Surgery - "Of Little Hep To Older Knees"

[WillBrink]

Think twice before saying yes to any surgery:

Middle-aged and older patients are unlikely to benefit in the long term from surgery to repair tears in the meniscus, pads of cartilage in the knee, a new review of studies has found.

Researchers at McMaster University combined data from seven randomized, placebo-controlled trials involving more than 800 subjects treated for meniscal tears with surgery, sham surgery or nonoperative care. The subjects’ average age was 56.

In six of the trials, the surgery provided a significant improvement in short-term functioning. But the pooled data showed no significant difference in long-term functioning among patients in the three groups. Nor did surgery provide either short- or long-term pain relief.

Dr. Moin Khan, a research fellow at the university and lead author of the study, published in the Canadian Medical Journal, said that its conclusion does not pertain to an acute meniscus tear in a young person. That requires surgery.

“But chronic pain from a small meniscus tear in a middle-aged person may not benefit from surgery,” he said.

“Treatment with weight loss, anti-inflammatory medicine and physical therapy may be helpful for many patients.”

http://well.blogs.nytimes.com/2014/0...=fb-share&_r=0

[ALCOAR]

Excellent post, and article Will.

My mother had this surgery, and I can 100% attest to the fact that this is a HUGE SCAM!

Just another reason why I don't trust doctors in the least. My sister is a surgeon too.

[GTF425]

The timing on this couldn't be funnier. I have a pretty decent tear in my meniscus and have a follow-up with my PA in two days to discuss my options.

I'm personally hoping to be able to avoid the surgery route.

[TAZ]

Not a huge fan of surgery. Have basically no right ACL and very minor meniscal damage. Right shoulder labrum tear along worth a few tendons and ligament damage to same shoulder. No survey yet. My doc was the one who suggested the no surgery route as starting points to both injuries; so you need to be find a good doc and be wary of people who don't suggest alternatives. I may be regretting the no surgery choice in 30 years or so; but I'll cross that bridge when I get to it.

With that stated there are more factors that go into the decision making process. The average middle aged guy who doesn't place a lot of physical strain on his/her body may not truly benefit for the surgery. A young athlete on the other hand might be a different story. Your end goals are also a deciding factor. When I blew out my knee I was still playing at a relatively competitive level and wanted to eventually do so again. The doc knew this and we laid out a plan to try without surgery. That included an aggressive PT schedule with lots of follow ups to verify that no further damage was being done and that the joint was fully stable. The shoulder on the other hand was different. The question came down to what did I want to do @ my age and moving forward. @45 still playing against college kids was out of the question without surgery. Playing semi seriously within my age group was still going to be problematic. Hanging up the boots and continuing to enjoy an active (non contact sport) life was likely doable without surgery. I went that route.

It was very nice having a surgeon who was willing to listen to my needs and act accordingly. It was also beneficial to understand and get a grip on my own needs going in.

Anyone who uses terms like never, won't help.... Whether they are your surgeon or a academic is not being truly honest.

[jmoore]

Some things to consider……

1 – Cartilage (the material menisci are made from) is poorly vascularized, hence it only tends to truly repair/regenerate in those under 40 because as you get past that age, there isn’t enough bloodflow to get the job done. YMMV

2 – A lot depends on both the degree of the meniscal tear, as well as the location of the tear (is the tear near any of the attachment locations for either the medial or lateral collateral ligaments, thus possibly influencing future damage or function there?). Repair of the tear will usually NOT cause any improvement of pain that was there before the tear, as that was most likely d/t other cause – e.g., chondromalacia or similar problems. YMMV

3 – If the tear is minor, the pt is “older”, and the pain is tolerable enough to treat pharmacologically – then skipping surgery is often done. (I, too, avoid the knife whenever possible. Been the recipient of a “medical mistake” in a different system.)
HOWEVER, there is one additional thing to consider before writing off surgery! Depending on a whole bunch of variables, once again – there is the possibility that the slight tear will allow the meniscus enough mobility from the tibial plateau to raise its ugly little head at the most inopportune moment and WEDGE the torn piece in the actively working joint. When this happens – your joint WILL LOCK in whatever position it is in, and you WILL NOT be able to over-ride the lock. It is a strange and terrible feeling to want to extend your leg for the next step – and the damned thing won’t extend!!!!!! Yes – a fall will usually result. (Don’t ask me how I know!!!!) A “pie wedge” menisectomy is often quite useful if healing isn’t expected, as the possibly offending little piece of meniscus is removed from any possible interaction with the remaining anatomy of the knee.

So I guess my take-home message is that one needs to really delve deeply into your specific injury and then decide the pros & cons of surgery. In addition to a meniscal tear, I have also had a torn ACL and the required surgery for that (yes, SOME ignore the surgery for that, too. Depends on how much activity you plan to do afterwards:) I will say that the ACL surgery and the associated repair of the patellar chondomalacia was THE BEST SURGERY choice I have ever made. Allowed me to continue another 10-15 years in my martial arts training/teaching (I was back on the dojo floor 1 week after the surgery, btw:)

Again and as always – YMMV.

john

[Hmac]

Many patients do benefit from debriding the torn pieces, however no one is surprised that repairing cartilage doesn't work. Labeling it a scam is stupid, however. The choices that those patients faced was either arthroscopic debridement, with or without meniscal repair vs ongoing pain from the arthritis vs total joint replacement.

[WillBrink]

Some things to consider……

1 – Cartilage (the material menisci are made from) is poorly vascularized, hence it only tends to truly repair/regenerate in those under 40 because as you get past that age, there isn’t enough bloodflow to get the job done. YMMV

2 – A lot depends on both the degree of the meniscal tear, as well as the location of the tear (is the tear near any of the attachment locations for either the medial or lateral collateral ligaments, thus possibly influencing future damage or function there?). Repair of the tear will usually NOT cause any improvement of pain that was there before the tear, as that was most likely d/t other cause – e.g., chondromalacia or similar problems. YMMV

3 – If the tear is minor, the pt is “older”, and the pain is tolerable enough to treat pharmacologically – then skipping surgery is often done. (I, too, avoid the knife whenever possible. Been the recipient of a “medical mistake” in a different system.)
HOWEVER, there is one additional thing to consider before writing off surgery! Depending on a whole bunch of variables, once again – there is the possibility that the slight tear will allow the meniscus enough mobility from the tibial plateau to raise its ugly little head at the most inopportune moment and WEDGE the torn piece in the actively working joint. When this happens – your joint WILL LOCK in whatever position it is in, and you WILL NOT be able to over-ride the lock. It is a strange and terrible feeling to want to extend your leg for the next step – and the damned thing won’t extend!!!!!! Yes – a fall will usually result. (Don’t ask me how I know!!!!) A “pie wedge” menisectomy is often quite useful if healing isn’t expected, as the possibly offending little piece of meniscus is removed from any possible interaction with the remaining anatomy of the knee.

So I guess my take-home message is that one needs to really delve deeply into your specific injury and then decide the pros & cons of surgery. In addition to a meniscal tear, I have also had a torn ACL and the required surgery for that (yes, SOME ignore the surgery for that, too. Depends on how much activity you plan to do afterwards I will say that the ACL surgery and the associated repair of the patellar chondomalacia was THE BEST SURGERY choice I have ever made. Allowed me to continue another 10-15 years in my martial arts training/teaching (I was back on the dojo floor 1 week after the surgery, btw

Again and as always – YMMV.

john

I would not recommend to anyone simply writing off surgery. It's a tool in the tool box for fixing the human machine. As always, when you have a hammer, things tend to look like a nail. I think this info is just a cautionary finding that in many cases of minor meniscus tear in a middle-aged person may not be the appropriate choice. I do think there's plenty to try, docs and non alike, don't look into prior to surgery, but that's another topic for another day.

[Airhasz]

My rule is no surgery unless injury interferes with making a living. This coming from a total hip replacement recipient.

[Hot Holster]

I haven't worked in 3 months. I'm getting one new knee in 2 weeks and the other 6 weeks later. Both knees are bone to bone with very little flex, I can't walk without some type of support, ie: cane, or walker, even then both knees buckle on me at varying times, sitting is uncomfortable, sleeping a full night is impossible. I was told 34 years ago that I would need a new left knee in 10 years so I beat the odds on that one. The right one wore out protecting the left one for so long.

I had the gel shots in March of 2013 hoping to prolong the knee surgery a few years, so I did gain another year on them, but now, it is time.

[Hmac]

I haven't worked in 3 months. I'm getting one new knee in 2 weeks and the other 6 weeks later. Both knees are bone to bone with very little flex, I can't walk without some type of support, ie: cane, or walker, even then both knees buckle on me at varying times, sitting is uncomfortable, sleeping a full night is impossible. I was told 34 years ago that I would need a new left knee in 10 years so I beat the odds on that one. The right one wore out protecting the left one for so long.

I had the gel shots in March of 2013 hoping to prolong the knee surgery a few years, so I did gain another year on them, but now, it is time.

Yup. Been there, done that. Bilateral knee replacement about 5 years ago. It's a life-changer.