Don't have arthroscopic cleanup or the meniscus cut just because middle-aged or older knees slowly start to hurt (osteoarthritis, degenerative meniscal tear); lose weight and strengthen the thigh muscles first

Cost

No surgery costs, and you also skip the 2 to 6 weeks of recovery after surgery. What you do is build up the thigh and hip muscles over the long term, a few times a week, ideally having a rehabilitation doctor or physical therapist teach you a routine first. If you are overweight, eat less and move more to bring your weight down. The hard part is that both training and weight loss are slow to work, while surgery sounds like it settles things in one go.

What you get

First, osteoarthritis. A 2002 trial split 180 patients with knee osteoarthritis into three groups: arthroscopic debridement (cleanup), arthroscopic lavage (flushing), and sham surgery. In sham surgery only a few cuts were made in the skin and the arthroscope was not put in. Neither the patients nor the assessors knew who had which. At every checkup over two years, neither real operation had better pain or function than sham surgery. The knee pain score runs from 0 to 100, and the higher the score, the more it hurts. At one year it was 48.9 in the sham group, 54.8 in the lavage group and 51.7 in the debridement group. In 2008 another trial enrolled 178 patients with moderate to severe knee osteoarthritis. One group had arthroscopic debridement plus physical therapy and medicine. The other had only physical therapy and medicine. The total symptom score runs from 0 to 2400, and the higher the worse. After two years the two groups scored 874 versus 897, a difference of 23 points (95% CI −208 to 161, the plausible range), so there was no difference. Now the meniscus. A 2013 trial in Finland enrolled 146 people aged 35 to 65. All had symptoms from a degenerative tear of the medial meniscus, without osteoarthritis. One group had a partial meniscus removal and one had sham surgery. At 12 months there was no difference in any of the three main scores. For example, knee pain after exercise (0 to 10 points) eased by 3.1 points in one group and 3.3 in the other. A 2015 meta-analysis pooled 9 trials. People who had surgery had 3 to 5 points less pain (on a 0 to 100 scale) at 3 to 6 months. By 1 to 2 years there was no difference, and function did not improve. Now the harms. Symptomatic deep vein thrombosis in the leg occurred about 4.13 times per 1000 operations (1.78–9.60). There were also pulmonary embolism, infection and death. In 2017 an international expert panel organized by the BMJ (British Medical Journal) strongly recommended against arthroscopy for almost all people with degenerative knees on this basis. The panel states that recovery takes 2 to 6 weeks after surgery. Finally, what to do. A 2016 trial in Norway enrolled 140 middle-aged people with a degenerative meniscal tear. One group did 12 weeks of supervised exercise and one had a partial meniscus removal. After two years the knee scores differed by only 0.9 points (−4.3 to 6.1), so there was no difference. The exercise group had stronger thigh muscles at 3 months. The 2015 edition of a Cochrane systematic review pooled 44 trials with 3537 people. Exercise reduced knee pain by the equivalent of 12 points (on a 0 to 100 scale, plausible range 10 to 15), with high-quality evidence. Two to six months after training stopped, it was still 6 points less. In 2013 a U.S. trial enrolled 454 overweight or obese knee osteoarthritis patients over 55. People who dieted and exercised lost an average of 10.6 kg (11.4% of body weight). At 18 months their pain score (0 to 20) was 3.6, versus 4.7 for those who only exercised. It looks like a good deal because “cleaning out what is worn and torn” sounds like it fits the problem exactly, and many people do feel better after the operation.

Notes

Dispute. China's 2018 osteoarthritis guideline says something different. It says arthroscopic cleanup works fairly well for knee osteoarthritis with “mechanical symptoms,” such as loose fragments of bone in the joint or a meniscus that has shifted after a tear. It also states that the long-term effect is comparable to conservative treatment, and that the benefit may be limited when the joint space is clearly narrowed. The site hosting the original text of the new 2021 guideline requires manual verification, so it could not be checked word for word and is not cited. The BMJ panel's view is that mechanical symptoms such as catching and clicking are also covered by its recommendation against, and only a knee that truly locks and cannot be straightened may be an exception. The panel's recommendation against also does not cover two kinds of people: those whose knee swells quickly after a major injury (the joint is most likely bleeding), and young people with sports injuries. For these, see an orthopedic doctor in person. Arthroscopy is not a knee replacement; the panel says replacement is for those with severe disease for whom conservative treatment has failed. For what painkillers you can take when it hurts, see §34.3 (ask a doctor before taking painkillers such as ibuprofen). Don't count on glucosamine for relief; see §6.5 (glucosamine and chondroitin). For what exercises to do, see §2.16 (strength training), and for weight loss see §2.32 (lose weight if overweight). The benefit is rated medium on judgment: no official figure was found for what this kind of surgery costs in China. The benefit is mainly the surgery cost and the weeks of recovery saved, plus avoiding rare harms such as blood clots. The beneficiaries are you and the older people in your family.

Evidence grade

A : Specific numbers from meta-analyses, large cohorts or randomized trials; for law and policy, the statute or official text.

Sources

1. Moseley JB, O'Malley K, Petersen NJ, et al. (2002). A controlled trial of arthroscopic surgery for osteoarthritis of the knee. New England Journal of Medicine, 347(2), 81–88. https://doi.org/10.1056/NEJMoa013259
2. Kirkley A, Birmingham TB, Litchfield RB, et al. (2008). A randomized trial of arthroscopic surgery for osteoarthritis of the knee. New England Journal of Medicine, 359(11), 1097–1107. https://doi.org/10.1056/NEJMoa0708333
3. Sihvonen R, Paavola M, Malmivaara A, et al. (2013). Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. New England Journal of Medicine, 369(26), 2515–2524. https://doi.org/10.1056/NEJMoa1305189
4. Thorlund JB, Juhl CB, Roos EM, Lohmander LS. (2015). Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms. BMJ, 350, h2747. https://doi.org/10.1136/bmj.h2747
5. Siemieniuk RAC, Harris IA, Agoritsas T, et al. (2017). Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline. BMJ, 357, j1982. https://doi.org/10.1136/bmj.j1982
6. Kise NJ, Risberg MA, Stensrud S, et al. (2016). Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: randomised controlled trial with two year follow-up. BMJ, 354, i3740. https://doi.org/10.1136/bmj.i3740
7. Fransen M, McConnell S, Harmer AR, et al. (2015). Exercise for osteoarthritis of the knee. Cochrane Database of Systematic Reviews, CD004376. https://doi.org/10.1002/14651858.CD004376.pub3
8. Messier SP, Mihalko SL, Legault C, et al. (2013). Effects of intensive diet and exercise on knee joint loads, inflammation, and clinical outcomes among overweight and obese adults with knee osteoarthritis: the IDEA randomized clinical trial. JAMA, 310(12), 1263–1273. https://doi.org/10.1001/jama.2013.277669
9. 反方：中华医学会骨科学分会关节外科学组 (2018). 骨关节炎诊疗指南（2018年版）（四、治疗 （三）手术治疗 2．关节镜清理术）. 中华骨科杂志, 38(12), 705–715. https://doi.org/10.3760/cma.j.issn.0253-2352.2018.12.001（全文 https://cmab.yiigle.com/uploads/guide_html/%E9%AA%A8%E5%85%B3%E8%8A%82%E7%82%8E%E8%AF%8A%E7%96%97%E6%8C%87%E5%8D%97%EF%BC%882018%E5%B9%B4%E7%89%88%EF%BC%89.html）

Translated from the Chinese original. Original book, section 6, tip 33. Content may be out of date and rules differ by place. When you actually deal with an agency, a doctor or a court, follow what local officials, doctors and lawyers tell you. Disclaimer