OrthoVirginia Blog

Do I Really Need an Operation?

By: Ben W. Kittredge, IV, MD

Two patients asked me this question last week while seeing me for a second opinion regarding knee arthroscopy.
The first patient, a 19-year-old college football player, has had intermittent discomfort in his knee for 6 months. There was no injury, just some soreness with running and doing squats. He had not tried any treatment aside from rest. He saw a popular, well-regarded sports medicine specialist in the area. This orthopaedic surgeon ordered an x-ray and an MRI of his knee. The MRI was read by a radiologist as normal. The orthopaedic surgeon recommended knee arthroscopy to “see what is going on.” He also recommended stem cell injections.
When I examined the patient, he had some mild discomfort underneath his knee cap and no other areas of tenderness. This is chondromalacia of the patella or softening of the cartilage under the knee cap. It is the most common cause of pain in the knee. It can also be referred to as patellofemoral syndrome, anterior knee pain or even runner’s knee.
Patellar chondromalacia is most effectively treated with a combination of anti-inflammatory medicine, activity modification, and physical therapy. Arthroscopic surgery is not predictably helpful for chondromalacia of the patella and should be a last choice, not the only choice.
The second patient was an 80-year woman with knee pain for the last several months. She had no injury. She had pain going up and down stairs and getting out of a chair. Walking was also uncomfortable. Her x-ray showed some arthritis in her knee. The MRI showed a medial meniscus tear, but, more importantly, significant arthritis underneath her knee cap.
A different orthopaedic surgeon recommended knee arthroscopy to take care of her medial meniscus tear, with no other options given. During my examination, I found that she was most uncomfortable underneath her knee cap. Her medial meniscus tear did not cause her any pain. Arthritis, which is the loss of cartilage from the ends of the bone, can be effectively treated successfully in a variety of non-operative ways. These include anti-inflammatory medication, physical therapy, cortisone injections, synthetic joint fluid injections (Synvisc, Hyalgan, Supartz, Orthovisc, Euflexxa), and multiple different types of braces. Arthroscopic surgery for a meniscus tear in the face of arthritis has a low success rate. In this patient, her pain was coming from the patella (knee cap) and not the meniscus.
Arthroscopy of the knee is one of the most common procedures performed in the US annually: about 1 million are done per year. As such, most orthopaedic surgeons feel very comfortable performing these operations and have likely done thousands over the span of their career. Arthroscopy is an extremely effective way to treat a torn meniscus.
Part of the job of the orthopaedic surgeon is to make the right diagnosis and advise patients the best treatment options for their condition. For these patients, knee arthroscopy was not the best choice. The best choice for their road to recovery would be non-operative treatment.
The message here is that patients need their orthopaedic surgeon, in the words of Spike Lee, to “Do the Right Thing.”

About the Author:

Dr. Ben Kittredge is a Sports Medicine Specialist out of our Alexandria and Springfield offices in Northern Virginia. He especially enjoys using his skills as an orthopedist to help athletes get back into their game. As one who always encourages his patients to remain active, he finds great satisfaction in seeing someone he has treated running alongside him at a marathon or local road race or playing on the tennis court across from him. As a runner, Dr. Kittredge has a special interest in treating running and triathlon injuries, as well as caring for all knee, shoulder, and sports injuries. His surgical specialties include ACL reconstruction and arthroscopic shoulder stabilization.

Active in a number of professional medical roles, Dr. Kittredge is the former Chief of Orthopaedics at Inova Alexandria Hospital and Chair of the Medical Records Committee at Inova Alexandria Hospital. In addition to treating amateur and professional athletes, he is also involved in student athletics within the community where he serves as team physician for St. Stephen’s/St. Agnes, and Episcopal High School.