Uffe Jørgensen

Patient reported outcomes in patients undergoing arthroscopic partial meniscectomy for traumatic or degenerative meniscal tears: comparative prospective cohort study

Objectives To compare patient reported outcomes from before surgery to 52 weeks after surgery between individuals undergoing arthroscopic partial meniscectomy for traumatic meniscal tears and those for degenerative meniscal tears. Design Comparative prospective cohort study. Setting Four public orthopaedic departments in the Region of Southern Denmark. Participants were recruited between 1 February 2013 and 31 January 2014, and at one of the original four hospitals from 1 February 2014 to 31 January 2015. Participants Individuals selected from Knee Arthroscopy Cohort Southern Denmark, aged 18-55, and undergoing arthroscopic partial meniscectomy for a traumatic or degenerative meniscal tear (defined by a combination of age and symptom onset). Interventions Both participant groups underwent arthroscopic partial meniscectomy for a meniscal tear, with operating surgeons recording relevant information on knee pathology. Patient reported outcomes were recorded via online questionnaires. Main outcome measures Primary outcome was the average between-group difference in change on four of five subscales of the knee injury and osteoarthritis outcome score (KOOS). The four subscales covered pain, symptoms, sport and recreational function, and quality of life (KOOS4). A 95% confidence interval excluding differences greater than 10 KOOS points between groups was interpreted as absence of a clinically meaningful difference. Analyses adjusted for age, sex, and body mass index. Results 397 eligible adults (42% women) with a traumatic or degenerative meniscal tear (n=141, mean age 38.7 years (standard deviation 10.9); n=256, 46.6 years (6.4); respectively) were included in the main analysis. At 52 weeks after arthroscopic partial meniscectomy, 55 (14%) patients were lost to follow-up. Statistically, participants with degenerative meniscal tears had a significantly larger improvement in KOOS4 scores than those with traumatic tears (adjusted between-group difference −5.1 (95% confidence interval −8.9 to −1.3); P=0.008). In the analysis including KOOS4 score at all time points, a significant time-by-group interaction was observed in both the unadjusted (P=0.025) and adjusted analysis (P=0.024), indicating better self-reported outcomes in participants with degenerative tears. However, the difference between groups was at no time point considered clinically meaningful. Conclusions These results question the current tenet that patients with traumatic meniscal tears experience greater improvements in patient reported outcomes after arthroscopic partial meniscectomy than patients with degenerative tears. Trial registration ClinicalTrials.gov identifier NCT01871272.

Structural pathology is not related to patient-reported pain and function in patients undergoing meniscal surgery

Background The relationship between meniscal tears and other joint pathologies with patient-reported symptoms is not clear. We investigated associations between structural knee pathologies identified at surgery with preoperative knee pain and function in patients undergoing arthroscopic meniscal surgery. Methods This study included 443 patients from the Knee Arthroscopy Cohort Southern Denmark (KACS), a prospective cohort following patients 18 years or older undergoing arthroscopic meniscal surgery at 4 hospitals between 1 February 2013 and 31 January 2014. Patient-reported outcomes, including the Knee Injury and Osteoarthritis Outcome Score (KOOS), were obtained by online questionnaires prior to surgery. Knee pathology was assessed by the operating surgeons using a modified version of the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) classification of meniscal tears questionnaire, supplemented with information extracted from surgery reports. Following hypothesis-driven preselection of candidate variables, backward elimination regressions were performed to investigate associations between patient-reported outcomes and structural knee pathologies. Results Regression models only explained a small proportion of the variability in self-reported pain and function (adjusted R2=0.10−0.12) and this association was mainly driven by age, gender and body mass index. Conclusions Specific meniscal pathology and other structural joint pathologies found at meniscal surgery were not associated with preoperative self-reported pain and function in patients with meniscal tears questioning inferences made about a direct relationship between these. Our findings question the role of arthroscopic surgery to address structural pathology as a means to improve patient-reported outcomes in patients having surgery for a meniscal tear.

Knee Arthroscopy Cohort Southern Denmark (KACS): protocol for a prospective cohort study

Background Meniscus surgery is a high-volume surgery carried out on 1 million patients annually in the USA. The procedure is conducted on an outpatient basis and the patients leave the hospital a few hours after surgery. A critical oversight of previous studies is their failure to account for the type of meniscal tears. Meniscus tears can be categorised as traumatic or non-traumatic. Traumatic tears (TT) are usually observed in younger, more active individuals in an otherwise ‘healthy’ meniscus and joint. Non-traumatic tears (NTT) (ie, degenerative tears) are typically observed in the middle-aged (35–55 years) and older population but the aetiology is largely unclear. Knowledge about the potential difference of the effect of arthroscopic meniscus surgery on patient symptoms between patients with traumatic and NTT is sparse. Furthermore, little is known about the natural time course of patient perceived pain, function and quality of life after meniscus surgery and factors affecting these outcomes. The aim of this prospective cohort study is to investigate the natural time course of patient-reported outcomes in patients undergoing meniscus surgery, with particular emphasis on the role of type of symptom onset. Methods/design This prospective cohort study enrol patients assigned for meniscus surgery. At the baseline (PRE surgery), patient characteristics are assessed using an email-based questionnaire also comprising several validated questionnaires assessing general health, knee-specific characteristics and patients expectations of the surgery. Follow-up will be conducted at 12 and 52 weeks after meniscus surgery. The major outcomes will be differences in changes, from before to 52 weeks after surgery, in each of the five domains on the Knee injury and Osteoarthritis Outcome Score (KOOS) between patients undergoing surgery for traumatic compared with non-traumatic meniscus tears. Dissemination The study findings will be disseminated in peer-reviewed journals and presented at national and international conferences. Trial registration number ClinicalTrials.gov Identifier: NCT01871272.

Signs of knee osteoarthritis common in 620 patients undergoing arthroscopic surgery for meniscal tear

Background and purpose — Recent evidence has questioned the effect of arthroscopic knee surgery for middle-aged and older patients with degenerative meniscal tears with or without concomitant radiographic knee osteoarthritis (OA). We investigated the prevalence of early or more established knee OA and patients’ characteristics in a cohort of patients undergoing arthroscopic surgery for a meniscal tear. Patients and methods — 641 patients assigned for arthroscopy on suspicion of meniscus tear were consecutively recruited from February 2013 through January 2015. Of these, 620 patients (mean age 49 (18–77) years, 57% men) with full datasets available were included in the present study. Prior to surgery, patients completed questionnaires regarding onset of symptoms, duration of symptoms, and mechanical symptoms along with the knee injury and osteoarthritis outcome score (KOOS). At arthroscopy, the operating surgeon recorded information about meniscal pathology and cartilage damage. Early or more established knee OA was defined as the combination of self-reported frequent knee pain, cartilage damage, and the presence of degenerative meniscal tissue. Results — 43% of patients (269 of 620) had early or more established knee OA. Of these, a large proportion had severe cartilage lesions with almost half having a severe cartilage lesion in at least 1 knee compartment. Interpretation — Based on a definition including frequent knee pain, cartilage damage, and degenerative meniscal tissue, early or more established knee OA was present in 43% of patients undergoing knee arthroscopy for meniscal tear.

Over-optimistic patient expectations of recovery and leisure activities after arthroscopic meniscus surgery

Background and purpose — Patients’ expectations of outcomes following arthroscopic meniscus surgery are largely unknown. We investigated patients’ expectations concerning recovery and participation in leisure-time activities after arthroscopic meniscus surgery and the postoperative fulfillment of these. Patients and methods — The study sample consisted of 491 consecutively recruited patients (mean age 50 (SD 13) years, 55% men) who were assigned for arthroscopy on suspicion of meniscus injury and later verified by arthroscopy. Before surgery, patients completed questionnaires regarding their expectations of recovery time and postoperative participation in leisure activities. 3 months after surgery, the patients completed questionnaires on their actual level of leisure activity and their degree of satisfaction with their current knee function. We analyzed differences between the expected outcome and the actual outcome, and between fulfilled/exceeded expectations and satisfaction with knee function. Results — 478 patients (97%) completed the follow-up. 91% had expected to be fully recovered within 3 months. We found differences between patients’ preoperative expectations of participation in leisure activities postoperatively and their actual participation in these, with 59% having unfulfilled expectations (p < 0.001). Satisfaction with current knee function was associated with expectations of leisure activities being fulfilled/exceeded. Interpretation — In general, patients undergoing arthroscopic meniscus surgery were too optimistic regarding their recovery time and postoperative participation in leisure activities. This highlights the need for shared decision making which should include giving the patient information on realistic expectations of recovery time and regarding participation in leisure-time activities after meniscal surgery.

A positive viewpoint regarding arthroscopy for degenerative knee conditions

Sir—In the latest issue of Acta Orthopaedica, Thorlund et al. (2014) report figures from the Danish National Patient Register (DNPR) showing a 2-fold increase in knee arthroscopy with meniscal surgery from 2000 to 2011, and they conclude that arthroscopy for degenerative conditions in particular has increased in the middle-aged population. In a guest editorial in the same issue, Jarvinen et al. (2014; from Finland and Sweden) conclude that since any additional effect of arthroscopic operations in these conditions has not been shown, that arthroscopy is contraindicated, and that political decisions may be the next step to stop arthroscopic operations. In Thorlund’s article, 2 significant confounders are of importance for the results and conclusions. The authors state that in the year 2000, several hospitals did not report to the DNPR and they suggest an under-reporting rate of about 5%, based on a general estimate of all operations. This cannot be extrapolated to knee arthroscopy, which is a small operation that is performed more often in private hospitals and in orthopedic specialist practices (often under local anesthesia) than in public hospitals, in contrast to larger operations. Private hospitals and clinics did not report to the DNPR before the mid-2000s. Therefore, the increase between 2000 and 2011 is substantially overestimated; the authors could have contacted the Danish National Board of Health to make the estimate of missing operations more qualified. Alternatively, the authors could have excluded hospitals and clinics that did not report over the whole period of 11 years. It is a mistake to regard meniscal changes coded as DM232 as degenerative. The distinction between DS832 and DM232 is only related to the duration of symptoms, and most clinicians would use 3 months as the dividing time. In addition, the salary for diagnosing and non-operatively treating meniscal changes is higher if the code DM23.2 is used, which may make clinicians aware of the time consideration regarding individual patients. Thus, how many of the meniscal operations were actually performed on degenerative meniscal changes and how many were performed on traumatic ruptures is pure speculation. Although it is not stated clearly in Thorlund’s article, we assume that the incidences are based on population numbers for each age category and not for the whole population. On the internet, it is easy to obtain numbers of inhabitants in Denmark for every 3 months—and with 1-year age intervals (http://www.statistikbanken.dk/02). If this information had been used, the extrapolation that is used for population numbers in the article could have been avoided. Is it bad to arthroscope and debride knees with meniscal or degenerative changes? The “well-conducted” randomized studies have all shown an effect, but have not been able to demonstrate any difference between operative and non-operative treatments. No one has had a control group (with no treatment). Thus, there may not be any difference, or the outcome measures that are used in these studies, which are generally constructed for much more painful conditions, might not be relevant or sensitive enough for people with milder disease to show any difference. But the randomized studies show that arthroscopy has an effect—which is not less than non-operative treatment. Another important issue with the data from these randomized studies is that they contain too few patients to be able to perform relevant subgroup analysis. From clinical experience, we know that male patients with mechanical symptoms have very good outcome compared to female patients without mechanical symptoms. In the editorial, Jarvinen et al. (2014 state – quite strangely – that on top of no difference, there are complications to arthroscopy. In well-conducted randomized studies, these complications are included in the outcome comparisons. Jarvinen et al. missed 2 very important points that should have been considered before they abandoned arthroscopy for the degenerative knee. Firstly, the number of people who engaged in regular sports activity increased by 30% in Denmark between 1998 and 2011; in the middle-aged group, almost 70% had regular physical activity and 42% had sports activity 3–4 hours a week or more (Laub 2013). 20% of adults must stop sports because of health problems. Symptoms from degenerative conditions are load-related, and it could be expected that higher numbers of middle-aged people would have symptoms from their knees in 2011 than in 2000, just because of the substantially increased physical activity in this age group. In addition, this can be expected to increase over the coming years. The second point has, strangely enough, not been part of this discussion at any time. What if non-operative treatment is not working? There has been an annual increase in public physiotherapy treatment in Denmark of 3–5 % every year from 2000 to 2011 ([Praksisplan for fysioterapi] Reports from the Danish regions 2012–13), particularly in the middle-aged population. The total amount of physiotherapy and other non-operative interventions has most probably increased much more, as many Danes obtained a private health insurance during this period. So there is quite substantial data on a marked increase in non-operative treatments of the degenerative knee during the period in question. So, banning arthroscopy is not based on scientific evidence but has a much more political sound. For us as clinicians seeing many of these patients, in contrast to several of the authors of the articles that have created this debate, it is evident that most patients have tried relevant non-operative interventions before they are seen by the orthopedic surgeon. There is an increasing demand to stay fit and to be able to engage in physical activity irrespective of age, and the general health benefits of this have been substantially documented. A large proportion of these patients are very fit, and for them it is difficult to argue for further exercise as treatment. We suggest that, instead of closing one eye and pressing the patients into the same standard protocol, the healthcare staff should evaluate the individual person. A fit 50-year-old plumber who is in danger of loosing his job because of knee pain from mild cartilage changes and meniscal flaps, might be helped most quickly with an arthroscopic debridement. An unfit, overweight person might best be treated with muscle training and weight loss. And a person who has become fit from training and has lost weight etc., should not be kept from the possibility of arthroscopic debridement when non-operative treatment has failed. Clinicians know that the situation of failed non-operative treatment is very common. Knee arthroscopy is one option among several in treatment of the degenerative knee. Based on the available data outlined above and our long clinical experience, it is our view that in Denmark the use of arthroscopy has not increased more than non-operative treatments (and probably less). We feel that increases in the numbers of treatments (both operative and non-operative) must be expected during the coming years, and these are important modalities to keep the Danish population physically active as they get older. This benefits everyone, and also the public finances.

Study protocol for a randomised controlled trial of meniscal surgery compared with exercise and patient education for treatment of meniscal tears in young adults

Introduction Arthroscopic surgery is a very common orthopaedic procedure. While several trials have investigated the effect of knee arthroscopy for middle-aged and older patients with meniscal tears, there is a paucity of trials comparing meniscal surgery with non-surgical treatment for younger adults. The aim of this randomised controlled trial (RCT) is to investigate if early arthroscopic surgery is superior to exercise therapy and education, with the option of later surgery if needed, in improving pain, function and quality of life in younger adults with meniscal tears. Methods and analysis This is a protocol for a multicentre, parallel-group RCT conducted at six hospitals across all five healthcare regions in Denmark. 140 patients aged 18–40 years with a clinical history and symptoms consistent with a meniscal tear, verified on MRI, found eligible for meniscal surgery by an orthopaedic surgeon will be randomly allocated to one of two groups (1:1 ratio). Participants randomised to surgery will undergo either arthroscopic partial meniscectomy or meniscal repair followed by standard postsurgical care, while participants allocated to exercise and education will undergo a 12-week individualised, supervised neuromuscular and strengthening exercise programme and patient education. The primary outcome will be difference in change from baseline to 12 months in the mean score on four Knee Injury and Osteoarthritis Outcome Score subscales, covering pain, symptoms, function in sports and recreation and quality of life (Knee Injury and Osteoarthritis Outcome Score (KOOS4)) supported by the individual subscale scores allowing clinical interpretation. Alongside, the RCT an observational cohort will follow patients aged 18–40 years with clinical suspicion of a meniscal tear, but not fully eligible or declining to participate in the trial. Ethics and dissemination Results will be presented in peer-reviewed journals and at international conferences. This study is approved by the Regional Committees on Health Research Ethics for Southern Denmark. Registration details ClinicalTrials.gov (NCT02995551).

Do Exercisers With Musculoskeletal Injuries Report Symptoms of Depression and Stress

CONTEXT Sports injuries in athletes can lead to negative emotional responses in terms of anger, anxiety, confusion, and sadness. Severe injuries can be understood as a stressful life event with increased levels of psychological distress, but injury assessment and rehabilitation typically focus on somatic symptoms. OBJECTIVE The primary aim of this study was to estimate the prevalence of depression and emotional stress and to measure self-rated health in regular exercisers presenting to a sports medicine clinic with musculoskeletal injury. The secondary aim was to identify psychosocial factors associated with depression in injured exercisers and the potential need for psychological counseling. DESIGN A cross-sectional survey study. SETTING A sports medicine clinic for injuries of the foot, knee, or shoulder. PARTICIPANTS Regular exercisers with present injuries (N = 694) and exercisers without injuries (N = 494). Regular exercisers were defined as those undertaking moderate exercise at least once a week. INTERVENTION A questionnaire survey completed on paper by patients in a sports medicine clinic and a web-based version completed by online sports communities. MAIN OUTCOME MEASURES Participants completed the Major Depression Inventory, Perceived Stress Scale, health-related quality of life, and questions on sociodemographics, exercise habits, and injury history. RESULTS Symptoms of depression were reported by 12% of injured exercisers and 5% of noninjured controls (P < .001). Clinical stress was found in 30% of injured exercisers and 22% of controls (P = .002), and the EQ-5D-5L Visual Analog Scale score was lower for injured (69 [SD = 19]) than noninjured exercisers (87 [SD = 13], P < .001). Injured exercisers with symptoms of depression reported high stress levels and impaired daily functioning, were younger, and were more likely to have over 10 days injury-related work absence. CONCLUSIONS The authors recommend psychological assessment of exercisers attending a sports medicine clinic for musculoskeletal injury and a supplemental clinical psychological interview for suspected depression or stress-related psychopathology.

The effect of targeted exercise on knee-muscle function in patients with persistent hamstring deficiency following ACL reconstruction – study protocol for a randomized controlled trial

BackgroundAnterior cruciate ligament (ACL) reconstruction, using hamstring auto-graft is a common surgical procedure, which often leads to persistent hamstring muscle-strength deficiency and reduced function. The purpose of this randomized controlled trial (RCT) is to investigate the effect of a combined, progressive, strength and neuromuscular exercise intervention on knee muscle strength, functional capacity and hamstring muscle-tendon morphology in ACL-reconstructed patients with persistent hamstring muscle-strength deficiency compared with controls.Methods/designThe study is designed as a multicenter, parallel-group RCT with balanced randomization (1:1) and blinded outcome assessments (level of evidence: II) and will be reported in accordance with the CONSORT Statement. Fifty ACL-reconstructed patients (hamstring auto-graft) with persistent limb-to-limb knee-flexor muscle-strength asymmetry at 12–24 months’ post surgery, will be recruited through outpatient clinics and advertisements. Patients will be randomized to a 12-week progressive, strength and neuromuscular exercise group (SNG) with supervised training twice weekly or a control intervention (CON) consisting of a home-based, low-intensity exercise program. Outcome measures include between-group change in maximal isometric knee-flexor strength (primary outcome) and knee-extensor muscle strength, hamstring-to-quadriceps strength ratios of the leg that has been operated on and Knee injury and Osteoarthritis Outcome Score (KOOS) (secondary outcomes).In addition, several explorative outcomes will be investigated: The International Knee Documentation Committee Subjective Knee Form (IKDC), the Tegner Activity Score, rate of force development (RFD) for the knee flexors and extensors, tendon regeneration and potential muscle hypertrophy at graft harvest site evaluated by magnetic resonance imaging (MRI), postural control, kinetic/kinematic gait characteristics and knee-related functional capacity.DiscussionThis RCT is designed to investigate the effect of combined, progressive-resistance and neuromuscular exercises on knee-flexor/extensor strength, in the late rehabilitation phase following ACL reconstruction. Reduced hamstring strength represents a potential risk factor for secondary ACL rupture and accelerated progression of osteoarthritis. If deemed effective, the intervention paradigm introduced in this study may help to improve current treatment strategies in ACL-reconstructed patients.Trial registrationClinicalTrials.gov, ID: NCT02939677 (recruiting). Registered on 20 October 2016.

Association of specific meniscal pathologies and other structural pathologies with self-reported mechanical symptoms: A cross-sectional study of 566 patients undergoing meniscal surgery

OBJECTIVES We explored associations between specific meniscal pathologies and other concurrent structural knee pathologies with presence of self-reported mechanical symptoms in patients undergoing meniscal surgery. DESIGN Cross-sectional study. METHODS We included patients undergoing surgery for a meniscal tear from Knee Arthroscopy Cohort Southern Denmark (KACS). Pre-surgery, patients completed online questionnaires including self-reported presence of mechanical symptoms. At arthroscopy, surgeons recorded information about specific meniscal pathologies and other concurrent structural knee pathologies. Relative risks (RR) were estimated to assess associations between specific meniscal pathologies and other structural knee pathologies with preoperative mechanical symptoms from multivariable logistic regression. RESULTS 566 of 641 patients (mean age 48.6[SD 12.9] years, 57% men) with complete data were included. 386 (68%) patients reported mechanical symptoms of knee catching/locking and/or extension deficit. Most evaluated joint pathologies were not associated with mechanical symptoms of any kind with RRs close to 1.0. Meniscal tears involving both the posterior and anterior horn (n=22) were associated with knee catching/locking (RR: 1.49[95%CI:1.15-1.93]), and a tear in both menisci (n=49) was associated with extension deficit of the knee (RR: 1.32[95%CI:1.01-1.73]). A partial (n=29) and total ACL rupture (n=37) were each associated with extension deficit (RR: 1.83[95%CI:1.47-2.28] and RR: 1.44[95%CI:1.05-1.98], respectively). CONCLUSIONS Limited associations between specific meniscal pathology and other concurrent knee joint pathologies with presence of self-reported mechanical symptoms were found in patients undergoing meniscal surgery. The findings question the clinical importance of mechanical symptoms as an indicator for arthroscopy for specific meniscal tears with the specific aim to relieve such symptoms.