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Arthroscopy for mechanical symptoms in osteoarthritis: a cost-effective procedure


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Purpose: The place of knee arthroscopy as a therapeutic option for osteoarthritis (OA) has been the subject of some debate. The hypothesis for this study was that arthroscopic debridement is beneficial in patients with OA who have significant mechanical symptoms. Methods: Forty-three patients with radiological OA on plain radiographs and mechanical symptoms were prospectively followed. No further imaging was obtained. They were assessed pre- and postoperatively with an Oxford Knee Score (OKS) and pain visual analogue score (VAS). Postoperative patient satisfaction was measured with a VAS. A cost-benefit analysis was performed using a transformed OKS to generate a quality-adjusted life year (QALY) measurement. Results: At a mean of 1.5 years, seven patients (16 %) had undergone total knee arthroplasty at a mean of 8.2 months postarthroscopy. For the remaining 35 patients, there were significant improvements in pain (median 7-5, p < 0.05) and OKS (median 24-36.5, p < 0.05). Satisfaction was a median 6.2 for all patients. The mean calculated EQ-5D improved from 0.43 (SD 0.16) to 0.79 (SD 0.23), which gave a gain of 0.52 QALYs in the study period. This generated a cost per QALY of £2,088, well below the threshold of £30,000 quoted by the UK National Institute for Health and Care Excellence as demonstration of cost-effective treatment. Conclusions: This prospective study demonstrates that although not universally effective, arthroscopic debridement for patients with knee OA and mechanical symptoms can result in significant improvements in pain and function. The procedure gave good patient satisfaction, and even at an early follow-up period proves to be cost-effective. LEVEL OF EVIDENCE: IV.
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Knee Surgery, Sports Traumatology,
ISSN 0942-2056
Knee Surg Sports Traumatol Arthrosc
DOI 10.1007/s00167-014-3220-1
Arthroscopy for mechanical symptoms in
osteoarthritis: a cost-effective procedure
Jonathan R.B.Hutt, Johnathan Craik,
Joideep Phadnis & Andrew G.Cobb
1 23
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1 3
Knee Surg Sports Traumatol Arthrosc
DOI 10.1007/s00167-014-3220-1
Arthroscopy for mechanical symptoms in osteoarthritis:
a cost‑effective procedure
Jonathan R. B. Hutt · Johnathan Craik ·
Joideep Phadnis · Andrew G. Cobb
Received: 18 November 2013 / Accepted: 28 July 2014
© Springer-Verlag Berlin Heidelberg 2014
Conclusions This prospective study demonstrates that
although not universally effective, arthroscopic debride-
ment for patients with knee OA and mechanical symptoms
can result in significant improvements in pain and function.
The procedure gave good patient satisfaction, and even at
an early follow-up period proves to be cost-effective.
Level of evidence IV.
Keywords Arthroscopy · Knee · Osteoarthritis ·
Osteoarthritis (OA) of the knee is a growing problem, and
surgery for this condition is on the rise [6]. Surgeons are
often faced with the conundrum of a significantly symp-
tomatic patient with only mild or moderate radiographic
evidence of OA. Knee arthroplasty is a major undertaking
with up to 20 % of patients said to be dissatisfied with their
outcome [20], but the value of other interventions is con-
troversial. Arthroscopic debridement of degenerate menis-
cal tears, unstable chondral flaps and removal of loose bod-
ies was a previously widely used technique [2, 7, 12], with
cited advantages including low risk, quick recovery and
rapid improvement in symptoms for many patients. How-
ever, other studies have been less favourable towards such
intervention. Moseley et al. [13] compared arthroscopic
lavage, arthroscopic debridement and sham surgery in
165 patients and did not demonstrate any benefit of either
arthroscopic procedure over placebo surgery. In addition,
Kirkley et al. [10] did not demonstrate any significant ben-
efit of a treatment programme including arthroscopic lav-
age, debridement and physical and medical therapy, ver-
sus physical and medical therapy alone. Herrlin et al. [7]
Purpose The place of knee arthroscopy as a therapeutic
option for osteoarthritis (OA) has been the subject of some
debate. The hypothesis for this study was that arthroscopic
debridement is beneficial in patients with OA who have
significant mechanical symptoms.
Methods Forty-three patients with radiological OA on
plain radiographs and mechanical symptoms were pro-
spectively followed. No further imaging was obtained.
They were assessed pre- and postoperatively with an
Oxford Knee Score (OKS) and pain visual analogue score
(VAS). Postoperative patient satisfaction was measured
with a VAS. A cost-benefit analysis was performed using
a transformed OKS to generate a quality-adjusted life year
(QALY) measurement.
Results At a mean of 1.5 years, seven patients (16 %) had
undergone total knee arthroplasty at a mean of 8.2 months
postarthroscopy. For the remaining 35 patients, there were
significant improvements in pain (median 7–5, p < 0.05)
and OKS (median 24–36.5, p < 0.05). Satisfaction was a
median 6.2 for all patients. The mean calculated EQ-5D
improved from 0.43 (SD 0.16) to 0.79 (SD 0.23), which
gave a gain of 0.52 QALYs in the study period. This gener-
ated a cost per QALY of £2,088, well below the threshold
of £30,000 quoted by the UK National Institute for Health
and Care Excellence as demonstration of cost-effective
J. R. B. Hutt · J. Craik · J. Phadnis · A. G. Cobb
Epsom General Hospital, Dorking Road, Epsom,
Surrey KT18 7EG, UK
J. R. B. Hutt (*)
3535 Av Papineau, Apt 406, Montreal, QC H2K 4J9, Canada
Author's personal copy
Knee Surg Sports Traumatol Arthrosc
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compared arthroscopic meniscectomy and physiotherapy
with physiotherapy alone in patients with atraumatic
meniscal tears and were unable to identify any significant
benefit from arthroscopy. Vermesan et al. [23] conducted
a randomised trial of arthroscopic meniscectomy versus
steroid injection for degenerative meniscal tears and asso-
ciated arthritic change and found improvements with both
techniques but no significant differences between them
at 1 year. The effect at a local level has been a reluctance
of primary care bodies to fund arthroscopic procedures in
degenerative disease despite some surgeons still advocating
its use in certain circumstances. The current UK National
Institute for Health and Care Excellence (NICE) guidelines
state that arthroscopic surgery should not be offered in the
presence of OA unless there is a ‘clear history of mechani-
cal locking (not gelling, giving way or x-ray evidence of
loose bodies)’ [15]. However, such broad statements do not
take into account specific cohorts of patients who may ben-
efit. Arthroscopic surgery with partial meniscectomy, chon-
droplasty and removal of loose bodies in carefully selected
patients to address mechanical symptoms could help with
relieving pain and maintaining function and may postpone
the need for arthroplasty [18, 22].
The hypothesis for this study was that knee arthroscopy
for certain patients would provide significant clinical ben-
efit. In contrast to other studies, patients were included
using specific symptomatic criteria with evidence of degen-
erative change on radiographs that gave a diagnosis of OA
but would not make them candidates for arthroplasty. The
benefits of arthroscopy in this group are likely to be tem-
porary. Further analysis was performed to examine a fur-
ther hypothesis that despite this, arthroscopy would dem-
onstrate a favourable cost-benefit profile when compared
with national standards for the use of procedures in clinical
Materials and methods
Patients were prospectively recruited for inclusion if they
had radiographic evidence of OA of the knee and the pres-
ence of one or more specific mechanical symptoms in the
form of locking, giving way, clicking and sharp pains. They
were specifically examined for the presence of an effusion,
point tenderness and for a positive McMurray’s meniscal
provocation test. All patients had failed a trial of nonopera-
tive treatment that included appropriate analgesia, activity
modification and physiotherapy. Patients who had already
been given an intra-articular injection of steroid or visco-
supplementary products were excluded. The study was
approved by the institutional review board, and informed
consent for data collection was taken from each participant
in the study. Preoperative standing anteroposterior and lat-
eral radiographs were taken for all patients, and the degree
and pattern of arthrosis was recorded using the Kellgren–
Lawrence grading [9]. Patients with grade IV changes
were excluded. No further imaging was performed prior to
Operative technique
All patients underwent arthroscopic surgery as a day case
procedure performed by or under the direct supervision of
the senior author. Standard anterolateral and anteromedial
portals were utilised to perform a systematic examina-
tion of the knee joint. The degree of arthrosis was graded
according to the Outerbridge system [16]. At surgery, any
unstable meniscal tears and chondral flaps were debrided
to stable edges and loose bodies were removed. No other
meniscal procedures, microfracture or any other form
of cartilage augmentation surgery was performed in this
cohort of patients. About 10 ml of 0.5 % marcaine was
instilled into the knee joint at the end of the procedure.
Patients were discharged on the same day after consultation
with a physiotherapist with immediate weight bearing and
full range of knee motion permitted.
The outcomes studied pre- and postoperatively were the
Oxford Knee Score (OKS) and pain visual analogue score
(VAS). Patient satisfaction was also evaluated at follow-
up with a VAS, and progression to arthroplasty was docu-
mented. A cost-benefit analysis was performed to assess
the economic impact of the procedure expressed as cost per
quality-adjusted life years (QALYs).
Statistical analysis
Pre- and postoperative OKS and VAS were compared with
the Wilcoxon signed rank test. For inclusion in the analy-
sis, patients who had undergone arthroplasty were assumed
to have neither improved nor worsened after their arthros-
copy. A power analysis using previously published data on
the OKS [14] with a SD of 10 points and a conservative
minimally important clinical difference of 5 points calcu-
lated that a minimum of 34 patients would be required to
achieve a power of 80 % and an alpha value of 0.05.
For the cost-benefit analysis, preoperative OKS and
postoperative OKS were converted to an EQ-5D score
using a published mapping algorithm [3]. For compari-
son, the assumption was made that without intervention,
the OKS on presentation would neither have improved nor
worsened, and similarly that the intervention had no effect
on those patients who progressed to total knee arthroplasty
(TKA). The EQ-5D score was then used to calculate any
gain in QALYs.
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Knee Surg Sports Traumatol Arthrosc
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Forty-three patients were recruited into the study, with a
male to female ratio of 20:23 and a mean age of 64 years
(range 35–82). Thirty-one patients had grade 2 radio-
graphic changes in at least one compartment; the remaining
12 patients had grade 3. The worst intra-operative Outer-
bridge grade in any compartment was 3 in 22 patients and 4
in 21. The prevalence of mechanical symptoms and preop-
erative findings is shown in Table 1. At surgery, all patients
had chondral flaps that were debrided, but only 27 patients
had an identifiable meniscal tear.
The latest follow-up was at a mean of 1.5 years; with a
minimum follow-up of 1 year. Seven patients (16 %) had
undergone TKA at a mean of 8.2 months post arthroscopy.
Pre- and postoperative scores are shown as box and whisker
plots in Fig. 1. The median OKS improved from 24 (range
12–42) to 36.5 (range 14–48) (p < 0.05). The median
pain VAS improved from 7 (range 3–10) to 5 (range 0–8)
(p < 0.05). Patient satisfaction was a median of 6.2 (range
0–10) for all patients.
The mean calculated EQ-5D score improved from 0.43
(SD 0.16) to 0.79 (SD 0.23). Over the time period stud-
ied, this equated to a gain in QALYs of 0.52. A cost-ben-
efit analysis was then performed. The NHS trust where the
study was performed receives £1,105 per procedure, giving
a cost per QALY of £2,088.
The most important finding of this prospective study is
that arthroscopic debridement in the presence of OA and
mechanical symptoms, although not universally effective,
can have significant clinical benefit in selected patients and
gives good patient satisfaction with a very reasonable cost-
to-benefit ratio even at short-term follow-up.
This study has its limitations. Although prospective,
it is only a small cohort of patients. Quality of life scores
were not collected prospectively, and although the mapping
algorithm provides a useful estimate in order to allow us
to undertake a cost-benefit analysis, it is probably not as
Table 1 Prevalence of mechanical symptoms and examination find-
Number (total n = 43)
Clicking 21
Locking 16
Giving way 19
Sharp pain 34
Examination findings
Effusion 23
Pain localisation 28
Positive McMurray’s test 22
Fig. 1 Outcome scores
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Knee Surg Sports Traumatol Arthrosc
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Presumably on the basis of the available evidence so
far, the popularity of performing arthroscopy for the treat-
ment of OA has declined [6, 17], and currently, neither the
American Academy of Orthopaedic Surgeons in the US
or NICE in the UK recommends arthroscopic debride-
ment for patients with symptomatic OA of the knee. One
possible reason that our findings differ from other, above-
mentioned studies is their more diverse patient cohorts. As
a result, benefits to a subgroup of patients may have been
missed. Kirkley et al. [10] only included patients with mod-
erate to severe OA, and Moseley et al. [13] enroled partici-
pants that demonstrated a greater degree of OA than those
who declined involvement. Vermesan et al. [23] included
all symptomatic patients with MRI proven degenerative
changes in the medial compartment but did not provide
information on radiographic severity or symptomatology.
The arthroscopic group did demonstrate improvement,
however there was significant cross-over from the steroid
injection cohort. A prospective study by Aichroth et al. [1]
demonstrated that patients presenting with less advanced
arthritis both radiologically and arthroscopically demon-
strated improved outcomes following arthroscopy, with
high satisfaction rates reported and a more favourable out-
come associated with patients of a younger age.
In the presence of degenerative disease, it is also unclear
how to delineate the various intra-articular pathologies in
terms of their contribution to patient symptoms. A recent
randomised trial by Sihvonen et al. [21] in patients with
degenerative meniscal tears did not demonstrate differ-
ence in outcome between arthroscopic meniscectomy and
washout. The study was performed specifically in patients
with no evidence of radiographic OA; thus, the assumption
was that the meniscus was the main surgical target. Herrlin
et al. looked at a similar randomised cohort of patients with
degenerative meniscal tears detected on MRI and minimal
evidence of OA on radiographs. There were no differences
in outcomes between exercise therapy alone or therapy
combined with arthroscopy either in the short or longer
term [7, 8]. Interestingly, although all patients in the cur-
rent study had chondral flaps debrided at arthroscopy, only
27 (63 %) had an identifiable meniscal tear, suggesting that
further preoperative imaging such as an MRI scan would
not have necessarily have helped with patient selection and
that multiple intra-articular pathologies were contributing
to the problem. Of further interest from the study by Herrlin
et al. was that approximately a quarter of the nonsurgical
group had significantly worse early outcomes. Their scores
did improve to the level of the remainder of the cohort but
only after they underwent arthroscopy prior to the later
follow-up points, suggesting that there may be a subgroup
for which surgery is beneficial. This study selected patients
on the basis of particular symptoms and signs, and other
studies have also shown that preoperative symptoms and
examination findings may be of value when predicting
outcomes following arthroscopy in the presence of OA. A
prospective study by Dervin et al. [4] demonstrated that the
presence of medial joint line tenderness, a positive Stein-
man’s test or the presence of an unstable meniscal tear were
significantly associated with an improved outcome. In addi-
tion, Fond et al. [5] demonstrated high satisfaction rates
following arthroscopy at 5-year follow-up in patients with
less severe preoperative symptoms or preoperative flexion
contractures of <10 °. A recent survey of 170 European sur-
geons demonstrated significant agreement for the potential
of arthroscopy to improve symptoms in young patients with
low-grade OA. Treatments considered successful included
meniscectomy and notchplasty, whereas removal of osteo-
phytes or joint lavage were not [11].
It is likely that any benefit from arthroscopy will only be
temporary, as the degenerative process has already begun.
All the patients in this study had only moderate degrees of
arthritis, significant enough to be noticeable radiographi-
cally, but not necessarily to a level advanced enough for
consideration of TKA. A retrospective cohort study by Har-
ris et al. [6] demonstrated that 21.5 % of patients over the
age of 65 undergoing knee arthroscopy proceeded to TKA
within 24 months suggesting that there may be limited
benefit for arthroscopy in patients of this age. Raaijmaak-
ers et al. [19] demonstrated a similar arthroplasty rate in a
cohort of patients over the age of 65 at mean follow-up of
38 months. However, the temporal value of a procedure is
not measured only by clinical outcomes but also in terms of
healthcare costs, and it is for this reason that the cost analy-
sis was included in this study, as even short-term benefits
from interventions can prove cost-effective.
Along with other authors, we would not advocate for a
role for arthroscopy in all patients, but we believe there is
a role for it in patients without advanced disease present-
ing in a specific way. It is a straightforward and relatively
cheap operation. NICE has previously suggested that a cost
per QALY of £30,000 represents a cost-effective treatment:
That is well above the calculated value in the cost-benefit
analysis for this study. Further research is required to fur-
ther clarify which cohorts of patients with symptomatic
early OA may benefit from arthroscopic intervention.
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... However, after more than 40 years development, a study [2] found that about one third of TKA surgery were currently inappropriate, and it was an "over-medical" problem. Therefore, conservative treatments, such as non-drug therapy, drug therapy, arthroscopic surgery [3], high tibial osteotomy [4], joint traction [5], and platelet-rich plasma (PRP) therapy [6], are still the first choice for early KOA. However, there is still a controversy about conservative treatments because of their various efficacy. ...
Full-text available
Background: Many previous studies lack sufficient quantitative evidences about changes in biomechanical properties of the knee in response to proximal fibular osteotomy (PFO). Therefore, the aim of this study was to compare the preoperative and postoperative effects of PFO on mechanical stresses in the knee joint and provide with a biomechanical basis for PFO in the treatment of mild knee osteoarthritis (KOA) with varus deformity. Methods: A total of 10 patients suffering mild KOA with varus deformity were enrolled in this study. Their image data from computerized tomography (CT) and magnetic resonance imaging (MRI) were used for finite element models, and PFO models were established. Static structural analysis was carried out using ABAQUS to compare the von Mises stress distribution and values of the maximal von Mises stress of femoral cartilage, meniscuses, tibial cartilages, and tibial plateau before and after surgery. Results: The stress distribution in the cortical bone of the tibial plateau showed that stresses were transferred from the anterior medial area to the posterior medial area after PFO. Values of the maximal von Mises stress in femoral cartilage, medial meniscus, medial tibial cartilage, and tibial plateau after surgery were significantly lower than the preoperative values, with statistically significant differences (P < 0.05). Postoperative values of the maximal von Mises stress of lateral meniscus and lateral tibial cartilage were significantly higher than the preoperative ones, with statistically significant differences (P < 0.05). Conclusion: PFO could reduce the stresses in the medial compartment of the knee joint with stress pathways transferring from the anterior medial area to the posterior medial area of the tibial plateau. Therefore, PFO is recommended for the treatment of mild KOA with varus deformity featuring favorably pain-relieving effects.
... 3 Several studies have supported the role of arthroscopic surgery in degenerative knee disorders. [4][5][6][7][8] Arthroscopic techniques suggested in these studies include lavage, debridement, abrasion arthroplasty, subchondral penetration procedures (drilling and microfractures), laser/thermal chondroplasty, etc. However, there is also the availability of literature suggesting that there is no benefit of arthroscopic surgery in degenerative knees. ...
Full-text available
Background This study was conducted to evaluate functional outcome in patients undergoing/underwent arthroscopic surgery for degenerative knees with mechanical symptoms or acute exacerbation of symptoms, not amenable to conservative measures. Materials and Methods This was a longitudinal type of study (prospective and retrospective). For the prospective cohort, followup was done at an interval of 2 weeks, 6 weeks, 6 months and 1 year to record visual analog scale (VAS), International Knee Documentation Committee (IKDC), and short form-8 (SF-8) scores. For the retrospective cohort, hospital records were studied to record the preoperative VAS score. Preoperative IKDC and SF-8 scores were recorded at final followup based on recall method (patient's memory). Furthermore, postoperative VAS, IKDC, and SF-8 scores at final followup were recorded. Results There were a total of 46 knees (28 retrospective and 18 prospective) in 44 patients. The mean age was 52.34 ± 11.73 years. There were 28 female knees and 18 male knees. The mean followup of patients in the retrospective cohort was 55 months (range: 13–126 months), whereas all patients in prospective cohort completed the minimum followup of 1 year. The improvements in VAS, IKDC, and SF-8 were statistically significant. Forty-one cases were successful and five cases were failure. All successful patients (41 cases) said “yes” and all failure cases (05) said “no” to the question-”If given a choice, would you still like to get the same surgery done for the same problem??”. There was one complication deep venous thrombosis. Conclusion We recommend arthroscopic surgery in patients with degenerative knees, with mechanical symptoms and acute exacerbation of symptoms, not amenable to conservative measures.
... [6][7][8][9][10] Aligned with the evidence, most guidelines and expert opinion now refrain from recommending APM as the first-line treatment for patients with a degenerative meniscus tear, but still advocate surgery after a failed attempt of conservative treatment. [11][12][13][14][15][16] Such recommendations rest on three issues: generally favourable clinical experience, some before-after studies on patients undergoing APM due to persisting symptoms despite conservative treatment 17 18 and particularly the evidence from three RCTs [19][20][21] in which one-third of participants initially allocated to non-surgical treatment opted for crossing over to APM due to persisting knee symptoms or insufficient improvement. After undergoing APM, participants achieved similar outcomes compared with those initially assigned to surgery and those responding favourably to initial non-surgical/conservative treatment. ...
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Objective: To assess if arthroscopic partial meniscectomy (APM) is superior to placebo surgery in the treatment of patients with degenerative tear of the medial meniscus. Methods: In this multicentre, randomised, participant-blinded and outcome assessor-blinded, placebo-surgery controlled trial, 146 adults, aged 35-65 years, with knee symptoms consistent with degenerative medial meniscus tear and no knee osteoarthritis were randomised to APM or placebo surgery. The primary outcome was the between-group difference in the change from baseline in the Western Ontario Meniscal Evaluation Tool (WOMET) and Lysholm knee scores and knee pain after exercise at 24 months after surgery. Secondary outcomes included the frequency of unblinding of the treatment-group allocation, participants' satisfaction, impression of change, return to normal activities, the incidence of serious adverse events and the presence of meniscal symptoms in clinical examination. Two subgroup analyses, assessing the outcome on those with mechanical symptoms and those with unstable meniscus tears, were also carried out. Results: In the intention-to-treat analysis, there were no significant between-group differences in the mean changes from baseline to 24 months in WOMET score: 27.3 in the APM group as compared with 31.6 in the placebo-surgery group (between-group difference, -4.3; 95% CI, -11.3 to 2.6); Lysholm knee score: 23.1 and 26.3, respectively (-3.2; -8.9 to 2.4) or knee pain after exercise, 3.5 and 3.9, respectively (-0.4; -1.3 to 0.5). There were no statistically significant differences between the two groups in any of the secondary outcomes or within the analysed subgroups. Conclusions: In this 2-year follow-up of patients without knee osteoarthritis but with symptoms of a degenerative medial meniscus tear, the outcomes after APM were no better than those after placebo surgery. No evidence could be found to support the prevailing ideas that patients with presence of mechanical symptoms or certain meniscus tear characteristics or those who have failed initial conservative treatment are more likely to benefit from APM.
Purpose To determine whether knee arthroscopy alleviates the symptom constellation of knee grinding/clicking, catching/locking, and pivot pain. Methods One-year follow-up data from 584 consecutive subjects who underwent knee arthroscopy from August 2012 to December 2019 were collected prospectively. Subjects reported frequency of knee grinding/clicking, catching/locking, and/or pivot pain preoperatively and one and two years postoperatively. A single surgeon performed each procedure and documented all intraoperative pathology. We measured the postoperative resolution or persistence of these symptoms and used multivariable regression models to identify preoperative demographic and clinical variables that predicted symptom persistence. We also assessed changes in the Pain, Activities of Daily Living (ADL), and Quality of Life (QOL) subscales of the Knee Injury and Osteoarthritis Outcome Score (KOOS). Results Postoperative symptom resolution was more likely for grinding/clicking (65.6%) and pivot pain (67.8%) than for catching/locking (44.1%). Smoking status, overweight/obesity, absence of meniscal tear, and number of compartments with focal cartilage lesions predicted persistence of one or more PRKS. KOOS subscale scores consistently improved by at least one standard deviation. Individuals who had resolution of PRKS exhibited roughly twofold improvements in KOOS Pain, ADL and Quality of Life scores compared to those whose symptoms persisted. Persistence of pivot pain was associated with the least improvement of the three KOOS subscales. Conclusions Two in three patients with grinding/clicking or pivot pain experience symptom resolution after knee arthroscopy, though catching/locking is more likely to persist. Smoking status, overweight/obesity, absence of meniscal tear, and number of compartments with focal cartilage lesions predict symptom persistence after knee arthroscopy.
The rate of total knee arthroplasty continues to increase in the United States due to the reproducible success of the procedure, as well as an increasingly older population with symptomatic osteoarthritis. Cost of care for a total knee arthroplasty comprises a significant portion of healthcare expenditures but is considered cost-effective in restoring quality-adjusted life years. Value-based care models, including alternative payment models such as “bundled payment programs”, have been paramount to address the economic impact by controlling cost while maintaining quality. Bundled payment programs must avoid the potential “race to the bottom” associated with other cost-cutting measures; a condition-based bundle may help address this concern. This chapter addresses the economic considerations common to management of knee arthritis in the United States, with a focus on the economics of total knee arthroplasty.
Purpose The purpose of this study was to rank Knee Injury and Osteoarthritis Outcome Score (KOOS) questions from most to least improvement after arthroscopic partial meniscectomy (APM) and compare improvement of meniscal versus mechanical symptoms. Methods A secondary analysis of the Chondral Lesions and Meniscus Procedures (ChAMP) Trial was performed. Inclusion criteria were age 30 years or greater with degenerative meniscal tear failing non-operative management, with or without associated unstable chondral lesions. No chondral debridement was performed. Responses to the 42 KOOS questions ranged from 0 (extreme problems) to 4 (no problems), and were answered preoperatively and at 1-year after isolated APM. The 1-year mean change, or delta (Δ), was calculated for each KOOS question and the Δ for meniscal and mechanical symptoms were statistically compared. Results Greatest improvement in 135 eligible patients was observed for questions about: 1) awareness of knee problems (Δ = 1.93, SD=1.38), 2) frequency of knee pain (Δ = 1.93, SD=1.29), 3) degree of difficulty while twisting/pivoting on the injured knee (Δ = 1.88, SD=1.13), 4) degree of difficulty while running (Δ = 1.67, SD=1.30), and 5) being troubled by lack of confidence in the knee (Δ = 1.67, SD=1.11). Least improvement was observed for questions about: 1) degree of difficulty while getting on/off the toilet (Δ=0.94, SD=0.96), 2) feel grinding or hear clicking when the knee moves (Δ=0.90, SD=1.25), 3) degree of difficulty while getting in/out of the bath (Δ=0.88, SD=1.00), 4) knee catches/hangs up during movement (Δ=0.80, SD=1.09), and 5) the ability to straighten the knee fully (Δ=0.54, 1.44). There was greater improvement for the KOOS questions pertaining to meniscal versus mechanical symptoms (p<0.00001). Conclusion KOOS symptoms as reported by subjects’ responses to the questions pertaining to the frequency of knee pain, twisting/pivoting, running, squatting, and jumping showed the most improvement 1-year after isolated APM, while those relating to mechanical symptoms improved the least. Focusing on meniscal rather than mechanical symptoms may help surgeons better identify patients expected to benefit from APM.
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Background:. The goal of this study was to evaluate the societal costs of using in-office diagnostic arthroscopy (IDA) compared with magnetic resonance imaging (MRI) for the diagnosis of intra-articular knee and shoulder pathology in employed patients receiving Workers’ Compensation or disability coverage. The prevalence is estimated at 260,000 total cases per year. Methods:. A cost-minimization analysis of IDA compared with MRI was conducted. Direct costs (in 2018 U.S. dollars) were calculated from private reimbursement amounts and Medicare. Indirect costs were estimated from a societal perspective including effects of delayed surgical procedures on the ability to work, lost income, Workers’ Compensation or disability coverage, and absenteeism. Four regions were selected: Boston, Massachusetts; Detroit, Michigan; Denver, Colorado; and San Bernadino, California. Sensitivity analyses were performed using TreeAge Pro 2019 software. The base assumption was that it would take approximately 4 weeks for a diagnosis with MRI and 0 weeks for a diagnosis with IDA. Results:. Direct costs to determine a knee diagnosis with IDA were $556 less expensive (California) to $470 more expensive (Massachusetts) than MRI. Assuming a 4-week wait, societal costs (indirect and direct) for knee diagnosis were anywhere from $7,852 (Denver) to $11,227 (Boston) less using IDA. Direct costs were similar for shoulder pathology. In order for MRI to be the less costly option, the MRI and the follow-up visit to the physician would need to occur directly after consultation. Under Medicare, direct costs were similar for both the knee and shoulder when comparing IDA and MRI. Including indirect costs resulted in IDA being the less costly option. Conclusions:. The use of IDA instead of MRI for the diagnosis of knee and shoulder pathology reduced costs. The potential savings to society were approximately $7,852 to $11,227 per operative patient and were dependent on scheduling and follow-up using MRI and on Workers’ Compensation. Level of Evidence:. Economic and Decision Analysis Level IV. See Instructions for Authors for a complete description of levels of evidence.
Background: Traditionally defined "meniscal" and "mechanical" symptoms are thought to arise from meniscal tears. Yet meniscal tears and cartilage damage commonly coexist in symptomatic knees. To better characterize the primary driver of these symptoms, we investigated whether the presence of preoperative patient-reported knee symptoms (PRKS), including knee catching/locking, grinding/clicking/popping, and pain with pivoting, are associated with various intra-articular pathological conditions diagnosed at knee arthroscopy. Methods: We collected prospective data from 565 consecutive patients who underwent knee arthroscopy from 2012 to 2019 and had PRKS collected via the Knee injury and Osteoarthritis Outcome Score (KOOS) questionnaire. The diagnosis of meniscal pathology and concomitant cartilage damage was confirmed and classified intraoperatively. We used multivariable regression models, adjusting for possible confounders, to examine the association of specific pathological conditions of the knee with the presence of preoperative PRKS. Results: Tricompartmental cartilage damage was strongly associated with significantly worse PRKS, with an increase of 0.33 point (95% confidence interval [CI] = 0.08 to 0.58; p = 0.01) on a 0 to 4-point scale. We did not observe an association between meniscal pathology and preoperative PRKS. Conclusions: Contrary to current dogma, this study demonstrates that traditionally defined "meniscal" and "mechanical" knee symptoms are strongly associated with the burden and severity of underlying cartilage damage rather than with specific meniscal pathology. Level of evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
The purpose of this chapter is to highlight arthroscopic and supplementation treatment options in osteoarthritis of the knee. Respective therapies are described with indications, contraindications, and literature workup. Arthroscopic knee osteoarthritis treatment comprises lavage, debridement, abrasion arthroplasty, and microfractures. While stand-alone lavage and abrasion arthroplasty can no longer be recommended, debridement with resection of chondral flaps, non-stable meniscus tears, scar tissue, and loose bodies causing mechanical symptoms as well as inflammatory synovia can yield good results in selected patient populations. Both intra-articular and oral supplementations in knee osteoarthritis are controversially discussed. There are no clear recommendations for intra-articular injection therapy with corticosteroids, hyaluronic acid, or PRP (platelet-rich plasma). Still, studies suggest good short-term results with corticosteroids and good long-term result with hyaluronic acid and PRP. Combined with their safety profile, they constitute viable options for patients not qualifying for surgical therapy or suffering comorbidities limiting oral NSAID (nonsteroidal anti-inflammatory drug) use. Oral NSAIDs are an important part of treatment regimes for all stages of knee osteoarthritis, whereas other oral supplements at best have mild influence on pain. Arthroscopic and supplementation therapies play important roles in comprehensive knee osteoarthritis treatment. To achieve good results, appropriate patient selection is key.
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New evidence argues against meniscectomy for all patients with non-traumatic tears and medial joint pain The NHS performs around 150 000 arthroscopic knee operations a year, with more than half involving resection of the meniscus. Therefore, close scrutiny of this intervention in the United Kingdom is entirely appropriate, particularly in the context of the ongoing drive towards providing evidence based and value based care. Considering such high rates of surgery, it would be natural to assume that this operation is backed up by adequate evidence. However, unlike knee replacement surgery, which is supported by population based patient reported outcomes (PROMs) data and the National Joint Registry, healthcare commissioners lack the necessary data to allow informed decision making for knee arthroscopy. Detailed indications for its use need further refinement. With this backdrop, any results from high quality randomised controlled trials in this area are welcome. The recent study by Sihvonen and colleagues therefore makes interesting reading.1 In 2005, when the trial was started, investigators were worried about the increasing numbers of arthroscopic meniscectomies performed for patients with degenerative meniscal tears. At this time it was common …
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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; number, NCT00549172.).
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Meniscus surgery is a high-volume surgery carried out on 1 million patients annually in the USA. The procedure is conducted on an outpatient basis and the patients leave the hospital a few hours after surgery. A critical oversight of previous studies is their failure to account for the type of meniscal tears. Meniscus tears can be categorised as traumatic or non-traumatic. Traumatic tears (TT) are usually observed in younger, more active individuals in an otherwise 'healthy' meniscus and joint. Non-traumatic tears (NTT) (ie, degenerative tears) are typically observed in the middle-aged (35-55 years) and older population but the aetiology is largely unclear. Knowledge about the potential difference of the effect of arthroscopic meniscus surgery on patient symptoms between patients with traumatic and NTT is sparse. Furthermore, little is known about the natural time course of patient perceived pain, function and quality of life after meniscus surgery and factors affecting these outcomes. The aim of this prospective cohort study is to investigate the natural time course of patient-reported outcomes in patients undergoing meniscus surgery, with particular emphasis on the role of type of symptom onset. This prospective cohort study enrol patients assigned for meniscus surgery. At the baseline (PRE surgery), patient characteristics are assessed using an email-based questionnaire also comprising several validated questionnaires assessing general health, knee-specific characteristics and patient's expectations of the surgery. Follow-up will be conducted at 12 and 52 weeks after meniscus surgery. The major outcomes will be differences in changes, from before to 52 weeks after surgery, in each of the five domains on the Knee injury and Osteoarthritis Outcome Score (KOOS) between patients undergoing surgery for traumatic compared with non-traumatic meniscus tears. The study findings will be disseminated in peer-reviewed journals and presented at national and international conferences. Identifier: NCT01871272.
Virtually all early cases of knee osteoarthritis have degenerative medial meniscus lesions accompanying the chondral defects on MRI. It is difficult to determine if the symptoms are caused by the unstable meniscus or by osteoarthritis, hence unclear guidance towards treatment. We, therefore, aimed to determine the clinical improvement following arthroscopic meniscectomy compared to intraarticular administration of corticosteroids for degenerative ruptures of the medial meniscus in the presence of early stage medial compartment knee osteoarthritis. We included 120 consecutive cases of nontraumatic symptomatic knees which had degenerative lesions of the medial compartment (cartilage and meniscus) on MRI's. They were randomized to receive either intraarticular steroid injection or arthroscopic debridement. We also analyzed the correlation between BMI, age, gender, MRI, intraoperative aspect of the meniscus and cartilage and clinical improvement using the Oxford Knee Score up to one year. At one month there was significant improvement of the scores for all the examined cases. Also at one month, the arthroscopic group performed better in terms of symptom improvement. This was maintained for 79% of the knees in the arthroscopic group and 61% in the intraarticular steroid injection respectively, out of those available for follow up at one year. At one month, symptoms reappeared for 12 patients in the steroid group and 7 in the arthroscopy respectively. Gender and age did not correlate with treatment, whereas extrusion of the meniscus, bone marrow edema, duration of the clinical symptoms, obesity and a low preoperative score were negative prognostic factors. Degenerative medial meniscal tears, in the presence of osteoarthritis, can only marginally benefit from arthroscopic debridement over intraarticular steroid injections in short term follow up. When considering individual cases, factors become more predictive when analyzed in group.
The treatment of osteoarthritis of the knee is a difficult problem. In the senior author's opinion, nonaggressive arthroscopic debridement of the knee is an effective procedure to relieve pain and restore function in patients with osteoarthritis of the knee. A subjective telephone interview of patients done 10 or more years after arthroscopic debridement evaluated the long term results of this treatment in patients with osteoarthritis of the knee. The patients all were candidates for total knee replacement who selected arthroscopy as a temporizing procedure. Of the 191 knees in patients undergoing arthroscopic debridement, 77 patients (91 knees) were contacted for followup. Sixty-seven percent of the 91 knees did not have total knee arthroplasty at an average of 13.2 years followup. The Tegner activity score averaged 3.5 and patient satisfaction averaged 8.6 on a 0 to 10 scale. Twenty-one patients (30 knees) or (33%) had total knee arthroplasty at an average of 6.7 years. Seven of these had total knee arthroplasty within 2 years of arthroscopic debridement. Six of these seven knees had Outerbridge Grade 4 articular cartilage changes and clinically significant meniscus tears. Seven of the 19 knees (37%) with Outerbridge Grade 4 changes in 80% of one knee compartment did not require total knee arthroplasty after greater than 10 year followup. The difficulties in long term followup in this patient population is evident, yet the number of patients who had a functional lifestyle after arthroscopic debridement was notable.