Arthroscopic knee surgery for arthritis.

[Raul_SJ]

http://www.arthritistoday.org/condit...ee-surgery.php

9/11/08

Arthroscopic knee surgery, the most commonly performed orthopaedic procedure in the United States, may be no better than medical or physical therapy for relieving chronic pain, according to the results of two studies published in the New England Journal of Medicine.

Researchers at the University of Western Ontario randomly assigned 178 people with moderate to severe osteoarthritis of the knee to either arthroscopic surgery, where the inside of the joint is cleaned and smoothed with the aid of a pencil-sized camera, or to a combination of medications, supplements and physical therapy. After two years, both groups reported nearly the same levels of pain, stiffness and disability.

In addition to cleaning and smoothing the inside of the knee, arthroscopic knee surgery is commonly performed to repair tears to a wedge of cartilage in the joint called the meniscus.

“What typically happens is that a doctor will get a patient with knee pain and give them an MRI [magnetic resonance imaging] scan, and they’ll find a meniscal tear,” said David T. Felson, MD, MPH, a rheumatologist with the Boston University School of Medicine.

But in a separate study in the same issue, Dr. Felson and his colleagues performed MRI scans on 991 people living in Framingham, Mass. They found that meniscal tears were common and often did not correspond to a patient’s pain. In fact, 61 percent of people who had meniscal tears in their knees reported that they had no pain, aching or stiffness during the previous month.

"I think this shows pretty persuasively that arthroscopy does not benefit osteoarthritis of the knee," Dr. Felson said.

[Raul_SJ]

Originally Posted by Raul_SJ

http://www.arthritistoday.org/condit...ee-surgery.php


But in a separate study in the same issue, Dr. Felson and his colleagues performed MRI scans on 991 people living in Framingham, Mass. They found that meniscal tears were common and often did not correspond to a patient’s pain. In fact, 61 percent of people who had meniscal tears in their knees reported that they had no pain, aching or stiffness during the previous month.

How is it possible for someone with knee osteoarthritis not to experience pain with a meniscal tear?

It seems that a meniscal tear would indicate that the knee osteoarthritis has advanced and there would be pain when engaging in physical activity.

[ollinger]

That arthroscopy is not useful for arthritis in the knee is fairly old news; recent studies have merely confirmed what was known (but what some orthopedists were unwilling to admit). As for a meniscal tear not being painful, imagine a tear in your bed pillow, and imagine your head resting on that pillow. Whether your head pokes through to the bed beneath (and produces pain) depends on where the tear is and where your head is resting. So it is with the knee, bulges of arthritic bone being analagous to your head.

[Raul_SJ]

================

[corners]

That study is very poorly titled. Rather than "arthroscopy", the title should identify "arthroscopic joint resurfacing" as the intervention that does no good. I don't think they're doing this very much anymore - going in with a tool and sanding down your articular cartilage to make it "smooth," probably because of this study. Articular, or hyaline, cartilage is a complex 3D material that is very strong against compression, and when compressed becomes 100 times more slippery than ice, allowing our joints to freely rotate nearly free of friction. But despite this strength under compression, hyaline cartilage has a fragile structure and is vulnerable to shear. Once the surface is torn it doesn't perform as well. I guess the thinking was that if there is a surface tear then why not go in and "smooth" it all over? But the 2008 paper in the OP showed that it didn't work.

More recently, studies have shown that 1) hyaline cartilage, contrary to long-held belief, is continually repairing itself. Studies on animals have shown that even large defects (tears and divots) can fill in and heal on their own. But it's not clear what conditions favor this. Clearly, young people have a greater capacity to heal, and it may be that we are damaging our joints continually throughout life, but only when we get old does this damage not get repaired. Once the hyaline cartilage stops repairing itself, there seems to be a reversal of fortunes - where the body starts breaking down the cartilage instead of repairing it, and then you've got osteoarthritis. 2) stem cells produced by our own bodies are critical for cartilage regeneration. Young people have more stem cells floating around that can be used for healing, while old people have few. The use of autologous mesenchymal stem cells, harvested from our own bone morrow and then re-injected into our joints, arthroscopically, has shown promise in regenerating hyaline cartilage in veterinary medicine for some time and is being offered by a handful of clinics in the US and around the world for people. This is not well studied and not yet considered a "bona fide" form of medicine. Exercise increases the production of stem cells in our bodies, which may be one of the reasons why people with osteoarthritis do better with more exercise rather than less. 3) pastes made of cartilage, sometimes mixed with stem cells, have also shown promise to regenerate divots in hyaline cartilage. The paste is placed into the defect arthroscopically and apparently will be incorporated into the cartilage in time, healing the defect..

[Chas Tennis]

I more view arthritis and meniscus injuries separately.

I read that of people 70 years old about 30% have had a torn meniscus injury. Most don't know that they have had a torn meniscus. Many meniscus injuries apparently don't seriously affecting knee function.

Recently a friend of mine hurt his knee and was examined. I interpreted this to mean that an injured area of the meniscus was out of place and stopped him from playing tennis. He had a torn meniscus and serious arthritis, with say 5-10% of the area of the articular cartilage worn through to the bone. The Dr said that if he had the operation he would need a second surgery in very few years with the time shortened if he played tennis, that is, another surgery expected in maybe 3 years. He had the operation last year, did OK, and returned to tennis. However, since the first surgery he has required surgery on the other knee with similar arthritis and meniscus issues. He is bow-legged and that is a contributing factor.

If a meniscus tear over a short time stopped me from playing tennis or otherwise using my knee, arthritis or not, I would give it a few months to heal/remodel. If it did not heal I would probably get surgery.

I had a meniscus injury in 1999 and gave it 4 months to heal. It did not heal and I had surgery. Good result. I had another meniscus injury 2011 on the other knee and gave it 3 months to heal/remodel? and it did. No surgery. Good result. The degree of arthritis in my knee joints is not bad with good cartilage separation maintained in both knees.

An important point - there is some risk especially of blood clots after surgery. Some of my friends have had bad experiences after meniscus surgery. The incidence of post surgery problems is something to research and understand.

If I had serious arthritis and I got a meniscus tear that reduced my knee function even after some months of rest I wound consider the surgery to be a big improvement. If my knee recovered function with some months rest - the torn meniscus was no longer affecting function - I would try to avoid the surgery.

[Raul_SJ]

Yes, I think it's important to make the distinction between a "wear and tear" injury to the meniscus over time due to advanced arthritis vs. a traumatic single-event injury to the meniscus in an otherwise healthy (non-arthritic) knee.

As I understand the recent medical findings, Arthroscopic surgery does not work well in the presence of knee arthritis and meniscal
tears. I think the studies show surgery works not much better than physical therapy or placebo.

I suspect that your friend with arthritis and meniscus tear, would have fared just as well without the surgery.

[Chas Tennis]

Originally Posted by Raul_SJ

.................................
I suspect that your friend with arthritis and meniscus tear, would have fared just as well without the surgery.

He had to stop playing. After the surgery he was able to play again.

A torn meniscus can involve a torn piece out of position that, for example, can cause the knee sometimes to lock in a bent position. I don't understand how those issues are factored in the statement 'that after two years both surgery and non-surgery have the similar outcomes'. How would the person get along without bending his knee? Does the study only involve asymptomatic meniscus tears? That might make more sense. ?

Just reread your first post. It sounds as if the patients were asymptomatic regarding meniscus injury. Seems reasonable. I don't think that a meniscus that is causing problems can be ignored because the surgery may not be effective for arthritis treatment, at the same time surgery may be effective for a meniscus injury with symptoms. Obviously a very complicated problem with both a meniscus injury causing symptoms along with serious arthritis. ? My friend and his Dr discussed exactly this issue and (second hand) the Dr sounded very familiar with dealing with it.

Here is a recent thread discussing the issues of arthritis and articular and meniscus cartilages. See especially the CF illustrations.
http://tt.tennis-warehouse.com/showthread.php?t=438433

[Raul_SJ]

I have been reading the links below and it seems the studies are ongoing, unless I am missing some recent news...

http://www.mayoclinic.org/medicalpro...eor-study.html

Meniscal Tear With Osteoarthritis Research (MeTeOR) study

Comparing arthroscopy to nonoperative therapy for meniscal tears in patients with osteoarthritis of the knee

Each year in the United States, more than 300,000 knee arthroscopies are performed for patients who have both a meniscal tear and osteoarthritis in the same compartment of the knee. Yet the frequency with which this treatment is performed belies significant uncertainty surrounding outcomes associated with its use.

Ambiguity and arthroscopy

Mayo orthopedic surgeon Bruce A. Levy, MD, explains that the challenge starts in the consult room, when a patient presents with, for example, medial-sided knee pain. "But if they have a medial meniscus tear and concomitant medial compartment osteoarthritis, it is almost impossible to figure out what is generating the pain," Dr Levy says. "Is it the meniscal tear? Or is it the osteoarthritis in the medial compartment?"

This ambiguity over the identity of pain origin and generation is problematic because meniscal tears and osteoarthritis tend to respond differently to arthroscopy. Data show that arthroscopy is very effective in treating meniscal tears without osteoarthritis — and highly ineffective for treating advanced osteoarthritis of the knee.

MeTeOR to clarify treatment

But what is the best course of treatment when both conditions are present? Currently physicians tell this subset of patients who are contemplating treatment that knee arthroscopy is unpredictable in the setting of meniscal tear and concomitant osteoarthritis.

MeTeOR at a glance

Enrollment goal: 340 by February 2011
Mayo Clinic contribution to total enrollment: ~80 patients

Centers involved: 7 U.S. advanced orthopedic centers, sponsored by the National Institutes of Health
Principal Investigator: Jeffrey N. Katz, MD, MS, Brigham and Women's Hospital, Boston
Mayo Clinic investigators: Bruce A. Levy, MD, Diane L. Dahm, MD, Michael J. Stuart, MD

Randomized to 2 arms: Arthroscopy vs nonoperative treatments. These treatments may include physical therapy, use of antiinflammatory drugs, intraarticular cortisone injections, activity modification, braces.
Main inclusion criteria > age 45:

Presence of symptomatic meniscal tear with mechanical indicators such as locking, buckling, catching
Presence of mild to moderate osteoarthritis on MRI
No comorbidities, not pregnant

[Raul_SJ]

I will have to study these threads... but my first thoughts are

1)
Did your friend (with serious arthritis and meniscus tear) have surgery to repair the meniscus? or for the articular cartilage damaged by arthritis? or both?

2)
When the Doctor advised him that he would likely need surgery again in a few years, what specific surgery is he referring to? to repair the meniscus again?

3)
How long had your friend with serious arthritis and meniscus tear wait before having the surgery? Is it possible that physical therapy would have resulted in the same outcome had he given it enough time?... That seems to be what these studies of meniscal tears and concomitant arthritis are suggesting?


Also note the quote from Ollinger in the other thread:

"
You may have seen in some newpapers or magazines reports of a pretty good study recently published on this topic. Conclusion was that if you have any evidence of arthritis in the knee, a meniscus procedure is worthless."

4)
If the surgery enabled your friend to play tennis for additional time -- something that would've been impossible with non-surgical
treatment -- it sounds like the surgery was successful.

But the successful surgery would seem counter to what Ollinger is saying...

[Raul_SJ]

Originally Posted by ollinger

That arthroscopy is not useful for arthritis in the knee is fairly old news; recent studies have merely confirmed what was known (but what some orthopedists were unwilling to admit).

If there is severe knee osteoarthritis present, then repairing the meniscal tear (caused by wear and tear) will not benefit, because the meniscus will soon be damaged again by the osteoarthritis.

Is that the reasoning?

Also, is there a link to the conclusions that arthroscopy is not useful?

This link indicates the study is still ongoing and does not state any conclusions.

http://www.mayoclinic.org/medicalpro...eor-study.html

[Chas Tennis]

Originally Posted by Raul_SJ

......................................

1)
Did your friend (with serious arthritis and meniscus tear) have surgery to repair the meniscus? or for the articular cartilage damaged by arthritis? or both? Both.

2)
When the Doctor advised him that he would likely need surgery again in a few years, what specific surgery is he referring to? to repair the meniscus again? I believe that one possibly future surgery was the artificial new joint surface but I'm not sure. Not a complete knee replacement.

3)
How long had your friend with serious arthritis and meniscus tear wait before having the surgery? Is it possible that physical therapy would have resulted in the same outcome had he given it enough time?... That seems to be what these studies of meniscal tears and concomitant arthritis are suggesting?
I told him that waiting a few months to see if the meniscus would heal is what I did with good results in 2011. He did not want to wait and had it done in a month or two after the decision. I believe that he wanted to deal with the arthritis by smoothing the articular cartilage and drilling some holes in the bone where it was worn through in hopes of stimulating some new cartilage growth. I am very uncertain of this description and the exposed bone may have been discovered during the surgery.


Also note the quote from Ollinger in the other thread:

"
You may have seen in some newpapers or magazines reports of a pretty good study recently published on this topic. Conclusion was that if you have any evidence of arthritis in the knee, a meniscus procedure is worthless."

Seems reasonable for an asymptomatic meniscus injury but not for a meniscus injury with symptoms. My meniscus injuries had sudden out-of-kilter and bone-on-bone feelings that were very distinct, acute injuries. How typical I don't know.
4)
If the surgery enabled your friend to play tennis for additional time -- something that would've been impossible with non-surgical
treatment -- it sounds like the surgery was successful.

He was happy with several months, a year?, of play until he got his second injury & operation on the other knee.

But the successful surgery would seem counter to what Ollinger is saying...

Is Ollinger's statement for asymptomaytic meniscus injuries?

The MeTeOR study dealing with this issue is a future study?

Many people have meniscus injuries that aren't causing problems as the "61%" of your first post indicates. If the damaged part of the meniscus gets in the way inside the joint in my opinion something has to be done.

Find a well qualified Dr for these issues.

[Raul_SJ]

In your case, there was no advanced arthritis coupled with the meniscal tear, and surgery can be effective in these cases.

In your friend's case, there was advanced arthritis along with the meniscal tear (which I presume was caused by wear and tear over a prolonged time).

In these cases, surgery (to either treat the articular cartilage or repair the tear) is not effective.

[Raul_SJ]

Is this the typical progression of knee arthritis?

First, the wearing down of the articular cartilage, followed by the wearing down of the meniscus?

So a person with a meniscus tear caused by "wear and tear", and not due to an acute injury, can be presumed to be in the advanced stages of knee arthritis?

[Chas Tennis]

Originally Posted by Raul_SJ

Is this the typical progression of knee arthritis?

First, the wearing down of the articular cartilage, followed by the wearing down of the meniscus?

So a person with a meniscus tear caused by "wear and tear", and not due to an acute injury, can be presumed to be in the advanced stages of knee arthritis?

I don't know. I don't know how to grade arthritis. Your word "advanced" might not be appropriate.

What can you find to support your assumptions about various pathologies? Finds stats as best you can for the various pathologies.

There is a lot of uncertainty with injuries, pathology and treatments.

[drak]

Originally Posted by corners

That study is very poorly titled. Rather than "arthroscopy", the title should identify "arthroscopic joint resurfacing" as the intervention that does no good. I don't think they're doing this very much anymore - going in with a tool and sanding down your articular cartilage to make it "smooth," probably because of this study. Articular, or hyaline, cartilage is a complex 3D material that is very strong against compression, and when compressed becomes 100 times more slippery than ice, allowing our joints to freely rotate nearly free of friction. But despite this strength under compression, hyaline cartilage has a fragile structure and is vulnerable to shear. Once the surface is torn it doesn't perform as well. I guess the thinking was that if there is a surface tear then why not go in and "smooth" it all over? But the 2008 paper in the OP showed that it didn't work.

More recently, studies have shown that 1) hyaline cartilage, contrary to long-held belief, is continually repairing itself. Studies on animals have shown that even large defects (tears and divots) can fill in and heal on their own. But it's not clear what conditions favor this. Clearly, young people have a greater capacity to heal, and it may be that we are damaging our joints continually throughout life, but only when we get old does this damage not get repaired. Once the hyaline cartilage stops repairing itself, there seems to be a reversal of fortunes - where the body starts breaking down the cartilage instead of repairing it, and then you've got osteoarthritis. 2) stem cells produced by our own bodies are critical for cartilage regeneration. Young people have more stem cells floating around that can be used for healing, while old people have few. The use of autologous mesenchymal stem cells, harvested from our own bone morrow and then re-injected into our joints, arthroscopically, has shown promise in regenerating hyaline cartilage in veterinary medicine for some time and is being offered by a handful of clinics in the US and around the world for people. This is not well studied and not yet considered a "bona fide" form of medicine. Exercise increases the production of stem cells in our bodies, which may be one of the reasons why people with osteoarthritis do better with more exercise rather than less. 3) pastes made of cartilage, sometimes mixed with stem cells, have also shown promise to regenerate divots in hyaline cartilage. The paste is placed into the defect arthroscopically and apparently will be incorporated into the cartilage in time, healing the defect..

they are now using "adipose" or fat derived stem cells which are much cheaper and easier to harvest (just as effective) and often combining it with PRP therapy. It's a 90-minute out patiend procedure and a local Doc here charges $1750 per treatment. at 57 my knees are still doing fairly well, but I have had 3 scopes for meniscus tears and I am think of getting this done for each knee as a preventative or try to make them last longer option.

Unfortunately thsese treatments are not covered by insurance at this time, so it's all out your own pockets

[Chas Tennis]

Regarding knee surgery with "unstable" meniscus injury -

See reply by Dr Fleisig
http://asmiforum.proboards.com/index...ay&thread=1909

[drak]

Originally Posted by drak

they are now using "adipose" or fat derived stem cells which are much cheaper and easier to harvest (just as effective) and often combining it with PRP therapy. It's a 90-minute out patiend procedure and a local Doc here charges $1750 per treatment. at 57 my knees are still doing fairly well, but I have had 3 scopes for meniscus tears and I am think of getting this done for each knee as a preventative or try to make them last longer option.

Unfortunately thsese treatments are not covered by insurance at this time, so it's all out your own pockets

My left knne has started to bother me, saw the Doc who does the knee Stem cell/PRP therapy yesterday and I have some instability and probably another cartilage tear and developing osteoarthritis. I am going to have a the Stem Cell/PRP shot done in the next two weeks. I will report back amd give updates on progress once I have the shot.

Drak

[drak]

Originally Posted by drak

My left knne has started to bother me, saw the Doc who does the knee Stem cell/PRP therapy yesterday and I have some instability and probably another cartilage tear and developing osteoarthritis. I am going to have a the Stem Cell/PRP shot done in the next two weeks. I will report back amd give updates on progress once I have the shot.

Drak

Just had my stem cell/prp knee treatment this afternoom, the doc said I would be really sore for the first 12 hrs, he was right. The procedure itself was pretty easy, the drawing of the adipose fat cells from the stomach felt "weird" but no big deal. I'll update on progress in the weeks ahead

[Raul_SJ]

Originally Posted by drak

My left knne has started to bother me, saw the Doc who does the knee Stem cell/PRP therapy yesterday and I have some instability and probably another cartilage tear and developing osteoarthritis. I am going to have a the Stem Cell/PRP shot done in the next two weeks. I will report back amd give updates on progress once I have the shot.

Drak

Do you have a tear in the articular cartilage? Or a tear in the meniscus? Or both?

Des the Stem cell/PRP treatment help for both types of tears?