We use the term degenerative knee disease to explicitly include patients with knee pain, particularly if they are >35 years old, with or without: Locking, clicking, or other mechanical symptoms except persistent objective locked knee, Most people with degenerative arthritis have at least one of these characteristics.1 The term degenerative knee disease does not include patients having recent debut of their symptoms after a major knee trauma with acute onset of joint swelling (such as haemarthrosis). Arthroscopic knee surgery for degenerative knee disease is the most common orthopaedic procedure in countries with available data14 and on a global scale is performed more than two million times each year (fig 1⇓).15 16 17 18 Arthroscopic procedures for degenerative knee disease cost more than $3bn per year in the US alone.19 A high prevalence of features advocated to respond positively to arthroscopic surgery (such as meniscal tears, mechanical symptoms, and sudden symptom onset) as well as financial incentives may explain why arthroscopic knee surgery continues to be so common despite recommendations against its use for osteoarthritis. endobj . Key Words: Degenerative meniscus--Osteoarthritis. A rigorous economic analysis found that knee arthroscopy for degenerative knee disease is not close to cost effective by traditional standards, even in extreme scenarios that assume a benefit with arthroscopy.30 The panel made a strong recommendation against arthroscopy, which applies to almost all patients with degenerative knee disease, implying that non-use of knee arthroscopy can be used as a performance measure or tied to health funding.31. The panel is confident that the randomised controlled trials included adequate representation from groups commonly cited to derive benefit from arthroscopic knee surgery for degenerative knee disease—notably those with meniscal tears, no or minimal radiographic evidence of osteoarthritis, and those with sudden but non-traumatic symptom onset. 263 0 obj <>/Font<>/ProcSet[/PDF/Text]/XObject<>>>/Rotate 0/TrimBox[0.0 0.0 595.276 793.701]/Type/Page>> endobj Although the included studies reported these patient-important outcomes, it is difficult to know whether changes recorded on an instrument measuring subjective symptoms are important to those with symptoms—for example, a change of three points might have completely different meanings in two different pain scales. It is unlikely that new information will change interpretation of the key outcomes of pain, knee function, and quality of life (as implied by high to moderate quality of evidence). Finally, in patients who had degenerative meniscus tears (tears due to wear and tear), 10% had medial knee arthritis prior to surgery while just under 67% had knee arthritis after. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Knee Arthroscopic Surgery for Meniscus Tears . For several decades in orthopedic care, the traditional solution to meniscus tears has been to identify them on an MRI and cut out the offending piece. endstream The most common procedure for a torn meniscus is knee arthroscopy. Further, patients may be frustrated with their symptoms, having tried several less invasive management strategies by the time that they see the surgeon, and in many cases this may come with an expectation for surgical management. The torn meniscus is repaired by a variety of minimally invasive techniques and requires postoperative protection to allow healing. The systematic review on the net benefit of knee arthroscopy compared with non-operative care pools data from 13 randomised trials for benefit outcomes (1668 patients) and an additional 12 observational studies for complications (>1.8 million patients).21Figure 2⇓ gives an overview of the patients included, the study funding, and patient involvement in the design of the studies. Arthroscopic Partial Meniscectomy versus Sham Surgery for a Degenerative Meniscus Tear – Surgery does not alleviate knee catching or knee locking after surgery. We also thank Tahira Devji for expertly leading the systematic review of minimally important differences. endobj 111 0 obj The BMJin June 2016, which found that, among patients with a degenerative medial meniscus tear, knee arthroscopy was no better than exercise therapy. Adobe InDesign CS6 (Windows) Those reading and using these recommendations should consider individual patient circumstances, and their values and preferences and may want to use consultation decision aids in MAGICapp to facilitate shared decision making with patients. Most tears of the meniscus occur in the portion of the meniscus that does not have a blood supply and therefore, arthroscopic surgery to remove the torn portion of the meniscus is how these tears are typically treated. <>stream A summary is offered here and the full version including decision aids is on the MAGICapp (www.magicapp.org), for all devices in multilayered formats. Rand JA. Professional and academic interests are minimised as much as possible, while maintaining necessary expertise on the panel to make fully informed decisions. 1985;1(4):253-8. BMJ Rapid Recommendations represent a collaborative effort between the MAGIC group (www.magicproject.org) and The BMJ. proof:pdf As new evidence is published, a group will assess the new evidence and make a judgment on to what extent it is expected to alter the recommendation. 10.1503/cmaj.140433 [PMC free article] [Google Scholar] 34. 2021-05-21T21:48:11-07:00 The members participated in the teleconferences and email discussions and met all authorship criteria. default Doctors and Patients Say ‘No’ to Arthroscopy for Arthritis. Table 2⇓ shows evidence which has emerged since the publication of this article. The panel make a strong recommendation against arthroscopy for degenerative knee disease. National Institute for Health and Clinical Excellence. Thorlund JB, Juhl CB, Roos EM, et al. endobj Key research questions to inform decision makers and future guidelines are: Randomised trials—Does arthroscopic knee surgery benefit patients who are objectively unable to fully extend their knee or who have persistent, severe, and frequent mechanical symptoms? Fig 3 Practical issues about use of arthroscopic knee surgery versus non-surgical management for degenerative knee disease, Degenerative knee disease is a chronic condition in which symptoms fluctuate. New evidence which has emerged after initial publication. Sihvonen R, Englund M, Turkiewicz A, Järvinen TL. This information is provided without any representations, conditions or warranties that it is accurate or up to date. Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline . This BMJ Rapid Recommendation article is one of a series that provides clinicians with trustworthy recommendations for potentially practice changing evidence. Knee replacement is the only definitive therapy, but it is reserved for patients with severe disease after non-operative management has been unsuccessful.4 5 Some believe that arthroscopic debridement, including washout of intra-articular debris, with or without arthroscopic partial meniscectomy to remove damaged meniscus, may improve pain and function. 2016. from application/x-indesign to application/pdf Occasionally other arthroscopic portals may need to be used in addition to these. Approximately 25% of people older than 50 years experience knee pain from degenerative knee disease (box 2).2 3 Management options include watchful waiting, weight loss if overweight, a variety of interventions led by physical therapists, exercise, oral or topical pain medications such as non-steroidal anti-inflammatory drugs, intra-articular corticosteroid and other injections, arthroscopic knee surgery, and knee replacement or osteotomy. <>/ExtGState<>/Font<>/ProcSet[/PDF/Text/ImageC/ImageI]/Properties<>/XObject<>>>/Rotate 0/TrimBox[0.0 0.0 595.276 793.701]/Type/Page>> application/pdf “Many degenerative meniscus tears will get better without surgery. Table 2 below shows any evidence that has emerged since the publication of this article. Arthroscopic surgery for treatment of degenerative meniscus tears is less predictable. Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms. False The knee is one of the most commonly injured parts of the body, and meniscus tears are often the cause of knee pain and knee injury. <>>> The majority of patients would likely want this option. Healthcare administrators and funders may use the number of arthroscopies performed in patients with degenerative knee disease as an indicator of quality care. doi:doi:10.1136/bmjopen-2017-161114, Review of all available randomised trials that assessed the benefits of knee arthroscopy compared with non-operative care and observational studies that assessed risks, Devji T, Guyatt GH, Lytvyn L, et al. One of them is Arthroscopic surgery for degenerative knee arthritis and meniscus tears. 2021-05-21T21:48:11-07:00 A camera is inserted into the joint via a small 1cm incision (or “portal”), and the instruments via a second 1cm portal. endobj Ann Rheum Dis 2017;0:1-9; Sihvonen et al. The preferred combination or sequence of these options is not clear and probably varies between patients. However, implementation of this recommendation will almost certainly result in considerable cost savings for health funders. Mechanical symptoms as an indication for knee arthroscopy in patients with degenerative meniscus tear: a prospective cohort study. xmp.iid:F5DC32078211E811ADF3A2C58AA45C21 Fig 1 Population adjusted trends in frequency of knee arthroscopy; percent. British Orthopaedic Association, British Association for Surgery of the Knee. In addition to the burden of undergoing knee arthroscopy (see practical issues below), there are rare but important harms, although the precision in these estimates is uncertain (low quality of evidence). An arthroscopy is an operation on the knee joint via “keyhole” surgery. Moreover, many patients experience important and marked improvements after arthroscopy, which may be erroneously attributed to the effects of the procedure itself instead of the natural course of the disease, co-interventions, or placebo effects.
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