Acta Orthop Scand 2000 71 (5) 455ndash460 455

A B ST R AC T ndash W e rep ort sh ort-term data from 82 con-secutive patients w ith arthroscopic m eniscectom y 1995ndash1998 in stable kn ees an d w ithout severe cartilage changesA ll p atien ts w ere treated as ou tp atients the op eratingtim e w as on average 23 SD 12 m in utes and 3 of 4 pa tientsw ere b ack at w ork w ithin 1 w eek A lm ost half o f th e p a-tien ts still had som e knee problem s 3 m on th s after sur-gery but th ereafter a sub stantial im provem ent w as seen

W e a lso rep ort orig in a l d a ta from a consecu tive serieso f p a tients h av in g arth roscop ic m en iscectom y 1980ndash81 In th at s eries th e freq u en cy o f to ta l m en iscectom ies w ash igh er the operatin g tim e lon ger bu t th e tim e to recov-ery w as sh orter than in 1995ndash98 In con trast to 1995ndash98 m ost of th e p at ien ts in 1980ndash81 w ere fo llow ed b y thed octor an d h ad sup erv ised rehab ilita t ion H ow ever sickleave w as sim ilar in th e tw o series T h e to ta l costs for anarth roscop ic m en iscectom y in 1998 w as less th an h a lfth e costs in 1980ndash81

W e con clu d e th at th e im p roved tech n iq u e for arth ro-scop ic m eniscectom y d u rin g the la st 15ndash20 years an dles s sup erv ised reh ab ilita tion h ave red u ced th e costsbu t n o t th e recovery t im e

n

The shortness of rehabilitation time after arthro-scopic meniscectomy was regarded as a sensationseveral studies reported a return to sports within3ndash4 weeks (Guhl 1979 Lysholm and Gillquist1981 Pettrone 1982 Hamberg and Gillquist1984) These studies mirror the situation at centerswhere the technique was being developed and thepatients were followed carefully for research pur-poses Today arthroscopic meniscectomy has be-come routine performed as an outpatient proce-

Arthroscopic meniscectomyTreatment costs and postoperative function in a historical perspective

Peter Rockborn1 Per Hamberg2 and Jan Gillquist1

1Sports Medicine Faculty of Health Sciences Linkoumlping University SE-581 85 Linkoumlping Tel +46 11 222000 E-mailPeterRockbornliose 2Department of Orthopedic Surgery South Hospital SE-118 83 Stockholm SwedenSubmitted 99-05-13 Accepted 00-07-23

Copyright copy Taylor amp Francis 2000 ISSN 0001ndash6470 Printed in Sweden ndash all rights reserved

dure and usually the patient receives only a simpleprinted training program for postoperative reha-bilitation at home In most cases no further con-tact with the doctor is planned It is well knownthat successful experimental programs are notequally successful when used on a routine basis(Nation 1997) The question is whether the resultsof arthroscopic meniscectomy have changed dur-ing the last 15 years

Therefore we analyzed a series of patients un-dergoing arthroscopic meniscectomy 1995ndash1998To make a historical comparison we also studiedoriginal protocolsdata from a series of previouslyreported patients with meniscectomy (Hambergand Gillquist 1984)

Patients and methods

We prospectively collected data from 82 consecu-tive unilateral arthroscopic meniscectomies per-formed at the County Hospital of Norrkoumlping be-tween January 1995 and January 1998 (Table 1)

A diagnostic arthroscopy using a central ap-proach was performed as described byGillquist and Hagberg (1976) and Gillquist etal (1979) A protocol was used to record allfindings concerning meniscus pathology liga-ment and cartilage changes (Lundberg et al1984) The latter changes were classified ac-cording to a modified Outerbridge scale laterpresented by Lysholm et al (1987) Patientswith unstable knees and severe cartilage chang-es (more than modified Outerbridge grade 2)were excluded from the study

456 Acta Orthop Scand 2000 71 (5) 455ndash460

All operations were performed under general orregional anesthesia with the limb in a thigh-hold-ing device and the operating table at knee level soplaced that both knees hung over the edge at 90degflexion A tourniquet was applied but inflated onlyif bleeding blocked the view In all operations weused a video system for visualization and an in-flow-outflow pump system with automatically-maintained intraarticular pressure was used

The operations were performed by one and thesame surgeon (PR) A simple printed training pro-gram was given to all patients postoperatively Nopostoperative visit was planned but the patientswere told to return if they did not improve or ifany other problem arose

At the postoperative unit the patients received aquestionnaire about the pre- and postoperative pe-riod and were asked to return it by mail after 3months On the basis of the questionnaire we di-vided the activity level into 5 categories (Table 1)Knee function was assessed with the modified Ly-sholm score (Tegner and Lysholm 1985) The pa-tient was also asked about time from injury to op-eration sick leave physiotherapy recovery andown opinion

71 of 82 patients returned the questionnaires af-ter 3 months Patients not completely recovered orsatisfied at 3 months or who did not answer thequestionnaire (n 50) were sent a second one amean of 24 (12ndash44) months after the operationThis questionnaire included questions about thepresent activity level and knee function ownopinion recovery and new operations The patientwas reminded by phone if the questionnaire hadnot been returned Finally all patients returned thequestionnaires

Statistics

For non-parametric data (Lysholm score Activitylevel) the Wilcoxon signed rank test was used toanalyze repeated measurements in the samepatient For parametric data (sick-leave) theunpaired t-test was used for differences betweengroups of patients Differences in proportionswere calculated with the chi-square test Thestatistical evaluation was done with Statisticasoftware (Statsoft Inc Tulsa OK USA)

Results

Only 2 of 82 meniscectomies were subtotal 9 pa-tients had a meniscectomy on both the medial andlateral meniscus (Tables 1 and 3) The mean oper-ation time including diagnostic arthroscopy was23 minutes (Table 3) and all were treated as outpa-tients Most had no postoperative visit (Table 2)18 patients took part in a supervised physiothera-py program after the operation

Three fourths of the patients were back at workwithin 1 week and almost 90 within 2 weeks Sickleave was not affected by cartilage changes type oftear or age at surgery (gtlt 40 years) type of menisc-ectomy or the side of the tear (mediallateral)

Complications

1 patient needed aspiration 1 had a superficialskin infection 1 a deep venous thrombosis and 4

Table 1 Patient characteristics

1995ndash98 1980ndash81

n 82 86Age mean SD 39 12 35 13 range (16ndash72) (15ndash67)Sex (malefemale) 65 17 77 9Meniscus (mediallateralboth) 66 7 9 74 11 1Activity level (medianrange) 3 (1ndash5) 3 (1ndash4)

Activity level divided into 5 categories (1) team sportson elite level (2) other strenuous sports and heavywork (3) recreational sports (4) ordinary work (5) lowactivity retired

Table 2 Time from injury to operation and number ofpostoperative visits within 10 months in 1995ndash98 Origi-nal data from patients operated on 1980ndash81 are alsopresented

1995ndash98 1980ndash81

Time injuryndashoperation n 71a 86Acute 8 91 weekndash3 months 15 203ndash6 months 16 23gt 6 months 32 33

Postoperative visits n 82b 860 56 01 19 522ndash5 7 34

a Time from injury to operation is based on 71 patientsreturning their questionnaires after 3 monthsb Number of postoperative visits is based on all patientsstudied (n 82)

Acta Orthop Scand 2000 71 (5) 455ndash460 457

other patients complained about pain and tender-ness at the patella tendon 1 patient had an extend-ed meniscectomy within the first 10 months

Activity knee function and patientrsquos ownopinion

The preinjury activity level was high 3 of 4 pa-tients were active in sports on a competitive orrecreational level

53 patients had regained their previous activitylevel 3 months after surgery and 73 after morethan 12 months No specific factor such as age orperoperative degenerative changes were related toa lower level of activity

Sports-active patients seemed to recover theircapacity slowly because only 19 of 53 were backat the preinjury level at 4 weeks and 27 of 53 at 10weeks Information about early return to sportswas available in 71 patients of whom 53 had beenactive in sports before injury

Almost half of the patients had knee problems

that a check-up would have been appropriate

Historical patients with arthroscopic menis-cectomy

Original protocolsdata were available from aseries of consecutive patients having unilateralarthroscopic meniscectomy from October 1980to May 1981 at the University Hospital ofLinkoumlping Sweden These were included in a se-ries of 100 patients with meniscectomy previouslyreported by Hamberg and Gillquist (1984) Fromthis series 86 patients who had no ACL-ruptureand no severe cartilage changes were retrospec-tively selected

In 78 of them a follow-up examination hadbeen carried out 10 (6ndash17) months after surgery 8had returned a questionnaire by mail The pre- andpostoperative activity level was assessed in 5 cate-gories (Table 1) The activity levels 4 and 10weeks after meniscectomy were available fromthe original protocols

Table 4 Average costs per patient for an arthroscopic meniscectomy 1995ndash98 The costs 1980ndash81 are theoretical and calculated by comparing the his-torical conditions in 1998 with the present costs USD

1995ndash98 1980ndash81USD USD

Operation694operation 694 694

Extra op-time14minute 0 135

Hospital stay574day 0 234

Postoperative doctorrsquos visit209visit 94 293

Physiotherapy training session33session 73 428

Total costs 861 1784

Table 3 Number of patients with different types of meniscectomy and opera-tion time in minutes 1995ndash98 Original data from a series of patients operatedon 1980ndash81 are also presented

Type of meniscectomy 1995ndash98 1980ndash81n mean SD (range) n mean SD (range)

All 82 23 12 (10ndash55) 86 33 13 (5ndash95)Partial meniscectomy 66 22 7 (10ndash53) 54 29 14 (5ndash65)Total meniscectomy 2 30 7 (25ndash35) 14 40 13 (20ndash75)Bucket handle resection 14 26 11 (12ndash55) 18 37 18 (15ndash95)

in daily life activities (scorelt 85) 3 months after surgerybut at 12 months or more ninetenths had a score gt 84(p lt 00001) 2 patients regard-ed their knee problems as un-changed after surgery A lowLysholm score was not relatedto age or to cartilage changesseen at the initial arthroscopyWhen the patients were askedabout time to complete recov-ery 57 of 82 patients consid-ered the knee have been com-pletely recovered at the latestfollow-up Of these half hadrecovered within 2 months andtwo thirds within 4 months

However 54 of 71 were sat-isfied with the result at 3months and 73 of 82 were sat-isfied at the latest follow-up

A common comment fromthe dissatisfied patients wasthat time to full recovery hadbeen too long Some patientssaid that they did not feel safein the postoperative period and

458 Acta Orthop Scand 2000 71 (5) 455ndash460

Knee function was evaluated with a scoringscale having a maximum of 95 where the maxi-mum score for instability was 20 (Hamberg et al1984) The scores were individually corrected tothe scale with a maximum score of 100 including25 for instability (Tegner and Lysholm 1985)

Data about time from injury to operation opera-tion time hospital stay sick leave and physiother-apy were also available Of 4 surgeons involved 2performed nine tenths of the operations

14 of 86 meniscetomies were total but only 1patient had meniscectomy on both the medial andlateral meniscus (Tables 1 and 3) The mean oper-ation time was 33 minutes (Table 3) 56 of the 86patients were treated as outpatients All patientshad one or more postoperative visits excludingthose for purposes of research and four fifths ofthe patients took part in supervised physiotherapyprogram postoperatively

Three fifths of the patients were back at workwithin 1 week and four fifths within 2 weeks Sickleave was not affected by cartilage changes typeside of meniscus tear or age at surgery 1 patienthad an extended meniscectomy within 10 months

Similar to the series 1995ndash98 3 of 4 patientswere active in sports on a competitive or recre-ational level before injury All patients except 2had regained their activity level until the final fol-low-up Sports-active patients quickly regainedtheir activity levelmdashie 34 of 64 patients wereback at the preinjury level after 4 weeks and 62after 10 weeks Only 4 patients had symptoms indaily life activities (Lysholm score lt 85) and 23had symptoms in sports activities (Lysholm scorelt 95) after 10 months but only half regarded theirknees as completely recovered at this time

Comparison of costs 1980ndash81 and 1995ndash98

An attempt was made to compare costs related tosurgery and rehabilitation in 1980ndash81 and 1995ndash98 (Table 4) When the conditions in 1980ndash81 re-garding operation time hospital stay number ofpostoperative visits and physiotherapy were com-pared in 1998 with the present costs the total costfor an arthroscopic meniscectomy was shown tobe 50 less in 1998 than the theoretical calculatedcosts in 1980ndash81

Discussion

Initial short-term follow-up studies of arthro-scopic meniscectomy have shown a fast function-al recovery and early return to sports (Guhl 1979Lysholm and Gillquist 1981 Pettrone 1982 Ham-berg and Gillquist 1984) Most of them mirror thedevelopmental phase of the arthroscopic tech-nique and report circumstances in research anddevelopment centers The alternative to arthro-scopic meniscectomy was an open procedurefollowed by a considerably longer rehabilitationperiod (Northmore-Ball et al 1983 Bergstroumlm etal 1984 Martens et al 1986)

We report the outcome after todayrsquos routineoutpatient arthroscopic meniscectomy The oper-ating time has decreased by more than one thirdsince 1980 The most plausible explanation is theexplosive development of video-control systemsfor better visualization and systems for irrigationImprovement in surgical instruments and in-creased technical skills of the surgeons are alsofactors which may have shortened the operationtime

More knowledge about the effects of meniscec-tomy and the importance of saving meniscus tis-sue (Fukubayashi and Kurusawa 1980 Baratz etal 1986 Weiss et al 1989 Fitzgibbons and Shel-bourne 1995 Rockborn and Gillquist 1996 Rooset al 1998) are shown by the 7 times lower fre-quency of total meniscectomies in the recent se-ries which cannot be explained by a difference inthe distribution of types of tear Despite a higherrate of total meniscectomies in 1980ndash81 the reop-eration rate was the same in both series a fact thatfurther speaks for a tissue-preserving approach

A delayed recovery in general and a delayed re-turn to sports in particular was seen in the seriesfrom 1995ndash98 with only about one third returningto sports within 4 weeks as compared to twothirds in 1980ndash81 but at the end a similar im-provement was seen in the two series Differencesin attitudes to the operation may explain the earli-er recovery in 1980ndash81 Then arthroscopic menis-cectomy was a new technique associated with en-thusiasm This phenomenon is called the Haw-thorne effect (Nation 1997) the patients knowingthat they had been subjected to a new and im-proved technique also wanted to show a sensa-

Acta Orthop Scand 2000 71 (5) 455ndash460 459

tional recovery In answering the questionnaire itwas also easier for them to express even minordissatisfaction in the later series (Lieberman et al1996 McGrory et al 1996 Houmlher et al 1997)

Another important factor influencing recoveryis probably the postoperative care In 1980ndash81the patients had more supervised rehabilitationand more postoperative visits During these visitsthe surgeon could answer any questions the pa-tients may have had and he probably also encour-aged them to return to sports as soon as possibleIn contrast the patients in the 1995ndash98 series wereleft to rehabilitate themselves without any contactwith the hospital unless they felt a need for itMany patients today may have unrealistic expec-tations about recovery since previous reports andthe media have stressed the early recovery afterarthroscopic meniscectomy With no guidanceduring rehabilitation the patient may start sportstoo early which can result in a prolonged disabili-ty These findings are also well in line withVervest et al (1999) who showed in a randomizedstudy that physiotherapy improves the functionalrecovery of the knee after meniscectomy

A thorough rehabilitation is probably neededbecause abnormalities in joint motion and musclestrength have been found in the operated limb solong as 2ndash3 months after partial meniscectomy(Durand et al 1993 Matthews and St-Pierre1996) Contact with medical personnel may alsobe necessary to alleviate the patientrsquos concernsand diminish apprehension caused by various mi-nor symptoms in the postoperative period

In 1982 Pettroni reported a 30 decrease in to-tal costs when meniscectomy changed from anopen to a closed procedure In our study a furthercost reduction of 52 for an arthroscopic menis-cectomy including postoperative rehabilitationhas occurred since 1980-81 Reductions in opera-tion time hospital bed occupancy and supervisedrehabilitation have also freed substantial resourc-es for other patients The direct costs of the pa-tients have been unchanged since 1980ndash81 asshown by similar access to operation and durationof sick leave

This study was supported by a scholarship from the CountyHospital in Norrkoumlping and a grant from the Swedish Na-

tional Center for Research in Sports We thank Mrs IngerEriksson RN for technical assistance and Per CarlssonCMT Linkoumlping University for help in calculating costs

Baratz M E Fu F H Mengato R Meniscal tears The effectof meniscectomy and of repair on intraarticular contactareas and stress in the human knee joint Am J SportsMed 1986 14 270-5

Bergstroumlm R Hamberg P Lysholm J Gillquist J Compari-son of open and endoscopic meniscectomy Clin Orthop1984 184 133-6

Durand A Richards C L Malouin F Bravo G Motor re-covery after arthroscopic meniscectomy J Bone JointSurg (Am) 1993 75 (2) 202-14

Fitzgibbons RE Shelbourne D ldquoAggressiverdquo nontreatmentof lateral meniscal tears seen during anterior cruciateligament reconstruction Am J Sport Med 1995 23 (2)156-9

Fukubayashi T Kurosawa H The contact area and pressuredistribution pattern of the knee Acta Orthop Scand1980 51 871-9

Gillquist J Hagberg G A new modification of the tech-nique of arthroscopy of the knee joint Acta Chir Scand1976 142 123-30

Gillquist J Hagberg G Oretorp N Therapeutic arthrosco-py of the knee Injury 1979 10 128-32

Guhl J F Operative arthroscopy Am J Sports Med 1979 7328-35

Hamberg P Gillquist J Knee function after arthroscopicmeniscectomy A prospective study Acta Orthop Scand1984 55 172-5

Hamberg P Gillquist J Lysholm J A comparison betweenarthroscopic meniscectomy and modified open menis-cectomy A prospective randomised study with emphasison postoperative rehabilitation J Bone Joint Surg (Br)1984 66 189-92

Houmlher J Bach T Muumlnster A Bouillon B Tiling T Does themode of data collection change results in a subjectiveknee score Self-administration versus interview Am JSports Med 1997 25 (5) 642-7

Lieberman J R Dorey F Shekelle P Schumacher L Tho-mas B Kilgus D Finerman G A Differences betweenpatientsrsquo and physiciansrsquo evaluations of outcome aftertotal hip arthroplasty J Bone Joint Surg (Am) 1996 78(6) 835-8

Lundberg M Odensten M Hammer R Hamberg P Lys-holm J Gillquist J Instruments for routine arthroscopicsurgery of the knee Acta Chir Scand (Suppl 520) 198479-83

Lysholm J Gillquist J Endoscopic meniscectomy Int Or-thop 1981 5 265-70

Lysholm J Hamberg P Gillquist J The correlation be-tween osteoarthristis as seen on radiographs and on ar-throscopy Arthroscopy 1987 3 (3) 161-5

Martens M A Backaert M Heyman E Mulier J C Partialarthroscopic meniscectomy versus total open meniscec-tomy Arch Orthop Trauma Surg 1986 105 31-5

456 Acta Orthop Scand 2000 71 (5) 455ndash460

All operations were performed under general orregional anesthesia with the limb in a thigh-hold-ing device and the operating table at knee level soplaced that both knees hung over the edge at 90degflexion A tourniquet was applied but inflated onlyif bleeding blocked the view In all operations weused a video system for visualization and an in-flow-outflow pump system with automatically-maintained intraarticular pressure was used

The operations were performed by one and thesame surgeon (PR) A simple printed training pro-gram was given to all patients postoperatively Nopostoperative visit was planned but the patientswere told to return if they did not improve or ifany other problem arose

At the postoperative unit the patients received aquestionnaire about the pre- and postoperative pe-riod and were asked to return it by mail after 3months On the basis of the questionnaire we di-vided the activity level into 5 categories (Table 1)Knee function was assessed with the modified Ly-sholm score (Tegner and Lysholm 1985) The pa-tient was also asked about time from injury to op-eration sick leave physiotherapy recovery andown opinion

71 of 82 patients returned the questionnaires af-ter 3 months Patients not completely recovered orsatisfied at 3 months or who did not answer thequestionnaire (n 50) were sent a second one amean of 24 (12ndash44) months after the operationThis questionnaire included questions about thepresent activity level and knee function ownopinion recovery and new operations The patientwas reminded by phone if the questionnaire hadnot been returned Finally all patients returned thequestionnaires

Statistics

For non-parametric data (Lysholm score Activitylevel) the Wilcoxon signed rank test was used toanalyze repeated measurements in the samepatient For parametric data (sick-leave) theunpaired t-test was used for differences betweengroups of patients Differences in proportionswere calculated with the chi-square test Thestatistical evaluation was done with Statisticasoftware (Statsoft Inc Tulsa OK USA)

Results

Only 2 of 82 meniscectomies were subtotal 9 pa-tients had a meniscectomy on both the medial andlateral meniscus (Tables 1 and 3) The mean oper-ation time including diagnostic arthroscopy was23 minutes (Table 3) and all were treated as outpa-tients Most had no postoperative visit (Table 2)18 patients took part in a supervised physiothera-py program after the operation

Three fourths of the patients were back at workwithin 1 week and almost 90 within 2 weeks Sickleave was not affected by cartilage changes type oftear or age at surgery (gtlt 40 years) type of menisc-ectomy or the side of the tear (mediallateral)

Complications

1 patient needed aspiration 1 had a superficialskin infection 1 a deep venous thrombosis and 4

Table 1 Patient characteristics

1995ndash98 1980ndash81

n 82 86Age mean SD 39 12 35 13 range (16ndash72) (15ndash67)Sex (malefemale) 65 17 77 9Meniscus (mediallateralboth) 66 7 9 74 11 1Activity level (medianrange) 3 (1ndash5) 3 (1ndash4)

Activity level divided into 5 categories (1) team sportson elite level (2) other strenuous sports and heavywork (3) recreational sports (4) ordinary work (5) lowactivity retired

Table 2 Time from injury to operation and number ofpostoperative visits within 10 months in 1995ndash98 Origi-nal data from patients operated on 1980ndash81 are alsopresented

1995ndash98 1980ndash81

Time injuryndashoperation n 71a 86Acute 8 91 weekndash3 months 15 203ndash6 months 16 23gt 6 months 32 33

Postoperative visits n 82b 860 56 01 19 522ndash5 7 34

a Time from injury to operation is based on 71 patientsreturning their questionnaires after 3 monthsb Number of postoperative visits is based on all patientsstudied (n 82)

Acta Orthop Scand 2000 71 (5) 455ndash460 457

other patients complained about pain and tender-ness at the patella tendon 1 patient had an extend-ed meniscectomy within the first 10 months

Activity knee function and patientrsquos ownopinion

The preinjury activity level was high 3 of 4 pa-tients were active in sports on a competitive orrecreational level

53 patients had regained their previous activitylevel 3 months after surgery and 73 after morethan 12 months No specific factor such as age orperoperative degenerative changes were related toa lower level of activity

Sports-active patients seemed to recover theircapacity slowly because only 19 of 53 were backat the preinjury level at 4 weeks and 27 of 53 at 10weeks Information about early return to sportswas available in 71 patients of whom 53 had beenactive in sports before injury

Almost half of the patients had knee problems

that a check-up would have been appropriate

Historical patients with arthroscopic menis-cectomy

Original protocolsdata were available from aseries of consecutive patients having unilateralarthroscopic meniscectomy from October 1980to May 1981 at the University Hospital ofLinkoumlping Sweden These were included in a se-ries of 100 patients with meniscectomy previouslyreported by Hamberg and Gillquist (1984) Fromthis series 86 patients who had no ACL-ruptureand no severe cartilage changes were retrospec-tively selected

In 78 of them a follow-up examination hadbeen carried out 10 (6ndash17) months after surgery 8had returned a questionnaire by mail The pre- andpostoperative activity level was assessed in 5 cate-gories (Table 1) The activity levels 4 and 10weeks after meniscectomy were available fromthe original protocols

Table 4 Average costs per patient for an arthroscopic meniscectomy 1995ndash98 The costs 1980ndash81 are theoretical and calculated by comparing the his-torical conditions in 1998 with the present costs USD

1995ndash98 1980ndash81USD USD

Operation694operation 694 694

Extra op-time14minute 0 135

Hospital stay574day 0 234

Postoperative doctorrsquos visit209visit 94 293

Physiotherapy training session33session 73 428

Total costs 861 1784

Table 3 Number of patients with different types of meniscectomy and opera-tion time in minutes 1995ndash98 Original data from a series of patients operatedon 1980ndash81 are also presented

Type of meniscectomy 1995ndash98 1980ndash81n mean SD (range) n mean SD (range)

All 82 23 12 (10ndash55) 86 33 13 (5ndash95)Partial meniscectomy 66 22 7 (10ndash53) 54 29 14 (5ndash65)Total meniscectomy 2 30 7 (25ndash35) 14 40 13 (20ndash75)Bucket handle resection 14 26 11 (12ndash55) 18 37 18 (15ndash95)

in daily life activities (scorelt 85) 3 months after surgerybut at 12 months or more ninetenths had a score gt 84(p lt 00001) 2 patients regard-ed their knee problems as un-changed after surgery A lowLysholm score was not relatedto age or to cartilage changesseen at the initial arthroscopyWhen the patients were askedabout time to complete recov-ery 57 of 82 patients consid-ered the knee have been com-pletely recovered at the latestfollow-up Of these half hadrecovered within 2 months andtwo thirds within 4 months

However 54 of 71 were sat-isfied with the result at 3months and 73 of 82 were sat-isfied at the latest follow-up

A common comment fromthe dissatisfied patients wasthat time to full recovery hadbeen too long Some patientssaid that they did not feel safein the postoperative period and

458 Acta Orthop Scand 2000 71 (5) 455ndash460

Knee function was evaluated with a scoringscale having a maximum of 95 where the maxi-mum score for instability was 20 (Hamberg et al1984) The scores were individually corrected tothe scale with a maximum score of 100 including25 for instability (Tegner and Lysholm 1985)

Data about time from injury to operation opera-tion time hospital stay sick leave and physiother-apy were also available Of 4 surgeons involved 2performed nine tenths of the operations

14 of 86 meniscetomies were total but only 1patient had meniscectomy on both the medial andlateral meniscus (Tables 1 and 3) The mean oper-ation time was 33 minutes (Table 3) 56 of the 86patients were treated as outpatients All patientshad one or more postoperative visits excludingthose for purposes of research and four fifths ofthe patients took part in supervised physiotherapyprogram postoperatively

Three fifths of the patients were back at workwithin 1 week and four fifths within 2 weeks Sickleave was not affected by cartilage changes typeside of meniscus tear or age at surgery 1 patienthad an extended meniscectomy within 10 months

Similar to the series 1995ndash98 3 of 4 patientswere active in sports on a competitive or recre-ational level before injury All patients except 2had regained their activity level until the final fol-low-up Sports-active patients quickly regainedtheir activity levelmdashie 34 of 64 patients wereback at the preinjury level after 4 weeks and 62after 10 weeks Only 4 patients had symptoms indaily life activities (Lysholm score lt 85) and 23had symptoms in sports activities (Lysholm scorelt 95) after 10 months but only half regarded theirknees as completely recovered at this time

Comparison of costs 1980ndash81 and 1995ndash98

An attempt was made to compare costs related tosurgery and rehabilitation in 1980ndash81 and 1995ndash98 (Table 4) When the conditions in 1980ndash81 re-garding operation time hospital stay number ofpostoperative visits and physiotherapy were com-pared in 1998 with the present costs the total costfor an arthroscopic meniscectomy was shown tobe 50 less in 1998 than the theoretical calculatedcosts in 1980ndash81

Discussion

Initial short-term follow-up studies of arthro-scopic meniscectomy have shown a fast function-al recovery and early return to sports (Guhl 1979Lysholm and Gillquist 1981 Pettrone 1982 Ham-berg and Gillquist 1984) Most of them mirror thedevelopmental phase of the arthroscopic tech-nique and report circumstances in research anddevelopment centers The alternative to arthro-scopic meniscectomy was an open procedurefollowed by a considerably longer rehabilitationperiod (Northmore-Ball et al 1983 Bergstroumlm etal 1984 Martens et al 1986)

We report the outcome after todayrsquos routineoutpatient arthroscopic meniscectomy The oper-ating time has decreased by more than one thirdsince 1980 The most plausible explanation is theexplosive development of video-control systemsfor better visualization and systems for irrigationImprovement in surgical instruments and in-creased technical skills of the surgeons are alsofactors which may have shortened the operationtime

More knowledge about the effects of meniscec-tomy and the importance of saving meniscus tis-sue (Fukubayashi and Kurusawa 1980 Baratz etal 1986 Weiss et al 1989 Fitzgibbons and Shel-bourne 1995 Rockborn and Gillquist 1996 Rooset al 1998) are shown by the 7 times lower fre-quency of total meniscectomies in the recent se-ries which cannot be explained by a difference inthe distribution of types of tear Despite a higherrate of total meniscectomies in 1980ndash81 the reop-eration rate was the same in both series a fact thatfurther speaks for a tissue-preserving approach

A delayed recovery in general and a delayed re-turn to sports in particular was seen in the seriesfrom 1995ndash98 with only about one third returningto sports within 4 weeks as compared to twothirds in 1980ndash81 but at the end a similar im-provement was seen in the two series Differencesin attitudes to the operation may explain the earli-er recovery in 1980ndash81 Then arthroscopic menis-cectomy was a new technique associated with en-thusiasm This phenomenon is called the Haw-thorne effect (Nation 1997) the patients knowingthat they had been subjected to a new and im-proved technique also wanted to show a sensa-

Acta Orthop Scand 2000 71 (5) 455ndash460 459

tional recovery In answering the questionnaire itwas also easier for them to express even minordissatisfaction in the later series (Lieberman et al1996 McGrory et al 1996 Houmlher et al 1997)

Another important factor influencing recoveryis probably the postoperative care In 1980ndash81the patients had more supervised rehabilitationand more postoperative visits During these visitsthe surgeon could answer any questions the pa-tients may have had and he probably also encour-aged them to return to sports as soon as possibleIn contrast the patients in the 1995ndash98 series wereleft to rehabilitate themselves without any contactwith the hospital unless they felt a need for itMany patients today may have unrealistic expec-tations about recovery since previous reports andthe media have stressed the early recovery afterarthroscopic meniscectomy With no guidanceduring rehabilitation the patient may start sportstoo early which can result in a prolonged disabili-ty These findings are also well in line withVervest et al (1999) who showed in a randomizedstudy that physiotherapy improves the functionalrecovery of the knee after meniscectomy

A thorough rehabilitation is probably neededbecause abnormalities in joint motion and musclestrength have been found in the operated limb solong as 2ndash3 months after partial meniscectomy(Durand et al 1993 Matthews and St-Pierre1996) Contact with medical personnel may alsobe necessary to alleviate the patientrsquos concernsand diminish apprehension caused by various mi-nor symptoms in the postoperative period

In 1982 Pettroni reported a 30 decrease in to-tal costs when meniscectomy changed from anopen to a closed procedure In our study a furthercost reduction of 52 for an arthroscopic menis-cectomy including postoperative rehabilitationhas occurred since 1980-81 Reductions in opera-tion time hospital bed occupancy and supervisedrehabilitation have also freed substantial resourc-es for other patients The direct costs of the pa-tients have been unchanged since 1980ndash81 asshown by similar access to operation and durationof sick leave

This study was supported by a scholarship from the CountyHospital in Norrkoumlping and a grant from the Swedish Na-

tional Center for Research in Sports We thank Mrs IngerEriksson RN for technical assistance and Per CarlssonCMT Linkoumlping University for help in calculating costs

Baratz M E Fu F H Mengato R Meniscal tears The effectof meniscectomy and of repair on intraarticular contactareas and stress in the human knee joint Am J SportsMed 1986 14 270-5

Bergstroumlm R Hamberg P Lysholm J Gillquist J Compari-son of open and endoscopic meniscectomy Clin Orthop1984 184 133-6

Durand A Richards C L Malouin F Bravo G Motor re-covery after arthroscopic meniscectomy J Bone JointSurg (Am) 1993 75 (2) 202-14

Fitzgibbons RE Shelbourne D ldquoAggressiverdquo nontreatmentof lateral meniscal tears seen during anterior cruciateligament reconstruction Am J Sport Med 1995 23 (2)156-9

Fukubayashi T Kurosawa H The contact area and pressuredistribution pattern of the knee Acta Orthop Scand1980 51 871-9

Gillquist J Hagberg G A new modification of the tech-nique of arthroscopy of the knee joint Acta Chir Scand1976 142 123-30

Gillquist J Hagberg G Oretorp N Therapeutic arthrosco-py of the knee Injury 1979 10 128-32

Guhl J F Operative arthroscopy Am J Sports Med 1979 7328-35

Hamberg P Gillquist J Knee function after arthroscopicmeniscectomy A prospective study Acta Orthop Scand1984 55 172-5

Hamberg P Gillquist J Lysholm J A comparison betweenarthroscopic meniscectomy and modified open menis-cectomy A prospective randomised study with emphasison postoperative rehabilitation J Bone Joint Surg (Br)1984 66 189-92

Houmlher J Bach T Muumlnster A Bouillon B Tiling T Does themode of data collection change results in a subjectiveknee score Self-administration versus interview Am JSports Med 1997 25 (5) 642-7

Lieberman J R Dorey F Shekelle P Schumacher L Tho-mas B Kilgus D Finerman G A Differences betweenpatientsrsquo and physiciansrsquo evaluations of outcome aftertotal hip arthroplasty J Bone Joint Surg (Am) 1996 78(6) 835-8

Lundberg M Odensten M Hammer R Hamberg P Lys-holm J Gillquist J Instruments for routine arthroscopicsurgery of the knee Acta Chir Scand (Suppl 520) 198479-83

Lysholm J Gillquist J Endoscopic meniscectomy Int Or-thop 1981 5 265-70

Lysholm J Hamberg P Gillquist J The correlation be-tween osteoarthristis as seen on radiographs and on ar-throscopy Arthroscopy 1987 3 (3) 161-5

Martens M A Backaert M Heyman E Mulier J C Partialarthroscopic meniscectomy versus total open meniscec-tomy Arch Orthop Trauma Surg 1986 105 31-5

Acta Orthop Scand 2000 71 (5) 455ndash460 457

other patients complained about pain and tender-ness at the patella tendon 1 patient had an extend-ed meniscectomy within the first 10 months

Activity knee function and patientrsquos ownopinion

The preinjury activity level was high 3 of 4 pa-tients were active in sports on a competitive orrecreational level

53 patients had regained their previous activitylevel 3 months after surgery and 73 after morethan 12 months No specific factor such as age orperoperative degenerative changes were related toa lower level of activity

Sports-active patients seemed to recover theircapacity slowly because only 19 of 53 were backat the preinjury level at 4 weeks and 27 of 53 at 10weeks Information about early return to sportswas available in 71 patients of whom 53 had beenactive in sports before injury

Almost half of the patients had knee problems

that a check-up would have been appropriate

Historical patients with arthroscopic menis-cectomy

Original protocolsdata were available from aseries of consecutive patients having unilateralarthroscopic meniscectomy from October 1980to May 1981 at the University Hospital ofLinkoumlping Sweden These were included in a se-ries of 100 patients with meniscectomy previouslyreported by Hamberg and Gillquist (1984) Fromthis series 86 patients who had no ACL-ruptureand no severe cartilage changes were retrospec-tively selected

In 78 of them a follow-up examination hadbeen carried out 10 (6ndash17) months after surgery 8had returned a questionnaire by mail The pre- andpostoperative activity level was assessed in 5 cate-gories (Table 1) The activity levels 4 and 10weeks after meniscectomy were available fromthe original protocols

Table 4 Average costs per patient for an arthroscopic meniscectomy 1995ndash98 The costs 1980ndash81 are theoretical and calculated by comparing the his-torical conditions in 1998 with the present costs USD

1995ndash98 1980ndash81USD USD

Operation694operation 694 694

Extra op-time14minute 0 135

Hospital stay574day 0 234

Postoperative doctorrsquos visit209visit 94 293

Physiotherapy training session33session 73 428

Total costs 861 1784

Table 3 Number of patients with different types of meniscectomy and opera-tion time in minutes 1995ndash98 Original data from a series of patients operatedon 1980ndash81 are also presented

Type of meniscectomy 1995ndash98 1980ndash81n mean SD (range) n mean SD (range)

All 82 23 12 (10ndash55) 86 33 13 (5ndash95)Partial meniscectomy 66 22 7 (10ndash53) 54 29 14 (5ndash65)Total meniscectomy 2 30 7 (25ndash35) 14 40 13 (20ndash75)Bucket handle resection 14 26 11 (12ndash55) 18 37 18 (15ndash95)

in daily life activities (scorelt 85) 3 months after surgerybut at 12 months or more ninetenths had a score gt 84(p lt 00001) 2 patients regard-ed their knee problems as un-changed after surgery A lowLysholm score was not relatedto age or to cartilage changesseen at the initial arthroscopyWhen the patients were askedabout time to complete recov-ery 57 of 82 patients consid-ered the knee have been com-pletely recovered at the latestfollow-up Of these half hadrecovered within 2 months andtwo thirds within 4 months

However 54 of 71 were sat-isfied with the result at 3months and 73 of 82 were sat-isfied at the latest follow-up

A common comment fromthe dissatisfied patients wasthat time to full recovery hadbeen too long Some patientssaid that they did not feel safein the postoperative period and

458 Acta Orthop Scand 2000 71 (5) 455ndash460

Knee function was evaluated with a scoringscale having a maximum of 95 where the maxi-mum score for instability was 20 (Hamberg et al1984) The scores were individually corrected tothe scale with a maximum score of 100 including25 for instability (Tegner and Lysholm 1985)

Data about time from injury to operation opera-tion time hospital stay sick leave and physiother-apy were also available Of 4 surgeons involved 2performed nine tenths of the operations

14 of 86 meniscetomies were total but only 1patient had meniscectomy on both the medial andlateral meniscus (Tables 1 and 3) The mean oper-ation time was 33 minutes (Table 3) 56 of the 86patients were treated as outpatients All patientshad one or more postoperative visits excludingthose for purposes of research and four fifths ofthe patients took part in supervised physiotherapyprogram postoperatively

Three fifths of the patients were back at workwithin 1 week and four fifths within 2 weeks Sickleave was not affected by cartilage changes typeside of meniscus tear or age at surgery 1 patienthad an extended meniscectomy within 10 months

Similar to the series 1995ndash98 3 of 4 patientswere active in sports on a competitive or recre-ational level before injury All patients except 2had regained their activity level until the final fol-low-up Sports-active patients quickly regainedtheir activity levelmdashie 34 of 64 patients wereback at the preinjury level after 4 weeks and 62after 10 weeks Only 4 patients had symptoms indaily life activities (Lysholm score lt 85) and 23had symptoms in sports activities (Lysholm scorelt 95) after 10 months but only half regarded theirknees as completely recovered at this time

Comparison of costs 1980ndash81 and 1995ndash98

An attempt was made to compare costs related tosurgery and rehabilitation in 1980ndash81 and 1995ndash98 (Table 4) When the conditions in 1980ndash81 re-garding operation time hospital stay number ofpostoperative visits and physiotherapy were com-pared in 1998 with the present costs the total costfor an arthroscopic meniscectomy was shown tobe 50 less in 1998 than the theoretical calculatedcosts in 1980ndash81

Discussion

Initial short-term follow-up studies of arthro-scopic meniscectomy have shown a fast function-al recovery and early return to sports (Guhl 1979Lysholm and Gillquist 1981 Pettrone 1982 Ham-berg and Gillquist 1984) Most of them mirror thedevelopmental phase of the arthroscopic tech-nique and report circumstances in research anddevelopment centers The alternative to arthro-scopic meniscectomy was an open procedurefollowed by a considerably longer rehabilitationperiod (Northmore-Ball et al 1983 Bergstroumlm etal 1984 Martens et al 1986)

We report the outcome after todayrsquos routineoutpatient arthroscopic meniscectomy The oper-ating time has decreased by more than one thirdsince 1980 The most plausible explanation is theexplosive development of video-control systemsfor better visualization and systems for irrigationImprovement in surgical instruments and in-creased technical skills of the surgeons are alsofactors which may have shortened the operationtime

More knowledge about the effects of meniscec-tomy and the importance of saving meniscus tis-sue (Fukubayashi and Kurusawa 1980 Baratz etal 1986 Weiss et al 1989 Fitzgibbons and Shel-bourne 1995 Rockborn and Gillquist 1996 Rooset al 1998) are shown by the 7 times lower fre-quency of total meniscectomies in the recent se-ries which cannot be explained by a difference inthe distribution of types of tear Despite a higherrate of total meniscectomies in 1980ndash81 the reop-eration rate was the same in both series a fact thatfurther speaks for a tissue-preserving approach

A delayed recovery in general and a delayed re-turn to sports in particular was seen in the seriesfrom 1995ndash98 with only about one third returningto sports within 4 weeks as compared to twothirds in 1980ndash81 but at the end a similar im-provement was seen in the two series Differencesin attitudes to the operation may explain the earli-er recovery in 1980ndash81 Then arthroscopic menis-cectomy was a new technique associated with en-thusiasm This phenomenon is called the Haw-thorne effect (Nation 1997) the patients knowingthat they had been subjected to a new and im-proved technique also wanted to show a sensa-

Acta Orthop Scand 2000 71 (5) 455ndash460 459

tional recovery In answering the questionnaire itwas also easier for them to express even minordissatisfaction in the later series (Lieberman et al1996 McGrory et al 1996 Houmlher et al 1997)

Another important factor influencing recoveryis probably the postoperative care In 1980ndash81the patients had more supervised rehabilitationand more postoperative visits During these visitsthe surgeon could answer any questions the pa-tients may have had and he probably also encour-aged them to return to sports as soon as possibleIn contrast the patients in the 1995ndash98 series wereleft to rehabilitate themselves without any contactwith the hospital unless they felt a need for itMany patients today may have unrealistic expec-tations about recovery since previous reports andthe media have stressed the early recovery afterarthroscopic meniscectomy With no guidanceduring rehabilitation the patient may start sportstoo early which can result in a prolonged disabili-ty These findings are also well in line withVervest et al (1999) who showed in a randomizedstudy that physiotherapy improves the functionalrecovery of the knee after meniscectomy

A thorough rehabilitation is probably neededbecause abnormalities in joint motion and musclestrength have been found in the operated limb solong as 2ndash3 months after partial meniscectomy(Durand et al 1993 Matthews and St-Pierre1996) Contact with medical personnel may alsobe necessary to alleviate the patientrsquos concernsand diminish apprehension caused by various mi-nor symptoms in the postoperative period

In 1982 Pettroni reported a 30 decrease in to-tal costs when meniscectomy changed from anopen to a closed procedure In our study a furthercost reduction of 52 for an arthroscopic menis-cectomy including postoperative rehabilitationhas occurred since 1980-81 Reductions in opera-tion time hospital bed occupancy and supervisedrehabilitation have also freed substantial resourc-es for other patients The direct costs of the pa-tients have been unchanged since 1980ndash81 asshown by similar access to operation and durationof sick leave

This study was supported by a scholarship from the CountyHospital in Norrkoumlping and a grant from the Swedish Na-

tional Center for Research in Sports We thank Mrs IngerEriksson RN for technical assistance and Per CarlssonCMT Linkoumlping University for help in calculating costs

Baratz M E Fu F H Mengato R Meniscal tears The effectof meniscectomy and of repair on intraarticular contactareas and stress in the human knee joint Am J SportsMed 1986 14 270-5

Bergstroumlm R Hamberg P Lysholm J Gillquist J Compari-son of open and endoscopic meniscectomy Clin Orthop1984 184 133-6

Durand A Richards C L Malouin F Bravo G Motor re-covery after arthroscopic meniscectomy J Bone JointSurg (Am) 1993 75 (2) 202-14

Fitzgibbons RE Shelbourne D ldquoAggressiverdquo nontreatmentof lateral meniscal tears seen during anterior cruciateligament reconstruction Am J Sport Med 1995 23 (2)156-9

Fukubayashi T Kurosawa H The contact area and pressuredistribution pattern of the knee Acta Orthop Scand1980 51 871-9

Gillquist J Hagberg G A new modification of the tech-nique of arthroscopy of the knee joint Acta Chir Scand1976 142 123-30

Gillquist J Hagberg G Oretorp N Therapeutic arthrosco-py of the knee Injury 1979 10 128-32

Guhl J F Operative arthroscopy Am J Sports Med 1979 7328-35

Hamberg P Gillquist J Knee function after arthroscopicmeniscectomy A prospective study Acta Orthop Scand1984 55 172-5

Hamberg P Gillquist J Lysholm J A comparison betweenarthroscopic meniscectomy and modified open menis-cectomy A prospective randomised study with emphasison postoperative rehabilitation J Bone Joint Surg (Br)1984 66 189-92

Houmlher J Bach T Muumlnster A Bouillon B Tiling T Does themode of data collection change results in a subjectiveknee score Self-administration versus interview Am JSports Med 1997 25 (5) 642-7

Lieberman J R Dorey F Shekelle P Schumacher L Tho-mas B Kilgus D Finerman G A Differences betweenpatientsrsquo and physiciansrsquo evaluations of outcome aftertotal hip arthroplasty J Bone Joint Surg (Am) 1996 78(6) 835-8

Lundberg M Odensten M Hammer R Hamberg P Lys-holm J Gillquist J Instruments for routine arthroscopicsurgery of the knee Acta Chir Scand (Suppl 520) 198479-83

Lysholm J Gillquist J Endoscopic meniscectomy Int Or-thop 1981 5 265-70

Lysholm J Hamberg P Gillquist J The correlation be-tween osteoarthristis as seen on radiographs and on ar-throscopy Arthroscopy 1987 3 (3) 161-5

Martens M A Backaert M Heyman E Mulier J C Partialarthroscopic meniscectomy versus total open meniscec-tomy Arch Orthop Trauma Surg 1986 105 31-5

458 Acta Orthop Scand 2000 71 (5) 455ndash460

Knee function was evaluated with a scoringscale having a maximum of 95 where the maxi-mum score for instability was 20 (Hamberg et al1984) The scores were individually corrected tothe scale with a maximum score of 100 including25 for instability (Tegner and Lysholm 1985)

Data about time from injury to operation opera-tion time hospital stay sick leave and physiother-apy were also available Of 4 surgeons involved 2performed nine tenths of the operations

14 of 86 meniscetomies were total but only 1patient had meniscectomy on both the medial andlateral meniscus (Tables 1 and 3) The mean oper-ation time was 33 minutes (Table 3) 56 of the 86patients were treated as outpatients All patientshad one or more postoperative visits excludingthose for purposes of research and four fifths ofthe patients took part in supervised physiotherapyprogram postoperatively

Three fifths of the patients were back at workwithin 1 week and four fifths within 2 weeks Sickleave was not affected by cartilage changes typeside of meniscus tear or age at surgery 1 patienthad an extended meniscectomy within 10 months

Similar to the series 1995ndash98 3 of 4 patientswere active in sports on a competitive or recre-ational level before injury All patients except 2had regained their activity level until the final fol-low-up Sports-active patients quickly regainedtheir activity levelmdashie 34 of 64 patients wereback at the preinjury level after 4 weeks and 62after 10 weeks Only 4 patients had symptoms indaily life activities (Lysholm score lt 85) and 23had symptoms in sports activities (Lysholm scorelt 95) after 10 months but only half regarded theirknees as completely recovered at this time

Comparison of costs 1980ndash81 and 1995ndash98

An attempt was made to compare costs related tosurgery and rehabilitation in 1980ndash81 and 1995ndash98 (Table 4) When the conditions in 1980ndash81 re-garding operation time hospital stay number ofpostoperative visits and physiotherapy were com-pared in 1998 with the present costs the total costfor an arthroscopic meniscectomy was shown tobe 50 less in 1998 than the theoretical calculatedcosts in 1980ndash81

Discussion

Initial short-term follow-up studies of arthro-scopic meniscectomy have shown a fast function-al recovery and early return to sports (Guhl 1979Lysholm and Gillquist 1981 Pettrone 1982 Ham-berg and Gillquist 1984) Most of them mirror thedevelopmental phase of the arthroscopic tech-nique and report circumstances in research anddevelopment centers The alternative to arthro-scopic meniscectomy was an open procedurefollowed by a considerably longer rehabilitationperiod (Northmore-Ball et al 1983 Bergstroumlm etal 1984 Martens et al 1986)

We report the outcome after todayrsquos routineoutpatient arthroscopic meniscectomy The oper-ating time has decreased by more than one thirdsince 1980 The most plausible explanation is theexplosive development of video-control systemsfor better visualization and systems for irrigationImprovement in surgical instruments and in-creased technical skills of the surgeons are alsofactors which may have shortened the operationtime

More knowledge about the effects of meniscec-tomy and the importance of saving meniscus tis-sue (Fukubayashi and Kurusawa 1980 Baratz etal 1986 Weiss et al 1989 Fitzgibbons and Shel-bourne 1995 Rockborn and Gillquist 1996 Rooset al 1998) are shown by the 7 times lower fre-quency of total meniscectomies in the recent se-ries which cannot be explained by a difference inthe distribution of types of tear Despite a higherrate of total meniscectomies in 1980ndash81 the reop-eration rate was the same in both series a fact thatfurther speaks for a tissue-preserving approach

A delayed recovery in general and a delayed re-turn to sports in particular was seen in the seriesfrom 1995ndash98 with only about one third returningto sports within 4 weeks as compared to twothirds in 1980ndash81 but at the end a similar im-provement was seen in the two series Differencesin attitudes to the operation may explain the earli-er recovery in 1980ndash81 Then arthroscopic menis-cectomy was a new technique associated with en-thusiasm This phenomenon is called the Haw-thorne effect (Nation 1997) the patients knowingthat they had been subjected to a new and im-proved technique also wanted to show a sensa-

Acta Orthop Scand 2000 71 (5) 455ndash460 459

tional recovery In answering the questionnaire itwas also easier for them to express even minordissatisfaction in the later series (Lieberman et al1996 McGrory et al 1996 Houmlher et al 1997)

Another important factor influencing recoveryis probably the postoperative care In 1980ndash81the patients had more supervised rehabilitationand more postoperative visits During these visitsthe surgeon could answer any questions the pa-tients may have had and he probably also encour-aged them to return to sports as soon as possibleIn contrast the patients in the 1995ndash98 series wereleft to rehabilitate themselves without any contactwith the hospital unless they felt a need for itMany patients today may have unrealistic expec-tations about recovery since previous reports andthe media have stressed the early recovery afterarthroscopic meniscectomy With no guidanceduring rehabilitation the patient may start sportstoo early which can result in a prolonged disabili-ty These findings are also well in line withVervest et al (1999) who showed in a randomizedstudy that physiotherapy improves the functionalrecovery of the knee after meniscectomy

A thorough rehabilitation is probably neededbecause abnormalities in joint motion and musclestrength have been found in the operated limb solong as 2ndash3 months after partial meniscectomy(Durand et al 1993 Matthews and St-Pierre1996) Contact with medical personnel may alsobe necessary to alleviate the patientrsquos concernsand diminish apprehension caused by various mi-nor symptoms in the postoperative period

In 1982 Pettroni reported a 30 decrease in to-tal costs when meniscectomy changed from anopen to a closed procedure In our study a furthercost reduction of 52 for an arthroscopic menis-cectomy including postoperative rehabilitationhas occurred since 1980-81 Reductions in opera-tion time hospital bed occupancy and supervisedrehabilitation have also freed substantial resourc-es for other patients The direct costs of the pa-tients have been unchanged since 1980ndash81 asshown by similar access to operation and durationof sick leave

This study was supported by a scholarship from the CountyHospital in Norrkoumlping and a grant from the Swedish Na-

tional Center for Research in Sports We thank Mrs IngerEriksson RN for technical assistance and Per CarlssonCMT Linkoumlping University for help in calculating costs

Baratz M E Fu F H Mengato R Meniscal tears The effectof meniscectomy and of repair on intraarticular contactareas and stress in the human knee joint Am J SportsMed 1986 14 270-5

Bergstroumlm R Hamberg P Lysholm J Gillquist J Compari-son of open and endoscopic meniscectomy Clin Orthop1984 184 133-6

Durand A Richards C L Malouin F Bravo G Motor re-covery after arthroscopic meniscectomy J Bone JointSurg (Am) 1993 75 (2) 202-14

Fitzgibbons RE Shelbourne D ldquoAggressiverdquo nontreatmentof lateral meniscal tears seen during anterior cruciateligament reconstruction Am J Sport Med 1995 23 (2)156-9

Fukubayashi T Kurosawa H The contact area and pressuredistribution pattern of the knee Acta Orthop Scand1980 51 871-9

Gillquist J Hagberg G A new modification of the tech-nique of arthroscopy of the knee joint Acta Chir Scand1976 142 123-30

Gillquist J Hagberg G Oretorp N Therapeutic arthrosco-py of the knee Injury 1979 10 128-32

Guhl J F Operative arthroscopy Am J Sports Med 1979 7328-35

Hamberg P Gillquist J Knee function after arthroscopicmeniscectomy A prospective study Acta Orthop Scand1984 55 172-5

Hamberg P Gillquist J Lysholm J A comparison betweenarthroscopic meniscectomy and modified open menis-cectomy A prospective randomised study with emphasison postoperative rehabilitation J Bone Joint Surg (Br)1984 66 189-92

Houmlher J Bach T Muumlnster A Bouillon B Tiling T Does themode of data collection change results in a subjectiveknee score Self-administration versus interview Am JSports Med 1997 25 (5) 642-7

Lieberman J R Dorey F Shekelle P Schumacher L Tho-mas B Kilgus D Finerman G A Differences betweenpatientsrsquo and physiciansrsquo evaluations of outcome aftertotal hip arthroplasty J Bone Joint Surg (Am) 1996 78(6) 835-8

Lundberg M Odensten M Hammer R Hamberg P Lys-holm J Gillquist J Instruments for routine arthroscopicsurgery of the knee Acta Chir Scand (Suppl 520) 198479-83

Lysholm J Gillquist J Endoscopic meniscectomy Int Or-thop 1981 5 265-70

Lysholm J Hamberg P Gillquist J The correlation be-tween osteoarthristis as seen on radiographs and on ar-throscopy Arthroscopy 1987 3 (3) 161-5

Martens M A Backaert M Heyman E Mulier J C Partialarthroscopic meniscectomy versus total open meniscec-tomy Arch Orthop Trauma Surg 1986 105 31-5

Acta Orthop Scand 2000 71 (5) 455ndash460 459

tional recovery In answering the questionnaire itwas also easier for them to express even minordissatisfaction in the later series (Lieberman et al1996 McGrory et al 1996 Houmlher et al 1997)

Another important factor influencing recoveryis probably the postoperative care In 1980ndash81the patients had more supervised rehabilitationand more postoperative visits During these visitsthe surgeon could answer any questions the pa-tients may have had and he probably also encour-aged them to return to sports as soon as possibleIn contrast the patients in the 1995ndash98 series wereleft to rehabilitate themselves without any contactwith the hospital unless they felt a need for itMany patients today may have unrealistic expec-tations about recovery since previous reports andthe media have stressed the early recovery afterarthroscopic meniscectomy With no guidanceduring rehabilitation the patient may start sportstoo early which can result in a prolonged disabili-ty These findings are also well in line withVervest et al (1999) who showed in a randomizedstudy that physiotherapy improves the functionalrecovery of the knee after meniscectomy

A thorough rehabilitation is probably neededbecause abnormalities in joint motion and musclestrength have been found in the operated limb solong as 2ndash3 months after partial meniscectomy(Durand et al 1993 Matthews and St-Pierre1996) Contact with medical personnel may alsobe necessary to alleviate the patientrsquos concernsand diminish apprehension caused by various mi-nor symptoms in the postoperative period

In 1982 Pettroni reported a 30 decrease in to-tal costs when meniscectomy changed from anopen to a closed procedure In our study a furthercost reduction of 52 for an arthroscopic menis-cectomy including postoperative rehabilitationhas occurred since 1980-81 Reductions in opera-tion time hospital bed occupancy and supervisedrehabilitation have also freed substantial resourc-es for other patients The direct costs of the pa-tients have been unchanged since 1980ndash81 asshown by similar access to operation and durationof sick leave

This study was supported by a scholarship from the CountyHospital in Norrkoumlping and a grant from the Swedish Na-

tional Center for Research in Sports We thank Mrs IngerEriksson RN for technical assistance and Per CarlssonCMT Linkoumlping University for help in calculating costs

Baratz M E Fu F H Mengato R Meniscal tears The effectof meniscectomy and of repair on intraarticular contactareas and stress in the human knee joint Am J SportsMed 1986 14 270-5

Bergstroumlm R Hamberg P Lysholm J Gillquist J Compari-son of open and endoscopic meniscectomy Clin Orthop1984 184 133-6

Durand A Richards C L Malouin F Bravo G Motor re-covery after arthroscopic meniscectomy J Bone JointSurg (Am) 1993 75 (2) 202-14

Fitzgibbons RE Shelbourne D ldquoAggressiverdquo nontreatmentof lateral meniscal tears seen during anterior cruciateligament reconstruction Am J Sport Med 1995 23 (2)156-9

Fukubayashi T Kurosawa H The contact area and pressuredistribution pattern of the knee Acta Orthop Scand1980 51 871-9

Gillquist J Hagberg G A new modification of the tech-nique of arthroscopy of the knee joint Acta Chir Scand1976 142 123-30

Gillquist J Hagberg G Oretorp N Therapeutic arthrosco-py of the knee Injury 1979 10 128-32

Guhl J F Operative arthroscopy Am J Sports Med 1979 7328-35

Hamberg P Gillquist J Knee function after arthroscopicmeniscectomy A prospective study Acta Orthop Scand1984 55 172-5

Hamberg P Gillquist J Lysholm J A comparison betweenarthroscopic meniscectomy and modified open menis-cectomy A prospective randomised study with emphasison postoperative rehabilitation J Bone Joint Surg (Br)1984 66 189-92

Houmlher J Bach T Muumlnster A Bouillon B Tiling T Does themode of data collection change results in a subjectiveknee score Self-administration versus interview Am JSports Med 1997 25 (5) 642-7

Lieberman J R Dorey F Shekelle P Schumacher L Tho-mas B Kilgus D Finerman G A Differences betweenpatientsrsquo and physiciansrsquo evaluations of outcome aftertotal hip arthroplasty J Bone Joint Surg (Am) 1996 78(6) 835-8

Lundberg M Odensten M Hammer R Hamberg P Lys-holm J Gillquist J Instruments for routine arthroscopicsurgery of the knee Acta Chir Scand (Suppl 520) 198479-83

Lysholm J Gillquist J Endoscopic meniscectomy Int Or-thop 1981 5 265-70

Lysholm J Hamberg P Gillquist J The correlation be-tween osteoarthristis as seen on radiographs and on ar-throscopy Arthroscopy 1987 3 (3) 161-5

Martens M A Backaert M Heyman E Mulier J C Partialarthroscopic meniscectomy versus total open meniscec-tomy Arch Orthop Trauma Surg 1986 105 31-5

460 Acta Orthop Scand 2000 71 (5) 455ndash460

Matthews P St-Pierre D M Recovery of muscle strengthfollowing arthroscopic meniscectomy J Orthop SportsPhys Ther 1996 23 (1) 18-26

McGrory B J Morrey B F Rand J A Ilstrup D M Correla-tion of patient questionnaire responses and physicianhistory in grading clinical outcome following hip andknee arthroplasty A prospective study of 201 joint ar-throplasties J Arthroplasty 1996 11 (1) 47-57

Nation J R Research methods New Jersey Prentice HallInc 1997 202-3

Northmore-Ball M D Dandy D J Jackson R W Arthro-scopic open partial and total meniscectomy A compar-ative study J Bone Joint Surg (Br) 1983 65 (4) 400-4

Pettrone F A Meniscectomy arthrotomy versus arthrosco-py Am J Sports Med 1982 10 (6) 355-9

Rockborn P Gillquist J Long-term results after arthro-scopic meniscectomy The role of preexisting cartilagefibrillation in a 13-year follow-up of 60 patients Int JSports Med 1996 17 608-13

Roos H Lauren M Adalberth T Roos E M Jonsson KLohmander L S Knee osteoarthrosis after meniscecto-my prevalence of radiographic changes after twenty-one years compared with matched controls ArthritisRheum 1998 41 (4) 687-93

Tegner Y Lysholm J Rating systems in the evaluation ofknee ligament injuries Clin Orthop 1985 198 43-9

Vervest A M J S Maurer C A J Schambergen T G R de BieR A Bulstra S K Effectiveness of physiotherapy aftermeniscectomy Knee Surg Sports Traumatol Arthrosco-py 1999 7 360-4

Weiss C B Lundberg M Hamberg P DeHaven K EGillquist J Non-operative treatment of meniscal tears JBone Joint Surg (Am) 1989 71 (6) 811-22