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THE rate of non-reconstructive arthroscopic knee surgery in people aged over 50 years has fallen over the past decade, according to new research, but an expert says that regulatory measures may now be needed to close the remaining evidence–practice gap.
In a research letter published in the MJA, researchers found that the incidence rate ratio of arthroscopic knee procedures for patients (aged 50 years and over) had dropped from 756.2 operations per 100 000 people in 2009–09 to 483.5 operations per 100 000 people in 2017–18.
The researchers wrote that randomised controlled trials over the past 6 years had suggested that the outcomes of arthroscopic partial meniscectomies in people with non-obstructive degenerative meniscal tears were similar to those of sham surgeries or structured rehabilitation. They added that older randomised controlled trials had also found no benefit in arthroscopic lavage and debridement.
Professor David Hunter, Florance and Cope Chair of Rheumatology Chair of Institute of Bone and Joint Research at the University of Sydney, said the evidence of a lack of benefit from knee arthroscopy had been mounting since the early 2000s.
Education of primary care practitioners and the community would be helpful in further reducing the rate of knee arthroscopies, Professor Hunter said, but it may also be time for regulatory measures.
“The carrot approach has been tried for so long with regards education and reinforcement, and I honestly think it’s about time we made it difficult from a reimbursement perspective for surgeons,” he said, noting that exceptions could be made for necessary procedures, such as in the “very rare” case of a locked knee after a meniscus tear.
Professor Hunter said the arthroscopy item numbers would be reviewed under the orthopaedic segment of the Medicare Benefits Schedule Review, with the findings expected to be released this year.
He also noted that the 258% increase in arthroscopic meniscal repairs over the same decade – which the MJA authors cited from a separate analysis – may be cause for concern.
“Arthroscopic meniscus repair is not particularly successful, so it just raises a question for me about whether there has been some diversion away from arthroscopies but towards meniscus repair,” he said.
Professor Ian Harris, orthopaedic surgeon and honorary professor at the University of Sydney’s School of Public Health, said the health system currently incentivised surgical interventions.
“Unfortunately, our health system does not prioritise or incentivise weight loss, but it does incentivise surgical interventions,” he said. “It is harder for a patient to get a course of [physiotherapy] – in terms of cost and effort – than to be booked in for a knee arthroscopy, and the latter is easier to reimburse for insurers [or through] Medicare.”
Professor Flavia Cicuttini, Head of the Musculoskeletal Unit at Monash University and Head of Rheumatology at Alfred Hospital, said most knee disease in people over 50 was osteoarthritis, and the high rate of procedures reflected a lack of simple, effective therapies for the condition.
“A procedure such as an arthroscopy may be an attractive option to some consumers and some heath care providers.” Professor Cicuttini said. “The problem is that that there is no evidence for its effectiveness compared to non-surgical procedures, and it is associated with high costs and the potential for complications.”
Professor Cicuttini added that it was concerning to note that arthroscopy was often followed by a knee replacement.
“This has to be seen as a waste of resources because if the knee [osteoarthritis] is severe enough for a knee replacement to be considered in the next 2–3 years, then there is no place for an arthroscopy in uncomplicated knee osteoarthritis.”
She said it was not surprising that arthroscopies in people aged over 50 years, often targeting meniscal pathology, were ineffective.
“All the epidemiological work over the last 10–15 years has shown that osteoarthritis is a disease of the whole joint, not just cartilage, and that degenerative meniscal changes in the knee are common, and, although associated with knee pain, are not the cause of the pain,” she said.
The MJA authors noted that the discrepancy between research findings and practice could take a decade to resolve. They identified several barriers to practice change, including confirmation bias, pressure from patients, few therapeutic alternatives, and time pressure.
Professor Harris said confirmation bias – “or a lack of scientific literacy and objective understanding of the evidence” – was the biggest factor.
“Patients pressure you for all sorts of things, but you don’t do them unless you think they work. We are all under time pressure, but that doesn’t mean we commit to procedures that we know to be ineffective. The only thing that really makes sense is that surgeons are doing it because they think it works,” he said.
“The thing to remember in all of this is that this procedure is done for lots of different reasons, many of which may be very effective – we only have good evidence for degenerative conditions. Having said that, I believe that most knee arthroscopies in this age group are still being performed for degenerative conditions, so that rate will continue to fall as the message gets through.”
The MJA authors said the role of primary care in managing knee osteoarthritis was “vital”, pointing to the Royal Australian College of General Practitioners’ 2018 guidelines on managing knee and hip osteoarthritis.
Professor Cituttini said exercise and weight management remained the mainstay of osteoarthritis management. Education programs were also important, she said, to enable patients to understand osteoarthritis and what they can expect in its management.
“Symptoms from osteoarthritis tend to fluctuate. Weight management, including prevention of weight gain are important, as is doing regular exercise,” she said. “During episodes of pain, then analgesics such as paracetamol or nonsteroidal anti-inflammatory medications (topical or oral if appropriate) can improve symptoms.”
Professor Harris agreed that conservative management, such as weight loss, exercise and anti-inflammatory medication, may be effective for degenerative knee conditions.
“Surgeons may feel that these – especially [weight loss and exercise] – are more difficult and, to be honest, I think many patients feel the same way: why exercise or lose weight when you can have a procedure?” he said. “I think the benefits of weight loss and exercise are undersold because of this nihilism about the likelihood of uptake, but the benefits of weight loss alone in this age group can be enormous, in that it can prevent or treat heart disease, diabetes and all the associated conditions.”
Professor Hunter said meaningful behavioural change was difficult to achieve in the current primary care system.
“The GP’s job here is really hard. Guidelines advocate that we should be doing exercise, weight loss and educating our patients as the first line treatments for osteoarthritis; unfortunately, [most] of the time – 80–90% of the time – that’s not happening,” he said. “We have these expensive interventions like arthroscopy and [magnetic resonance imaging] for the knee, which are reimbursed, but if you are a public patient and you want to access meaningful intervention centred around exercise and diet, you don’t get a lot of support from Medicare.”
I had arthroscopy on my right knee some 11/12 years ago with a good outcome allowing me to regular do 5 miles speed walks 2/3 weekly.. But, now over the past 6/8 months have constant pain with gels and paracetamol not helping Tried physio exercises but again no good. The surgeon who did the original op stated only 2 arhroscopy’s are done if needed then a knee replacement who be needed. As I currently wait to see an orthopaedic surgeon I would happily hope to get the latter as being 74 years old it would hopefully last me!
I am 70 years of age. Female average height, good weight 60kgm. I tripped over a brick left under a step of a door way, feel onto my Right knee. Initial swelling and soreness subsided within a week. Idid not go to the Doctor as it felt OK by the time I could get an appointment. About three months later knee went ‘click’ as I bent to a sqwat position,something I could always do with ease. The knee became sore and swollen, on and off over a couple of weeks, limiting my activity, which was no means strenuous. (yoga, walking and gardening) I sought referral to an ortho. specialist.
X-ray apparently NAD. MRI showed lateral and medial meniscus tear, a loose chondral, large joint effusion, ‘fluid’ /Bakers cyst. articular surface looked healthy, ACL swollen, likely sprained,not torn.
I am on warfarin so do not take anti imflammatory meds., panadol osteo. one occaisionally, BD.
RICE reduced swelling but movement was limited and I could not do do a 1-2km walk without swelling for a few days. I opted for a R knee arthroscopy, cleaning out and removal of the floating bits which allowed me to get on with day to day activitiy. Most important to me as at 70 years I can de-condition fairly quickly!
I went to physio at about week 5 post-op to get some help to regain flexibility and quad. strength. 3 months on I still require some rest after a full day of gardening and I use a cold pack. I wear a support bandage if I intend walking any distance, or uneven ground. I figure it is all good in that I can continue quality life and my guess is by 6 months post op I should be back to pre injury status.
“Professor Harris agreed that conservative management, such as weight loss, exercise and anti-inflammatory medication, may be effective for degenerative knee conditions.”
The current Cochrane Collaboration statement on weight loss is “Surgery results in greater improvement in weight loss outcomes and weight associated comorbidities compared with non-surgical interventions, regardless of the type of procedures used.” (Surgery for Obesity, 8 August 2014) Furthermore, the more invasive procedures were more effective: “Outcomes were similar between RYGB and sleeve gastrectomy, and both of these procedures had better outcomes than adjustable gastric banding. For people with very high BMI, biliopancreatic diversion with duodenal switch resulted in greater weight loss than RYGB.”
Given the process of informed consent for a sleeve gastrectomy versus an arthroscopy, I’m not sure how many people would consider evidence based weight loss as “conservative management”. I suspect even the stingy NSW Health department would rather fund 100 arthroscopies than 100 gastrectomies.
Prof Harris asks rhetorically: “why exercise or lose weight when you can have a procedure?” and Prof Hunter asserts: “Guidelines advocate that we should be doing exercise, weight loss and educating our patients…” yet neither seems to embrace the Cochrane EBM that weight loss is best achieved via a procedure.
My understanding of weight loss protocols was a success rate of approximately 5-10% in adults. This makes the so-called ideal treatment of weight loss and exercise almost impossible in 90-95% of patients with obesity as part of their problem. It is all very well to say that weight loss and exercise works (which I have found to be true WHEN you can get it to happen in real life situations as opposed to regulated trials!) but it is facetious to say that it is a panacea for all patients. That is not to say that one should not try or that arthroscopy is the immediate alternative, however the rheumatologists and Prof Harris don’t really explain how we surgeons are to manage the patient who is unable to lose weight and gets nowhere with exercising.
I agree that the many anecdotal cases of successful arthroscopic chondroplasties in elderly OA suggest trials showing no benefit were under powered to show benefit in these patients
Reimbursement should be left alone until bigger more definitive studies show no benefit
Bert Boffa
I had a middle aged painful knee. I limped around for several months, as a busy GP. It got better and stopped hurting. If I’d had treatment I would have thought it was wonderfully successful! I appreciate the remarks above where some people have done well after arthroscopy for what seemed to be offending meniscal fragments. There may be the need for a trial that includes information on the MRI appearance. However the cases mentioned seem to have been identifiable as likely acute meniscal injuries at their presentation, whereas most painful middle aged knees develop gradually.
My husband recently had medial meniscus tear for which 9 weeks conservative treatment was instituted . As there was also underlining mild osteoarthritis, unfortunately most of the emphasis by the GP & orthopaedic surgeon was on strengthening exercises for his knee … despite his inability to bear weight on that knee. Upon my insistence, MRI was done – revealing medial meniscus tear with a fragment lodged deep in the joint. Laparoscopic trimming of the meniscus and removal of the fragment resulted in immediate loss of pain the next morning!! Functionality of that knee returned from almost zero!! The worry of restricting knee laparoscopy in the face of oa (osteoarthritis) is that it can be a scapegoat and can result in treatable lesions to be missed. The GP & Orthopaedic surgeon were obviously (appropriately?) & understandably being overly cautious to abide by so called guidelines of MRI & surgery. I feel sorry for the many patients who have to live through a life of pain , from so called well meaning guidelines to limit knee laparoscopy.
How is it that the significant income to the orthopaedic surgeon has not been mentioned??
Sometimes one needs to call a spade a spade for proper discussion to proceed.
I experienced an ‘unexpected’ angina episode 2014. I was not exercising eating convenience food and working way too long hours. 3 stents and low carb intake and loss of 30kg weight led to an unbelievable increased quality of life. 4 half marathons later a simple skiing twisting injury resulted in medial meniscus tear. No articular surface damage and painful incapacitating effusion whenever a return to running occurred. The loss of regular training has been psychologically devastating but now at 5 months post injury I am looking forward to the predicted removal of the offending posterior fragment. At 54 I believe this is an appropriate scenario and cannot wait to get it done.
I had an arthroscopy and repair of meniscus a few years back. Now instead of one pain, I have three different ones. There is a split in the cartridge, and another meniscus tear. Rather than intermittent pain is now constant. So unlike the other two it was not an effective treatment.
I concur with the recommendations to further attempt to limit arthroscopic knee surgery when weight bearing exercise, physiotherapy and weight reduction supplemented by analgesics and anti-inflammatories have shown equal pain relief, swelling and limited ROM resolution. Through self and client experience I have seen benefit within weeks by the methods stated including initially exercising with soft slip-on knee support. Conversely in clients who proceeded to arthroscopic surgery when it was very common practice most still proceeded to TKR earlier than had been anticipated.
Retired Consultant Physician
A big part of the problem is that primary care providers, particularly GPs, don’t understand the underlying problem in obesity. They still focus on calorie-restriction which has been proven to fail every time. And that’s because it doesn’t address insulin resistance which is the cause of obesity not the consequence. IR develops secondary to excessive insulin. So the management has to be limiting refined carbs for a significant part of the day. This abolishes IR, boosts BMR and establishes a calorie deficit at the expense of calories-out not calories-in. This and more is explained in my book: The User’s Manual For Your Body
Eight years ago I had an arthroscopy and repair of meniscus. I had been having significant knee pain. This settled completely after the arthroscopy and has not returned, so I believe that it was a very effictive treatment.
I tried exercise, physio, medication for 2 years and was getting nowhere with my knee meniscal disease which
was preventing me from being able to play 18 holes of golf or do any running or jogging at all.
I then had an arthroscopic meniscal cleanup and have not looked back. it’ll never be 100% but my knee doesn’t swell up like a football anymore and I can play 18 holes of golf without pain or misery.
I suppose you’ll tell me it is just a placebo effect…..