Meniscal Surgery May Raise Risk for Osteoarthritis
When damaging tears form on the knee's meniscus cartilage, meniscal surgery is a common solution. But according to new research, meniscal surgery may cause more harm than good, including an increased incidence of osteoarthritis (OA).
"We found that patients without knee osteoarthritis who underwent meniscal surgery had a highly increased risk for developing OA and cartilage loss in the following year compared to those that did not have surgery, regardless of presence or absence of a meniscal tear in the year before," said Frank W. Roemer, MD, Research Associate Professor of Radiology at Boston University School of Medicine.
“Medicine is science based on data and personal experience, we are presenting data that clearly show an increased risk for OA after [meniscal] surgery,” said Dr. Roemer, who presented the study in December 2014, at the Radiological Society of North America’s (RSNA) annual meeting in Chicago, Illinois.
The investigators reviewed records from 4,796 participants in the ongoing Osteoarthritis Initiative study. Dr. Roemer and colleagues studied magnetic resonance imaging (MRI) exams of 355 knees that developed OA during a 5-year period, and compared those to a control group matched for age, gender, arthritic severity in both knees, and body mass index (BMI). Imaging studies were read for medial and lateral meniscal damage (including maceration) and for cartilage morphology. The study patients were, on average, 60.2 years old, predominantly women (66.5%), and overweight (mean BMI 28.3).1
Of all knees, 31 underwent meniscal surgery during the year prior to the arthritis diagnosis (radiographic osteoarthritis [ROA]), and 280 knees had signs of meniscal damage on MRI but did not have surgery. The researchers then assessed the risk of developing arthritis and cartilage loss during the following year for the different groups, according to a press release from RSNA.
The study found that all 31 knees (100%) that underwent meniscal surgery during the prior year developed OA compared with 165 (59%) of the knees with meniscal damage that didn't have surgery. Interestingly, knees that had undergone meniscal surgery showed even more risk for cartilage loss than those with serious meniscal damage. Cartilage loss occurred in 80.8% of knees that had meniscal surgery, compared with and only 39.5% of knees that did not undergo surgery. This suggests that meniscal surgery may actually have "deleterious effects" on knee joints at risk for ROA, speeding up knee degeneration instead of slowing it down, the researchers said. The study is under peer review and pending publication.
Dr. Roemer said his data doesn't assert that meniscal surgery is wholly detrimental, as oftentimes it's needed "in cases of knee locking or an unstable tear." However, Dr. Roemer said "that [meniscal] surgery should be carefully discussed between doctor and patient to weigh the pros and cons, especially in cases of stable degenerative tears—maybe more carefully than is the case today."
Debate Over OA Risk
There has been some debate over the added risk for OA from meniscal surgery in recent years.2 However, as clinicians continue to study the variable nature of meniscal problems,3,4 data is scarce as to the possible connection between knee surgery and later OA, a condition that incurs costs in the billions of dollars.5
Moin Khan, MD, MSc, a senior orthopedic resident at McMaster University in Hamilton, Ontario, told Practical Pain Management that he found Dr. Roemer study interesting, although he expressed his own reservations about the implication that surgical intervention could contribute to osteoarthritis incidence.
"This study demonstrates an association, however, that does not necessarily imply causation," Dr. Kahn said. "We need larger prospective studies of high methodological quality with longer follow up times given that osteoarthritis is multi factorial–genetics, activity level, age, and BMI all play a role in the development of osteoarthritis."
Dr. Kahn recently published a meta-analysis showing that arthroscopic meniscal debridement had no greater benefit to treating meniscal tears than nonoperative treatments.6
Physical therapy, weight loss, moderation of daily activity, anti-inflammatory medications, and "potentially cortisone or viscosupplementation joint injections" could all be useful ways to treat meniscal tears, Dr. Kahn said. Other treatments, like neuromuscular exercise, are receiving further attention, as well.7 So, while the evidence may be unclear as to how meniscal surgery might influence osteoarthritis incidence in the long term, there are numerous nonoperative methods for handling degenerative knee disease that are commonly lauded by practitioners.
Dr. Roemer concluded that “the decision for meniscal surgery needs to be carefully considered in order to avoid accelerated osteoarthritis onset.”