Knee surgery: Have we been doing it wrong?

BUFFALO, N.Y. — A team of University at Buffalo medical doctors has published a study that challenges a surgical practice used for decades during arthroscopic knee surgery.

When treating meniscal tears — one of the most common orthopedic surgical procedures — surgeons also have clipped and smoothed any dislodged cartilage they found in the belief it was helping patients. But the new study finds that practice does not benefit the patient. Patients who did not have dislodged cartilage removed, recovered faster, with less pain, and ended up a year later with identical results.  

“Those with less surgery got better faster in comparison with the people we did more surgery on,” said Leslie J. Bisson, MD, professor and chair in the Department of Orthopaedics at the Jacobs School of Medicine and Biomedical Sciences at UB and lead author of the study.

The finding was so surprising that an editor at The Journal of Bone & Joint Surgery, which published the study, also published a commentary that said, “The conclusion that unstable cartilage lesions do not need debridement could have a dramatic impact on practice management, save health-care dollars, and improve early patient outcomes.”

The American Academy of Orthopaedic Surgeons also distributed the study on its weekly collection of papers of note.

Doctors check for arthritis — the tearing or dislodgement of articular cartilage called chondral lesions — using X-rays when they are preparing to treat a meniscus in the knee. But sometimes low level arthritis is not visible, and doctors find it only when they are inside the knee, Bisson said. At that point, doctors have always opted to clip and smooth any loose cartilage.

Better early outcomes

The study followed 190 patients who were having arthroscopic partial meniscectomies (APM). Of those, 98 received debridement of the damaged cartilage and 92 did not receive debridement. Both groups had the same results one year after surgery, but prior to that, the group without debridement had less pain and better function than those who had the cartilage trimmed and smoothed.

“That was very surprising to us,” Bisson said. “We are bringing those patients back and doing X-rays at five years to see if it made a difference in their arthritis.”

In the meantime, the surgeons at UBMD Orthopaedics & Sports Medicine, where Bisson and the other doctors involved in the study practice, are no longer debriding knee cartilage when repairing meniscal tears.

“That’s a marked change. In my group, with five sports medicine doctors, we do close to 1,000 APMs a year,” he said.

Middle age injury

A meniscus is a little cartilage cushion on the inside and outside of the knee, and it can breakdown in middle age, or it can become damaged by trauma as gentle as squatting down to get something out of a cupboard or to line up a putt on the golf course.

“You stand up and you feel something catch in your knee,” Bisson said.

Bisson expects that not everyone will embrace a challenge to the way such injuries have always been treated. “One of the things we say in surgery is you can’t practice based on the last study that was done. Hopefully this will push others to investigate this topic and consider things they are doing on a daily basis,” he said. “We should question everything that we are doing that is not based on evidence.”

The study is titled, “Patient Outcomes After Observation Versus Debridement of Unstable Chondral Lesions During Partial Meniscectomy: The Chondral Lesions And Meniscus Procedures (ChAMP) Randomized Controlled Trial.” The other authors are Melissa A. Kluczynski; William M. Wind, MD; Marc S. Fineberg, MD; Geoffrey A. Bernas, MD; Michael A. Rauh, MD; John M. Marzo, MD; Zehua Zhou; and Jiwei Zhao, PhD.