• Hip and knee surgery

The overall aim of this PhD thesis was to report the incidence of meniscus surgery and symptoms reported by middle-aged patients with degenerative meniscus tears eligible for surgery and to report the study design and process of a placebo-controlled trial evaluating the outcome of middle-aged patients undergoing arthroscopic partial meniscectomy.

In paper I, the incidence of meniscus procedures in Denmark over a 12-year period was determined. The incidence almost doubled in this time and in particular for middle-aged and older patients.

Paper II showed that a large proportion of the increase occurred in private hospitals and clinics. The regional provision of arthroscopic procedures on the meniscus varied widely in Denmark.

Paper III examined the prevalence and severity of commonly assessed self-reported knee symptoms by the use of a patient-administered questionnaire, and investigated if concomitant signs of radiographic structural disease influenced presence of self-reported knee symptoms. Middle-aged patients with a degenerative medial meniscus tear reported symptoms commonly associated with knee osteoarthritis. Patients with meniscus tears reporting swelling of the knee, stiffness later in day or catching were at higher risk of radiographic signs of concomitant structural disease.

Paper IV described the protocol for a randomized placebo controlled trial designed as a superiority study to test whether the benefit from arthroscopic partial meniscectomy in patients aged 35-55 years with knee pain and an MRI-verified medial meniscus lesion is greater after arthroscopic partial meniscectomy than following sham surgery.

In Paper V, the challenges of recruiting patients into this trial were described. The number of patients needed to be screened, and the number of patients needed to be allocated, in order to include the required number of participants into the RCT, were 11.9 and 4.8, respectively.

The large increase of arthroscopic procedures on the meniscus contrast the existing lack of evidence of added benefit of surgery compared to non-surgical interventions. Catching or locking symptoms is generally acknowledged as an indication for meniscus surgery but catching was rarely reported prior to surgery and the evidence for its relation to a meniscal tear or an added benefit from partial meniscectomy is scanty. This lack of consensus on when to perform arthroscopic meniscus surgery may partly be a reason for the large regional variation in provision of meniscus surgery. The association of catching with concomitant signs of radiographic structural disease support a proposal that a symptomatic degenerative meniscal tear is an early sign of knee osteoarthritis, and that neither mechanical nor other symptoms are specifically attributed to the degenerative meniscal tear as such, but rather to the ongoing degenerative process. Even though the randomized controlled trial is considered gold standard in therapeutic trials, it is only seldom used to evaluate even the most common orthopedic surgical procedures. There are well-known challenges in recruiting patients for surgical trials in general and adding a placebo component only adds to these challenges.

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