Hello! I hope most of you have either avoided or are not candidates for the unfortunate trend of unnecessary orthopedic surgeries aimed at enhancing knee cartilage in symptomatic patients.
My journey into this issue began quite unexpectedly. I discovered that orthopedic specialists generally rely on four primary treatments: rest, ice, compression, and elevation; physical therapy; steroid injections; and surgery. Unfortunately, many seem eager to suggest surgery when the first three approaches yield minimal results.
Apologies if you’ve encountered this story before. Back in the early 1990s, after I paid to have a trainer injure my knee,1 I was referred to what was said to be one of New York City’s top knee specialists. We exchanged a few pleasantries about Harvard, where I had some acquaintances from his class, but we had no mutual connections.
After ten days with no improvement, he ordered an MRI.
During my follow-up visit, he flung the radiologist’s report at me and demandingly said, “You went to Radcliffe. What do you make of this?”
The report was concise, consisting of five paragraphs on one page, with just one paragraph stating the diagnosis.
I read, “Possibility of a medial meniscus tear or a potential false positive.” I understood that a tear typically points toward surgery.
The doctor replied, “They all include ‘possible false positive’ to cover themselves. I’ll go in on Friday and take a look. You’ll be walking by Monday.”
Leaving his office, I thought, “There’s no way I’m allowing you to operate on my knee like that.”
This incident turned out to be one of those situations I now refer to as, “What seems like bad luck is actually good luck.”
If he hadn’t pressured me into reading the radiology report, I likely would have sought a second orthopedic opinion. Instead, I recognized the necessity of getting a second radiological opinion.
A college friend of mine was married to a radiologist. I reached out, and she put me in touch with Frank.
Frank asked me, “Can you read me the report?” which I did.
“Who signed it?” he queried. I provided the name.
“I know him,” Frank replied. “He wouldn’t have written ‘Possible false positive’ unless he truly had doubts. Send me the films.”
A team at Cedars Sinai thoroughly examined the MRI. Frank later called to say, “Your knee appears perfectly normal.”
The second part of this story involves the orthopedist’s intent to “clean things up” in my knee, suggesting that he would trim any rough cartilage he noticed. I didn’t grasp the importance of this until I met a man in his 50s at another gym in NYC, performing what I recognized as knee rehabilitation exercises. I expressed my hope that he was finding some relief.
He brightened and explained that he visited his orthopedist roughly every 18 months for routine “scoping,” during which rough cartilage was removed.
I was taken aback. How could gradually shaving away knee cartilage be considered beneficial? I consulted a physical therapist friend who worked with elite athletes, and he agreed.
By Elisabeth Rosenthal. Originally published at KFF Health News
Thousands of Americans undergoing a prevalent knee surgery might inadvertently be exacerbating their problems instead of alleviating them.
Research following patients for a decade after they received either actual arthroscopic knee surgery to trim degenerated cartilage or merely “sham surgery”—a skin incision—revealed that the surgery offered negligible benefits and was linked to accelerated osteoarthritis and increased reoperation rates, which often culminated in total knee replacements.
“I genuinely don’t see how I could justify this procedure,” stated Teppo Järvinen, an orthopedist and head of the Finnish Centre for Evidence-Based Orthopaedics, one of the study’s authors. “What we have observed is striking: patients undergoing this procedure experience more pain and worse outcomes. Every score points in that direction.”
Järvinen noted that a Finnish study published in April in the New England Journal of Medicine was the first to reveal that many patients ended up in a worse condition post-surgery. Although the study had a small sample size, its findings were compelling, as the team selected patients “most likely to benefit.”
This study does not pertain to cartilage tears caused by acute trauma, but rather included subjects who were middle-aged or older, suffering from knee pain with MRIs indicating cartilage tears.
Evidence has been steadily accumulating for over ten years that arthroscopic knee surgery to trim degenerated cartilage is no more effective than physical therapy. According to Järvinen, arthroscopic procedures in Finland have dropped by 90%, a trend mirrored in the U.S., though at a much slower pace.
One study of commercial claims in the U.S., which surveyed over two million meniscus surgeries from 2010 to 2020, indicated a yearly decrease of about 4%. Most surgeries were conducted on women and patients in their 50s.
In the traditional Medicare fee-for-service system, the number of procedures has consistently declined, from approximately 169,000 in 2014 to 91,000 in 2024, according to federal data. These figures do not encompass beneficiaries in Medicare Advantage plans, which cover more than half of Medicare enrollees.
Previous studies have shown that such tears are prevalent in individuals over 50, resulting from wear and tear and often not causing pain.
“Nothing suggests that a patient’s pain originates from the meniscus,” Järvinen remarked.
Robert Brophy, director of the Orthopaedic Clinical Research Center at Washington University in St. Louis, acknowledged that “evidence is mounting for the careful application of this surgery within this demographic,” but also noted, “many patients do experience benefits.”
Nonetheless, he recognized that the current approaches among his colleagues can be quite inconsistent. For example, data indicates that meniscus tear surgeries among the Medicare population are significantly more prevalent in the South compared to the Northeast.
A major study committee from orthopedic societies in Europe and the U.S. released a consensus statement last June, asserting that “degenerative meniscus lesions can be treated with comparable outcomes through either non-operative approaches (including physical therapy) or surgical methods.” It recommended attempting physical therapy prior to surgery while still endorsing the operation.
An ongoing campaign led by orthopedic specialty societies, termed the Save the Meniscus Society, promotes the preservation and maintenance of long-term knee health through non-surgical treatments, surgical repair, and other therapies.
A intrinsic issue across medical fields is that treatment appropriateness can often be subjective, influenced by the specialist’s perspective, leading to varying guidelines on necessary interventions. Financial factors may also impact this decision, according to Järvinen.
In the U.S., physician payments are determined by the Relative Value Scale Update Committee (RUC), a body within the American Medical Association primarily composed of specialists. Secretary of Health and Human Services Robert F. Kennedy Jr. and his advisors have reportedly considered the possibility of taking control of that committee, although the logistics remain uncertain since the AMA owns the billing codes that dictate patient charges.
Arthroscopic knee surgery typically lasts 30 to 60 minutes, with patients recovering for a few hours either in a surgery center or outpatient department. Medicare allocates between $2,159 and $3,875 for the procedure, depending on the location; patients typically pay 20% as coinsurance. Additional costs may arise, especially if multiple doctors are involved in the procedure. Commercial insurers usually allocate much more than that, commented Marcus Dorstel, a senior vice president at the data analytics firm Turquoise Health, while stressing the significant variability in procedure charges. Surgeons’ and anesthesiologists’ fees are extra.
Addressing chronic knee pain has evolved considerably.
Fifty years ago, treating cartilage tears—whether from acute injury or wear and tear—often involved removing the entire cartilage piece. At that time, it was treated as a vestige, akin to an appendix, rather than the essential shock absorber that it is understood to be today.
Present-day first-line treatment for a painful knee with degenerative tears typically involves physical therapy and sometimes weight management, with arthroscopic surgery considered based on the surgeon’s assessment.
A range of injections is also available: steroid injections have shown efficacy in the short term, while stem cell and plasma-rich protein injections are widely available yet controversial—many insurance plans do not cover them due to inconclusive scientific backing.
As orthopedists move away from trimming meniscus tears, they are promoting a newer procedure that involves suturing the torn cartilage back into position. However, this option is generally reserved for patients under 50 with acute injuries and clean tears, and the criteria for which patients would benefit remain uncertain.
When all else fails, there exists another surgery, which also brings significant revenue for hospitals and practitioners: knee replacement.
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1 Years later, when that trainer named John appeared at a gym I was frequenting, I mentioned to a staff member, “That’s the guy who ruined my knee.”
The reply? “Oh, you mean Johnny Kevorkian? His other nickname is ‘007, Licensed to Kill.’”
