DO YOU REALLY NEED AN OPERATION FOR KNEE MENISCAL TEAR?

An injury to the cartilage of the knee can occur suddenly on the sporting field or can occur gradually.  A surgeon will typically smooth damaged cartilage and remove fragments in an attempt to address the cause of the patient's symptoms. This is knee arthroscopic surgery and it is the most common orthopaedic procedure performed.  Often you'll hear about a football player getting a "clean out" of their knee.  Well that's a knee arthroscope. It is often used as the first treatment for meniscal tears but is this a good idea? 

The knee has two thick pieces of fibrocartilage that function as shock absorbers, protecting the cartilage covered surfaces of the knee.  Each one is called a meniscus.  Just like the shock absorbers of your car they wear out.  A meniscal tear can be acute and come on suddenly however they can be degenerative in nature. Degenerative meniscal tears don't require a specific injury to occur and they tend to develop slowly.  They are quite prevalent affecting 25% of 50-59 year olds, 35% of 60-69 year olds and 45% of 70-79 year olds. In fact 75-95% of knee osteoarthritis sufferers have meniscal tears.

So do you need an operation?

Like the management of any injury factors must be taken into account such as the patient's age, the severity of the condition and how long it has been persisting for. A big thing to consider with meniscal injuries is whether pain is accompanied with a locking of the joint. A thorough examination is essential for an accurate diagnosis and the implementation of an effective treatment plan.  But what does the evidence say?

Evidence is suggesting we try conservative methods first especially for middle aged (35-65 year old) sufferers.  A study in 2016 compared exercise therapy to surgery for degenerative meniscal tears.  They found no difference in the outcomes of the two groups except that strength had increased in the exercise group at the 3 month mark. A 2015 published study split patients with degenerative meniscal tears into two groups that received either keyhole surgery or a sham procedure.  The sham procedure group were anaesthetised, incisions were made however no internal work was done.  By doing this the patient was unable to tell if they had received surgical work to their meniscus. On review there was no difference between the group that had undergone surgery to their meniscal tears and the group that didn't at a one year follow up.

So what does this mean?

Well firstly it's important to have your knee correctly assessed. A thorough assessment both verbal and physical is essential.  Scans of the joint may be required.  Surgery in some case is absolutely required however it's very important to understand that in many cases attempting to treat the knee conservatively with things like physiotherapy and a graduated exercise program is the best course of action. So if or when you have a grumbling knee consider this before running for the knife.

 

R, Paavola M, Malmivaara A et al. Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. N Engl J Med 2013;369(26):2515–24. 36.

Kise NJ, Risberg MA, Stensrud S et al. Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle-aged patients: randomised controlled trial with two-year follow-up. BMJ 2016;354:i3740

Salata MJ, Gibbs AE, Sekiya JK. A systematic review of clinical outcomes in patients undergoing meniscectomy. AM J Sports Med. 2010 Sep;38(9):1907-16.

http://c.ymcdn.com/sites/www.esska.org/resource/resmgr/Docs/meniscus-consensus-project-s.pdfSihvonen

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