Sunday, 24 June 2012

Knee arthroscopy in arthritis: an evidence-practice mismatch


Osteoarthritis, where the cartilage lining a joint gets worn down, is common (Australian data, UK data, US data). Most people will get it if they live long enough, and the knee joint is commonly affected. There is little that can be done to repair or reverse this process, and a related paper that covers many osteoarthritis treatments shows that most of the things we do (analgesics, anti-inflammatory medication, injections etc.) only provide temporary relief, and many of them hardly work at all. Treatment, if severe enough, often means a knee replacement.

Knee replacement surgery is major surgery so it is only reserved for those with severe osteoarthritis. So what do surgeons do with patients who have knee pain and mild or moderate arthritis? They often do an arthroscopy: a low risk, day-only procedure that pays well and seems to work some of the time. Hundreds of thousands are done in the US every year, and in my state the rate of arthroscopy is high and is rising.

The trouble is: it doesn’t work. Most patients still have pain, some get worse, and about 20% will end up having a knee replacement within 2 years anyway. Feel free to skip to the last paragraph for the Bottom Line, or read on for the details.

There are many studies that show that some people feel better for a while after an arthroscopy, and this matches the experience and opinion of many surgeons, but that does not constitute evidence that the arthroscopic procedure (cleaning up the knee and removing debris and torn meniscus fragments) actually improves the patient’s condition. In clinical trials comparing arthroscopy with anything else, arthroscopy never wins.

An early study showed that arthroscopy was not as good as just washing the knee out with a needle, but the bombshell article from Moseley came in 2002, in the New England Journal of Medicine. The researchers compared arthroscopic debridement (‘cleaning up”) and lavage (‘washing out’) with a sham procedure. A sham procedure, in which an incision is made and the patients are blinded (unaware of which treatment they received), is a good way of controlling for the placebo effect of surgery. The researchers measuring the outcomes did not know what group the patients were in, and when they asked the patients which group they thought they were in, they had no clue. So this study was randomly allocated, had a good placebo arm, and involved effective blinding of the patients and the assessors. They measured many outcomes (pain and function) at several times points over a two year period and found that the arthroscopic (active) groups did no better than the placebo group for any outcome at any time point. Criticisms, centred around the ways they measured pain, or on the age or gender of the patients (for example) seem a little desperate.

A later trial from 2008 comparing arthroscopy combined with medical management to medical management alone (without a sham procedure) addressed some of the criticisms of the earlier trial by using validated outcome scores, by including more women and younger patients, and by excluding those with deformity. They showed no difference between the two groups for any of the outcomes, except for a brief improvement in the operative group post-operatively, which was an expected result of the placebo effect of surgery.

When faced with evidence like this, many surgeons state: “Everybody knows that the procedure doesn’t work for everybody. It works for some, and the trick is to do this operation on the subgroup of patients for which the surgery will work.” The problem with this is the reason why it works in some people. It is quite possible that some people improve because of fluctuations in the disease, or expectations, or concomitant treatments, and not because of the procedure. Some patients improved in all of these studies – that doesn’t mean that they improved because of the surgery. The only conclusion we can make on this point is that the patients who had the surgery were no more likely to improve than the patients who did not have surgery.

The subgroups usually targeted by surgeons are those with mild arthritis and those with meniscus tears (or mechanical symptoms). Both of the studies above looked at different subgroups of arthritis severity (and excluded the severe cases) and found no correlation. In Moseley’s article, 172 of the 180 patients had mechanical symptoms and most of the patients in the later article had their torn meniscus removed. And the procedure still didn’t work. The arguments about age and gender are equally invalid, as there is no difference in the results in these groups, and there is no reason to expect a difference. Every way you look at it in every study, arthroscopy doesn’t help the patients any more than NOT doing an arthroscopy, for every outcome in every study.

Yet surgeons still say arthroscopy works for meniscus tears in younger patients. If you want to make the argument that arthroscopy will work in patients aged between 45 and 64 with mild arthritis and a confirmed meniscus tear on MRI, you will need to do a clinical trial to test that hypothesis, rather than just assume that you can pick the winners. Oh, wait: that study has been done. In a 2007 study from Sweden those exact patients were randomised to either an arthroscopy or physical therapy alone. No advantage was shown for those treated with arthroscopy, for any outcome measure, at any time point.

What about pain from arthritis behind the knee-cap, maybe there is a role for arthroscopy for those patients? In this initial study, and the later follow up study, there is no advantage in doing an arthroscopy in those patients.

The Cochrane review of arthroscopy for knee osteoarthritis can be accessed here.

The bottom line
If you have pain and osteoarthritis in your knee, then regardless of the kind of symptoms you have (‘mechanical’ or not), regardless of what your X-rays look like, regardless of where the arthritis is, regardless of how bad your pain is, and regardless of whether or not the MRI scans show your meniscus to be torn, having an arthroscopy will not increase your chances of getting better. It will not arrest or reverse the degenerative changes in your knee, nor will it “create an environment in which healing may occur” (as one surgeon states in his reports in order to justify the procedure). At this point, most patients say: “But what can I do for the pain, it’s really bad?” All I can say is that the severity of your pain does not change the fact that the operation does not work. You will have to try something from the list of (much less expensive) non-operative treatments available. I will say what surgeons seem reluctant to say: “I am sorry, but for this condition, surgery is unlikely to provide any benefit over the non-operative alternatives.”

Addit 19 Oct 2013:
In a multicentre randomised trial published in the New England Journal of Medicine in 2013 (here), patients aged 45 and up with mild to moderate osteoarthritis and a proven meniscal tear were randomised to arthroscopy or physical therapy. The results at 6 months by intention to treat analysis were not statistically or clinically different.
Within 6 months, 6% of those randomised to surgery did not have surgery, and 30% of those randomised to physical therapy had surgery. However, when analysing this study in an "as-treated" manner, it is open to bias. For example, those who believed surgery was better, or who had friends who had surgery who felt better, might not have been "satisfied" with non-operative treatment and were only satisfied when they got what they wanted. This is why blinded, placebo trials are much more effective at differentiating effectiveness between treatment options.

64 comments:

  1. Knee replacement surgery can be extremely painful. But now there are many knee replacement alternatives that help to relieve pain and correct the problem faced.

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    1. Tahera,
      You are correct, there are many alternatives to knee replacement surgery, and most people will agree with me that knee replacement surgery should be the last option. Unfortunately, many of the alternatives available don't actually work - at least not when pitted against a placebo in scientific tests.
      Your link goes to a site that suggests stem cell therapy. My earlier post (http://doctorskeptic.blogspot.com.au/2012/04/stem-cell-therapy-still-science-fiction.html) provides a perspective on stem cell therapy. It has never been shown to be effective for osteoarthritis.

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    2. I had a torn meniscus and osteoarthritis in my right knee. I started with an injection of cortisone. That helped for exactly 10 days. I then had arthroscopic surgery to repair the meniscus and clean up the arthritis. The pain after that surgery just increased. Seven months later I opted for total knee replacement, that was Sept. 2012. I have had no pain relief whatsoever... the pain just continues to increase. I also have a torn meniscus in my left knee and arthritis in it as well. There is no pain relief for me... and I will not go the surgery route again.

      I hear I am the exception to the rule regarding the knee replacement, that most people do get relief with it. I have personally talked with about 12 to 15 people that have had total knee replacement, they all sing it's praises. I just happen to be the one person it hasn't helped.

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  2. This is an interesting article regarding the ethical issues surrounding sham surgery, definitely worth a read -

    http://www.ncbi.nlm.nih.gov/pubmed/14986782

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  3. What about the fact that a torn meniscus (fixable with arthroscopy) induces in time knee arthitis ? Is this true? Can arthroscopy stop the arthrits?
    Ioana

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    1. My meniscus surgery (removal of 50% of the meniscus and debridement) allowed not only the progression, but the rapid advancement of arthritis producing joint deformity and much pain. TKR is the only solution now, I am told.

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    2. The question you raise is an interesting one: does arthroscopic meniscectomy increase the progression of arthritis. Like many things, I could make a theoretical argument for it, but I am not aware of any hard evidence that this is the case.

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  4. I had osteoarthritis and two of my runner mates advised me to have a stem cell therapy, which I had with my ortho surgeon, Dr Grossman. I was about to believe that the treatment was not for me. My friends only waited 2 months to get the final beneficial results and I was on my fourth month that time. I called my doctor and he said that some patients may take several months to get the effect of stem cell treatment. He also advised me few things to help boost its effect like the suitable exercises for my knees. On my 5th month, I noticed some changes. The level of pain dropped, as well as the soreness. The benefits of having stem cell therapy took effect on me on my 6th month and I really think it was worth waiting. It has been 4 years now and I am still joint pain free, despite of my very active lifestyle. I am a runner and a ballet dancer. :)

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    1. Thanks Kirsten,
      Unfortunately, the causal link between the injection and your symptomatic improvement is weak. Many things happened to you in those 6 months, and knee pain is unpredictable and variable over time, so to say that the improvement you felt at that time was due to an injection 6 months earlier might 'sound' right, but no such causal link has ever been shown previously, and there is no biological plausible mechanism for such an association.
      I think we need to be more objective (read: scientific) about things so that we do not jump to endorsing every apparently effective treatment, and then paying for it at the cost of true therapies.

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  5. There may come to a point where there is no alternative option than Knee surgery. It's important to know that with medical breakthroughs today, knee replacement has become a routine procedure and is now relatively risk free.

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    1. Thanks, but I respectfully disagree. In the case of osteoarthritis and elective orthopaedic surgery, there is always an alternative option to knee surgery: not having knee surgery. The failure of non-operative treatments does not make and ineffective operation become effective.
      Regarding knee replacement surgery, it has certainly become commonplace, but is still plagued by a high rate of patient dissatisfaction (up around 20%) as well as persistent, but low, risks of infection and venous thromboembolism.

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  6. This comment has been removed by a blog administrator.

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    1. Weird. I published this comment by Anonymous (above) but it was "removed by a blog administrator" that wasn't me. I can't fix it so I have pasted it below, and then I will reply afterwards:

      Current Med J Aust 2013; 199 (2): 100.:
      Wayne Adams, Manager, Safety and Quality in Health Care
      Benefits Management, HCF, Sydney, NSW.

      "In their editorial, Buchbinder and Harris conclude that “The use of arthroscopy for knee osteoarthritis has been allowed to continue, exposing patients to an intervention that is at best ineffective, and at worst, harmful”

      "It would be fair to say that the patient’s view of the benefits of the procedure is a leading indicator and should form an integral part of assessing the success of knee arthroscopies for osteoarthritis."

      Rachelle Buchbinder and Ian A Harris, Med J Aust 2013; 199 (2): 100.
      "In reply: We thank Adams for providing private health insurance data that confirm the continued use of arthroscopic surgery for patients with osteoarthritis."

      "We do not doubt that many patients are happy with the results of arthroscopic knee surgery, but this does not necessarily imply that the surgery has had any specific effect, as satisfaction rates are high after many ineffective placebo treatments. Indeed, high-quality randomised controlled trials have consistently failed to demonstrate clinically relevant self-assessed benefits of arthroscopy compared with sham surgery1 or non-surgical comparators.2-4 Potential risks of arthroscopy are also an important consideration."

      An interesting, and revealing exchange. I am still baffled by Mr Adam's managerial position at Safety and Quality in Health Care. He is not working at the Headquarters of Placebo, so... yeah. Baffled.

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    2. Thanks,

      An interesting exchange, because Mr Adams was referring to patient satisfaction surveys - something that I use regularly and that I consider important. However, patient satisfaction surveys only measure perceived outcome, and if that outcome is the same with placebo treatment, then we have a problem.

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  7. I just had an Oxford implant put in my right knee after 3 previous scopes - over a 9 year period. After the 3rd scope, I felt better for a few months - but the pain returned worse than ever. My doc said that when she saw my knee during the Oxford surgery that is was apparent why I was in so much pain - my bones were grinding away. My question is this: why do they start cutting stuff away when they know what will eventually happen?
    I have the utmost respect for my doc and I trust her 100% - but my knee still doesn't feel right 3 months after the Oxford. I exercise every day - recumbent bike, stretching, weights, etc. I still can't squat or kneel at all - will my knee ever be fully functional?

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    1. Thanks Paul,
      You ask two separate questions:
      1. Why do doctors do surgery that doesn't work or even make sense (like arthroscopy for OA)?
      To answer that properly would take a whole blog - this blog. In general I do not believe that it is a conscious decision to deceive or harm. Doctors believe the treatment works because that belief is based on biased evidence from the literature and, most of all, from their own eyes. Many doctors who step back and think about it start to realise that a lot of what they do is placebo, but continue to use it as legitimate treatment (I am surprised at how many doctors know that their treatments are placebos but still use them).
      2. Why isn't your knee better?
      A tougher one, and a little outside the scope of this blog. Knee replacements are painful for some time afterwards. At 3 months you are only in the early stages. Also, knee replacement don't do as well as hips, and many remain painful. Also, you cannot get normal function from a knee replacement, so think about where you have set your expectations.

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  8. Hi I had and torn Menicus and had surgery it's been over a year . I'm still in alot of pain it's getting worse do you think I might need a knee replacement . I had a friend with the same problem he got the knee replacement done he says he feels much better .can I ask my doctor for the surgery or is it up to him in alot of pain

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    1. Firstly, I apologise but this is not an advice column. My ability to diagnose and treat you is hindered by the fact that I know very little about you or your knee.
      Secondly, in my experience nearly everybody who said they had a friend with the same condition didn't. Your friends are trying to help but usually they do not.
      Thirdly, having said all that, I can tell you that you don't need a knee replacement for a torn meniscus; you need it for arthritis. If you have arthritis, the meniscectomy was a waste of time. If your surgeon has offered a knee replacement as a reasonable treatment option, it is up to you to decide, based on a sound assessment of the relative risks and benefits as they apply to you, taking advice from reliable sources (like your doctor, not your friend).

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    2. You said, that you do not need a knee replacement for a torn meniscus, you need it (depending) upon the degree of arthritis. My question is, I have moderate meniscus tear (horn tear and through the body segment with minor extrusion) with moderate OA in knee, will (or rather can) the current meniscus tear contribute to the worsening of the OA of the knees? Certainly, it would seem from everything that I am reading including your wonderful commentary that having surgery for the tear would only expedite that OA but conversely is the same true and I am screwed either way? I can live with the god damn meniscus pain (which is 24/7 but fluctuates from severe to almost nothing) if it means "cutting and snipping and thus removing meniscus cartilage will lean in favor of negatively expediting the OA? My final question and forgive for the length, is it possible through yoga (which actually cause through wrong yoga the tear, then probably underlying mild OA to moderate), other physical exercises (walking, biking) and MSM, K2, intense Omega DHA, etc., including meditation help heal the tear? What does seem to be working is the natural synivisc injections? Thanks for your time.

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    3. If the meniscus is torn, it functions less effectively and may contribute to OA. Removing the torn piece, however, doesn't help that, and depending on how much is removed, it might even make it worse.
      For all the other things you mentioned, you would need to look for high-level evidence of their effectiveness (you can find a post on my site for synvisc), but once you have OA, there are no good treatments to reverse or slow the progress - only to make you feel better for a while. We are only lucky that progression is naturally slow anyway.

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    4. Thank you so much. I appreciate your quick reply and the breadth and depth of your responses throughout.

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  9. I had a botched arthroscope on my right knee by a well known orthopaedic surgeon in Melbourne about 15 years ago while in my 30's, and have had much worse pain with it since. Both knees were in the same condition just before the operation, and the plan was to do one knee and then the other. A lateral release was done and roughness behind the kneecap smoothed. The surgeon explained that I just happened to be at the worst end of the recovery spectrum. Prior to the operation the surgeon had explained that he did these operations everyday and that there was no reason why I wouldn't be able to run, play tennis etc after the operation. In fact, by doing the operation then, he said it would help prevent arthritis later . I naively didn't get a second opinion. After months on crutches and having considerable intermittent swelling, I tried to have another surgeon in Collins St look at it but he would not comment on another surgeon's work. I eventually found a leading orthopaedic surgeon who was brave enough to state that the operation should never have been done, and that a lateral release should be anchored on the other side, which it wasn't. As the pain in my knees, most particularly my right knee, has heightened this year, I have decided against the cortisone-arthroscope- knee replacement process, opting to have a series of PRP injections instead . The left knee, which was never operated on, is manageable now, but the right knee is much slower to improve. I remain hopeful, as I am terrified of knee replacement surgery. Apart from the possibility of infection, I worry about the possibility of continued pain, and the prospect of having a knee which is probably functional for everyday living purposes, but will not allow me to do the non-impactful activities I love like pilates, yoga, brisk walking and cycling upright on a stationery bike. I don't want to become a sedentary old woman getting around slowly in flat, orthotic based shoes. How very depressing!! So I will persevere with the PRP's, and perhaps move to PRP with growth factor and then if that doesn't do the trick, stem-cell treatment. I need to have hope, and have seen encouraging stats. I have always made such an effort to keep fit and active, and I without that, my life will lose a great deal of it's mojo. There are both emotional and physical effects.

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    1. Thanks for commenting. If you have osteoarthritis, then the arthroscopy, the "smoothing over" (sounds so good, doesn't it?) and the lateral release are all a waste of time. Unfortunately, the evidence for PRP or stem cells providing any real benefit is just as bad (see my other blog posts here http://doctorskeptic.blogspot.com.au/2012/06/platelet-rich-plasma-continues-to.html and here http://doctorskeptic.blogspot.com.au/2012/06/platelet-rich-plasma-continues-to.html). The good news is that you won't need orthopaedic shoes, because they are also ineffective for knee OA.
      If you are doing pilates and yoga and brisk walking unaided, then you probably don't need a knee replacement.
      But don't fear a knee replacement just because of the complications. Weigh the potential complications against the potential benefits. For bad OA, it is much more effective than any of the treatments you have tried so far.

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  10. i do not have osteoarthritis in my knee, but i do have anterior and posterior meniscus tears with a fluid cyst. the problem presented itself quite suddenly with a great deal of swelling and pain. in this case, can arthroscopy, which my orthopedist has suggested, be helpful?

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    1. Arthroscopy is used for many different things. I cannot and should not give personal advice, particularly without all the information. I suggest you discuss it with your treating doctor and remember that you can always seek a second opinion if you are not satisfied.

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  11. Dear Dr. Skeptic, I can't imagine how arthroscopy could help knee OA--but what about Regenokine? If it's helping Kobe Bryant--it must have some merit? Can you prove that it does not? We aging but still fit, active and lovely baby boomers with knee OA must have something to hope for! I am bone-on bone in some focal areas (unicompartmental Patellar OA) --and I still run and hike and dance---although my ortho says if I keep on, it will make my OA worse and worse. What to do? Anyway, thanks for your blog.

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    1. Thanks, your post raises several issues that I would like to address.
      1. "if it's helping Kobe Bryant-it must have some merit?". The answer to that question is no. If you read my blog, you will know that just about every treatment you can imagine giving, from stem cells to copper bracelets, "helps". Usually, however the improvement seen is one or more of: natural history / fluctuations, placebo response, or concomitant treatment, and many of these things, including platelet rich plasma and stem cells are no better than placebo.
      2. "Can you prove that it does not?" I shouldn't have to. Otherwise every half-baked scam treatment out there will be accepted because we have not proven that it does not work. The burden of proof is on those who promote the new treatments. Given that similar treatments HAVE been shown to be no more effective than placebo, I am going to go out on a limb and sya that the same will go for Regenokine.
      3. "[we] must have something to hope for". No we don't, but if it was necessary for us to have something to hope for, that hope does not provide proof of effectiveness
      4. Keep exercising. You ortho has very little evidence that this is making your knees worse and it is probably helping you in other ways.
      Hope this helps, sorry if it sounded harsh.

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  12. Eileen Plunkett15 December 2013 07:42

    I am 77, suffered a torn meniscus, had xray, MRI and finally arthroscopic surgery. It is now 2 and 1/2 month since surgery, my knee hurts much more than prior to surgery. Doctor gave me a cortisone shot two weeks ago, no help at all. Pain goes from knee to ankle. Riding recummbent bike every day for 30 minutes and taking chair exercise class (this class initially helped but now it seems to be making things worse). Prior to surgery my pain level was one of discomfort and not all the time. My primary suggested only a cortisone shot but of course surgeons recommend what they do, cut...I would never tell anyone to get AS if they ask me. I wish I had never had it. All the anti inflammatory (I had tons of cartilage floating and hanging in the joint when they showed me the dvd) meds help little and also make me nauseous if I take them too often. I feel that all the cutting and vacumming of the cartilage made my knee worse because (and this is strictly a lay person's opinion) all the cartilage hanging and floating was actually buffering the bones and his cutting and sucking took that away and that is why I have such an increase in pain and stiffness. Sometimes when I get out of a chair, if there more than 30 minutes, I cannot walk for the first few minutes and use a cane for balance....prior to this I was extremely active, going to the gym three days a week, walking around my community and riding my bike every day. My vote for AS is a large NO!!!

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    1. Thanks. I think it is fairly well established that arthroscopy is no better than placebo for an arthritic knee at your age. However, arthroscopic surgery should not be completely discouraged, because for some conditions (not arthritis) it can be helpful.
      I would also point out that the cortisone injections are also a waste of time.

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    2. Part of my question that I posted a few minutes ago, includes a query./comment by Eileen. Is in fact however, painful more cartilage floating around due to a torn meniscus and OA knees acting a type of cushion nonetheless than cutting, sniping and removing?

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    3. Not sure of the exact question, but if there are fragments floating around your knee, they are not providing any cushioning. Also, unless they are getting jammed in the knee (locking) they are probably not doing a great deal of harm either.

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  13. I have had the Mako Knee partial done on my left knee 2 years ago and still in pain. I have Osteoarthritis in both knees. They gave me the cortisone injections in the left knee and even a more expensive shot in my left knee. All in all still have pain and knee does not feel right nor can I kneel. They are thinking of removing scar tissue arthoscopicly to see if that will fix the issue or is it worth doing?

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    1. I shouldn't really give specific advice, but I can state that in general, injections are not helpful for knee OA, no matter what it is: stem cells, platelet rich plasma, hyaluronic acid or steroids. And on average, arthroscopy is probably a little less useful than an injection.

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    2. I am sure you've learned of the Finnish study published this week in the NEJM showing that knee arthroscopy is not beneficial for many (if not most) patients. In this case, the subjects were only operated on (or received sham surgeries) if they did not have osteoarthritis. I was to have knee arthroscopy tomorrow, but realized I'd been negligent in not asking more questions about alternative treatments, etc., as well as getting a second opinion. I've postponed the procedure. Do you have any advice about finding a doctor for a second opinion? So many orthopedic surgeons are... well, keen to do surgery, and I'd like to find a doctor who's a bit of a skeptic himself.

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    3. A new blog post is coming regarding the new study.
      The only advice I will give is to get more opinions: 2nd, 3rd, 4th, whatever. Don't be worried about offending the doctors; we are used to patients wanting another opinion and we often recommend it if the patient is not satisfied.

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  14. I have had four othroscopys during my 45 years, two when I was 14 years old and two last year. I have meniscus tears. I have been pain most of my life and even walking gives me pain. I was told by my surgeon I am too young for a knee replacement and have heard good and bad stories about these. What other solutions are there?

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    1. There aren't many invasive alternatives. Injections (stem cells, platelet rich plasma or steroids) are no better than placebo. The best advice is anti-inflammatory and simple analgesic medication, activity modification and acceptance. If these are not enough, a knee replacement is an alternative.

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  15. Hi ,
    thanks for your views Dr Skeptic.
    I am aged 49 with mild osteo, male height 172 cm weight 88 kg My left leg is little deformed. my mechanical axis is deviated 2.5 on right leg and 3 cm on left. my right leg has no problem , but left was hurting after i run for 5 to 8 km. I have taken x ray, MRI etc.Physio after careful examination says it can corrected non invasively by doing proper exercise and weight reduction. Surgeon recommend HTA, so that I can resume my running.my cartilages are fine otherwise and I do not have much pain
    Can you pl give your views

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    1. Depends on what is wrong with your knee. If you have degeneration of the medial compartment, an HTO is an option. You need to discuss this with someone who can see your images and your knee.
      Having said that, keep your expectations reasonable. If you are 49 and have knee pain after running 5-8km, your knee is better than mine, which hurts after about 2km.

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  16. I am from India , seen reputed ortho Surgeon. upon through physical examination, X ray and MRI, he suggested that intensive 3 to 6 months Physio therapy may
    help quite well. But his charges are quite high, I am in dilemma. I have degeneration in the medial compartment only.

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    1. Physio may help, but there is very little evidence that it will. If you can cope with analgesics alone, then spend your money on something else.

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  17. hello i am 37 years old and grown up my right knee has dislocated my whole life like 2-4 times a day with any squatting bending lifting anything heavy,which i thought it was normal due to the fact you never went to the hospital unless you was dyeing back in them days.anyway i learned to put it back in and go on like no big deal .back in 2006 i was jumping on a trampoline once i went up my knee popped out and when i came down everything was cut ,so i had to go under surgery to fix everything,but one problem happened i woke up during surgery ,yes i said woke up,for some reason the stuff they use to knock you out only worked on me for like 10 mins and i came to ,all i remember is seeing the drill and hearing it then the doc and nurses screaming and they knocked me back out again,i had trouble with my right knee for sometime after that it just didn't work right,so i did therapy for 1 year ,2007 went to work and slipped on black ice had what they called bone bruising and some bleeding and now factor hip with a small tear in the acl,doc just had me do more therapy for the next year,so after all the therapy and surgery didn't change i still was having problems with right knee and hip,so went to another ortho doc in 2008 he said do therapy for awhile and lets see what happens on a mri it showed i still had the bone bruising and little tear on the acl and my hip was healing,2013 went to ortho surgent he did mri and xray on my right knee and said i have server ostoe.in right knee and also have some bleeding in there and a bone spur in there,he did a scope and cleaned it out also smoothed and also loosen out side tendent ,he also noticed that my right leg is 38 on a inch shorter then my left,i have always walked with a limp but never knew why til now,he also said i have no cartilage in my knee iam bone to bone,before he did the scop he did orhto visk injections but only made things worst,sorry for the story but what you to wrap your head around it,so question for you after doing everything i am getting ready to go back to him to have a talk about doing a part knee replacement or a full,taking into the fact i am 37 what would you do ? what are pros and cons to having this done ? also what to thank you for posting this info not to many people straight to the point ,and your right i felt like the scope thing was a waste of time and money and only made things worst ,i feel even more unstable now then before.thanks for you time.

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    1. Thanks. If you truly have "no cartilage" in your knee, arthroscopy and injections (of anything) are a waste of time. The decision to have a knee replacement (total or partial) is a big one and ultimately needs to be your decision, based on your acceptance of the risks and likely benefits. Discuss it with your surgeon and get more opinions and information if you like. Apologies, but it is too complex for me to give you any more advice on this.

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  18. I am 78, a former marathon runner, now a jogger. I am dealing with torn meniscus, baker's cyst, a bone bruise and very little cartilage (basically bone on bone) My ortho said scoping would only give me relief from pain for a short time. A knee replacement is really the only option; but I was told I would not be able to jog afterwards. Since exercise is important to me, I am choosing to do nothing at this time. It is a pain to not be able to squat and do deep knee bends, but as long as jogging doesn't hurt (only if I'm going downhill) I am going to continue it. The ortho says if I do the knee will get worse, but this is my choice. Just wanted to share my story

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    1. I agree with you. Arthroscopy will not be helpful, and a knee replacement is a big deal, and probably not necessary. Keep jogging, it got you this far and the evidence that it will make things worse is not good.

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    2. Sorry for a string of queries.comments here. But is it indeed true as you say that light jogging will not worsen conditions such above?

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    3. Yes. And there are other benefits (beyond your knee) from regular exercise.

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  19. Thanks Doctor! Appreciate your comment. In 1984 I broke my arm while marathon training. The ortho was very much against running and jogging and told me how bad it was for my bones. However, after I healed from the surgery he was so impressed with my rapid healing and told me "Keep on running."

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  20. I had one knee replacement. The other knee was sore but bearable. I opted for PRP trying to avoid the operation. Now the pain is unbearable and I am actually looking forward to the operation

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  21. Dear Dr. Skeptic, What do you think really causes knee osteoarthritis? I've heard the "wear and tear" theory---overuse, improper use--and I've also heard that it doesn't matter what you do--- its just a genetic problem. Also, do you think there is any significance to, or different causation inferred, if the arthritis is confined entirely to the patellofemoral compartment? Thanks for any info,
    JK

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    1. Probably a mixture of things.
      For example, medial compartment osteoarthritis is very common, particularly in some races, but some people never get it. Also, it is very common to see bad arthritis in someone who has previously had their meniscus removed, or who had a fracture in the knee joint. Patellofemoral arthritis can be associated with knee injuries or abnormal alignment. Cartilage ages and loses its mechanical properties as we age, but injuries that disturb the mechanics of the knee make cartilage wear out faster.
      I tend not to dwell on it. I am more interested in what works. I am not smart enough or young enough to find the answer to that question.

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  22. Thanks for your reply. Yes, I understand. Sometimes the "why" doesn't matter so much. Unless of course, the causative factors are still in progress and there is something one could do to modify them so as not to cause more damage! If you have advice about this, I'd appreciate hearing it. Since you are apparently not one to be easily impressed by new and untested treatments, if science ever comes up with a treatment that you will approve of, I will take note!! Hope you will post to your readers if there is something new that you think promising.

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  23. Found this thread to be interesting to read. I'm 35 and facing my own knee problems. Had arthroscopy 5 years ago and already having problems again. Seeing a different surgeon now and the osteoarthritis has gotten bad enough he's mentioning knee replacement. Recently had some cartilage snap off from behind the knee cap (we think, next step is MRI), but we are going through the "conservative phase" of treatment right now. Gives me time to weigh my options and think about the next steps before my next appointment. I'm thinking another arthroscopy isn't going to do me any good.

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    1. I'm thinking you might be right.

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    2. I am 63 years old wIth a moderate horizontal menicus tear with moderate arthritis. I am a 4.0 tennis player and in the past played three times a week. I was scheduled to have arthroscopic surgery but cancelled because after reading the info wasn't sure if I was doing the rift thing. I have been doing physical therapy and have little pain good range of motion of knee can go up and down stairs easily but am afraid to go back and play tennis because I do not want to injure it more. I have not played since dec because I hurt something bad then and that's when I had the MRI with the above diagnosis. I feel now it is better but don't know whether to proceed with surgery or just wait it out. Please help.. Very active person

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    3. If you now feel better, then why would you want surgery? Your knee will have its ups and downs. Having treatment that is timed to match the downs, usually leads to an "up" period, that can be attributed to the treatment.
      If you had pain, I wouldn't recommend an arthroscopy. If you feel OK, surgery is not even in the picture.

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  24. I'm 46 years old, I have baker's cyst's, bone spurs and almost no cartlidge in my right knee, I also had arthoscopic suregery in 1990. Doctor gave me two choices, arthoscopic again, or total knee replacement, I pretty much have bone against bone in my knee, not a pleasant feeling. So I was wandering if total knee replacement is best for me

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    1. Thanks. Total knee replacement can relieve pain from knee osteoarthritis. It has not been subjected to a randomised trial, but the differences in knee pain and function before-and-after surgery are large and consistent. The decision, however, is a big one and needs to e made with your orthopaedic surgeon. It doesn't sound like arthroscopy will be an effective option, though.

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  25. What about the meniscus "tear" that is causing "catching" or "locking" of the knee. My knee almost get hung up when I bend it back and forth and there is pain when I do this. Are you suggesting I just keep moving my knee back and forth until the cartilage wears down?

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    1. You are theorising about what is causing the pain and what may resolve it. This is sometimes a useful exercise, but is usually only useful in justifying our decisions. The only thing I can tell you (without taking a proper history and examination) is that unless you are experiencing true locking (which this doesn't sound like), your chances of getting better with an arthroscopy are not much better than placebo.

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  26. Hello Dr Skeptic,
    I had my first knee operation in 1995 whist serving in the British Army. Following the op my knee seemed okay however on returning to running I suffered from very severe Achilles tendonitis on my first run. I could not remedy this new condition and had to leave the Army with this impairment.
    A few years later I banged my knee after falling from a bike. Back in for my second arthroscopy to cut away ‘loose’ cartridge. Knee seemed okay.
    Fast forward to 2012 I felt a click in my knee whilst teeing off playing golf. Ouch here we go again. After resting for a while I managed to get back to normal activity in terms of cycling 3-4 times per week. However, after a long ride or a long walk I would be in pain the next day. I went to see Doctor and NHS physio and Surgeon. They said three arthroscopies were fine but that would be the last.
    They took an MRI scan; which subsequently went missing. I was booked in for the third arthroscopy. On arrival I met the surgeon and he said that the scan still hadn’t shown up but that he’d take a look anyway and “we’ll have you out riding you bike in no time”. After the op the surgeon said “your haven’t got much [cartridge] left have you”. This last statement made me worried. Why cut away what cartridge was left if there wasn’t much to start with? Why go ahead with the procedure without first obtaining the MRI scan image in the first place. If the surgeon had managed to viewer the image we he have gone ahead and advised surgery.
    Around 4 months after surgery I suffered terrible pain for about 3-4 weeks. The pain was unbearable. My Doctor proscribed very strong pain killers not available over the counter. By the time I got see to my original surgeon (another 4 months) the pain had gone. The surgeon was baffled – he’d never come across anything like that.
    In the period that followed I’ve cycled 3-4 times a week to work (20 mins each way) and alonger ride for 2 hours at the weekend for a year or so; but my knee is pretty numb and dead feeling and recently I’ve started to ache a lot; it’s especially painful after walking for short distances or say watching my son play football for an hour. Strage thing is that cycling seems to help curb the pain?

    My prognosis on my general detoriation is the onset of osteoarthiriuts.
    I’ve started reviewing online resources (hence finding your blog) about options such as total knee replacement which based on past experience fill me with dread. But the NHS treat these things as business a usual; which when viewing other articles is a very serious undertaking.

    I wish I’d never had the last op ;-( I’m only 44 and I’m really worried about what the future holds. I think we live in hope that there a cure for such conditions and we have high expectations - and that surgery is the solution. Not once has anybody in the NHS made a point of stating the risks associated with these procedures. It’s all on the documentation but never said face to face.

    Any advice in terms of moving on with a strategy for the future would be appreciated. Looks like a life on pain killers and the at some point a decision on knee replacement with the prospect of being worse than I am now.

    Regards BW

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    1. Thanks. Sounds like you are still pretty active. Keep it up. You will have exacerbations of pain every now and then - these will resolve, with or without an arthroscopy. You might need a knee replacement one day but that will be your decision, not mine.

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  27. How long does it take to get back to normal activities after a knee scope?

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    1. Hi. It depends on too many things, like what is "normal", why was the scope done, etc. Needs to be discussed with treating doctor.

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