This blog post is an update to my earlier Twitter thread in which I presented trends of knee arthroscopy procedures in different countries. Full thread about arthroscopic partial meniscectomy (APM) can be found here.
Finally, how has the orthopaedic community responded to this bulk of evidence? Not as would be expected. Further studies are urgently warranted to investigate more recent trends in meniscectomy surgeries. pic.twitter.com/ISXc7JwCHn— Aleksi Reito (@AleksiReito) June 10, 2019
That harsh truth is that routine treatment of nontraumatic, degenerative medial meniscus lesions with APM is not beneficial. This claim is based on high-quality, sham-controlled randomized trials. Most recent summary of current evidence is published by Abram et al. in the British Journal of Sports Medicine.
Below is the summary of evidence comparing APM to non-surgical interventions for function in 6-12 months follow-up. APM may have small-to-moderate effect in function as the authors conclude. This does not, however, justify routine use of APM. These studies have major source of bias: surgical placebo effect. Hence the actual treatment effect is even lower.
Best evidence is provided by sham-controlled studies of which the study by Sihvonen et al. is the best to date. Roos et al. tried to conduct a similar study but they had to stop it early. Their study, however, provides an effect estimate which can be pooled with that of Sihvonen et al. Results are quite clear that when controlled with sham-surgery, APM offers a negligible benefit at best for knee function.
APM is probably the most common procedure in the field of orthopaedics. In the light of the above it is evident that we need to change our current practice in patient care. APM is low value care. A procedure, without well proven benefits, cannot longer be the most common surgery we perform. It is therefore very important to document and report any changes in our practices followed by high level evidence. APM makes no expection. We can´t improve our patient care if we don´t have information what is happening in the larger scale.
Annual numbers of knee arthroscopy procedures
Annual incidences of knee surgeries have been extracted from following studies:
- Denmark: Thorlund et al. Large increase in arthroscopic meniscus surgery in the middle-aged and older population in Denmark from 2000 to 2011. Acta Orthopaedica 2014; 85 (3): 287–292
- Finland I: Mattila et al. Changes in rates of arthroscopy due to degenerative knee disease and traumatic meniscal tears in Finland and Sweden. Acta Orthopaedica 2016; 87 (1): 5–11
- Finland II: Karelson et al. Lower nationwide rates of arthroscopic procedures in 2016 compared with 1997 (634925 total arthroscopic procedures): has the tide turned? Published Online First: 02 April 2020.
- Sweden: Mattila et al. Changes in rates of arthroscopy due to degenerative knee disease and traumatic meniscal tears in Finland and Sweden. Acta Orthopaedica 2016; 87 (1): 5–11
- Netherlands: Rongen et al. Meniscus surgery is still widely performed in the treatment of degenerative meniscus tears in The Netherlands. Knee Surg Sports Traumatol Arthrosc (2018) 26:1123–1129
- France: Jacquet et al. Analysis of the trends in arthroscopic meniscectomy and meniscus repair procedures in France from 2005 to 2017. Orthopaedics & Traumatology: Surgery & Research 105 (2019) 677–682
- Australia I: Bohensky et al. Trends in Elective Knee Arthroscopies in a Population-Based Cohort, 2000-2009. Med J Aust. 2012 Oct 1;197(7):399-403.
- Australia II: Lee et al. Changing practice: incidence of non-reconstructive arthroscopic knee surgery in people over 50 years of age, Australia, 2008–2018. Med J Aust. 2020 Jan;212(1):29-30.
- Australia III: Smith et al. Trends in knee magnetic resonance imaging, arthroscopies and jointreplacements in older Australians: still too much low-value care? ANZ J Surg. 90 (2020) 833–839
- Norway: Holtedahl et al. Changes in the rate of publicly financed knee arthroscopies: an analysis of data from the Norwegian patient registry from 2012 to 2016. BMJ Open 2018;8:e021199
- England: Abram et al. Temporal trends and regional variation in the rate of arthroscopic knee surgery in England: analysis of over 1.7 million procedures between 1997 and 2017. Has practice changed in response to new evidence? Br J Sports Med 2018;0:1–6.
- USA, Florida: Howard. Trends in the Use of Knee Arthroscopy in Adults. JAMA Intern Med. 2018;178(11):1557-1558.
- Japan: Kawata et al. Annual trends in arthroscopic meniscus surgery: Analysis of a national database in Japan. PLoS ONE 13(4): e0194854
Definition of procedure(s) and population included in the studies were as follows (between-study variation should be noted):
- Denmark (Thorlund et al.): meniscal procedures (all codes)
- Finland I (Mattila et al.): knee arthroscopy degenerative meniscal tear
- Finland II (Karelson et al.): Arthroscopic exploration of knee joint (16.7% of all knee arthroscopies), Arthroscopic partial excision of meniscus of knee (46.8% of all knee arthroscopies), Arthroscopic total excision of meniscus of knee, Arthroscopic reinsertion of meniscus of knee, Arthroscopic incision of capsule of knee, Arthroscopic suture or reinsertion of ligament of knee, lateral collateral, Arthroscopic plastic repair of ligament of knee not using prosthetic material, anterior cruciate, Arthroscopic plastic repair of ligament of knee not using prosthetic material, posterior or posterior and anterior cruciate, Arthroscopic plastic repair or reinsertion of cruciate and collateral ligaments of the knee, Arthroscopic plastic repair of patellar ligaments, Arthroscopic excision of plica of synovia of knee, Arthroscopic operation for osteochondritis of knee
- Sweden (Mattila et al.): knee arthroscopy degenerative meniscal tear
- Netherlands (Rongen et al.): arthroscopic procedures for meniscus tears
- France (Jacquet et al.): lateral or medial meniscectomy of the knee, by arthroscopy
- Australia I (Bohensky et al.): elective knee arthroscopy
- Australia II (Lee et al.): arthroscopic knee procedures excluding reconstructive and reparative procedures
- Australia III (Smith et al.): arthroscopic surgery involving partial or total meniscectomy, removal of a loose body or lateral release, with an associated debridement, osteoplasty or chondroplasty, partial or total meniscectomy, removal of a loose body or lateral release, debridement, osteoplasty or chondroplasty (patients aged 50 years or more)
- Norway (Holtedahl et al.): meniscal resection
- USA, Florida (Howard): arthroscopic knee operations
- England (Abram et al.): arthroscopic partial meniscectomy
- Japan (Kawata et al.): arthroscopic meniscectomy
Results were reported as crude number of annual surgeries, as incidence or as incidence rate ratios. All results were re-scaled setting the first reported estimate as a reference value of 100.
Annual volume of knee arthroscopy procedures in 9 different countries is shown below.
General trend which can be seen is that from 2012-2013 the annual volume of knee arthroscopy procedures have been clearly decreasing. Most drastic changes are seen in Finland and in Australia. An interesting observation is the massive increase in England from 1997 to 2010. Since then, a major decrease can be, however, seen.
We need more studies on this topic. Similar to APM, arthroscopic subacromial decompression (ASD) for shoulder pain has not been proven to be beneficial when compared to sham or non-operative treatment. Hence it seems that ASD is also low value care for our patients. In addition to annual incidences of APM, we need studies investigating annual number of ASD procedures as well.
Stahel et al. summarizes this topic quite nicely:
We propose that the annual proportion of knee arthroscopy procedures that are APM-only in patients with degenerative disease is a surgeon-level measure of appropriateness in surgical care.Stahel et al. 2018, JAMA Surgery
I thank Dr Awal from Griffith University, Dr Holtedahl from Innlandet Hospital Trust-Division Ottestad, Dr Tuomas Huttunen from Tampere University Hospital, Dr Smith from University of Sydney and Dr Howard from Emory University providing raw data from their original studies.