When To Have Knee Surgery
The choice to have an orthopaedic surgical procedure has many facets. Here are a few decision trees that make sense for the knee joint.
Deciding when to have something repaired versus just rehabilitating it non-operatively is sometimes challenging and sometimes straightforward.
Here are six points to consider: It is important to have surgery when you are sure of the diagnosis, the tissues injured can be treated effectively, the non-operative options are not good enough, your confidence in your ability to rehabilitate is high, your belief in the biases and skills of your surgeon are super high, and you are optimistic about your outcome. Otherwise, delay.
A few stories:
“Doc, I twisted my knee, heard a pop, and my knee swelled.” This is 90% of the time a surgically repairable problem such as a torn meniscus cartilage, a damaged ligament, or damaged articular cartilage (the bearing surface of the joint). If repaired early, each of these critical tissues can be saved and the knee joint returned to full activity. Untreated, arthritis often sets in.
“Doc, I have bone-on-bone arthritis and was told to give up sports, stay home and rest my knee, or just bike and swim—both of which I hate.” Here the patient has a choice. Many first try a cocktail injection: a mixture of the lubricant hyaluronic acid and PRP (Platelet-Rich Plasma), growth factors present in their own blood. Even with bone-on-bone arthritis, these injections—when combined with a great rehab program—often allow them to enjoy the ski season. The strategy is so effective that I commonly hear “Doc, I won’t let you fix my knee until those lube jobs stop working!”
When the bone-on-bone knee arthritis is causing pain and loss of motion and not responding to lube jobs and rehab, it is time to repair it. Still, a huge number of people who were told they need a total knee replacement might be able to have a biologic solution. This involves replacing the missing tissues and repairing the articular cartilage. A partial knee replacement requires less surgery, and results in a more normal-feeling knee, better range of motion, and an earlier return to full sports.
“Doc, my kneecap is loose. It used to dislocate, and now just hurts.” Anterior knee pain (i.e., pain in the front of the knee) can be the most difficult to diagnose, deduce the cause, and treat. And living with anterior knee pain is difficult, as every time you go up and down stairs or walk and hike the hills, your knee talks to you.
Muscle strengthening, knee braces, taping, and gait training are employed by almost every therapist. These strategies are sometimes effective, yet patients rarely comply enough to make a big difference. If the kneecap is unstable, a ligament reconstruction procedure using a donor graft can stabilize the kneecap. Our ballet dancers and hyper-mobile athletes are the most common recipients of this treatment.
If the kneecap is arthritic and has bone-on-bone grinding, either a cartilage repair procedure or a partial knee replacement for just the patella femoral joint is quite effective in restoring pain-free function. If the arthritis is not too bad, and the cartilage is just frayed, simple smoothing of the tissue, combined with lubrication and growth factor cocktails, can often solve it.
“Doc, my knee buckles and gives way when twisting.” Instability in life and in knee joints leads to bigger problems. Fortunately, all of the knee joint ligaments, if freshly torn, can be repaired or reconstructed with your own or donor ligament. The techniques are now often combined with using factors to recruit your own stem-cell-derived repair cells. This can speed up a return to full sports.
“Doc, my knee locks and has hurt on the joint line since I had part of my meniscus removed. Isn’t there just a shock absorber you can put in my knee?” Even small sections of loss can lead to significant arthritis. A torn meniscus should be repaired if at all possible, and replaced if necessary. It can be replaced later in life as well. Our recent data shows that, in many cases, doing this can delay and often eliminate the need for an artificial knee replacement.
So: Get an early, accurate diagnosis, then treat with non-operative methods when critical tissues are not at risk. Surgically repair, reconstruct, or replace when tissues are dysfunctional. Millions of years of evolution gave you those tissues for a reason. A few decades of surgical skill improvements can now give them back to you.
