Does Arthroscopic Knee Surgery Really Help?

By Dr. Peter Abaci

Arthroscopic knee surgery has long been considered one of medicine’s best advances to the specialty of orthopedic surgery, but a series of studies over the last several years now raise serious doubts to that sentiment. The allure of minimally invasive procedures has to do with factors like less tissue swelling, less post-operative pain, quicker recoveries, and lower costs in comparison to more invasive approaches. Being able to get a procedure done in about an hour or less with minimal anesthesia and then go home with the hope of solving a problem like a painful knee sounds like a pretty nice way to go. In fact, many of us have embraced this approach as a good use of modern medical technology. Orthopedic surgeons perform approximately 1 million arthroscopic knee surgeries in the U.S. each year at an estimated cost of $4 billion.

The first modern cystoscope was invented in the late 1800s, and the first doctor to adapt this technology to the knee joint was the Japanese physician, Takagi. In the 1920s, the Swiss physician, Bircher, started to publish studies using a laparoscope to diagnose meniscus tears and arthritis. Dr. Robert Jackson later brought the technology to North America in 1965, and with the introduction of fiberoptics and miniature television cameras in the 1970s, arthroscopic surgeries took off shortly thereafter.

Starting several years ago, studies started to question whether or not arthroscopic knee surgery really provided successful outcomes. First, researchers started looking at the results of arthroscopic knee surgeries done on stiff, painful, arthritic knees. Their findings suggested that arthroscopic knee surgery done on arthritic knees offered no real value when it came to improving pain or function. Studies also indicated that physical therapy, exercises, and over the counter pain relievers like Tylenol yielded about the same results over time in treating arthritic knees, regardless of whether arthroscopic surgery was done or not. In other words, the surgery didn’t seem to add any extra benefit.

Other studies started to find that cartilage tears inside knees joints are not only quite common in the general population, but also are often asymptomatic. In fact, two-thirds of randomly selected patients with evidence of meniscus tears actually had no knee pain or stiffness. This then begged the question of are we over-relying on MRI findings in treating knee pain and misdiagnosing the problem, leading to a lack of improvement with many arthroscopic knee surgeries? Are the surgeries ineffective because the most appropriate cases are not being chosen? I think we have raised very similar questions to this with back surgery. Experience dictates that the general over-emphasis on MRI findings has been one reason why so many failed spine surgeries occur.

Now researchers are raising doubts about using arthroscopic knee surgery to treat meniscus tears in younger patients without osteoarthritis. A new study from Finland was recently published in the New England Journal of Medicine that found no difference in outcomes in patients aged 35-65 who had arthroscopic knee surgery for meniscus tears compared to those who had what is known as a “sham” operation. (In this case, think of the sham operation as the placebo treatment used to compare the results of the surgery being studied) Again, for quite some time now, the “knee jerk treatment” for painful knees has been to try arthroscopic surgery, but the deeper we dive into this, the more we see a need to be selective about choosing when to operate. This latest study suggests a necessity to re-focus our approach on how best to treat basic knee problems and perhaps create a new algorithm that better defines when surgery should be deemed necessary.

I have documented in the past some of my own problems with knee pain, and you may be wondering what does the doctor prescribe for his own rickety knee? Well, here are some tips that I have personally found to be useful to live by:

  • Keep moving. Nothing aggravates my knee more than sitting in a fixed position for too long. Luckily, as a physician, I am always moving throughout the day. Going to the movies can be a real killer even though I still love the big screen.
  • Pedal hard. Cycling, both outdoor and indoor, seems to keep my knee feeling well-lubricated and allows me to get some heart-healthy cardio exercise without pounding my knee while running. Cycling also strengthens muscles that support the knee.
  • Don’t over bend. Any activity or exercise that forces me to put too much flexion in my knee seems to really flare it up. For example, squatting too low is a sure fire way to inflame my knee.
  • Keep it light. Though it is hard to quantify the effect, I think maintaining an ideal body weight decreases knee pain. Being even 10 pounds overweight can put added stress on the knee joint, and researchers seem to think that fat cells release pro-inflammatory mediators.
  • If for some reason I have a need to run, going uphill or running in sand seems to feel much better than something like jogging on flat pavement or even grass.
  • Take the stairs. Avoid using the elevator whenever possible. My knee typically hurts more going down stairs, as opposed to up, but if I use the stairs regularly, then I don’t seem to have that problem.
  • Yoga. In general, my knee started to feel noticeably better once I started practicing yoga. I have to be careful with certain poses, like deep squats.
  • If my knee gets really flared-up, then a little ibuprofen helps, but I don’t take it regularly.