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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

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