Introduction: Arthroscopic knee surgery with meniscus resection is common for middle aged or older people with persistent knee pain.
The knees of these patients often show “degenerative” lesions of
cartilage, meniscus, and other tissues, suggestive of osteoarthritis.
However, population based studies using magnetic resonance imaging show
that incidental findings of such lesions are also very common among
people without knee symptoms and among those without plain radiographic
signs of osteoarthritis, suggesting that the clinical significance of
such findings is unclear.
All but one of the nine randomised clinical trials to date of
arthroscopic surgery in middle aged or older people with persistent knee
pain failed to show an added benefit of interventions including
arthroscopic surgery over a variety of control treatments.
Uncertainty thus exists about the benefit of arthroscopic surgery
including meniscus resection for these patients. However, many
specialists are convinced of the benefits of the procedure from their
own experience
and several recent reports show an increase, or no decrease, in the
incidence of arthroscopic knee surgery with meniscus resection during
the past decade
The arthroscopic procedures discussed here are reported to be
associated with adverse events, including deep venous thrombosis,
infections, cardiovascular events, pulmonary embolism, and death.
The
balance of benefits and harms weighs importantly in the choice of
treatment. To inform the choice of treatment for these patients, we did a
comprehensive, up to date systematic review and meta-analysis of the
benefits and harms of arthroscopic surgery compared with control
treatments for middle aged and older people with persistent knee pain.
We extend existing knowledge by including more patients and by
presenting outcomes on pain, function, and harms in patients ranging
from those with degenerative meniscal tears and no radiographic signs of
osteoarthritis to those with degenerative meniscal tears and more
severe signs of osteoarthritis. We also accounted for the study designs
used and, when appropriate, did a priori defined subgroup analyses.
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.
