Clinical Practice and Post-Operative Rehabilitation After Knee Arthroscopy: Comparison Between Polish Experts and Non-Experts.

Background: The purpose of this study was to compare the clinical practices between polish expert and non-expert arthroscopy knee surgeons. Methods: 205 registered orthopedic surgeons took part in surveys. The survey included 35 questions regarding general arthroscopy and postoperative management, including physician’s level of expertise, arthroscopy anesthesia, postoperative treatment, rehabilitation and procedures performed. Comparisons were made between knee arthroscopy experts (> 100 arthroscopies performed per year) and non-experts ( ≤ 100 cases) on aspects of patient care. Results: The most important nding of this study is an agreement in almost all aspects of knee arthroscopy approach. A consensus between polish surgeons was noticed in choosing regional anesthesia for knee arthroscopy, no need for knee braces nor knee medications, using LMW heparin as thromboprophylaxis, 1-2 days hospitalization, recommendation of rehabilitation and magnetic resonance as a diagnostic test for meniscus damage. Surgical expertise was signicantly associated with the performance of meniscus sewing procedures (p = 0.009). Experts recommended starting rehabilitation already on the day of surgery (p=0.007) and more likely used objective physical tests (p=0.003). Nonexpert surgeons recommended longer period from meniscus suture to a full range knee motion (p=0.001) and admitted that patient’s age does matter for meniscus repair qualication (0.002). Conclusions: Clinical practice varies among orthopeadists performing knee arthroscopy procedures, based on their level of expertise. Polish knee arthroscopy experts agreed with non-experts in the type of anesthesia during knee arthroscopy and numerous aspects of postoperative treatment. Surgical expertise was associated with the performance of advanced meniscus suturing techniques.

anesthesia for knee arthroscopy, no need for knee braces nor knee medications, using LMW heparin as thromboprophylaxis, 1-2 days hospitalization, recommendation of rehabilitation and magnetic resonance as a diagnostic test for meniscus damage. Surgical expertise was signi cantly associated with the performance of meniscus sewing procedures (p = 0.009). Experts recommended starting rehabilitation already on the day of surgery (p=0.007) and more likely used objective physical tests (p=0.003). Nonexpert surgeons recommended longer period from meniscus suture to a full range knee motion (p=0.001) and admitted that patient's age does matter for meniscus repair quali cation (0.002).
Conclusions: Clinical practice varies among orthopeadists performing knee arthroscopy procedures, based on their level of expertise. Polish knee arthroscopy experts agreed with non-experts in the type of anesthesia during knee arthroscopy and numerous aspects of postoperative treatment. Surgical expertise was associated with the performance of advanced meniscus suturing techniques.

Background
The knee joint is one of the most common joints subjected to injuries. Due to its localization and function, it is of vital importance to working ability, daily tasks and recreational and professional sports.
For many in the young and active population who injure their knee, this commonly involves injury to the menisci [1].
Moreover, a prolonged untreated damage may lead to the development of osteoarthritis [5][6][7]. Therefore, a proper treatment of damaged meniscus is of crucial importance for the patients. The main treatment options for damaged meniscus are surgical arthroscopic partial meniscectomy (meniscus removal) or meniscus repair. Many advances have been made in tissue engineering strategies recently and they gain more attention [8,9]. Current orthopaedic practice aims to preserve meniscal integrity and restore function through a variety of different methods. Therefore studying and analyzing of the existing therapeutic methods to nd a Results 205 participants were questioned by 5 hostesses. All survey forms were used for the analysis. Table 1 presents the educational background of the participating surgeons in the eld of knee arthroscopy. 169 of 205 (82%) orthopaedists participated in a knee arthroscopy at early stages of their career (residency, specialization) more than 30 times. Only 8 participants (4%) had no contact with knee arthroscopy during their residency or specialization. 55 orthopaedists (28%) performed more than 100 knee arthroscopies per year independently and were classi ed as experts for this study. The remaining 150 orthopaedists (72%) performed up to 100 knee arthroscopies per year and therefore were classi ed as non-experts. consensus is constantly timely and necessary. Recently the ESSKA (European Society for Sports Traumatology, Knee Surgery and Arthroscopy) European consensus provided recommendations for the treatment of meniscus tears based on both scienti c evidence and the clinical experience of knee experts [10,11]. Other studies have shown that the surgeon's level of expertise signi cantly affects the clinical outcomes in patients undergoing knee arthroscopy [12,13]. We have therefore hypothesized that polish expert arthroscopic knee surgeons have different clinical practices in some aspects of clinical care and post-operative treatment compared to non-expert arthroscopic knee surgeons. The main goal of the study was to determine a consensus in meniscus tear treatment in the environment of Polish orthopedists.

Methods
For this study, a questionnaire was presented to 205 orthopaedists with various levels of clinical expertise A pilot survey was conducted before the meeting. The questionnaire was distributed to 10 orthopedic surgeons and a biostatistician to ensure that it was scienti cally sound and the question stems were easy to understand. We de ned experts as any participating orthopaedist who had performed > 100 knee arthroscopies per year. Orthopaedists who had performed 100 or fewer knee arthroscopies per year were classi ed as non-experts for this study.

Statistical analysis
Statistics were conducted using GraphPad Prism software (Graphpad Software, Inc.). Power analysis was conducted to identify the minimum number of participants required in each group to detect statistical signi cance. A total of 43 participants were necessary. To test proportional differences in categorical variables, a Chi square test was performed. Fisher exact tests were used when cells contained less than ve subjects. Statistical signi cance was determined as p < 0.05.  In total, we have examined 55 expert orthopaedist who had performed > 100 knee arthroscopies per year and 150 non-expert orthopaedists who had performed 100 or fewer knee arthroscopies per year.
Considering anesthesia during arthroscopy, general anesthesia was reported by 12 (6%) orthopaedists in patients undergoing knee arthroscopy, a combined version of both, general and regional -by 21 (10%).
The comparison between post-operative treatment is shown in Table 2. Only 13% orthopaedists recommended using an orthosis to their patients immediately after knee arthroscopy: 4 of 55 experts (7%) and 23 of 150 non-experts (15%). There was a statistically signi cant difference observed in knee drain usage between experts and nonexperts: 9% of experts and 28% of non-experts did not recommend using a knee drains (p = 0.012).
Experts and non-experts answered almost equally when asked about anti-thrombotic prophylaxis administered to the patients. Low molecular weight heparin was recommended by 88% of surgeons after the patient was discharged: 94% of experts and 87% of non-experts.
Both, knee arthroscopy experts (85%) and non-experts (75%) recommended one day of hospitalization after non-reconstructive arthroscopy, rather than shorter (few hours) or longer period (more than one day). However, 1 or 2 days of hospitalization were most frequently recommended after reconstructive arthroscopy: 52% of experts and 32% of non-experts recommended 1 day, 31% of experts and 49% of non-experts recommended 2 day-long hospitalization.
Comparisons of rehabilitation recommendations are shown in Table 3. 135 surgeons (64%) reported that they always recommend rehabilitation (excluding physical therapy) and 99% (203) discuss with the patient about the importance of rehabilitation. There was a statistically signi cant difference noticed (p = 0.032) when surgeons were asked about their patients' compliance with the rehabilitation program. 85% of experts and 75% of non-experts admitted their patients being compliant with the protocol.   reported that the rehabilitation protocol was dependent on procedures performed. 189 surgeons (92%) reported that the physical therapist was the key person responsible for patient rehabilitation. Cryotherapy was a preferred option of rehabilitation by 77% orthopaedists (42 experts and 113 non-experts) and physical therapy -by 65% (133 orthopaedists). Within this group, lasertherapy and magnetotherapy were most frequently used. Table 4 shows the factors considered when recommending return to sport by patients which underwent knee arthroscopy procedure. In most cases either surgeon or surgeon together with a physical therapist were responsible for the decision whether a patient is ready to return to sport. The most important factor in a decision process was a functional state of the patient (93% of experts and 74% non-experts, p = 0.002). Objective measurements were used to aid in the decision to return to sport by 159 (78%) surgeons. Objective physical tests were reported to be signi cantly more involved in the decision about the patient's return to activity in the case of experts compared to non-expert surgeons (p = 0.003). Among them, functional tests were signi cantly preferred by experts than non-experts (p = 0.006). The arthroscopic procedures used by experts were as follows (Table 5 and Fig. 1): ACL reconstruction (100%), meniscus suturing all inside (96%) and meniscus removal (93%). Non-experts had signi cantly less experience with these procedures: ACL reconstruction was reported by 81% non-experts, meniscus suturing all inside by 79% and meniscus removal by 81% (p < 0.0001).  Experts mostly performed meniscus suturing (38%), non-experts -meniscus removal (25%), p = 0.009 (Table 5 and Fig. 2).
Diagnostic tests used by experts when meniscus tear was suspected in their patients were the same as chosen by non-experts (Table 5 and Fig. 4). Both, experts and non-experts agreed that magnetic resonance was their preferred diagnostic method. Ultrasounds were used by ~ 50% of experts and nonexperts. X-ray method was the least frequently used.
Both, experts and non-experts recommended similar time of using elbow crutches after meniscus removal (2 weeks) or orthosis after meniscus suture (6 weeks). The answers were however different when surgeons were asked about how soon after meniscus sewing they recommend a full range of knee motion (Table 6 and Fig. 5). Experts recommendation was 4 weeks and non-experts -6 weeks (p = 0.001). Table 6 Post-arthroscopic procedures.   Both, experts and non-experts named similar factors when they considered whether to remove or to repair meniscus -damage type and zone. They also selected patient's age, however experts stated that age does not matter when they consider for meniscus repair quali cations signi cantly more frequently than nonexperts (Table 6 and Fig. 6, p = 0.002).
Surgeons were also asked about patient's sport discipline in uence on to repair or to remove decision. 103 orthopaedist: 23 experts (42%) and 80 non-experts (54%) admitted taking into consideration a discipline.
At the end of the rst part of the survey participating orthopaedist were asked about their preferred procedure in case of traumatic meniscus tear in an 18-year-old or 30-year-old professional football player.
Summarizing the results from the survey, we have noticed a consensus in the following areas of knee arthroscopy: regional anesthesia used for knee arthroscopy -reported by 84% orthopaedists, no need for using a knee orthosis -reported by 87% orthopaedists, no need for knee medications immediately after arthroscopy -by 89% orthopaedists, low molecular weight heparine as thromboprophylaxis after knee arthroscopy − 90% orthopaedists, 1 day duration of hospital stay after non-reconstructive knee arthroscopy − 78% orthopaedists, 1-2 days duration of hospital stay after reconstructive knee arthroscopy − 87% orthopaedists, recommendation of rehabilitation − 85% of surgeons, talking with the patient about the need of postoperative rehabilitation − 99% orthopaedists, dependence of rehabilitation program on procedures performed -86% orthopaedists, recommendation of rehabilitation with a physiotherapist-92% orthopaedists, magnetic resonance as a diagnostic test for meniscus damage − 97% orthopaedists, repair as preferred procedure in case of meniscus damage in an 18-year-old professional footballer − 87% orthopaedists, repair as preferred procedure in case of meniscus damage in an 30-year-old professional footballer − 81% orthopaedists.

Discussion
The most important nding of this study is an agreement in almost all aspects of knee arthroscopy approach. A consensus between polish surgeons was noticed when it comes to anesthesia during knee arthroscopy as well as numerous aspects of postoperative treatment, hospital stay and rehabilitation.
A consensus between polish orthopaedists was reached in choosing of the regional anesthesia for knee arthroscopy. This is with an agreement with world standards. Regional anesthesia, in contrast to the general one, is a simple, safe technique, well accepted by patients and reducing hospital stay. Therefore, both experts and non-experts also agreed on short duration of hospital stay after knee arthroscopy (1-2 days). Polish surgeons also agreed on no need for routine recommendation of using a knee orthosis, which is in agreement with previous studies showing no bene cial effect of bracing after knee arthroscopy [14,15] or even indirect prevention of ACL reruptures in case of rehabilitation without a knee brace [16].
The presentation of pain after arthroscopic surgery is determined by the procedure of surgery. In this survey, all surgeons agreed that there is no need for intraarticular knee medications immediately after arthroscopy. This is in agreement with studies where it was found that a signi cant proportion of patients have only very mild or mild pain after knee arthroscopic procedures [17].
Current guidelines for thromboprophylaxis recommend the use of vitamin K antagonists (e.g. warfarin), low-molecular-weight heparins (LMW heparin) or aspirin [18,19]. LMW heparine has a long half-life with good bioavailability [20] and is administered once daily subcutaneous dose without laboratory monitoring or dose adjustment. Experts and non-experts in this survey agreed that the e cacy and safety of LMW heparin is well established and is a good choice for knee arthroscopy.
There is a wide range of rehabilitation protocols after knee arthroscopic procedures, mainly based on specialist exercises. The goal of the postoperative rehabilitation period is to reduce knee pain and regain good knee control, range of motion, strength and knee function. The surgeon plays a key role in educating the patient about the importance of post-surgical rehabilitation. Polish surgeons taking part in this survey agreed that proper post-operative rehabilitation of the knee is essential, especially 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 this study showed that 1% of surgeons never recommends rehabilitation, 5% -rarely and 7% -sometimes.
Most of the surgeons recommended a rehabilitation with a physiotherapist, which is now considered as a gold standard in the eld, as its effectiveness has been proved by a number of control studies [21][22][23][24].
Different treatment requires a different rehabilitation approach, which is why individual cooperation between the physiotherapist and the patient is so important [25]. On the other hand, there are no direct evidences for good results with physical therapy, as Evidence Based Medicine (EBM) does not exist in physical therapy eld, in contrary to physiotherapy. In our survey, both, experts and non-experts recommended physical therapy less frequently (65%) than rehabilitation with physiotherapist (92%). The results of this survey suggest a need for a broad discussion in the polish environment if physical therapy should be advisable and recommended by polish National Health Fund.
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 83-94% [26][27][28]. Moreover, the ESSKA European meniscus consensus group recommended using MRI when arthroscopy would be considered to identify concomitant pathologies [11]. Magnetic resonance as a diagnostic test for meniscus damage was recommended by 97% orthopaedists in this study. However, 50% of surgeons recommended ultrasounds as a diagnostic method and this should not be practiced since ESSKA European meniscus consensus group does not recommend ultrasounds for traumatic nor degenerative damage.
On the other hand, surgical expertise was signi cantly associated with the performance of reconstructive procedures, in comparison to diagnostic arthroscopy performed more often by non-experts (p = 0.009).
Experts were signi cantly more likely to perform meniscus sewing procedures than non-experts, which are considered advanced and challenging techniques with signi cant biomechanical consequences.
Moreover, the clinical experience of participating in this survey orthopeadists 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 eld of musculoskeletal medicine very recently [4,9]. 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.
Experts admitted that they patients comply with the rehabilitation protocol to high extend (p = 0.032), 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 (p = 0.007). Surgeons from all over the world have increasingly emphasized early mobilization, which may produce favorable post-operative outcomes [29][30][31].
Nonexpert surgeons less likely used objective physical tests (p = 0.003), recommended longer period from meniscus suture to a full range knee motion (p = 0.001) and admitted that patient's age does matter for meniscus repair quali cation (0.002). All of these issues might be correlated with less experience of this group of surgeons.
Both expert and non-expert preferred to perform meniscus suturing rather than meniscus removal in both 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.

Conclusions
Clinical practice varies among orthopeadists performing knee arthroscopy procedures, based on their level of expertise. Polish knee arthroscopy experts agreed with non-experts in the type of anesthesia during knee arthroscopy and numerous aspects of postoperative treatment. Surgical expertise was associated with the performance of advanced meniscus suturing techniques.
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 di cult to collect detailed information about the post-operative aspects of care with fewer questions. De ning the level of expertise at a cutoff of more than 100 arthroscopies performed per year could be considered a biased decision for this study. Verbal informed consent was obtained from study participants before completing the survey (based on the opinion of Rehasport Clinic Scienti c Council).

Consent to publish: Not applicable
Availability of data and materials: The datasets used during the current study are available from the corresponding author on reasonable request.

Competing interests: Not applicable
Funding: Not applicable Authors' Contributions: PB conceived and designed the study. PB and TP participated in the setup of the study, participants recruitment, and data collection. KBŻ conducted the analysis. KBŻ drafted the rst version of the manuscript. All authors helped in revising the manuscript and gave their nal approval of the submitted version. All authors had full access to the data and take responsibility for the integrity of the data and the accuracy of the data analysis.