Richard Kendall MD FRCSC, Orthopaedic Surgeon (biography)
Disclosure: Involved in research grants/funding with Bionet Canada. Ownership of a specialist referral clinic. No perceived conflict of interest.
What frequently asked question have I noticed
I am frequently asked to consider knee arthroscopy as a treatment option for patients who have a diagnosis of degenerative conditions of the knee. These patients are referred because they have osteoarthritis of the knee or a suspected meniscal tear. Arthroscopy is often thought of as an effective, low morbidity procedure for the treatment of arthritis, symptomatic meniscus tears, or possible intra-articular loose bodies. Often patients have been investigated with MRI which has proven the presence of a meniscus tear in an arthritic knee. The question is however, “Is arthroscopy effective in the treatment of arthritis or degenerative meniscus tears?”
Data that answers these questions
In a blinded study done in 2002, Moseley et al demonstrated that knee debridement or lavage in the arthritic knee was no better than a sham surgical procedure (1). Pain and function scores were similar at 2 years between the operative versus non-operative treatments.
Kirkley et al in 2008 demonstrated that arthroscopic surgery followed by optimized physical therapy in the arthritic knee offered no additional benefit when compared to optimized physical therapy alone (2). Even in patients complaining of mechanical symptoms (locking and catching) within the knee, there was no added benefit of arthroscopy.
More recently, Katz et al in 2013 performed meniscectomy alone in patients with arthritic knees (3). When compared to physical therapy alone, the surgical group showed no difference in functional outcome.
As a result, the American Academy of Orthopaedic Surgeons’ currently recommends; “ against performing arthroscopy with debridement or lavage in patients with the primary diagnosis of symptomatic OA of the knee” (Level of Evidence 1&2, Grade of recommendation: A) (4).
Finally, in another 2013 article, Sihvonen et al found no benefit in the arthroscopic treatment of the degenerative meniscus tear in the absence of osteoarthritis (5).
What I recommend (practice tip)
In older individuals (>45 years) with refractory knee pain (unresponsive to a course of RICE: Rest, Ice, Compression and Elevation), weight-bearing radiographs should be ordered. Minimal views should include weight-bearing AP, lateral, and skyline views. These 3 views are effective in demonstrating osteoarthritis in all 3 compartments of the knee.
If osteoarthritis is noted, there only rare indication to obtain an MRI of the knee and routine MRI is not indicated. Knee arthroscopy has little, if any role in the treatment of knee osteoarthritis, even in the presence of mechanical symptoms.
Treatment of the symptomatic arthritic knee includes activity modification, analgesics/NSAID’s, weight loss, and active physiotherapy. Optimized physical therapy may include weekly therapy sessions with a physical therapist as well as once or twice daily self-directed exercises emphasizing range of motion and strengthening exercises as well as instruction on ADL’s, stair walking, and hot/cold therapy. Typical duration of therapy in most of the studies cited above was 12 weeks.
Atraumatic degenerative tears of the meniscus are also best treated non-operatively.
There remains an important role for arthroscopy in traumatic meniscus tears, chondral, or ligament injuries.
Orthopaedic, rheumatologic, or physiatrist opinion may be necessary in cases of knee pain refractory to treatment.
- Moseley JB, O’Malley K, Petersen NJ et al. A Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee. NEJM 2002; 347(2):81-88. Full Text
- Kirkley A, Birmingham TB, Litchfield RB et al. A Randomized Trial of Arthroscopic Surgery for Osteoarthritis of the Knee. NEJM 2008; 359(11): 1097-107. Full Text
- Katz JN, Brophy RH, Chaisson CE et al. Surgery versus Physical Therapy for a Mensical Tear and Osteoarthritis. NEJM 2013; 368(18): 1675-84. Full Text
- AAOS: Treatment of Osteoarthrits of the Knee, 2nd Edition. (Summary of Recommendations. http://www.aaos.org/research/guidelines/OAKSummaryofRecommendations.pdf Full Text (of full guideline)
- Sihvonen R, Paavola M, Malmivaara A et al. Arthroscopic Partial Meniscectomy versus Sham Surgery for a Degenerative Meniscal Tear. NEJM 2013; 369(26): 2515-24. Full Text
Knee Conditioning Program http://orthoinfo.aaos.org/PDFs/Rehab_Knee_6.pdf