Has a surgeon recommended knee arthroscopy as a treatment for your arthritis? Confused? Read this commentary for clarification.
A Clinical Practice Guideline (CPG) was published in the BMJ, clearly recommending that knee arthroscopy not be the treatment of choice for those with knee osteoarthritis. It could not be any more clear: “We recommend against arthroscopic knee surgery in patients with degenerative knee disease.”
The CPG was the result of a review of previously published clinical research studies on the topic, called a Metanalysis, where each study is assigned a level of strength in terms of evidence (parameters of the study, number of subjects, how it was conducted, etc) and then it’s results were factored into a pool of similar studies, in order to come up with a clear recommendation.
You can follow this link to the study, with infographics. Most items have drop-downs or pop-ups with additional explanations when you click. For example, clicking on the recommendations presents another chart with a “Comparison of Benefits and Harms” with each having a separate explanation by clicking “More v” beside it.
What is Knee Arthritis?
Osteoarthritis of the Knee, commonly called Knee OA, is a degenerative condition in which the cartilage of the knee is torn, damaged, chipped, or worn away. This leads to chronic inflammation and swelling, which then leads to knee stiffness and weakness.
What is Cartilage?
There are two different types of cartilage. One is rubbery. Not to gross you out, but it’s the “gristle” when you’re eating fried chicken and get a bite too close to the joint. The other looks like white teflon with a very slight rubbery feel to it, and is on the end of the bones. The first is Meniscal Cartilage, which helps seat the knee in place, stabilize it, and help with twisting, pivoting, bending, and some shock absorption. The latter is Articular Cartilage, which covers the ends of the bones.
Why Does it Degenerate?
One word generally covers it: Age. Knee Osteoarthritis is the byproduct of age, along with other factors. The articular cartilage starts to blister, crack, and wear off, while the meniscal cartilage goes from firm and rubbery, to more like a ring of Play-Dough. Weight, previous injuries, and genetics can hasten the process.
What is Arthroscopy?
A surgery using an arthroscope (a small device with a camera, inserted into the joint), also called “scoping,” has been the standard of care for years when one suffers a tear of a mensicus, or a crack or blistering of articular cartilage. Cartilage doesn’t heal so arthroscopy allows a surgeon to gently shave and smooth surfaces, so that the jagged, torn, edges, don’t create more inflammation and problems.
Why Wouldn’t I Have My Knee Scoped?
If you’re young and tore your meniscal cartilage as a result of a sudden pivoting movement, then arthroscopy is an effective treatment. However, if you’re older (nearing or past 50 years old) and you can’t trace your problem to a specific injury, then there has been research evidence for some time indicating that at the very best, arthroscopy provides 18-24 months of relief before the knee ends up in the same state as it was before surgery.
During the time that this limited view of arthroscopy was becoming more clear, the effects of physical therapy were also being studied. When applied directly to counteract the results of knee OA – stiffness, weakness, and lack of agility – physical therapy was being found, over and over, to be an effective treatment. It’s also not invasive, and relative to surgery, is very inexpensive. More importantly (at least in my mind) the effects are lasting, and when the patient is trained well, he can troubleshoot and treat himself down the road, without having to return to the doctor.
Is It Wrong to Scope a Knee Past 50?
Not in all situations. Sometimes the limited benefit, especially when combined with therapy, can be just what a patient needs. It’s a case-by-case basis though.
Example: One patient of mine a few years back was a Big XII Conference Football Official. He had played professionally and one of his knees was arthritic. He was just about 2 seasons from retiring, and the lack of mobility that would have come with a knee replacement would have prevented him from finishing his career. He underwent arthroscopy as soon as the season was over, and started a very slow, well-planned, steady physical therapy regime that was altered each visit so that he could continue his forward progress, without losing yards. He was a Back Judge, so I had to put that joke in there.
Anyway, over the off-season, the scope and therapy bought him the two additional seasons that he needed, and then some. To my knowledge, he has not yet returned for a knee replacement, and it has been several years.
What If Arthroscopy Was Recommended for Me?
Any good surgeon should be able to field your questions and concerns without being insulted or suprised. Any good surgeon would never be offended if you put off surgery for a second opinion, or to give you time to see a physical therapist. If your surgeon is upset by your questions, concerns, or a desire to delay surgery for therapy, you should definitely get a second opinion! Go with a surgeon that comes well-recommended by your therapist or primary care physician. Your PT is the “end user” of the orthopedic surgeon’s work. You’ll always be better off doing it that way rather than getting an appointment with someone you saw on TV.
Feel free to contact me with any questions. Good luck!