tag:blogger.com,1999:blog-6193043695356712843.post8582553981559193891..comments2023-09-02T23:55:45.583+10:00Comments on Doctor Skeptic: Knee arthroscopy in arthritis: an evidence-practice mismatchDr Skeptichttp://www.blogger.com/profile/09376469049519802493noreply@blogger.comBlogger152125tag:blogger.com,1999:blog-6193043695356712843.post-55381168177710259802019-05-05T11:23:51.883+10:002019-05-05T11:23:51.883+10:00Is there anything to be found in your knee on the ...Is there anything to be found in your knee on the imaging that has been done? If not, the arthroscopy will be a fishing expedition (a 'diagnostic' arthroscopy). This may be considered reasonable if your symptoms are particularly bothersome and have not resolved over time or with alternative treatments. If it is not too bothersome and has not been present for that long, then doing nothing is may also be considered reasonable.Dr Skeptichttps://www.blogger.com/profile/09376469049519802493noreply@blogger.comtag:blogger.com,1999:blog-6193043695356712843.post-6153583461578559652019-05-05T00:25:35.342+10:002019-05-05T00:25:35.342+10:00I am scheduled to have arthroscopy for OA next wee...I am scheduled to have arthroscopy for OA next week. I am now wondering if this is a bad idea. The doctor told me it would be 50/50 if I have success. I was willing to take the chance but now wondering if it will make it worse. My biggest complaint is a catching feeling when i walk. My meniscus is intact. Most people that post have had meniscal tears? Is there any difference?Marshahttps://www.blogger.com/profile/06475904858394546585noreply@blogger.comtag:blogger.com,1999:blog-6193043695356712843.post-91353706619692136582017-08-12T08:54:24.860+10:002017-08-12T08:54:24.860+10:00I think the pain Dr nailed it. Sounds like you hav...I think the pain Dr nailed it. Sounds like you have arthritis and degenerative tears, in which case arthroscopy is no more effective than placebo. Follow up MRI is a waste of time - you already have the diagnosis.Dr Skeptichttps://www.blogger.com/profile/09376469049519802493noreply@blogger.comtag:blogger.com,1999:blog-6193043695356712843.post-19216870563723519272017-08-12T08:49:33.656+10:002017-08-12T08:49:33.656+10:00The MRI is very accurate at seeing things, but the...The MRI is very accurate at seeing things, but the things it sees are not necessarily the cause of the pain, and even if degeneration was correlated with pain, arthroscopic surgery (and injection therapies and anything that uses the phrase "cartilage restoration") are ineffective. It's not a matter of risks - risks are only important if there is some real benefit against which to weigh them.Dr Skeptichttps://www.blogger.com/profile/09376469049519802493noreply@blogger.comtag:blogger.com,1999:blog-6193043695356712843.post-4094364462599552252017-08-12T00:08:21.698+10:002017-08-12T00:08:21.698+10:00Thanks Dr Harris.
Frankly, I was surprised to rea...Thanks Dr Harris.<br /><br />Frankly, I was surprised to read about your negative assessment of the MRI. From what I have read, the accuracy, especially if it's a high-grade lesion, is relatively high. Anyhow, if the MRI isn't informative enough, is arthroscopic surgery simply to have a look inside without performing any kind of shaving and trimming a viable option? Or does the procedure bear with it some serious potential complication that outweigh the benefit of knowing what goes on inside my knees? <br /><br />My knees don't seem to be improving (it's actually the opposite, sadly), and my thoughts about some kind of surgery for cartilage restoration have been steadily growing. Here in Ukraine where I live it isn't too expensive to have investigative arthroscopy but I am not sure what to expect and what the real risks are. pinnocchiohttps://www.blogger.com/profile/18302147742820701841noreply@blogger.comtag:blogger.com,1999:blog-6193043695356712843.post-56227717727789168232017-08-02T17:02:19.100+10:002017-08-02T17:02:19.100+10:00Not sure if you can give me advise but here goes. ...Not sure if you can give me advise but here goes. Trauma to the posterior aspect of both knees in 2012. Diagnosed with complex tear of the meniscus that would require surgery. In the interim, 2013, 6 weeks post trauma, DVT & pulmonary emboli diagnosed. Also CRPS. Arthroscopic medial meniscectomy & chondroplasty & R/O plica deferred for 7 months until DVT stable. Knee never the same. Further MRI 2014 showed knee complicated by a new posterior horn root attatchment tear of the medial meniscus. Also new radial tear involving the free margin of the body of the lateral meniscus. Pain Dr advised they were non surgical... Fast forward 2017 mobility compromised, arthritis both knees, and tears reactive to the point on some days, the pain can literally stop me in my tracks. Having a follow up MRI and believe Pain Dr got the non surgical part wrong. Opinion pleaseAnonymousnoreply@blogger.comtag:blogger.com,1999:blog-6193043695356712843.post-34798632065762106942017-07-10T10:36:36.781+10:002017-07-10T10:36:36.781+10:00I am not sure of how much healing is possible, par...I am not sure of how much healing is possible, particularly because in many cases the factors that caused the problem (whether it be malalignment, obesity, age etc) are still present.<br />I would not get an MRI to determine the "extent of damage". The MRI can't even diagnose "damage" from natural changes, let alone the extent of them. Correlation between MRI and clinical findings are minimal.Dr Skeptichttps://www.blogger.com/profile/09376469049519802493noreply@blogger.comtag:blogger.com,1999:blog-6193043695356712843.post-3719877539752655442017-07-10T06:56:34.392+10:002017-07-10T06:56:34.392+10:00Thanks again Dr Harris. I've read your book--i...Thanks again Dr Harris. I've read your book--it's great, and accidentally I've also stumbled upon "Wasted" just today--a great watch too.<br /><br />After giving the issue a great deal of thought and reading about it rather extensively recently, I can now see your point more clearly. I realize what a huge risk any kind of knee surgery is, especially as it may disturb the gentle balance of tissue homeostasis and lead to unintended grave consequences. There's some chance I might end up okay, but even that will only "buy" some time at best. <br /><br />I now hope my knee issues do not get worse and I am able to restore the "envelope of function" as per Dr. Dye, with whose approach you might be familiar, by avoiding aggravating activities and moving my knees in a gentle manner (mostly walking). Sadly, the idea that any kind of surgery (or any medical treatment out there) might bring me back to where I was a year ago--able to life heavily and do Olympic weightlifting--now starts seeming further and further less viable. I will now be glad if I am able not to degrade into a more severe arthritis form. I am thinking of having an MRI to see the extend of damage though.<br /><br />In your last sentence you sound as if the eventual attrition is inevitable, but from what I've read not all people, even those with advance chondromalacia, advance into "eventual attrition." Do you believe cartilage can restore itself or at least stop deteriorating? There's some research there claiming hyaline cartilage restoration even where the subchondral bone isn't exposed. Most of sources claim it's impossible though. There are also people who seem to have had their cartilage restored without surgical or any other kind of intervention. <br /><br /> pinnocchiohttps://www.blogger.com/profile/18302147742820701841noreply@blogger.comtag:blogger.com,1999:blog-6193043695356712843.post-34909141759472111352017-06-28T05:01:02.903+10:002017-06-28T05:01:02.903+10:00Thanks so much!Thanks so much!Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-6193043695356712843.post-57489843656052087532017-06-27T09:18:50.301+10:002017-06-27T09:18:50.301+10:00Most people who have a knee replacement end with a...Most people who have a knee replacement end with about the same function, regardless of where you started off. Therefore, people with worse knees to start with have a much greater degree of functional improvement than people with only mild problems.<br />As far as the stem cells go, see m blog post on that one but there is no good evidence that it is helpfulDr Skeptichttps://www.blogger.com/profile/09376469049519802493noreply@blogger.comtag:blogger.com,1999:blog-6193043695356712843.post-35960237427980085132017-06-21T05:17:59.562+10:002017-06-21T05:17:59.562+10:00Hello Dr Skeptic, What is your opinion of abdomina...Hello Dr Skeptic, What is your opinion of abdominal fat (stem cell) transfer to knee for OA. I was referred by my OS (who does sports medicine) to see one that does replacements. I was told by that one that I was "too early" for a replacement and he recommended the fat transfer procedure (Lipogems). He also said that patients that have a replacement "too early" do not do as well as patients with more advanced disease-that surprised me-as I would think the less damaged your joint is-the better outcome you would have? Thanks in advance!Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-6193043695356712843.post-84849788792295581092017-06-11T10:12:00.113+10:002017-06-11T10:12:00.113+10:00I don't think rest does anything at all. And d...I don't think rest does anything at all. And debridement may remove a loose body (locking), but as far as 'smoothing out' the cartilage defect, surgery will not help. It will not slow down eventual attrition, it will only remove more cartilage in the process and, if anything, accelerate degeneration.Dr Skeptichttps://www.blogger.com/profile/09376469049519802493noreply@blogger.comtag:blogger.com,1999:blog-6193043695356712843.post-47566099628524918272017-06-11T02:36:08.671+10:002017-06-11T02:36:08.671+10:00Hello Dr Skeptic,
Thanks a lot for you responses ...Hello Dr Skeptic,<br /><br />Thanks a lot for you responses so far. I know that you aren't in favor of giving medical advice, and so I will put it as a general question of the applicability of arthroscopy, not whether I should or should not do it.<br /><br />You mention in your responses that debridement might indeed be useful in some cases though not in general. What is your opinion about its possible relevancy for someone who had sustained a traumatic articular cartilage defect that had led to chronic, four-five months long "catching" and grinding of the patella on the femoral condyle at the end of knee extension and to further irritation of patellar articular cartilage at the point of contact? If such catching doesn’t seem to be alleviated by rest and has only become more prominent and has eventually led to lateral patellar pain, wouldn't gentle debridement, if possible and if the articular damage isn't too severe, be of use in stopping the catching in such particular case and therefore stopping or slowing further patellar attrition? And if you believe rest is still the best option, how long do you believe the rest should be before jumping to conclusions?<br /><br />Thanks<br />pinnocchiohttps://www.blogger.com/profile/18302147742820701841noreply@blogger.comtag:blogger.com,1999:blog-6193043695356712843.post-6750943155398301832017-05-28T22:11:57.973+10:002017-05-28T22:11:57.973+10:00Possible, but difficult to predict.Possible, but difficult to predict.Dr Skeptichttps://www.blogger.com/profile/09376469049519802493noreply@blogger.comtag:blogger.com,1999:blog-6193043695356712843.post-40524645806872599002017-05-28T20:54:16.407+10:002017-05-28T20:54:16.407+10:00Thanks. After reading your blog and giving some th...Thanks. After reading your blog and giving some thought to the issue, I understand that you are of the opinion that for some (many?) people PT has the same placebo effect that many other possible "treatments" (surgery, injections, etc.) out there that seemingly help but when tested thoroughly are no better than sham treatment. I tend to agree with you and there is indeed a very good possibility PT is not beneficial in my case too. But I want to keep my muscle tone and I do enjoy working out, so I guess PT fits into that picture, as long as it doesn't exacerbate the problem (I judge it by the amount of pain during and after workouts). And, of course, I try to avoid knee-stressing activities. Do you think there's actually a reasonable chance that crepitus and grinding might actually get better in time? pinnocchiohttps://www.blogger.com/profile/18302147742820701841noreply@blogger.comtag:blogger.com,1999:blog-6193043695356712843.post-12637170508477337932017-05-28T00:03:38.148+10:002017-05-28T00:03:38.148+10:00Thanks, and apologies. I can't really give goo...Thanks, and apologies. I can't really give good advice for individual cases without examining them properly. It sounds like an MRI will not help and if pain is not a big issue (not stopping you from doing daily activities) then the crepitus doesn't worry me that much.<br />The only exercise I do is run. Why not give the gym and PT a rest and just do what you like doing and see how it goes? Like your quads tendinitis (and most other tendinitis) it will get better in time.Dr Skeptichttps://www.blogger.com/profile/09376469049519802493noreply@blogger.comtag:blogger.com,1999:blog-6193043695356712843.post-80900340212941046712017-05-26T22:40:34.291+10:002017-05-26T22:40:34.291+10:00Thanks for your really great blog. I've carefu...Thanks for your really great blog. I've carefully read several posts of yours and your thoughtful responses, and I'd appreciate if you would be able to answer a question of mine.<br /><br />I am 38, 6.2 feet, 200 pounds, athletic. I've been very active (Brazilian jiu jitsu, some running, a gym) all my life and beside some minor knee aches and clicks here and there have never had serious problems with my knees. Unfortunately, it all changed in the last year after I started doing Crossfit. First, I developed quadriceps tendinosis which refused to go away. After studying the issue, I began “treating” the problem with isometric heavy barbell holds on my ankles with legs in full extension, putting pressure on my quadriceps. Only later did I realize this exercise might lead to the softening of the patella cartilage in the knee. But at the time, the exercise was able to help me with my tendinosis, which is no longer a problem for me. BUT, about 6 months ago there was a workout with heavy lunges (where you hold weight above your head and then place your knee on the ground and step forward and so further). I didn't lend too hard on the floor with my knees but I still landed hard enough--the next morning I found out I developed crepitus (a rice krispies sound) in both of my knees (much more serious in the left one). Since then my knees have been clicking and grinding (mostly when I extend my leg from flexion) much more than before and the crepitus has never gone away. The knees would click and the kneecaps would track incorrectly at times and at other times they won’t. Stretching quads would help one day and would help less another one. Likewise, at times, several "clicks" would seemingly stabilize the kneecap and there would be no clicks anymore. <br /><br />Even though I have a fool ROM, can easily squat and do pretty much everything and feel no pain, all this clicking and crepitus has finally led to me to realized that I most probably have damaged my knees to the point that I now have chondromalacia, perhaps even at an advanced stage. Curiously, only after discontinuing all activity and starting PT have I also started feeling some minor aches around my kneecaps, and though I am not certain what they are about I've become even more concerned.<br /><br />So, I've been thinking of what to do next. Firstly, I started a PT regimen and started avoiding all exercises that put pressure on my kneecaps in a flexed position. But I was also thinking about having something else done (perhaps some injection or whatever) in order to prevent further deterioration and was thinking about having my knees MRI'ed to see what's going on there.<br /><br />But if I get you right, an MRI is not such a good investment right now, and I should just stick with the PT and avoid exacerbating activities (like squatting and lunging with weights). That’s because even if I find I have mild or advanced chondromalacia it won’t matter because at this point there isn’t much that can or should be done besides PT to prevent its further deterioration anyway. Am I right or would you still recommend I do MRI due to some benefit I might have from it? Like, for instance, if I have some torn pieces of cartilage in the knee, perhaps removing them might be beneficial? I am afraid that if I find out I have some bad cartilage changes “there,” it might have a negative psychological effect on me and future exacerbate my situation.<br /><br />Thankspinnocchiohttps://www.blogger.com/profile/18302147742820701841noreply@blogger.comtag:blogger.com,1999:blog-6193043695356712843.post-58864132871816719912017-04-17T15:20:41.429+10:002017-04-17T15:20:41.429+10:00Thanks. It is likely that the arthroscopic procedu...Thanks. It is likely that the arthroscopic procedures added no benefit and may have contributed to your decline. There is no good evidence that stem cells will help you and some evidence that they will not. You can have a TKR at 43, but there are risks involved and it will be up to you whether or not you are happy to accept those risks.<br />A TKR may be effective (there is evidence that it can be) but injections are unlikely to help you.Dr Skeptichttps://www.blogger.com/profile/09376469049519802493noreply@blogger.comtag:blogger.com,1999:blog-6193043695356712843.post-23590771364755373732017-04-17T13:16:24.926+10:002017-04-17T13:16:24.926+10:00I had torn miniscus which was repiared via arthosc...I had torn miniscus which was repiared via arthoscopy, then within a few months tore again (which my Dr says is very rare) since second arthoscopy, now almost 11 months post op, knee is severly swollen and ache's constantly. He did find osteo while in and "smoothed" the OA during first and second surgery, most severe behind knee cap, says next step is most likely stem cell injections (steriods did nothing) but insurance wont pay for stemcell injections and he says if i was 20 yrs older would recomend TKR. Im 43 & have to use a cane now. How old is old enough for a TKR!!Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-6193043695356712843.post-11503279944454420832017-03-30T12:11:02.557+11:002017-03-30T12:11:02.557+11:00I had torn cartilage removed from my left knee 48 ...I had torn cartilage removed from my left knee 48 years ago, it was never the same afterwards, but I had more movement and much less pain.<br /> It has troubled me for years, stiff, achy, locking etc but not really painful. Over time the range of movement has become less and less, I can't squat to do simple chores etc, have to bend from the hips now to do anything low down. This knee has OA now and has become knock kneed, if I stand with my knees together my feet are about 4 inches apart, and it aches constantly especially at the back of the knee. It really gets me down and makes me feel so much older, I am limping all the time,mainly with my leg held straight as bending it is worse,and I'm now getting pain in my right hip too because of the way I walk. Even preparing dinner in the kitchen for an hour I can hardly bend it enough to sit down without holding onto the table. I don't expect to be able to squat or kneel down but really hope a TKR will make a difference if I can get it done. Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-6193043695356712843.post-85663714474287673102016-09-28T20:58:13.181+10:002016-09-28T20:58:13.181+10:00Thanks. Unfortunately I can't really give you ...Thanks. Unfortunately I can't really give you any advice without seeing you and your scans etc. All I can say is to see another surgeon for a second opinion. TKR may be a option but that is a big decision and I would get more than one opinion on that.Dr Skeptichttps://www.blogger.com/profile/09376469049519802493noreply@blogger.comtag:blogger.com,1999:blog-6193043695356712843.post-15644275003525675772016-09-22T03:48:48.134+10:002016-09-22T03:48:48.134+10:00Thank you so much for this blog and this insightfu...Thank you so much for this blog and this insightful and thought provoking information. I would GREATLY appreciate any advise you may be able to give me.<br />I am 48 yo, and have long given up any impact activities for close to 15 yrs d/t some knee arthritis (cant bend, sqauat, etc..). I have stayed active in the gym doing mainly weights and the elliptical. Over the last year I have developed stabbing type pains in the lateral portion of my knee, just doing random activities. 4 months ago, I moved "wrong" and had another sharp pain, and... whammo!... my knee blew up like a giant balloon and I had no ROM, couldn't walk. Could not get rid of the pain and swelling. Went to PT faithfully for 2 months with no change. Had a cortisone injection which also did nothing. Was on crutches this whole time. My quad pooped out. MRI showed pothole in cartilage, synovitis, and arthritis. Ended up having arthroscopic surgery and they "smoothed" pothole in meniscal cartilage, and scraped the grade 4 arthritis under patella. They told me it was "bone on bone". (no other tears). It has now been 8 weeks since the surgery and I am still in a lot of pain, stiffness and intermittent swelling. Still in PT. I tried to get off crutches for a couple weeks, but now am back on them, as the pain under my knee cap is intense. (??) The annoying thing is.. I never HAD pain under my knee cap before the surgery! I experienced the aching and throbbing feelings d/t the arthritis and couldn't do any impact stuff.. but never had the pain under the patella like this. (Like I said, it was on the lateral side where I was hurting before). So now, I feel like I have a NEW problem that I didn't have before. I'm still going to PT 2xs a week, and scheduled for gel injections in a month. (which I think I read that you stated don't really help that much?) I am SO frustrated... I don't know what to do. <br />Is 3 months post surgery too soon to be expecting to be better? I feel as if it shouldn't be still in this condition after this time. <br />I am meeting with a surgeon who does TKR in December. I have been out on disability since the injury in May.. (btw.. Im a floor nurse in a hospital). I don't know if this is ever going to heal?<br />I am not looking for a diagnosis... just thoughts? Im so discouraged.. :(<br />If you have read to the end..thanks for your time and consideration. I value your inputAnonymousnoreply@blogger.comtag:blogger.com,1999:blog-6193043695356712843.post-6146553212125470472016-09-02T07:18:49.659+10:002016-09-02T07:18:49.659+10:00Your age is not an obstacle to surgery. The questi...Your age is not an obstacle to surgery. The question should not be "can" they operate. OF course, we "can" operate on anyone. The question is: for the condition you have (which I don't know), is surgery more likely to provide you with benefit compared to a non-operative alternative?Dr Skeptichttps://www.blogger.com/profile/09376469049519802493noreply@blogger.comtag:blogger.com,1999:blog-6193043695356712843.post-58784263427414620182016-09-02T05:22:31.921+10:002016-09-02T05:22:31.921+10:00i wonder why can't they do surgery on a 23 yea...i wonder why can't they do surgery on a 23 year old. can anybody tell me. I have a swollen knee thats been going on for almost 3 yearsAnonymousnoreply@blogger.comtag:blogger.com,1999:blog-6193043695356712843.post-68945040439502910742016-09-02T05:22:09.721+10:002016-09-02T05:22:09.721+10:00i wonder why can't they do surgery on a 23 yea...i wonder why can't they do surgery on a 23 year old. can anybody tell me. I have a swollen knee thats been going on for almost 3 yearsAnonymousnoreply@blogger.com