To Have Or Not To Have Surgery: A Multi-Part Series
Part 1: The Knee
Here we are once again, as the fall sports season is well underway. During this past summer, my practice was filled with active people presenting with various musculoskeletal conditions. Many were scheduled for surgery to repair meniscus tears in the knee, shoulder ‘impingements,’ labral tears of the hip, or herniated discs in the neck and low back.
I could spend an entire newsletter (several, in fact) discussing the propriety of using surgery as a first choice rather than a last resort, and how the current health care model is procedures-driven. For the astute consumer of health care, this might be stating the obvious.
In this newsletter, let’s focus on how one makes an educated decision to either have or not have surgery at a given time. A percentage of my practice is seeing patients who would like to avoid surgery, if possible. If you have been a patient at my practice, you may have heard me say; ‘You can always have surgery, you just can’t un-have it.’ It is like trying to un-ring a bell. The method of evaluation, treatment and education we use, known as The McKenzie Method, is a perfect ‘second opinion.’
This is not the same as ‘you don’t believe in surgery, Todd.’ For those who require a surgical procedure, doing it for the right reason, at the right time, under the skillful hands of a good-to-excellent surgeon, the outcomes are amazing (including with positive results that might not be achieved in any other way).
However, outside of an emergency situation (e.g. fracture/trauma or serious pathology) an invasive procedure should not be the first choice. There is an axiom that I frequently use when discussing interventions with patients; ‘Do as little as possible, but as much as necessary.’ When deciding whether or not to have an elective procedure, this is an excellent axiom to live by.
Since this topic is very broad and the criteria are somewhat specific to each joint, I have chosen to break this topic up into several newsletters. In this post, we will start with the knee.
When I first started practicing 42 years ago, the most common reason for undergoing knee surgery was for meniscus injuries. The meniscus, or semi-lunar cartilage, acts as a cushion, lying between the two longest bones in the body (the femur or thigh bone and the tibia or shin bone).
In 1982, the common knee surgery procedure was an arthrotomy (surgically opening up the joint with a large incision (see photo). At the time, it was considered heresy not to remove the entire meniscus, as opposed to the removal or repair of the damaged section. As one might imagine, this led to terrible outcomes in the long term, because any cushion available to the joint was now completely gone.
These patients often ended up having total knee replacements in short order. We will discuss joint replacement surgery in a moment. Despite the fact that arthroscopic surgeries were being performed routinely in Europe during the late 1970s (and, in fact, appear in the medical literature in the early part of the 20th century), arthroscopic surgery did not become widespread in the U.S. until the mid-1980s. It seemed that everyone with knee pain or swelling was undergoing arthroscopic meniscus surgery.
The euphemism used by surgeons and patients alike was ‘the knee was cleaned up.’ To this day, I still do not understand how a knee gets dirty! The phrase meant something entirely different when I was growing up on the playground.
Despite the fact that arthroscopic meniscus surgery is far less invasive than its predecessor, the arthrotomy, like any invasive procedure, it is associated with risks (development of arthritic changes in the joint, less stability, as a portal for infection, etc).
Until the beginning of 2014, arthroscopic meniscus surgery was one of the most commonly performed orthopedic procedures. So what changed in 2014? A sentinal study was published in the New England Journal of Medicine that actually changed practice patterns.
In health care, practice patterns are very slow to change (sometimes decades, sometimes never!). There needs to be a very strong motivation in order for health care providers to change the way they practice. In this case, the motivation was reimbursement.
The study, by Sivohnen et al (2013), randomized 100 people with confirmed meniscus tears on MRI to 2 groups. One group had arthroscopic meniscus repair and the second group had a sham surgery (the patients in both groups were awake). The sham surgery group had the arthroscope inserted into the knee but nothing was done to repair or remove the damaged meniscus. Both groups were assigned the exact same rehabilitation exercise post-surgery.
At the one- year follow up, there was no difference in outcomes between the two groups. Third party payors stopped reimbursing for arthroscopic menisectomy as a first-line treatment.
I must emphasize: if the procedure is indicated, it is an effective, safe and game-changing intervention that can restore a person to a functional state that might not otherwise be achievable with conservative care.
All this begs the question: what are the indications for having an arthroscopic meniscus surgery? There are 2 main indications for having the procedure:
- The knee joint is unstable, buckling and/or locking and has not responded to a course of conservative treatment (physical therapy)
- There is a persistent hemarthrosis (the joint is hot and red for an extended period of time and not responding to conservative care). This may indicate that the tear is in the outer 1/3 of the meniscus, the portion that actually has a blood supply, known as the ‘Red Zone.’ It may also indicate that other structures within the knee have been damaged.
In each case, safety becomes the main issue in deciding whether or not to proceed with arthroscopic meniscal repair. The mere presence of a meniscus tear on MRI does not indicate the need for surgery and should not be the deciding factor. It is one piece of the puzzle. This was clearly shown in the Sivohnen et al (2013) study.
If we look at total knee replacement (or total knee arthroplasty – TKA) surgery, we see similarities. Modern knee replacement surgery began in the early 1970s. Prior to the advent of TKA surgery, the available treatment was fusion (also known as knee arthrodesis or tibiofemoral fusion). The procedure involves connecting the thigh bone (femur) to the shin bone (tibia), eliminating any rotation of the knee joint. The goal of knee fusion is to create a stable, pain-free knee. The procedure is still performed today, as a last resort, where reconstruction has failed and knee replacement is no longer an option. Knee fusion is accomplished by removing any remaining portion of the knee replacement and placing the femur and tibia in direct contact. The bone ends are held in place with internal fixation (rod or plate) or external fixation for a several months to allow them to fuse.
Over the last fifty years, TKA has been refined and improved and is now one of the most successful surgical procedures for the treatment of knee arthritis. According to the Agency for Healthcare Research and Quality, more than 600,000 people undergo knee replacement surgery. According to Singh, et al (2019), this number is expected to increase to more than two million by 2030. The number of projected total knee replacements will increase by 182% over the current numbers during that period of time.
When I began practicing (1981), the two main criteria for having a total hip or knee replacement were an inability to walk or function, and intolerable pain. This remained unchanged for more than three decades.
About seven years ago, on a Friday evening in early June, I was driving to the country for an enjoyable summer weekend. As an avid baseball fan, what better way to start a summer drive than listening to my local team (the New York Mets) on the radio? During the commercial break, an advertisement for major joint replacements came on the radio. The announcer was urging the listener to have a knee replacement before the joint became painful (in other words, before it was needed), stating that doing so would result in a better outcome.
I nearly drove off the road. After 30+ years, the criteria for surgery was no longer to have the surgery when you needed it, but to have it before you needed it! The question I asked myself at that moment was “If I had the surgery before I needed it, how would I know that I actually did need it?
What I hear from patients now is; ‘My X-ray is bone on bone,’ or, ‘the doctor told me ‘this is the worst I’ve ever seen,’ or, the very popular ‘with an X-ray like this, I can’t believe you are still standing.’
Again, the image should not make the diagnosis. It is one piece of a multi-factorial presentation. The criteria should remain essentially the same: You are no longer able to perform your daily activities or your knee is so painful that you are unable to function.
Once again, if the procedure is warranted, it is life changing.
One additional note: the stronger, more fit and flexible you are going into the surgery, the faster and more complete the recovery. If you have any questions about conservative treatment for knee pain or dysfunction, do not hesitate to contact me.
Yours in health,
Kremers Hilal Maradit , Larson Dirk R., Crowson, Cynthia S., Kremers, Walter K., Washington Raynard E., Steiner, Claudia A., Jiranek, William A., and Berry, Daniel J., MD. Prevalence of Total Hip and Knee Replacement in the United States. J Bone Joint Surg Am. 2015 Sep 2; 97(17): 1386–1397.
Singh, Jasvinder A., Yu, Shaohua, Chen, Lang and Cleveland, John D. Rates of Total Joint Replacement in the United States: Future Projections to 2020–2040 Using the National Inpatient Sample. Journal of Rheumatology (2019), 46:10, pg. 1-7.
Raine Sihvonen, M.D., Mika Paavola, M.D., Ph.D., Antti Malmivaara, M.D., Ph.D., Ari Itälä, M.D., Ph.D., Antti Joukainen, M.D., Ph.D., Heikki Nurmi, M.D., Juha Kalske, M.D., Teppo L.N., Järvinen, M.D., Ph.D. for the Finnish Degenerative Meniscal Lesion Study (FIDELITY) Group. Arthroscopic Partial Meniscectomy versus Sham Surgery for a Degenerative Meniscal Tear. N Engl J Med 2013; 369:2515-2524. December 26, 2013