In our previous post, we cited a number of recent studies that resoundingly concluded that arthroscopic meniscus repair among middle-aged patients is pretty much useless. Yet more than 400,000 middle-aged and older Americans a year undergo this surgery.
What are we middle-aged athletes with knee pain to make of all this?
We turned to an expert who happens to be one of us. Kevin G. Shea MD (pictured above on the right, with his friend and fellow surgeon John Werdel MD) is an orthopedic surgeon based at St. Luke’s Clinic in Boise, Idaho. He’s 53, a trail runner, XC skier, road and mountain bike racer—and chairman of the Evidence-Based Quality and Value Committee for the American Academy of Orthopaedic Surgeons—the group responsible for issuing clinical practice guidelines to the academy.
We focused on the benefit, or lack of, meniscus surgery among middle-aged athletes—who, when experiencing knee pain, are very likely suffering from osteoarthritis. They hope that a meniscus repair will somehow put their knee pain to rest. Are their hopes in vain?
TMA: Given these recent studies, are orthopedic surgeons backing away from meniscus surgery?
Dr. Shea: There’s slow but progressive recognition that osteoarthritis patients are not going to benefit from meniscus surgery. Many, if not most, orthopedic surgeons have moved away from routine arthroscopy in these patients. It’s fair to say that if there’s a fair amount of arthritis present, the knee won’t get better from arthroscopy in most cases. People in their 40s and 50s with significant osteoarthritis probably won’t benefit from surgery.
TMA: Are the clinical guidelines regarding meniscus surgery likely to change soon? Will orthopedic surgeons be getting (and giving) new advice based on these recent studies?
Dr. Shea: It’s a high-priority topic for us (American Academy of Orthopaedic Surgeons), but it takes about 18 months to generate new guidelines.
TMA: Okay, so I’ve got a torn meniscus and a lot of knee pain. I show up in your office. What do you tell me, and what should I do?
Dr. Shea: Well, first, my job is not to tell the patient what to do, but to present the options. Much depends on the level of arthritis. In the middle-aged patient, arthroscopy is the third or fourth choice of treatment. We need to get better at communicating the alternatives. An appropriate therapy program, activity modifications, and weight loss may be just as effective as surgery, with lower cost, and lower risk. For older, active patients without significant osteoarthritis, treating symptomatic meniscus tears with surgery may be very beneficial in carefully selected cases.
TMA: What are other alternatives?
Dr. Shea: Sometimes it’s weight loss, or changing the physical activity. Go to cycling, elliptical training, or swimming instead of running. Or reduce the amount of running, and replace it with lower-impact fitness and cardiovascular activities.In many cases, meniscus symptoms may go away with time. There’s typically no time urgency. So I’m here to help patients know what their options are.
TMA: Are the days of “let’s go in there and clean it out a bit” over?
Dr. Shea: For the most part, yes. If you’ve got significant osteoarthritis, “cleaning out a knee”—trimming away loose, torn bits of meniscus or worn fragments of bone cartilage—is not a good idea. At one point we thought it was of value, but most of the time, for most patients, cleaning it out is not indicated.
TMA: But are there times when a meniscus repair is still indicated?
Dr. Shea: It may be indicated for acute symptoms. If a 40- to 50-year-old doesn’t have any osteoarthritis, we might treat them like a 20-year-old. Surgery may be indicated. In Idaho, we see see a fair number of 40- to 50-year-old skiers and mountain bikers with acute traumatic ACL and meniscus tears. Many of these patients may have better knee function with ACL and/or meniscus repair surgery. Furthermore, many of them do not have significant osteoarthritis. But I would still suggest options like switching activities for a while, especially for those with osteoarthritis.
Kevin Shea concluded the interview by recounting his own experience with a suspected meniscus tear. About four years ago, a couple of days after playing soccer, he suddenly felt popping and intermittent pain in one knee. He thought he had a tear of the outer meniscus. When it didn’t improve after a month or two, he went to a surgeon friend and said, “Hey, want to scope my knee?”
His doctor suggested an MRI first. It turned out that Shea simply had a small, loose piece of bone cartilage in his knee, possibly from an old high school injury. He opted for a couple of steroid shots to address significant swelling. And time.
“I stopped running almost completely for four months,” Shea says, “but continued cycling, swimming, and some elliptical training almost immediately, but at reduced intensity and volume. At one year, I resumed a more normal running program, and have had no return of symptoms over the last four years.”
Kevin Shea MD, orthopedic surgeon, middle-aged athlete—and poster guy for the benefit of shunning the all-too-common practice of meniscus surgery.