Rates of knee arthroplasty within one-year of undergoing arthroscopic partial meniscectomy in England: temporal trends, regional and age-group variation in conversion rates

Evaluation of Trends in Knee Arthroscopy from 2004 to 2019 in Ontario, Canada

BACKGROUND: How changes in recommendations for the use of knee arthroscopy have influenced real-world practice remains unclear. We assessed temporal trends in knee arthroscopy volume, costs, and rates of progression to knee arthroplasty following arthroscopy in Ontario, Canada. METHODS: We used diagnostic codes from population-based administrative databases from Ontario, Canada, to identify patients who underwent knee arthroscopy from April 1, 2004 to March 31, 2019. We calculated arthroscopy volume, costs, and rates of progression to knee arthroplasty within 1, 2, and 5 years following arthroscopy. RESULTS: A total of 408,040 arthroscopy procedures were included. The number of procedures declined 8.9% from 24,070 in 2004/2005 to 21,930 in 2018/2019. The volume of arthroscopy for osteoarthritis declined by 77.9% between 2007/2008 and 2018/2019. For degenerative meniscus disorders, the volume increased by 57.6% between 2004/2005 and 2013/2014, and then declined by 34.6% between 2013/2014 and 2018/2019. Among patients with osteoarthritis, rates of progression to knee arthroplasty were 3.8%, 9.6%, and 16.0%, at 1, 2, and 5 years, respectively, compared with rates among patients with degenerative meniscal disorders, which were 1.6%, 4.1%, and 7.3% at 1, 2, and 5 years, respectively. Over this period, progression to knee arthroplasty rates declined across diagnosis groups. These trends remained after adjusting for patient, surgeon, and hospital characteristics. CONCLUSIONS: In Ontario, Canada, utilization of knee arthroscopy declined between 2004/2005 and 2018/2019, with a concomitant decline in the rates of progression to knee arthroplasty within 1 to 5 years. Among the possible interpretations, our data are consistent with the hypothesis that clinical practice evolved as evidence-based recommendations against the use of knee arthroscopy for degenerative diagnoses were promulgated. (Funded by the Toronto General and Western Hospital Foundation through the University Health Network–Schroeder Arthritis Institute.)

Arthroscopic surgery for degenerative knee disease (osteoarthritis including degenerative meniscal tears)

BACKGROUND

Arthroscopic knee surgery remains a common treatment for symptomatic knee osteoarthritis, including for degenerative meniscal tears, despite guidelines strongly recommending against its use. This Cochrane Review is an update of a non-Cochrane systematic review published in 2017.

OBJECTIVES

To assess the benefits and harms of arthroscopic surgery, including debridement, partial menisectomy or both, compared with placebo surgery or non-surgical treatment in people with degenerative knee disease (osteoarthritis, degenerative meniscal tears, or both).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and two trials registers up to 16 April 2021, unrestricted by language.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), or trials using quasi-randomised methods of participant allocation, comparing arthroscopic surgery with placebo surgery or non-surgical interventions (e.g. exercise, injections, non-arthroscopic lavage/irrigation, drug therapy, and supplements and complementary therapies) in people with symptomatic degenerative knee disease (osteoarthritis or degenerative meniscal tears or both). Major outcomes were pain, function, participant-reported treatment success, knee-specific quality of life, serious adverse events, total adverse events and knee surgery (replacement or osteotomy).

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, extracted data, and assessed risk of bias and the certainty of evidence using GRADE. The primary comparison was arthroscopic surgery compared to placebo surgery for outcomes that measured benefits of surgery, but we combined data from all control groups to assess harms and knee surgery (replacement or osteotomy).

MAIN RESULTS

Sixteen trials (2105 participants) met our inclusion criteria. The average age of participants ranged from 46 to 65 years, and 56% of participants were women. Four trials (380 participants) compared arthroscopic surgery to placebo surgery. For the remaining trials, arthroscopic surgery was compared to exercise (eight trials, 1371 participants), a single intra-articular glucocorticoid injection (one trial, 120 participants), non-arthroscopic lavage (one trial, 34 participants), non-steroidal anti-inflammatory drugs (one trial, 80 participants) and weekly hyaluronic acid injections for five weeks (one trial, 120 participants). The majority of trials without a placebo control were susceptible to bias: in particular, selection (56%), performance (75%), detection (75%), attrition (44%) and selective reporting (75%) biases. The placebo-controlled trials were less susceptible to bias and none were at risk of performance or detection bias. Here we limit reporting to the main comparison, arthroscopic surgery versus placebo surgery. High-certainty evidence indicates arthroscopic surgery leads to little or no difference in pain or function at three months after surgery, moderate-certainty evidence indicates there is probably little or no improvement in knee-specific quality of life three months after surgery, and low-certainty evidence indicates arthroscopic surgery may lead to little or no difference in participant-reported success at up to five years, compared with placebo surgery. Mean post-operative pain in the placebo group was 40.1 points on a 0 to 100 scale (where lower score indicates less pain) compared to 35.5 points in the arthroscopic surgery group, a difference of 4.6 points better (95% confidence interval (CI) 0.02 better to 9 better; I² = 0%; 4 trials, 309 participants). Mean post-operative function in the placebo group was 75.9 points on a 0 to 100 rating scale (where higher score indicates better function) compared to 76 points in the arthroscopic surgery group, a difference of 0.1 points better (95% CI 3.2 worse to 3.4 better; I² = 0%; 3 trials, 302 participants). Mean post-operative knee-specific health-related quality of life in the placebo group was 69.7 points on a 0 to 100 rating scale (where higher score indicates better quality of life) compared with 75.3 points in the arthroscopic surgery group, a difference of 5.6 points better (95% CI 0.36 better to 10.68 better; I² = 0%; 2 trials, 188 participants). We downgraded this evidence to moderate certainty as the 95% confidence interval does not rule in or rule out a clinically important change. After surgery, 74 out of 100 people reported treatment success with placebo and 82 out of 100 people reported treatment success with arthroscopic surgery at up to five years (risk ratio (RR) 1.11, 95% CI 0.66 to 1.86; I² = 53%; 3 trials, 189 participants). We downgraded this evidence to low certainty due to serious indirectness (diversity in definition and timing of outcome measurement) and serious imprecision (small number of events). We are less certain if the risk of serious or total adverse events increased with arthroscopic surgery compared to placebo or non-surgical interventions. Serious adverse events were reported in 6 out of 100 people in the control groups and 8 out of 100 people in the arthroscopy groups from eight trials (RR 1.35, 95% CI 0.64 to 2.83; I² = 47%; 8 trials, 1206 participants). Fifteen out of 100 people reported adverse events with control interventions, and 17 out of 100 people with surgery at up to five years (RR 1.15, 95% CI 0.78 to 1.70; I² = 48%; 9 trials, 1326 participants). The certainty of the evidence was low, downgraded twice due to serious imprecision (small number of events) and possible reporting bias (incomplete reporting of outcome across studies). Serious adverse events included death, pulmonary embolism, acute myocardial infarction, deep vein thrombosis and deep infection. Subsequent knee surgery (replacement or high tibial osteotomy) was reported in 2 out of 100 people in the control groups and 4 out of 100 people in the arthroscopy surgery groups at up to five years in four trials (RR 2.63, 95% CI 0.94 to 7.34; I² = 11%; 4 trials, 864 participants). The certainty of the evidence was low, downgraded twice due to the small number of events.

AUTHORS' CONCLUSIONS

Arthroscopic surgery provides little or no clinically important benefit in pain or function, probably does not provide clinically important benefits in knee-specific quality of life, and may not improve treatment success compared with a placebo procedure. It may lead to little or no difference, or a slight increase, in serious and total adverse events compared to control, but the evidence is of low certainty. Whether or not arthroscopic surgery results in slightly more subsequent knee surgery (replacement or osteotomy) compared to control remains unresolved.

Loss of Autophagy Causes Increased Apoptosis of Tibial Plateau Chondrocytes in Guinea Pigs with Spontaneous Osteoarthritis

OBJECTIVE

The goal of the present study was to observe the effect of autophagy in tibial plateau chondrocytes on apoptosis in spontaneous knee osteoarthritis (OA) in guinea pigs.

DESIGN

Fifty 2-month-old female Hartley guinea pigs were divided into a normal group (10 animals, all euthanized after 7 months) and an OA group (40 animals, 10 of which were euthanized after 10 months). Immunohistochemistry, RT-qPCR and Western blotting were used to evaluate autophagy levels, intracellular glycogen accumulation and apoptosis in tibial plateau chondrocytes in vivo and in vitro. The remaining 30 guinea pigs in the OA group were divided into 3 groups: a rapamycin group, a normal saline group, and a 3-methyladenine (3-MA) group. Intracellular glycogen accumulation and chondrocyte apoptosis were assessed by altering the level of autophagy in chondrocytes in vivo.

RESULTS

When spontaneous OA occurred in guinea pigs, autophagy levels in tibial plateau chondrocytes decreased, while intracellular glycogen accumulation and the rate of chondrocyte apoptosis increased. After enhancing the level of autophagy in tibial plateau chondrocytes in guinea pigs with OA, intracellular glycogen accumulation and the rate of chondrocyte apoptosis decreased, while inhibiting autophagy had the opposite effects.

CONCLUSION

The results indicate that the function of autophagy in chondrocytes may at least partly involve the catabolism of glycogen. In guinea pigs with OA, the level of autophagy in tibial plateau chondrocytes decreased, and chondrocytes were unable to degrade intracellular glycogen into glucose, leading to less energy for chondrocytes and increased apoptosis.

Rates and Risk Factors of Revision Arthroscopy or Conversion to Total Knee Arthroplasty Within 1 Year Following Isolated Meniscectomy

Purpose

To identify the rates of and risk factors for revision arthroscopy and conversion to total knee arthroplasty (TKA) within 1 year of isolated meniscectomy.

Methods

Humana and Medicare national insurance databases were queried for patients who underwent isolated meniscectomy. Patients who underwent revision arthroscopy or TKA within 1 year postoperatively were identified by International Classification of Diseases Procedural Codes, Ninth Revision, and Current Procedural Terminology codes. Multivariate binomial logistic regression analysis was used to identify risk factors, and adjusted odds ratios (ORs) and 95% confidence intervals (Cis) were calculated, with P < .05 considered significant.

Results

A total of 13,142 patients and 407,888 patients underwent isolated meniscectomy in the Humana and Medicare databases, respectively. Of the patients, 395 (3.01%) and 3,770 patients (0.92%) underwent revision arthroscopy, and 629 patients (4.79%) and 38,630 patients (9.47%) underwent TKA within 1 year of meniscectomy in the Humana and Medicare databases, respectively. Obesity (Humana: OR = 1.33, P = 0.003; Medicare: OR = 1.10, P < 0.001) and age < 20 years (Humana: OR = 2.64, P = 0.022), 20-29 years (Humana: OR = 3.30, P = 0.002), 40-49 years (Humana: OR = 3.80, P < 0.001), 50-59 years (Humana: OR = 1.99, P = 0.027), and < 64 years (Medicare: OR = 1.74, P < 0.001) were risk factors for revision arthroscopy. Obesity (Humana: OR = 1.64, P < 0.001; Medicare: OR = 1.37, P < 0.001), morbid obesity (Medicare: OR = 1.20, P < 0.001), age 70-74 (Medicare: OR = 1.12, P < 0.001), 75-79 (Medicare: OR = 1.25, P < 0.001), 80-84 (Medicare: OR = 1.20, P < 0.001), and concomitant osteoarthritis (Humana: OR = 1.42, P < 0.001; Medicare: OR = 1.46, P < 0.001) were risk factors for conversion to TKA.

Conclusions

Medicare and Humana databases showed that 0.92%-3.01% and 4.79%-9.47% of patients undergo revision arthroscopy or conversion to TKA within a year of isolated meniscectomy. Obesity was a risk factor for early revision arthroscopy and conversion to TKA, whereas concomitant osteoarthritis was a risk factor for conversion to TKA.

Level of Evidence

Level III, retrospective comparative trial.

Patients with lateral compartment knee osteoarthritis during arthroscopy are at highest risk of subsequent knee arthroplasty

BACKGROUND

Arthroscopic treatment of knee osteoarthritis has declined, in part due to concerns with conversion to arthroplasty. Some studies have investigated the demographic predictors for conversion to arthroplasty, few have assessed the risk factors within the knee itself. Our aim was to analyse the demographics and anatomical wear features of a large cohort of patients undergoing knee arthroscopy.

METHODS

A retrospective analysis of 1760 cases spanning over 17 years undergoing knee arthroscopy was performed. Patients were 36 years or older at time of the index arthroscopy. Each patient received the International Cartilage Regeneration and Joint Preservation Society (ICRS) grade of all regions as well an estimate of the remaining meniscal percentage. Demographic factors as well as intraoperatively collected data were analysed as predictive variables for subsequent conversion to arthroplasty using a multi-step Cox regression analysis.

RESULTS

A total of 102 patients (6.2%) were converted to arthroplasty. Age at arthroscopy (hazard ratio (HR) 1.073; 95% confidence interval (CI) 1.058-1.088) and ICRS grade of the lateral tibial plateau (HR 1.166; 95% CI 1.066-1.276) were statistically significant predicting variables for conversion to arthroplasty.

CONCLUSIONS

The results of this study indicate that higher ICRS grade of the lateral tibial plateau at arthroscopy is the most significant predictor for conversion to knee arthroplasty, with a hazard equal to an increase in age. The absence of these factors does not justify arthroscopic treatment of patients with knee osteoarthritis.

LEVEL OF EVIDENCE

III.