Don’t have arthroscopic clean-out or meniscus trimming for slowly worsening middle-aged and older knee pain (osteoarthritis, degenerative meniscus tear); lose weight and train thigh muscle first

For middle-aged and older people with degenerative knee pain, arthroscopic clean-out or cutting a piece of meniscus is no better than sham surgery. Sham surgery only cuts a few skin holes; afterward pain and walking match real surgery. Any benefit lasts a few months at most and may invite leg clots. Sticking with leg training eases knee pain; overweight people who also lose weight hurt even less.

Cost

No surgery fee, and you also save 2 to 6 weeks of recovery. What to do is train thigh and hip muscle long term, several times a week; best have rehab or a physiotherapist teach a set first. People who are overweight also need to eat less, move more, and bring weight down. The hard part is that training and weight loss work slowly, while surgery sounds like a one-shot fix.

Benefit

First osteoarthritis. A 2002 trial split 180 people with knee osteoarthritis into three groups: arthroscopic clean-out, arthroscopic lavage, and sham surgery. Sham only cut a few skin holes; the scope was not inserted. Patients and assessors did not know who got which. At every follow-up over two years, neither real surgery beat sham on pain or function. Knee-pain score is 0 to 100; higher hurts more. At one year: sham 48.9, lavage 54.8, clean-out 51.7. A 2008 trial enrolled 178 people with moderate-to-severe knee osteoarthritis. One group had arthroscopic clean-out plus physiotherapy and drugs. The other only physiotherapy and drugs. Symptom total is 0 to 2400; higher is worse. At two years the groups were 874 versus 897, difference 23 (95% CI −208 to 161, credible range) — no difference. Next meniscus. A 2013 Finnish trial enrolled 146 people aged 35 to 65 with symptoms of a degenerative medial meniscus tear and no osteoarthritis. One group had partial meniscectomy; one had sham surgery. At 12 months three main scores did not differ. For example post-exercise knee pain (0 to 10): groups improved 3.1 and 3.3. A 2015 meta-analysis pooled 9 trials. People who had surgery had 3 to 5 points less pain at 3 to 6 months (0 to 100). By 1 to 2 years there was no difference, and function did not improve. Next harms. Symptomatic deep-vein thrombosis in the leg: about 4.13 per 1000 operations (1.78–9.60). Also pulmonary embolism, infection, and death. A 2017 BMJ international expert panel therefore strongly opposed arthroscopy for almost all people with degenerative knees. The panel states recovery takes 2 to 6 weeks after surgery. Finally what to do. A 2016 Norwegian trial enrolled 140 middle-aged people with degenerative meniscus tears. One group did 12 weeks of supervised exercise; one had partial meniscectomy. At two years knee scores differed by only 0.9 (−4.3 to 6.1) — no difference. At 3 months the exercise group had stronger thigh muscle. The 2015 Cochrane systematic review pooled 44 trials and 3537 people. Exercise cut knee pain by the equivalent of 12 points (0 to 100, credible range 10 to 15), evidence quality high. Two to six months after stopping, still 6 points less. A 2013 U.S. trial enrolled 454 people aged 55 and above, overweight or obese, with knee osteoarthritis. Diet plus exercise lost a mean 10.6 kg (11.4% of body weight). At 18 months their pain score (0 to 20) was 3.6 versus 4.7 for exercise alone. It looks worthwhile because “cleaning out worn and torn bits” sounds on-target, and many people do feel better after surgery.

Notes

Controversy. China’s 2018 osteoarthritis diagnosis-and-treatment guideline differs. It says arthroscopic clean-out works better for knee osteoarthritis with “mechanical symptoms,” such as loose bone fragments in the joint or a meniscus tear that has shifted. It also says long-term results match conservative care, and benefit may be limited when joint space is clearly narrowed. The 2021 guideline’s original site needs manual verification and was not checked word for word, so it is not cited. The BMJ panel’s view is that catching and clicking mechanical symptoms are also inside the opposition; only a truly locked knee that will not straighten may be an exception. The panel’s opposition also excludes two groups: a knee that swells fast after major trauma (usually bleeding in the joint), and sports injuries in young people. Those need an orthopaedic visit. Arthroscopy is not knee replacement; the panel says replacement is for severe disease when conservative care fails. What painkillers to take when it hurts: Section 34, Item 3 (ask a doctor before ibuprofen-class painkillers). Don’t count on glucosamine for relief — Item 5 in this section (glucosamine, chondroitin). What to train: Section 2, Item 16 (strength training); weight loss: Section 2, Item 32 (if overweight, lose weight). Benefit set to medium by judgment: no official published figure for what such surgery costs in China. Main gain is saving surgery money and postoperative weeks, plus avoiding uncommon harms such as clots. Beneficiaries are you and older family members.

Sources · 9

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