17 Aug Arthroscopy – A Personal Perspective from a Physio with a Dodgy Knee
I’m a physiotherapist. I’ve been round the block a few times and must have treated and rehabilitated hundreds if not thousands of knees injuries over the years. Currently I have a specialist triage role in the management of spinal and lower limb disorders. So when I injured my knee scrabbling around in the loft when moving house earlier this year, the management should have been fairly clear to me right? Eh… No.
After more than 6 months of ‘seeing how it goes’ and unsuccessfully trying to rehabilitate my own knee I still had pain squatting and twisting. I was unable to even play football with my two young boys. An MRI confirmed a radial tear of the lateral meniscus. I needed surgery I thought, or did I?
Surgery should rightly not be undertaken lightly but I’ve noticed that in physiotherapy and musculoskeletal clinical circles more generally, there seems to be an inherent distrust of surgery and this view seems to be gaining some traction. I think one reason for this is that it’s becoming more apparent that so called ‘abnormalities’ on imaging are actually quite often a normal finding in people with no pain. This phenomenon will only become more marked as imaging techniques advance. The table below from Brinjikji et al (2015) illustrated the point with reference to the spine:
You’re clearly on slightly dodgy ground having spinal surgery for a bad back if the only MRI finding is degenerative disc pathology, but lets not throw the baby out with the bathwater… Spinal surgery is entirely appropriate in some circumstances. I once did a quick pole on social media to see how many physiotherapists would opt for surgery if they themselves had a foot drop with confirmed nerve root compression on MRI. I was staggered to learn that the majority of those who responded would want to want to manage things conservatively in the first instance, risking a permanent floppy foot in the longer term. There is of course no absolute guarantee that surgery would fully resolve the situation but if it was me, the sooner it was decompressed the better!
Knee arthroscopy is another case in point. The more physiotherapists I spoke to about my dodgy knee, the more I heard that ‘the evidence base for arthroscopy is poor’ and ‘give it more time’. There is certainly some credence to this view. High quality randomised controlled trials have shown that arthroscopy is no better and sham surgery for osteoarthritis (Moseley et al 2002) or degenerative meniscal tears (Sihvonen et al 2013). We have also known for some time that contact stressed on the joint surfaces increase in proportion to the amount of meniscus removed which may increase the risk of developing osteoarthritis (Baratz et al 1986, Papalia et al 2011).
As with the spine however there is another side to the story. Just because certain conditions don’t respond to arthroscopy it doesn’t mean that all don’t. Radial tears and root tears can have a devastating effect on the function of the meniscus and may in themselves lead to degenerative change (Bhatia et al 2014, McDermott and Amis 2006) and unstable tears such as bucket handle tears can irritate the knee and cause it to lock.
When I sought the opinion of two orthopaedic surgeons, their advice was the same (and largely in contrast to the advice I’d had from most of my colleagues) – “you need an arthroscopy”. Not surprising I suppose coming from orthopaedic surgeons but by this time I was having flair ups that were putting me on crutches for a few days at a time and my knee wasn’t functioning at all well. I decided to opt for the surgery for two reasons, firstly my function and quality of life, but secondly the type of tear (a point often overlooked by those who strongly advocate conservative management).
In the event, as well as a complex radial tear (image 4 below), there was a horizontal split in the meniscus, which was folded underneath (image 5 below). I do not think this would have got better and I’m now clear that surgery was the right option for me. It’s early days and I’m expecting osteoarthritis in the coming years but I’m hopeful I will be able to slowly return to my previous level of activity.
I still think musculoskeletal pain should be managed conservatively wherever possible but I think clinicians’ need to avoid a partisan approach to surgery. Surgery is neither good nor bad, it’s simply another tool in the bag: When it fits, it’s an option. There is a time and a place. Some conditions are not appropriate for surgery and that’s fine, but that doesn’t mean that the surgery is inappropriate for all related conditions. As clinicians we should take a case-by-case pragmatic approach to patient management.
Baratz ME, Fu FH, Mengato R. 1986. Meniscal tears: the effect of meniscectomy and of repair on intraarticular contact areas and stress in the human knee: a preliminary report .Am. J. Sports Med. 14, pp. 270–275
Bhatia S, LaPrade CM, Ellman MB, LaPrade RF. 2014 Meniscal root tears: significance, diagnosis, and treatment. Am J Sports Med. 42(12):3016-30.
Brinjikji, W, Luetmer, PH, Comstock, B, Bresnahan, BW, Chen, LE, Deyo, RA, Halabi, S, Turner, JA, Avins, AL, James, K, Wald, JT, Kallmes, DF & Jarvik, JG .2015, ‘Systematic literature review of imaging features of spinal degeneration in asymptomatic populations’ American Journal of Neuroradiology, vol 36, no. 4, pp. 811-816., 10.3174/ajnr.A4173
McDermott ID, Amis AA (2006) The consequences of meniscectomy. J Bone Joint Surg Br 88: 1549–1556.
Moseley J B, OʼMalley K, Petersen N J, Menke T J, Brody B A, Luykendall D H, Hollingsworth J C, Ashton C M, Wray N P. 2002. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 347: 81-8.
Papalia R, Del Buono A, Osti L, Denaro V, Mafulli N. 2011: Meniscectomy as a risk factor for knee osteoarthritis: a systematic review. Br Med Bull, 99:89-106.
Sihvonen R, Paavola M, Malmivaara A, Itälä A, Joukainen A, Nurmi H, et al. 2013. Arthroscopic Partial Meniscectomy versus Sham Surgery for a Degenerative Meniscal Tear. N Engl J Med. 369:2513-22.