Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms

Abstract

ObjectiveTo determine benefits and harms of arthroscopic knee surgery involving partial meniscectomy, debridement, or both for middle aged or older patients with knee pain and degenerative knee disease.DesignSystematic review and meta-analysis.Main outcome measuresPain and physical function.Data sourcesSystematic searches for benefits and harms were carried out in Medline, Embase, CINAHL, Web of Science, and the Cochrane Central Register of Controlled Trials (CENTRAL) up to August 2014. Only studies published in 2000 or later were included for harms.Eligibility criteria for selecting studiesRandomised controlled trials assessing benefit of arthroscopic surgery involving partial meniscectomy, debridement, or both for patients with or without radiographic signs of osteoarthritis were included. For harms, cohort studies, register based studies, and case series were also allowed.ResultsThe search identified nine trials assessing the benefits of knee arthroscopic surgery in middle aged and older patients with knee pain and degenerative knee disease. The main analysis, combining the primary endpoints of the individual trials from three to 24 months postoperatively, showed a small difference in favour of interventions including arthroscopic surgery compared with control treatments for pain (effect size 0.14, 95% confidence interval 0.03 to 0.26). This difference corresponds to a benefit of 2.4 (95% confidence interval 0.4 to 4.3) mm on a 0–100 mm visual analogue scale. When analysed over time of follow-up, interventions including arthroscopy showed a small benefit of 3–5 mm for pain at three and six months but not later up to 24 months. No significant benefit on physical function was found (effect size 0.09, −0.05 to 0.24). Nine studies reporting on harms were identified. Harms included symptomatic deep venous thrombosis (4.13 (95% confidence interval 1.78 to 9.60) events per 1000 procedures), pulmonary embolism, infection, and death.ConclusionsThe small inconsequential benefit seen from interventions that include arthroscopy for the degenerative knee is limited in time and absent at one to two years after surgery. Knee arthroscopy is associated with harms. Taken together, these findings do not support the practise of arthroscopic surgery for middle aged or older patients with knee pain with or without signs of osteoarthritis.Systematic review registrationPROSPERO CRD42014009145.

Unsatisfactory outcomes following unicompartmental knee arthroplasty in patients with partial thickness cartilage loss

“…Having failed non-operative treatment modalities, in three-quarters of cases their pain and functional scores are the same, if not worse than patients with more advanced structural changes 2 . In randomised studies arthroscopy has been shown not to help this group of patients and there is uncertainty over the role of nonoperative treatments including the use of corticosteroids, hyaluronic acid and platelet rich plasma [3][4][5][6] . As such these patients represent a significant clinical challenge and the optimum treatment of this group, including the role of expectant management, is unclear.…”

Atraumatic knee pain

“…Since 2002, a number of randomised, controlled studies of this procedure have been conducted, in Norway as well as in other countries. The majority of the studies have been unable to show any better effect of arthroscopy than of physical exercise under the auspices of a physiotherapist, or placebo surgery (38,39).…”

Home Treatment: Von der Forschung zur klinischen Umsetzung

“…Diese Kritik trifft aber genauso auf somatische Erkrankungen wie arterielle Hypertonie, Asthma bronchiale und Diabetes mellitus zu [5]. Selbst bei chirurgischen Interventionen ist der Placeboeffekt groß [6,7]. Psychotherapeutische oder Systeminterventionen in der Psychiatrie lassen sich wohl in RCTs jedoch aufgrund der komplexen Interventionen kaum in einem placebokontrollierten Doppelblinddesign untersuchen.…”

“…Auch in der Schweiz werden "mobile Equipen" (Home Treatment) seit 2008 gefordert [2,3] [6,7]. Psychotherapeutische oder Systeminterventionen in der Psychiatrie lassen sich wohl in RCTs jedoch aufgrund der komplexen Interventionen kaum in einem placebokontrollierten Doppelblinddesign untersuchen.…”