One Third of Knee Arthroscopies Are Potentially Low-Value Care

Jonathan Gelber, MD, MS

July 28, 2021

A recent study published in Knee Surgery, Sports Traumatology, Arthroscopy found that there were no valid indications in the medical record for one third of knee arthroscopies performed for patients older than 50 years.

Dutch researchers performed a retrospective review of medical records from 2016 of patients aged 50 years or older with degenerative knee disease for whom arthroscopy had been performed.

The researchers obtained a random selection of 50 medical records from 13 orthopedic centers in the Netherlands and evaluated them for proper surgical indications, as determined on the basis of Dutch national guidelines and expert opinion.

Included among the surgical indications in the national guidelines are anterior cruciate ligament injuries, traumatic knee injuries, failure of physical therapy, and true-locking of the knee.

Invalid indications include mechanical symptoms without objective locking and decisions made solely on the basis of patient-surgeon discussion following patient request.

Dr Leti van Bodegom-Vos

Leti van Bodegom-Vos, PhD, of the Department of Biomedical Data Sciences at Leiden University Medical Center, Leiden, the Netherlands, was senior author of the article. She noted that knee arthroscopies performed without a valid indication are of low value, waste resources, and carry risk for unnecessary harm.

"One third of the performed arthroscopies among patients aged 50 years and over with degenerative knee disease is potentially low-value care," she told Medscape Medical News.

Indications for knee arthroscopy have evolved continuously over the past several decades. After a period of rapid expansion, indications have begun to tighten. Research suggests that patients with certain conditions do not fare as well following knee arthroscopy.

Degenerative meniscus tears in patients older than 50 years, for example, can often be successfully treated without surgery.

That said, there are advantages to surgery in many cases, such as potentially faster improvement in outcome scores or meniscal preservation. Finding the right balance between conservative treatment and operative indications is part of the art of medicine.

"Knowing the proportion of low-value arthroscopies allows us to estimate the improvement potential regarding our goal to strive towards efficient, safe, and high quality of care for patients with degenerative knee disease," said van Bodegom-Vos.

Dr Semon Bader

Asked to comment on the study, Semon Bader, MD, a sports medicine surgeon in Walnut Creek, California, wondered whether the Dutch guidelines may overlook potentially repairable problems, such as meniscus root tears.

"Many patients with meniscus root tears present with a pop in the back of the knee. However, some present more insidiously with posterior knee pain," he told Medscape.

The Dutch guidelines focus on acute, traumatic injuries as well as failure of nonoperative treatment, which may take up valuable time. "Meniscal root tears are actually time sensitive, and nonoperative treatment will actually be detrimental for patients," Bader said.

Surgical indications also involve informed consent discussions with patients. In countries such as the Netherlands, this alone may not be enough to justify surgery.

Prior to deciding on elective surgery, physicians and patients typically use mutual decision making to arrive at a joint care plan. However, according to the Dutch guidelines, "A decision that was made in consultation with the patient or on patient's request" is not a valid indication for knee arthroscopy.

Van Bodegom-Vos found it interesting that more than one fourth of the indications relied only on patient-surgeon discussion. "Although the Choosing Wisely campaign encourages physicians and patients to engage in conversations about unnecessary tests, treatments, and procedures, it can be questioned whether low-value treatments should be considered by orthopedic surgeons as result of a patient-provider decision," she said.

These discussions with a patient can be challenging, van Bodegom-Vos pointed out. "Patients may be frustrated with their symptoms, having tried several less invasive management strategies by the time that they see the surgeon, and in many cases, this may come with an expectation for surgical management," she said.

Further, many patients experience marked improvements after arthroscopy, but that result may be erroneously attributed to the effects of the procedure itself rather than the natural course of the disease, co-interventions, or placebo effects.

Financial considerations often lurk in the background. Such considerations may involve the hospital, the surgeon, or the patient and their insurance deductible.

Although the wording or indications listed in the Dutch national guidelines may be debatable, van Bodegom-Vos hopes that surgeons at least consider whether their indications are objectively valid.

She believes surgeons tend to overestimate the benefits of arthroscopies for patients with degenerative knee disease and to underestimate the harms that come from them. "Although we know surgeons try to help patients and want the best for patients, we ask surgeons to look critically at the decisions they made and evaluate whether there are valid indications for performing an arthroscopy." she said.

The study was funded by the Netherlands Organization for Health Research. Van Bodegom-Vos and Bader have disclosed no relevant financial relationships.

Knee Surg Sports Traumatol Arthrosc. Published online June 19, 2021. Full text

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