205 participants were questioned by 5 hostesses. All survey forms were used for the analysis. Table 1 presents the educational background of the participating surgeons in the field of knee arthroscopy. 169 of 205 (82%) orthopaedists participated in a knee arthroscopy at early stages of their career (residency, specialization) more than 30 times. Only 8 participants (4%) had no contact with knee arthroscopy during their residency or specialization. 55 orthopaedists (28%) performed more than 100 knee arthroscopies per year independently and were classified as experts for this study. The remaining 150 orthopaedists (72%) performed up to 100 knee arthroscopies per year and therefore were classified as non-experts.
Table 1
Physician’s level of education and experience.
Participation in knee arthroscopy during residency or specialization | 0 cases: 4% (8/205) 1–30 cases: 14% (28/205) > 30 cases: 82% (169/205) |
Independent knee arthroscopies performed per year | 0–50 cases: 47% (98/205) 50–100 cases: 25% (52/205) > 100 cases: 28% (55/205) |
Independent knee arthroscopies performed during career | 0-500 cases: 62% (127/205) > 500 cases: 38% (78/205) |
Joints currently subjected to arthroscopy procedures | shoulder: 41% (83/205) elbow: 14% (28/205) wrist: 4% (9/205) spine: 0.5% (1/205) hip: 20% (41/205) knee: 98% (200/205) ankle: 40% (82/205) |
Most participating in the study orthopaedists were best trained in a knee arthroscopy (200 of 205, 98%), but a prominent number of them had additional expertise in shoulder (83 of 205, 41%) and ankle (82 of 205, 40%) arthroscopy .
In total, we have examined 55 expert orthopaedist who had performed > 100 knee arthroscopies per year and 150 non-expert orthopaedists who had performed 100 or fewer knee arthroscopies per year.
Considering anesthesia during arthroscopy, general anesthesia was reported by 12 (6%) orthopaedists in patients undergoing knee arthroscopy, a combined version of both, general and regional - by 21 (10%). The use of regional anesthesia (spinal/epidural) was favored and reported by 172 orthopaedists (84%, n.s.), of which 48 were experts (87% of experts) and 98 were non-experts (65% of non-experts). General anesthesia was used by 2 of 55 (3%) expert surgeons and 10 of 150 (6%) non-expert surgeons (n.s.). 5 experts (9%) and 14 (9%) non-experts reported combined anesthesia (n.s.).
The comparison between post-operative treatment is shown in Table 2. Only 13% orthopaedists recommended using an orthosis to their patients immediately after knee arthroscopy: 4 of 55 experts (7%) and 23 of 150 non-experts (15%).
Table 2
Postoperative treatment and hospital stay.
| | All (n = 205) | Experts (n = 55) | Non-experts (n = 150) | p value |
Orthosis | Yes No | 27 (13%) 178 (87%) | 4 (7%) 51 (93%) | 23 (15%) 127 (85%) | n.s. |
Knee drain | Yes No | 189 (92%) 16 (8%) | 50 (91%) 5 (9%) | 139 (72%) 11 (28%) | 0.012 |
Knee medications | Yes No | 22 (10%) 183 (90%) | 8 (15%) 47 (85%) | 10 (7%) 140 (93%) | n.s. |
Anti-thrombotic prophylaxis | Aspirin Heparin LMW heparin Other | 1 (1%) 8 (3%) 181 (88%) 3 (2%) 12 (6%) | 0 0 51 (94%) 0 4 (6%) | 1 (1%) 8 (5%) 130 (87%) 3 (2%) 8 (5%) | n.s. |
Hospitalization after non-reconstructive arthroscopy | Hours 1 day 2 days ≥3 days | 8 (4%) 160 (77%) 28 (14%) 9 (5%) | 4 (7%) 47 (85%) 4 (7%) 0 | 4 (3%) 113 (75%) 24 (15%) 9 (7%) | n.s. |
Hospitalization after reconstructive arthroscopy | Hours 1 day 2 days ≥3 day | 3 (2%) 81 (39%) 90 (44%) 22 (15%) | 1 (1%) 29 (52%) 17 (31%) 0 | 2 (1%) 52 (35%) 73 (49%) 22 (14%) | n.s. |
p value is presented to establish statistical significance between expert and non-expert treatment. n.s. – not significant, LMW heparin – low molecular weight heparin. |
There was a statistically significant difference observed in knee drain usage between experts and non-experts: 9% of experts and 28% of non-experts did not recommend using a knee drains (p = 0.012).
Only 10% of orthopaedists admitted that they administer knee medications immediately after arthroscopy: 15% of experts and 7% of non-experts. The most commonly reported pain medications used in the first 24 h after surgery were local anaesthetic drugs belonging to the amino amide group (8), hyaluronic acid (7 cases), platelet rich plasma (1 case), steroids (1 case), antibiotics (1 case), pain killers (1 case), levonor (1) or morphine (2 cases).
Experts and non-experts answered almost equally when asked about anti-thrombotic prophylaxis administered to the patients. Low molecular weight heparin was recommended by 88% of surgeons after the patient was discharged: 94% of experts and 87% of non-experts.
Both, knee arthroscopy experts (85%) and non-experts (75%) recommended one day of hospitalization after non- reconstructive arthroscopy, rather than shorter (few hours) or longer period (more than one day). However, 1 or 2 days of hospitalization were most frequently recommended after reconstructive arthroscopy: 52% of experts and 32% of non-experts recommended 1 day, 31% of experts and 49% of non-experts recommended 2 day-long hospitalization.
Comparisons of rehabilitation recommendations are shown in Table 3. 135 surgeons (64%) reported that they always recommend rehabilitation (excluding physical therapy) and 99% (203) discuss with the patient about the importance of rehabilitation. There was a statistically significant difference noticed (p = 0.032) when surgeons were asked about their patients’ compliance with the rehabilitation program. 85% of experts and 75% of non-experts admitted their patients being compliant with the protocol.
Table 3
Post-surgical rehabilitation.
| | All (n = 205) | Experts (n = 55) | Non-experts (n = 150) | p value |
Rehabilitation recommendation | Never Rarely Sometimes Mostly Always Depends | 1 (1%) 7 (4%) 10 (5%) 43 (21%) 135 (64%) 9 (5%) | 0 0 0 8 (14%) 41 (75%) 6 (11%) | 1 (1%) 7 (5%) 10 (7%) 35 (23%) 94 (63%) 3 (1%) | n.s. |
Patient compliance | Rarely Sometimes Mostly Always | 48 (23%) 122 (60%) 28 (14%) 6 (3%) | 11 (20%) 30 (55%) 12 (22%) 6 (11%) | 37 (25%) 92 (61%) 16 (14%) 0 | 0.032 |
Talk about the need for rehabilitation | Yes No | 203 (99%) 2 (1%) | 55 (100%) 0 | 148 (99% 2 (1%) | n.s. |
Beginning of rehabilitation | Day of surgery 1 day after 2 days after 3d-1week after 1-2weeks after > 2weeks after | 22 (11%) 124 (60%) 14 (7%) 22 (11%) 18 (9%) 4 (2%) | 14 (25%) 33 (60%) 3 (6%) 2 (3%) 3 (6%) 0 | 8 (5%) 91 (61%) 11 (8%) 20 (14%) 15 (10%) 4 (2%) | 0.007 |
Standardized rehabilitation | Yes No | 84 (42%) 120 (58%) | 21 (38%) 34 (62%) | 63 (43%) 86 (57%) | n.s. |
Dependence of rehabilitation program on performed procedure | Yes No | 176 (86%) 28 (14%) | 47 (85%) 8 (15%) | 129 (63%) 75 (37%) | n.s. |
Physiotherapist | Yes No | 189 (92%) 16 (8%) | 49 (89%) 6 (11%) | 140 (93%) 10 (7%) | n.s. |
Cryotherapy | Yes No | 158 (77%) 46 (23%) | 45 (82%) 10 (8%) | 113 (75%) 91 (25%) | n.s. |
Physical therapy *multiple answers allowed | Yes No Lasertherapy Magnetotherapy Ultrasounds Solux lamps Ionophoresis Galvanization Diadynamics TENS Other | 133 (65%) 72 (35%) 69 (34%) 71 (34%) 58 (28%) 7 (3%) 39 (19%) 0 0 38 (19%) 7 (3%) | 29 (53%) 26 (47%) 16 (29%) 18 (32%) 7 (13%) 0 8 (14%) 0 0 7 (13%) 0 | 104 (69%) 46 (31%) 53 (35%) 53 (35%) 51 (34%) 7 (5%) 31 (20%) 0 0 31 (20%) 7 (5%) | n.s. |
p value is presented to establish statistical significance between expert and non-expert treatment. n.s. – not significant. |
124 (60%) of the physicians, experts and non-experts, recommended beginning rehabilitation within one day after the surgery. However, knee arthroscopy experts frequently recommended the beginning of the rehabilitation procedure at the day of surgery (14 of 55 experts, 25%, p = 0.007). In contrast, only 8 out of 149 non-expert were choosing this option (5%).
A standardized rehabilitation protocol was recommended by 84 surgeons (42%). 176 surgeons (86%) reported that the rehabilitation protocol was dependent on procedures performed. 189 surgeons (92%) reported that the physical therapist was the key person responsible for patient rehabilitation. Cryotherapy was a preferred option of rehabilitation by 77% orthopaedists (42 experts and 113 non-experts) and physical therapy – by 65% (133 orthopaedists). Within this group, lasertherapy and magnetotherapy were most frequently used.
Table 4 shows the factors considered when recommending return to sport by patients which underwent knee arthroscopy procedure. In most cases either surgeon or surgeon together with a physical therapist were responsible for the decision whether a patient is ready to return to sport. The most important factor in a decision process was a functional state of the patient (93% of experts and 74% non-experts, p = 0.002). Objective measurements were used to aid in the decision to return to sport by 159 (78%) surgeons. Objective physical tests were reported to be significantly more involved in the decision about the patient’s return to activity in the case of experts compared to non-expert surgeons (p = 0.003). Among them, functional tests were significantly preferred by experts than non-experts (p = 0.006).
Table 4
| | All (n = 205) | Experts (n = 55) | Non-experts (n = 150) | p value |
Decision making *multiple answers allowed | Surgeon Physical therapist Surgeon and physical therapist Patient | 77 (37%) 3 (2%) 87 (42%) 7 (3%) | 23 (45%) 1 (1%) 30 (54%) 1(1%) | 54 (36%) 2 (1%) 57 (38%) 6 (4%) | n.s. |
Criteria of decision *multiple answers allowed | Time No discomfort Functional state Correct image in examination | 72 (35%) 86 (42%) 162 (80%) 39 (19%) | 24 (44%) 19 (34%) 51 (93%) 12 (22%) | 48 (32%) 67 (45%) 111 (74%) 27 (18%) | 0.002 |
Objective physical tests *multiple answers allowed | Yes No Dynamometer Functional tests Survey | 159 (78%) 56 (22%) 58 (28%) 119 (58%) 35 (17%) | 50 (91%) 5 (9%) 22 (40%) 44 (80%) 11 (20%) | 109 (66%) 51 (34%) 36 (24%) 75 (50%) 24 (16%) | 0.003 0.006 |
p value is presented to establish statistical significance between expert and non-expert treatment. n.s. – not significant. |
The arthroscopic procedures used by experts were as follows (Table 5 and Fig. 1): ACL reconstruction (100%), meniscus suturing all inside (96%) and meniscus removal (93%). Non-experts had significantly less experience with these procedures: ACL reconstruction was reported by 81% non-experts, meniscus suturing all inside by 79% and meniscus removal by 81% (p < 0.0001).
Table 5
| | All (n = 205) | Experts (n = 55) | Non-experts (n = 150) | p value |
Procedures used *multiple answers allowed | Diagnostic arthroscopy Synovial folds removal Meniscus removal Meniscus suturing all inside Meniscus suturing inside-out/outside-in Meniscus transplant Ramp lesion repair Microfractures Cartilage reconstruction ACL reconstruction PCL reconstruction Simultaneous multi-ligament reconstruction Pediatric multi-ligament reconstruction | 119 (58%) 164 (80%) 173 (84%) 171 (83%) 161 (79%) 32 (16%) 66 (32%) 170 (83%) 99 (48%) 177 (86%) 66 (32%) 76 (37%) 36 (18%) | 25 (45%) 40 (73%) 51 (93%) 53 (96%) 48 (87%) 17 (31%) 30 (55%) 49 (89%) 41 (75%) 55 (100%) 32 (58%) 33 (60%) 18 (33%) | 94 (63%) 124 (83%) 122 (81%) 118 (79%) 113 (75%) 15 (10%) 36 (24%) 121 (81%) 58 (39%) 122 (81%) 34 (23%) 43 (29%) 18 (12%) | < 0.0001 |
Procedures performed most frequently *multiple answers allowed | Diagnostic arthroscopy Synovial folds removal Meniscus removal Meniscus suturing Meniscus transplant Microfractures Cartilage reconstruction ACL reconstruction Simultaneous multi-ligament reconstruction Pediatric multi-ligament reconstruction | 24 (12%) 15 (7%) 47 (23%) 45 (22%) 1 (1%) 7 (3%) 1 (1%) 44 (21%) 2 (1%) 3 (1%) | 3 (5%) 2 (4%) 10 (18%) 21 (38%) 0 2 (4%) 1 (2%) 9 (16%) 0 2 (4%) | 21 (14%) 13 (9%) 37 (25%) 25 (17%) 1 (1%) 5 (3%) 0 35 (23%) 2 (1%) 1 (1%) | 0.009 |
Meniscus repair methods used *multiple answers allowed | Suturing all inside Suturing inside-out Suturing outside-out Scarification PRP BMC AAT Biomaterials | 164 (80%) 132 (64%) 105 (51%) 68 (33%) 48 (23%) 13 (6%) 6 (3%) 12 (6%) | 47 (85%) 44 (80%) 34 (62%) 21 (38%) 19 (35%) 11 (20%) 4 (7%) 7 (13%) | 117 (78%) 88 (59%) 71 (47%) 47 (31%) 29 (19%) 2 (1%) 2 (1%) 5 (3%) | 0.001 |
Diagnostic methods *multiple answers allowed | None X-ray USG MR Other | 1 (1%) 28 (14%) 101 (49%) 200 (98%) 2 (1%) | 1 (2%) 7 (13%) 28 (51%) 54 (98%) 1 (2%) | 0 21 (14%) 73 (49%) 146 (97%) 1 (1%) | n.s. |
p value is presented to establish statistical significance between expert and non-expert treatment. n.s. – not significant. PRP – platelet rich plasma, BMC – bone marrow cells, AAT – autologous adipose tissue. |
Experts mostly performed meniscus suturing (38%), non-experts – meniscus removal (25%), p = 0.009 (Table 5 and Fig. 2).
When it comes to meniscus repair methods (Table 5 and Fig. 3), experts were performing significantly more suturing methods than non-experts (p = 0.001). Bone marrow cells were used almost mostly by experts (11 out of 55 experts, 20%) and only 1 non-expert. Similar trend was observed in biomaterials usage (7 experts – 13% and 5 non-experts – 3%) and autologous adipose tissue usage (4 experts – 7% and only 2 non-experts – 1%).
Diagnostic tests used by experts when meniscus tear was suspected in their patients were the same as chosen by non-experts (Table 5 and Fig. 4). Both, experts and non-experts agreed that magnetic resonance was their preferred diagnostic method. Ultrasounds were used by ~ 50% of experts and non-experts. X-ray method was the least frequently used.
Both, experts and non-experts recommended similar time of using elbow crutches after meniscus removal (2 weeks) or orthosis after meniscus suture (6 weeks). The answers were however different when surgeons were asked about how soon after meniscus sewing they recommend a full range of knee motion (Table 6 and Fig. 5). Experts recommendation was 4 weeks and non-experts – 6 weeks (p = 0.001).
Table 6
Post-arthroscopic procedures.
| | All (n = 205) | Experts (n = 55) | Non-experts (n = 150) | p value |
Elbow crutches usage after meniscus removal | No 1–6 days 1 week 2 weeks 3 weeks 4 weeks 6 weeks Other | 20 (10%) 34 (17%) 23 (11%) 57 (28%) 5 (2%) 22 (11%) 17 (8%) 17 (8%) | 9 (16%) 11 (20%) 7 (13%) 13 (24%) 2 (3%) 4 (7%) 4 (7%) 5 (10%) | 11 (7%) 23 (15%) 16 (11%) 54 (36%) 3 (2%) 18 (11%) 13 (8%) 12 (7%) | n.s. |
Orthosis usage after meniscal repair | No 1–6 days 1 week 2 weeks 3 weeks 4 weeks 5 weeks 6 weeks 8 weeks Other | 24 (12%) 3 (2%) 4 (2%) 19 (10%) 14 (7%) 43 (21%) 6 ( 4%) 70 (34%) 3 (2%) 13 (6%) | 6 (10%) 0 0 3 (5%) 5 (10%) 15 (27%) 0 19 (35%) 1 (2%) 6 (10%) | 18 (11%) 3 (2%) 4 (2%) 16 (10%) 9 (6%) 28 (19%) 6 (3%) 51 (30%) 3 (2%) 12 (8%) | n.s. |
Time since meniscus suture to recommendation of a full range knee motion | 1–6 days 1 week 2 weeks 3 weeks 4 weeks 5 weeks 6 weeks 7 weeks 8 weeks Other | 11 (5%) 5 (2%) 14 (7%) 14 (7%) 48 (24%) 5 (2%) 79 (39%) 1 (1%) 15 (7%) 12 (6%) | 1 (2%) 1 (2%) 4 (7%) 2 (4%) 18 (33%) 1 (2%) 19 (34%) 1 (2%) 3 (5%) 5 (9%) | 10 (7%) 4 (3%) 10 (7%) 12 (8%) 30 (20%) 4 (3%) 60 (40%) 1 (1%) 12 (8%) 7 (3%) | 0.001 |
Consideration whether to remove or repair meniscus | Patient’s age Time since injury Physical activity Damage type Damage zone Damage MR Accompanying damage | 151 (74%) 118 (58%) 105 (51%) 175 (85%) 167 (76%) 44 (23%) 75 (36%) | 37 (67%) 30 (54%) 24 (44%) 50 (91%) 46 (84%) 14 (25%) 22 (40%) | 114 (76%) 88 (59%) 81 (54%) 125 (83%) 121 (82%) 30 (20%) 53 (35%) | n.s. |
Patient’s age for meniscus repair qualification | < 20 y.o. < 30 y.o. < 40 y.o. < 50 y.o. < 60 y.o. < 70 y.o. Does not matter | 3 (2%) 14 (7%) 34 (16%) 45 (22%) 23 (11%) 0 86 (42%) | 0 2 (4%) 10 (18%) 10 (18%) 2 (4%) 0 31 (56%) | 3 (2%) 12 (8%) 24 (16%) 35 (23%) 21 (14%) 0 55 (36%) | 0.002 |
p value is presented to establish statistical significance between expert and non-expert treatment. n.s. – not significant. |
Both, experts and non-experts named similar factors when they considered whether to remove or to repair meniscus - damage type and zone. They also selected patient’s age, however experts stated that age does not matter when they consider for meniscus repair qualifications significantly more frequently than non-experts (Table 6 and Fig. 6, p = 0.002).
Surgeons were also asked about patient’s sport discipline influence on to repair or to remove decision. 103 orthopaedist: 23 experts (42%) and 80 non-experts (54%) admitted taking into consideration a discipline.
At the end of the first part of the survey participating orthopaedist were asked about their preferred procedure in case of traumatic meniscus tear in an 18-year-old or 30-year-old professional football player. 179 orthopaedists decided to repair the damaged part of the meniscus in an 18-year-old patient: 53 experts (97%) and 126 non-experts (84%). Similarly, 166 surgeons decided to repair the damaged part of the meniscus in an 30-year-old patient: 44 experts (80%) and 122 non-experts (81%).
Summarizing the results from the survey, we have noticed a consensus in the following areas of knee arthroscopy:
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regional anesthesia used for knee arthroscopy - reported by 84% orthopaedists,
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no need for using a knee orthosis – reported by 87% orthopaedists,
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no need for knee medications immediately after arthroscopy –by 89% orthopaedists,
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low molecular weight heparine as thromboprophylaxis after knee arthroscopy − 90% orthopaedists,
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1 day duration of hospital stay after non-reconstructive knee arthroscopy − 78% orthopaedists,
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1–2 days duration of hospital stay after reconstructive knee arthroscopy − 87% orthopaedists,
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recommendation of rehabilitation − 85% of surgeons,
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talking with the patient about the need of postoperative rehabilitation − 99% orthopaedists,
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dependence of rehabilitation program on procedures performed – 86% orthopaedists,
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recommendation of rehabilitation with a physiotherapist- 92% orthopaedists,
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magnetic resonance as a diagnostic test for meniscus damage − 97% orthopaedists,
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repair as preferred procedure in case of meniscus damage in an 18-year-old professional footballer − 87% orthopaedists,
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repair as preferred procedure in case of meniscus damage in an 30-year-old professional footballer − 81% orthopaedists.