What do we do with that worn-out knee?

2 March 2023

Surgery does not appear to be helpful for a meniscus tear when it is caused by wear and tear. But what care can a patient expect then?

Fifteen patients a day for keyhole surgery, that was quite normal for an orthopedist some 20 years ago. 'I remember making a quick drawing after every operation of exactly what I had done in a knee,' says Tony van Tienen, orthopedic surgeon at ViaSana and researcher at the Radboudumc. 'Otherwise, by the end of the day, I couldn't remember which piece of meniscus I had removed from a patient in the morning.'

His work has since changed considerably, as the number of surgeries for meniscus tears has decreased dramatically. Van Tienen: "In the past ten years, many studies appeared, showing that surgery for a meniscus tear is no better than physical therapy or even fake surgery. We are not talking about young people who tear their meniscus due to a hard blow, for example on the soccer field; in them, surgery often makes sense. This is about people over forty who get a tear due to wear and tear. In them, surgery does not prove useful or cost-effective, although a few may benefit.'

Who those few are who do benefit is proving impossible to estimate, researchers Gerjon Hannink and Stan Wijn of the Radboudumc and colleagues wrote last January in Osteoarthritis Cartilage. Hannink based his conclusion on an analysis of six hundred operations with a tear caused by wear and tear. He looked for subgroups that do better after surgery, but did not find them. His advice? 'Stop operating except for very obvious symptoms, such as when the knee is locked.' But if we do much less surgery for a torn meniscus, what can we still offer patients?

Ignition

That starts with prevention. Van Tienen: "Such a tear often occurs during everyday activities: working in the garden, unclogging the sink or laying a floor. For that, the following applies: avoid sitting squatting for long periods with deeply bent knees, because that can cause a tear in the meniscus.

If the meniscus does rupture, time is an important factor in recovery. The latest guidelines therefore recommend a wait-and-see approach for at least the first three months. That means a doctor can employ all sorts of things, such as physical therapy and an injection of corticosteroids, but not surgery. Eventually, many people get rid of their pain symptoms during those three months even without surgery.

'That is because the pain is usually not caused by the tear itself,' Hannink explains. 'A lot of over-40s have tears in their meniscus, even though they don't know it at all and they don't experience any symptoms because of it. But a tear can release inflammatory factors in the knee, and inflammation can cause pain. It's important then that the inflammation goes away.'

Cycling

Physical therapy and exercise are important parts of treatment during those first three months. The knee needs activity, and the muscle mass around the knee needs to be maintained. 'Movement improves blood flow, and that leads to faster recovery from inflammation,' Van Tienen says. 'We don't actually know very well whether a meniscus tear can heal, but we do know that inflammation can disappear. Cycling is a very good form of activity in this regard.'

If physical therapy and exercise do not work well because of knee pain, an injection of corticosteroids may help. These substances temporarily inhibit inflammation and thus reduce pain. In doing so, they can break the vicious cycle of pain, sitting still and little recovery. Doctors are cautious about these injections, however. Van Tienen: "A single injection is fine, but multiple injections increase the risk of damage in the knee in the long term, because the quality of the cartilage then decreases.

This new conservative approach with physical therapy, exercise and possibly an injection, but without surgery, proves difficult in the consulting room. 'If I tell a patient we're going to do keyhole surgery, I'm done in five minutes. That's concrete and people understand it,' says Van Tienen. 'Now I have to explain that not operating is actually better, and that's complicated. Then a conversation takes twenty minutes.'

Still, more and more orthopedists are following the new guideline. 'We are in a transition phase,' said Van Tienen. 'For thirty years we operated a lot. Actually, everyone was happy with that, both orthopaedists and patients. Now we are learning more and more that operating on tears caused by wear and tear is rarely useful. As a result, the field has changed a lot and that requires orthopaedists to adapt. It will take time before this new way of working is fully established.

 

This is a background article to this news story dated 1 February 2023.

 

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