When to operate, wait or avoid soft tissue knee surgery

It’s worth noting that far too much keyhole surgery is done and has been done. I think it’s improving but the insurance companies have worked out that excessive use of surgery is fairly widespread.

A meniscus tear: to treat this common issue or not?

For example, the most common problem is somebody with a degenerate tear of their meniscus - usually the medial meniscus. And that’s a normal part of ageing and those people do not need an operation.

I’ve got one of those tears, it was sore for a couple of months but it’s got completely better. The usual scenario is someone my age - I’m 58 - decide they’re going to die so they start running having not run for over 20 years, and they overload their knee and get a sore kneecap.

If they’re well off, they’re insured so they get an MRI scan and it will show a meniscus tear - they’re very, very common. And if you meet someone who’s either foolish or perhaps unscrupulous, they will offer you surgery - when what you need is a strength and conditioning programme with a good physiotherapist. So, that’s one example of where surgery is rarely needed.

Who might or might not need ACL surgery?

There are some more controversial areas. Not everybody who has an anterior cruciate ligament rupture would need surgery. But, what I would summarise is that most young active people would benefit from a good operation. But, I choose my words very carefully because the worst thing is a bad operation.

So, you need to choose your surgeon very well if you’re going to have an operation. But if you’re active, if you want to play sport, if you want do activity that involves change in direction - that may even be dancing - and certainly if you want to ski, then most people benefit from the operation.

When meniscus tear surgery is crucial

There are some things, of course that always need surgery. For example, if there’s a big meniscus tear that displaces into the joint and jams it and you can’t get it knee straight - then that will need surgery within a matter of a few days: either to repair the meniscus or remove it, depending on the state of it and which meniscus it is. If it’s the lateral meniscus I would always do my best to save it because the consequences of losing it are so great.

The impact of delaying surgery (caused by covid)

With some soft tissue injuries, you do need to get on with surgery. And with the covid experience, when quite rightly, the elective planned surgery was very restricted, we have seen unfortunate consequences of that. For example, patients with a locked knee, with a meniscus a meniscus that’s displaced and jamming the joint, patients couldn’t get the knee out straight. If that’s left too long, they may never get their knee straight and then require surgery to correct that.

Around the country there have been cases of that - sadly you can understand the circumstances. There are other cases where it’s less urgent but for example with anterior cruciate ligament surgery, the success of an operation long term can be determined partly by the time between injury and surgery. And there’s increasing evidence that if an ACL is left for a year or more and in some reports, even 6 months or more, that the long-term results are inferior.

Can you operate too early?

On the contrary,there are some situations where having surgery too early is bad and this is really important for skiers to know because there are resorts in the alps that will encourage patients to have surgery immediately, within a day or so of injury. Very rarely is that necessary and it often leads to problems.

In fact, if somebody has an injury and the knee is very inflamed and stiff, they then have a second injury – and surgery is a controlled injury – it can make all of that worse. We do see patients being flown back from the Alps following what I would say is excessively early surgery with significant complications of stiffness, that can be permanent.

Mr Andy Williams is a co-founder of Fortius Clinic in London - a specialist centre for orthopaedics, with a strong emphasis on sporting injury. He treats many of this country's elite athletes, so timing treatment and rehabilitation are of deep special interest.