Friday, May 31, 2013

Another Reason to Think Twice About Surgery

Operations to repair a torn meniscus are fairly common. I once thought this was one of those instances where surgery was appropriate. How else would this rubbery disk in the knee joint, only a small part of which receives a flow of blood, get better?

But maybe I was wrong.

If you’re older, and have a meniscus tear, it appears that you’ll do just as well skipping surgery and focusing on physical therapy instead. That’s according to a Brigham and Women’s Hospital study, the results of which were published a few months ago in the New England Journal of Medicine.

351 patients, aged 45 and older, who had a torn meniscus and arthritis as well were randomly assigned either to surgery or six weeks of physical therapy (those whose treatment consisted of physical therapy were allowed to have surgery if their bad knee didn’t improve; 30 percent opted to do so before the end of the one-year study).

The patients who didn’t have surgery fared as well as those who did. They had a similar level of pain relief and improvement in function. (Note: It’s important to point out that chances are good they had less severe meniscus tears that were more likely to heal without intervention.)

There’s still a role for surgeons, notes Dr. Jeffrey Katz, who led the study and was quoted in this Boston Globe summary of the results.
Immediate surgery may ... be more appropriate for younger folks who get a torn meniscus from an injury rather than from arthritis and aging, according to Katz, since previous research suggests these sudden tears often require surgery to fix and take longer to heal on their own. People in their 20s and 30s also recuperate more quickly from the procedure than those over age 65.
Even so, it’s nice to know that studies are confirming what a lot of us already suspect: that for a lot of knee problems, surgery shouldn’t be considered the first option, but rather the last.


  1. It depends on the type of meniscus tear. Some are major tears that get caught in the joint and the individual can't walk painless without getting it fixed. Some people only have it act up with high physical activity. Some it acts up at certain ROM points. Some have no symptoms.

    A generalistic comment that all relatively senior patients should not consider surgery and instead opt for physical therapy is just that: generalistic. And therefore wrong in certain cases. People should see their doctor if there problem persists and is not solved with rest.

  2. Right, it definitely does depend on the severity of the meniscus tear (that's why I included the line about how "chances are good they had less severe meniscus tears that were more likely to heal without intervention.") In any event, if I had any sort of painful meniscus tear -- even a minor one -- I'd start off by seeing a doctor and talking about the best course of action. The good news is, that may not be surgery.

  3. 50 YO male presenting with catch behind patella and after PT for six months and slow improvement, got impatient and was convinced it was no big deal and elected for surgery. MRI at time showed small meniscal tear. When inside OS "discovered" grade 3 degeneration of medial femoral condyle, patella and small area of trochlea. OS opted for chondral shave and lateral release. This was 18 months ago and I am still walking with a limp and have considerable atrophy on bad side and present with a severe catch now behind patella. OS says this is consequence of my arthritic degeneration and I am being led to believe not the result of a bad surgery.

    Looking at above study, it seems impossible to separate out meniscus tears form arthritis in aging knees- Which makes me wonder if there is a protocol with some OS' whereby they go in for radiologically indicated meniscus tears, "discover" arthritis and butter their bread? Anyone else had like experience?

    My ex-OS has a website that indicates (in the fine print) that chondral shaving is only a stopgap procedure to buy a few years of relief (in my case no relief, in fact the opposite- destroyed knee) before the inevitable TKR. No one told me that. I think people would spend more time healing their cartilage if they knew this.

    1. I had a large medial meniscus tear in left knee, which would pop in and out of place & hurt like hell when out. I was also signed up for my first Ironman, so was in 'get this fixed fast mode' so I could race. I had the tear removed, then rapidly developed PFPS on BOTH knees within weeks. The meniscal area is still 'twitchy', though nothing like the pain I had before surgery.

      In hindsight, I should have waited at least 6 mths to see if the meniscus healed itself (my GP actually advised waiting at least 3 mths, as he healed his own tear, but I was on a stupid mission!).

      I'm also wondering if surgery can trigger PFPS? It seems bizarre that before surgery, both my knees could tolerate extreme exercise quite well, but after they both got sore (even though I only had surgery on the left, and the right is now worse).

      This also puzzles me about Richards knees. You would have thought all that hard cycling gave him strong joints, but something clearly tipped the balance where suddenly his knees objected to quite minor activity. It's almost like a switch is flicked which suddenly rapidly accelerates cartilage breakdown.


    2. TriAgain: Yes, it probably is like a switch is flicked. See my notion of the "breakdown point." These are two of the best original, creative posts I think I've done (he says, immodestly):

      Yes, I had strong joints. But they weren't indestructible. Bad behaviors on my part (doing hard sprints up a mountain, cycling while dehydrated or sick, pushing too hard on back-to-back days) set into motion a deterioration process of my cartilage. But there was no pain until another stupid behavior: going on a very long, arduous "cross-training" hike that left my leg muscles very, very sore for days -- and my knees damaged and hurting.