An international panel of experts announced in the BMJ on Wednesday that arthroscopic surgery should not be used in almost all patients with degenerative knee disease, a condition more commonly known as osteoarthritis.
That advice, which is part of the BMJ’s “Rapid Recommendation” initiative, includes patients whose knee pain occurs suddenly and/or is accompanied by tears of the meniscus, the cartilage that helps stabilize the knee.
The experts came to their conclusion after reviewing all the latest evidence, including a 2016 study in BMJ that showed arthroscopic surgery was no better than exercise therapy for treating meniscus tears.
A common procedure for a common problem
Knee pain from degenerative knee disease is quite common, affecting about 1 in 4 adults aged 50 and older, according to background information in the BMJ paper. The chronic condition is managed with a variety of strategies, including “watchful waiting,” weight loss (if the patient is overweight), physical therapy, pain medication, and cortisol and other types of injections.
As the BMJ experts point out, “knee replacement is the only definitive therapy, but it is reserved for patients with severe disease,” after other management strategies have been unsuccessful.
Arthroscopic surgery, which uses tiny (keyhole-like) incisions to remove torn pieces of cartilage from the knee and to smooth out rough areas of the remaining cartilage, is also a frequently used treatment — despite a steady string of studies over the past decade that have questioned its effectiveness.
About 750,000 arthroscopic knee surgeries are carried out in the United States each year at an annual cost of about $3 billion.
Although it’s considered minor surgery, arthroscopic surgery is not without risks, including infections and blood clots.
Studying the evidence
Current medical guidelines generally discourage the use of arthroscopic surgery for patients whose X-rays show clear evidence of knee osteoarthritis. But many guidelines still recommend the procedure for certain subgroups of patients, such as those with meniscus tears, or whose symptoms (pain and swelling) come on suddenly, or who have mild to moderate difficulties with knee movement.
The problem, say the panel of experts, is that “most people with degenerative arthritis have at least one of these characteristics.” (The experts stress that degenerative knee disease does not include people whose symptoms develop after a sudden, traumatic injury to their knee.)
In their examination of the evidence, which included systematic reviews of 13 randomized clinical trials and 12 observational studies, the panel members looked for three key surgical outcomes — pain, function and quality of life. These are the outcomes patients with degenerative knee disease consider most important when deciding on whether to have surgery.
They found that arthroscopic knee surgery does not, on average, lead to any significant improvement in long-term pain or function to all — or almost all — patients with degenerative knee disease.
“Given that there is evidence of harm and no evidence of important lasting benefit in any subgroup, the panel believes that the burden of proof rests with those who suggest benefit for any other particular subgroups before arthroscopic surgery is routinely performed in any subgroup of patients,” they write.
FMI: You can read the panel’s “Rapid Recommendation” regarding arthroscopic knee surgery on the BMJ website.
