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Birmingham TB, Primeau CA, Shariff SZ, Reid JNS, Marsh JD, Lam M, Dixon SN, Giffin JR, Willits KR, Litchfield RB, Feagan BG, Fowler PJ. Incidence of Total Knee Arthroplasty After Arthroscopic Surgery for Knee Osteoarthritis: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open 2024; 7:e246578. [PMID: 38635272 DOI: 10.1001/jamanetworkopen.2024.6578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2024] Open
Abstract
Importance It is unclear whether arthroscopic resection of degenerative knee tissues among patients with osteoarthritis (OA) of the knee delays or hastens total knee arthroplasty (TKA); opposite findings have been reported. Objective To compare the long-term incidence of TKA in patients with OA of the knee after nonoperative management with or without additional arthroscopic surgery. Design, Setting, and Participants In this ad hoc secondary analysis of a single-center, assessor-blinded randomized clinical trial performed from January 1, 1999, to August 31, 2007, 178 patients were followed up through March 31, 2019. Participants included adults diagnosed with OA of the knee referred for potential arthroscopic surgery in a tertiary care center specializing in orthopedics in London, Ontario, Canada. All participants from the original randomized clinical trial were included. Data were analyzed from June 1, 2021, to October 20, 2022. Exposures Arthroscopic surgery (resection or debridement of degenerative tears of the menisci, fragments of articular cartilage, or chondral flaps and osteophytes that prevented full extension) plus nonoperative management (physical therapy plus medications as required) compared with nonoperative management only (control). Main Outcomes and Measures Total knee arthroplasty was identified by linking the randomized trial data with prospectively collected Canadian health administrative datasets where participants were followed up for a maximum of 20 years. Multivariable Cox proportional hazards regression models were used to compare the incidence of TKA between intervention groups. Results A total of 178 of 277 eligible patients (64.3%; 112 [62.9%] female; mean [SD] age, 59.0 [10.0] years) were included. The mean (SD) body mass index was 31.0 (6.5). With a median follow-up of 13.8 (IQR, 8.4-16.8) years, 31 of 92 patients (33.7%) in the arthroscopic surgery group vs 36 of 86 (41.9%) in the control group underwent TKA (adjusted hazard ratio [HR], 0.85 [95% CI, 0.52-1.40]). Results were similar when accounting for crossovers to arthroscopic surgery (13 of 86 [15.1%]) during follow-up (HR, 0.88 [95% CI, 0.53-1.44]). Within 5 years, the cumulative incidence was 10.2% vs 9.3% in the arthroscopic surgery group and control group, respectively (time-stratified HR for 0-5 years, 1.06 [95% CI, 0.41-2.75]); within 10 years, the cumulative incidence was 23.3% vs 21.4%, respectively (time-stratified HR for 5-10 years, 1.06 [95% CI, 0.45-2.51]). Sensitivity analyses yielded consistent results. Conclusions and Relevance In this secondary analysis of a randomized clinical trial of arthroscopic surgery for patients with OA of the knee, a statistically significant association with delaying or hastening TKA was not identified. Approximately 80% of patients did not undergo TKA within 10 years of nonoperative management with or without additional knee arthroscopic surgery. Trial Registration ClinicalTrials.gov Identifier: NCT00158431.
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Affiliation(s)
- Trevor B Birmingham
- Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, London, Canada
- School of Physical Therapy, Faculty of Health Sciences, University of Western Ontario, London, Canada
- Bone and Joint Institute, University of Western Ontario, London, Canada
| | - Codie A Primeau
- Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, London, Canada
- School of Physical Therapy, Faculty of Health Sciences, University of Western Ontario, London, Canada
- Bone and Joint Institute, University of Western Ontario, London, Canada
| | - Salimah Z Shariff
- Bone and Joint Institute, University of Western Ontario, London, Canada
- ICES Western, Lawson Health Research Institute, London Health Sciences Centre, London, Ontario, Canada
- Arthur Labatt Family School of Nursing, Faculty of Health Sciences, University of Western Ontario, London, Canada
| | - Jennifer N S Reid
- ICES Western, Lawson Health Research Institute, London Health Sciences Centre, London, Ontario, Canada
| | - Jacquelyn D Marsh
- School of Physical Therapy, Faculty of Health Sciences, University of Western Ontario, London, Canada
- Bone and Joint Institute, University of Western Ontario, London, Canada
| | - Melody Lam
- ICES Western, Lawson Health Research Institute, London Health Sciences Centre, London, Ontario, Canada
| | - Stephanie N Dixon
- ICES Western, Lawson Health Research Institute, London Health Sciences Centre, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
| | - J Robert Giffin
- Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, London, Canada
- Bone and Joint Institute, University of Western Ontario, London, Canada
- Department of Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
| | - Kevin R Willits
- Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, London, Canada
- Bone and Joint Institute, University of Western Ontario, London, Canada
- Department of Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
| | - Robert B Litchfield
- Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, London, Canada
- Bone and Joint Institute, University of Western Ontario, London, Canada
- Department of Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
| | - Brian G Feagan
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
- Department of Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
| | - Peter J Fowler
- Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, London, Canada
- Bone and Joint Institute, University of Western Ontario, London, Canada
- Department of Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
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Katz JN, Collins JE, Brophy RH, Cole BJ, Cox CL, Guermazi A, Jones MH, Levy BA, MacFarlane LA, Mandl LA, Marx RG, Selzer F, Spindler KP, Wright RW, Losina E, Chang Y. Radiographic Changes Five Years After Treatment of Meniscal Tear and Osteoarthritic Changes. Arthritis Care Res (Hoboken) 2023:10.1002/acr.25197. [PMID: 37474452 PMCID: PMC10799184 DOI: 10.1002/acr.25197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 06/20/2023] [Accepted: 07/06/2023] [Indexed: 07/22/2023]
Abstract
OBJECTIVE Meniscal tear in persons aged ≥45 years is typically managed with physical therapy (PT), and arthroscopic partial meniscectomy (APM) is offered to those who do not respond. Prior studies suggest APM may be associated with greater progression of radiographic changes. METHODS We assessed changes between baseline and 60 months in the Kellgren-Lawrence (KL) grade and OARSI radiographic score (including subscores for joint space narrowing and osteophytes) in subjects aged 45-85 years enrolled into a seven-center randomized trial comparing outcomes of APM with PT for meniscal tear, osteoarthritis changes, and knee pain. The primary analysis classified subjects according to treatment received. To balance APM and PT groups, we developed a propensity score and used inverse probability weighting (IPW). We imputed a 60-month change in the OARSI score for subjects who underwent total knee replacement (TKR). In a sensitivity analysis, we classified subjects by randomization group. RESULTS We analyzed data from 142 subjects (100 APM, 42 PT). The mean ± SD weighted baseline OARSI radiographic score was 3.8 ± 3.5 in the APM group and 4.0 ± 4.9 in the PT group. OARSI scores increased by a mean of 4.1 (95% confidence interval [95% CI] 3.5-4.7) in the APM group and 2.4 (95% CI 1.7-3.2) in the PT group (P < 0.001) due to changes in the osteophyte component. We did not observe statistically significant differences in the KL grade. Sensitivity analyses yielded similar findings to the primary analysis. CONCLUSION Subjects treated with APM had greater progression in the OARSI score because of osteophyte progression but not in the KL grade. The clinical implications of these findings require investigation.
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Affiliation(s)
- Jeffrey N Katz
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jamie E Collins
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Robert H Brophy
- Washington University School of Medicine, St. Louis, Missouri
| | | | | | - Ali Guermazi
- Boston Veteran's Medical Center and Boston University Medical Center, Boston, Massachusetts
| | - Morgan H Jones
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | | | - Lisa A Mandl
- Hospital for Special Surgery, New York, New York
| | | | - Faith Selzer
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | | | - Elena Losina
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Yuchiao Chang
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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Rizk E, Tajchman S, Fink E, Aryal DK, Iso T, Flores E, Brown AE, Chokshi SP, Desai SN, Dewan AK, Kazzaz SA, Guevara M, Nagaraj S, Robben CP, Vittone V, Swan JT. Quality indicators for osteoarthritis pain management in the primary care setting. BMC Musculoskelet Disord 2023; 24:538. [PMID: 37391737 DOI: 10.1186/s12891-023-06637-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 06/14/2023] [Indexed: 07/02/2023] Open
Abstract
BACKGROUND Development of valid and feasible quality indicators (QIs) is needed to track quality initiatives for osteoarthritis pain management in primary care settings. METHODS Literature search identified published guidelines that were reviewed for QI extraction. A panel of 14 experts was assembled, including primary care physicians, rheumatologists, orthopedic surgeons, pain specialists, and outcomes research pharmacists. A screening survey excluded QIs that cannot be reliably extracted from the electronic health record or that are irrelevant for osteoarthritis in primary care settings. A validity screening survey used a 9-point Likert scale to rate the validity of each QI based on predefined criteria. During expert panel discussions, stakeholders revised QI wording, added new QIs, and voted to include or exclude each QI. A priority survey used a 9-point Likert scale to prioritize the included QIs. RESULTS Literature search identified 520 references published from January 2015 to March 2021 and 4 additional guidelines from professional/governmental websites. The study included 41 guidelines. Extraction of 741 recommendations yielded 115 candidate QIs. Feasibility screening excluded 28 QIs. Validity screening and expert panel discussion excluded 73 QIs and added 1 QI. The final set of 15 prioritized QIs focused on pain management safety, education, weight-management, psychological wellbeing, optimizing first-line medications, referral, and imaging. CONCLUSION This multi-disciplinary expert panel established consensus on QIs for osteoarthritis pain management in primary care settings by combining scientific evidence with expert opinion. The resulting list of 15 prioritized, valid, and feasible QIs can be used to track quality initiatives for osteoarthritis pain management.
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Affiliation(s)
- Elsie Rizk
- Department of Pharmacy, Houston Methodist, Houston, TX, USA
- Department of Surgery, Houston Methodist, TX, Houston, USA
| | | | - Ezekiel Fink
- Department of Neurology, Houston Methodist, Houston, TX, USA
| | - Dipendra K Aryal
- Department of Pharmacy, Houston Methodist, Houston, TX, USA
- Department of Surgery, Houston Methodist, TX, Houston, USA
| | - Tomona Iso
- Department of Pharmacy, Houston Methodist, Houston, TX, USA
- Department of Surgery, Houston Methodist, TX, Houston, USA
| | - Eleazar Flores
- Houston Methodist Primary Care Group, Houston Methodist, Houston, TX, USA
| | - Anthony E Brown
- Houston Methodist Primary Care Group, Houston Methodist, Houston, TX, USA
| | - Sagar P Chokshi
- Department of Neurosurgery, Houston Methodist, Houston, TX, USA
| | | | - Ashvin K Dewan
- Department of Orthopedic Surgery, Houston Methodist, Houston, TX, USA
| | - Sarah A Kazzaz
- Houston Methodist Academic Medicine Associates - Rheumatology, Houston Methodist, Houston, TX, USA
| | - Myriam Guevara
- Houston Methodist Academic Medicine Associates - Rheumatology, Houston Methodist, Houston, TX, USA
| | - Sudha Nagaraj
- Houston Methodist Primary Care Group, Houston Methodist, Houston, TX, USA
| | | | - Veronica Vittone
- Houston Methodist Primary Care Group, Houston Methodist, Houston, TX, USA
| | - Joshua T Swan
- Department of Pharmacy, Houston Methodist, Houston, TX, USA.
- Department of Surgery, Houston Methodist, TX, Houston, USA.
- Center for Outcomes Research, Houston Methodist, Houston, TX, USA.
- Department of Surgery, Houston Methodist Hospital, 6550 Fannin Street, SM1661, Houston, TX, 77030, USA.
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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] [MESH Headings] [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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5
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Chan EW, Chaulk RC, Cheng Y, Shin J. No decrease in incidence of arthroscopic meniscectomy in a Canadian province. Knee Surg Sports Traumatol Arthrosc 2021; 29:4223-4231. [PMID: 33745007 DOI: 10.1007/s00167-021-06534-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 03/09/2021] [Indexed: 01/05/2023]
Abstract
PURPOSE Arthroscopic meniscectomy (APM) is the most common procedure in orthopedic surgery, despite increasing evidence questioning its benefit over conservative management for treatment of degenerative meniscal tears. The purpose of this study is to determine the epidemiology and trends of APM in Saskatchewan, a Canadian province, over a 20 year period. METHODS Physician billing codes were used to identify patients who underwent APM in Saskatchewan between January 1, 1998 and December 31, 2017. Records were obtained from eHealth Saskatchewan, a provincial health database. Data was analyzed for overall incidence and age-specific trends of APM. RESULTS A total of 35,099 APMs were performed during the study period. The population of Saskatchewan ranged from 992,314 to 1,150,782 (median 1,017,368) during this time interval, with 81 orthopedic surgeons performing APM. Overall incidence rate of APM did not change significantly over time. No decrease was observed in patients presumed to have degenerative tears (≥ 50 years). The number of meniscectomies in patients ≥ 50 years was significantly greater during the second decade of study compared to the first (OR 1.48, p < 0.01). Conversely, the increase in incidence rate among older patients was not statistically significant (R2 = 0.125, n.s.). CONCLUSION Overall incidence rate of APM in Saskatchewan has not decreased during the last 20 years. Furthermore, APM frequency increased over time for individuals ≥ 50 years. Several regional factors may have contributed to these findings, including the large proportion of Saskatchewan residents engaged in physically demanding work and barriers to accessing physiotherapy services. Given recent evidence disputing the benefit of APM over conservative measures, this study highlights the need for improved dissemination of evidence, as well as the importance of an individualized treatment plan to address patient-specific factors. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Emily W Chan
- Department of Surgery, University of Saskatchewan College of Medicine, 107 Wiggins Road, Saskatoon, SK, S7N 5E5, Canada. .,Division of Orthopedic Surgery, University of Saskatchewan College of Medicine, Saskatoon, Canada.
| | - Richard C Chaulk
- Department of Surgery, University of Saskatchewan College of Medicine, 107 Wiggins Road, Saskatoon, SK, S7N 5E5, Canada
| | - Yanzhao Cheng
- Department of Surgery, University of Saskatchewan College of Medicine, 107 Wiggins Road, Saskatoon, SK, S7N 5E5, Canada
| | - Jason Shin
- Department of Surgery, University of Saskatchewan College of Medicine, 107 Wiggins Road, Saskatoon, SK, S7N 5E5, Canada.,Division of Orthopedic Surgery, University of Saskatchewan College of Medicine, Saskatoon, Canada.,Dr. F. H. Wigmore Regional Hospital, Moose Jaw, Canada
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Time to Achievement of Clinically Significant Outcomes After Isolated Arthroscopic Partial Meniscectomy: A Multivariate Analysis. Arthrosc Sports Med Rehabil 2020; 2:e723-e733. [PMID: 33364610 PMCID: PMC7754524 DOI: 10.1016/j.asmr.2020.06.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 06/04/2020] [Indexed: 12/31/2022] Open
Abstract
Purpose To define the time required to achieve the minimally clinically important difference (MCID), substantial clinical benefit (SCB) and patient acceptable symptomatic state (PASS) for isolated arthroscopic partial meniscectomy (APM), and define preoperative and intraoperative factors that predict both early and late achievement of the stated metrics. Methods Patients who underwent isolated APM between 2014 and 2017 were retrospectively included. Patients without preoperative and 6-month patient-reported outcome measure scores, revision procedures, and significant concomitant procedures were excluded. The MCID, SCB, and PASS were calculated for knee-based patient-reported outcome measure scores using receiver operating curve analysis. Kaplan-Meier survival analysis established the time required to achieve MCID, SCB and PASS. Hazard ratios from multivariate Cox regression allowed for the isolation of demographic and intraoperative factors predictive of the delayed time required to achieve MCID, SCB and PASS. Results A total of 126 patients (42.86% female, age: 48.9 ± 12.4 years) were included. Overall achievement rates ranged between 73.0% and 89.7% for MCID, 43.7% and 68.2% for SCB, and 50.8% and 68.3% for PASS. Median achievement time for MCID was 5.68-5.78 months, 5.73-6.05 months for SCB and 6.54-7.72 months for PASS. Multivariate Cox regression identified older age, workers' compensation status, diabetes, and various tear types (i.e., longitudinal, transverse, bucket handle, complex) as predictors of early clinically significant outcome achievement (hazard ratio: 1.02-24.72), whereas subsequent steroid injection, higher preoperative scores and root and flap tears predicted delays in clinically significant outcome achievement (hazard ratio: 0.12-0.99). Conclusions The majority of patients undergoing APM achieve benefit within 6 months of surgery, with diminishing proportions at later timepoints. Important factors for consideration of the the timeline of achieving clinically significant outcome include age, diabetes, workers' compensation, preoperative score, and tear type. The timeline for achieving improvement that was established by this study may aid in setting patient expectations and designing future outcome studies involving APM. Study design Level IV, Therapeutic Case Series.
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Kopka M, Sheehan B, Degen R, Wong I, Hiemstra L, Ayeni O, Getgood A, Beavis C, Volesky M, Outerbridge R, Matache B. Arthroscopy Association of Canada Position Statement on Intra-articular Injections for Knee Osteoarthritis. Orthop J Sports Med 2019; 7:2325967119860110. [PMID: 31367647 PMCID: PMC6643188 DOI: 10.1177/2325967119860110] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
| | - Michaela Kopka
- Michaela Kopka, MD, FRCSC, DipSportMed, Banff Sport Medicine, PO
Box 1300, Banff, AB T1L 1B3, Canada (
)
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