Applications for pre-approval for arthroscopic surgery of the knee: to approve or not to approve?

Issue

Arthroscopic knee surgery is one of the most common orthopaedic procedures in the world, however recent studies have revealed that this surgery is not effective in patients with degenerative knee disease, such as osteoarthritis. So what do you do if a worker submits an application for pre-approval of arthroscopic knee surgery? Should it be approved? Based on the available data, the consensus is that the application should be rejected.

Degenerative knee disease affects approximately 25% of people above 50 years old. Knee pain experienced by workers with degenerative knee disease, including medial meniscus tears, often provides the catalyst for an application for pre-approval for arthroscopic knee surgery. In the last five years, the British Medical Journal (BMJ) has published a number of studies that focus on medial meniscus tears. In 2016, a randomised controlled trial published in the BMJ found that ‘among patients with a degenerative medial meniscus tear, knee arthroscopy was no better than exercise therapy.¹ Two years later, the BMJ published two further articles that reviewed the results of the randomised trial, and ultimately concluded with a strong recommendation against the use of arthroscopic knee surgery.

Review of the Medical Literature

The first article, ‘Arthroscopic Surgery for Degenerative Knee Arthritis and Meniscal Tears: A Clinical Practice Guideline’² reviewed the randomised trial by way of an expert panel. The trial involved two groups of patients, all with degenerative medial meniscus tears. One half of the group received arthroscopic knee surgery, whilst the other half received placebo surgery. After review of the patients, there was no evidence to suggest that arthroscopic surgery was any more effective than the placebo surgery. The expert panel concluded: ‘We make a strong recommendation against the use of arthroscopy in nearly all patients with degenerative knee disease, based on linked systematic reviews: further research is unlikely to alter this recommendation’.³ The panel suggested that conservative management of the knee (including watchful waiting, physical exercise and pain medications) was preferable for patients with degenerative knee disease as opposed to surgery.

The BMJ released a second publication in 2018 which reviewed the progress of those patients that had participated in the trial. The article, ‘Arthroscopic Partial Meniscectomy v Placebo Surgery for a Degenerative Meniscus Tear: A Two Year follow-up of Randomised Controlled Trial’⁴ confirmed the position of the first publication. The article states that the results show no significant benefit of arthroscopic partial meniscectomy (APM) over placebo surgery in patients with a degenerative meniscal tear, supporting the consensus that a degenerative meniscus tear is a sign of knee osteoarthritis, rather than a clinical entity on its own. The article warns that caution should be exercised when referring patients to APM, even after a failed attempt of conservative treatment.

A publication of Choosing Widely Australia, ‘5 Things Clinicians and Consumers Should Question’,⁵ drew heavily on these articles to also recommend against the use of arthroscopic knee surgery for degenerative knee disease. The Australian Rheumatology Association (ARA) advised ‘not [to] perform arthroscopy with lavage and/or debridement or partial meniscectomy for patients with symptomatic osteoarthritis of the knee and/or degenerate meniscal tear’. The ARA further noted that ‘[t]here appears to be a high rate of conversion from knee arthroscopy to total knee arthroplasty, which arises with increased age, further suggesting arthroscopic surgery should be avoided in people over the age of 50 years.’

Learnings

The medical evidence tends to suggest that arthroscopic knee surgery is not effective in patients with degenerative knee disease, and may in fact accelerate the need for a total knee replacement (TKR). If you have approved the arthroscopic surgery of the knee, that will make it more difficult to decline approval of the TKR. As we know, once a worker has a TKR performed in compensable circumstances, that will result in a prima facie whole person impairment of 15% for a good result, 20% for a fair result and 30% for a poor result. In the context of workers compensation claims, this evidence may provide a basis for rejecting an application for pre-approval and therefore putting in issue, and limiting, the future liability that may flow from a compensable knee injury. In the event that you receive an application for a pre-approval for arthroscopic knee surgery, we suggest that you:

1. Defer the decision on the application to investigate.
2. As part of the investigations:
   1. request a copy of the worker’s clinical records and all radiological investigations in relation to the worker’s lower extremities.
   2. arrange for the worker to be independently assessed by a reputable orthopaedic surgeon and put the abovementioned medical literature to the doctor and seek their opinion on the appropriateness and reasonableness of the arthroscopic knee surgery and whether the need for the same relates to the worker’s degenerative knee condition or the work injury.
3. We expect that the outcome of those investigations will provide a sufficient basis upon which to decline the application for pre-approval for arthroscopic surgery of the knee.

This article was written by by Shane Thurnwald, Partner, and Simone Basso, Law Graduate.

¹ Siemieniuk et al, ‘Arthroscopic Surgery for Degenerative Knee Arthritis and Meniscal Tears: A Clinical Practice Guideline’ (2018) 52(3) British Journal of Sports Medicine 313, citing Kise et al, ‘Exercise Therapy Versus Arthroscopic Partial Meniscectomy for Degenerative Meniscal tear in Middle Aged Patients: Randomised Controlled Trial with Two Tear Follow-Up’ (2016) 50(1) British Medical Journal 1473.
² Siemieniuk et al, ‘Arthroscopic Surgery for Degenerative Knee Arthritis and Meniscal Tears: A Clinical Practice Guideline’ (2018) 52(3) British Journal of Sports Medicine 313.
³ Ibid.
⁴ Sihvonen et al, ‘Arthroscopic Partial Meniscectomy v Placebo Surgery for a Degenerative Meniscus Tear: A Two Year follow-up of Randomised Controlled Trial’ (2018) 77(2) British Medical Journal 188.
⁵ Choosing Widely Australia, ‘5 Things Clinicians and Consumers Should Question’ (Guideline, 2018).