Knee Surgery - Do you actually need it?

Wednesday, July 4, 2018

So you have a sore knee, the question is: Do you need knee surgery to fix it? The answer to this questions is not as clear-cut as some people might think or hope. More to the point, the more research that continues to be published, the more the facts are steering us away from knee surgery in the majority of cases. 

There are always going to be cases where surgery is the clear option. For instance, if you have ruptured your ACL and want to return to playing soccer or skiing – you're going to want to get that ACL repaired. This article however is for the cases that are not so clear cut, in particular where a solid course of physiotherapy has not yet been undertaken.

Let's imagine you are a runner, a soccer player, a gym goer – for that matter that you are anyone that requires you to walk on run on your own two legs. You have developed knee pain – either that has come on slowly or that all of a sudden came on when you landed, twisted, fell or whatever it might be. You had an MRI which showed some degenerative changes of the cartilage, perhaps a torn meniscus, perhaps osteoarthritis. You proceed to get a referral to an orthopaedic surgeon, because of course only they can fix these changes that have been seen on MRI. A few days later you are on the operating table, about to undergo some kind of knee surgery. Is all this really necessary? – Is there another way?

The FIRST thing we should all be aware of is that changes that are seen on medical imaging do not correlate with our pain experience. Studies have shown that 85% of adults with no actual knee pain have x-rays that show knee arthritis. This means that there is little correlation between the degree of arthritis seen on x-ray, and actual pain. One study showed that 48% of healthy professional basketball players had meniscal (cartilage) "damage" on their knee MRIs. So just because something funky has come up on your scan doesn't mean you need to fix it with surgery. In a lot of cases, the deficit that has been found on MRI is not actually what it causing your pain.

The SECOND thing we should all know is that numerous studies have now been published comparing the effects of Knee Arthroscopy Surgery with the effects of physiotherapy alone. These are rigorous studies where they compared groups of people who actually had surgery with groups of people who THOUGHT they had surgery (yes  - these people actually thought they had surgery – they were put under general anaesthetic and incisions created in the skin but no surgery was actually performed). The functional outcomes at 6 months are similar and at 2 years they are the SAME. That's right, at 2 years after surgery, there was no difference between those who did and didn't have surgery.

What is the reason for this? It COULD simply be a placebo affect and this is the opinion of many people. I think of greater importance is the fact that after surgery, patients are more likely to commit to an intense rehabilitation plan - they put the hours in strengthening their knee back in again. Those who have not undergone surgery as less likely to do this.

The take home message – if you have some changes on MRI that are normal in a lot of people, then strengthen the knee! Get yourself to a physio and hopefully avoid going under the knife.

This is by no means implying that no one should ever have knee surgery again. Large, obvious and important structural deficits will require surgery to correct them, depending on the level of activity you require. In a lot of cases however, surgery is not required, and it definitely is not the better option.

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