscus surgery or sham surgery, in which incisions were made but no operations were performed.

After 10 years of follow-up, the meniscus surgery group had poorer knee function, greater osteoarthritis progression, and a higher likelihood of undergoing subsequent knee surgery.

Mark Bowditch, consultant knee surgeon and former president of the British Orthopedic Association, said best practice guidelines had changed in recent years to reflect emerging concerns about the limited benefits of surgery. This included extending the recommended waiting period to see if symptoms go away on their own or through physiotherapy, from three months to six months.

“In the past, three quarters of patients might have had surgery, but this is now the case. [closer to a quarter]”, he said. “We have a ‘think before you strike’ approach. Surgery should not be the first step.

However, he said certain subsets of patients may still benefit, based on his clinical experience. “If you’re operating to treat pain, it’s very unpredictable,” he said. “But there is a group that has a mechanical feel of something that attracts – this group has a more predictable edge.”

Järvinen said many independent non-orthopedic organizations providing clinical guidelines have recommended stopping the procedure. “Yet, for example, the American Academy of Orthopedic Surgeons (AAOS) and the British Association for Knee Surgery (BASK) continued to support the operation,” he added. “This illustrates how difficult it is to abandon ineffective therapies. »

The results are published in the New England Journal of Medicine.