Expert advice against surgery for almost all patients with degenerative knee damage

Knee arthroscopy (keyhole surgery to relieve pain and improve movement) should not be performed in almost all patients with degenerative knee disease, say a panel of international experts in the British Medical Journal, BMJ today.

Medical Xpress May 10, 2017

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 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 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 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.”

Source Medical Xpress

References

Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline, Siemieniuk RAC, Harris IA, Agoritsas T, Poolman RW, Brignardello-Petersen R, Van de Velde S, Buchbinder R, Englund M, Lytvyn L, Quinlan C, Helsingen L, Knutsen G, Olsen NR, Macdonald H, Hailey L, Wilson HM, Lydiatt A, Kristiansen A. BMJ 2017;357:j1982  doi: 10.1136/bmj.j1982 (Published 10 May 2017)

Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: randomised controlled trial with two year follow-up, Kise NJ, Risberg MA, Stensrud S, Ranstam J, Engebretsen L, Roos EM. BMJ. 2016 Jul 20;354:i3740. doi: 10.1136/bmj.i3740.

Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms, JB Thorlund, CB Juhl, EM Roos, LS Lohmander. BMJ 2015;350:h2747 doi: 10.1136/bmj.h2747 (Published 16 June 2015)

Knee arthroscopy versus conservative management in patients with degenerative knee disease: a systematic review, Romina Brignardello-Petersen, Gordon H Guyatt, Rachelle Buchbinder, Rudolf W Poolman, Stefan Schandelmaier, Yaping Chang, Behnam Sadeghirad, Nathan Evaniew, Per O Vandvik. BMJ Open 2017;7:e016114. doi: 10.1136/bmjopen-2017-016114

A knee monitoring device and the preferences of patients living with osteoarthritis: a qualitative study, Enrica Papi, Athina Belsi, Alison H McGregor. BMJ Open 2015;5:e007980. doi: 10.1136/bmjopen-2015-007980

Re: Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline

There are dangers in over interpreting this paper in a similar manner to reports showing no benefit from back pain. For back pain you will find physical therapists (e.g. osteopaths) have a very different paradigm of classification and find it difficult to lump all back pain as one for a RCT. Treating knee pain as a homogenous condition has dangers where as an individualised approach is important depending on the MRI, your occupation, sports and other co-morbidities.

So my personal N-of-1 trial with a degenerative medical meniscal tear with loss of function (flexion and extension) has been vastly improved with arthroscopy, Post-op I had no pain requiring analgesics and driving and working by week two. I am a working GP who runs, cycles and skis. I admit it is early days and according to the review I will be no better in one year.

Yes I agree arthroscopy is not a panacea for all degenerative knee conditions but there is a place for arthroscopy. By the time a patient is referred for arthroscopy the conservative alternatives have been long exhausted. What is required is a consultation with the patient and making a shared decision using this an other evidence. An appropriate shared decision tool would be helpful to illustrate the choices and risks. A number of patients will opt to continue with conservative management but I suspect many would risk surgery on the basis it could improve their quality of life, unlikely to be worse and risks are low.

Our commissioners are likely to use the article to make arthroscopy one of “limited clinical value” purely on the basis of saving money. Handle the interpretation with care.

Yours sincerely,
Dr Martin Wilkinson
GP, Harlequin Surgery
160 Shard End Crescent
Birmingham. B34 7BP

Rapid responses are electronic letters to the editor. They enable our users to debate issues raised in articles published on thebmj.com. Although a selection of rapid responses will be included online and in print as readers’ letters, their first appearance online means that they are published articles. Letters are indexed in PubMed.

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