For the nearly 20 percent of Americans considering surgery to fix their knee pain, a new Brigham and Women’s Hospital study suggests that they may want to hold off for a bit — even if an imaging scan reveals a torn meniscus, the rubbery disc that cushions the knee joint. Most older individuals with meniscus tears that often occur with aging and arthritis get the same long-term relief with time and physical therapy as they do with surgery, according to the findings published last Tuesday in the New England Journal of Medicine.
The researchers looked at 351 patients aged 45 and older who had a torn meniscus along with arthritis and randomly assigned them to have either surgery or six weeks of physical therapy. The therapy group could switch to surgery if their knee problems didn’t improve over weeks or months, and 30 percent of the group eventually did before the year-long study was complete.
The 70 percent who skipped surgery had similar amounts of pain relief and functional restoration after a year, though they likely had less severe tears that were able to heal on their own.
The findings should be “very reassuring to those with meniscus tears who don’t want surgery right away,” said study leader Dr. Jeffrey Katz, a rheumatologist at the Brigham.
Others who want a faster recovery from pain and quicker return to their full physical activities might consider having surgery sooner. And the research makes the case for performing surgery in those who aren’t getting relief after several months of unrelenting discomfort.
The minimally invasive procedure — performed via an arthroscope that’s inserted through small incisions — led to less discomfort after three months in study participants compared with those who had physical therapy.
Immediate surgery may also be more appropriate for younger people 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.
“Younger people can bounce back over a weekend,” Katz said, “while older people can be pretty uncomfortable for a week or two or maybe longer.”
Sometimes the surgery doesn’t help much, especially if the knee pain is due to arthritis rather than the meniscus tear. “About one-third of adults in their 50s and 60s have tears that show up on MRI scans without having any symptoms at all,” Katz said. “It can be very hard to determine how much of the symptoms are caused by a torn meniscus and how much are caused by the arthritis.”
What’s more, researchers found years ago that arthroscopic surgery to remove arthritic tissue doesn’t work any better than a sham surgery to alleviate knee pain in those with arthritis.
Patients weighing elective knee surgery also need to consider the risk of rare complications such as blood clots, pneumonia, infections, and nerve damage. And there’s not much data on how well surgery controls knee pain long-term.
“It’s possible doing surgery has a downside down the road,” Katz said. “We worry that trimming off some of the meniscus may leave the cartilage that cushions the bone less protected, making arthritis worse.”
He and his study colleagues from Boston University and various other academic hospitals plan to follow the participants for five years to see whether their knee pain recurs.
For those considering surgery to repair a torn meniscus, Katz recommended finding an orthopedic surgeon who does at least one of these surgeries a week. “The other thing I’d look for in a surgeon is more subtle,” he added. “Find someone who is comfortable discussing your values and preferences as a patient.”
Surgeons should tailor advice based on what a patient is comfortable with. A risk-taker looking to get back on the job as quickly as possible, he said, shouldn’t necessarily get the same treatment as a patient who is wary of surgery and willing to give the injury time to heal.