Dr. Tom Miller talks to orthopedic surgeon Dr. Bruce Thomas about new approaches doctors and patients can take to examine and treat knee injuries before choosing surgery to "scope" a knee. Find out what to do if you have knee pain from an injury.">

Nov 29, 2016 — Have you recently injured your knee? You may not need surgery. Dr. Tom Miller talks to orthopedic surgeon Dr. Bruce Thomas about new approaches doctors and patients can take to examine and treat knee injuries before choosing surgery to "scope" a knee. Find out what to do if you have knee pain from an injury.

Interview

Dr. Miller: You've injured your knee, what's the next step? Should you have it scoped? We're going to talk about that next on Scope Radio.

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Dr. Miller: Hi, I'm Dr. Tom Miller and I'm here with Dr. Bruce Thomas. He's an orthopedic surgeon here in the Department of Orthopedic Surgery at the University of Utah. He also has a practice at our Farmington facility. And Bruce, what's the story? There's been a lot of changes. I think folks who have injured their knees and have some swelling or clicking or pain, it used to be that a number of people would obtain or go to the orthopedic surgeon and they would have an arthroscopic procedure. That is, they would put a little scope inside the knee and look around. And more recently, there's been some changes in that thinking.

Dr. Thomas: That's true. There's more of a collaborative effort. In the old days, a doctor told the patient what the treatment was, and these days the doctor will share information with them and make recommendations. Not every meniscus tear requires surgery. Many people can do their regular life activities and the pain will subside, and it's not clear, in those patients, that knee arthroscopy will help them.

Dr. Miller: It's interesting to me because, I mean, do they know that they have a meniscal tear before we do the arthroscopy, or do we do the arthroscopy to find out that they have a meniscal tear? Or there might be a misunderstanding among patients about the purpose of the arthroscopy.

Dr. Thomas: For many meniscus tears, you can tell if it's present by the patient's history and by the physical exam. If there's questions, an MRI is 96% accurate at predicting a meniscus tear.

Dr. Miller: So now we have way, radiologically, to look at the joint, find out if you have a tear, without doing a surgical procedure?

Dr. Thomas: That's correct.

Dr. Miller: So, if you have a meniscal tear and you either figure that out based on the examination or the MRI, what role would arthroscopy play nowadays?

Dr. Thomas: If the patient has significant symptoms that aren't resolving with conservative measures and it prevents them from doing their regular activities, arthroscopy can assist the restoration of function and decrease in pain. It's a small out-patient surgery with, usually, two or three very small incisions, and the meniscus is either repaired or the damaged portion trimmed out, depending on the findings at surgery.

Dr. Miller: So, what you said I think is important, is that you don't do the arthroscopy immediately, you try some conservative measures first.

Dr. Thomas: That's true.

Dr. Miller: Is that the standard now?

Dr. Thomas: I believe that's the standard, because many people can function with a meniscus tear. The older literature suggested that an untreated meniscus tear will lead to earlier arthritis. Subsequent studies are less clear on that, and it depends much on the size, location, geometry of the tear, as well as the patient's activity level.

Dr. Miller: You know, many years ago they used to go in, when you had a meniscal tear, and they just took out a lot of the meniscus, a large percentage of it, and I think that was the standard back in the day. Is that right?

Dr. Thomas: That's true. Before the invention of arthroscopy, an open procedure would be made and the entire meniscus would be removed. And there are some papers that suggest that those patients would have end-stage arthritis within seven years of that procedure.

Dr. Miller: So they don't do that anymore?

Dr. Thomas: We don't do that anymore.

Dr. Miller: So the concept was, if you used an arthroscope, you could go in and take smaller pieces of the meniscus near where it was damaged, and that that might result in improved function, less pain.

Dr. Thomas: True. That's true. It will decrease their pain, improve their function, and if we can save even a rim of 3mm or 4mm, that's been shown to still function in preventing arthritis for the patient.

Dr. Miller: What were some of the things that patients received arthroscopy for in the not-too-distant past that are no longer done? For instance, I know that some patients have had an arthroscope to wash out the knee joint. Do they still do that, and does that have any therapeutic value?

Dr. Thomas: That really, probably, has no therapeutic value. Arthroscopy is not a treatment for arthritis. You use arthroscopy to treat mechanical symptoms associated with meniscus tears or, infrequently, loose fragments of cartilage. Symptoms like catching, locking, giving out, those kind of symptoms.

Dr. Miller: After you do an arthroscopy, how soon can the patient get back to normal activity?

Dr. Thomas: If there are no surprises and the articular cartilage is in good shape, we usually encourage them to start walking the day of surgery. Swelling takes longer to go away. Maybe four to eight weeks, depending on the setting. Many patients can get back to most of their life activities within eight weeks.

Dr. Miller: Now, are there any risks with arthroscopy? Obviously, there are risks with any surgical or invasive procedure. I would assume that those risks are less than they would be if you had an open procedure, an open, standard surgical procedure.

Dr. Thomas: That's true. The risk of infection, for example, is going to be far less than 2% with arthroscopy. There is some evidence that once you've had a meniscus tear on one side, you're a little more likely to have it on your opposite knee. And with removal of meniscal tissue, the loads on your joint surface are higher, and so you do wear your cartilage quicker and may be a little more likely to get arthritis down the road.

Dr. Miller: So, bottom-line, basically, is if you have knee pain and potentially a meniscal tear, you're going to probably want to go through conservative treatment first, before proceeding onto an arthroscopic procedure, and that you're working with your orthopedic surgeon you can define the best time for that, if that needs to occur.

Dr. Thomas: That's true.

Dr. Miller: Thank you very much, Bruce.

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