Hip and knee joint replacements are on the rise.  According to the Canadian Institute for Health Information (CIHI) in 2018-2019 62,000 hip replacements and 75,000 knee replacements were performed in Canada.  This represents a 20 and 22% increase respectively over the last 5 years!!  Eek.  

The majority (75-99% according to CIHI) of these cases are the result of osteoarthritis.  This is the so called “wear and tear” form of arthritis.  But “wear and tear” is highly misleading as adequate wear and use is what keeps the cartilage lubricated and healthy.  Inadequate use of the joint on the other hand allows the cartilage to become more brittle and prone to an accelerated degeneration over time.  

But wait…  We are treating a disorder of poor joint function, by…replacing it?  Doesn’t sound right, does it?  This is a microcosm of our health care system’s approach.  Find the “broken part” and fix it.  Highly reactionary and problematic and representative of a broader systemic issue.

In short the knee pain story, all to often goes like this:

Family physician–>imaging–>orthopedic surgeon–>scope—->replacement

But follow along to see why this can be a slippery slope.

If you go to your family physician enough about knee pain, eventually you will get some imaging (likely an x-ray and/or MRI).  Chances are something will show up on imaging, because, well many of us have some flaws in our hardware which may or may not be part of the clinical problem.  A systematic review and meta-analysis (high level of evidence) in 2019 concluded in asymptomatic individuals over the age of 40, 43% had MRI findings of cartilage defects and 19% had MRI features of a meniscal tear.  A previous study found a 76% prevalence of meniscal damage in asymptomatic individuals and up to 91% in symptomatic individuals over the age of 50. 

So your imaging shows some findings, and if you are still struggling with your knee you eventually find your way to an orthopedic surgeon’s office.  And you can likely predict what happens next.  Your surgeon offers you an intervention based on your clinical and imaging findings of some cartilage irregularity/tear.  This is not just an issue with knee pain, check out a blog we wrote with a similar problem in the typical management of low back pain (back in 2015!)

Knee arthroscopy (commonly called a knee scope) is the likely starting point for cartilage issues of the knee.  It is one of the least invasive surgical procedures available and is commonly viewed as a temporary measure that can achieve pain relief and delay full knee replacement.  Not surprisingly it is one of the most common orthopaedic procedures performed and is also on the rise.

On the surface, this may seem like a fairly benign procedure.  But it is still surgery, with it’s inherent risks…and questionable efficacy.

A 2016 randomized controlled trial demonstrated no benefit after 2 years of follow up for middle aged patients with meniscal tears who underwent a partial meniscectomy (scope) versus 12 weeks of supervised exercise.  

In addition a recent study showed that patients who opted for a scope versus physiotherapy were 30% more likely to have a partial or total knee replacement.

Getting a scope, an invasive, risky and costly procedure, isn’t more effective and doesn’t delay a partial or full replacement better than exercise alone.  Again this doesn’t seem right.

Virtual knee Surgery

What if this whole goose chase of wasted precious time and health care resources could be skipped with a free, immediate virtual procedure?  No I’m not talking about some new age high tech robotic procedure you may have heard about on a TED talk.  I’m talking about a conceptual framework for managing chronic knee pain that I’ve borrowed from retired world renowned spine biomechanist Stuart McGill.  McGill recommends this for managing complicated back pain cases, but the premise is similar.

You get to pick your knee surgery date.  Imagine yourself in the days that follow that procedure.  What would your life be like if you just had knee surgery?  You would likely be resting for a short period, you would be eliminating all other activities and generally putting the health and care of your knee as your priority.  At some point in the first week or two you would look to start rebuilding your knee, starting the rehabilitation process.

If this sounds overly simplistic and possibly even rediculous, remember 12 weeks of supervised exercise is just as effective as surgery for managing meniscal tears in middle aged adults and you are less likely to eventually get a total knee replacement.  

Do yourself a favour, give yourself a virtual surgery and commit to the exercise process the same way you would if you just had surgery.