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Nin DZ, Chen YW, Talmo CT, Hollenbeck BL, Niu R, Chang DC, Smith EL, Mattingly D. Arthroscopic Procedures Are Performed in 5% of Patients With Knee Osteoarthritis 1 Year Preceding Total Knee Arthroplasty and Are Associated With Increased Stiffness and Increased Costs. Arthrosc Sports Med Rehabil 2023; 5:100776. [PMID: 38155763 PMCID: PMC10753171 DOI: 10.1016/j.asmr.2023.100776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 06/15/2023] [Indexed: 12/30/2023] Open
Abstract
Purpose To describe the different types of arthroscopic procedures that patients undergo in the year prior to total knee arthroplasty (TKA), reveal the cost associated with these procedures, and understand the relationship between preoperative arthroscopy and clinical outcomes after TKA. Methods An observational cohort study was conducted using the IBM Watson Health MarketScan databases. Patients with knee osteoarthritis who underwent unilateral isolated primary TKA between January 1, 2018, and September 30, 2019, were included. Knee arthroscopic procedures performed in the 1-year period before a primary TKA was identified. The primary outcomes of interest were cost of these procedures and the risk of 90-day postoperative complications. Results In total, 2,904 patients, representing 5.2% of the analyzed cohort, underwent arthroscopic procedures in the year prior to TKA. The most common procedure and diagnosis were meniscectomy and meniscal tear, respectively, with procedures performed an average of 7.2 ± 3.0 months before TKA. Average per patient costs were $9,716 ± $5,500 in the highest payment quartile vs $1,789 ± 636 in the lowest payment quartile. Patients with a history of arthroscopy were more likely to develop postoperative stiffness (P = .001), while no difference was found in the risk of 90-day periprosthetic joint infection (PJI). Conclusions Of the patients, 5.2% underwent knee arthroscopy in the year prior to TKA. While no association was seen with PJI risk, the costs associated with these procedures are high and may increase the overall cost of management of knee osteoarthritis. Level of Evidence Level III, retrospective comparative study.
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Affiliation(s)
- Darren Z. Nin
- Department of Orthopedic Surgery, New England Baptist Hospital, Boston, Massachusetts, U.S.A
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Ya-Wen Chen
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Carl T. Talmo
- Department of Orthopedic Surgery, New England Baptist Hospital, Boston, Massachusetts, U.S.A
| | - Brian L. Hollenbeck
- Division of Infectious Diseases, New England Baptist Hospital, Boston, Massachusetts, U.S.A
| | - Ruijia Niu
- Department of Orthopedic Surgery, New England Baptist Hospital, Boston, Massachusetts, U.S.A
| | - David C. Chang
- Department of Orthopedic Surgery, New England Baptist Hospital, Boston, Massachusetts, U.S.A
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Eric L. Smith
- Department of Orthopedic Surgery, New England Baptist Hospital, Boston, Massachusetts, U.S.A
| | - David Mattingly
- Department of Orthopedic Surgery, New England Baptist Hospital, Boston, Massachusetts, U.S.A
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Rampersaud YR, Canizares M, Zywiel MG, Leroux T, Gandhi R, Veillette C, Marshall W, Ogilvie-Harris D, Cram P, Coyte P, Mohamed N. Evaluation of Trends in Knee Arthroscopy from 2004 to 2019 in Ontario, Canada. NEJM EVIDENCE 2022; 1:EVIDoa2100036. [PMID: 38319226 DOI: 10.1056/evidoa2100036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
BACKGROUND: How changes in recommendations for the use of knee arthroscopy have influenced real-world practice remains unclear. We assessed temporal trends in knee arthroscopy volume, costs, and rates of progression to knee arthroplasty following arthroscopy in Ontario, Canada. METHODS: We used diagnostic codes from population-based administrative databases from Ontario, Canada, to identify patients who underwent knee arthroscopy from April 1, 2004 to March 31, 2019. We calculated arthroscopy volume, costs, and rates of progression to knee arthroplasty within 1, 2, and 5 years following arthroscopy. RESULTS: A total of 408,040 arthroscopy procedures were included. The number of procedures declined 8.9% from 24,070 in 2004/2005 to 21,930 in 2018/2019. The volume of arthroscopy for osteoarthritis declined by 77.9% between 2007/2008 and 2018/2019. For degenerative meniscus disorders, the volume increased by 57.6% between 2004/2005 and 2013/2014, and then declined by 34.6% between 2013/2014 and 2018/2019. Among patients with osteoarthritis, rates of progression to knee arthroplasty were 3.8%, 9.6%, and 16.0%, at 1, 2, and 5 years, respectively, compared with rates among patients with degenerative meniscal disorders, which were 1.6%, 4.1%, and 7.3% at 1, 2, and 5 years, respectively. Over this period, progression to knee arthroplasty rates declined across diagnosis groups. These trends remained after adjusting for patient, surgeon, and hospital characteristics. CONCLUSIONS: In Ontario, Canada, utilization of knee arthroscopy declined between 2004/2005 and 2018/2019, with a concomitant decline in the rates of progression to knee arthroplasty within 1 to 5 years. Among the possible interpretations, our data are consistent with the hypothesis that clinical practice evolved as evidence-based recommendations against the use of knee arthroscopy for degenerative diagnoses were promulgated. (Funded by the Toronto General and Western Hospital Foundation through the University Health Network–Schroeder Arthritis Institute.)
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Affiliation(s)
- Y Raja Rampersaud
- Schroeder Arthritis Institute, University Health Network, Toronto
- Division of Orthopaedic Surgery, University Health Network, Toronto
- Department of Surgery, University of Toronto, Toronto
| | | | - Michael G Zywiel
- Schroeder Arthritis Institute, University Health Network, Toronto
- Division of Orthopaedic Surgery, University Health Network, Toronto
- Department of Surgery, University of Toronto, Toronto
| | - Timothy Leroux
- Schroeder Arthritis Institute, University Health Network, Toronto
- Division of Orthopaedic Surgery, University Health Network, Toronto
- Department of Surgery, University of Toronto, Toronto
| | - Rajiv Gandhi
- Schroeder Arthritis Institute, University Health Network, Toronto
- Division of Orthopaedic Surgery, University Health Network, Toronto
- Department of Surgery, University of Toronto, Toronto
| | - Christian Veillette
- Schroeder Arthritis Institute, University Health Network, Toronto
- Division of Orthopaedic Surgery, University Health Network, Toronto
- Department of Surgery, University of Toronto, Toronto
| | - Wayne Marshall
- Schroeder Arthritis Institute, University Health Network, Toronto
- Division of Orthopaedic Surgery, University Health Network, Toronto
- Department of Surgery, University of Toronto, Toronto
| | - Darrel Ogilvie-Harris
- Schroeder Arthritis Institute, University Health Network, Toronto
- Division of Orthopaedic Surgery, University Health Network, Toronto
- Department of Surgery, University of Toronto, Toronto
| | - Peter Cram
- Department of Internal Medicine, University of Texas Medical Branch, Galveston
| | - Peter Coyte
- Institute of Health Policy, Management and Evaluation, School of Public Health, University of Toronto, Toronto
| | - Nizar Mohamed
- Schroeder Arthritis Institute, University Health Network, Toronto
- Division of Orthopaedic Surgery, University Health Network, Toronto
- Department of Surgery, University of Toronto, Toronto
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Previous History of Knee Arthroscopy in Patients Undergoing Total Knee Arthroplasty: An Examination of the Effect of the Literature and American Academy of Orthopaedic Surgeons 2013 Arthroscopy Guidelines on Clinical Practice. Arthrosc Sports Med Rehabil 2021; 3:e861-e866. [PMID: 34195655 PMCID: PMC8220600 DOI: 10.1016/j.asmr.2021.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 02/18/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose To compare the rate of previous knee arthroscopy in patients undergoing total knee arthroplasty (TKA) before (2005-2006) and after (2018) publication of landmark studies that examined the effectiveness of knee arthroscopy as well as the American Academy of Orthopaedic Surgeons 2013 knee arthroscopy guidelines. Methods We performed a retrospective chart review of 214 patients who underwent a TKA between 2005 and 2006 (Group 1) and 213 patients who underwent a TKA in 2018 (Group 2). We reviewed medical records to determine whether previous knee arthroscopy was performed. Group comparisons were made using the t test for continuous data and the χ2 test for categorical data, and means ± standard deviation are presented. Results Patients in Group 2 were older than those in Group 1 (67.0 ± 8.3 vs 64.3 ± 11.5 years, P = .01); however, there were no differences between groups with respect to sex (P = .40), body mass index (P = .36), and laterality of TKA (P = .05). There was no difference in the history of previous knee arthroscopy between Groups 1 and 2 overall (27% vs 32%, P = .27) and within 10 years of TKA (17% vs 15%, P = .44). Conclusions We did not find a difference in the number of previous knee arthroscopies for patients undergoing TKA in 2018 versus 2005-2006. This suggests that the recommendations set forth by landmark clinical trials that examined the effectiveness of knee arthroscopy and the AAOS 2013 knee arthroscopy guidelines did not have a sudden impact within our geographic region, but there is some evidence to suggest a gradual shift in treatment, where knee arthroscopy is withheld near imminent knee arthroplasty. Level of Evidence III, retrospective comparative study.
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Agarwalla A, Gowd AK, Liu JN, Amin NH, Werner BC. Rates and Risk Factors of Revision Arthroscopy or Conversion to Total Knee Arthroplasty Within 1 Year Following Isolated Meniscectomy. Arthrosc Sports Med Rehabil 2020; 2:e443-e449. [PMID: 33134979 PMCID: PMC7588599 DOI: 10.1016/j.asmr.2020.04.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Accepted: 04/17/2020] [Indexed: 02/01/2023] Open
Abstract
Purpose To identify the rates of and risk factors for revision arthroscopy and conversion to total knee arthroplasty (TKA) within 1 year of isolated meniscectomy. Methods Humana and Medicare national insurance databases were queried for patients who underwent isolated meniscectomy. Patients who underwent revision arthroscopy or TKA within 1 year postoperatively were identified by International Classification of Diseases Procedural Codes, Ninth Revision, and Current Procedural Terminology codes. Multivariate binomial logistic regression analysis was used to identify risk factors, and adjusted odds ratios (ORs) and 95% confidence intervals (Cis) were calculated, with P < .05 considered significant. Results A total of 13,142 patients and 407,888 patients underwent isolated meniscectomy in the Humana and Medicare databases, respectively. Of the patients, 395 (3.01%) and 3,770 patients (0.92%) underwent revision arthroscopy, and 629 patients (4.79%) and 38,630 patients (9.47%) underwent TKA within 1 year of meniscectomy in the Humana and Medicare databases, respectively. Obesity (Humana: OR = 1.33, P = 0.003; Medicare: OR = 1.10, P < 0.001) and age < 20 years (Humana: OR = 2.64, P = 0.022), 20-29 years (Humana: OR = 3.30, P = 0.002), 40-49 years (Humana: OR = 3.80, P < 0.001), 50-59 years (Humana: OR = 1.99, P = 0.027), and < 64 years (Medicare: OR = 1.74, P < 0.001) were risk factors for revision arthroscopy. Obesity (Humana: OR = 1.64, P < 0.001; Medicare: OR = 1.37, P < 0.001), morbid obesity (Medicare: OR = 1.20, P < 0.001), age 70-74 (Medicare: OR = 1.12, P < 0.001), 75-79 (Medicare: OR = 1.25, P < 0.001), 80-84 (Medicare: OR = 1.20, P < 0.001), and concomitant osteoarthritis (Humana: OR = 1.42, P < 0.001; Medicare: OR = 1.46, P < 0.001) were risk factors for conversion to TKA. Conclusions Medicare and Humana databases showed that 0.92%-3.01% and 4.79%-9.47% of patients undergo revision arthroscopy or conversion to TKA within a year of isolated meniscectomy. Obesity was a risk factor for early revision arthroscopy and conversion to TKA, whereas concomitant osteoarthritis was a risk factor for conversion to TKA. Level of Evidence Level III, retrospective comparative trial.
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Affiliation(s)
- Avinesh Agarwalla
- Department of Orthopaedic Surgery, Westchester Medical Center, Valhalla, New York, U.S.A
| | - Anirudh K Gowd
- Department of Orthopaedic Surgery, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina, U.S.A
| | - Joseph N Liu
- Department of Orthopaedic Surgery, Loma Linda University Medical Center, Loma Linda, California, U.S.A
| | - Nirav H Amin
- Department of Orthopaedic Surgery, Loma Linda University Medical Center, Loma Linda, California, U.S.A
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A
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Kiadaliri A, Bergkvist D, Dahlberg LE, Englund M. Impact of a national guideline on use of knee arthroscopy: An interrupted time-series analysis. Int J Qual Health Care 2020; 31:G113-G118. [PMID: 31725873 PMCID: PMC7076349 DOI: 10.1093/intqhc/mzz089] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 06/25/2019] [Accepted: 08/27/2019] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE To assess the impact of the Swedish health authority recommendation against the use of knee arthroscopy in patients aged ≥40 years with knee osteoarthritis (OA). DESIGN Interrupted time series analysis. SETTING Public health care in Skåne region. PARTICIPANTS Patients aged ≥40 years who underwent knee arthroscopy from January 2010 to December 2015. INTERVENTION(S) National guideline's recommendation against the use of knee arthroscopy in patients with knee OA. MAIN OUTCOME MEASURE(S) 1) proportion of patients aged ≥40 years with a main diagnosis of Knee OA and/or degenerative meniscal lesions (DML) who underwent knee arthroscopy, and 2) overall knee arthroscopy rate per 100,000 Skåne population aged ≥40 years. RESULTS A total of 6,155 knee arthroscopy were performed among people aged ≥40 years during study period. Of 42,044 patients with Knee OA/DML, 3,728 had knee arthroscopy. The recommendation was associated with reductions in the use of knee arthroscopy and two years after the recommendation, there was a reduction of 28.6% (95% CI: 9.3, 47.8) and 34.7% (23.9, 45.4) in proportion of Knee OA/DML patients with knee arthroscopy and the overall knee arthroscopy rate, respectively, relative to that expected if pre-recommendation trend continued. Our sensitivity analysis showed that the use of total knee replacement was stable over the study period. CONCLUSION The national recommendation was associated with reduction in use of knee arthroscopy in public health care in southern Sweden. However, still 4.5% of these patients underwent knee arthroscopy in 2015 implying that more efforts are required to achieve the recommended target.
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Affiliation(s)
- Ali Kiadaliri
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopaedics, Clinical Epidemiology Unit, Lund, Sweden.,Lund University, Faculty of Medicine, EPI@LUND (Epidemiology, Population studies, and Infrastructures at Lund University), Lund, Sweden.,Centre for Economic Demography, Lund University, Lund, Sweden
| | - Dan Bergkvist
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopaedics, Clinical Epidemiology Unit, Lund, Sweden
| | - Leif E Dahlberg
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopaedics, Lund, Sweden
| | - Martin Englund
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopaedics, Clinical Epidemiology Unit, Lund, Sweden.,Clinical Epidemiology Research and Training Unit, Boston University School of Medicine, Boston, MA, USA
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6
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Comparison of Arthroscopic Partial Meniscectomy to Physical Therapy following Degenerative Meniscus Tears: A Systematic Review and Meta-analysis. BIOMED RESEARCH INTERNATIONAL 2020; 2020:1709415. [PMID: 32190650 PMCID: PMC7073498 DOI: 10.1155/2020/1709415] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 02/14/2020] [Indexed: 11/17/2022]
Abstract
Objective To compare the effectiveness of arthroscopic partial meniscectomy (APM) and physical therapy (PT) for degenerative meniscus tears. Method We conducted a literature search through PubMed, Embase, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov. Randomized controlled trials in adults with degenerative meniscal tears without symptoms of locking were considered for inclusion. Two researchers independently performed the literature search, assessed the risk of bias, and selected eligible studies. The primary outcome was function at different follow-up time points and the secondary outcome was pain at different follow-up time points. Results We included 6 randomized controlled trials, with a total of 1006 participants, among which 495 were in the APM group and 511 were in the PT group. We found a small benefit in functional outcomes in the APM group until the 12 months follow-up time point (SMD = 0.20; 95%CI = 0.0-0.33; p = 0.002; I 2 = 34%), but no significant differences in function between groups at the 24-month follow-up time point (SMD = 0.12; 95%CI = -0.04 - 0.28; p = 0.002; I 2 = 34%), but no significant differences in function between groups at the 24-month follow-up time point (SMD = 0.12; 95%CI = -0.04 - 0.28; p = 0.002; I 2 = 34%), but no significant differences in function between groups at the 24-month follow-up time point (SMD = 0.12; 95%CI = -0.04 - 0.28; p = 0.002; I 2 = 34%), but no significant differences in function between groups at the 24-month follow-up time point (SMD = 0.12; 95%CI = -0.04 - 0.28. Conclusion In the treatment of degenerative meniscus tears, APM yielded better functional and pain outcomes compared with physical therapy in the short term until 12 months, but there were comparable results for pain and functional outcomes between the groups at the 24 months follow-up time point.
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7
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Trends in knee arthroscopy utilization: a gap in knowledge translation. Knee Surg Sports Traumatol Arthrosc 2020; 28:439-447. [PMID: 31359100 DOI: 10.1007/s00167-019-05638-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 07/17/2019] [Indexed: 12/21/2022]
Abstract
PURPOSE To evaluate the longitudinal trends in knee arthroscopy utilization in relation to published negative randomized controlled trials, focusing on annual rates, patient demographics and associated 30-day post-operative complications. METHODS The American College of Surgeons National Surgical Quality Improvement Program database was queried using Current Procedural Terminology billing codes to identify arthroscopy cases between 2006 and 2016. 30-day post-operative complications were identified, and potential risk factors analysed using univariate and multivariate analyses. RESULTS 68,346 patients underwent knee arthroscopy, of which 47,446 (69.5%) represented partial meniscectomies. The annual procedural rate, as a proportion of all reported cases, increased significantly from 2006 (0.3%) to 2016 (1.6%; p < 0.001), along with a significant increase in average patient age (44.3 ± 15.5 to 48.4 ± 14.5; p < 0.001). Specifically focusing on the meniscectomy cohort, average patient age significantly increased from 47.9 ± 15.1 to 50.7 ± 13.5 (p = 0.001). The overall incidence of complications was 2.0% (n = 1333), with major complications in 0.9% (n = 639) and minor complications in 1.0% (n = 701). Common complications included a return to the operating room (0.5%), deep vein thrombosis/thrombophlebitis (0.4%), and superficial infection (0.2%). Operating time > 90 min, diabetes, steroid use, ASA class 2+, and dialysis-dependency were the predictors of overall complication rates. CONCLUSION Despite the publication of negative trials and new clinical practice guidelines, knee arthroscopy utilization and average patient age continue to increase. Given the high utilization, even low adverse event rates equate to substantial numbers of patients with minor and major complications. The NSQIP data show a gap in knowledge translation to clinical practice and highlight the need for improved clinical guidelines. LEVEL OF EVIDENCE Cohort study; Level III.
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8
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Essilfie A, Kang HP, Mayer EN, Trasolini NA, Alluri RK, Weber AE. Are Orthopaedic Surgeons Performing Fewer Arthroscopic Partial Meniscectomies in Patients Greater Than 50 Years Old? A National Database Study. Arthroscopy 2019; 35:1152-1159.e1. [PMID: 30871904 DOI: 10.1016/j.arthro.2018.10.152] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 10/31/2018] [Accepted: 10/31/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To report the trends in arthroscopic partial meniscectomy (APM) for degenerative meniscal tears in a large private insurance database among patients older than 50 years. METHODS The Humana database between 2007 and 2015 was queried for this study. Patients meeting the inclusion criteria with degenerative meniscal tears who underwent APMs were identified by International Classification of Diseases, Ninth Revision codes, followed by Current Procedural Terminology codes. A linear regression analysis was performed with a significance level set at F < 0.05. RESULTS A total of 21,759 APMs were performed between 2007 and 2015 in patients older than 50 years. Normalized data for total yearly enrollment showed a significant increase in APMs performed from 2007 to 2010 (R2 = 0.986, P = .007). The average percentage increase per year from 2007 to 2010 was 18.59%. However, there was a significant decrease in APMs performed from 2010 to 2015 (R2 = 0.748, P = .026). The average percentage decrease per year from 2010 to 2015 was 7.74%. The percentage decrease overall from 2010 to 2015 was 71.68%. No difference in statistical significance was found when age was broken into 5-year age intervals. We found a significant difference in APM based on region (P < .001). CONCLUSIONS The rate of APMs in patients older than 50 years increased from 2007 until 2010. Since 2010, the rate of APMs in patients older than 50 years has significantly decreased. These trends are likely multifactorial. Regardless of cause, it appears that the orthopaedic surgery community is performing fewer APMs in this patient population. LEVEL OF EVIDENCE Level III, retrospective database epidemiological study.
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Affiliation(s)
- Anthony Essilfie
- Department of Orthopaedic Surgery, University of Southern California, Los Angeles, California, U.S.A
| | - Hyunwoo P Kang
- Department of Orthopaedic Surgery, University of Southern California, Los Angeles, California, U.S.A
| | - Erik N Mayer
- Department of Orthopaedic Surgery, University of Southern California, Los Angeles, California, U.S.A
| | - Nicholas A Trasolini
- Department of Orthopaedic Surgery, University of Southern California, Los Angeles, California, U.S.A
| | - Ram K Alluri
- Department of Orthopaedic Surgery, University of Southern California, Los Angeles, California, U.S.A
| | - Alexander E Weber
- Department of Orthopaedic Surgery, University of Southern California, Los Angeles, California, U.S.A..
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Abram SGF, Hopewell S, Monk AP, Bayliss LE, Beard DJ, Price AJ. Arthroscopic partial meniscectomy for meniscal tears of the knee: a systematic review and meta-analysis. Br J Sports Med 2019; 54:652-663. [PMID: 30796103 DOI: 10.1136/bjsports-2018-100223] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To assess the benefit of arthroscopic partial meniscectomy (APM) in adults with a meniscal tear and knee pain in three defined populations (taking account of the comparison intervention): (A) all patients (any type of meniscal tear with or without radiographic osteoarthritis); (B) patients with any type of meniscal tear in a non-osteoarthritic knee; and (C) patients with an unstable meniscal tear in a non-osteoarthritic knee. DESIGN Systematic review and meta-analysis. DATASOURCES A search of MEDLINE, Embase, CENTRAL, Scopus, Web of Science, Clinicaltrials.gov and ISRCTN was performed, unlimited by language or publication date (inception to 18 October 2018). ELIGIBILITYCRITERIA Randomised controlled trials performed in adults with meniscal tears, comparing APM versus (1) non-surgical intervention; (2) pharmacological intervention; (3) surgical intervention; and (4) no intervention. RESULTS Ten trials were identified: seven compared with non-surgery, one pharmacological and two surgical. Findings were limited by small sample size, small number of trials and cross-over of participants to APM from comparator interventions. In group A (all patients) receiving APM versus non-surgical intervention (physiotherapy), at 6-12 months, there was a small mean improvement in knee pain (standardised mean difference [SMD] 0.22 [95% CI 0.03 to 0.40]; five trials, 943 patients; I2 48%; Grading of Recommendations Assessment, Development and Evaluation [GRADE]: low), knee-specific quality of life (SMD 0.43 [95% CI 0.10 to 0.75]; three trials, 350 patients; I2 56%; GRADE: low) and knee function (SMD 0.18 [95% CI 0.04 to 0.33]; six trials, 1050 patients; I2 27%; GRADE: low). When the analysis was restricted to people without osteoarthritis (group B), there was a small to moderate improvement in knee pain (SMD 0.35 [95% CI 0.04 to 0.66]; three trials, 402 patients; I2 58%; GRADE: very low), knee-specific quality of life (SMD 0.59 [95% CI 0.11 to 1.07]; two trials, 244 patients; I2 71%; GRADE: low) and knee function (SMD 0.30 [95% CI 0.06 to 0.53]; four trials, 507 patients; I2 44%; GRADE: very low). There was no improvement in knee pain, function or quality of life in patients receiving APM compared with placebo surgery at 6-12 months in group A or B (pain: SMD 0.08 [95% CI -0.24 to 0.41]; one trial, 146 patients; GRADE: low; function: SMD -0.08 [95% CI -0.41 to 0.24]; one trial, 146 patients; GRADE: high; quality of life: SMD 0.05 [95% CI -0.27 to 0.38]; one trial; 146 patients; GRADE: high). No trials were identified for people in group C. CONCLUSION Performing APM in all patients with knee pain and a meniscal tear is not appropriate, and surgical treatment should not be considered the first-line intervention. There may, however, be a small-to-moderate benefit from APM compared with physiotherapy for patients without osteoarthritis. No trial has been limited to patients failing non-operative treatment or patients with an unstable meniscal tear in a non-arthritic joint; research is needed to establish the value of APM in this population. PROTOCOL REGISTRATION NUMBER PROSPERO CRD42017056844.
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Affiliation(s)
- Simon G F Abram
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sally Hopewell
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Oxford, UK
| | - Andrew Paul Monk
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Lee E Bayliss
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - David J Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Andrew J Price
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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10
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Roos EM, Hare KB, Nielsen SM, Christensen R, Lohmander LS. Better outcome from arthroscopic partial meniscectomy than skin incisions only? A sham-controlled randomised trial in patients aged 35-55 years with knee pain and an MRI-verified meniscal tear. BMJ Open 2018; 8:e019461. [PMID: 29420232 PMCID: PMC5829931 DOI: 10.1136/bmjopen-2017-019461] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 12/19/2017] [Accepted: 12/22/2017] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Compare arthroscopic partial meniscectomy to a true sham intervention. METHODS Sham-controlled superiority trial performed in three county hospitals in Denmark comparing arthroscopic partial meniscectomy to skin incisions only in patients aged 35-55 years with persistent knee pain and an MRI-confirmed medial meniscus lesion. A computer-generated table of random numbers generated two comparison groups. Participants and outcome assessors were blinded to group allocation. Exclusions were locking knees, high-energy trauma or severe osteoarthritis. Outcomes were collected at baseline, 3 and 24 months. We hypothesised no difference between groups. The primary outcome was the between-group difference in change from baseline to 2 years in the mean score across all five normalised Knee injury and Osteoarthritis Outcome Score (KOOS) subscales (KOOS5). RESULTS Forty-four patients (of the estimated 72) underwent randomisation; 22 in each group. Sixteen participants (36%) were non-blinded and eight participants (36%) from the sham group crossed over to the surgery group prior to the 2-year follow-up. At 2 years, both groups reported clinically relevant improvements (surgery 21.8, skin incisions only 13.6), the mean difference between groups was 8.2 in favour of surgery, which is slightly less than the cut-off of 10 prespecified to represent a clinically relevant difference; judged by the 95% CI (-3.4 to 19.8), a possibility of clinically relevant difference could not be excluded. In total, nine participants experienced 11 adverse events; six in the surgery group and three in the skin-incisions-only group. CONCLUSION We found greater improvement from arthroscopic partial meniscectomy compared with skin incisions only at 2 years, with the statistical uncertainty of the between-group difference including what could be considered clinically relevant. Because of the study being underpowered, nearly half in the sham group being non-blinded and one-third crossing over to surgery, the results cannot be generalised to the greater patient population. TRIAL REGISTRATION NUMBER NCT01264991.
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Affiliation(s)
- Ewa M Roos
- Department of Sport and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Kristoffer Borbjerg Hare
- Department of Sport and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
- Department of Orthopaedics, Slagelse Hospital, Slagelse, Denmark
| | - Sabrina Mai Nielsen
- Musculoskeletal Statistics Unit, The Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Robin Christensen
- Musculoskeletal Statistics Unit, The Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - L Stefan Lohmander
- Department of Clinical Sciences Lund, Orthopaedics, Lund University, Lund, Sweden
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11
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Dernek B, Kesiktas FN, Duymus TM, Diracoglu D, Aksoy C. Therapeutic efficacy of three hyaluronic acid formulations in young and middle-aged patients with early-stage meniscal injuries. J Phys Ther Sci 2017; 29:1148-1153. [PMID: 28744035 PMCID: PMC5509579 DOI: 10.1589/jpts.29.1148] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Accepted: 04/12/2017] [Indexed: 12/26/2022] Open
Abstract
[Purpose] To investigate and compare the efficacy of three hyaluronic acid formulations in patients with early-stage meniscal injuries. [Subjects and Methods] Male and female patients who were admitted to our clinic between January 2013 and December 2013, diagnosed with early-stage meniscus lesions of the knee, and given a hyaluronic acid treatment were included in this retrospective study. Patients were categorized into 3 groups according to their treatments: MONOVISC, OSTENIL PLUS, or ORTHOVISC. Scores from a Visual Analog Scale and the Western Ontario and McMaster Universities Arthritis Index were evaluated at baseline and one, three, and six months after baseline. [Results] A total of 55 patients were included in this study. Most of the patients were female (55%), and the mean age of the patients was 42.4 (± 8.1) years. Based on the pre- and post-injection data, there was significant reductions both in the Visual Analog Scale score and the Western Ontario and McMaster Universities Arthritis Index score after the injections for all groups. According to intergroup comparisons, no significant difference was observed in terms of efficacy. [Conclusion] Three hyaluronic acid formulations produced a similar efficacy in patients with meniscal injuries, and further studies are needed to evaluate long-term results.
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Affiliation(s)
- Bahar Dernek
- Istanbul Kanuni Sultan Suleyman Training and Research
Hospital, Physical Medicine and Rehabilitation Clinic, Turkey
| | - Fatma Nur Kesiktas
- Istanbul Kanuni Sultan Suleyman Training and Research
Hospital, Physical Medicine and Rehabilitation Clinic, Turkey
| | - Tahir Mutlu Duymus
- Istanbul Kanuni Sultan Suleyman Training and Research
Hospital, Orthopedics Clinic, Turkey
| | - Demirhan Diracoglu
- Department of Physical Medicine and Rehabilitation,
Istanbul Faculty of Medicine, Istanbul University, Turkey
| | - Cihan Aksoy
- Department of Physical Medicine and Rehabilitation,
Istanbul Faculty of Medicine, Istanbul University, Turkey
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12
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Amin NH, Hussain W, Ryan J, Morrison S, Miniaci A, Jones MH. Changes Within Clinical Practice After a Randomized Controlled Trial of Knee Arthroscopy for Osteoarthritis. Orthop J Sports Med 2017; 5:2325967117698439. [PMID: 28451610 PMCID: PMC5400146 DOI: 10.1177/2325967117698439] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND In 2002, Moseley et al published a randomized controlled trial (RCT) that showed no difference between knee arthroscopy and placebo for patients with osteoarthritis (OA). We wanted to assess the impact of the trial on clinical practice in the United States. PURPOSE/HYPOTHESIS To evaluate changes in knee arthroscopy practice before and after publication of the article by Moseley et al and to assess the effect of this landmark RCT on the behavior of practicing orthopaedic surgeons. We hypothesized that after publication of the Moseley trial, the overall frequency of knee arthroscopy would decrease, that the mean age of patients undergoing knee arthroscopy would decrease, and that the proportion of arthroscopies for a diagnosis of OA would decrease. STUDY DESIGN Descriptive epidemiology study. METHODS The State Ambulatory Surgery Database was used to analyze cases from 1998 to 2006, which were classified as meniscus tear, OA, or OA with meniscus tear. Changes in age, surgery rates, and case classification were evaluated before and after Moseley's trial using Student t tests and analysis of variance. RESULTS After publication of the trial, the number of knee arthroscopies per year increased from 155,057 in 1998 to 172,317 in 2006 (P ≤ .001). Mean patient age increased from 47.6 to 49.2 years (P < .001). Meniscus tears increased from 69.1% to 70.8%, representing approximately 15,500 additional cases per year. OA decreased from 10.6% to 7.2%, representing approximately 4000 fewer cases per year. OA with meniscus tear increased from 20.3% to 22.0%, representing approximately 6400 additional cases per year. CONCLUSION While overall age and rates of knee arthroscopy increased contrary to our hypothesis, we identified a decrease in rates of knee arthroscopy for OA after publication of the Moseley trial, demonstrating that well-publicized RCTs can influence patterns of clinical practice.
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Affiliation(s)
- Nirav H Amin
- Loma Linda University, Loma Linda, California, USA
| | | | - John Ryan
- Ohio State University, Columbus, Ohio, USA
| | - Shannon Morrison
- Cleveland Clinic Center for Sports Health, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA
| | - Anthony Miniaci
- Cleveland Clinic Center for Sports Health, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA
| | - Morgan H Jones
- Cleveland Clinic Department of Orthopaedic Surgery, Cleveland, Ohio, USA
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13
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McIntyre LF. Making Sure the Media Gets It Right on Orthopaedic Research. Arthroscopy 2016; 32:2416-2417. [PMID: 27816102 DOI: 10.1016/j.arthro.2016.09.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2016] [Accepted: 09/02/2016] [Indexed: 02/02/2023]
Abstract
Patient-centered medicine requires an informed health care consumer. Traditionally, orthopaedic surgeons were the primary source for patients regarding diagnostic and treatment options for musculoskeletal conditions. Now patients get information from a variety of sources including the Internet, social media, and print journalism. Most of these sources are not vetted or peer reviewed and some not even fact checked. Part of the role of the orthopaedic surgeon is to educate patients, and interpreting this type of information is an increasingly demanding but essential task. A recent article in the New York Times titled "Why 'Useless' Surgery Is Still Popular" illustrates the importance of this educational role. Patients deserve the most up-to-date and accurate assessment of medical information. The most appropriate source of that information is their treating physician and surgeon.
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Affiliation(s)
- Louis F McIntyre
- Westchester Orthopedic Associates, White Plains, New York, U.S.A..
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Sofu H, Oner A, Camurcu Y, Gursu S, Ucpunar H, Sahin V. Predictors of the Clinical Outcome After Arthroscopic Partial Meniscectomy for Acute Trauma-Related Symptomatic Medial Meniscal Tear in Patients More Than 60 Years of Age. Arthroscopy 2016; 32:1125-32. [PMID: 26882967 DOI: 10.1016/j.arthro.2015.11.040] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 11/04/2015] [Accepted: 11/20/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine predictors of the clinical outcome after arthroscopic partial meniscectomy performed for acute trauma-related medial meniscal tear leading to mechanical symptoms in patients more than 60 years of age. METHODS In this retrospective study with 4.1 years' follow-up, the clinical data of 154 arthroscopic partial medial meniscectomies were evaluated. The body mass index (BMI), duration of symptoms, the hip-knee-ankle angle, type of the meniscal tear, presence of any chondral lesions, degenerative changes in the patellofemoral joint, the status of the cruciate ligaments and lateral meniscus, and the presence of any plica or synovitis were the independent variables. Visual Analog Scale (VAS) and Lysholm Knee Scoring Scale were the instruments used as outcome measures. Multivariate analysis was performed to determine the major predictors. RESULTS The mean VAS score for 154 knees evaluated in this study improved from 5.6 points preoperatively to 2.3 points at the latest follow-up. The mean Lysholm score improved from 43 points to 72.7 points. VAS and Lysholm scores at the latest follow-up were significantly worse in patients with a preoperative BMI ≥ 26 kg/m(2), hip-knee-ankle angle > 5°, grade III or IV chondral lesion of the medial compartment according to Outerbridge classification, degenerative changes in patellofemoral joint surfaces, and an anterior cruciate ligament that was either partially ruptured or degenerative with increased laxity. CONCLUSIONS A preoperative BMI ≥ 26 kg/m(2), Outerbridge grade III or IV chondral lesion of the medial compartment of the operated knee joint diagnosed during arthroscopic intervention, degenerative changes in patellofemoral joint surfaces, and the presence of an anterior cruciate ligament either partially ruptured or degenerative with increased laxity should be considered as the major predictors of the clinical outcome after arthroscopic partial meniscectomy performed for acute trauma-related symptomatic medial meniscal tear in patients more than 60 years of age. LEVEL OF EVIDENCE Level IV, prognostic case series.
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Affiliation(s)
- Hakan Sofu
- Department of Orthopedics and Traumatology, Erzincan University Faculty of Medicine, Erzincan, Turkey.
| | - Ali Oner
- Department of Orthopedics and Traumatology, Erzincan Mengucekgazi Education and Research Hospital, Erzincan, Turkey
| | - Yalkin Camurcu
- Department of Orthopedics and Traumatology, Devrek State Hospital, Zonguldak, Turkey
| | - Sarper Gursu
- Department of Orthopedics and Traumatology, Baltalimani Bone and Joint Diseases Education and Research Hospital, Istanbul, Turkey
| | - Hanifi Ucpunar
- Department of Orthopedics and Traumatology, Baltalimani Bone and Joint Diseases Education and Research Hospital, Istanbul, Turkey
| | - Vedat Sahin
- Department of Orthopedics and Traumatology, Erzincan University Faculty of Medicine, Erzincan, Turkey
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15
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Arthroscopy for Knee Osteoarthritis Has Not Decreased After a Clinical Trial. Clin Orthop Relat Res 2016; 474:489-94. [PMID: 26290345 PMCID: PMC4709284 DOI: 10.1007/s11999-015-4514-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 08/10/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Multiple clinical trials have shown that arthroscopy for knee osteoarthritis is not efficacious. It is unclear how these studies have affected orthopaedic practice in the USA. QUESTIONS/PURPOSES We questioned whether, in the Veterans Health Administration system, rates of knee arthroscopy in patients with osteoarthritis have changed after publication of the initial clinical trial by Moseley et al. in 2002, and whether rates of arthroplasty within 2 years of arthroscopy have changed during the same period. METHODS Patients 50 years and older with knee osteoarthritis who underwent arthroscopy between 1998 and 2010 were retrospectively identified and an annual arthroscopy rate was calculated from 1998 through 2002 and from 2006 through 2010. Patients who underwent knee arthroplasty within 2 years of arthroscopy during each period were identified, and a 2-year conversion to arthroplasty rate was calculated. RESULTS Between 1998 and 2002, the annual arthroscopy rate decreased from 4% to 3%. Of these arthroscopies, 4% were converted to arthroplasty within 2 years. Between 2006 and 2010, the annual arthroscopy rate increased from 3% to 4%. Of these arthroscopies, 5% were converted to arthroplasty within 2 years. CONCLUSIONS Rates of arthroscopy in patients with knee osteoarthritis and conversion to arthroplasty within 2 years have not decreased with time. It may be that evidence alone is not sufficient to alter practice patterns or that arthroscopy rates for arthritis for patients in the Veterans Health Administration system were already so low that the results of the initial clinical trial had no substantial effect. LEVEL OF EVIDENCE Level III, Retrospective cohort study.
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16
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Marsh JD, Birmingham TB, Giffin JR, Isaranuwatchai W, Hoch JS, Feagan BG, Litchfield R, Willits K, Fowler P. Cost-effectiveness analysis of arthroscopic surgery compared with non-operative management for osteoarthritis of the knee. BMJ Open 2016; 6:e009949. [PMID: 26758265 PMCID: PMC4716206 DOI: 10.1136/bmjopen-2015-009949] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To determine the cost-effectiveness of arthroscopic surgery in addition to non-operative treatments compared with non-operative treatments alone in patients with knee osteoarthritis (OA). DESIGN, SETTING AND PARTICIPANTS We conducted an economic evaluation alongside a single-centre, randomised trial among patients with symptomatic, radiographic knee OA (KL grade ≥ 2). INTERVENTIONS Patients received arthroscopic debridement and partial resection of degenerative knee tissues in addition to optimised non-operative therapy, or optimised non-operative therapy only. MAIN OUTCOME MEASURES Direct and indirect costs were collected prospectively over the 2-year study period. The effectiveness outcomes were the Western Ontario McMaster Osteoarthritis Index (WOMAC) and quality-adjusted life years (QALYs). Cost-effectiveness was estimated using the net benefit regression framework considering a range of willingness-to-pay values from the Canadian public payer and societal perspectives. We calculated incremental cost-effectiveness ratios and conducted sensitivity analyses using the extremes of the 95% CIs surrounding mean differences in effect between groups. RESULTS 168 patients were included. Patients allocated to arthroscopy received partial resection and debridement of degenerative meniscal tears (81%) and/or articular cartilage (97%). There were no significant differences between groups in use of non-operative treatments. The incremental net benefit was negative for all willingness-to-pay values. Uncertainty estimates suggest that even if willing to pay $400,000 to achieve a clinically important improvement in WOMAC score, or ≥$50,000 for an additional QALY, there is <20% probability that the addition of arthroscopy is cost-effective compared with non-operative therapies only. Our sensitivity analysis suggests that even when assuming the largest treatment effect, the addition of arthroscopic surgery is not economically attractive compared with non-operative treatments only. CONCLUSIONS Arthroscopic debridement of degenerative articular cartilage and resection of degenerative meniscal tears in addition to non-operative treatments for knee OA is not an economically attractive treatment option compared with non-operative treatment only, regardless of willingness-to-pay value. TRIAL REGISTRATION NUMBER NCT00158431.
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Affiliation(s)
- Jacquelyn D Marsh
- Faculty of Health Sciences; Bone and Joint Institute; Western University, London, Ontario, Canada
| | - Trevor B Birmingham
- School of Physical Therapy, Faculty of Health Sciences; Fowler Kennedy Sport Medicine Clinic; Bone and Joint Institute; Western University, London, Ontario, Canada
| | - J Robert Giffin
- Department of Surgery, Schulich School of Medicine and Dentistry; Fowler Kennedy Sport Medicine Clinic; Bone and Joint Institute; Western University, London, Ontario, Canada
| | - Wanrudee Isaranuwatchai
- Centre for Excellence in Economic Analysis Research (CLEAR), St. Michael's Hospital, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Jeffrey S Hoch
- Department of Public Health Sciences, University of California, Davis (UCD); Center for Healthcare Policy and Research, UCD; Centre for Excellence in Economic Analysis Research (CLEAR), St. Michael's Hospital; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario Canada
| | - Brian G Feagan
- Departments of Medicine, and Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry; Robarts Clinical Trials, Robarts Research Institute; Western University, London, Ontario, Canada
| | - Robert Litchfield
- Department of Surgery, Schulich School of Medicine and Dentistry; Fowler Kennedy Sport Medicine Clinic; Bone and Joint Institute; Western University, London, Ontario, Canada
| | - Kevin Willits
- Department of Surgery, Schulich School of Medicine and Dentistry; Fowler Kennedy Sport Medicine Clinic; Bone and Joint Institute; Western University, London, Ontario, Canada
| | - Peter Fowler
- Department of Surgery, Schulich School of Medicine and Dentistry; Fowler Kennedy Sport Medicine Clinic; Bone and Joint Institute; Western University, London, Ontario, Canada
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Abstract
"Arthroscopic Partial Meniscectomy versus Sham Surgery for a Degenerative Meniscal Tear" published in the New England Journal of Medicine on December 26, 2013 draws the conclusion that arthroscopic partial medial meniscectomy provides no significant benefit over sham surgery in patients with a degenerative meniscal tear and no knee osteoarthritis. This result argues against the current practice of performing arthroscopic partial meniscectomy (APM) in patients with a degenerative meniscal tear. Since the number of APM performed has been increasing, the information provided by this study should lead to a change in clinical care of patients with a degenerative meniscus tear.
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Affiliation(s)
- Shaw-Ruey Lyu
- 1 Joint Center, Dalin Tzu-Chi General Hospital, Chiayi, Taiwan ; 2 School of Medicine, Tzu-Chi University, Hualien, Taiwan
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18
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Perceptions of orthopaedic surgeons regarding arthroscopic surgery for osteoarthritis of the knee - an international survey. CURRENT ORTHOPAEDIC PRACTICE 2015. [DOI: 10.1097/bco.0000000000000180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Advances in optical technology, instrumentation and implants now enable arthroscopic surgery to be performed on all large joints and most small joints of the limbs. Arthroscopic techniques are usually a development of surgical procedures previously performed through a large open incision, although the critical element of each procedure (for example removal of a torn meniscus) usually remains unchanged. The smaller size of incisions and reduction in tissue damage associated with arthroscopic surgery can reduce morbidity and complications. Therapeutic arthroscopy now encompasses excision, reconstruction and replacement of damaged or abnormal tissue. Improvements in the accuracy of MRI, CT and high-definition ultrasonography have limited the use of diagnostic arthroscopy to rare indications, but in the past 10 years the rates of some arthroscopic surgeries have increased by over 7-fold. Considerable variation in the type and utilization of arthroscopic procedures exists in practice, partly explained by the slow diffusion of new techniques and technology, but also by differences in clinician and patient beliefs and expectations. This Review reflects on both the success of arthroscopy and the general lack of evidence-based assessment of the efficacy and cost-effectiveness of arthroscopic procedures-a clear sign that more clinical trials in this field are required.
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Jevsevar DS. The Role of Evidence-Based Medicine in Clinical Practice Policy. JBJS Rev 2014; 2:01874474-201409000-00002. [DOI: 10.2106/jbjs.rvw.m.00116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Katz JN, Brownlee SA, Jones MH. The role of arthroscopy in the management of knee osteoarthritis. Best Pract Res Clin Rheumatol 2014; 28:143-56. [PMID: 24792949 DOI: 10.1016/j.berh.2014.01.008] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Technological advances throughout the 20th century enabled an increase in arthroscopic knee surgery, particularly arthroscopic debridement for osteoarthritis (OA) and arthroscopic partial meniscectomy for symptomatic meniscal tear in the setting of OA. However, evaluation of the outcomes of these procedures lagged behind their rising popularity. Not until the early 2000s were rigorous outcomes studies conducted; these showed that arthroscopic debridement for OA was no better than a sham procedure in relieving knee pain or improving functional status, and that patients who underwent arthroscopic partial meniscectomy for a degenerative meniscal tear generally did not show more improvement than those who underwent sham meniscal resection or an intensive course of physical therapy. Though the number of arthroscopic knee procedures for OA performed each year has begun to decline, there remains a significant gap between the evidence and actual practice. Further investigation is needed to shore up the evidence base and bring policy and practice in line with rigorous research.
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Affiliation(s)
- Jeffrey N Katz
- Orthopedic and Arthritis Center for Outcomes Research, Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Orthopedic and Arthritis Center for Outcomes Research, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA.
| | - Sarah A Brownlee
- Orthopedic and Arthritis Center for Outcomes Research, Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Morgan H Jones
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH, USA
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Sihvonen R, Paavola M, Malmivaara A, Itälä A, Joukainen A, Nurmi H, Kalske J, Järvinen TLN. Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. N Engl J Med 2013; 369:2515-24. [PMID: 24369076 DOI: 10.1056/nejmoa1305189] [Citation(s) in RCA: 547] [Impact Index Per Article: 49.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Arthroscopic partial meniscectomy is one of the most common orthopedic procedures, yet rigorous evidence of its efficacy is lacking. METHODS We conducted a multicenter, randomized, double-blind, sham-controlled trial in 146 patients 35 to 65 years of age who had knee symptoms consistent with a degenerative medial meniscus tear and no knee osteoarthritis. Patients were randomly assigned to arthroscopic partial meniscectomy or sham surgery. The primary outcomes were changes in the Lysholm and Western Ontario Meniscal Evaluation Tool (WOMET) scores (each ranging from 0 to 100, with lower scores indicating more severe symptoms) and in knee pain after exercise (rated on a scale from 0 to 10, with 0 denoting no pain) at 12 months after the procedure. RESULTS In the intention-to-treat analysis, there were no significant between-group differences in the change from baseline to 12 months in any primary outcome. The mean changes (improvements) in the primary outcome measures were as follows: Lysholm score, 21.7 points in the partial-meniscectomy group as compared with 23.3 points in the sham-surgery group (between-group difference, -1.6 points; 95% confidence interval [CI], -7.2 to 4.0); WOMET score, 24.6 and 27.1 points, respectively (between-group difference, -2.5 points; 95% CI, -9.2 to 4.1); and score for knee pain after exercise, 3.1 and 3.3 points, respectively (between-group difference, -0.1; 95% CI, -0.9 to 0.7). There were no significant differences between groups in the number of patients who required subsequent knee surgery (two in the partial-meniscectomy group and five in the sham-surgery group) or serious adverse events (one and zero, respectively). CONCLUSIONS In this trial involving patients without knee osteoarthritis but with symptoms of a degenerative medial meniscus tear, the outcomes after arthroscopic partial meniscectomy were no better than those after a sham surgical procedure. (Funded by the Sigrid Juselius Foundation and others; ClinicalTrials.gov number, NCT00549172.).
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Affiliation(s)
- Raine Sihvonen
- From the Department of Orthopedics and Traumatology, Hatanpää City Hospital, Tampere (R.S.), the Department of Orthopedics and Traumatology, Helsinki University Central Hospital and University of Helsinki (M.P., J.K., T.L.N.J.), and the National Institute for Health and Welfare, Center for Health and Social Economics (A.M.), Helsinki, the Department of Orthopedics and Traumatology, University of Turku, Turku (A.I.), the Department of Orthopedics, Traumatology, and Hand Surgery, Kuopio University Hospital, Kuopio (A.J.), and the Department of Orthopedics and Traumatology, Central Finland Central Hospital, Jyväskylä (H.N.) - all in Finland
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