The Role of Knee Arthroscopy
October 2018
"Knee arthroscopy does work, when it is done at the right time, for the right reasons, in the right patient, with the right techniques and procedures, by a good surgeon with the right training and the correct experience" |
BKS Position Statement on the Role of Knee Arthroscopy:
There has recently been significant comment in both the general press as well as in some general medical journals regarding the role of knee arthroscopy in degenerate knees. This has culminated in some very poorly informed and misleading comments, such as ‘knee arthroscopy doesn’t work!’. Some non-specialists have even published their own guidelines, recommending that the use of knee arthroscopy should be restricted and that surgery should be withheld from and denied to some patients. This includes articles and comments from publications such as The British Medical Journal and The British Journal of Sports Medicine (i.e. journals that are not actually specialist surgical journals).
Knee arthroscopy is a term that simply describes a method for looking into a knee joint with a camera. It says nothing about why surgery might be needed, what might actually be found inside the joint or what the surgeon might actually do inside the knee. Knee arthroscopy does work, when it is done at the right time, for the right reasons, in the right patient, with the right techniques and procedures by a good surgeon with the right training and the correct experience.
It is important that guidelines are seen for what they are, and only used in an appropriate fashion: they should be considered purely as just aids to assist professionals and patients in their clinical decision-making. They should not be used as blunt weapons to ration patients’ access to appropriate healthcare. Guidelines are particularly dangerous when written by individuals who are not actually specialists in the field on which they are commenting.
Appropriately selected patients with degenerative changes in their knee can benefit significantly from knee arthroscopic surgery. The decision as to whether any individual patient might benefit from arthroscopic knee surgery is a decision that should be taken purely between the patient themselves and an appropriately qualified experienced specialist knee surgeon.
Background
The phrase ‘knee arthroscopy’ simply means ‘looking into a knee joint with a camera’. It is nothing more than a method whereby surgeons can look inside a knee. The term ‘knee arthroscopy’ tells you nothing about why a patient might actually need the surgery, what might actually be found inside the joint or what might actually need to be done inside the knee. There is a very long list of different ‘arthroscopic procedures’ covering a wide array of surgical techniques available for ‘tidying up’, repairing or reconstructing the various structures within a knee joint. To lump all of these together under the single term ‘knee arthroscopy’ is enormously over-simplistic at best, and perhaps even quite disingenuous at worst!
Knee arthroscopy was first introduced into the UK back in the 1970s as a tool for improving the treatment of patients’ knees with more delicate, less invasive tissue-preserving techniques. Many of the comments that have recently been made have come from people who are not experts in the field, and who are not actually knee specialists. It is our opinion that many of these comments are ill-informed, naïve, over-simplistic, inappropriate and, indeed, actually quite damaging for patient care. As surgeons, we strongly deplore the practice of any patient ever undergoing any kind of surgery that they might not need, and we would most certainly strongly condemn any such malpractice. However, we believe that the decision as to whether any particular individual patient might potentially benefit from surgery, and the details of exactly what surgery might be required, is something that can and should only ever be made after a full and detailed assessment, and after a proper face-to-face discussion between the patient themselves and a fully qualified appropriately experienced specialist knee surgeon.
To deny patients access to appropriate surgical solutions and to unduly ration patients’ access to appropriate healthcare through scaremongering by non-experts is something that should be deplored.
Published 27/10/18
There has recently been significant comment in both the general press as well as in some general medical journals regarding the role of knee arthroscopy in degenerate knees. This has culminated in some very poorly informed and misleading comments, such as ‘knee arthroscopy doesn’t work!’. Some non-specialists have even published their own guidelines, recommending that the use of knee arthroscopy should be restricted and that surgery should be withheld from and denied to some patients. This includes articles and comments from publications such as The British Medical Journal and The British Journal of Sports Medicine (i.e. journals that are not actually specialist surgical journals).
Knee arthroscopy is a term that simply describes a method for looking into a knee joint with a camera. It says nothing about why surgery might be needed, what might actually be found inside the joint or what the surgeon might actually do inside the knee. Knee arthroscopy does work, when it is done at the right time, for the right reasons, in the right patient, with the right techniques and procedures by a good surgeon with the right training and the correct experience.
It is important that guidelines are seen for what they are, and only used in an appropriate fashion: they should be considered purely as just aids to assist professionals and patients in their clinical decision-making. They should not be used as blunt weapons to ration patients’ access to appropriate healthcare. Guidelines are particularly dangerous when written by individuals who are not actually specialists in the field on which they are commenting.
Appropriately selected patients with degenerative changes in their knee can benefit significantly from knee arthroscopic surgery. The decision as to whether any individual patient might benefit from arthroscopic knee surgery is a decision that should be taken purely between the patient themselves and an appropriately qualified experienced specialist knee surgeon.
Background
The phrase ‘knee arthroscopy’ simply means ‘looking into a knee joint with a camera’. It is nothing more than a method whereby surgeons can look inside a knee. The term ‘knee arthroscopy’ tells you nothing about why a patient might actually need the surgery, what might actually be found inside the joint or what might actually need to be done inside the knee. There is a very long list of different ‘arthroscopic procedures’ covering a wide array of surgical techniques available for ‘tidying up’, repairing or reconstructing the various structures within a knee joint. To lump all of these together under the single term ‘knee arthroscopy’ is enormously over-simplistic at best, and perhaps even quite disingenuous at worst!
Knee arthroscopy was first introduced into the UK back in the 1970s as a tool for improving the treatment of patients’ knees with more delicate, less invasive tissue-preserving techniques. Many of the comments that have recently been made have come from people who are not experts in the field, and who are not actually knee specialists. It is our opinion that many of these comments are ill-informed, naïve, over-simplistic, inappropriate and, indeed, actually quite damaging for patient care. As surgeons, we strongly deplore the practice of any patient ever undergoing any kind of surgery that they might not need, and we would most certainly strongly condemn any such malpractice. However, we believe that the decision as to whether any particular individual patient might potentially benefit from surgery, and the details of exactly what surgery might be required, is something that can and should only ever be made after a full and detailed assessment, and after a proper face-to-face discussion between the patient themselves and a fully qualified appropriately experienced specialist knee surgeon.
To deny patients access to appropriate surgical solutions and to unduly ration patients’ access to appropriate healthcare through scaremongering by non-experts is something that should be deplored.
Published 27/10/18
NHSE Evidence-Based Interventions Programme December 2018
"The current climate where ‘knee arthroscopy’ is being used as a sweeping generic term that is being inappropriately demonised, is having an adverse effect on patient care" |
BKS Position Statement on NHSE Evidence-Based Interventions Programme:
The UK Biological Knee Society believes that patients in the United Kingdom, whether in the National Health Service or the Private Sector, should have access to high quality healthcare for the management of traumatic and degenerative conditions in the knee.
We believe that in order to achieve this, patients must have access to experienced and informed specialists providing evidence-based practice in this field, who are supported by their healthcare organisations. Patients should also be given an opportunity to benefit from innovative technologies within a suitable clinical governance framework.
We believe that this goal has been significantly undermined by some of the recent misinformed and ill-conceived guidelines that have been published by bodies that do not represent the opinions of specialist knee surgeons in the UK. Some of these blanket guidelines based on limited evidence of moderate quality are inadequate when considering the management of often complex conditions in a heterogenous group of patients with differing demands and aspirations.
These ‘guidelines’ are in effect simply being used as a tool to ration patients’ access to appropriate healthcare, both in the NHS and via certain insurers in the Private sector, effectively for their financial gain but directly against the best interests of some patients. They have also led to the undermining of the type of professional opinion that can only be provided from a proper face-to-face assessment by an experienced consultant orthopaedic surgeon.
Currently, decision-making for patients within the NHS is often devolved to ‘over the phone’ assessments, physiotherapy triage clinics and musculoskeletal physicians. Increasingly within the Private Healthcare Sector, we are beginning to see insurance companies interfering with patient referrals, with patients having to talk to clerks in a call centre who are vetting their cases. These kinds of people are not qualified knee surgeons and they do not have the breadth of experience or expertise needed to make fully-informed choices in conjunction with the patient.
‘Arthritis’ and ‘knee arthroscopy’ are often used as ‘catch-all’ terms. The former, however, is a complex, varied and evolving disease process that affects the knee, and the latter simply a mechanism by which the knee is accessed to provide a number of established and novel therapies, including articular cartilage surgery, meniscal cartilage surgery, ligament repair, reconstruction and augmentation. These are the actual procedures, using ‘knee arthroscopy’ simply as the method of accessing the joint.
At no stage do the BKS wish to defend poor practice, unnecessary surgery or indiscriminate use of arthroscopic techniques where the clinical situation does not warrant it; however, the current climate where ‘knee arthroscopy’ is being used as a sweeping generic term that is being inappropriately demonised is having an adverse effect on patient care.
The UK is already falling behind in this area, with a number of potential therapies for cartilage damage no longer available in this country. Companies have come to realise that the UK is not a market to invest in as innovation is constantly stifled. It is our belief that UK patients are being put at a disadvantage when compared to their counterparts in the developed world as a result of the current climate.
Summary
Published 02/12/18
The UK Biological Knee Society believes that patients in the United Kingdom, whether in the National Health Service or the Private Sector, should have access to high quality healthcare for the management of traumatic and degenerative conditions in the knee.
We believe that in order to achieve this, patients must have access to experienced and informed specialists providing evidence-based practice in this field, who are supported by their healthcare organisations. Patients should also be given an opportunity to benefit from innovative technologies within a suitable clinical governance framework.
We believe that this goal has been significantly undermined by some of the recent misinformed and ill-conceived guidelines that have been published by bodies that do not represent the opinions of specialist knee surgeons in the UK. Some of these blanket guidelines based on limited evidence of moderate quality are inadequate when considering the management of often complex conditions in a heterogenous group of patients with differing demands and aspirations.
These ‘guidelines’ are in effect simply being used as a tool to ration patients’ access to appropriate healthcare, both in the NHS and via certain insurers in the Private sector, effectively for their financial gain but directly against the best interests of some patients. They have also led to the undermining of the type of professional opinion that can only be provided from a proper face-to-face assessment by an experienced consultant orthopaedic surgeon.
Currently, decision-making for patients within the NHS is often devolved to ‘over the phone’ assessments, physiotherapy triage clinics and musculoskeletal physicians. Increasingly within the Private Healthcare Sector, we are beginning to see insurance companies interfering with patient referrals, with patients having to talk to clerks in a call centre who are vetting their cases. These kinds of people are not qualified knee surgeons and they do not have the breadth of experience or expertise needed to make fully-informed choices in conjunction with the patient.
‘Arthritis’ and ‘knee arthroscopy’ are often used as ‘catch-all’ terms. The former, however, is a complex, varied and evolving disease process that affects the knee, and the latter simply a mechanism by which the knee is accessed to provide a number of established and novel therapies, including articular cartilage surgery, meniscal cartilage surgery, ligament repair, reconstruction and augmentation. These are the actual procedures, using ‘knee arthroscopy’ simply as the method of accessing the joint.
At no stage do the BKS wish to defend poor practice, unnecessary surgery or indiscriminate use of arthroscopic techniques where the clinical situation does not warrant it; however, the current climate where ‘knee arthroscopy’ is being used as a sweeping generic term that is being inappropriately demonised is having an adverse effect on patient care.
The UK is already falling behind in this area, with a number of potential therapies for cartilage damage no longer available in this country. Companies have come to realise that the UK is not a market to invest in as innovation is constantly stifled. It is our belief that UK patients are being put at a disadvantage when compared to their counterparts in the developed world as a result of the current climate.
Summary
- ‘Knee arthroscopy’ is nothing more than just a method for looking into a knee joint with a ‘camera’. It tells you nothing about why a patient might need surgery or what the actual surgical procedure inside the knee might actually be.
- The practice of patient referrals being diverted and patient care being interfered with by individuals who are not suitably qualified is to be deplored.
- Guidelines issued by non-experts have the propensity to be misleading and even dangerous, and should not be used as tools to ration healthcare and to deny patients access to appropriate treatments that they might benefit from.
- The decision as to whether any individual patient might potentially need knee arthroscopic surgery is a decision that should only ever be made between the patient themselves and a fully-qualified experienced knee surgeon, after a proper clinical assessment, which must include a hands-on clinical examination, a review of all relevant imaging and a face-to-face in-depth discussion between the patient and their specialist surgeon.
Published 02/12/18
Disclaimer / Footnote
The Biological Knee society was set up to promote very latest and best possible surgical options and techniques for knee reconstruction. It is dedicated to the study, evaluation and promotion of the very best surgical options for patients with damaged knees who are too young for artificial knee replacement