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November 7, 2015 at 9:51 pm #3262
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Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms
BMJ 2015; (Published 16 June 2015)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.Discussion
In this meta-analysis, in which the primary endpoint of each of the nine included randomised trials ranged from three to 24 months after surgery, we found a small but statistically significant effect on pain relief from interventions including arthroscopic surgery compared with control treatments, corresponding to a 2.4 mm between group difference on a 0-100 mm visual analogue scale.
When we analysed pain for different postoperative time points, the benefit favouring arthroscopic surgery was present only at three and six months, but not at later time points.
We found no between group differences for self reported physical function in any of the analyses.Deep venous thrombosis was the most frequently reported symptomatic adverse event, followed by infection, pulmonary embolism, and death.
Unanswered questions and future research
Available evidence supports the reversal of a common medical practice.
However, disinvestment of commonly used procedures remains a challenge, and use of arthroscopy seems to be undiminished, in analogy with use of vertebroplasty following the publication of trials showing absence of benefit of this procedure.
Surgeon confirmation bias in combination with financial aspects and administrative policies may be factors more powerful than evidence in driving practice patterns.What is already known on this topic
Arthroscopic knee surgery is frequently and increasingly used to treat middle aged and older patients with persistent knee pain
All but one published randomised trials have shown no added benefit for arthroscopic surgery over that of the control treatment, but many specialists are convinced of the benefits of the surgical interventionWhat this study adds
Interventions that include arthroscopy are associated with a small benefit and with harms; the small benefit is inconsequential and of short duration
The benefit is markedly smaller than that seen from exercise therapy as treatment for knee osteoarthritis
These findings do not support the practice of arthroscopic surgery as treatment for middle aged or older patients with knee pain with or without signs of osteoarthritis.G Mohan.
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