Knee Pain? Broken Cartilage? Research Suggests Surgery Is Not the Best Solution
Yves here. I hope that many readers were not selected or managed to escape the bad orthopedic surgery fad of knee cartilage augmentation in symptomatic patients.
By accident, I had early exposure to the fact that orthopedists only have four remedies: rest, ice, compression and elevation; physical therapy; steroids, and surgery, and that too many are willing to recommend surgery when none of the first three do all that much.
Forgive me if you have read this story. In the early 1990s, after I paid for the privilege of having a trainer with a knee injury,1 I was referred to what I was told was one of the top two knee specialists in New York City. We had talked briefly about Harvard, as I knew a few people in his class, but no one like him.
After 10 days, I was no better. He ordered an MRI.
When I came for the next visit, he threw me the radiologist’s report and said, “He went to Radcliffe.
The report was five paragraphs on one page. One stage was diagnosis.
I said, “It says it’s either a medial meniscus tear or something that’s not true. I knew medial meniscus tears = surgery.”
The doctor said they all said to close the buttocks, I will come in on Friday and clean what I see and he will leave on Monday.
I walked out, thinking, “I’m not letting you go on a fishing trip kneeling on my knee.”
This was one of those situations where I often say, “What looks like bad luck is good luck.”
If the orthopedist had not made me read the radiology report, I would have sought a second orthopedist opinion. I realized I needed a second radiological opinion.
One of my college friends was married to a radiologist. I called him. Put Frank on the phone.
Frank said, “Read me the report” which I did.
He said, “Who signed?” Give me a name.
Frank said, “I know him. He wouldn’t write ‘You might be lying’ unless he had real doubts. Send me the films”
The entire Cedars Sinai team looked at the photo. Frank called and said, “Your knee looks pretty normal.”
The second part of this anecdote is that the osteologist says he will “clean things up” no matter what, such as cutting out any cartilage that looks hard. I didn’t understand the importance until I met a 50-year-old man at yet another NYC gym, doing what I saw as knee rehabilitation exercises. I made sympathetic noises, saying that I hoped he would be free.
He was discouraged and told me that he was seeing his orthopedist every 18 months or so, and he would “check” his knee and “clean up” any rough cartilage.
I was shocked. How would it be a good idea to gradually shave the cartilage of the knees? I asked a physical therapist friend who has rehabilitated elite athletes and he agreed.
Written by Elisabeth Rosenthal. Originally published at KFFHealth News
Thousands of Americans who undergo routine knee surgery may be making their problems worse rather than better.
Researchers who followed patients for 10 years after receiving any real procedure, arthroscopic knee surgery to cut degenerative cartilage tears, or just “sham surgery” – skin incision – for knee pain, found that the surgery provided little or no benefit and, in fact, was associated with faster osteoarthritis and higher rates of reoperation. That usually meant a total knee replacement.
“I don’t know how to defend this procedure at all,” said one of the study’s authors, Teppo Järvinen, orthopedic surgeon and head of the Finnish Center for Evidence-based Orthopaedics. “What has been shown remarkably is that patients who have this procedure have more pain – worse. All points point in the same direction.”
Järvinen said the Finnish study, published in April in the New England Journal of Medicine, was the first to show the surgery left many patients in a worse condition. Although the study was small, the results were compelling, he said, because his team selected patients “most likely to benefit.”
The study does not apply to cartilage tears caused by traumatic injuries that cause pain. It included middle-aged or older subjects who had knee pain and whose MRIs showed cartilage tears.
Evidence has been slowly accumulating for more than a decade that arthroscopic knee surgery to shave off torn, degenerative cartilage is no more effective than physical therapy. Arthroscopic rates in Finland have dropped by 90%, says Järvinen. They have been falling in the US, too, but at a much lower rate.
Another study of commercial claims in the US, which counted more than 2 million meniscus surgeries from 2010 to 2020, found the number decreased by 4% each year. Most procedures are performed on women and patients over the age of 50.
In the traditional Medicare Fee-for-service system, the number of procedures has fallen steadily in recent years, from about 169,000 in 2014 to 91,000 in 2024, federal data show. These figures do not include beneficiaries of Medicare Advantage, the private insurance plans that cover more than half of Medicare enrollees.
A previous scan study found that such tears are common in people over the age of 50, a result of aging and are usually painless.
“There is nothing to support the idea that the patient’s pain is coming from the meniscus,” says Järvinen.
Robert Brophy, director of the Orthopedic Clinical Research Center at Washington University in St. But, he noted, “many patients benefit.”
However, he admitted that the current trend among his peers is “all over the map.” For example, data show that surgical meniscus tears in Medicare populations are more common in the South than in the Northeast.
A major research committee of orthopedic societies in Europe and the US last June issued a consensus statement in which it said that “degenerative meniscus lesions can be treated with comparable results by nonoperative (including physical therapy) or surgical approach.” It recommended preoperative physical therapy but also approved surgery.
A joint campaign of specialized orthopedic organizations called Save the Meniscus Society has been going on for years. The group advocates protecting and maintaining long-term knee health through non-surgical treatments, surgical repair, and other treatments.
One problem in all aspects of medicine is that the right treatment is often in the eye of the beholder, meaning that experts make guidelines for when treatment is appropriate. And financial considerations may influence that decision, Järvinen said.
In the US, physician fees are determined by the Scale Review Committee, or RUC, an American Medical Association committee made up mostly of experts. Secretary of the Department of Health and Human Services, Robert F. Kennedy Jr. and his advisers are reported to have looked at controlling that committee at the association, although it is not clear how that could be done, since the AMA owns the billing codes used to calculate patient rates.
Arthroscopic knee surgery takes 30 to 60 minutes in the operating room, and patients spend several hours recovering in a surgery center or hospital outpatient department. Medicare copays average $2,159 to $3,875 per procedure, depending on where it’s performed; patients pay 20% of the fee as coinsurance. There may be additional costs, for example, if more than one doctor is involved in the procedure. Commercial insurers average more than double that, said Marcus Dorstel, senior vice president at data analytics firm Turquoise Health, adding that the amount providers charge for the procedure varies widely. Those costs do not include fees for surgeons and anesthesiologists.
Treating chronic knee pain has a different history.
Fifty years ago, the treatment for cartilage tears, from severe injury or wear and tear, was to remove the entire cartilage framework. At the time, doctors didn’t consider it a shock absorber but a useless piece like a supplement.
Today, the first line of treatment for a painful knee with degenerative tears is physical therapy and, for some people, weight loss. Then there is arthroscopic surgery, depending on the surgeon’s opinion about its use.
There is also a menu of injections: Steroids have proven to be scientifically valuable in the short term. And injections of stem cells and plasma-rich protein are widely offered but controversial — and not covered by most insurance — because studies have been inconsistent about their benefits.
And as orthopedic surgeons move away from repairing meniscus tears, they’re highlighting a new technique — sewing the torn cartilage back together. But that’s usually an option for patients under 50 with severe injuries and clean tears, and it’s not clear which patients would benefit.
When all else fails, there is a different surgery that is also making a big contribution to hospitals and doctors: knee replacement.
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1 When years later, said trainer, whose first name is John, came to the gym I used. I said to one of the workers there, “That’s the guy who knocked my knee down.”
What was the answer? “Oh, you mean Johnny Kevorkian? His other nickname is ‘007, Licensed to Kill.”
