Reference: BMJ Open. 2017 May 11;7(5):e016114
Level 2 [mid-level] evidence
Symptomatic degenerative knee disease (osteoarthritis of the knee) leads to significant pain and/or decreased function that negatively impacts the quality of life of an estimated 25% of adults over 45 years old. The annual cost of treating osteoarthritis (OA) to the US economy is about $128 billion dollars, including procedural costs from knee arthroscopy (Morb Mort Wkly Rep 2007 Jan;56(1):4-7). American Academy of Orthopedic Surgery guidelines from 2013 recommend against arthroscopic lavage and/or debridement in patients with symptomatic knee OA but no comment was made regarding partial meniscectomies (J Am Acad Orthop Surg 2013 Sep;21(9):577–9). In July 2016, a randomized controlled trial (RCT) comparing partial arthroscopic meniscectomy to exercise therapy in middle-aged patients with meniscal disease revealed no significant long-term difference in pain, function in sport or recreation, or knee quality of life between the two treatment groups (BMJ 2016 July;354;i3740). Given the negative 2013 recommendation and subsequent null result trial, how sure can we be that knee arthroscopy with debridement and/or partial meniscectomy does not add significant benefits when compared to conservative management (such as exercise therapy, injections, and drugs)?
A recent systematic review evaluated the effects of arthroscopic knee surgery on pain, function, and quality of life in 13 RCTs comparing arthroscopic debridement and/or partial meniscectomy to any form of conservative management (including exercise therapy, injections, drugs, and sham surgery) in 1,519 adults with symptomatic degenerative knee disease with or without OA. 12 observational studies with 1,816,923 patients and 3 RCTs with 314 patients that reported complications associated with knee arthroscopy were also reviewed. Studies of patients with acute trauma were excluded. Allocation concealment was unclear in 4 trials and blinding was absent in 11 trials. Follow-up duration ranged from three months to two years. For standardization of comparison measures, patient-reported outcomes were transformed into scores that range from 0-100 points, with higher scores indicating better outcomes for pain, function, and quality of life. The proportion of patients who achieved a credible Minimally Important Difference (MID) between groups was reported.
Compared to conservative therapy in the short-term (up to 3 months), knee arthroscopy was associated with a very small reduction in pain (mean difference of 5.4 points [MID 12 points], 95% CI 2 to 8.8, p < 0.05) in analysis of 10 trials with 1,231 patients, and a minimal improvement in function (mean difference 4.9 points [MID 12 points], 95% CI 1.5 to 8.4, p < 0.07) in analysis of seven trials with 964 patients. The proportion of arthroscopy patients achieving improvement above the MID was 12.4% for pain and 13.4% for function. There were no significant differences between groups in the long-term (up to 2 years) in pain, function, or quality of life. There were no differences in outcomes between groups in subgroup analyses including RCTs with patient blinding vs. without, and RCTs with >50% vs. <50% study participants with radiographic OA.
This systematic review provides the most comprehensive evidence on the topic to date by including 7 new studies (RCTs and observational studies) and further refining methodology and appraisal of component RCTs. Arthroscopy does not appear to improve pain, function, or quality of life beyond a very small degree in very few patients in the short term or long term. Despite this evidence, many arthroscopies are still being performed for degenerative knee disease requiring both a surgical procedure and extensive recovery efforts. Primary care and orthopedic physicians should consider these results in assessing management options for patients with degenerative knee disease.
Editorial Note
This article was included in the evidence base used to create the “BMJ RapidRecs: Arthroscopic surgery for degenerative knee disease” guideline which includes multilayered recommendations, evidence summaries, and decision aids and can be found at the MAGICapp site.
For more information, see the Osteoarthritis (OA) of the knee topic in Dynamed Plus. DynaMed users, see the Osteoarthritis (OA) of the knee topic in Dynamed Classic.
COLTON L. WOOD, MD completed his medical training at the University of Georgia and is currently a second year Family Medicine resident at the University of Virginia. He has a strong interest in sports medicine and hopes to continue building a strong foundation in general Family Medicine with aspirations of becoming a Primary Care Sports Medicine doctor.
Faculty contributions by Katharine C. DeGeorge, MD, MS.