Knee “Clean Ups” Make A Mess: PRP vs. Knee Debridement

Samuel G Oltman, ND, RMSK

Knee pain that stops you from doing the activity you like and living your life to the fullest is frustrating. It is even more frustrating when the treatment options you are presented with are limited to cortisone and ineffective surgery, like the surgical “clean up”. It sounds so simple and, well, clean. Unfortunately, it is not that simple and nothing is being cleaned up– your tissue is being cut out. The evidence for knee "clean ups" (arthroscopic debridements) for degenerative meniscus and osteoarthritis is very poor yet continues to be recommended. Platelet Rich Plasma (PRP) presents an alternative to this route by reducing pain while preserving joint health long term. 

The Cochrane Review is a rigorous, systematic review, seen as the gold standard in evidence-based medicine. The Cochrane Review on knee clean ups for degenerative meniscus tears concludes (1): 

High‐certainty evidence indicates arthroscopic surgery leads to little or no difference in pain or function at three months after surgery, moderate‐certainty evidence indicates there is probably little or no improvement in knee‐specific quality of life three months after surgery, and low‐certainty evidence indicates arthroscopic surgery may lead to little or no difference in participant‐reported success at up to five years, compared with placebo surgery.

Arthroscopic surgery provides little or no clinically important benefit in pain or function, probably does not provide clinically important benefits in knee‐specific quality of life, and may not improve treatment success compared with a placebo procedure. It may lead to little or no difference, or a slight increase, in serious and total adverse events compared to control, but the evidence is of low certainty. 

Translation: Knee clean ups do not work at all and add additional risk of the knee getting worse over the long term.

Additionally:

• Clean ups also have no benefit in knee osteoarthritis (2).

• Clean ups are more expensive with no significant alteration of progression to knee replacement (3).

• The more of the meniscus that is cut out, the more arthritis develops afterwards (4).

Despite this, roughly 7500,000 knee cleans up are done every year in the US (5), under the guise of “evidence-based medicine”, while the majority of them are not supported by science, do not provide benefit, and likely cause long term harm.

*The evidence does support clean ups when there are “mechanical symptoms” that prevent normal function. This is when the knee gets locked in place and cannot be moved without jiggling it free. It is not when there are pops and cracks, those are commonplace and not a reason to get a clean up. True mechanical symptoms are rare and represent a minority of meniscus cases. Let’s be really generous and say a third of cases do indicate a clean up– that’s still half a million surgeries every year done in contradiction to the highest level evidence available. 

Importantly, meniscus repair is beneficial and is preferable when possible, especially for younger patients. This is when the meniscus is sewn back together, as opposed to chunks being cut out. However, sewing a tear together is most often not possible. And doing PRP after a meniscus repair can help improve pain following surgery (6).

Cortisone injections are also commonly offered in these cases, and they too, are only short term band-aides that makes the underlying issue worse, creating long term downside (read our previous article on this subject here). 

Why is it still done so often and covered by insurance if it doesn’t work? Bad incentives, entrenched financial interests, bias toward surgical solutions, slow change in practice in response to new evidence, surgeons who have been doing it for 20 years that say “well it works for me” (the antithesis of an evidence-based approach). 

PRP Is Beneficial Without The Downside

The evidence on PRP for meniscus degeneration (with or without osteoarthritis) is promising: systematic reviews indicate that PRP consistently lowers pain level and improves knee function within 3 months of treatment and can last for up to one year (7). The biggest flaw in the current evidence is the lack of clarity in regards to the "platelet dose" in PRP studies. Studies that do track platelet dose show that a higher dose is more effective and provides a longer lasting positive effect.

The evidence for PRP in degenerative meniscus tears shows (8): 

• Lowered pain levels

• High satisfaction rates

• Improved knee function scores

• Successful return to sport

• No elevated risk of developing OA

• Radiographic improvement and healing of tears

The evidence for PRP needs to continue improving, it’s far from perfect. There is a barrier in funding because PRP is not a drug (your PRP comes from your body so cannot be patented). The research that is published on PRP is often highly biased. But it is a treatment that has the potential for significant improvement with low-invasiveness and no long term downside for the joint. 

In conclusion, the evidence for knee clean ups is conclusive: they don’t work and are harmful. The evidence for PRP is suggestive of long lasting benefit with no downside for joint health. Please consider all your options when faced with knee pain, not just the surgical ones and advocate that your friends and family do the same. At Cascade Regenerative Medicine we offer the best non-surgical solutions for joint pain available. Schedule with us today and see the difference.

References:

1. O’Connor D, Johnston RV, Brignardello-Petersen R, et al. Arthroscopic surgery for degenerative knee disease (Osteoarthritis including degenerative meniscal tears). The Cochrane Database of Systematic Reviews. 2022;2022(3):CD014328.

2. Zhang Z, Hu Z, Zhao D, Huang H, Liang Y, Mao B. Arthroscopic surgery is not superior to conservative treatment in knee osteoarthritis: a systematic review and meta-analysis of randomized controlled trails. BMC Musculoskelet Disord. 2024;25(1):712.

3. Barnds B, Morris B, Mullen S, Schroeppel JP, Tarakemeh A, Vopat BG. Increased rates of knee arthroplasty and cost of patients with meniscal tears treated with arthroscopic partial meniscectomy versus non-operative management. Knee Surg Sports Traumatol Arthrosc. 2019;27(7):2316-2321.

4. Rocco Papalia, Angelo Del Buono, Leonardo Osti, Vincenzo Denaro, Nicola Maffulli, Meniscectomy as a risk factor for knee osteoarthritis: a systematic review, British Medical Bulletin, Volume 99, Issue 1, September 2011, Pages 89–106, https://doi.org/10.1093/bmb/ldq043

5. Kahan JB, Burroughs P, Petit L, et al. Rates of subsequent surgeries after meniscus repair with and without concurrent anterior cruciate ligament reconstruction. PLoS One. 2023;18(11):e0294964.

6. Xie YL, Jiang H, Wang S, et al. Effect of platelet-rich plasma on meniscus repair surgery: A meta-analysis of randomized controlled trials. Medicine (Baltimore). 2022;101(33):e30002.

7. Elphingstone JW, Alston ET, Colorado BS. Platelet-rich plasma for nonoperative management of degenerative meniscal tears: A systematic review. J Orthop. 2024;54:67-75.

8. Gopinatth V, Batra AK, Chahla J, et al. Degenerative meniscus tears treated nonoperatively with platelet-rich plasma yield variable clinical and imaging outcomes: a systematic review. Arthroscopy, Sports Medicine, and Rehabilitation. 2024;6(2):100916.