Meniscus Injuries in Arthritic Knees: To Arthroscopy or Not?
August 7, 2018
Modern imaging techniques such as MRI often reveal meniscus injuries in middle-aged or older individuals who suffer from osteoarthritis and knee pain. In cases of knee problems and knee pain with arthrotic-degenerative changes combined with meniscus signs/symptoms, arthroscopic surgery on the meniscus is widespread and often the first choice in conventional medicine. According to the literature, approximately 4 million knee arthroscopies are performed worldwide each year.
As a manual therapist, the question often arises whether surgery is always directly necessary, and how much better it is afterward. Was it worth it? What exactly has improved or changed? What can be most influenced by surgical intervention?
This topic is not easy to answer. Because knee pain can certainly have many interrelated and influencing causes. And it is not easy to distinguish the clinical symptoms of meniscus lesions from osteoarthritis. [1]
In conventional medical science, various interventions or treatment methods are examined for their effectiveness through clinical studies and trials. Care must be taken not to compare apples with oranges; only similar injuries should be compared.
Therefore, having the correct medical diagnosis at the beginning is crucial: if this is wrong or misinterpreted, the outcome is not guaranteed, as an unsuitable therapy form may be chosen. These factors make it difficult to obtain clean, accurate, and thus meaningful studies in medicine.
Henry Vandyke Carter Henry Gray, Gray348-de, marked as public domain
Moreover, the individual is the focus of these studies. And each person brings their own physiological conditions that influence a precise prognosis regarding the healing process, whether after an injury or surgery. Therefore, clear and correct inclusion and exclusion criteria of the subjects being compared (diagnosis, age, gender, extent of complaints, range of motion, duration of complaints, etc.), a sufficiently large and thus meaningful case population (with a corresponding comparison cohort), and then the correct application of statistical techniques and means are needed to provide an evidence-based recommendation.
At BodyLab Osteopathy and Physiotherapy, we have searched the medical literature for reviews and meta-analyses to get an understanding of current studies. We have dealt with four papers that exclusively address degenerative changes in the knee (not traumatic injuries!).
Foremost, it can be said that the studies do not produce clear results. In our specific case, it is not always easy (as mentioned) to distinguish and diagnose meniscus problems from degenerative arthrotic knee issues. [1]
From our papers, the following evidence seems to prevail regarding meniscus injuries of an arthritic or degeneratively altered knee:
Regarding pain and mobility, there is no significant difference between an arthroscopic procedure and conservative treatment with physiotherapy regarding long-term results. [2]
It seems that there is no clear benefit from an arthroscopic procedure compared to conservative treatment with physiotherapy. [3, 4]
A conservative approach should be considered as initial treatment. Surgery after starting physiotherapy at a later stage does not negatively affect the long-term outcome and did not delay the healing process. [4]
However, certain contributing factors seem to significantly negatively affect the outcome of knee arthroscopy for degenerative meniscus injuries: for example, the duration of pain (> 1 year), involvement of knee arthritis, and how large the part of the meniscus to be removed is. [5]
Degenerative changes (osteoarthritis and arthritis) that occur with age are one of the main diagnoses and a very common cause of knee pain. And as already mentioned, it is not easy to distinguish the clinical symptoms of meniscus lesions from osteoarthritis. [1]
This should be considered since, in arthritis, due to the anatomical proximity and function of the menisci (see our blog meniscus), these are usually also compromised and damaged, or the entire functional unit of an affected joint (everything involved) is affected. Often, (age-related) changes to the meniscus occur hand in hand with knee osteoarthritis!
A conservative approach aimed at achieving full mobility of the knee joint and muscle-building training often forms the foundation for a positive outcome, even if interrupted by surgical intervention. Therefore, we, as physiotherapists and osteopaths, recommend starting with the conservative approach whenever possible and not too quickly or prematurely opting for surgery.
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References
[1] The role of the meniscus in knee osteoarthritis: a cause or consequence?
Englund M, Guermazi A, Lohmander SL
Radiol Clin North Am 2009; 47:703–712.
Brignardello-Petersen R, Guyatt GH, Buchbinder R, Poolman RW, Schandelmaier S, Chang Y, Sadeghirad B, Evaniew N, Vandvik PO.
BMJ Open. 2017 May 11;7(5):e016114. doi: 10.1136/bmjopen-2017-016114.
Khan M1, Evaniew N, Bedi A, Ayeni OR, Bhandari M
CMAJ. 2014 Oct 7;186(14):1057-64. doi: 10.1503/cmaj.140433. Epub 2014 Aug 25.
[4] The METEOR trial: no rush to repair a torn meniscus.
Hwang YG, Kwoh CK
Cleve Clin J Med. 2014 Apr;81(4):226-32. doi: 10.3949/ccjm.81a.13075.
[5] Can we predict the clinical outcome of arthroscopic partial meniscectomy? A systematic review.
Eijgenraam SM, Reijman M, Bierma-Zeinstra SMA, van Yperen DT, Meuffels DE.
Br J Sports Med. 2018 Apr;52(8):514-521. doi: 10.1136/bjsports-2017-097836. Epub 2017 Nov 28.
Image Credit
Henry Vandyke Carter Henry Gray, Gray352, marked as public domain, details on Wikimedia Commons
All images used here are marked as public domain, further details on Wikimedia Commons.
