Study Questions Arthroscopic Knee Surgery for Degenerative Cartilage Tears

Thousands of Americans who have arthroscopic knee surgery for degenerative cartilage tears may not be getting the relief they expect. New research suggests the procedure may do little to help pain and could be tied to worse long-term outcomes, including faster osteoarthritis and more repeat operations, often leading to total knee replacement.

The study followed patients for 10 years after they received either the actual operation or sham surgery, which in this case meant only a skin incision. Researchers found little or no benefit from the surgery itself. Teppo Järvinen, an orthopedist and head of the Finnish Centre for Evidence-Based Orthopaedics, said the results were striking.

“I don’t know how I would defend this procedure at all,” Järvinen said. “What has been shown dramatically is that patients who have this procedure have more pain — they do worse. All the scores pointed in the same direction.”

Järvinen said the Finnish study, published in April in the New England Journal of Medicine, was the first to show the surgery left many patients worse off. He said the study was small, but he argued that the findings were compelling because his team selected patients they considered most likely to benefit.

The study did not include cartilage tears caused by an acute injury that led to pain. Instead, it focused on middle-aged or older patients with knee pain whose MRI scans showed cartilage tears. In that group, the surgery to trim degenerative cartilage tears was associated with accelerated osteoarthritis and higher rates of reoperation.

Evidence against the procedure has been building for more than a decade. Research has suggested that arthroscopic knee surgery to shave torn, degenerative cartilage does not help more than physical therapy. Järvinen said arthroscopic rates in Finland have fallen 90%. They have also been declining in the United States, though at a slower pace.

One U.S. commercial claims study counted more than 2 million meniscus surgeries from 2010 to 2020 and found the number dropped by about 4% a year. Most of those procedures were performed on women and on patients in their 50s. In traditional Medicare fee-for-service, procedures fell from about 169,000 in 2014 to 91,000 in 2024, according to federal data. That total does not include people enrolled in Medicare Advantage, which covers more than half of Medicare enrollees through private plans.

Prior scan studies have shown that meniscus tears are common in people over 50, often reflecting wear and tear rather than an acute injury. They are often not painful. Järvinen said, “Nothing supports the idea that a patient’s pain comes from the meniscus.”

Not everyone sees the issue in such absolute terms. Robert Brophy, director of the Orthopaedic Clinical Research Center at Washington University in St. Louis, said evidence is growing for careful use of the surgery in this population. Still, he said, many patients do benefit. He also acknowledged that current practice among orthopedic physicians is inconsistent.

That inconsistency shows up in the data. In the Medicare population, surgery for meniscus tears is much more common in the South than in the Northeast. At the same time, a large committee of orthopedic societies in Europe and the United States released a consensus statement last June saying that degenerative meniscus lesions can be treated with comparable results using either non-operative care, including physical therapy, or surgery.

That statement recommended trying physical therapy before surgery, but it still supported the operation. For years, orthopedic specialty societies have also promoted a campaign called the Save the Meniscus Society, which says the goal should be long-term knee health through nonsurgical treatment, surgical repair and other therapies.

The debate highlights a broader challenge in medicine: the specialists who perform procedures often help shape the rules for when those procedures are considered appropriate. Järvinen said financial considerations may also play a role.

In the United States, physician payments are determined by the Relative Value Scale Update Committee, or RUC, a committee of the American Medical Association made up largely of specialists. Department of Health and Human Services Secretary Robert F. Kennedy Jr. and his advisers have reportedly looked into taking control of that committee away from the AMA, though it is not clear how that could be done, since the AMA owns the billing codes used to calculate patients’ charges.

Arthroscopic knee surgery is usually a short procedure, taking about 30 to 60 minutes in the operating room. Patients typically spend a few hours recovering in a surgery center or hospital outpatient department. Medicare pays an average of $2,159 to $3,875 for the procedure, depending on where it is performed, and patients generally pay 20% as coinsurance. Additional costs may apply if more than one doctor is involved.

Commercial insurers pay more than twice that amount on average, according to Marcus Dorstel, a senior vice president at the data analytics firm Turquoise Health. He said the amount providers charge varies widely. Those figures do not include surgeon or anesthesiologist fees.

The treatment of chronic knee pain has changed over time. About 50 years ago, cartilage tears from either injury or wear and tear were often treated by removing the entire piece of cartilage. At the time, doctors did not view cartilage as a shock absorber, but as a useless remnant, like the appendix.

Today, the first-line approach for a painful knee with degenerative tears is physical therapy and, for some people, weight loss. Arthroscopic surgery remains an option, depending on the surgeon’s view of its usefulness. There is also a range of injections. Steroid injections have been scientifically useful in the short term. Stem cell injections and plasma-rich protein are widely offered, but they are controversial and not covered by most insurance because research has been inconclusive.

As orthopedists move away from shaving off meniscus tears, they are drawing attention to another procedure: sewing the torn cartilage back together. But that approach is usually reserved for patients under 50 with acute injuries and clean tears, and it is not yet clear exactly which patients may benefit.

If other measures do not work, there is still knee replacement, another major source of revenue for hospitals and doctors. For patients with chronic pain and degenerative cartilage tears, however, the newer Finnish findings add to a growing body of evidence questioning whether arthroscopic trimming is worth the cost, the recovery and the risk of a worse outcome.