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

J B Thorlund, C B Juhl, E M Roos, L S Lohmander, J B Thorlund, C B Juhl, E M Roos, L S Lohmander

Abstract

Objective: To 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.

Design: Systematic review and meta-analysis.

Main outcome measures: Pain and physical function.

Data sources: Systematic 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 studies: Randomised 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.

Results: The 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.

Conclusions: The 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 registration: PROSPERO CRD42014009145.

Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: LSL has received personal fees from Össur, Flexion Therapeutics, Medivir, Teijin, MerckSerono, Allergan, and Galapagos and is editor-in-chief of Osteoarthritis and Cartilage; EMR has received personal fees for lectures and royalties for books from Össur, Finnish Orthopedic Society, Studentlitteratur, and Munksgaard and is an associate editor of Osteoarthritis and Cartilage; no other relationships or activities that may appear to have influenced the submitted work.

© Thorlund et al 2015.

Figures

https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4794021/bin/thoj023058.f1_default.jpg
Fig 1 Results of primary analysis on benefit on patient reported pain of interventions including arthroscopic knee surgery compared with control interventions (follow-up time range: 3-24 months)
https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4794021/bin/thoj023058.f2_default.jpg
Fig 2 Effect of interventions including arthroscopic knee surgery compared with control interventions on patient reported pain presented as difference in mm on 0-100 mm visual analogue scale, with 95% confidence interval error bars. Table below shows number of studies and patients included in analyses at different follow-up time points, with estimated difference between interventions calculated as effect size and estimates of heterogeneity (I2). Data from 2 months’ follow-up from Osteraas et al and Sihvonen et al are included in 3 month estimate
https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4794021/bin/thoj023058.f3_default.jpg
Fig 3 Results of main analysis on benefit on patient reported physical function of interventions including arthroscopic knee surgery compared with control interventions (follow-up time range: 3-24 months)
https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4794021/bin/thoj023058.f4_default.jpg
Fig 4 Effect of interventions including arthroscopic knee surgery compared with control interventions on patient reported physical function presented as difference in mm on 0-100 mm visual analogue scale, with 95% confidence interval error bars. Table below shows number of studies and patients included in analyses at the different follow-up time points, with estimated difference between interventions calculated as effect size and estimates of heterogeneity (I2)
https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4794021/bin/thoj023058.f5_default.jpg
Fig 5 Evaluation of risk of bias in primary analysis of pain. P value indicates difference between studies dependent on risk of bias scoring (that is, adequate, inadequate, and unclear)
https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4794021/bin/thoj023058.f6_default.jpg
Fig 6 Subgroup analysis on primary analysis of pain stratified by study population knee osteoarthritis status, surgery type, and study design. P value indicates difference between different subgroups

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