Dr. Roach: A second opinion is warranted after ‘clean out’ for knee arthritis

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Dear Dr. Roach: I am a 71-year-old male, 6 feet 1 inch tall, weigh 240 pounds and have atrial fibrillation. It has not impacted my lifestyle. About 90 days ago I had meniscus surgery called a “clean out.” Afterward, my orthopedic surgeon said I should be much better, even though there was significant arthritis. The surgery has not provided me much relief. After examination yesterday, the doctor injected my knee with cortisone, explaining this was the last alternative before a knee replacement.

The surgeon explained he has had two patients with a similar physical condition die within days of having a knee replacement, and he is reluctant to do one for me. I’d like your thoughts as how to proceed if the cortisone does not bring me relief.

Dr. Keith Roach

— M.H.

Dear M.H.: I am puzzled by what the orthopedic surgeon has done and said. You’ve identified two diagnoses in your knee: arthritis and meniscal disease. The “clean out” you describe sounds like a procedure called arthroscopic debridement that used to be done back in the 1980s and ‘90s, when I was a student and resident. These procedures have largely been abandoned as they have been repeatedly shown in well-done trials to have no benefit when compared with standard treatment, such as exercise and physical therapy.

Similarly, cortisone injections used to be a standard part of therapy, but again, several trials have shown that they do not offer any improvement over injection with just an anesthetic, suggesting that most of the benefit perceived by patients is a placebo response. Repeated cortisone injections over years damage the cartilage in the knee.

In an experienced hospital, where cardiologists and surgeons work together, there is no significant increase in risk for knee replacement surgery in a person with atrial fibrillation. Precautions must be taken, of course, but many patients with AFib sail through knee replacement surgery.

Based only on what you are saying, I am concerned the orthopedic surgeon is not practicing the current standard of care. He also may have allowed his own bad experience to keep him from recommending a procedure that could dramatically improve your quality of life. There are two sides to every story, and maybe there are good reasons for what the surgeon has done based on medical information I don’t know, but I recommend you get a second evaluation by a different surgeon.

Dear Dr. Roach: I became lactose intolerant after back surgery last summer. The recovery was difficult only because my appetite was gone for over two weeks. Trying to regain some weight, I did smoothies but I had an unpleasant digestive reaction. I am on lactose-free everything but wish I could go back to using even small amounts of lactose-containing foods. What happened? Will I be able to go back to having anything with milk in it? I am 76.

— C.L.

Dear C.L.: Intolerance to lactose-containing foods, mostly milk and cheese, is increasingly common as we age. Still, it is unusual to see sudden onset of symptoms in a person in their 70s, and I suspect it was due to the challenge to your gut of having increased amounts of lactose in your smoothies.

There are many foods available in a lactose-free version. You can try taking a lactase enzyme supplement prior to having regular lactose-containing foods. My experience is that they work pretty well for some people and not at all well for others, and that too much lactose will always overcome the benefits of the enzyme.

Readers may email questions to ToYourGoodHealth@med.cornell.edu.