Last month a paper was published exploring treatment of meniscal tears in patients with osteoarthritis (OA). The study found that surgical treatments (i.e. knee operations) increased the tell-tale signs of OA quicker than non-surgical treatments (for example, physiotherapy). Osteoarthritis is a degenerative condition – that is, it always gets worse – but according to this study, it worsens faster when you have surgery to repair a meniscal tear.
On the face of it, you might expect the medical community to be recommending against meniscal surgery for patients with OA. The fact that hasn’t happened is because the above study is yet another example of research that, if anything, has added to the level of confusion surrounding OA and meniscal tears, rather than offering clarity.
What happens when you tear a meniscus?
The menisci are the knee’s cartilage-like ‘shock absorbers’, preventing bone grinding against bone. Tear them, and you’ll feel pain sufficient to interfere with everyday activities. Over time, with less (or no) ‘cartilage’ to prevent damage, the surfaces of the bone will grind away – and this wear and tear is osteoarthritis.
Tear a meniscus when you already have OA and, without repair, it’s likely to make the OA problem worse.
No knee surgeon’s first instinct is surgery. There’s always a level of risk (albeit small) associated with surgery that doesn’t exist with non-surgical options such as physiotherapy. So if you tear your meniscus, whether you have OA or not, the chances are your surgeon will first recommend conservative treatment (rest, physiotherapy etc). If, over a reasonable period (typically 6-12 weeks depending on the severity of symptoms) things don’t improve, surgery may be the next logical option to enable you to return to regular activities and reduce pain.
The problem with the research
But there’s an issue with this. The more severe the OA, the less likely it is that meniscal surgery will be successful in achieving significant medium to long term benefit. That’s especially the case when the meniscal tear isn’t a prime contributor to the OA. In these situations, a knee replacement is likely to be the treatment of choice.
Yet there remain some occasions when a torn meniscus could be considered to be a significant contributor to the OA symptoms. On those occasions, surely surgery is entirely appropriate?
You can see the challenge. With so many variables: the severity of the tear, the severity of the OA, the differences between patients and their weights, lifestyles and activity levels; the relationship between the tear and the OA, and the likely effect of surgery – it has been extremely difficult to reach any consensus on whether arthroscopic (keyhole) surgery is ever the right choice for a torn meniscus, because it’s extremely difficult to arrange research which consistently compares like with like.
Finding a solution
It was this lack of clarity that led to a major collaborative project by BASK (the British Association for Surgery of the Knee) that has recently been completed and published in the UK, and which seeks to clarify guidelines for surgery. This is a critical piece of work designed to assist primary care doctors, commissioning groups and insurance companies (as well as knee surgeons) in determining appropriate meniscal surgery. Yorkshire Knee Clinic’s Prof. Nick London and Dave Duffy were asked to be part of the county-wide consensus panel which has aimed to “develop an evidence-based treatment guideline for patients with meniscal lesions of the knee.”
The resulting guidelines sensibly avoid trying to identify one common recommendation for a condition which has many facets. Instead, the project whittled down 45 clinical scenarios into the five most common, with six corresponding treatment recommendations.
The guidance, BASK says, “will facilitate the consistent identification and treatment of patients with meniscal lesions. It is hoped that this guidance will be adopted nationally by surgeons and help inform healthcare commissioning guidance.”
The guidelines don’t cover every scenario – there remain some areas of uncertainty – but they do take us much closer to understanding in what circumstances it makes sense to carry out meniscal tear surgery on an OA patient, and when alternative routes should be considered.
If you knee pain has started to interfere with your daily activities, talk to us about a treatment route that, thanks to the guidelines, should be an awful lot clearer.
Symptoms, diagnosis & treatment of tears of the knee's shock absorbers
Symptoms of, treatment & support for osteoarthritis sufferers
Prof. Nick London
Specialist Knee Surgeon & Visiting Professor to Leeds Beckett University
“An excellent knee surgeon. He probably does as many partial knee replacements as anyone in the country.”
Consultant Orthopaedic Surgeon & District NHS Foundation Trust
“Mr Duffy is a wonderful knee surgeon but he’s a very approachable guy as well… That makes a huge difference.”