Trends in meniscus surgery by patient age and societal changes in Korea from 2010 to 2020

doi:10.21203/rs.3.rs-2579791/v1

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Trends in meniscus surgery by patient age and societal changes in Korea from 2010 to 2020

https://doi.org/10.21203/rs.3.rs-2579791/v1

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Background

Surgery related to the meniscus can be divided into three categories: meniscectomy, meniscal repair and meniscus allograft transplantation (MAT). Meniscus injury is closely related to osteoarthritis, and the patient's age affects the choice of surgical method. As Korean society is rapidly changing into an aging society, the trend of meniscus treatment is expected to change according to the change in age structure.

Methods

This study analyzed longitudinal trends in meniscus surgery (e.g., meniscectomy, meniscal repair, and MAT) in Korea from 2010 to 2020 according to age distribution, hospital size, and region. Data were collected from the Korean Statistical Information Service and the Korean Health Insurance Review and Assessment Service.

Results

During the 2010–2020 study period, the rate of MAT per 1,000,000 people increased from 7.206 to 10.303 (time trend = 1.05; 95% confidence interval [CI]: 1.01–1.10, p = 0.025). The rate of meniscus repair per 1,000,000 people increased from 179.251 to 331.031 (time trend = 1.054; 95% CI: 1.04–1.07; P < 0.001). The rate of meniscectomy per 1,000,000 people decreased from 1301.616 to 1243.763, but the difference was not statistically significant (time trend = 0.991; 95% CI: 0.975–1.006, p = 0.260).

Conclusions

The number of patients presenting for MAT increased during the study period; it significantly increased among individuals aged 10–19 years and 50–59 years. The overall rate of meniscus repair increased; the increase was greatest in general hospitals and orthopedic surgery clinics. The overall rate of meniscectomy did not significantly increase or decrease, although the rate tended to decrease in tertiary hospitals and Seoul.

Meniscus

meniscal repair

meniscus allograft transplantation

trends

national trend

Korea

The meniscus is one of the most injured structures in the knee,¹⁾ and the surgery related to meniscus is the most common surgery performed on the knee.²⁾ The three main categories of knee surgery related to the meniscus are meniscectomy, meniscal repair, and meniscus allograft transplantation (MAT).³⁾

Meniscectomy disrupts the circumferential fibers and may eventually increase contact stress in the knee joint; this can lead to osteoarthritis because it is difficult to effectively control hoop stress.⁴⁾ Patient age affects the surgical method for management of meniscus injury, and meniscus repair is preferred over meniscectomy if possible.⁵⁾ MAT is indicated to restore function and prevent osteoarthritis in patients who have undergone partial meniscectomy or total meniscectomy.^6–8) Therefore, the rate of MAT may be associated with the rate of meniscectomy, as well as various demographic factors.

Korea has a rapidly aging and changing population structure.⁹⁾ There is a need to predict future rates of meniscus surgery on the basis of current national trends and epidemiological factors. Moreover, demographic disparity in the Korean population is increasing, such that approximately half of the total population lives in metropolitan areas (e.g., Seoul and Gyeonggi-do), whereas the rural population is decreasing.^10,11) Additionally, regional changes in domestic orthopedic surgery are occurring with the expansion of orthopedic joint specialty hospitals.¹²⁾ Thus, there is a need to assess current trends in meniscus surgery according to changes in these sociodemographic factors.

The Korean Health Insurance Review and Assessment Service (HIRA) database is among the most accurate national data sources worldwide because it contains medical records of the entire population and is maintained by the Korean government.¹³⁾ Therefore, current trends in meniscus surgery can be assessed with general accuracy and future trends can be predicted using this database. This study used the HIRA database to analyze longitudinal trends in meniscus surgery (e.g., meniscectomy, meniscus repair, and MAT) in Korea from 2010 to 2020 according to changes in age distribution, hospital size, and region.

This study does not require institutional review board approval and informed consent because it does not involve human subjects (SCHUH 2023-01-011).

Data collection

All patients’ medical records are included in the Korean HIRA database.³⁾ There, surgical procedure codes in Korea area mostly recorded in HIRA format. We collected and analyzed data related to procedure codes for meniscectomy, meniscus repair, and MAT in Korea from 2010 to 2020.

Since 2014, meniscus surgery (meniscectomy, meniscus repair, and MAT) procedures in the HIRA database have been divided according to complexity. From 2014 to 2020, simple and complex were combined to calculate the total number of surgeries. MAT codes were simple MAT (N0825) and complex MAT (N0820). Meniscectomy and meniscus repair were divided into “medial or lateral”; simultaneous procedures were classified as “medial and lateral”. There are several surgery codes for meniscectomy including simple meniscectomy in the medial or lateral compartment (N0821), complex meniscectomy in the medial or lateral compartment (N0826), simple meniscectomy in both medial and lateral compartments (N0822), and complex meniscectomy in both medial and lateral compartments (N0827). There are several surgery codes for meniscus repair, including simple meniscus repair in the medial or lateral compartment (N0823), complex meniscus repair in the medial or lateral compartment (N0828), simple meniscus repair in both medial and lateral compartments (N0824), and complex meniscus repair in both medial and lateral compartments (N0829).

The total number of cases per year and the incidence of meniscus surgery per 1,000,000 person-years were investigated. Subsequently, detailed analyses were performed according to age, hospital size, and region. The incidence per 1,000,000 person-years was determined using information from the Korean Statistical Information Service (KOSIS, Sitemap, Seoul, Korea) for the period from 2010 to 2020 (Table 1).

Table 1

Codes for MAT, meniscus repair, and meniscectomy in the HIRA database
Surgery category	Complexity	Location	Code
MAT	Simple		N0825
MAT	Complex		N0820
Meniscus repair	Simple	Medial or lateral	N0823
	Simple	Medial and lateral	N0824
	Complex	Medial or lateral	N0828
	Complex	Medial and lateral	N0829
Meniscectomy	Simple	Medial or lateral	N0821
	Simple	Medial and lateral	N0822
	Complex	Medial or lateral	N0826
	Complex	Medial and lateral	N0827

Statistical analysis

An annual estimate of the cumulative patients was conducted. All results were approximated based on the formula number of patients (for the year) x 1,000,000/total population (for the year). The primary outcomes were prevalence trends per year and the associations (if any) of age, hospital size, and region with distinct patterns. The age groups were divided into 10-year increments, and patients aged > 80 years were grouped into one group. Hospitals were classified as tertiary referral centers (university hospitals with approved residency programs), general hospitals (hospitals that have medical departments but lack residency programs), or orthopedic surgery clinics (institutions that specialize in orthopedic surgery and lack other medical departments). Three geographic areas were defined: Seoul, Gyeonggi-do, and other regions. Data were processed using Poisson regression analysis. The effect size of the general time trend was calculated with respect to the rate of patients per year. Potential intergroup discrepancies divided according to age, hospital size, and region were investigated in a time trend based on integration of the interactive effect into the reference group. The results are presented as incidence rate ratios and 95% confidence intervals (CIs); age, hospital size, and region were used to characterize rates per 1,000,000 population. All statistical tests were two-sided, and p-values < 0.05 were considered statistically significant. R software version 3.6.3 (R Foundation for Statistical Computing, Vienna, Austria) was used for data analysis.

Meniscus allograft transplantation

From 2010 to 2020, the rate of MAT per 1,000,000 people increased from 7.206 to 10.303 (time trend = 1.05; 95% CI: 1.01–1.10, p = 0.025) (Fig. 1A). The numbers of patients aged < 10 years and > 70 years were excluded from the year × age model. Excluding patients aged 20–29 years, the overall number of patients increased, but significant increases were only observed among patients aged 10–19 years and 50–59 years (Fig. 2A). The change in annual trend according to hospital size was not statistically significant (Fig. 3A), but there as a significant increase in the Gyeonggi-do region (time trend = 1.157; 95% CI: 1.081–1.239) (Fig. 4A).

Meniscus repair

From 2010 to 2020, the rate of meniscus repair per 1,000,000 people increased from 179.251 to 331.031 (time trend = 1.054; 95% CI: 1.04–1.07; p < 0.001) (Fig. 1B). No difference in slope was detected in the year × age model, and the number of patients increased in all age groups; however, when patients were stratified according to age group, there were no significant increase (Fig. 2B). The year × hospital model showed no significant trend in the number of patients at tertiary referral center, but general hospitals (time trend = 1.067; 95% CI 1.019–1.082) and orthopedic surgery clinics (time trend = 1.050; 95% CI: 1.019–1.082) exhibited increasing numbers of patients (Fig. 3B). The year × region model revealed an increasing trend in all regions, and each region exhibited a significant increase; however, regional differences in slope increase were not statistically significant (Fig. 4B).

Meniscectomy

From 2010 to 2020, the rate of meniscectomy per 1,000,000 people decreased from 1301.616 to 1243.763, but the difference was not statistically significant (time trend = 0.991; 95% CI 0.975–1.006, p = 0.260) (Fig. 1C). Although the year × age model revealed a decreasing trend in all age groups, none of the differences were statistically significant (Fig. 2C). The year × hospital model showed that the change in annual trend according to hospital size significantly decreased in tertiary referral centers (time trend = 0.956; 95% Cl: 0.917–0.997; P = 0.043). When tertiary hospitals were used as the reference, there was a significant difference in slope between tertiary referral centers and general hospitals, but there was no significant change in annual trend among general hospitals or orthopedic surgery clinics (Fig. 3C). The year × region model revealed a significant decrease in Seoul (time trend = 0.961; 95% Cl: 0.943–0.981; p-value = 0.001), compared with other regions. The other regions exhibited a significantly smaller decrease in slope, and the number of patients did not decrease (Fig. 4C).

Kim et al.¹²⁾ reported that the societal aging problem is more severe in Korea than in most other Organization for Economic Cooperation and Development member countries; Korea is expected to experience structural changes in terms of age distribution. Additionally, there are regional differences in medical access and hospital-level inconsistencies in Korea; thus there have been efforts to elucidate the epidemiology of total knee replacement arthroplasty in Korea. Trends in meniscus surgery have been evaluated in the United States and Japan.^14–16) A trend toward an increased rate of meniscus surgery has been reported in Korea.^3,13) To our knowledge, the present study is the first to analyze MAT, meniscal repair, and meniscectomy; it revealed significant differences according to region, hospital size, and age.

Chung et al. reported that the total number of MAT procedures in Korea increased by 124% from 2010 to 2017.¹³⁾ Similarly, we found that the overall number of patients who underwent MAT increased until 2017, then decreased. Because Korea has a nationwide national health insurance system, it is important to apply for insurance coverage for each surgery as determined by the government. The MAT insurance application criteria changed on September 1, 2016, and the following additional guidance was provided: “the conservative treatment period is 1 year for medial meniscus and 6 months for lateral meniscus after total meniscectomy or subtotal meniscectomy in principle.” Because the number of patients has decreased, the change in MAT insurance coverage may have had an impact.

Jacquet et al. reported that the rate of meniscectomy decreased from 19.80/10,000 inhabitants to 15.77/10,000 inhabitants between 2005 and 2017 in France, whereas the rate of meniscus repair increased from 0.42/10,000 inhabitants to 1.36/10,000 inhabitants.¹⁷⁾ In Korea, the rate of meniscus repair per 1,000,000 people increased from 179.251 to 331.031 (time trend = 1.054; 95% Cl: 1.04–1.07; P < 0.05); the rate of meniscectomy per 1,000,000 people decreased from 1301.616 to 1243.763, but the difference was not statistically significant (time trend = 0.991; 95% CI: 0.975–1.006; P = 0.260). However, the numbers of meniscectomy patients in tertiary referral centers and Seoul area significantly decreased during the study period.

Chung et al. defined the meniscus repair ratio as (number of meniscus repairs) / (total number of meniscus repairs + numbers of meniscectomies); they reported that the meniscus repair ratio increased from 12.1–16.8% during the period from 2010 to 2017.³⁾ Our analysis showed that the meniscus repair ratio steadily increased from 2010 to 2020. When the rates of meniscus repair and meniscectomy were stratified according to hospital size, tertiary referral centers exhibited a considerably higher meniscus repair ratio, compared with hospitals of other sizes (Fig. 5).

In Seoul, the rate of each meniscus repair surgery relative to the population in each region was high for all three surgeries. The rates of MAT and meniscal repair were stable, but the rate of meniscectomy decreased. Patients from other regions often undergo surgery at hospitals in Seoul; this trend has persisted for MAT and meniscal repair surgeries, indicating that patients continue to prefer Seoul hospitals for surgery.

Despite the importance of the findings, this study had some limitations. First, coding errors may have been present in the large database used for this study. Second, patients in our analysis did not include individuals injured in traffic accidents or industrial accidents. Third, the comparisons in this study were made based on a limited number of patients. However, both knees may be affected in patients with a meniscus tear. Fourth, the most accurate method for measuring rates according to hospital size involves dividing the number of patients who underwent surgery by the number of patients who visited the hospital; however, we could not determine the number of patients who visited the hospital. Accordingly, we used the total population as the denominator, which may have influenced the findings. Finally the Korean Institute for Healthcare Accreditation regularly conducts medical institution certification evaluations to determine hospital grade, the factor used in our analysis of hospital size. The grades of some medical institutions were modified because of certification-related changes between 2010 and 2020, which may have led to bias in our results.

This study analyzed trends in meniscus surgery in Korea from 2010 to 2020. The number of patients presenting for MAT increased during the study period; it significantly increased among individuals aged 10–19 years and 50–59 years. The overall rate of meniscus repair increased, the increase was greatest in general hospitals and orthopedic surgery clinics. The overall rate of meniscectomy did not significantly increase or decrease, although the rate tended to decrease in tertiary hospitals and Seoul.

MAT : meniscus allograft transplantation

HIRA : Health Insurance Review and Assessment Service

KOSIS : Korean Statistical Information Service

Disclaimer: The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

Ethics approval and consent to participate

Not applicable

Consent for publication

Not applicable

Availability of data and materials

The data area distributed to registered users through the official website of HIRA Healthcare Bigdata Hub (Https://opendata.hira.or.kr/home.do, accessed on 24 February 2022). After the evaluation of a research proposal by the HIRA review committee, registered users can receive special access privileges to the data.

Competing interests

The authors declare that they have no competing interests.

Funding

This work was supported by the Soonchunhyang University Research Fund. Funding bodies did not play a role in the collection, analysis, or interpretation of data, and did not contribute to the writing of this manuscript. The funding bodies supported the cost of correcting the English in this paper.

Author contributions

All authors have read and approved the manuscript. (1) Conceiving and designing the study, collecting and analyzing the data: GWS, JK. (2) Statistical analysis and correction: SP (3) Approving the final version to be submitted: HSC, YBK

Acknowledgement

Not applicable

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No competing interests reported.

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Trends in meniscus surgery by patient age and societal changes in Korea from 2010 to 2020

Status:

Version 1

Abstract

Background

Methods

Results

Conclusions

Figures

Background

Methods

Data collection

Statistical analysis

Result

Meniscus allograft transplantation

Meniscus repair

Meniscectomy

Discussion

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1