Evaluation of Knee Arthroscopy as a Low-Value Intervention for Treatment of Meniscal Damage in Patients With Osteoarthritis
orthopedic surgery, comparative effectiveness
Background/Aims: Patients presenting to their physicians with knee pain are often evaluated for osteoarthritis (OA) and/or meniscal damage. To alleviate pain and delay/prevent more invasive knee surgery, meniscal damage is typically treated with knee arthroscopy (KA) even if mild/moderate OA is present. However, recent randomized trials suggest that KA for meniscal damage in the setting of OA does not result in improved physical functioning and/or greater pain relief than treatment with physical therapy (PT) alone. Given these data, our aims were: 1) determine the demographic/clinical patient factors that lead to treatment with KA or PT-only, and 2) assess differences in clinical outcomes for KA vs. PT-only.
Methods: The cohort is comprised of patients aged > 45 years, with > 2 years membership, no prior knee surgery and recent history of OA at the time of meniscal tear diagnosis (2003–2006). Patients were followed from date of surgery (KA) or first PT visit (PT-only) until partial/total knee replacement surgery, death, disenrollment or end of study (12/31/2013), whichever occurred first. Cox proportional hazards and robust Poisson models were used to estimate the risk of knee replacement surgery and greater utilization/medication use, respectively, associated with KA vs. PT-alone. Demographic/clinical characteristics were used to derive a propensity score, and inverse probability of treatment weights applied to individual observations in the estimation of model parameters.
Results: Among 7,026 patients (69% KA, 31% PT-only), 27% had partial/total knee replacement surgery during follow-up. PT-only patients were older and more likely to be female, have greater comorbidity and utilize health services more frequently than patients with KA. After accounting for differences between groups, KA patients were no better off than PT-only patients in terms of time to knee replacement surgery; cumulative incidence of knee surgery was significantly higher for those who received KA vs. PT-only (HR: 1.30, 95% CI: 1.16–1.46). No differences in utilization for knee pain, narcotic medication dispenses or knee injections were observed between the groups.
Discussion: For patients with meniscal damage complicated by OA, treatment with KA does not result in better clinical outcomes than PT-alone. Considering Choosing Wisely and Kaiser Permanente organizational goals, reduction in KA procedures performed for these patients may be warranted.
Black MH, Navarro RA, Adams AL. Evaluation of Knee Arthroscopy as a Low-Value Intervention for Treatment of Meniscal Damage in Patients With Osteoarthritis. J Patient Cent Res Rev 2015;2:91. http://dx.doi.org/10.17294/2330-0698.1085