Is Teen Knee Surgery Appropriate? Do Not Operate on a Meniscus Tear in an 8th Grader
POSTED ON 3/3/2018 IN Knee BY Christopher Centeno
One of the more harmful trends in orthopedic surgery of the last decade is treating kids like they are pro athletes. So this morning I'll share the case of an 8th grader who tore a meniscus and began a destructive surgical rabbit hole orchestrated by the world's best orthopedic surgeons. There are no two ways about it—the orthopedic surgical system failed this poor girl, and now she's in an awful spot, looking at a possible knee replacement before she turns 40.
Teen Knee Surgery Explodes
A decade or more ago, knee surgery in teens was rare. After all, kids heal well, and if they had a serious knee injury that didn't heal completely, it may be time to find a new sport. However, the rise of elite kids sports teams and 24/7 sports coverage of professional athletes and their surgeries have pushed many parents to want to get their kids treated like the pros. What these parents don't realize is that these pro athletes often end up disabled and wrecked by multiple aggressive surgeries when they're still young. Most hobble around in the 40s. However, a kid from the projects who is suddenly making millions a year really doesn't care if his knee works well when he's 40 if a knee surgery will get him a contract extension worth millions.
Knee Meniscus Surgery in an 8th Grader?
My patient was an 8th grader who injured her meniscus. Like most parents, since the surgeons often couch these procedures in terms of "repairing" the meniscus, they all likely thought that the tear would be repaired. However, only 4% of these procedures end up saving and repairing the meniscus. This one turned out to be one of the 96% of tears that was extensive enough that a partial meniscectomy was needed (part of the torn meniscus was removed). This one procedure began a surgical rabbit hole that involved treatment for an MCL injury and eventually more surgeries and a meniscus transplant. Eventually, she did well for seven years until things went south again, and she had a revision meniscus transplant and surgery to change the shape of her tibia. She's now 35, and her knee images are above. She's had many surgeries on this knee, and, quite frankly, it's trashed. Let's first look at the dead and dying bone in the tibia. This residual damage was caused by the surgery where they tried to reshape this bone to improve her chances of a revision meniscus transplant (her second) working. It didn't work, which brings us to the status of her meniscus, first operated on in 8th grade and since replaced twice with a transplant. It's trashed again. She also has had a huge bone spur form on her lateral femur that was removed surgically once already and now may be back (awaiting a new MRI). Finally, since all of these surgeries entered in through the area where the fat pad in the front of the knee lives, that structure, which is an important reservoir of natural stem cells in the knee, is now trashed and scarred.
Where Did All of This Go Wrong?
No matter how you cut it, these are awful surgical results. While complications can occur with any medical or surgical procedure, that's not what happened here. Instead, this has been a lollapalooza of over-the-top surgical aggressiveness that had no business ever being used in a teenager. First, there was no rationale for teen knee surgery on an 8th grader with a meniscus tear. She should have been told that this was ill-advised and given months to heal. However, this was the late '90s, before we knew that removing parts of the meniscus could wreck a knee and cause arthritis. Before we knew through three large randomized controlled trials that partial meniscectomy for all medical indications was not better than physical therapy or sham surgery.
We're Still Operating on Teens with Knee Meniscus Tears
Recently, a teen friend of my son's had an MRI taken of his knee for a two-year-old ski injury. A meniscus tear was identified, and he was told by a local surgeon that he needed a meniscus repair. However, the tear is extensive enough that it's more likely than not that this procedure will turn into a partial meniscectomy, just like our 8th grader above. I told the dad that if this were my son, I would try a high-dose PRP shot to this area before considering any type of surgery. That was before I met the patient whose journey began in the 8th grade above, but after seeing many teen surgical "train wrecks" who are now thirtysomethings who need a knee replacement. Suffice it to say that this road the surgeon was asking them to travel can be very treacherous. The upshot? This 8th grader saw the best surgeons in America, and all of them failed her. Why? The basic idea that an 8th grader with a meniscus tear should get surgery was flawed. While we really didn't know this based on research in the late '90s, the way we know it today, kids are still getting surgeries like they're thirtysomething NFL athletes trying to eek out a 5M contract extension. Time to stop this craziness! We should consider aggressive orthopedic surgery in a teen not an advancement of modern medicine, but a failure of imagination and our sacred duty to first do no harm! If we still need to operate, then at least we did everything we could to avoid another thirtysomething patient who needs a knee replacement.
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