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      Inappropriate use of arthroscopic meniscal surgery in degenerative knee disease : An observational study from Switzerland

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          Abstract

          Background and purpose

          Current evidence suggests that arthroscopic knee surgery has no added benefit compared with non-surgical management in degenerative meniscal disease. Yet in many countries, arthroscopic partial meniscectomy (APM) remains among the most frequently performed surgeries. This study quantifies and characterizes the dynamics of the current use of knee arthroscopies in Switzerland in a distinctively non-traumatic patient group.

          Methods

          We assessed a non-accident insurance plan of a major Swiss health insurance company for surgery rates of APM, arthroscopic debridement and lavage in patients over the age of 40, comparing the years 2012 and 2015. Claims were analyzed for prevalence of osteoarthritis, related interventions and the association of surgery with insurance status.

          Results

          648,708 and 647,808 people were examined in 2012 and 2015, respectively. The incidence of APM, debridement, and lavage was 388 per 10 5 person-years in 2012 and 352 per 10 5 person-years in 2015 in non-traumatic patients over the age of 40, consisting mostly of APM (96%). Between years, APM surgery rates changed in patients over the age of 65 (p < 0.001) but was similar in patients aged 40–64. Overall prevalence of osteoarthritis was 25%. Insurance status was independently associated with arthroscopic knee surgery.

          Interpretation

          APM is widely used in non-traumatic patients in Switzerland, which contrasts with current evidence. Many procedures take place in patients with degenerative knee disease. Surgery rates were similar in non-traumatic middle-aged patients between 2012 and 2015. Accordingly, the potential of inappropriate use of APM in non-traumatic patients in Switzerland is high.

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          A controlled trial of arthroscopic surgery for osteoarthritis of the knee.

          J Bruce Moseley, Kimberly O'malley, Nancy Petersen … (2002)
          Many patients report symptomatic relief after undergoing arthroscopy of the knee for osteoarthritis, but it is unclear how the procedure achieves this result. We conducted a randomized, placebo-controlled trial to evaluate the efficacy of arthroscopy for osteoarthritis of the knee. A total of 180 patients with osteoarthritis of the knee were randomly assigned to receive arthroscopic débridement, arthroscopic lavage, or placebo surgery. Patients in the placebo group received skin incisions and underwent a simulated débridement without insertion of the arthroscope. Patients and assessors of outcome were blinded to the treatment-group assignment. Outcomes were assessed at multiple points over a 24-month period with the use of five self-reported scores--three on scales for pain and two on scales for function--and one objective test of walking and stair climbing. A total of 165 patients completed the trial. At no point did either of the intervention groups report less pain or better function than the placebo group. For example, mean (+/-SD) scores on the Knee-Specific Pain Scale (range, 0 to 100, with higher scores indicating more severe pain) were similar in the placebo, lavage, and débridement groups: 48.9+/-21.9, 54.8+/-19.8, and 51.7+/-22.4, respectively, at one year (P=0.14 for the comparison between placebo and lavage; P=0.51 for the comparison between placebo and débridement) and 51.6+/-23.7, 53.7+/-23.7, and 51.4+/-23.2, respectively, at two years (P=0.64 and P=0.96, respectively). Furthermore, the 95 percent confidence intervals for the differences between the placebo group and the intervention groups exclude any clinically meaningful difference. In this controlled trial involving patients with osteoarthritis of the knee, the outcomes after arthroscopic lavage or arthroscopic débridement were no better than those after a placebo procedure.
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            Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear.

            Raine Sihvonen, Mika Paavola, Antti Malmivaara … (2013)
            Arthroscopic partial meniscectomy is one of the most common orthopedic procedures, yet rigorous evidence of its efficacy is lacking. 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. 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). 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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              A comparative study of meniscectomy and nonoperative treatment for degenerative horizontal tears of the medial meniscus.

              Hyeon Yim, Ik Kyun Choi, Cheol Kim … (2013)
              It is still debated whether a degenerative horizontal tear of the medial meniscus should be treated with surgery. The clinical outcomes of arthroscopic meniscectomy will be better than those of nonoperative treatment for a degenerative horizontal tear of the medial meniscus. Randomized controlled trial; Level of evidence, 1. A total of 102 patients with knee pain and a degenerative horizontal tear of the posterior horn of the medial meniscus on magnetic resonance imaging were included in this study between January 2007 and July 2009. The study included 81 female and 21 male patients with an average age of 53.8 years (range, 43-62 years). Fifty patients underwent arthroscopic meniscectomy (meniscectomy group), and 52 patients underwent nonoperative treatment with strengthening exercises (nonoperative group). Functional outcomes were compared using a visual analog scale (VAS) for pain, Lysholm knee score, Tegner activity scale, and patient subjective knee pain and satisfaction. Radiological evaluations were performed using the Kellgren-Lawrence classification to evaluate osteoarthritic changes. In terms of clinical outcomes, meniscectomy did not provide better functional improvement than nonoperative treatment. At the final follow-up, the average VAS scores were 1.8 (range, 1-5) in the meniscectomy group and 1.7 (range, 1-4) in the nonoperative group (P = .675). The average Lysholm knee scores at 2-year follow-up were 83.2 (range, 52-100) and 84.3 (range, 58-100) in the meniscectomy and nonoperative groups, respectively (P = .237). In addition, the average Tegner activity scale and subjective satisfaction scores were not significantly different between the 2 groups. Although most patients initially had intense knee pain with mechanical symptoms, both groups reported a relief in knee pain, improved knee function, and a high level of satisfaction with treatment (P < .05 for all values). Two patients in the meniscectomy group and 3 in the nonoperative group with Kellgren-Lawrence grade 1 progressed to grade 2 at the 2-year follow-up. There were no significant differences between arthroscopic meniscectomy and nonoperative management with strengthening exercises in terms of relief in knee pain, improved knee function, or increased satisfaction in patients after 2 years of follow-up.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Acta Orthop
                Journal ID (iso-abbrev): Acta Orthop
                Journal ID (publisher-id): IORT
                Title: Acta Orthopaedica
                Publisher: Taylor & Francis
                ISSN (Print): 1745-3674
                ISSN (Electronic): 1745-3682
                Publication date (Print): October 2017
                Publication date (Electronic): 30 June 2017
                Volume: 88
                Issue: 5
                Pages: 550-555
                Affiliations
                [1 ]Institute of Primary Care, University of Zurich, Zurich, Switzerland;
                [2 ]Department of Health Sciences, Helsana Group, Zurich, Switzerland
                Author notes
                Article
                Publisher ID: iort-88-550
                DOI: 10.1080/17453674.2017.1344915
                PMC ID: 5560220
                PubMed ID: 28665174
                SO-VID: 1471e79a-59b1-4c51-97e0-6b30101465e0
                Copyright © © 2017 The Author(s). Published by Taylor & Francis on behalf of the Nordic Orthopedic Federation.
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution-Non-Commercial License ( https://creativecommons.org/licenses/by-nc/3.0)

                History
                Date received : 19 January 2017
                Date accepted : 05 June 2017
                Categories
                Subject: Knee

                ScienceOpen disciplines: Orthopedics
                Data availability:
                ScienceOpen disciplines: Orthopedics

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