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Practice Rapid Recommendations

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

Population

Including people with or without: Mild to severe osteoarthritis Radiographic evidence of osteoarthritis i X-ray or MRI changes of arthritis Mechanical symptoms i Locking, clicking, catching Acute onset knee pain i Pain started suddenly or slowly Meniscal tears i Tear in knee cartilage People with degenerative knee disease

Choice of intervention

or Arthroscopic surgery Conservativemanagement Any conservative management strategy (exercise therapy, injections, drugs) Arthroscopic surgery with or without partial meniscectomy or debridement

Recommendations

Favours arthroscopicsurgery Favours conservativemanagement

Strong Weak We recommend against arthroscopic knee surgery in patients with degenerative knee disease All Applies to Click fordetails Weak Benefits outweigh harms for the majority, but not for everyone. The majority of patients would likely want this option. Strong Benefits outweigh harms for almost everyone. All or nearly all informed patients would likely want this option.

Comparison of benefits and harms

Long term benefits (1–2 years) Evidence quality Mean score (0–100, high better) Favours arthroscopic surgery Favours conservativemanagement No importantdifference The panel found that these differences were not important for most patients, because the intervention effects were negligible and/or very imprecise (such as statistically not significant)

Pain High 18.8 21.9 No important difference More

1 2 MID Mean improvement in pain scores Arthroscopic surgery Conservative management 0 20 40 60 80 100 18.8 3.1 The other 991 in 1000 would not benefit from arthroscopic surgery. On average, knee arthroscopy results in no difference, or a very small improvement, in long term pain, compared with conservative management. A separate review found that the “minimally important difference” for patients would be an improvement of 12 on this scale. About 9 in 1000 more people would reach the MID with arthroscopic surgery, compared with conservative management. Risk of Bias No concerns Imprecision No concerns Indirectness No concerns Inconsistency No concerns Publication bias No concerns 21.9 With conservative management, 622 of 1000 people had improved symptoms which reached the MID (minimally important difference) With arthroscopic surgery, 631 of 1000 people had improved symptoms which reached the MID (minimally important difference)

Function Moderate 13.3 10.1 No important difference More

8 MID Mean improvement in function scores 13.3 Arthroscopic surgery Conservative management 0 20 40 60 80 100 10.1 3.2 A separate review found that the “minimally important difference” for patients would be an improvement of 8 on this scale. About 98 in 1000 more people would reach the MID with arthroscopic surgery, compared with conservative management. The other 902 in 1000 would not benefit from arthroscopic surgery. On average, knee arthroscopy probably results in no improvement, or a very small improvement, in long term function, compared with conservative management. Risk of Bias Serious Imprecision No concerns Indirectness No concerns Inconsistency No concerns Publication bias No concerns With conservative management, 538 of 1000 people had improved symptoms which reached the MID (minimally important difference) With arthroscopic surgery, 636 of 1000 people had improved symptoms which reached the MID (minimally important difference)
Short term benefits (<3 months) Mean score (0–100, high better)

Pain High 15.0 5.38 higher 20.4 More

The other 876 in 1000 would not benefit from arthroscopic surgery. On average, knee arthroscopy results in a very small improvement in short term pain, compared with conservative management. 1 2 MID Mean improvement in pain scores 20.4 Arthroscopic surgery Conservative management 0 20 40 60 80 100 15.0 5.4 A separate review found that the “minimally important difference” for patients would be an improvement of 12 on this scale. About 124 in 1000 more people would reach the MID with arthroscopic surgery, compared with conservative management. Risk of Bias No concerns Imprecision No concerns Indirectness No concerns Inconsistency No concerns Publication bias No concerns With conservative management, 669 of 1000 people had improved symptoms which reached the MID (minimally important difference) With arthroscopic surgery, 793 of 1000 people had improved symptoms which reached the MID (minimally important difference)

Function Moderate 9.3 4.94 higher 14.2 More

The other 866 in 1000 would not benefit from arthroscopic surgery. Knee arthroscopy may improve function slightly more than conservative management in the short term. 8 MID Mean improvement in function scores 14.2 Arthroscopic surgery Conservative management 0 20 40 60 80 100 9.3 4.9 A separate review found that the “minimally important difference” for patients would be an improvement of 8 on this scale. About 134 in 1000 more people would reach the MID with arthroscopic surgery, compared with conservative management. Risk of Bias Serious Imprecision No concerns Indirectness No concerns Inconsistency No concerns Publication bias No concerns With conservative management, 519 of 1000 people had improved symptoms which reached the MID (minimally important difference) With arthroscopic surgery, 653 of 1000 people had improved symptoms which reached the MID (minimally important difference)
Events per 1000 people Short term harms (<3 months)

Venous thromboembolism Low 5 5 fewer 0 More

Risk of Bias Serious Imprecision No concerns Indirectness No concerns Inconsistency Serious Publication bias No concerns Arthroscopy may have a small risk of venous thromboembolism

Infection Low 2 2 fewer 0 More

Risk of Bias Serious Imprecision No concerns Indirectness No concerns Inconsistency Serious Publication bias No concerns Arthroscopy may have a small risk of infection
See all outcomes
Key practical issues Arthroscopic surgery Conservative management The panel believes that almost everyone would prefer to avoid the pain and inconvenience of the recovery period after arthroscopy, since it offers only a small chance of a small benefit. Preferences and values Resourcing Arthroscopy is not cost-effective from a societal perspective. Performed by a surgeon, in an operating theatre May be performed in hospital or the community Recovery typically between 2 to 6 weeks At least 1–2 weeks off work, depending on speed of recovery and physical demands of job Time off work may be required for appointments, such as physiotherapy and injections No recovery time

©BMJ Publishing Group Limited.

Disclaimer: This infographic is not a validated clinical decision aid. This information is provided without any representations, conditions or warranties that it is accurate or up to date. BMJ and its licensors assume no responsibility for any aspect of treatment administered with the aid of this information. Any reliance placed on this information is strictly at the user's own risk. For the full disclaimer wording see BMJ's terms and conditions: https://www.bmj.com/company/legal-information/

Find recommendations, evidence summaries and consultation decision aids for use in your practice
  1. Reed A C Siemieniuk, methodologist, panel chair1 2,
  2. Ian A Harris, professor of orthopaedic surgery3 4,
  3. Thomas Agoritsas, assistant professor1 5,
  4. Rudolf W Poolman, orthopaedic surgeon6,
  5. Romina Brignardello-Petersen, methodologist1 7,
  6. Stijn Van de Velde, methodologist and physiotherapist8,
  7. Rachelle Buchbinder, professor and rheumatologist9 10,
  8. Martin Englund, associate professor and epidemiologist11,
  9. Lyubov Lytvyn, patient liaison expert12,
  10. Casey Quinlan, patient representative13,
  11. Lise Helsingen, PhD student14,
  12. Gunnar Knutsen, orthopaedic surgeon15,
  13. Nina Rydland Olsen, associate professor and physiotherapist16,
  14. Helen Macdonald, general practitioner and clinical editor17,
  15. Louise Hailey, physiotherapist18,
  16. Hazel M Wilson, patient representative19,
  17. Anne Lydiatt, patient representative20,
  18. Annette Kristiansen, general internist, methods editor21 22
  1. 1Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada L8S 4L8
  2. 2Department of Medicine, University of Toronto, Toronto, Ontario, Canada
  3. 3South Western Sydney Clinical School, UNSW, Australia
  4. 4Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Liverpool, NSW 2170, Australia
  5. 5Division General Internal Medicine & Division of Clinical Epidemiology, University Hospitals of Geneva, CH-1211, Geneva, Switzerland
  6. 6Department of Orthopaedic Surgery, Joint Research, OLVG, 1090 HM Amsterdam, The Netherlands
  7. 7Faculty of Dentistry, Universidad de Chile, Independencia, Santiago, Chile
  8. 8Norwegian Institute of Public Health, Nydalen, N-0403 Oslo, Norway
  9. 9Department of Epidemiology and Preventive Medicine, School of Public Health & Preventive Medicine, Monash University, Melbourne, Vic 3004, Australia
  10. 10Monash Department of Clinical Epidemiology, Cabrini Institute; Suite 41 Cabrini Medical Centre, Malvern Vic, 3144, Australia
  11. 11Clinical Epidemiology Unit, Orthopaedics, Department of Clinical Sciences Lund Faculty of Medicine, Lund University, SE-221 85 Lund, Sweden
  12. 12Oslo University Hospital, Blindern 0317 Oslo, Norway
  13. 13Richmond, Virginia, USA
  14. 14Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Blindern 0317 Oslo, Norway
  15. 15University Hospital North Norway, 9038 Tromso, Norway
  16. 16Department of Occupational Therapy, Physiotherapy and Radiography, Faculty of Health and Social sciences, Bergen University College, 5020 Bergen, Norway
  17. 17BMJ Editorial, BMA House, London WC1H 9JR, UK
  18. 18Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 7HE, UK
  19. 19London, Ontario, Canada
  20. 20Ingersoll, Ontario, Canada N5C 3N1
  21. 21Department of Health and Science, University of Oslo, Oslo, Norway
  22. 22Department of Medicine, Hospital Innlandet Trust, Gjøvik, Norway
  1. Correspondence to: R Siemieniuk, Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada reed.siemieniuk{at}medportal.ca

What you need to know

  • We make a strong recommendation against the use of arthroscopy in nearly all patients with degenerative knee disease, based on linked systematic reviews; further research is unlikely to alter this recommendation

  • This recommendation applies to patients with or without imaging evidence of osteoarthritis, mechanical symptoms, or sudden symptom onset

  • Healthcare administrators and funders may use the number of arthroscopies performed in patients with degenerative knee disease as an indicator of quality care.

  • Knee arthroscopy is the most common orthopaedic procedure in countries with available data

  • This Rapid Recommendation package was triggered by a randomised controlled 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

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. Box 1 shows all of the articles and evidence linked in this Rapid Recommendation package. The infographic provides an overview of the absolute benefits and harms of arthroscopy in standard GRADE format. Table 2 below shows any evidence that has emerged since the publication of this article.

Box 1: Linked articles in this BMJ Rapid Recommendations cluster

  • Siemieniuk RAC, Harris IA, Agoritsas T, et al. Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline. BMJ 2017;257:j1982. doi:10.1136/bmj.j1982

    • Summary of the results from the Rapid Recommendation process

  • Brignardello-Peterson R, Guyatt GH, Schandelmaier S, et al. Knee arthroscopy versus conservative management in patients with degenerative knee disease: a systematic review. BMJ Open 2017;7:e016114. doi:doi:10.1136/bmjopen-2017-161114

    • Review of all available …

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