Q: I have knee osteoarthritis and have had increasing pain for two months. An MRI showed a torn meniscus. Does this mean I need surgery?
A: Maybe, but, in most cases, surgery in this situation should be considered only as a last resort.
A meniscus, the shock-absorbing pad of cartilage in the knee, may tear due to degeneration or an injury. Typical symptoms are pain, catching or locking of the knee. But some people with a torn meniscus on MRI have no pain.
The challenge is to figure out — based on details of your symptoms, examination and other testing — whether your pain is due to the tear seen on MRI.
During arthroscopy, an orthopedist inserts a hollow-tubed instrument with a camera and light on the end into an anesthetized knee. Instruments can be passed through the hollow tube to remove debris, smooth ragged edges, and cut away cartilage that is impairing knee function.
We already know that arthroscopy for osteoarthritis (the "wear-and-tear" type that is the most common type of arthritis) doesn't help most people. But how good is it for the combination of osteoarthritis and a meniscal tear?
A recent study followed 351 people with the combination of a meniscal tear and osteoarthritis and who had symptoms thought related to a meniscal tear. They had not improved with at least a month of medications, activity restriction and/or physical therapy. About half were randomly assigned to have arthroscopic surgery followed by physical therapy; the rest received physical therapy for 12 weeks. Within the first few months, improvement was similar in both groups. But nearly 40% of study subjects assigned to receive physical therapy "crossed over" into the arthroscopic surgery group due to lack of improvement.
Over five years, more study subjects receiving arthroscopy required knee replacement surgery during the study period. These results raise the concern that arthroscopy increases the chances that arthritis will progress and require knee replacement.
Other downsides of arthroscopic knee surgery include pain and a risk of bleeding or infection; a recovery period is required, lasting weeks to months; and, cost is also a factor. In the U.S., arthroscopic knee surgery commonly costs $5,000 to $10,000 with variable insurance coverage.
Together with previous studies, this study suggests that for people with meniscal tears and osteoarthritis, nonsurgical treatment should be the preferred option over arthroscopic meniscal repair. However, for someone whose knee is locked or who is unable to walk due to pain or catching, surgery may be needed sooner than later.
If knee surgery is recommended to you, ask your surgeon whether this study applies to your situation. The better plan may be to put off surgery and continue with more conservative treatment.
(Robert H. Shmerling, M.D., is a senior faculty editor at Harvard Health Publishing and associate professor of medicine at Harvard Medical School. For additional consumer health information, please visit www.health.harvard.edu.)
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