To present a clear and comprehensive summary of the published data on unicompartmental knee replacement (UKA) or total knee replacement (TKA), comparing domains of outcome that have been shown to be ...important to patients and clinicians to allow informed decision making.
Systematic review using data from randomised controlled trials, nationwide databases or joint registries, and large cohort studies.
Medline, Embase, Cochrane Controlled Register of Trials (CENTRAL), and Clinical Trials.gov, searched between 1 January 1997 and 31 December 2018.
Studies published in the past 20 years, comparing outcomes of primary UKA with TKA in adult patients. Studies were excluded if they involved fewer than 50 participants, or if translation into English was not available.
60 eligible studies were separated into three methodological groups: seven publications from six randomised controlled trials, 17 national joint registries and national database studies, and 36 cohort studies. Results for each domain of outcome varied depending on the level of data, and findings were not always significant. Analysis of the three groups of studies showed significantly shorter hospital stays after UKA than after TKA (-1.20 days (95% confidence interval -1.67 to -0.73), -1.43 (-1.53 to -1.33), and -1.73 (-2.30 to -1.16), respectively). There was no significant difference in pain, based on patient reported outcome measures (PROMs), but significantly better functional PROM scores for UKA than for TKA in both non-trial groups (mean difference -0.58 (-0.88 to -0.27) and -0.32 (-0.48 to -0.15), respectively). Regarding major complications, trials and cohort studies had non-significant results, but mortality after TKA was significantly higher in registry and large database studies (risk ratio 0.27 (0.16 to 0.45)), as were venous thromboembolic events (0.39 (0.27 to 0.57)) and major cardiac events (0.22 (0.06 to 0.86)). Early reoperation for any reason was higher after TKA than after UKA, but revision rates at five years remained higher for UKA in all three study groups (risk ratio 5.95 (1.29 to 27.59), 2.50 (1.77 to 3.54), and 3.13 (1.89 to 5.17), respectively).
TKA and UKA are both viable options for the treatment of isolated unicompartmental osteoarthritis. By directly comparing the two treatments, this study demonstrates better results for UKA in several outcome domains. However, the risk of revision surgery was lower for TKA. This information should be available to patients as part of the shared decision making process in choosing treatment options.
PROSPERO number CRD42018089972.
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.
We investigated the temporal trend and the geographical variation in the rate of an anterior cruciate ligament (ACL) reconstruction and meniscal repair (MR) performed in England during a 20-year ...window.
All hospital episodes for patients undergoing ACL reconstruction or MR between 1 April 1997 and 31 March 2017 were extracted by procedure code from the national hospital episode statistics. Age-standardised and sex-standardised rates of surgery were calculated using Office for National Statistics population data as the denominator and analysed over time both nationally and regionally by National Health Service clinical commissioning group (CCG).
Between 1997-1998 and 2016-2017, there were 133 270 cases of ACL reconstruction (124 489 patients) and 42 651 cases of MR (41 120 patients) (isolated or simultaneous). Nationally, the rate of ACL reconstruction increased 12-fold from 2.0/100K population (95% CI 1.9 to 2.1) in 1997-1998 to 24.2/100K (95% CI 23.8 to 24.6) in 2016-2017. The rate of MR increased more than twofold from 3.0/100K (95% CI 2.8 to 3.1) in 1997-1998 to 7.3/100K (95% CI 7.1 to 7.5) in 2016-2017. Of these cases, the rate of simultaneous ACL reconstruction and MR was 2.6/100K (95% CI 2.5 to 2.8) in 2016/2017. In 2016-2017, for patients aged 20-29, the sex-standardised rate of ACL reconstruction was 76.9/100K (95% CI 74.9 to 78.9) and for MR was 19.8/100K (95% CI 18.8 to 20.9). Practice varied by region-in 2016-2017, 14.5% (30/207) of the CCGs performed more than twice the national average rate of ACL reconstruction and 15.0% (31/207) performed more than twice the national average rate of MR.
The rate of ACL reconstruction (12-fold) and MR (2.4-fold) has increased in England over the last two decades. There is variation in these rates across geographical regions and further work is required to deliver standardised treatment guidance for appropriate use.
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.
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.
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.
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.
UK National Institute for Health Research.
To assess the benefit of arthroscopic partial meniscectomy (APM) in adults with a meniscal tear and knee pain in three defined populations (taking account of the comparison intervention): (A) all ...patients (any type of meniscal tear with or without radiographic osteoarthritis); (B) patients with any type of meniscal tear in a non-osteoarthritic knee; and (C) patients with an unstable meniscal tear in a non-osteoarthritic knee.
Systematic review and meta-analysis.
A search of MEDLINE, Embase, CENTRAL, Scopus, Web of Science, Clinicaltrials.gov and ISRCTN was performed, unlimited by language or publication date (inception to 18 October 2018).
Randomised controlled trials performed in adults with meniscal tears, comparing APM versus (1) non-surgical intervention; (2) pharmacological intervention; (3) surgical intervention; and (4) no intervention.
Ten trials were identified: seven compared with non-surgery, one pharmacological and two surgical. Findings were limited by small sample size, small number of trials and cross-over of participants to APM from comparator interventions. In group A (all patients) receiving APM versus non-surgical intervention (physiotherapy), at 6-12 months, there was a small mean improvement in knee pain (standardised mean difference SMD 0.22 95% CI 0.03 to 0.40; five trials, 943 patients; I
48%; Grading of Recommendations Assessment, Development and Evaluation GRADE: low), knee-specific quality of life (SMD 0.43 95% CI 0.10 to 0.75; three trials, 350 patients; I
56%; GRADE: low) and knee function (SMD 0.18 95% CI 0.04 to 0.33; six trials, 1050 patients; I
27%; GRADE: low). When the analysis was restricted to people without osteoarthritis (group B), there was a small to moderate improvement in knee pain (SMD 0.35 95% CI 0.04 to 0.66; three trials, 402 patients; I
58%; GRADE: very low), knee-specific quality of life (SMD 0.59 95% CI 0.11 to 1.07; two trials, 244 patients; I
71%; GRADE: low) and knee function (SMD 0.30 95% CI 0.06 to 0.53; four trials, 507 patients; I
44%; GRADE: very low). There was no improvement in knee pain, function or quality of life in patients receiving APM compared with placebo surgery at 6-12 months in group A or B (pain: SMD 0.08 95% CI -0.24 to 0.41; one trial, 146 patients; GRADE: low; function: SMD -0.08 95% CI -0.41 to 0.24; one trial, 146 patients; GRADE: high; quality of life: SMD 0.05 95% CI -0.27 to 0.38; one trial; 146 patients; GRADE: high). No trials were identified for people in group C.
Performing APM in all patients with knee pain and a meniscal tear is not appropriate, and surgical treatment should not be considered the first-line intervention. There may, however, be a small-to-moderate benefit from APM compared with physiotherapy for patients without osteoarthritis. No trial has been limited to patients failing non-operative treatment or patients with an unstable meniscal tear in a non-arthritic joint; research is needed to establish the value of APM in this population.
PROSPERO CRD42017056844.
The short-term and long-term consequences of septic arthritis are uncertain. We aimed to determine risk of mortality and adverse joint outcomes following septic arthritis of the native knee.
We did a ...retrospective cohort study in patients who received arthroscopic knee washout for septic arthritis in England between April 1, 1997, and March 31, 2017, using data in the national Hospital Episode Statistics database. Patients with previous knee surgery to the same knee were excluded. Mortality within 90 days, adverse joint outcomes (arthrodesis, amputation, arthroplasty) within 1 year, and arthroplasty within 15 years were determined. Mortality in patients with a primary admitting diagnosis of septic arthritis (ICD-10) was compared with that in patients in whom septic arthritis was a secondary diagnosis.
12 132 patients were included (mean age 56·6 years SD 24·9) of whom 4307 (36%) were female. In 10 195 (84%) patients with septic arthritis as the primary admitting diagnosis, 90-day mortality was 7·05% (95% CI 6·56–7·57; 719 patients), rising to 22·69% (20·80–24·68; 418 patients) in 1842 patients older than 79 years. Secondary septic arthritis diagnosis versus primary diagnosis was associated with an adjusted odds ratio for mortality of 2·10 (95% CI 1·79–2·46; p<0·0001). In 11 393 patients with at least 1 year follow-up, the 1 year rates were 0·13% (95% CI 0·07–0·22; 15 patients) for arthrodesis, 0·40% (0·30–0·54; 46 patients) for amputation, and 1·33%; (1·13–1·56; 152 patients) for arthroplasty. Within 15 years, 159 (8·76%; 95% CI 7·50–10·15) of 1816 patients had received arthroplasty, corresponding to an annual risk of arthroplasty that was about six times that of the general population (risk ratio 6·14, 95% CI 4·95–7·62; p<0·0001).
The consequences of septic knee arthritis in patients undergoing arthroscopic knee washout are serious. These findings highlight the potentially devastating outcomes associated with sepsis from musculoskeletal joint infection.
National Institute for Health Research.
We investigated trends and regional variation in the rate of arthroscopic knee surgery performed in England from 1997-1998 to 2016-2017.
Cross-sectional study of the national hospital episode ...statistics (HES) for England.
All hospital episodes for patients undergoing a knee arthroscopy between 1 April 1997 and 31 March 2017 were extracted from HES by procedure code. Age and sex-standardised rates of surgery were calculated using Office for National Statistic population data as the denominator. Trends in the rate of surgery were analysed by procedure both nationally and by Clinical Commissioning Group (CCG).
A total of 1 088 872 arthroscopic partial meniscectomies (APMs), 326 600 diagnostic arthroscopies, 308 618 knee washouts and 252 885 chondroplasties were identified (1 759 467 hospital admissions; 1 447 142 patients). The rate of APM increased from a low of 51/100 000 population (95% CI 51 to 52) in 1997-1998 to a peak at 149/100 000 (95% CI 148 to 150) in 2013-2014; then, after 2014-2015, rates declined to 120/100 000 (95% CI 119 to 121) in 2016-2017. Rates of arthroscopic knee washout and diagnostic arthroscopy declined steadily from 50/100 000 (95% CI 49 to 50) and 47/100 000 (95% CI 46 to 47) respectively in 1997-1998, to 4.8/100 000 (95% CI 4.6 to 5.0) and 8.1/100 000 (95% CI 7.9 to 8.3) in 2016-2017. Rates of chondroplasty have increased from a low of 3.2/100 000 (95% CI 3.0 to 3.3) in 1997-1998 to 51/100 000 (95% CI 50.6 to 51.7) in 2016-2017. Substantial regional and age-group variation in practice was detected. In 2016-2017, between 11% (22/207) and 16% (34/207) of CCGs performed at least double the national average rate of each procedure.
Over the last 20 years, and likely in response to new evidence, rates of arthroscopic knee washout and diagnostic arthroscopy have declined by up to 90%. APM rates increased about 130% overall but have declined recently. Rates of chondroplasty increased about 15-fold. There is significant variation in practice, but the appropriate population intervention rate for these procedures remains unknown.
The aim of this study was to investigate the clinical effectiveness of patella rim electrocautery “denervation” versus no denervation in patients undergoing total knee arthroplasty (TKA).
We ...conducted a single-center, double-blind randomized controlled trial. Patients aged 40 years or older, due to undergo a TKA who did not have patella resurfacing (usual care) were randomized with or without circumferential patella electrocautery. This was undertaken according to a randomly generated sequence of treatment allocation that was placed into numbered, sealed opaque envelopes. Participants were blinded to treatment allocation. There was no crossover. The primary outcome was Oxford Knee Score at 1 year postoperatively. Secondary outcomes were Bartlett Patella Score, Western Ontario and McMaster Universities Arthritis Index (WOMAC), and 12-Item Short Form Survey. Linear regression analyses were performed with adjustments by age, sex, and baseline (preoperative) scores. There were 142 participants recruited, of which 49 (35%) were allocated to the denervation intervention. Recruitment was stopped early when interim statistical analyses confirmed adequate numbers in both groups despite an imbalance in early treatment allocation rates due to the randomization method. The mean patient age was 71 years (range, 50 to 85) and 51% (n = 74) were women.
No difference in Oxford Knee Score was detected at 1 year (mean difference MD 1.87; 95% confidence interval CI −1.28 to 5.03). No difference was detected in Bartlett Patella Score (MD 0.490; 95% CI −1.61 to 2.59) or 12-Item Short Form Survey (MD 0.196; 95% CI −2.54 to 2.93). A statistically significant difference in WOMAC was detected, but at a level less than the minimal clinically important difference for WOMAC (MD 4.79; 95% CI 1.05 to 8.52).
No clinically relevant benefit was detected from patella rim electrocautery in patients undergoing TKA who did not have patella resurfacing (including no benefit in terms of anterior knee pain). This treatment is therefore not recommended for clinical practice.
Level 1.
The aim of this study was to determine the long-term risk of undergoing knee arthroplasty in a cohort of patients with meniscal tears who had undergone arthroscopic partial meniscectomy (APM).
A ...retrospective national cohort of patients with a history of isolated APM was identified over a 20-year period. Patients with prior surgery to the same knee were excluded. The primary outcome was knee arthroplasty. Hazard ratios (HRs) were adjusted by patient age, sex, year of APM, Charlson comorbidity index, regional deprivation, rurality, and ethnicity. Risk of arthroplasty in the index knee was compared with the patient's contralateral knee (with
without a history of APM). A total of 834 393 patients were included (mean age 50 years; 37% female).
Of those with at least 15 years of follow-up, 13.49% (16 256/120 493; 95% confidence interval (CI) 13.30 to 13.69) underwent subsequent arthroplasty within this time. In women, 22.07% (95% CI 21.64 to 22.51) underwent arthroplasty within 15 years compared with 9.91% of men (95% CI 9.71 to 10.12), corresponding to a risk ratio (RR) of 2.23 (95% CI 2.16 to 2.29). Relative to the general population, patients with a history of APM were over ten times more likely (RR 10.27; 95% CI 10.07 to 10.47) to undergo arthroplasty rising to almost 40 times more likely (RR 39.62; 95% CI 27.68 to 56.70) at a younger age (30 to 39 years). In patients with a history of APM in only one knee, the risk of arthroplasty in that knee was greatly elevated in comparison with the contralateral knee (no APM; HR 2.99; 95% CI 2.95 to 3.02).
Patients developing a meniscal tear undergoing APM are at greater risk of knee arthroplasty than the general population. This risk is three-times greater in the patient's affected knee than in the contralateral knee. Women in the cohort were at double the risk of progressing to knee arthroplasty compared with men. These important new reference data will inform shared decision making and enhance approaches to treatment, prevention, and clinical surveillance. Cite this article:
2019;101-B:1071-1080.
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