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  • Can even experienced orthopaedic surgeons predict who will benefit from surgery when patients present with degenerative meniscal tears? A survey of 194 orthopaedic surgeons who made 3880 predictions

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Original research
Can even experienced orthopaedic surgeons predict who will benefit from surgery when patients present with degenerative meniscal tears? A survey of 194 orthopaedic surgeons who made 3880 predictions
  1. Victor A van de Graaf1,2,
  2. Coen H Bloembergen MD1,3,
  3. Nienke W Willigenburg PhD1,
  4. Julia C A Noorduyn MSc1,
  5. Daniel BF Saris2,4,
  6. Ian A Harris5,6,
  7. Rudolf W Poolman1
  8. for the ESCAPE Research Group
  1. 1 Orthopaedic Surgery, Joint Research, OLVG, Amsterdam, The Netherlands
  2. 2 Orthopaedic Surgery, University Medical Centre, Utrecht, The Netherlands
  3. 3 Department of Orthopaedics, CORAL - Center for Orthopaedic Research Alkmaar, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
  4. 4 Orthopaedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
  5. 5 Injury and Rehabilitation Research Department, Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
  6. 6 Orthopaedic Department, South Western Sydney Local Health District, Liverpool Hospital, Liverpool, New South Wales, Australia
  1. Correspondence to Dr Victor A van de Graaf, Orthopaedic Surgery, Joint Research, OLVG, Oosterpark 9, 1091 AC, Amsterdam, The Netherlands; v.a.vandegraaf{at}olvg.nl

Abstract

Objectives To examine the ability of surgeons to predict the outcome of treatment for meniscal tears by arthroscopic partial meniscectomy (APM) and exercise therapy in middle-aged patients.

Design and setting Electronic survey. Orthopaedic surgeon survey participants were presented 20 patient profiles. These profiles were derived from a randomised clinical trial comparing APM with exercise therapy in middle-aged patients with symptomatic non-obstructive meniscal tears. From each treatment group (APM and exercise therapy), we selected five patients with the best (responders) and five patients with the worst (non-responders) knee function after treatment. 1111 orthopaedic surgeons and residents in the Netherlands and Australia were invited to participate in the survey.

Interventions For each of the 20 patient profiles, surgeons (unaware of treatment allocation) had to choose between APM and exercise therapy as preferred treatment and subsequently had to estimate the expected change in knee function for both treatments on a 5-point Likert Scale. Finally, surgeons were asked which patient characteristics affected their treatment choice.

Main outcomes The primary outcome was the surgeons’ percentage correct predictions. We also compared this percentage between experienced knee surgeons and other orthopaedic surgeons, and between treatment responders and non-responders.

Results We received 194 (17%) complete responses for all 20 patient profiles, resulting in 3880 predictions. Overall, 50.0% (95% CI 39.6% to 60.4%) of the predictions were correct, which equals the proportion expected by chance. Experienced knee surgeons were not better in predicting outcome than other orthopaedic surgeons (50.4% vs 49.5%, respectively; p=0.29). The percentage correct predictions was lower for patient profiles of non-responders (34%; 95% CI 21.3% to 46.6%) compared with responders (66.0%; 95% CI 57.0% to 75.0%; p=0.01).

In general, bucket handle tears, knee locking and failed non-operative treatment directed the surgeons’ choice towards APM, while higher level of osteoarthritis, degenerative aetiology and the absence of locking complaints directed the surgeons’ choice towards exercise therapy.

Conclusions Surgeons’ criteria for deciding that surgery was indicated did not pass statistical examination. This was true regardless of a surgeon’s experience. These results suggest that non-surgical management is appropriate as first-line therapy in middle-aged patients with symptomatic non-obstructive meniscal tears.

Clinical trial registration ClinicalTrials.gov Identifier: NCT03462134.

  • meniscus
  • knee
  • arthroscopic surgery
  • meniscal pathology
  • physiotherapy
http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bjsports-2019-100567

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    Footnotes

    • Correction notice This article has been corrected since it published Online First. Author names have been amended.

    • Collaborators Vanessa AB Scholtes, Eduard LAR Mutsaerts, Julius Wolkenfelt, Matthijs R Krijnen, Derek FP van Deurzen, Dirk Jan F Moojen, Ise K Butter, Arthur de Gast, Thom Snijders, Jelle J Halma, Nienke Wolterbeek, Camille Neeter, Gino MMJ Kerkhoffs, Rolf W Peters, Igor CJB van den Brand, Suzanne de Vos-Jakobs, Andy B Spoor, Taco Gosens, Wahid Rezaie, Dirk Jan Hofstee, Bart J Burger, Daniël Haverkamp, Anton MJS Vervest, Thijs A van Rheenen, Anne E Wijsbek, Ewoud RA van Arkel, Bregje JW Thomassen, Sheila Sprague, Ben W Mol, Maurits W van Tulder.

    • Contributors VG and CB equally contributed to this work. VG, CB and RP were co-chief investigators. VG, CB, NW, DS, IH and RP were involved in the design of the study and its implementation. VG, CB, NW, IH and RP designed the prespecified statistical analysis plan. The members of the ESCAPE Research Group were responsible for study progress of the ESCAPE Trial and data collection at site. VG, CB and NW did the statistical analyses. VG and CB wrote the first draft of the manuscript; NW, JN, DS, IH and RP made revisions. All authors and collaborators read and approved the final manuscript.

    • Funding This study was funded by the Netherlands Organisation for Health Research and Development (in Dutch: ZonMw; grant number 837002009), Zilverenkruis Health Insurance (grant number Z436) and the foundation of medical research of the OLVG, Amsterdam (grant number 15u.025). The funders had no role in design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. All authors had full access to all of the data in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis.

    • Competing interests VG, NW, JN, and RP received financial support from The Netherlands Organisation for Health Research and Development (in Dutch: ZonMw) for the submitted work; the Achmea Healthcare Foundation (in Dutch Stichting Achmea Gezonheidszorg fonds), and the foundation of medical research at the OLVG, Amsterdam, the Netherlands; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

    • Patient consent for publication Not required.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data availability statement Data are available upon request.