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. 2023 Jan 25;94:26–31. doi: 10.2340/17453674.2023.7131

Decreasing incidence of knee arthroscopy in Sweden between 2002 and 2016: a nationwide register-based study

Lukas BERGLUND 1, Cecilia LIU 1, Johanna ADAMI 3, Mårten PALME 4, Abdul Rashid QURESHI 2, Li FELLÄNDER-TSAI 1,✉
PMCID: PMC9880875  PMID: 36701119

Abstract

Background and purpose

Several randomized trials have demonstrated the lack of effect of arthroscopic lavage as treatment for knee osteoarthritis (OA). These results have in turn resulted in a change in Swedish guidelines and reimbursement. We aimed to investigate the use of knee arthroscopies in Sweden between 2002 and 2016. Patient demographics, regional differences, and the magnitude of patients with knee OA undergoing knee arthroscopy were also analyzed.

Patients and methods

Trends in knee arthroscopy were investigated using the Swedish Hospital Discharge Register (SHDR) to conduct a nationwide register-based study including all adults (>18 years of age) undergoing any knee arthroscopy between 2002 and 2016.

Results

The total number of knee arthroscopies performed during the studied period was 241,055. The annual surgery rate declined in all age groups, for males and females as well as patients with knee OA. The incidence dropped from 247 to 155 per 105 inhabitants. Over 50% of arthroscopies were performed in metropolitan regions.

Conclusion

We showed a dramatic decline in knee arthroscopy. There is variability in the surgery rate between males and females and among the regions of Sweden.

Several randomized controlled trials have shown that knee arthroscopy as a therapy for osteoarthritits (OA) did not yield better results than placebo in the form of sham surgery (1-4). This has caused a change in reimbursement regarding use of arthroscopic intervention of knee OA in many countries, including Sweden. The procedure was removed from Swedish National Guidelines in 2012 in accordance with the National Board of Health and Welfare (5).

After the publications by Moseley et al. and Kirkley et al. in 2002 and 2008, the number of arthroscopies undertaken for degenerative knee disease and traumatic meniscal tears in Finland and Sweden changed (1,3,6). In Sweden there was an initial increase during the first part of the 2000s with a peak in 2008 and a subsequent decline (6). Similar results can also be found in other countries (7,8), making it a global change.

Regarding cost and effect, the National Board of Health and Welfare in Sweden has estimated a cost reduction for avoiding arthroscopic lavage of OA knees to be approximately SEK 25 million per year (5). Although there have been continuous quality improvements in arthroscopic surgery and healthcare, surgical procedures, even though arthroscopic, are still not without risk of postoperative complications such as wound infection, hematoma, and deep vein thrombosis (10-13). Treatment of these types of diagnoses also contributes to indirect costs not included in the above-calculated cost reduction.

Our study investigated the incidence of knee arthroscopy in Sweden between 2002 and 2016 in the adult population, including patient demographics, diagnoses, and regional differences.

Patients and methods

This study is a nationwide population-based register study using data from the Swedish Hospital Discharge Register (SHDR). The register has been reviewed and validated (14). The Swedish National Board of Health and Welfare established the national register in 1964. The SHDR includes inpatient care since 1987 and outpatient appointments since 2001 with data on personal identification number, age, sex, domicile of the patient, length of hospital stay, primary and secondary diagnoses, and surgical procedures during the hospital stay (14). Annual population data between 2002 and 2016 was retrieved from Statistics Sweden (SCB) to calculate surgery rate (incidence per 105 inhabitants). The incidence of knee arthroscopy was based on the entire adult population.

All adult patients from 18 years of age were included. The International Classification of Diseases, Tenth Revision (ICD-10) was used to identify surgical procedures. Patients with an ICD-10 procedure code indicative of any knee arthroscopy surgery between 2002 and 2016 were included in the study (Table 1).

Table 1.

ICD operation codes included in the study

NGA11 Exploration of knee joint; arthroscopic
NGD01 Total excision of meniscus; arthroscopic
NGD10 Percutaneous or closed partial excision of meniscus
NGD11 Partial excision of meniscus; arthroscopic
NGD21 Reinsertion of meniscus; arthroscopic
NGD91 Other operation on meniscus; arthroscopic
NGE01 Incision or suture of joint capsule of knee; arthroscopic
NGE11 Transcision or excision of ligament of knee; arthroscopic
NGE21 Suture or replantation of ligament of knee; arthroscopic
NGE31 Transposition of ligament of knee; arthroscopic
NGE41 Reconstruction of ligament of knee without foreign object; arthroscopic
NGE51 Reconstruction of ligament of knee with foreign object; arthroscopic
NGE91 Other surgery on capsule or ligament of knee; arthroscopic
NGF01 Total synovectomy of knee; arthroscopic
NGF11 Partial synovectomy of knee; arthroscopic
NGF21 Fixation of fragment of surface of knee; arthroscopic
NGF31 Partial excision of joint cartilage of knee; arthroscopic
NGF91 Other operation on synovia or joint surface of knee; arthroscopic
NGH41 Extraction of foreign body or loose body of the knee; arthroscopic
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To analyze the rate of knee arthroscopy among OA patients, ICD-10 diagnosis codes M17.0–9 were used to identify patients with an underlying primary and secondary OA disease of the knee followed by knee arthroscopy.

The data has been sorted to match the 21 regions in Sweden to simplify comparison. The annual surgery rate for each region was assessed.

To give an overview of the difference in densely populated areas versus less densely populated areas, the 3 regions with the highest population density (population per square kilometer, PD) were compared with the 3 regions with the lowest PD. According to SCB population data, the 3 most densely populated regions in 2017 were: Region Stockholm (PD 348), Region Skåne (PD 121), and Västra Götalandsregionen (PD 70). The 3 least densely populated regions in 2017 were: Region Västerbotten (PD 5), Region Jämtland Härjedalen (PD 3), and Region Norrbotten (PD 3). They were grouped into 2 groups for comparison: metropolitan regions and rural regions. Data on the number of arthroscopies performed and incidence were compared for each year in the study period.

Outcomes

Primary outcome was the number of knee arthroscopy performed, both during hospitalization and in an ambulatory care setting, in Sweden.

Secondary outcome was the number of knee arthroscopy performed in patients with ICD-10 coding for knee OA.

Statistics

Descriptive statistics for each year between 2002 and 2016 were produced using the statistical software SPSS 25.0 (IBM Corp, Armonk, NY, USA), Stata 17.0 (Stata Corp, College Station, TX, USA), and SAS 9.4 level 1 M7 (SAS, Campus Drive, Cary, NC, USA). The frequency of knee arthroscopies performed in Sweden is presented, as well as the surgery incidence, calculated per 105 inhabitants, sorted by region, sex, and the following age groups: 18–29, 30–39, 40–49, 50–59, 60–69, and ≥ 70. Separate analysis has been carried out for OA patients and presented in the same categories as for the general study population.

Ethics, data sharing, funding, and potential conflicts of interest

Ethical approval from the institutional review board was granted for the study (Ref nos 2013/581-31/5 and 2016/2251-32). Data sharing is possible through SHDR. The study was fully financed by research grants from Region Stockholm (ALF Re No 20170479, 20180462, and 20200305). The authors report no conflict of interest. Completed disclosure forms for this article following the ICMJE template are available on the article page doi: 10.2340/17453674.2023.7131

Results

The total number of knee arthroscopies in Sweden reported to SHDR between 2002 and 2016 was 241,055, comprising 218,082 performed in an ambulatory setting and 22,973 performed as in-hospital care (Table 2). The absolute number of yearly knee arthroscopies in Sweden decreased by 29% during the study period. The incidence also decreased, going from 247 to 155 knee arthroscopies per 105 inhabitants during the study period. The mean age of the patients was 41 and remained steady during the study period (Table 2).

Table 2.

The annual number of arthroscopies divided by sex, incidence per 105 inhabitants, age and percentage performed in an outpatient clinic

Year Male (n) Female (n) Total (n) Incidence (per 105) Mean age Out-patient clinic (%)
2002 10,912 6,329 17,241 247 41 85
2003 10,324 6,160 16,484 235 41 86
2004 9,976 5,923 15,899 225 41 87
2005 10,303 6,353 16,656 235 41 89
2006 9,738 6,222 15,960 223 42 87
2007 9,668 6,410 16,078 223 42 89
2008 11,125 7,551 18,676 256 42 92
2009 10,684 7,065 17,749 241 42 95
2010 9,911 6,401 16,312 219 40 93
2011 9,448 6,521 15,969 212 41 92
2012 9,713 6,492 16,205 213 41 92
2013 9,966 6,500 16,466 215 41 92
2014 9,253 6,384 15,637 202 40 94
2015 7,899 5,633 13,532 174 40 93
2016 6,905 5,286 12,191 155 39 94
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More men (60%) than women (40%) underwent knee arthroscopy with the difference slightly decreasing towards the end of the study period (Figure 1). The age group 18–29 years underwent most knee arthroscopies and the age group > 70 the least (Table 3). The incidence per 105 inhabitants decreased in all age groups. The biggest change was seen in the age groups 30–39 and 60–69, which both decreased by 50%. A peak was seen in all age groups in 2008 (Figure 2).

Figure 1.

Figure 1

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Annual surgery frequency by sex.

Table 3.

Incidence of knee arthroscopies per 105 inhabitants divided into age groups

Year 18–29 30–39 40–49 50–59 60–69 ≥ 70 Total
2002 340 292 307 279 178 45 246
2003 330 278 299 265 157 40 234
2004 309 259 284 266 160 40 225
2005 327 259 308 274 164 42 234
2006 313 234 272 274 169 46 222
2007 310 227 285 264 170 48 222
2008 348 251 325 318 201 56 255
2009 327 237 318 297 177 50 239
2010 325 217 291 258 145 36 218
2011 313 214 275 248 149 38 211
2012 302 207 290 266 144 39 212
2013 310 210 291 263 147 38 214
2014 311 201 273 245 123 31 201
2015 277 168 235 201 106 29 173
2016 264 150 201 175 89 24 154
Mean 313 227 283 259 151 40 217
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Figure 2.

Figure 2

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Annual surgery frequency by age groups.

Figure 3.

Figure 3

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Annual surgery frequency in OA patients by sex.

Figure 4.

Figure 4

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Annual surgery frequency in OA patients by age groups.

There was a big difference between the absolute number of knee arthroscopies in metropolitan regions and rural regions (Table 4). Over 50% of total knee arthroscopies were performed in a metropolitan region. The difference was at its peak during the beginning of the study period, 2002–2004, and was less evident during 2006–2009, only to increase again towards the end of the period. In total, 4,048 knee arthroscopies were excluded from this analysis as specific hospital data was missing. The mean value for all regions was 157 arthroscopies per 105 inhabitants. In the Capital Region of Stockholm, the mean incidence was 285. In general, there has been a decrease in all regions (Table 5, see Appendix).

Table 4.

Comparison of metropolitan and rural regions. The annual number of arthroscopies and incidence per 105

Year Metropolitan regions Rural regions Incidence
metro. rural
2002 10,005 610 222 96
2003 9,566 703 211 110
2004 9,700 562 213 88
2005 9,582 1,019 209 160
2006 8,361 1,192 180 187
2007 8,422 1,039 179 164
2008 10,452 1,089 220 172
2009 9,587 1,214 199 191
2010 8,601 954 176 150
2011 8,288 779 168 123
2012 8,355 700 167 110
2013 8,828 768 175 121
2014 8,838 687 173 107
2015 7,934 586 153 91
2016 7,183 505 136 78
Total 133,702 12,407
Mean 185 130
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Table 5.

Incidence per 105 inhabitants per region, the mean of 2002–2016 and the mean for the whole of Sweden

Region 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Mean
Blekinge 205 193 240 174 163 135 154 140 105 107 104 94 74 62 52 133
Dalarna 210 176 172 148 166 165 188 176 155 150 129 117 110 104 94 151
Gävleborg 185 180 177 171 162 198 169 204 217 198 172 181 159 162 141 179
Gotland 274 240 115 30 30 239 231 252 164 164 183 212 168 178 137 174
Halland 149 141 128 162 125 105 88 113 112 96 106 130 55 44 128 112
Jämtland 108 128 117 172 188 151 154 60 29 23 17 28 20 21 8 82
Jönköping 95 94 160 226 209 197 199 244 179 154 132 141 127 114 102 158
Kalmar 113 162 228 307 526 391 565 549 260 510 420 366 301 200 121 335
Kronoberg 523 370 184 239 214 337 263 294 272 296 318 333 319 265 112 289
Norrbotten 152 146 119 95 171 174 141 161 141 105 91 109 85 84 89 124
Örebro 269 221 185 166 16 161 153 137 128 101 81 77 65 74 89 128
Östergötland 136 113 0 0 166 117 107 82 88 123 234 198 158 135 109 118
Skåne 186 147 136 145 132 141 125 144 139 113 119 130 117 130 115 134
Södermanland 193 165 138 136 119 137 156 172 150 138 124 91 91 75 71 130
Stockholm 335 339 332 316 268 261 359 318 274 255 271 245 254 236 214 285
Uppsala 205 175 176 173 155 146 149 140 187 174 222 212 199 189 160 178
Värmland 119 129 127 140 101 84 107 83 100 89 77 167 171 98 89 112
Västerbotten 33 67 44 218 203 159 210 285 218 189 174 177 172 132 103 159
Västernorrland 150 140 147 160 139 103 137 114 79 108 97 86 85 66 51 111
Västmanland 9 130 137 148 133 109 141 111 102 93 94 66 51 62 57 96
Västra Götaland 113 105 127 127 112 110 122 94 82 100 72 119 112 63 51 101
Sweden 179 170 152 164 167 172 186 185 152 156 154 156 138 119 100 157
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The total number of knee arthroscopies performed on patients with knee OA has decreased since 2002 (Table 6). In 2002, 4,277 operations were done on OA indication and in 2016 the number had dropped to 1,970 operations. The maximum amount occurred in 2008 (n = 5,116). The incidence per 105 inhabitants has also decreased in this patient group. In 2002 it was 61, in comparison with 25 in 2016. More male patients with knee OA were treated with knee arthroscopy than females (Table 6). The difference decreased over time. The largest age group undergoing knee arthroscopy for OA diagnosis was 50–59 (Table 6).

Table 6.

Annual number of knee arthroscopies of OA patients divided by sex, age groups, and incidence per 105

Year Male Female Total Age groups Incidence
18–29 30–39 40–49 50–59 60–69 ≥ 70 per 105
2002 2,449 1,828 4,277 157 487 958 1,510 864 301 61
2003 2,471 1,773 4,244 159 474 1012 1,529 809 261 60
2004 2,325 1,697 4,022 129 418 897 1,472 838 268 57
2005 2,325 1,773 4,098 140 360 1,026 1,421 892 259 58
2006 2,270 1,775 4,045 111 346 914 1,402 951 321 57
2007 2,253 1,831 4,084 111 356 920 1,388 982 327 57
2008 2,764 2,352 5,116 166 421 1,159 1,740 1,254 376 71
2009 2,565 2,171 4,736 164 350 1,175 1,627 1,100 320 64
2010 2,177 1,782 3,959 128 298 1,022 1,326 958 227 53
2011 1,862 1,597 3,459 98 268 876 1,157 844 216 46
2012 1,883 1,612 3,495 114 237 888 1,212 803 241 46
2013 1,775 1,475 3,250 92 220 842 1,073 807 216 42
2014 1,594 1,340 2,934 104 214 734 1,057 639 186 38
2015 1,154 1,080 2,234 71 138 580 789 505 151 29
2016 1,064 906 1,970 82 109 477 719 442 141 25
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Discussion

The main finding in this nationwide population-based register study is that the absolute number of knee arthroscopies performed each year in Sweden decreased between 2002 and 2016 even though the population as a whole increased. This includes all age groups, men and women, as well as patients with OA of the knee. The same change can also be seen in the incidence per 105 inhabitants. This does not mean that the total amount of knee surgeries in a broader sense has decreased. A study performed in Florida, USA, demonstrated that the rate of knee arthroscopies declined between 2002 and 2015 (15).

The Swedish National Guidelines for Musculoskeletal Diseases, published in 2012 (5), excluded arthroscopic lavage and debridement as treatment for OA, but the most cited studies on its ineffectiveness had already been published in 2002 and 2008 (1-4). Since then, there has been a consensus in Sweden that arthroscopic lavage and debridement should not be used for treating knee OA (16). The change of practice can be seen in the results, as patients in the older age groups are being operated on less frequently today. The arthroscopic surgery rate on patients with knee osteoarthritis decreased during the study period. Other studies have shown similar results up to 2012 (6) and it is noteworthy that there is a further decrease up to 2016. Evidence thus suggests that high-quality studies on the effectiveness of knee arthroscopy has, together with national guidelines, impacted healthcare on a global scale resulting in higher precision for the indication of knee arthroscopy, thus avoiding unnecessary complications. Taken together it is clear that change in practice requires time despite available evidence.

The mean age of patients undergoing knee arthroscopy has, in general, remained the same. Most of the patients are young, in the age group 18–29, and the change in incidence among them is small compared with the other groups. The result could speculatively be explained by the fact that these patients are treated with knee arthroscopy because of injuries occurring during sports or physical activity, with specific symptoms of knee injury compared with degenerative knee disorders. Recommendations regarding arthroscopic knee surgery for younger patient groups have remained the same although studies suggest that, even without OA, degenerative meniscus injuries may not be a future indication for surgery (9).

There was a notable increase in the number of arthroscopies performed from 2006 to 2008, followed by a rapid decrease. This reduction occurred before the guidelines were changed (in 2012). Despite the publication of studies on the ineffectiveness of arthroscopy as general treatment for OA in 2002 and 2008, the magnitude of the reduction in surgeries was considerable (Table 6). The reason for this rapid change is not clear. A connection between health, healthcare services, and macroeconomic conditions might play a role regarding behavior. A study in the United States by the American Association of Hip and Knee Surgeons showed that the demand for joint reconstruction surgery and the visits to outpatient clinics decreased by around 30% following the 2008 economic crisis (17). It is possible that the 2008 financial crisis and the following recession also affected the availability and use of knee arthroscopy in Sweden. Even though some studies show higher utilization of healthcare in a recession, orthopedic surgery in general and knee arthroscopies in particular are not lifesaving and might follow a different pattern. Knee arthroscopies are usually done in ambulatory care. These clinics in Sweden, many of which are privately owned and operated, might have been affected in times of economic instability.

Furthermore, the arthroscopic surgery rate showed great variability between metropolitan and rural regions in Sweden. This reflection of inequality deserves to be pointed out as all regions share the same national reimbursement, healthcare policy, and legislation. The regional variations may reflect variations in surgeons’ opinions and beliefs concerning clinical indications for surgery, which has also been demonstrated for knee arthroplasty (18). Large regional differences have previously also been shown regarding arthroscopic meniscal procedures (19) and a recent publication demonstrated a large decrease in the incidence of arthroscopic meniscal procedures and other arthroscopic knee procedures from 2010 to 2018 (20).

Strengths and limitations

The size of the data set is one of the strengths of this nationwide population-based register study. Because our study is registerbased, it is not possible to know how OA was diagnosed. There is a possibility that the coding was influenced by other factors, such as physician habits, insurance policies, patients’ presentation, etc. As we included both minor and major surgical codes, we cannot rule out changes also in major procedures separate from minor procedures due to the emerging debate following several RCTs published in high-impact journals.

The division of metropolitan regions and rural regions was simplified, as we studied only regions and not specific cities. The 3 largest cities in Sweden are Stockholm, Gothenburg, and Malmö, and they are considered as metropolitan areas (regions). However, the regions they are included in also cover a large number of smaller cities and rural areas. The difference in arthroscopy rate between the regions is suspected to be even larger if a finer analysis were to be made.

Conclusion

The incidence of knee arthroscopy in Sweden has declined in all age groups, for both male and female patients as well as patients with knee OA. There were considerable regional variations in the incidence of knee arthroscopy. Living in a densely populated area seems to increase the possibility of being treated with a knee arthroscopy.

LB, LFT, and JA designed the study. CL and TQ were responsible for the collection of the data. CL and TQ performed the statistical analysis in collaboration with LB. LB, CL, JA, MP, and LFT participated in the interpretation of data. LB, CL, and LFT wrote the first draft of the manuscript. All authors contributed to reviewing, editing, and approving the final version of manuscript.

The authors thank Dr Alejandro I Marcano for excellent help with data handling.

Handling co-editors: Søren Overgaard and Philippe Wagner

Acta thanks Michael Krogsgaard and Jonas Thorlund for help with peer review of this study.

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