Arthroscopic meniscal surgery: a national society treatment guideline and consensus statement.

AIMS: The aim of the British Association for Surgery of the Knee (BASK) Meniscal Consensus Project was to develop an evidence-based treatment guideline for patients with meniscal lesions of the knee. MATERIALS AND METHODS: A formal consensus process was undertaken applying nominal group, Delphi, and appropriateness methods. Consensus was first reached on the terminology relating to the definition, investigation, and classification of meniscal lesions. A series of simulated clinical scenarios was then created and the appropriateness of arthroscopic meniscal surgery or nonoperative treatment in each scenario was rated by the group. The process was informed throughout by the latest published, and previously unpublished, clinical and epidemiological evidence. Scenarios were then grouped together based upon the similarity of clinical features and ratings to form the guideline for treatment. Feedback on the draft guideline was sought from the entire membership of BASK before final revisions and approval by the consensus group. RESULTS: A total of 45 simulated clinical scenarios were refined to five common clinical presentations and six corresponding treatment recommendations. The final guideline stratifies patients based upon a new, standardized classification of symptoms, signs, radiological findings, duration of symptoms, and previous treatment. CONCLUSION: The 2018 BASK Arthroscopic Meniscal Surgery Treatment Guidance will facilitate the consistent identification and treatment of patients with meniscal lesions. It is hoped that this guidance will be adopted nationally by surgeons and help inform healthcare commissioning guidance. Validation in clinical practice is now required and several areas of uncertainty in relation to treatment should be a priority for future high-quality prospective studies. Cite this article: Bone Joint J 2019;101-B:652-659

Improving the management of patients with meniscal lesions of the knee

Meniscal lesions in the knee are common and keyhole surgery to excise a meniscal tear, arthroscopic partial meniscectomy (APM), is one of the most commonly performed orthopaedic surgical procedures worldwide. Despite the frequency with which the procedure is performed, the effectiveness of the procedure has been challenged by the publication of a series of clinical trials reporting similar outcomes following physiotherapy or placebo surgery. The broad aims of this thesis were (1) to determine trends and variation in the use of APM and consider if there is evidence for potential overuse of the procedure, (2) to systematically appraise the effectiveness of APM in different patient groups, (3) to determine the potential risks associated with undergoing APM, and (4) to deliver standardised descriptive terminology and treatment guidance informed by this new research. APM was found to be performed increasingly frequently in England over a twenty-year period to 31 March 2017 and there was variation both in the intervention rate and the rate of patients subsequently undergoing a knee arthroplasty within one-year. This variation implied potential overuse of the procedure in some populations, especially those with advanced osteoarthritis, and suggested the need for new clinical treatment guidance to improve and standardise the care pathway for these patients. The clinical effectiveness of APM was found to be limited in patients with osteoarthritis, improved in patients without osteoarthritis, but the interpretation of the evidence is limited by poor quality validation of outcome measures for use in patients with meniscal tears. No trial evidence was identified for patients meeting the strictest selection criteria, specifically a clinically and radiologically unstable meniscal tear, without osteoarthritis, for symptoms failing to resolve after physiotherapy. The short-term risk (90-days) from undergoing APM was found to be low, with serious medical complications (myocardial infarction, stroke, death) occurring less frequently than in the general population. The risk of pulmonary embolism and septic arthritis was, however, elevated and for every 1500 fewer APMs performed, one pulmonary embolism and two knee infections could be prevented. In the long-term, patients with a history of APM were ten-times more likely to undergo arthroplasty annually in comparison to the general population without a history of APM. Women were at greater risk, with 22% undergoing arthroplasty within 15-years, in comparison to 10% of men. A standardised terminology for the description and classification of the clinical and radiological features found in patients with meniscal lesions was developed through an expert consensus process. Using these definitions, a treatment appropriateness exercise was undertaken, informed by the new analysis of the latest clinical and epidemiological evidence, ultimately supporting the development of a new treatment guideline endorsed by the national knee society. In conclusion, the findings reported in this thesis suggest there has been variation within the care pathway for patients with meniscal lesions which may be associated with undesirable outcomes and uncommon but serious adverse events. This thesis reports new standardised treatment guidance, with supporting evidence, and a corresponding change in clinical practice to improve the management of patients with meniscal lesions of the knee is recommended.</p

Differences in mortality and complication rates following revision knee arthroplasty performed for urgent versus elective indications

Aims: To compare rates of serious adverse events in patients undergoing revision knee arthroplasty with consideration of the indication for revision (urgent versus elective indications), and compare these with primary arthroplasty and re-revision arthroplasty. Methods: Patients undergoing primary knee arthroplasty were identified in the national Hospital Episode Statistics (HES) between 1 April 1997 to 31 March 2017. Subsequent revision and re-revision arthroplasty procedures in the same patients and same knee were identified. The primary outcome was 90-day mortality and a logistic regression model was used to investigate factors associated with 90-day mortality and secondary adverse outcomes, including infection (undergoing surgery), pulmonary embolism, myocardial infarction, and stroke. Urgent indications for revision arthroplasty were defined as infection or fracture, and all other indications (e.g. loosening, instability, wear) were included in the elective indications cohort. Results: A total of 939,021 primary knee arthroplasty procedures were included (939,021 patients), of which 40,854 underwent subsequent revision arthroplasty, and 9,100 underwent re-revision arthroplasty. Revision surgery for elective indications was associated with a 90-day rate of mortality of 0.44% (135/30,826; 95% confidence interval (CI) 0.37 to 0.52) which was comparable to primary knee arthroplasty (0.46%; 4,292/939,021; 95% CI 0.44 to 0.47). Revision arthroplasty for infection was associated with a much higher mortality of 2.04% (184/9037; 95% CI 1.75 to 2.35; odds ratio (OR) 3.54; 95% CI 2.81 to 4.46), as was revision for periprosthetic fracture at 5.25% (52/991; 95% CI 3.94 to 6.82; OR 6.23; 95% CI 4.39 to 8.85). Higher rates of pulmonary embolism, myocardial infarction, and stroke were also observed in the infection and fracture cohort. Conclusion: Patients undergoing revision arthroplasty for urgent indications (infection or fracture) are at higher risk of mortality and serious adverse events in comparison to primary knee arthroplasty and revision arthroplasty for elective indications. These findings will be important for patient consent and shared decision-making and should inform service design for this patient cohort.</p

Adverse outcomes after arthroscopic partial meniscectomy: a study of 700 000 procedures in the national Hospital Episode Statistics database for England

Background Arthroscopic partial meniscectomy is one of the most common orthopaedic procedures worldwide. Clinical trial evidence published in the past 6 years, however, has raised questions about the effectiveness of the procedure in some patient groups. In view of concerns about potential overuse, we aimed to establish the true risk of serious complications after arthroscopic partial meniscectomy. Methods We analysed national Hospital Episode Statistics data for all arthroscopic partial meniscectomies done in England between April 1, 1997, and March 31, 2017. Simultaneous or staged (within 6 months) bilateral cases were excluded. We identified complications occurring in the 90 days after the index procedure. The primary outcome was the occurrence of at least one serious complication within 90 days, which was defined as either myocardial infarction, stroke, pulmonary embolism, infection requiring surgery, fasciotomy, neurovascular injury, or death. Logistic regression modelling was used to identify factors associated with complications and, when possible, risk was compared with general population data. Findings During the study period 1 088 782 arthroscopic partial meniscectomies were done, 699 965 of which were eligible for analysis. Within 90 days, serious complications occurred in 2218 (0·317% [95% CI 0·304–0·330]) cases, including 546 pulmonary embolisms (0·078% [95% CI 0·072–0·085]) and 944 infections necessitating further surgery (0·135% [95% CI 0·126–0·144]). Increasing age (adjusted odds ratio [OR] 1·247 per decade [95% CI 1·208–1·288) and modified Charlson comorbidity index (adjusted OR 1·860 per 10 units [95% CI 1·708–2·042]) were associated with an increased risk of serious complications. Female sex was associated with a reduced risk of serious complications (adjusted OR 0·640 [95% CI 0·580–0·705). The risk of mortality fell over time (adjusted OR 0·965 per year [95% CI 0·937–0·994]). Mortality, myocardial infarction, and stroke occurred less frequently in the study cohort than in the general population. The risks of infection and pulmonary embolism did not change during the study, and were significantly higher in the study cohort than in the general population. For every 1390 (95% CI 1272–1532) fewer knee arthroscopies done, one pulmonary embolism could be prevented. For every 749 (95% CI 704–801) fewer procedures done, one native knee joint infection could be prevented. Interpretation Overall, the risk associated with undergoing arthroscopic partial meniscectomy was low. However, some rare but serious complications (including pulmonary embolism and infection) are associated with the procedure, and the risks have not fallen with time. In view of uncertainty about the effectiveness of arthroscopic partial meniscectomy, an appreciation of relative risks is crucial for patients and clinicians. Our data provide a basis for decision making and consent

Rates of adverse outcomes and revision surgery after anterior cruciate ligament reconstruction: A study of 104,255 procedures using the national hospital episode statistics database for England, UK

Background: After an anterior cruciate ligament (ACL) injury, ACL reconstruction is an elective procedure, and therefore, an understanding of the attributable risk from undergoing ACL reconstruction is necessary for patients to make a fully informed treatment decision. Purpose: To determine the absolute risk of adverse outcomes including reoperation after ACL reconstruction with comparison, where possible, to the rate of adverse events reported in the general population. Study Design: Descriptive epidemiology study. Methods: National hospital data on all ACL reconstructions performed in England between April 1, 1997, and March 31, 2017, were analyzed. Revision cases, bilateral procedures within 6 months, and cases with concurrent cartilage or multiple ligament surgery were excluded. The primary outcome was the occurrence of at least 1 serious complication (myocardial infarction, stroke, pulmonary embolism, infection requiring surgery, fasciotomy, neurovascular injury, or death) within 90 days. Additionally, 5-year rates of revision ACL reconstruction, contralateral ACL reconstruction, and meniscal surgery were investigated. Results: There were 133,270 ACL reconstructions performed, of which 104,255 were eligible for analysis. Within 90 days, serious complications occurred in 675 (0.65% [95% CI, 0.60-0.70]), including 494 reoperations for infections (0.47% [95% CI, 0.43-0.52]) and 129 for pulmonary embolism (0.12% [95% CI, 0.10-0.15]). Of 54,275 procedures with at least 5 years’ follow-up, 1746 (3.22% [95% CI, 3.07-3.37]) underwent revision ACL reconstruction in the same knee, 1553 underwent contralateral ACL reconstruction (2.86% [95% CI, 2.72-3.01]), and 340 underwent meniscal surgery (0.63% [95% CI, 0.56-0.70]). The overall risk of serious complications fell over time (adjusted odds ratio [OR], 0.96 per year [95% CI, 0.95-0.98]); however, older patients (adjusted OR, 1.11 per 5 years [95% CI, 1.07-1.16]) and patients with a greater modified Charlson Comorbidity Index (adjusted OR, 2.41 per 10 units [95% CI, 1.65-3.51]) were at a higher risk. For every 850 (95% CI, 720-1039) ACL reconstructions, 1 pulmonary embolism could be provoked. For every 213 (95% CI, 195-233), 1 native knee joint infection could be provoked. Conclusion: The overall risk of adverse events after ACL reconstruction is low; however, some rare but serious complications, including infections or pulmonary embolism, may occur. Around 3% of patients undergo further ipsilateral or contralateral ACL reconstruction within 5 years. These data will inform shared decision making between clinicians and patients considering their treatment options.</p

Adverse outcomes after arthroscopic partial meniscectomy: a study of 700 000 procedures in the national Hospital Episode Statistics database for England

Background Arthroscopic partial meniscectomy is one of the most common orthopaedic procedures worldwide. Clinical trial evidence published in the past 6 years, however, has raised questions about the effectiveness of the procedure in some patient groups. In view of concerns about potential overuse, we aimed to establish the true risk of serious complications after arthroscopic partial meniscectomy. Methods We analysed national Hospital Episode Statistics data for all arthroscopic partial meniscectomies done in England between April 1, 1997, and March 31, 2017. Simultaneous or staged (within 6 months) bilateral cases were excluded. We identified complications occurring in the 90 days after the index procedure. The primary outcome was the occurrence of at least one serious complication within 90 days, which was defined as either myocardial infarction, stroke, pulmonary embolism, infection requiring surgery, fasciotomy, neurovascular injury, or death. Logistic regression modelling was used to identify factors associated with complications and, when possible, risk was compared with general population data. Findings During the study period 1 088 782 arthroscopic partial meniscectomies were done, 699 965 of which were eligible for analysis. Within 90 days, serious complications occurred in 2218 (0·317% [95% CI 0·304–0·330]) cases, including 546 pulmonary embolisms (0·078% [95% CI 0·072–0·085]) and 944 infections necessitating further surgery (0·135% [95% CI 0·126–0·144]). Increasing age (adjusted odds ratio [OR] 1·247 per decade [95% CI 1·208–1·288) and modified Charlson comorbidity index (adjusted OR 1·860 per 10 units [95% CI 1·708–2·042]) were associated with an increased risk of serious complications. Female sex was associated with a reduced risk of serious complications (adjusted OR 0·640 [95% CI 0·580–0·705). The risk of mortality fell over time (adjusted OR 0·965 per year [95% CI 0·937–0·994]). Mortality, myocardial infarction, and stroke occurred less frequently in the study cohort than in the general population. The risks of infection and pulmonary embolism did not change during the study, and were significantly higher in the study cohort than in the general population. For every 1390 (95% CI 1272–1532) fewer knee arthroscopies done, one pulmonary embolism could be prevented. For every 749 (95% CI 704–801) fewer procedures done, one native knee joint infection could be prevented. Interpretation Overall, the risk associated with undergoing arthroscopic partial meniscectomy was low. However, some rare but serious complications (including pulmonary embolism and infection) are associated with the procedure, and the risks have not fallen with time. In view of uncertainty about the effectiveness of arthroscopic partial meniscectomy, an appreciation of relative risks is crucial for patients and clinicians. Our data provide a basis for decision making and consent

Neues zum Bioraps

Neues zum Biorap