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  • BMJ: Guideline Strongly Recommends Against Arthroscopy for 'Nearly All' Patients With Knee OA or Meniscal Tears

    In brief:

    • In countries with data available, knee arthroscopy is the most common orthopedic procedure
    • Data reviewed by an international multidisciplinary panel that included physical therapists
    • Guideline makes a "strong recommendation" against the use of arthroscopy in nearly all patients with degenerative knee disease, based on linked systematic reviews; authors write that "further research is unlikely to alter this recommendation"
    • Authors write that "health care administrators and funders may use the number of arthroscopies performed in patients with degenerative knee disease as an indicator of quality care"

    For patients with knee pain, the small, short-term gains in pain and function from arthroscopy are greatly outweighed by the "burden, postoperative limitations, and rare serious adverse effects" associated with the surgery, write authors of a new clinical practice guideline. Instead, authors "strongly recommend" conservative treatment over arthroscopy for "nearly all" patients with degenerative knee disease.

    The guideline, published online May 10, 2017, in BMJ, is based on a 2016 systematic review that indicated outcomes for knee arthroscopy were no better than those for exercise in people with degenerative medial meniscus tear. The multidisciplinary, international panel included physical therapists, orthopedic surgeons, a rheumatologist, a general practitioner, general internists, epidemiologists, methodologists, and patients.

    Authors defined degenerative knee disease as knee pain not caused by traumatic injury in patients over age 35, "with or without" imaging evidence of osteoarthritis, meniscal tears, mechanical symptoms, or "acute or subacute onset of symptoms."

    The panel considered 3 patient outcomes in their analysis: pain, function, and quality of life. Authors write, "Arthroscopic knee surgery does not, on average, result in an improvement in long-term pain or function." Future evidence, they say, is unlikely to change this conclusion.

    While the panelists did not explicitly recommend any particular type of conservative management of degenerative knee disease, they suggested that nonuse of knee arthroscopy could be used "as a performance measure or tied to health funding."

    Authors conclude, "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 subgroup before arthroscopic surgery is routinely performed in any subgroup of patients."

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Comments

    • I like the direction this is going. Let's expand it to include hip arthroscopies as well! I.e. Labral tear repairs

      Posted by Lauren on 5/12/2017 4:16 PM

    • The use of arthroscopy needs consideration in that the surgeon is able to see the condition of the lateral meniscus that might lead a surgeon to use a unicompartmental appliance vs a total knee replacement.

      Posted by Margaret E Vitek, PT on 5/13/2017 5:30 PM

    • Finally a reasonable conclusion that you can't change arthritis with a metal instrument

      Posted by Doug Creighton on 5/13/2017 10:07 PM

    • Totally agree, conservative treatment is far more effective

      Posted by Iwona Matthews on 5/14/2017 1:23 AM

    • Hopefully this will catch traction within the entirety of the medical community. I imagine it will be quite difficult to get some surgeons onboard with the idea that something they've been doing for years/decades isn't effective or in the best interest of their patients -- the cognitive dissonance may be too much.

      Posted by Scott on 5/14/2017 8:28 PM

    • Please note that this research references knee pain not caused by traumatic injury. As to chronic knee pain caused by degenerative processes, would like to see more research into what actually works long term since the research did not indicate any specific treatment option.

      Posted by Marianne on 5/15/2017 10:39 AM

    • Marianne, this may shed some light on conservative treatment for knee OA. http://www.oarsijournal.com/article/S1063-4584(14)00016-8/fulltext?cc=y=

      Posted by John on 5/17/2017 11:11 AM

    • I would agree with the article and the comments above except in the case of an acute meniscal injury in someone with some already existing DJD/OA. This was not clear in the article, other than to say, "non traumatic injuries." In a case where there is no trauma,i.e. ("I just bent over or twisted putting my shoe on and my knee locked" existing degenerative changes but an acute cartilage or plica locking episode that will not resolve, the impediment in the joint must be removed or that will cause even further degenerative changes more quickly, never mind totally immobilize the individual and compromise their safety. Let's not jump to say ALL arthroscopic meniscectomies in OA knees are ALL inappropriate please.

      Posted by Larry Greenberg on 5/17/2017 5:44 PM

    • I totally disagree. I have been an athlete all of my life- baseball, football, running, rugby, soccer and others. My 1st arthroscopy was in my early 30s- a loose body which felt like a bowling ball moving in my knee. My 2nd arthroscopy was in my 40s and allowed me to return to rugby, soccer, running and mountain climbimg. My 3rd was in my 50s and I retrurned to soccer, rugby and mountain climbing (volcanoes in the Pacific Northwest). I am in my 70 year and no longer play contact sports but I waslk and ride my bike and am in better health than 90% of my peers. The arthroscopies were not wanted but they enabled me to keep moving and stay healthy.

      Posted by Tim Kauffman FAPTA on 5/17/2017 6:31 PM

    • As long as there is payment for a procedure it will continue. Outcomes don't really matter in the USA 'sickcare' system. What is profitable does. Why do you think all those 'evil' socialized medicine countries like Canada, Great Britain, Germany, France and many others like them have better outcomes and lower costs? Answer: They don't pay for stuff that doesn't work!

      Posted by Ed Scott on 5/18/2017 5:19 AM

    • To Tim Kaufmann: Authors write, "Arthroscopic knee surgery does not, on average, result in an improvement in long-term pain or function." The key here is "on average". For those with mechanical symptoms, i.e. locking, catching, etc. (Often concomitant symptoms with a loose body) it is quite likely to help. But in my 38 years in practice those patients are the minority by far.

      Posted by Ed Scott on 5/18/2017 7:06 AM

    • Clearly we see that conservative management should be the first option for this group of patients. That is our expertise and what the public needs to know too. We don't know whether a more defined sub-group would benefit greatly (such as those with a mechanical block limiting extension) from arthroscopy. We need to work with our surgeons and communicate effectively when there is a lack of progress or inability to improve the quality of life. Tim is spot on and do we know if surgery and high level training afterwards isn't a great option for some? George Barnard PT

      Posted by George Barnard -> ?FQ\ on 5/18/2017 9:42 AM

    • My how things change, and thank goodness for further research as the yrs go by.

      Posted by Barb Miller on 6/8/2017 12:19 AM

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