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Knee Arthroscopy Surgery (key hole surgery) – is this the end of this procedure?

By Jason Dodd, Clinic Manager and Sports Therapist at Bodylogics. Specialising in running related injuries and lower limb injuries.

It is said that 25% of people over the age of 50 years old experience knee pain from degeneration.  What is important to note here is that degeneration of bones is perfectly normal and just shows that you have lived!  Management of this pain usually comprises of watchful waiting, weight loss if over-weight, physical therapy, exercise or topical pain medication such as ibuprofen, corticosteroids, arthroscopic knee surgery and total knee replacement surgery.  The preferred treatment method is not clear and will vary between individuals.

The first question we may ask though is what is degenerative knee disease?  This term is usually associated with osteoarthritis but it can also include many other things.  When a person is above the age of 50 years old it is common to associate this degeneration of the knee with other common issues such as clicking knees or meniscus tears.

When we get knee pain, the only definitive therapy treatment is total knee replacement.  This however is a huge form of surgery and does not come without complications in itself.  The pain experienced and felt currently will diminish but the limitations that come with total knee replacement are vast.  If this were so good then everyone with knee pain would just be subjected to a total knee replacement.  It is therefore usually only used for the most severe cases of knee degeneration and pain.

Some though believe that arthroscopic (or key hole surgery), including washout of intra-articular debris may improve pain and function.  However, research and current recommendations from leading experts in this field are now advising against it saying it has no beneficial outcome.  Even the NICE guidelines, which is effectively the leading clinical/medical guidance council in the UK advise against the use of ‘keyhole surgery’ for those with clinical MRI of Osteoarthritis and refuse to comment on whether they believe it should be used for Meniscul Tears.  This is relevant in itself as if they truly believed in it having a positive impact they would state their thoughts on it clearly.

But why is it still such a common part of medical procedures if the research is saying that it doesn’t work.  Well there are many reasons for this.  First off, hospitals get paid money to carry out these types of surgeries on a daily basis.  With the loss of these services they would reduce their income significantly.  Then there are the manufactures of the equipment used.  They have a vested interest in ensuring this type of research does not come out as it will affect their sales.  You then have patient expectation.  When people go for a scan they want answers.  Some actually want a certain answer and they want that to be ‘you need surgery’.  We have been educated to believe that surgery is the answer to all issues and you cannot beat it.  But we now know this is not true.  But with hospitals eager to perform surgery for monetary purposes (cynical thinking of me I know) and patients eager to find the ‘quick solution’ because they have heard other people have it done and it work, we are fighting a tough battle.

Consider this though.  Your knee pain that you may be suffering from, you have good days and you have bad days.  Sometimes it feels fine then the next day it hurts before settling back down again.  This is not the knee getting better or worse, this is a sensitisation of the central nervous system which governs all feelings in the body.  After surgery, you will most likely feel pain as there has been an instrument in your knee which is alien to the body so it will be inflamed but then after 3-6 weeks of rest the knee starts to feel better (inflammation goes down) but people will then associate this feeling of little pain with surgery.  Then, caution prevails and the patient is more careful with their knee whilst they wait for their ‘recovery’ to happen.  Then, when they start to actually load it (usually without any rehabilitation for it) they start to experience pain again.  Studies have shown that even with a good rehabilitation programme adhered to, knee surgery is no better than standard physiotherapy intervention.  The added bonus of not having the surgery too is a decrease in the risk of arthritis developing further in the knee or the risk of them shaving away too much of the meniscus and taking away the bodies natural shock absorber.

The above information has been taken from the paper linked here and includes the thoughts of Jason Dodd who is one of Bodylogics trained Sports Therapists.  He specialises in running related injuries, including those of the knee.  The following text effectively summarises the overall beliefs of some of the panel of experts who were involved in this particular study;

The panel is confident that arthroscopic knee surgery does not, on average, result in an improvement in long term pain or function. Most patients will experience an important improvement in pain and function without arthroscopy. However, in <15% of participants, arthroscopic surgery resulted in a small or very small improvement in pain or function at three months after surgery—this benefit was not sustained at one year. In addition to the burden of undergoing knee arthroscopy, there are rare but important harms, although the precision in these estimates is uncertain.

It is unlikely that new information will change interpretation of the key outcomes of pain, knee function, and quality of life (as implied by high to moderate quality of evidence).

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