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Knee Arthroscopy

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

BMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j1982 (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 bmj.com).

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).

References

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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. www.kneesociety.org.au/resources/aks-arthroscopy-position-statement.pdf.

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