Arthroscopy meniscus or not?
January 5, 2014 | 30,00 EUR | answered by Dr.med. Tobias Theben
Hello,
I am faced with the question of whether I should have arthroscopy of the knee joint done. I am 69 years old, and I have had meniscus problems in both knees since I was a student and sports student, I was in hospitals, in casts, had to rest... Last time was in 1964 at the University Hospital in Kiel, they diagnosed degenerated meniscus, the operation was deemed hopeless. I dropped out of sports studies, did nothing sporty for 10 years, then started again with dancing, walking, etc. I had no complaints until 6 weeks ago (so for over 40 years) - then I woke up in the morning with the familiar pain, stabbing pain in the inner meniscus on the right, difficulty bending and stretching the leg. (Before that, I had completed several theater performances with dance interludes). MRI and CT showed the following results: The inner meniscus anterior and posterior horns are only hinted at and clearly hyperintense. The outer meniscus is intact. Anterior and posterior cruciate ligaments are inconspicuous. Proper collateral ligaments.. The cartilage in the medial and lateral main load-bearing zones is thin and shows significant defects medially. The retropatellar cartilage has defects on the medial facet. No subchondral edema. (So): Almost completely dissolved or resorbed inner meniscus. Intact ligaments.
But also: Insufficiency fracture of the dorsomedial tibia head. No fragment displacement.
The whole procedure: Orthopedist, MRI, CT, orthopedist again, clinic appointment has taken almost 6 weeks so far. During this time - with rest - I no longer have knee pain, I can even go into a squat without pain, although with noticeable stretching. What I feel is an uncertainty below the kneecap, no pain, but an indefinable warning sign: Caution! And I have taken that into account - rest.
My clinic appointment is on Wednesday - and I would like a second opinion: My orthopedist advised me - in a fairly busy practice and very short consultation - to have the surgery done and also gave me the name of the surgeon (St Jürgens Hospital Bremen), where I have an appointment on Wednesday.
I know that my meniscus has deficits, that the tibia fracture is a "fatigue fracture", and that there is progressing arteriosclerosis -
But: I have read so much about failed arthroscopies - I have no pain at the moment - although I am still not daring to dance again -
Despite clear meniscus damage diagnostics for 40 years, I have been able to do anything I wanted, could this still be possible after further rest - without surgery - in a senior-friendly sports extent (dancing, cycling)?
What is your opinion?
Dear patient,
Based on the situation you have described, one thing is particularly important to determine: your current lack of complaints, even under normal everyday stress (!!) - there are very few acute exceptional cases in which even a patient free of complaints in orthopedics should be advised to undergo a procedure. In your case, I strongly recommend a wait-and-see approach, preferably after consulting with your surgeon. Ultimately, the deciding factor for your decision should always be your complaints and not a previously agreed upon surgery date.
After 40 years of being complaint-free, your medial meniscus has indeed undergone extensive degenerative changes ("worn out") - it may no longer be partially distinguishable. As long as it does not bother you regularly, there is no real prospect of significantly improving anything through a joint arthroscopy - and as you rightly pointed out, certain risks must be taken into account for any procedure.
According to your information, the most likely diagnosis for you is a so-called "activated osteoarthritis" with severely thinned cartilage on the inside. Any joint wear and tear can sometimes cause such pronounced complaints, which can also be exacerbated by tears in the medial meniscus. In this case, (apart from rare exceptions such as meniscus entrapment or pronounced capsule irritations) conservative treatment should always be the first choice:
- Rest, controlled stress, cooling,
- Walking on flat ground,
- possibly using cushioning or corrective insoles,
- moderate strengthening of the thigh muscles in the pain-free range
(especially isometric exercise forms)
- initially also depending on complaints, "anti-inflammatory pain medication" (NSAIDs) such as Voltaren/Ibuprofen.
For manageable cartilage damage grades I-III°, in addition to a dietary supplement therapy with glucosamine/chondroitin sulfate (e.g. Dona 2 times a day), an infiltration treatment with cartilage-preserving injections into the joint (with hyaluronic acid) can provide sustained improvement of complaints for up to 6 months.
Only if these measures have been carefully considered and applied to you, and if no improvement in complaints has occurred after 6 weeks, should surgical intervention be considered. Clinical studies have not shown any truly sustainable improvement through arthroscopic joint debridement for such a finding.
I consider the "stress fracture" of the posterior tibial plateau without adequate impact or twisting trauma, or indeed a visible contour interruption in the CT scan, to be more of a so-called "bone bruise / bone edema", which in an MRI usually shows an overload of the bone beneath the fragile thin cartilage lamella - if you are completely free of complaints, you should still be able to fully bear weight. The "instability" below the kneecap may also improve further with some patience. A well-executable squat is always a good sign for any "aging" knee joint!
With this in mind, there is nothing stopping you now from trying moderate, pain-dependent activities such as walking, cycling, or dancing. If the joint swells under these activities, the dosage should be adjusted or the conservative treatment spectrum outlined above should be discussed with your orthopedic surgeon...
Best regards from Cologne,
Tobias Theben
