STONE ON THE GREAT MENISCUS DEBATE (Orthopedics This Week)
Clinical Research proves that a partial meniscus trim for a degenerative meniscus tear is unnecessary (Finnish Research article)
Kevin Stone M.D. responded to a request from OTW to comment on the recent sham knee surgery study out of Finland. Here is what he had to say:
“A recent comparative study compared sham knee surgery to a partial resection of the meniscus in 45- to 60-year-old people and noted no difference at one year. In other words, the study seems to suggest that people who just thought they had experienced arthroscopic knee surgery fared just as well as the people who really did have the surgery. If this is the case, patients may well be asking, is this particular procedure necessary?”
Sub Group Shortcomings
“The first thing to clarify is that the sub group of people who volunteered to take part in this study did not experience an injury that resulted in an acute meniscus tear. Their meniscus damage was the result of wear and tear over a period of time. Second and more importantly, the fact is that physical therapy alone helps all patients with knee injuries for some period of time. So it is not surprising to me that these patients all seem to be doing well after a year. The difference comes later. Unfortunately, the data is overwhelming that even small losses of meniscus tissue lead to big changes in force concentration on the tibia (20% loss leads to approximately 350% force concentration increase) and eventually arthritis.”
Disservice to Patients
“So if the recent study had followed the patients longer, they would have realized the disservice done to the patients whose torn meniscus cartilages are ignored. The meniscus is the key shock absorber in the knee. A torn meniscus produces intermittent pain and catching in the knee. The old approach was to tell patients to live with pain until they could not stand it any longer and would eventually have to have a knee replacement. The new approach is based on the fact that we now have the skills to repair, regenerate and replace the meniscus cartilage. These improved techniques mean that the development of arthritis may not be a fait accompli. The knee mechanics can be restored. The patients can return to full activities without damaging the joint surfaces if the meniscus tissue is anatomically replaced.”
New Techniques
“So what are the new techniques? If the meniscus is torn, a successful repair depends on stabilizing the tissue and bringing in a new blood supply with repair cells. Improved suture techniques and devices are now available that permit stabilizing even complex tears extending into the root of the meniscus. Growth factors and cell injections provide a stimulus to healing even in the areas without blood vessels. Collagen scaffolds are used to both re-grow the meniscus if segments are missing and to hold cells and blood clots into horizontal splits in the tissue. Partial and complete meniscus allografts (donor tissue) are used to replace the meniscus in pristine knees and even in the setting of advanced arthritis. The new meniscus provides a pain relieving shock absorber permitting the running and impact sports that artificial knees do not allow.”
Treating Causes Saves Money
“Osteoarthritis [OA] affects the knee in 11 million Americans and is first diagnosed on average at age 40. The average age of patients receiving knee replacement surgery is 68. Treating the arthritis symptoms alone without addressing the causes incurs 28 years of chronic arthritis care with outpatient and prescription costs of $5,133 per year. Treating the cartilage damage initially has the potential to save $143,000 per OA patient.
With data showing that total knee replacements leave up to 50% of patients with continued pain, it is no longer acceptable to tell patients with injured cartilage to wait for their arthritis to get worse and then have a total knee replacement. Cartilage repair, regeneration and replacement is here today.”
Evolution Saved Meniscus for a Reason
“For my patients, I always use physical therapy to optimize the outcome of a knee injury. But I recommend surgery when I know that it will help avoid arthritis and other knee problems in the future. The long-term results count. So when you hear press reports that meniscus surgery is no better than physical therapy alone, think about it; evolution preserved the key meniscus structure for a reason, without its full structure, the knee degrades and life does too.”