Professor Ewa Roos Center for Muscle and Joint Health Syddansk Universitet ewa_roos

Transcription

1 Professor Ewa Roos Center for Muscle and Joint Health Syddansk Universitet ewa_roos

2 Disclosures My salary and my department s budget is unaffected by my research results Developer of the KOOS, KOOS-Child, HOOS, HAGOS, FAOS, RAOS, NOOS. Instruments have been developed in an academic context. Instruments are freely available and no license is required for their use, neither for academic or commercial use. No funding from commercial parties or not-for-profit organizations has been received Developer of the GLA:D. GLA:D is a not-for-profit initiative to implement clinical guidelines for osteoarthritis, hosted at the University of the Southern Denmark Deputy Editor of Osteoarthritis & Cartilage, receive an annual honorarium Current funding: EU and EIT Health

3 Take home message Exercise therapy can be more effective than you think Only few and minor adverse events; pain flares No serious adverse events Knee surgery can be less effective than you think Adverse events like persistent pain are not uncommon Serious adverse events are rare but occur; including blood clots, infections and death Smart to follow clinical guidelines advising exercise therapy as first treatment Also from a health cost perspective

4 Have YOU had knee pain during the last month?

5 Scalpel or no scalpel?

6 When broken fix it!

7 When broken fix it!?

8 2015 Meniscal injuries arthroscopic surgeries Osteoarthritis total knee replacements Anterior Cruciate Ligament injury surgical reconstructions

9 Exercise therapy 1 hour sessions 2-3 times weekly 3 (6) months Supervised by experienced physical therapists

10 Acute ACL injury yrs

11 First and only RCT 121 young sporty adults (mean age 26, 70% soccer injuries) Randomized to: o Exercise therapy only (with delayed surgery if needed) o Exercise therapy + Early surgical reconstruction

12 Results: Knee function score Exercise Exercise+surgery Months Frobell et al. NEJM 2010, BMJ 2013 KOOS 4

13 Results: Return to sport Exercise therapy group Exercise therapy + Surgery group 4/10 6/10 Frobell NEJM 2010 & BMJ 2013, Arden et al. BJSM 2011

14 At 5 years, 51% had opted for delayed surgery, with no additional benefit KOOS Exercise Exercise+surgery Exercise+delayed surgery Months Frobell et al. NEJM 2010, BMJ 2013

15 Osteoarthritis mean age 66 yrs

16 First and only RCT Randomized to: o Non-surgical treatment only (with delayed surgery if needed) o Non-surgical treatment + Total knee replacement

17 Participants N=100 eligible for surgery The average participant was 66 years old, obese and had severe radiographic osteoarthritis 2/3 used pain medication in past week and had moderate pain and moderately impaired function

18 Results at 1 year 12 weeks of non-surgical treatment 30% pain relief 74% had not had TKR No serious adverse events 12 weeks of non-surgical treatment + surgery + 60% pain relief 11% had one or more serious adverse events Deep venous trombosis requiring treatment Knee stiffness mobilised under anesthesia Fracture Deep infection = 8 other surgeries incl. prosthesis removal, knee fusion, skin transplant and scar tissue removal

19 Shared decision making is key Surgical AND non-surgical route Greater pain relief 85% clinically relevant improvment 1/10 experience serious adverse events Non-surgical route Less pain relief 68% clinically relevant improvement 3 out of 4 postpone surgery for at least 1 yr No serious adverse events

20 Degenerative meniscal injury yrs

21 One of 10 RCTs 141 with pain & MRI-verified meniscal tear Randomized to: o Exercise therapy only o Arthroscopic partial meniscectomy only

22 Results at 2 years Harald, 60: After supervised exercise I could go back to all outdoor activities No difference: o Overall knee score Exercise therapy better: o Symptoms o Muscle strength o Physical activity level No serious adverse events 19% crossed-over to surgery, with no added benefit Dagbladet May 2, 2013; Kise et al. BMJ 2016

23 10 randomized trials (35-60) yrs 55 yrs 60 yrs Meniscus tear Tear + early OA Established OA K-L 0 K-L 1 K-L 2 K-L 3 K-L 4

24 Clinical guidelines SST, Denmark 2016: Overvej primært at tilbyde ikkekirurgisk behandling til patienter med ikke-traumatisk opståede knæsmerter og ledlinjeømhed BMJ 2017: We recommend against arthroscopic knee surgery in patients with degenerative knee disease Favours non-surgical management Strong NKR Meniskpatologi SST 2016, Siemieniuk et al. BMJ 2017

25 Patients, GPs and researchers have been blamed for the unexpected results from these 10 studies

26 Controversial study design US surgeons accuse participants in some of these 10 trials of being mentally unhealthy Lubowitz et al. Could the NEJM be biased against arthroscopic knee surgery? Arthroscopy 2014

27 British Orthopedic Association blames GPs for patients undergoing needless keyhole surgery You refer the wrong patients and expect that we can cure them! Werefer to get a second opinon. Who needs surgery is your decision! Pulse. July 1, 2015

28 Controversial findings Danish surgeon blames researchers for being biased against knee arthroscopy Politiken. June 17, 2015

29 Steady decrease since Antal meniskoperationer i DK (KNGD) Dataudtræk fra Landspatientregistret September 11, 2017

30 To start with exercise therapy seems to save surgeries (and costs) without compromizing the result ACL: 60% saved surgeries OA: 67% saved surgeries Meniscus >35yrs: 80% surgeries saved

31 Total annual health cost Patients with new knees cost more after the surgery 12 years before surgery 12 years after surgery patients with knee replacement Matched reference population Kjellberg & Kehlet. A nationwide analysis of socioeconomic outcomes after hip and knee replacement. Danish Medical Journal 2016

32 Is exercise therapy a realistic treatment option? Boring. Time consuming. Costly. Savings from saved surgeries can be shifted to reimburse exercise therapy

33 Summary of results GLA:D 2016 Sick leave Use of pain killers Pain Fear of movement Physical activity Gait speed Quality of life > Danes Canada Australia China

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35 Disclosure I choose exercise therapy

36 What would you choose? Scalpel or no scalpel? Thank you!