Categories: Dr. Kevin R. Stone

Why ‘useless’ surgery is useful

Recent news stories proclaiming meniscus surgery to be useless miss the point, due to outdated information. And they can do considerable harm by convincing people that leaving a torn meniscus in the knee is a good choice when, in fact, it destroys the knee.

The meniscus is the key shock absorber inside the knee. Traditionally, when torn, it was removed with a procedure called a partial or total meniscectomy. This procedure is performed 1.4 million times each year in the U.S. alone.

When a surgeon removes a significant amount of the torn meniscus, the knee is left unprotected from weight-bearing forces. Over time, the weight-bearing surface — called the articular cartilage — wears out and exposes the underlying bone. This condition is commonly called arthritis.

When symptoms of arthritis first appear, the area exposed is usually small. The symptoms can be moderate, with little impact on one’s lifestyle. But if it remains untreated, the wear continues. As the damaged area increases, the symptoms and pain increase as well, interfering with work and leisure activities.

It’s a serious problem, and the data is stunning. A recent study reported there is a 14 percent chance that adults in the U.S. over the age of 25 will be diagnosed with symptomatic knee osteoarthritis; the current standard of care is artificial knee replacement. While the average age of the first diagnosis of knee arthritis is age 54, knee replacement is not usually performed until an average age of 66, leaving 9.3 million people suffering for an average of 12 years.

The studies cited by journalists in recent stories look at this population and conclude that meniscectomy alone does not change their outcome. On this point they are correct. Removing more of the key shock absorber in the knee does not help cure or prevent the pain of arthritis and probably accelerates it.

What is not mentioned is that during the last 20 years, other methods of repair have evolved. Reconstruction and replacement of the meniscus cartilage and the articular cartilage have advanced to the point where a number of long-term studies document excellent pain relief and a return not only to daily activities but to sports as well.

In the past, these now common techniques were difficult and time consuming. Many were not reimbursed by insurance — so only 3 percent of all meniscus tears were properly repaired, despite the knowledge that meniscectomy can indeed lead to arthritis. Today’s repair techniques use new surgical tools that allow surgeons to repair the meniscus even in tight knees, and to place sutures in almost all types of tears. At this time, more meniscus tears are being repaired.

Meniscus reconstruction—using stem cells to regrow portions of the meniscus for patients who have pain after meniscectomy — is currently possible as well. The Collagen Meniscus Implant is a regeneration scaffold that has been used in more than 6,000 cases in Europe and is available in the U.S. as well.

Meniscus replacement using allograft, or donor meniscus, has been practiced selectively since the late 1980s. Several centers have extensive experience and have produced long-term studies showing improvement in pain and function. One study documents the remarkable reduction in artificial joint replacements for arthritic patients who underwent meniscus replacement with articular cartilage repair.

In addition to significantly improving a patient’s quality of life, reducing osteoarthritis has direct and indirect cost benefits. The average outpatient/drug cost for treating chronic osteoarthritis is $5,133/year. The average indirect cost (disability, lost wages) is $6,340/year. This means a five-year remission of symptoms can save $58,000 per patient. If you extend this over the average life expectancy from 66 — about 14 years, for a male — the savings is an impressive $160,000 per patient.

So when meniscus surgery is reported as useless, remember: Not all meniscus surgery is the same. Evolution over millions of years refined the meniscus cartilage to protect the wonderful knee joint we all depend upon. Surgeons now have the skills and tools to restore the injured meniscus. Patients, surgeons and insurance companies should all be motivated to expand the utilization of these tools. By doing so they can reduce arthritis, delay or prevent the need for artificial joint replacement, and return people to active lifestyles.

Dr. Kevin R. Stone is an orthopedic surgeon at The Stone Clinic and chairman of the Stone Research Foundation in San Francisco.

Dr. Kevin R. Stone
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Dr. Kevin R. Stone

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