Orthopaedic Surgeons Perceptions on Arthroscopy for Knee OA
Knee arthroscopy is one of the most common orthopaedic procedures currently performed worldwide. Arthroscopic debridement and lavage have been used extensively in sports medicine for the treatment of meniscal and ligamentous injuries. However, the role of arthroscopy in the treatment of OA remains controversial. Early studies investigating the potential role of arthroscopy in knee OA have shown promising results. Compared with open procedures, arthroscopy resulted in less pain and postoperative swelling and often reduced the risk of complications such as infection and arthrofibrosis. All of these benefits led to a rapid rise in arthroscopic surgeries, and by the mid-1980s, arthroscopy became the preferred method of treatment. However, during the past decade, the role of arthroscopy in the treatment of OA has been called into question. In 2002, Moseley et al. published the first randomized controlled trial that compared arthroscopy with nonoperative therapy for knee OA. They randomized 180 patients into three arms: arthroscopic debridement, arthroscopic lavage, and a sham procedure. Results showed no differences in early pain relief or any long-term clinical outcomes between the three groups. This landmark study established that arthroscopic debridement or lavage is not better than placebo surgery in the management of OA. A following trial by Kirkley et al. supported previous results. In their study, subjects were randomized into two arms: arthroscopic debridement and standardized physical therapy. Despite the differences in their control groups (sham surgery vs. nonoperative treatment), no differences were observed between the two groups in regards to pain relief or functional status. However, Kirkley et al. were not the only ones; further trials over the last decade have supported Moseley et al's. study and failed to demonstrate any substantial improvement when compared with placebo. Herrlin et al., for example, compared rigorous exercise alone with the same exercise accompanied by arthroscopic partial meniscectomy (APM). Similar to previous results, both groups improved the same over the first 6 months and maintained symptomatic improvements over 60 months. Comparable results also were documented in a considerably larger study entitled, 'The Meniscal Tear in Osteoarthritis Research (MeTeOR) Trial. In the MeTeOR trial, patients were randomized to receive either a physiotherapy or APM with postoperative physiotherapy. The results showed that both arms improved considerably in the first 6 months or 12 months after surgery, supporting the existing evidence that suggests that arthroscopy provides no therapeutic benefit.
After these results, several organizations have updated their guidelines for the management of OA. According to the 2008 National Institute for Clinical Excellence (NICE) guidelines, arthroscopic lavage and debridement should not be offered as part of treatment for OA, unless a patient suffers from knee OA with a clear history of mechanical locking associated with intraarticular loose bodies or meniscal tears, emphasizing the importance of proper patient selection. Contrarily, the most recent and previous (2013 and 2009, respectively) guidelines, suggested by the AAOS indicated that arthroscopic debridement or lavage is not recommended for patients with primary diagnosis of symptomatic OA of the knee (level of evidence: I and II). But did these studies and subsequent changes in guidelines influence practice? In the current study, we conducted a survey among 279 surgeons from 57 countries to try and evaluate whether the everyday practice was influenced by previous evidence. Our results demonstrated that up to 27% of orthopaedic surgeons still recommend arthroscopy for the treatment of OA. This treatment modality was found to be significantly more popular outside of the United States. Among the surgeons who chose to recommend arthroscopy for knee OA, only 13.5% were Americans in comparison to 56.7% Europeans and 29.8 of the remaining countries.
To date, only a limited number of studies have examined whether the utilization of these procedures has changed over the years. A relatively recent study by Potts et al. has asked this question, specifically among American surgeons. In their study, the authors demonstrated a significant, yet gradual decrease in the number of knee arthroscopy cases for patients with OA in the following years after the Moseley et al. study. However, the main limitation of Potts et al's. study was that the group of surgeons studied was composed of early career surgeons and was not necessarily representative of orthopaedic surgeons in general. According to Potts et al. young surgeons may practice differently based on the findings of Moseley et al. as well as orthopaedic texts such as Campbell's Operative Orthopaedics that reference the Moseley et al. trial as evidence that arthroscopy is not favorable for the treatment of OA. Therefore, Potts et al's. trial concluded that further study is needed to determine whether this change occurred in the orthopaedic community at large or if practice patterns only changed for surgeons during their board collection periods. Nevertheless, this theory was not supported by our results. No significant differences were found between the 'Yes' and 'No' groups when we preformed subgroup analysis based on subspecialty, seniority or years of experience. However, significant differences were observed between American and non-American surgeons.
Such differences have been previously identified. Recent studies by Kim et al. and Holmes et al., have also examined the changes in everyday practice among American surgeons. Interestingly, they both noted a decline in arthroscopic debridement for OA, while overall rates of other knee arthroscopies were actually increasing. In contrast to the American findings, an Australian study conducted by Bohensky et al., did not observe any changes in use of knee arthroscopy between the years 2000 and 2009, for any indication. These dissimilarities could be explained by the differences in the American and European guidelines in regards to this matter; while the AAOS chose to highly recommend against arthroscopy with debridement in symptomatic OA, the NICE preferred to be less decisive and recommended not to refer OA patient to arthroscopy, with reservation regarding a patient's history based on the argument that treatment is beneficial for patients with mechanical symptoms of catching or locking or those with early disease. The nonexplicit guidelines offered by the Europeans may have been the reason for the relative diversity of opinion among orthopaedic surgeons, in and outside of the U.S., but not solely.
In conclusion, these survey findings suggest that despite current available data, arthroscopy is still preferred by more than one-quarter of orthopaedic surgeons surveyed worldwide as the treatment for knee OA. Moreover, we found that geography may affect surgeons' preferences, as demonstrated by distinct choices of North American orthopaedic surgeons to avoid knee arthroscopy compared with non-American countries. These results were mainly attributed to the differences between the European and U.S. national guidelines. If so, new guidelines should be considered in a manner that will be more unanimous and will also include the exceptional patient who may benefit from this treatment approach. We believe that this study can be effective in changing orthopaedic surgeon practice in regards to this controversial matter.
Discussion
Knee arthroscopy is one of the most common orthopaedic procedures currently performed worldwide. Arthroscopic debridement and lavage have been used extensively in sports medicine for the treatment of meniscal and ligamentous injuries. However, the role of arthroscopy in the treatment of OA remains controversial. Early studies investigating the potential role of arthroscopy in knee OA have shown promising results. Compared with open procedures, arthroscopy resulted in less pain and postoperative swelling and often reduced the risk of complications such as infection and arthrofibrosis. All of these benefits led to a rapid rise in arthroscopic surgeries, and by the mid-1980s, arthroscopy became the preferred method of treatment. However, during the past decade, the role of arthroscopy in the treatment of OA has been called into question. In 2002, Moseley et al. published the first randomized controlled trial that compared arthroscopy with nonoperative therapy for knee OA. They randomized 180 patients into three arms: arthroscopic debridement, arthroscopic lavage, and a sham procedure. Results showed no differences in early pain relief or any long-term clinical outcomes between the three groups. This landmark study established that arthroscopic debridement or lavage is not better than placebo surgery in the management of OA. A following trial by Kirkley et al. supported previous results. In their study, subjects were randomized into two arms: arthroscopic debridement and standardized physical therapy. Despite the differences in their control groups (sham surgery vs. nonoperative treatment), no differences were observed between the two groups in regards to pain relief or functional status. However, Kirkley et al. were not the only ones; further trials over the last decade have supported Moseley et al's. study and failed to demonstrate any substantial improvement when compared with placebo. Herrlin et al., for example, compared rigorous exercise alone with the same exercise accompanied by arthroscopic partial meniscectomy (APM). Similar to previous results, both groups improved the same over the first 6 months and maintained symptomatic improvements over 60 months. Comparable results also were documented in a considerably larger study entitled, 'The Meniscal Tear in Osteoarthritis Research (MeTeOR) Trial. In the MeTeOR trial, patients were randomized to receive either a physiotherapy or APM with postoperative physiotherapy. The results showed that both arms improved considerably in the first 6 months or 12 months after surgery, supporting the existing evidence that suggests that arthroscopy provides no therapeutic benefit.
After these results, several organizations have updated their guidelines for the management of OA. According to the 2008 National Institute for Clinical Excellence (NICE) guidelines, arthroscopic lavage and debridement should not be offered as part of treatment for OA, unless a patient suffers from knee OA with a clear history of mechanical locking associated with intraarticular loose bodies or meniscal tears, emphasizing the importance of proper patient selection. Contrarily, the most recent and previous (2013 and 2009, respectively) guidelines, suggested by the AAOS indicated that arthroscopic debridement or lavage is not recommended for patients with primary diagnosis of symptomatic OA of the knee (level of evidence: I and II). But did these studies and subsequent changes in guidelines influence practice? In the current study, we conducted a survey among 279 surgeons from 57 countries to try and evaluate whether the everyday practice was influenced by previous evidence. Our results demonstrated that up to 27% of orthopaedic surgeons still recommend arthroscopy for the treatment of OA. This treatment modality was found to be significantly more popular outside of the United States. Among the surgeons who chose to recommend arthroscopy for knee OA, only 13.5% were Americans in comparison to 56.7% Europeans and 29.8 of the remaining countries.
To date, only a limited number of studies have examined whether the utilization of these procedures has changed over the years. A relatively recent study by Potts et al. has asked this question, specifically among American surgeons. In their study, the authors demonstrated a significant, yet gradual decrease in the number of knee arthroscopy cases for patients with OA in the following years after the Moseley et al. study. However, the main limitation of Potts et al's. study was that the group of surgeons studied was composed of early career surgeons and was not necessarily representative of orthopaedic surgeons in general. According to Potts et al. young surgeons may practice differently based on the findings of Moseley et al. as well as orthopaedic texts such as Campbell's Operative Orthopaedics that reference the Moseley et al. trial as evidence that arthroscopy is not favorable for the treatment of OA. Therefore, Potts et al's. trial concluded that further study is needed to determine whether this change occurred in the orthopaedic community at large or if practice patterns only changed for surgeons during their board collection periods. Nevertheless, this theory was not supported by our results. No significant differences were found between the 'Yes' and 'No' groups when we preformed subgroup analysis based on subspecialty, seniority or years of experience. However, significant differences were observed between American and non-American surgeons.
Such differences have been previously identified. Recent studies by Kim et al. and Holmes et al., have also examined the changes in everyday practice among American surgeons. Interestingly, they both noted a decline in arthroscopic debridement for OA, while overall rates of other knee arthroscopies were actually increasing. In contrast to the American findings, an Australian study conducted by Bohensky et al., did not observe any changes in use of knee arthroscopy between the years 2000 and 2009, for any indication. These dissimilarities could be explained by the differences in the American and European guidelines in regards to this matter; while the AAOS chose to highly recommend against arthroscopy with debridement in symptomatic OA, the NICE preferred to be less decisive and recommended not to refer OA patient to arthroscopy, with reservation regarding a patient's history based on the argument that treatment is beneficial for patients with mechanical symptoms of catching or locking or those with early disease. The nonexplicit guidelines offered by the Europeans may have been the reason for the relative diversity of opinion among orthopaedic surgeons, in and outside of the U.S., but not solely.
In conclusion, these survey findings suggest that despite current available data, arthroscopy is still preferred by more than one-quarter of orthopaedic surgeons surveyed worldwide as the treatment for knee OA. Moreover, we found that geography may affect surgeons' preferences, as demonstrated by distinct choices of North American orthopaedic surgeons to avoid knee arthroscopy compared with non-American countries. These results were mainly attributed to the differences between the European and U.S. national guidelines. If so, new guidelines should be considered in a manner that will be more unanimous and will also include the exceptional patient who may benefit from this treatment approach. We believe that this study can be effective in changing orthopaedic surgeon practice in regards to this controversial matter.
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