Intended for healthcare professionals

CCBYNC Open access
Practice Rapid Recommendations

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

BMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j1982 (Published 10 May 2017) Cite this as: BMJ 2017;357:j1982

Population

Including people with or without: Mild to severe osteoarthritis Radiographic evidence of osteoarthritis i X-ray or MRI changes of arthritis Mechanical symptoms i Locking, clicking, catching Acute onset knee pain i Pain started suddenly or slowly Meniscal tears i Tear in knee cartilage People with degenerative knee disease

Choice of intervention

or Arthroscopic surgery Conservativemanagement Any conservative management strategy (exercise therapy, injections, drugs) Arthroscopic surgery with or without partial meniscectomy or debridement

Recommendations

Favours arthroscopicsurgery Favours conservativemanagement

Strong Weak We recommend against arthroscopic knee surgery in patients with degenerative knee disease All Applies to Click fordetails Weak Benefits outweigh harms for the majority, but not for everyone. The majority of patients would likely want this option. Strong Benefits outweigh harms for almost everyone. All or nearly all informed patients would likely want this option.

Comparison of benefits and harms

Long term benefits (1–2 years) Evidence quality Mean score (0–100, high better) Favours arthroscopic surgery Favours conservativemanagement No importantdifference The panel found that these differences were not important for most patients, because the intervention effects were negligible and/or very imprecise (such as statistically not significant)

Pain High 18.8 21.9 No important difference More

1 2 MID Mean improvement in pain scores Arthroscopic surgery Conservative management 0 20 40 60 80 100 18.8 3.1 The other 991 in 1000 would not benefit from arthroscopic surgery. On average, knee arthroscopy results in no difference, or a very small improvement, in long term pain, compared with conservative management. A separate review found that the “minimally important difference” for patients would be an improvement of 12 on this scale. About 9 in 1000 more people would reach the MID with arthroscopic surgery, compared with conservative management. Risk of Bias No concerns Imprecision No concerns Indirectness No concerns Inconsistency No concerns Publication bias No concerns 21.9 With conservative management, 622 of 1000 people had improved symptoms which reached the MID (minimally important difference) With arthroscopic surgery, 631 of 1000 people had improved symptoms which reached the MID (minimally important difference)

Function Moderate 13.3 10.1 No important difference More

8 MID Mean improvement in function scores 13.3 Arthroscopic surgery Conservative management 0 20 40 60 80 100 10.1 3.2 A separate review found that the “minimally important difference” for patients would be an improvement of 8 on this scale. About 98 in 1000 more people would reach the MID with arthroscopic surgery, compared with conservative management. The other 902 in 1000 would not benefit from arthroscopic surgery. On average, knee arthroscopy probably results in no improvement, or a very small improvement, in long term function, compared with conservative management. Risk of Bias Serious Imprecision No concerns Indirectness No concerns Inconsistency No concerns Publication bias No concerns With conservative management, 538 of 1000 people had improved symptoms which reached the MID (minimally important difference) With arthroscopic surgery, 636 of 1000 people had improved symptoms which reached the MID (minimally important difference)
Short term benefits (<3 months) Mean score (0–100, high better)

Pain High 15.0 5.38 higher 20.4 More

The other 876 in 1000 would not benefit from arthroscopic surgery. On average, knee arthroscopy results in a very small improvement in short term pain, compared with conservative management. 1 2 MID Mean improvement in pain scores 20.4 Arthroscopic surgery Conservative management 0 20 40 60 80 100 15.0 5.4 A separate review found that the “minimally important difference” for patients would be an improvement of 12 on this scale. About 124 in 1000 more people would reach the MID with arthroscopic surgery, compared with conservative management. Risk of Bias No concerns Imprecision No concerns Indirectness No concerns Inconsistency No concerns Publication bias No concerns With conservative management, 669 of 1000 people had improved symptoms which reached the MID (minimally important difference) With arthroscopic surgery, 793 of 1000 people had improved symptoms which reached the MID (minimally important difference)

Function Moderate 9.3 4.94 higher 14.2 More

The other 866 in 1000 would not benefit from arthroscopic surgery. Knee arthroscopy may improve function slightly more than conservative management in the short term. 8 MID Mean improvement in function scores 14.2 Arthroscopic surgery Conservative management 0 20 40 60 80 100 9.3 4.9 A separate review found that the “minimally important difference” for patients would be an improvement of 8 on this scale. About 134 in 1000 more people would reach the MID with arthroscopic surgery, compared with conservative management. Risk of Bias Serious Imprecision No concerns Indirectness No concerns Inconsistency No concerns Publication bias No concerns With conservative management, 519 of 1000 people had improved symptoms which reached the MID (minimally important difference) With arthroscopic surgery, 653 of 1000 people had improved symptoms which reached the MID (minimally important difference)
Events per 1000 people Short term harms (<3 months)

Venous thromboembolism Low 5 5 fewer 0 More

Risk of Bias Serious Imprecision No concerns Indirectness No concerns Inconsistency Serious Publication bias No concerns Arthroscopy may have a small risk of venous thromboembolism

Infection Low 2 2 fewer 0 More

Risk of Bias Serious Imprecision No concerns Indirectness No concerns Inconsistency Serious Publication bias No concerns Arthroscopy may have a small risk of infection
See all outcomes
Key practical issues Arthroscopic surgery Conservative management The panel believes that almost everyone would prefer to avoid the pain and inconvenience of the recovery period after arthroscopy, since it offers only a small chance of a small benefit. Preferences and values Resourcing Arthroscopy is not cost-effective from a societal perspective. Performed by a surgeon, in an operating theatre May be performed in hospital or the community Recovery typically between 2 to 6 weeks At least 1–2 weeks off work, depending on speed of recovery and physical demands of job Time off work may be required for appointments, such as physiotherapy and injections No recovery time

©BMJ Publishing Group Limited.

Disclaimer: This infographic is not a validated clinical decision aid. This information is provided without any representations, conditions or warranties that it is accurate or up to date. BMJ and its licensors assume no responsibility for any aspect of treatment administered with the aid of this information. Any reliance placed on this information is strictly at the user's own risk. For the full disclaimer wording see BMJ's terms and conditions: https://www.bmj.com/company/legal-information/

Find recommendations, evidence summaries and consultation decision aids for use in your practice

Article usage

Article metrics provide readers and authors with an indication of how often a specific article has been accessed month by month. It counts three formats - abstract/extract, full text and pdf. The page is updated each day.

Usage statistics: May 2017 to June 2019

Rendering graph...
AbstractFullPdf
May 2017141779854405
Jun 201719131701779
Jul 2017050756343
Aug 2017053351807
Sep 2017038881257
Oct 2017059121781
Nov 2017040381404
Dec 2017036491069
Jan 201803009739
Feb 2018503477781
Mar 2018183469586
Apr 201813099547
May 2018103350677
Jun 201892645549
Jul 201872720540
Aug 201822334454
Sep 201822284568
Oct 201822235621
Nov 201802098573
Dec 201851594535
Jan 201962063638
Feb 201942061612
Mar 2019318871161
Apr 201941701861
May 201911927849
Jun 201941053437
Total28816205831573