About 1 million knee arthroscopies are performed each year in the United States, at a cost of more than $3 billion. Now, in new guidelines, an international panel of experts has strongly recommended against the surgery for nearly everyone with “degenerative knee disease.” Degenerative knee disease is another way to refer to knee osteoarthritis (OA), and includes degenerative meniscus tears, trouble with knee movement and sudden onset of pain and swelling. The guidelines were published in the journal BMJ in May.
OA is the most common type of arthritis. Of the 31 million people in the U.S. with OA, an estimated 14 million have symptomatic knee OA, which includes approximately 25 percent of people age 50 and older. End-stage disease often leads to knee replacement. Early conservative treatment includes weight loss, if needed, exercise, physical therapy, oral or topical pain drugs and injections of corticosteroids or hyaluronic acid. However, if symptoms continue and become more troubling, some surgeons do arthroscopic knee surgery. They make three or four small incisions around the knee, insert a camera in one and instruments in the others, mainly to remove loose debris and/or repair or remove part of a damaged meniscus – the C-shaped cartilage pad between the thighbone and shinbone, which can become ragged as OA attacks the joint tissues. The intent is to improve arthritis pain and function – but the panel said the procedure doesn’t do that.
The panel – put together by the BMJ as part of its Rapid Recommendations initiative — included doctors (including a rheumatologist), physical therapists, orthopedic surgeons and three patients with OA, including one who had undergone knee arthroscopy. The panel did not consider patients whose symptoms were due to sports injuries or other trauma. It reviewed 13 studies involving nearly 1,700 patients that compared knee arthroscopy to nonsurgical options such as corticosteroid or hyaluronic acid injections, exercise therapy and sham (fake) surgery. The review showed that most patients got no benefit from the surgery. A small percentage (fewer than 15 percent) saw an improvement in pain and function three months after arthroscopy, but those gains disappeared within a year.
The reviewers also looked at 12 studies that involved nearly 2 million patients about possible complications from knee arthroscopy. Although rare, complications can be serious, including blood clots and infections. They acknowledge that the evidence for serious harm is thin; it is focused more on practical matters, including recovery time (two to six weeks) and limited mobility after surgery.
In formulating its recommendation, the panel placed a high value on surgical outcomes that are important to patients, particularly pain relief. While the patient panelists identified pain, function and quality of life as the most important outcomes for patients considering surgery, they said a small improvement in function wouldn’t matter to them without a corresponding improvement in pain. Yet the studies showed that knee arthroscopy usually didn’t relieve pain, and any pain relief was short-lived. So, given the cost, the small potential for serious complications and the relatively long recovery for no (or very short-lived) measurable benefit, the panel concluded the surgery should not be performed for OA or related meniscus tears and mechanical knee problems.
The panel’s one possible exception to this recommendation is patients who have a fully locked knee and aren’t able to completely straighten it.
However, while the American Academy of Orthopaedic Surgeons agrees that knee arthroscopy shouldn’t be used to treat patients with primary arthritis, it suggests that the recommendations are too stringent and don’t take into account the needs of individual patients.
That’s echoed by Robert Marx, MD, an orthopedic surgeon at Hospital for Special Surgery and a professor at Weill Cornell Medical College, both in New York City.
“Several clinical trials have shown that arthroscopy of the knee isn’t an effective treatment for osteoarthritis,” he says. “However, patients who have displaced meniscal tears or loose bodies in a knee with pre-existing arthritis may benefit from this procedure. Individualized decision making must be made for and with each patient, and factors contributing to, or against, a successful outcome must be weighed in each case.”
Reed Siemieniuk, MD, a researcher at McMaster University in Hamilton, Ontario, Canada, and lead author of the recommendations, disagrees. He mentions a small 2015 Danish study, also in BMJ, that showed arthroscopic meniscus repair was no better than exercise at relieving pain. A 2017 follow-up study by the same researchers found that arthroscopic surgery was no more effective for meniscus tears than sham surgery.
Those are just two of several studies in the past 15 years that have raised questions about knee arthroscopy. At least four studies in The New England Journal of Medicine found that arthroscopy wasn’t effective for arthritis pain in older adults.
Dr. Siemieniuk says doctors keep performing arthroscopy for degenerative knee disease – despite the evidence against it – because it’s hard to deny desperate patients a known treatment, and, he adds, because it’s lucrative.
Because guidelines aren’t binding, it will continue to be up to patients and their doctors to decide whether the patient really needs or wants the surgery.
Author: Linda Rath for the Arthritis Foundation
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