Surgery for torn meniscus still too often unnecessarily performed

A surgery for a torn meniscus caused by wear and tear is rarely beneficial, this was already known. Now a study from Radboud university medical center shows that there are no smaller groups of patients who do benefit from this procedure. ‘We should not perform this surgery anymore, but offer a policy focused on prevention, combined with a personal approach with a focus on physiotherapy.’ This saves between 11 and 26 million euros in healthcare costs per year.

For people of middle age or older with a tear in the meniscus, but without a history of acute knee trauma, surgery is rarely useful. Many studies have already shown that an arthroscopic surgery, in which a doctor treats a tear, is no better than physiotherapy or even a sham surgery, in which a doctor only makes incisions in the knee. Tears in the meniscus also often occur in people who have no complaints and are often not the cause of pain. Yet many orthopedic surgeons still operate on a torn meniscus. How come?

‘At the population level, it has been shown that this surgery, a so-called partial meniscectomy, has no effect, but a few people can benefit from it. Many orthopedists say that they still often operate, because they know exactly who a surgery is useful for’, says researcher Gerjon Hannink from Radboudumc. ‘We wanted to know if there are smaller groups of patients who you should actually operate on.’

Surgery unnecessary

‘To find out, we needed a lot of data’, says Stan Wijn, who earned his doctorate on the study. ‘All studies so far were too small to find subgroups. That is why we collected data from four studies on the effect of meniscus surgery, giving us data from 605 patients in total. We reanalyzed the raw data in the larger context. We looked for subgroups for whom surgery could be useful based on 13 factors, including age, BMI, gender, location of the tear, and knee function.’

The researchers found no subgroup, even when they used artificial intelligence to analyze the data. Not one subgroup scored better in terms of knee pain, knee function, or mental well-being. ‘We show with this study that there are no smaller groups of patients who you should actually operate on’, says Wijn. ‘As far as we are concerned, we should hardly perform any surgery on the meniscus. Only in case of very obvious complaints, such as a locked knee or when stretching the knee is no longer possible.’

No more bargaining

What can we offer patients with knee pain? ‘Prevention, combined with a personalized approach focused on physiotherapy’, Hannink answers. ‘We need to consider a degenerative knee more as a chronic condition. A clear guideline is very important in this regard, and orthopedic surgeons must adhere to it. I still hear too often that they operate because "if I don't do it, someone else will." Some patients even go abroad if they can't get surgery in the Netherlands. Dutch health insurance companies should no longer reimburse the procedure if it is performed abroad.’

Maroeska Rovers, professor of Evidence-Based Surgery, adds: ‘For this surgery, we should move toward the principle of "no, unless there is a specific indication for it", such as a locked knee. This saves us 11 to 26 million euros in the Netherlands each year, without sacrificing quality of life. With the Integral Care Agreement, we choose appropriate care. Then we should also choose not to operate and stop bargaining.'