Strong recommendation against knee arthroscopy

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FocusKeyholeKnee arthroscopy is strongly recommended against in almost all patients with degenerative knee disease,  a panel of international experts report in The BMJ. A systematic review concluded it that does not, on average, result in a lasting improvement in pain or function.

Their strong recommendation against surgery is based on new evidence that it does not, on average, result in a lasting improvement in pain or function – and they say further research is unlikely to alter this advice.

Their advice is part of The BMJ’s ‘Rapid Recommendations’ initiative – to produce rapid and trustworthy guidance based on new evidence to help doctors make better decisions with their patients.

Degenerative knee disease (commonly known as arthritis) is a chronic condition in which symptoms fluctuate. Knee arthroscopy is one of the most common surgical procedures. Every year, an estimated two million people worldwide undergo knee arthroscopy at a cost of $3bn per year in the US alone. Yet current evidence suggests that arthroscopic knee surgery offers little benefit for most patients and is not cost effective.

For example, a trial published in The BMJ in 2016 showed that among patients with meniscus tear (damage to the rubbery discs that cushion the knee joint), surgery was no better than exercise therapy.

Yet, despite there being no evidence that arthroscopy is beneficial in any patient group, most guidelines continue to support the use of arthroscopy in key subgroups, including those with meniscus tear, sudden onset of symptoms (such as pain or swelling), or mild-moderate difficulties with knee movement. Most people with degenerative knee disease fit into at least one of these subgroups.

So an international panel – made up of bone surgeons, physiotherapists, clinicians and patients with experience of degenerative knee disease (including those who had undergone and those who had not undergone arthroscopy) decided to carry out a detailed analysis of the latest evidence.

Their rapid recommendation package includes a systematic review (published in BMJ Open) which adds the 2016 trial to the existing body of evidence, and a review of patients’ preferences on knee disease (also published in BMJ Open). These data were used as the basis for the recommendation.

Using the GRADE approach (a system used to assess the quality of evidence), they found that arthroscopic knee surgery does not, on average, result in an improvement in long term pain or function to all or almost all patients with degenerative knee disease.

In addition to the burden of undergoing knee arthroscopy, they say there are rare but important harms, although exactly how common these are is uncertain (low quality of evidence).

As such, they strongly recommend against arthroscopy for almost all patients with degenerative knee disease – and suggest that non-use of knee arthroscopy can be used as a performance measure or tied to health funding.

It is unlikely that new trials will alter the evidence, they add.

Casey Quinlan, a patient panel member said: “Knee arthroscopy has been oversold as a cure-all for knee pain. Participating in the working group that developed this guideline allowed for actual patient experience to be considered – mine was nowhere near what I had been told it would be, function and pain level were only marginally improved – giving real outcomes as a basis for the recommendations. The goal was to make it possible for people exploring this knee arthroscopy with their doctors to have a clearer view of when it might be helpful to them, or unnecessary surgery.”

Objective: To determine the effects and complications of arthroscopic surgery compared with conservative management strategies in patients with degenerative knee disease.
Design: Systematic review.
Main outcome measures: Pain, function, adverseMevents.
Data sources: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), Google Scholar and Open Grey up to August 2016.
Eligibility criteria: For effects, randomised clinical trials (RCTs) comparing arthroscopic surgery with a conservative management strategy (including sham surgery) in patients with degenerative knee disease. For complications, RCTs and observational studies.
Review methods: Two reviewers independently extracted data and assessed risk of bias for patient-important outcomes. A parallel guideline committee (BMJ Rapid Recommendations) provided input on the design and interpretation of the systematic review, including selection of patient-important outcomes. We used the GRADE approach to rate the certainty (quality) of the evidence.
Results: We included 13 RCTs and 12 observational studies. With respect to pain, the review identified high-certainty evidence that knee arthroscopy results in a very small reduction in pain up to 3 months (mean difference =5.4 on a 100-point scale, 95% CI 2.0 to 8.8) and very small or no pain reduction up to 2 years (mean difference =3.1, 95% CI −0.2 to 6.4) when compared with conservative management. With respect to function, the review identified moderate-certainty evidence that knee arthroscopy results in a very small improvement in the short term (mean difference =4.9 on a 100-point scale,
95% CI 1.5 to 8.4) and very small or no improved function up to 2 years (mean difference =3.2, 95% CI −0.5 to 6.8). Alternative presentations of magnitude of effect, and associated sensitivity
analyses, were consistent with the findings of the primary analysis. Low-quality evidence suggested a very low probability of serious complications after knee arthroscopy.
Conclusions: Over the long term, patients who undergo knee arthroscopy versus those who receivE conservative management strategies do not have important benefits in pain or function.

BMJ Open Access study
BMJ Open Access Rapid Recommendations

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