The most important finding of the present study was the agreement between expert and non-expert arthroscopic knee surgeons in most aspects of clinical care. This survey explored numerous aspects of the peri-operative and postoperative care of patients undergoing knee arthroscopy.
A consensus between polish orthopedists was reached in a preferential use of the regional anesthesia for knee arthroscopy. This is in agreement with world standards [20,21,22,23]. Regional anesthesia, in contrast to the general one, is a simple, safe technique, well accepted by patients and reducing hospital stay. Therefore experts and non-experts agreed on short duration of hospital stay after knee arthroscopy (1-2 days). Polish surgeons also agreed to no need for routine recommendation of using a knee orthosis, which is in agreement with previous studies, showing no beneficial effect of bracing after knee arthroscopy [24, 25] or even indirect prevention of ACL reruptures in case of rehabilitation without a knee brace .
Pain control after knee arthroscopy is an important aspect of the patient experience. In this survey all surgeons agreed that there is no need for intraarticular knee medications immediately after knee arthroscopy. This did not differ between the expert and non-expert surgeons. The presentation of pain is determined by the procedure of knee surgery and previous studies showed that a significant proportion of patients have only very mild or mild pain after knee arthroscopic procedures . Polish experts and non-experts are well-educated on pain control.
Current guidelines for thromboprophylaxis recommend the use of vitamin K antagonists (e.g. warfarin), low-molecular-weight heparins (LMW heparin) or aspirin [28,29,30]. Polish experts and non-experts agreed on the use of LMW heparin, following the recommendations regarding venous thromboembolism prevention in orthopedic surgery and traumatology developed by Polish orthopedic surgery experts under the auspices of the national consultant for orthopedic surgery and traumatology and the chairman of the Polish Society for Orthopedic Surgery and Traumatology .
Post-operative rehabilitation is crucial to achieve successful outcomes in patients undergoing knee arthroscopy . The surgeon plays a key role in educating the patient about the importance of post-surgical rehabilitation. Polish surgeons agreed that proper post-operative rehabilitation of the knee is essential for a return to active lifestyle. In our survey, 99% of the surgeons reported that they discussed the importance of compliance with the rehabilitation protocol with the patient. However, there is still a room for an improvement, since 1% of surgeons never recommends rehabilitation, 5% - rarely and 7% - only sometimes. Experts admitted that their patients comply with the rehabilitation protocol to high extend, in contrast to non-experts. This might be explained by greater authority of more experienced surgeons. Polish experts recommended starting rehabilitation already on the day of surgery. Surgeons from all over the world have increasingly emphasized early mobilization, which may produce favorable post-operative outcomes [33,34,35]. Most surgeons (92%) reported that they always recommended their patient a rehabilitation with a physiotherapist after knee arthroscopy, which is now considered as a gold standard and its effectiveness was showed by a number of control studies [36,37,38,39]. Expert surgeons did not use physical therapist as much as non-experts in making the decision on return to activity. This may be due to the newer surgeon being more conservative, relying on the physical therapist for another opinion. Evidence Based Medicine (EBM) does not exist in physical therapy, in contrary to the physiotherapy. In this survey experts and non-experts recommended a physical therapy less frequently (65%) than the rehabilitation with a physiotherapist (92%). More research is needed, and a consensus should be determined by the polish National Health Fund on recommendations of physical therapy after knee arthroscopy.
There is a lack of consensus regarding the optimal postoperative protocol following meniscal repair . Diverse treatment methods require individual and various rehabilitation approach, which is why individual cooperation between the physiotherapist and the patient is so important . Only 42% of polish surgeons recommend standardized rehabilitation and 86% confirm the dependence of rehabilitation program on performed procedure. Additional studies are needed to better clarify the interplay between tear type, repair method and optimal rehabilitation protocol.
Magnetic resonance imaging (MRI) is considered to be the most accurate method of imaging of the internal knee joint structure, with sensitivity in detecting medial meniscus lesions ranging from 83% to 94% [41,42,43]. The ESSKA European meniscus consensus group recommended using MRI when arthroscopy would be considered to identify concomitant pathologies . Magnetic resonance as a diagnostic test for meniscus damage was recommended by 97% orthopedists in this study. However, 50% of surgeons recommended ultrasounds as a diagnostic method and this should not be practiced, since it is not recommended by ESSKA European meniscus consensus group for traumatic nor degenerative damage. Experts and non-experts should be educated on this.
Surgical expertise was significantly associated with the performance of the reconstructive procedures, in comparison to the diagnostic arthroscopy performed more often by non-experts. Experts were significantly more likely to perform meniscus sewing procedures than non-experts, which are considered advanced and challenging techniques. The clinical experience of participating in this survey orthopedists was correlated with the using of newly established methods. Experts were deciding to use bone marrow cells, biomaterials or autologous adipose tissue as meniscus repair methods. All of these approaches that involve the use of cells and biomaterial scaffolds have gained an increasing attention as potential regenerative therapies in the field of musculoskeletal medicine very recently . Therefore the observation than non-experts are less frequently choosing these options could be explained with their less experience with new therapeutic options for patients, as they still gain experience with traditional meniscus treatment methods.
Non-expert surgeons less likely used objective physical tests, recommended longer period from meniscus suture to the full range knee motion and admitted that patient’s age does matter for meniscus repair qualification. All of these issues might be correlated with less experience.
Both expert and non-expert preferred to perform suturing of traumatic meniscus tears in 18-yeral old and 30-year old football player. That proves the willingness of meniscal repair and awareness of its role in knee arthritis prevention.
This study had limitations. The questionnaire included 35 questions, which is a prominent number and could cause a potential weariness and careless or ill-considered answers. However, during the pilot study the average time for competition did not exceed 10 minutes and it would be difficult to collect detailed information about the post-operative aspects of care with fewer questions. Defining the level of expertise at a cutoff of more than 100 arthroscopies performed per year could be considered a biased decision for this study. Further studies are required to demonstrate clinical comparisons or second-look arthroscopy outcomes.