Why I disagree with 2017 knee arthroscopy recommendations

Some of my patients have come to me worried after seeing media coverage of a report about knee arthroscopy, a minimally invasive surgery used to diagnose and treat knee joint conditions. The report, which was published in May 2017 in the journal BMJ, compares the effectiveness of arthroscopic surgery for treating degenerative disease with conservative treatments, such as physical therapy and medication.  

The authors reported that fewer than 15 percent of patients who had knee arthroscopy felt long-term improvement in pain or function. As such, they strongly recommend against the procedure for patients with degenerative knee problems. But I disagree with their conclusions.  

I’m not trying to be a snake oil salesman. Knee arthroscopic surgery is one of the most common orthopaedic procedures, with more than 2 million performed around the world each year. I’ve performed about 5,000 knee arthroscopies during my career, and the vast majority of my patients see improvement afterward. Many doctors in the trenches would say the same.  

While it’s true that not every patient with knee problems will benefit from arthroscopic surgery, the key is to look at each patient’s situation individually. Let me explain why I take issue with the report, how I treat patients with degenerative knee disease, and what you should consider before undergoing the procedure.

Why I disagree with the report’s knee arthroscopy recommendations  

Degenerative knee disease is an umbrella term for conditions in which the cartilage that covers the ends of the bones in the knee breaks down, causing pain, stiffness and limited mobility.  

The authors of the BMJ report define degenerative knee disease as patients older than 35 who have knee pain with or without:

  • Imaging evidence of osteoarthritis, the most common degenerative knee condition
  • Tears in the meniscus, a type of knee cartilage  
  • Locking, clicking or other mechanical symptoms
  • Symptoms that occur suddenly or have been ongoing  

The first issue with the report is that this is a huge category of people. The only patients they exclude are those whose symptoms appeared immediately after major knee trauma and have joint swelling.  

This just doesn’t make sense to me. If I have a 36-year-old patient with a meniscus tear whose X-ray shows no sign of osteoarthritis, this article seems to indicate arthroscopic knee surgery would not help. The weight of medical evidence from my experience says differently. I know repairing or removing a part of a damaged meniscus can improve pain and function.  

My second concern is how the studies were carried out. These were double blind studies, which are a high standard, but the treatments didn’t take into effect the specifics of each patient.  

The study split people with a meniscus tear and no evidence of arthritis into two treatment groups: arthroscopy and physical therapy. People with osteoarthritis also were split into arthroscopy and physical therapy groups.  

But we already know that patients who have osteoarthritis and no other conditions will not benefit from arthroscopy. However, the surgery can benefit patients with meniscus tears. The study is basically comparing apples to oranges.  

Finally, the report recommends physical therapy and medication in lieu of arthroscopy – or in severe cases total knee replacement. But many of these patients have tried physical therapy and medication such as lubricant injections, with no relief from pain. And they may be too young or not quite ready for a knee replacement.  

What are we supposed to offer these patients? They can’t do physical therapy and take anti-inflammatory medications forever. I’d hate to tell a 45-year-old patient with a meniscus tear and a little wear and tear on his knee cartilage that if physical therapy and medication doesn’t work, he must live with the pain until the day he absolutely needs a total knee replacement.

I never blanketly refuse surgery to all who have some degeneration in the knee, or those older than 35 as the article suggests. If something has occurred to the knee that is new and causing pain and it is subject to arthroscopic repair, I will always offer this option to the patient.  

We must offer these patients something, like arthroscopy, that may relieve some or all their pain. The trick is to examine each patient to determine what’s causing the problem, walk them through their options and have an honest discussion about how much pain each option may alleviate.  

How we treat degenerative knee disease

The only true cure for degenerative knee disease is knee replacement. I never treat degenerative knee disease with arthroscopy as the primary treatment, only if there is a new meniscus tear, or a tear of a degenerative meniscus that has become suddenly painful from a new tear-within-a-tear.  

But we almost always start with more conservative treatments, including:

  • Physical therapy
  • Anti-inflammatory medication such as ibuprofen
  • Injections that lubricate the joints
  • Corticosteroid injections for severe arthritis

If these treatments do not provide relief, we may discuss arthroscopic surgery. Arthroscopy can, among other things:

  • Repair anterior or posterior cruciate ligaments (ACL and PCL)
  • Repair meniscus tears  
  • Remove pieces of torn cartilage that are loose in the joint
  • Adjust a kneecap that is out of position  

I started performing knee arthroscopies in 1978, and I’ve learned who may benefit from the procedure and who won’t. I’ll be honest if I don’t think arthroscopy will help.  

In fact, I had a patient several months ago come to me for a second opinion. Her doctor had recommended arthroscopy, but I told her that due to the amount of arthritis in her knee, arthroscopy would not help and she needed a total knee replacement. She decided to do the arthroscopy with her doctor, but ended up having a knee replacement when the arthroscopy didn’t relieve the pain.  

As I said, arthroscopy will not cure or relieve pain from arthritis. However, we may recommend it to slow the arthritis down by removing loose fragments in the joint that can chip away at the cartilage.  

Questions to ask your surgeon before undergoing knee arthroscopy

We all need to be good healthcare consumers and do our due diligence when making medical decisions. Before you decide whether to have arthroscopic knee surgery, ask these questions:  

  • How many knee arthroscopies have you performed? A surgeon’s experience is crucial in knowing who may benefit and who won’t.  
  • What percent of pain will the procedure alleviate? If your doctor says you can expect 50 to 80 percent improvement in pain, you must decide whether that’s worth it. Some people say they’ll live with the pain, while others want to relieve at least some of the pain. Or your doctor may say the procedure can relieve pain for up to three years. For some people, that’s a long time to be free of knee pain. For others, it’s a sign to start considering total knee replacement.  
  • Are there alternative options? If you’re talking to a surgeon, you’ve likely already tried other conservative treatments, such as physical therapy, medications and injections. But it’s always worth asking if there’s anything else to try.  

For arthritis, knee arthroscopy is more damage control than curative. But the majority of patients who get arthroscopy for the right reasons experience relief from knee pain.   Request an appointment with an orthopedic surgeon to discuss whether arthroscopic knee surgery can help alleviate your knee pain.  

Request an appointment with an orthopedic surgeon to discuss whether arthroscopic knee surgery can help alleviate your knee pain.

Knee replacement alternative relieves pain, retains mobility

If you’ve been told you need a knee replacement due to arthritis, it can feel like you’re caught between a rock and a hard place. On one hand, walking around and being active is painful. But while a total or partial knee replacement can relieve the pain and return your mobility, it also means you may no longer be able to participate in high-impact activities like running, jumping and skiing.  

I see many patients with knee problems who don’t want to give up these activities. Though they have painful, degenerative conditions that gradually wear down parts of the knee, they don’t want to transition to a more sedentary lifestyle. They want an alternative to total knee replacement that will let them enjoy being active without pain or discomfort.  

Thanks to a number of medical advancements, we now have an alternative option to treat arthritic knees: cartilage restoration. 

How we treat arthritis with knee replacement surgery

To understand whether you may be a candidate for a knee replacement alternative such as cartilage restoration, it’s good to know a bit about arthritis and how we treat it with standard knee replacement surgery.  

The knee joint connects your femur (thighbone) to your tibia (shinbone). Cartilage covers the areas where these bones come together, allowing them to move against each other as you bend and straighten your leg without too much friction.    

Unlike bones, cartilage does not receive blood flow, so it doesn’t heal as easily. As we grow older, cartilage tends to wear down, causing inflammation and pain as bones rub against each other without the protective padding of cartilage. This “wear and tear” is called osteoarthritis, and it’s most common among people older than 50.  

Osteoarthritis is often treated with knee replacement surgery — also known as knee arthroplasty. In this procedure, a surgeon replaces arthritic parts of the knee with prosthetic parts. With total knee replacement, a surgeon basically installs an entire artificial knee, removing arthritis in the process.  

We perform hundreds of knee replacements each year, and the demand for this surgery is growing. A 2007 study found that U.S. surgeons performed about 700,000 knee replacements every year, but that’s expected to rise to nearly 3.5 million procedures by 2030!

Could you be a candidate for cartilage restoration? Let's find out.

Unfortunately, most people with osteoarthritis will eventually need a total knee replacement. So here’s the million-dollar-question for orthopedic surgeons: How long is it worth it to maintain a patient’s knee function with partial replacement, given that they’ll likely need total knee replacement in the future?  

Until recently, that was a hard question to answer. But for people with certain kinds of arthritis, we now have an alternative to total knee replacement that makes a temporary fix more worthwhile. By combining aspects of sports medicine with partial knee replacement procedures, we hope to give these patients as many active years as possible.  

How cartilage restoration relieves pain and retains mobility

Ligaments connect bones together in a joint. A standard knee replacement removes two ligaments: the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL). Losing these ligaments means your body loses its ability to know exactly where the knee joint is in relation to its other parts – a sort of “sixth sense” known as proprioception. Proprioception is key to movement. It lets you perform motor tasks like walking without having to think about them. Removing the ligaments in your knee throws that sense out of whack.  

In cartilage restoration, we replace arthritic knee cartilage with cartilage from a healthy part of the joint or with a synthetic cartilage-like substance. This way we can patch problematic areas without removing the ligaments. It’s like fixing a pothole on your knee. This procedure, called an autograft arthroplasty or an osteochondral autograft transplant, allows people with arthritis in a certain part of their knee to remain active without the mobility restrictions of a full knee replacement.  

Surgeons can even reconstruct ligaments that have been damaged by trauma alongside cartilage restoration, giving people with torn ligaments–a common sports injury–new hope of being active again.   

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Who is a candidate for cartilage restoration?

Whether someone is a good fit for cartilage restoration depends on the extent of their arthritis and how well they’ve responded to previous treatment.  

If multiple parts of the knee are arthritic, as is often the case with osteoarthritis, cartilage restoration isn’t likely to help for very long. These patients would only have a brief period of reduced pain and improved mobility before needing another surgery. Instead, we would recommend a total knee replacement.  

For someone to be a good candidate for cartilage restoration, they should only have arthritis in one area of the knee, making it easier to replace and more likely to succeed.  

We prefer to treat knee problems with noninvasive methods before recommending surgery. This can include:  

  • Braces: These supportive wraps take weight off arthritic areas
  • Orthotics: Changes how you distribute weight or the alignment of your foot to reduce stress on your knee
  • Physical therapy: Strengthens muscles and helps mitigate further damage by increasing the knee’s flexibility  
  • Steroid injections/medication: Medications taken orally or by injection can reduce inflammation in the knee joint, relieving pain  

Not everyone will benefit from cartilage restoration. Some people have arthritis so severe that it can only be successfully treated with a total replacement. But if you’re young (or young at heart), eligible for a replacement alternative and want to run, ski or play sports for years to come, this kind of procedure can help you live an active life without an arthritic knee getting in the way.   

Schedule an appointment online or call 202-877-6000 to see if you could be a candidate for cartilage restoration or another alternative to knee replacement.