Knee pain and injury: When is a surgical consult needed?
This review identifies clinical scenarios—such as unstable or displaced fractures, major tendon ruptures, and significant mechanical issues—that likely warrant surgical consultation.
PRACTICE RECOMMENDATIONS
› Consider surgical management, potentially emergently, for acute knee injuries that result in significant joint instability, unstable fractures, or neurovascular compromise. A
› Avoid arthroscopy for chronic, degenerative sources of knee pain, such as osteoarthritis and degenerative meniscus tears, as it is no longer routinely recommended. A
› Treat osteoarthritis surgically after nonsurgical treatments have failed. A
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Other common causes of chronic knee pain include chronic tendinopathy or biomechanical syndromes such as patellofemoral pain syndrome or iliotibial band syndrome. Surgical treatment of these conditions is pursued in select cases and only after exhausting nonoperative treatment programs, as recommended by international consensus statements,38 societal guidelines,39 and expert opinion.40 High-quality data on the effectiveness, or ineffectiveness, of surgical intervention for these conditions are lacking.
Despite being one of the most commonly performed surgical procedures in the United States,41 arthroscopic partial meniscectomy treatment of degenerative meniscus tears does not lead to improved outcomes compared to nonsurgical management, according to multiple recent studies.42-45 Evidence does not support routine arthroscopic intervention for degenerative meniscus tears or OA,42 and recent guidelines recommend against it46 or to pursue it only after nonsurgical treatments have failed.37
Surgical management of degenerative knee conditions generally consists of partial or total arthroplasty and is similarly considered after failure of conservative measures. Appropriate use criteria that account for multiple clinical and patient factors are used to enhance patient selection for the procedure.47
Takeaways
Primary care clinicians will treat patients sustaining knee injuries and see many patients with knee pain in the outpatient setting. Treatment options vary considerably depending on the underlying diagnosis and resulting functional losses. Several categories of clinical presentation, including neurovascular injury, unstable or displaced fractures, joint instability, major tendon rupture, significant mechanical symptoms such as a locked knee, certain osteochondral injuries, and septic arthritis, likely or almost always warrant surgical consultation (TABLE3-10,12-36). Occasionally, as in the case of neurovascular injury or septic arthritis, such consultation should be emergent.
CORRESPONDENCE
David M. Siebert, MD, Sports Medicine Center at Husky Stadium, 3800 Montlake Boulevard NE, Seattle, WA 98195; siebert@uw.edu
