Arthroscopy for Degenerative Knee Disease: Expert Panel Guideline

Conservative management (exercise therapy, injections, drugs) rather than arthroscopic knee surgery is recommended for nearly all patients with degenerative knee disease, according to guidelines formulated by an expert panel and recently published in The British Medical Journal as a Rapid Recommendation.¹

An international panel comprised of orthopedic surgeons, a rheumatologist, physiotherapists, a general practitioner, general internists, epidemiologists, methodologists, and patients with degenerative knee disease (including those who had and had not undergone arthroscopy) evaluated 2 systematic reviews using the Grading of Recommendations, Assessment, Development and Evaluations approach.

One review on the net benefit of knee arthroscopy vs nonoperative care included 13 randomized clinical trials (1665 patients) and 12 observational studies for complications (>1.8 million patients).² The second linked systematic review was focused on the level of individual change that is important to patients to interpret the magnitude of effect sizes as well as the strength of the recommendation.³

Current guidelines do not support the use of arthroscopy in patients with clear radiographic evidence of osteoarthritis alone, but they are less clear and in some cases support the use of arthroscopy in other subgroups of people with degenerative knee disease.^4,5

Based on their review of the evidence, the panel stated, “Our strong recommendation against arthroscopy reflects a low value on a modest probability (<15%) of small or very small improvement in short-term pain and function that does not persist to one year, and a higher value on avoiding the burden, postoperative limitations, and rare serious adverse effects associated with knee arthroscopy.”¹ The panel’s recommendations include patients with or without radiographic evidence of osteoarthritis and those with mild to severe osteoarthritis, mechanical symptoms, acute-onset knee pain, and meniscal tears.

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References

1. Siemieniuk RAC, Harris IA, Agoritsas T, et al. Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline. BMJ. 2017;357:j1982.
2. Brignardello-Peterson R, Guyatt GH, Buchbinder R, et al. Knee arthroscopy versus conservative management in patients with degenerative knee disease: a systematic review. BMJ Open. 2017;7:e016114.
3. 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 Open. 2017;7:e015587.
4. Jevsevar DS. Treatment of osteoarthritis of the knee: evidence-based guideline, 2nd edition. J Am Acad Orthop Surg. 2013;21:571-576.
5. National Institute for Health and Clinical Excellence. Osteoarthritis: care and management. Clinical guideline [CG177]. 2014. www.nice.org.uk/guidance/cg177. Accessed October 20, 2017.