Knee Arthroscopy

Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline

BMJ 2017; 357 doi: (Published 10 May 2017)

Cite this as: BMJ 2017;357:j1982

What is the role of arthroscopic surgery in degenerative knee disease?

An expert panel produced these recommendations based on a linked systematic review triggered by a randomised trial published in The BMJ in June 2016, which found that, among patients with a degenerative medial meniscus tear, knee arthroscopy was no better than exercise therapy. The panel make a strong recommendation against arthroscopy for degenerative knee disease. Our international panel including orthopaedic surgeons, a rheumatologist, physiotherapists, a general practitioner, general internists, epidemiologists, methodologists, and people with lived experience of degenerative knee disease (including those who had undergone and those who had not undergone arthroscopy) met to discuss the evidence. No person had financial conflicts of interest; intellectual and professional conflicts were minimised and managed (see appendix 1 on

Current practice

Approximately 25% of people older than 50 years experience knee pain from degenerative knee disease (box 2).2 3 Management options include watchful waiting, weight loss if overweight, a variety of interventions led by physical therapists, exercise, oral or topical pain medications such as non-steroidal anti-inflammatory drugs, intra-articular corticosteroid and other injections, arthroscopic knee surgery, and knee replacement or osteotomy. The preferred combination or sequence of these options is not clear and probably varies between patients.

Understanding the recommendations

The infographic provides an overview of the benefits and harms of arthroscopy in standard GRADE format. Estimates of baseline risk for effects comes from the control arms of the trials; for complications, comparator risk was assumed to be nil.

The panel is confident that arthroscopic knee surgery does not, on average, result in an improvement in long term pain or function. Most patients will experience an important improvement in pain and function without arthroscopy. However, in < 15% of participants, arthroscopic surgery resulted in a small or very small improvement in pain or function at three months after surgery—this benefit was not sustained at one year. In addition to the burden of undergoing knee arthroscopy (see practical issues below), there are rare but important harms, although the precision in these estimates is uncertain (low quality of evidence).

It is unlikely that new information will change interpretation of the key outcomes of pain, knee function, and quality of life (as implied by high to moderate quality of evidence).


- Englund M, Guermazi A, Gale D, et al. Incidental meniscal findings on knee MRI in middle-aged and elderly persons. N Engl J Med2008;359:1108-15. doi:10.1056/NEJMoa0800777 pmid:18784100.

- Nguyen US, Zhang Y, Zhu Y, Niu J, Zhang B, Felson DT. Increasing prevalence of knee pain and symptomatic knee osteoarthritis: survey and cohort data. Ann Intern Med2011;155:725-32. doi:10.7326/0003-4819-155-11-201112060-00004 pmid:22147711.

- Turkiewicz A, Gerhardsson de Verdier M, Engström G, et al. Prevalence of knee pain and knee OA in southern Sweden and the proportion that seeks medical care. Rheumatology (Oxford)2015;54:827-35. doi:10.1093/rheumatology/keu409 pmid:25313145.

- McGrory B, Weber K, Lynott JA, et al. American Academy of Orthopaedic Surgeons. The American Academy of Orthopaedic Surgeons evidence-based clinical practice guideline on surgical management of osteoarthritis of the knee. J Bone Joint Surg Am2016;98:688-92. doi:10.2106/JBJS.15.01311 pmid:27098328.

- Skou ST, Roos EM, Laursen MB, et al. A randomized, controlled trial of total knee replacement. N Engl J Med2015;373:1597-606. doi:10.1056/NEJMoa1505467 pmid:26488691.

Jevsevar DS. Treatment of osteoarthritis of the knee: evidence-based guideline, 2nd edition. J Am Acad Orthop Surg2013;21:571-6.pmid:23996988.

National Institute for Health and Clinical Excellence. Arthroscopic knee washout, with or without debridement, for the treatment of osteoarthritis (Interventional procedures guidance IPG230). 2007.

National Institute for Health and Clinical Excellence. Osteoarthritis: care and management (clinical guideline CG177). 2014.

Beaufils P, Roland B. ESSKA Meniscus Consensus Project. Degenerative meniscus lesions. European Society for Sports Traumatology, Knee Surgery and Arthroscopy, 2016.

British Orthopaedic Association, British Association for Surgery of the Knee. BOA/BASK response to media reports regarding knee arthroscopy. 2015.

Australian Knee Society on Arthroscopic Surgery of the Knee. Position statement from the Australian Knee Society on Arthroscopic Surgery of the Knee, including reference to the presence of osteoarthritis or degenerative joint disease. 2016.

Zhang W, Moskowitz RW, Nuki G, et al. OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis Cartilage2008;16:137-62. doi:10.1016/j.joca.2007.12.013 pmid:18279766.

Zhang W, Nuki G, Moskowitz RW, et al. OARSI recommendations for the management of hip and knee osteoarthritis: part III: Changes in evidence following systematic cumulative update of research published through January 2009. Osteoarthritis Cartilage2010;18:476-99. doi:10.1016/j.joca.2010.01.013 pmid:20170770.

- Cullen KA, Hall MJ, Golosinskiy A. Ambulatory surgery in the United States, 2006. Natl Health Stat Report2009;(11):1-25.pmid:19294964.

- Adelani MA, Harris AH, Bowe TR, Giori NJ. Arthroscopy for knee osteoarthritis has not decreased after a clinical trial. Clin Orthop Relat Res2016;474:489-94. doi:10.1007/s11999-015-4514-4 pmid:26290345.

- Bohensky MA, Sundararajan V, Andrianopoulos N, et al. Trends in elective knee arthroscopies in a population-based cohort, 2000-2009. Med J Aust2012;197:399-403. doi:10.5694/mja11.11645 pmid:23025737.

- Hamilton DF, Howie CR. Knee arthroscopy: influence of systems for delivering healthcare on procedure rates. BMJ2015;351:h4720. doi:10.1136/bmj.h4720 pmid:26405226.

- Thorlund JB, Hare KB, Lohmander LS. Large increase in arthroscopic meniscus surgery in the middle-aged and older population in Denmark from 2000 to 2011. Acta Orthop2014;85:287-92. doi:10.3109/17453674.2014.919558 pmid:24800623.

- Järvinen TL, Guyatt GH. Arthroscopic surgery for knee pain. BMJ2016;354:i3934. doi:10.1136/bmj.i3934 pmid:27439983.

- Devji T, Guyatt GH, Lytvyn L, et al. Application of minimal important differences in degenerative knee disease outcomes: a systematic review and case study to inform BMJ Rapid Recommendations. BMJ Open2017;7:e015587. doi:10.1136/bmjopen-2016-015587.

- Brignardello-Peterson R, Guyatt GH, Schandelmaier S, et al. Knee arthroscopy versus conservative management in patients with degenerative knee disease: a systematic review. BMJ Open2017;7:e016114. doi:10.1136/bmjopen-2017-016114.

- Guyatt GH, Juniper EF, Walter SD, Griffith LE, Goldstein RS. Interpreting treatment effects in randomised trials. BMJ1998;316:690-3. doi:10.1136/bmj.316.7132.690 pmid:9522799.

- Gauffin H, Tagesson S, Meunier A, Magnusson H, Kvist J. Knee arthroscopic surgery is beneficial to middle-aged patients with meniscal symptoms: a prospective, randomised, single-blinded study. Osteoarthritis Cartilage2014;22:1808-16. doi:10.1016/j.joca.2014.07.017 pmid:25086401.

- Kirkley A, Birmingham TB, Litchfield RB, et al. A randomized trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med2008;359:1097-107. doi:10.1056/NEJMoa0708333 pmid:18784099.

- Sihvonen R, Englund M, Turkiewicz A, Järvinen TL. Finnish Degenerative Meniscal Lesion Study Group. Mechanical symptoms and arthroscopic partial meniscectomy in patients with degenerative meniscus tear: a secondary analysis of a randomized trial. Ann Intern Med2016;164:449-55. doi:10.7326/M15-0899 pmid:26856620.

- Sihvonen R, Paavola M, Malmivaara A, et al. Finnish Degenerative Meniscal Lesion Study (FIDELITY) Group. Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. N Engl J Med2013;369:2515-24. doi:10.1056/NEJMoa1305189 pmid:24369076.

- Lubowitz JH, Ayala M, Appleby D. Return to activity after knee arthroscopy. Arthroscopy2008;24:58-61.e4. doi:10.1016/j.arthro.2007.07.026 pmid:18182203.

- Pihl K, Roos EM, Nissen N, JøRgensen U, Schjerning J, Thorlund JB. Over-optimistic patient expectations of recovery and leisure activities after arthroscopic meniscus surgery. Acta Orthop2016;87:615-21. doi:10.1080/17453674.2016.1228411 pmid:27622598.

- de Rooij M, van der Leeden M, Heymans MW, et al. Prognosis of pain and physical functioning in patients with knee osteoarthritis: a systematic review and meta-analysis. Arthritis Care Res (Hoboken)2016;68:481-92. doi:10.1002/acr.22693 pmid:26316234.

- Marsh JD, Birmingham TB, Giffin JR, et al. Cost-effectiveness analysis of arthroscopic surgery compared with non-operative management for osteoarthritis of the knee. BMJ Open2016;6:e009949. doi:10.1136/bmjopen-2015-009949 pmid:26758265.

- Andrews JC, Schünemann HJ, Oxman AD, et al. GRADE guidelines: 15. Going from evidence to recommendation-determinants of a recommendation’s direction and strength. J Clin Epidemiol2013;66:726-35. doi:10.1016/j.jclinepi.2013.02.003 pmid:23570745.

- Kise NJ, Risberg MA, Stensrud S, Ranstam J, Engebretsen L, Roos EM. Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: randomised controlled trial with two year follow-up. BMJ2016;354:i3740. doi:10.1136/bmj.i3740 pmid:27440192.

- Khan M, Evaniew N, Bedi A, Ayeni OR, Bhandari M. Arthroscopic surgery for degenerative tears of the meniscus: a systematic review and meta-analysis. CMAJ2014;186:1057-64. doi:10.1503/cmaj.140433 pmid:25157057.

- Thorlund JB, Juhl CB, Roos EM, Lohmander LS. Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms. BMJ2015;350:h2747. doi:10.1136/bmj.h2747 pmid:26080045.

- Siemieniuk RA, Agoritsas T, Macdonald H, Guyatt GH, Brandt L, Vandvik PO. Introduction to BMJ Rapid Recommendations. BMJ2016;354:i5191. doi:10.1136/bmj.i5191 pmid:27680768.

- Vandvik PO, Otto CM, Siemieniuk RA, et al. Transcatheter or surgical aortic valve replacement for patients with severe, symptomatic, aortic stenosis at low to intermediate surgical risk: a clinical practice guideline. BMJ2016;354:i5085. doi:10.1136/bmj.i5085 pmid:27680583.

- Guyatt GH, Oxman AD, Vist GE, et al. GRADE Working Group. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ2008;336:924-6. doi:10.1136/bmj.39489.470347.AD pmid:18436948.


Related Articles



Read More


Read More
Injury Prevention

Injury Prevention

Read More

Book A Time That Suits You