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A positive viewpoint regarding arthroscopy for degenerative knee conditions

M. Krogsgaard,M. Lind,U. Jørgensen

Published 2014 in Acta Orthopaedica

ABSTRACT

Sir—In the latest issue of Acta Orthopaedica, Thorlund et al. (2014) report figures from the Danish National Patient Register (DNPR) showing a 2-fold increase in knee arthroscopy with meniscal surgery from 2000 to 2011, and they conclude that arthroscopy for degenerative conditions in particular has increased in the middle-aged population. In a guest editorial in the same issue, Jarvinen et al. (2014; from Finland and Sweden) conclude that since any additional effect of arthroscopic operations in these conditions has not been shown, that arthroscopy is contraindicated, and that political decisions may be the next step to stop arthroscopic operations. In Thorlund’s article, 2 significant confounders are of importance for the results and conclusions. The authors state that in the year 2000, several hospitals did not report to the DNPR and they suggest an under-reporting rate of about 5%, based on a general estimate of all operations. This cannot be extrapolated to knee arthroscopy, which is a small operation that is performed more often in private hospitals and in orthopedic specialist practices (often under local anesthesia) than in public hospitals, in contrast to larger operations. Private hospitals and clinics did not report to the DNPR before the mid-2000s. Therefore, the increase between 2000 and 2011 is substantially overestimated; the authors could have contacted the Danish National Board of Health to make the estimate of missing operations more qualified. Alternatively, the authors could have excluded hospitals and clinics that did not report over the whole period of 11 years. It is a mistake to regard meniscal changes coded as DM232 as degenerative. The distinction between DS832 and DM232 is only related to the duration of symptoms, and most clinicians would use 3 months as the dividing time. In addition, the salary for diagnosing and non-operatively treating meniscal changes is higher if the code DM23.2 is used, which may make clinicians aware of the time consideration regarding individual patients. Thus, how many of the meniscal operations were actually performed on degenerative meniscal changes and how many were performed on traumatic ruptures is pure speculation. Although it is not stated clearly in Thorlund’s article, we assume that the incidences are based on population numbers for each age category and not for the whole population. On the internet, it is easy to obtain numbers of inhabitants in Denmark for every 3 months—and with 1-year age intervals (http://www.statistikbanken.dk/02). If this information had been used, the extrapolation that is used for population numbers in the article could have been avoided. Is it bad to arthroscope and debride knees with meniscal or degenerative changes? The “well-conducted” randomized studies have all shown an effect, but have not been able to demonstrate any difference between operative and non-operative treatments. No one has had a control group (with no treatment). Thus, there may not be any difference, or the outcome measures that are used in these studies, which are generally constructed for much more painful conditions, might not be relevant or sensitive enough for people with milder disease to show any difference. But the randomized studies show that arthroscopy has an effect—which is not less than non-operative treatment. Another important issue with the data from these randomized studies is that they contain too few patients to be able to perform relevant subgroup analysis. From clinical experience, we know that male patients with mechanical symptoms have very good outcome compared to female patients without mechanical symptoms. In the editorial, Jarvinen et al. (2014 state – quite strangely – that on top of no difference, there are complications to arthroscopy. In well-conducted randomized studies, these complications are included in the outcome comparisons. Jarvinen et al. missed 2 very important points that should have been considered before they abandoned arthroscopy for the degenerative knee. Firstly, the number of people who engaged in regular sports activity increased by 30% in Denmark between 1998 and 2011; in the middle-aged group, almost 70% had regular physical activity and 42% had sports activity 3–4 hours a week or more (Laub 2013). 20% of adults must stop sports because of health problems. Symptoms from degenerative conditions are load-related, and it could be expected that higher numbers of middle-aged people would have symptoms from their knees in 2011 than in 2000, just because of the substantially increased physical activity in this age group. In addition, this can be expected to increase over the coming years. The second point has, strangely enough, not been part of this discussion at any time. What if non-operative treatment is not working? There has been an annual increase in public physiotherapy treatment in Denmark of 3–5 % every year from 2000 to 2011 ([Praksisplan for fysioterapi] Reports from the Danish regions 2012–13), particularly in the middle-aged population. The total amount of physiotherapy and other non-operative interventions has most probably increased much more, as many Danes obtained a private health insurance during this period. So there is quite substantial data on a marked increase in non-operative treatments of the degenerative knee during the period in question. So, banning arthroscopy is not based on scientific evidence but has a much more political sound. For us as clinicians seeing many of these patients, in contrast to several of the authors of the articles that have created this debate, it is evident that most patients have tried relevant non-operative interventions before they are seen by the orthopedic surgeon. There is an increasing demand to stay fit and to be able to engage in physical activity irrespective of age, and the general health benefits of this have been substantially documented. A large proportion of these patients are very fit, and for them it is difficult to argue for further exercise as treatment. We suggest that, instead of closing one eye and pressing the patients into the same standard protocol, the healthcare staff should evaluate the individual person. A fit 50-year-old plumber who is in danger of loosing his job because of knee pain from mild cartilage changes and meniscal flaps, might be helped most quickly with an arthroscopic debridement. An unfit, overweight person might best be treated with muscle training and weight loss. And a person who has become fit from training and has lost weight etc., should not be kept from the possibility of arthroscopic debridement when non-operative treatment has failed. Clinicians know that the situation of failed non-operative treatment is very common. Knee arthroscopy is one option among several in treatment of the degenerative knee. Based on the available data outlined above and our long clinical experience, it is our view that in Denmark the use of arthroscopy has not increased more than non-operative treatments (and probably less). We feel that increases in the numbers of treatments (both operative and non-operative) must be expected during the coming years, and these are important modalities to keep the Danish population physically active as they get older. This benefits everyone, and also the public finances.

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