In people with degenerative knee disease, arthroscopic knee surgery is not recommended (strong recommendation)

Brignardello-Petersen R, Guyatt GH, Buchbinder R, et al. Knee arthroscopy versus conservative management in patients with degenerative knee disease: a systematic review. BMJ Open. 2017 May 11;7(5):e016114.

Siemieniuk RA, Harris IA, Agoritsas T, et al. Knee arthroscopy versus conservative management in patients with degenerative knee disease: a systematic review. BMJ. 2017 May 10;357:j1982.

Review and guideline question

In people with knee pain due to degenerative knee disease (which may include osteoarthritis and/or meniscal tears), is arthroscopic surgery better than placebo or nonsurgical therapy for improving pain, function, and quality of life?

Background

Degenerative knee disease is often associated with osteoarthritis or tears in the knee cartilage. It can cause knee pain, stiffness, swelling, and tenderness, and it often reduces quality of life.

Degenerative knee disease can be treated with pain medications, corticosteroid injections, weight loss if the person is overweight, physical therapy, exercise, and surgery, including arthroscopic surgery, knee replacement surgery, or osteotomy (removing or adding bone). Knee replacement surgery is the only definitive therapy, but it is only done in people with severe disease that has not improved with nonsurgical therapy. Arthroscopic knee surgery is done with small tools, including a camera, inserted through small cuts in the knee. It can include partial meniscectomy (removal of damaged knee cartilage) and/or debridement (cleaning out knee debris).

How the review was done and recommendation developed

The researchers did a systematic review, searching for studies up until August 2016.

They found 13 randomized controlled trials with 1665 people (average age 49 to 63 years).

The key features of the studies were:

• people had degenerative knee disease with ongoing knee pain that affected their quality of life and did not improve with conservative therapy;
• people with knee pain due to recent trauma were excluded;
• studies compared arthroscopic surgery with conservative therapy (mostly exercise therapy, drug injections, or sham [placebo] surgery); and
• outcomes were measured at 3 months and up to 2 years after treatment.

An international panel of experts reviewed the results of the studies and made recommendations. Recommendations could be strong (benefits outweigh harms for almost everyone or vice versa) or weak (benefits outweigh harms for most people but not everyone or vice versa). The panel included surgeons, other medical specialists and health care workers, research methods specialists, and patients.

What the researchers found

Compared with conservative therapy, arthroscopic surgery:

• improved short-term pain and function by a small amount;
• did not improve long-term pain or function; and
• did not improve short- or long-term quality of life.

Based on the results of the studies, the expert panel made one strong recommendation.

Recommendation

An international expert panel recommends against the use of arthroscopic surgery for people with degenerative knee disease (strong recommendation).

Arthroscopic surgery vs conservative therapy (mainly exercise therapy, drug injections, or sham surgery) in people with degenerative knee disease

*Score range 0 to 100, with higher scores = better outcomes. The minimal score difference considered important for patients was 12 points for pain and 8 points for function.

†Evidence quality (low, moderate, or high) was rated using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach.