Bilateral Arthroscopic Knee Surgery

[erijon]

I have had many knee injuries over the past few years with considerable chronic pain. MRIs of both knees show tears in the meniscus, bucket tears specifically, as well as grade II MCL tears. In addition to the soft tissue damage, both knees show degenerative OA. I have just relocated and started seeing a new Orthopedic surgeon and he is recommending doing arthroscopic surgeries on both knees which is scheduled for February 3rd. If he had his way, he would like to replace the left joint due to the advanced OA as he feels repairing the meniscus will relieve some of the pain but not all of it. My insurance company has recommended that he try repairing the meniscus issues first and if that fails they will authorize the knee replacement. I am a 50 year old male and the insurance company would prefer to put off the knee replacement for at least 5 years to keep from doing it twice.

I have a couple of questions, first is the insurance company being reasonable? My Orthopedic reluctantly agrees with them. Second, is it a good idea to do both knees at the same time and will it make recovery more difficult?

I can't continue like it is, I can't sleep or spend much time on my feet and I refuse to get on strong narcotic pain killers so I need to take action. I reluctantly take 7.5mg of Hydrocodone now at night so I can get some sleep. Your thoughts?

Thanks in advance.

Jon

[Michael L Gross, MD]

Debridement or lavage refers to an arthroscopic "clean out" of the arthritic knee.  Sort of a D & C of the knee.  This is the surgical procedure that is being adrressed, not meniscus surgery

If the meniscus tears are degenerative, and they are not acute; that is, if they are not the cause of your symptoms, then there is no indication to address them.  Also, I think your surgeon likely recommended removing the damaged meniscus, not repairing it.

If the meniscal damage is the cause of pain, and what we call "mechanical symptoms"  then the recommendation, is definitely arthroscopic medial menisectomy.

[erijon]

Not sure I fully understand what this means. Are they saying that we shouldn't repair the meniscus tears either?

[Michael L Gross, MD]

One last comment quoted from the recent recommendations for the treatment of knee arthritis by the American Academy of Orthopedic Surgeons:

Recommendation 18
We recommend against performing arthroscopy with debridement or lavage in patients with a primary diagnosis of symptomatic OA of the knee.
Level of Evidence: I and II
Grade of Recommendation: A

[erijon]

Thanks for the feedback, it helps considerably. I'm going to ask the insurance company to reconsider and see if I can get the Orthopedic involved as well. I also think I'll just do one knee at a time, don't like the idea of both being done at once, seems it would make rehab more difficult.

Also, I agree, the 7.5 mg of Hydrocodone is certainly a potent narcotic, I was not trying to downplay that fact. My point was I am prescribed one every 4 -6 hours as needed and refuse to take them at that level, I will only take one before bed so I can get enough relief to sleep, even with that it only lasts for about 4 hours. I am confident that through surgery we will get rid of most of the pain and I don't want my body accustomed to getting high dosages of Hydrocodone.

Thanks again!

Jon

[Michael L Gross, MD]

For mild to moderate OA without an angular deformity (bowlegs or knock knees) arthroscopy can give some relief in 80% of patients for up to five years.  If there is a acute onset of mechanical symptoms, such as locking, the success rate goes up even more.  However, one recent study suggested that for most cases of chronic arthritis, arthroscopy is no more successful that medical treatment and physical therapy.

In my practice, I do not allow for insurance companies to dictate a patients particular course of treatment.  Especially, if they are asking me to perform an operation which I don't think is appropriate. Since I dont know the specifics of your case, I would not be a good judge.  However, if your surgeon feels that a knee replacement would give you a more predictable result, then I would be inclined to argue with the insurance company.

Two last comments.  I don't routinely do bilateral cases.  7.5 mg of hydrocodone is a strong narcotic painkiller.