PositionStatementfromtheAustralianKneeSocietyonArthroscopicSurgeryoftheKnee,includingreferencetothepresenceof
OsteoarthritisorDegenerativeJointDiseaseUpdatedOctober2016
Inpreparingthefollowingevidencebaseddocument,theAustralianKneeSociety,onbehalfoftheAustralianOrthopaedicAssociation,hascombinedtheindividualclinicalexpertiseofitsmemberswithpublishedrandomized
controlledtrialsfromasystematicreviewoftheliterature.
PositionStatement
Arthroscopicdebridement, and /or lavage,hasbeen shown tohavenobeneficial effecton the
naturalhistoryofosteoarthritis,norisitindicatedasaprimarytreatmentinthemanagement of
osteoarthritis. However, this does not preclude the judicious use of arthroscopic surgery,when
indicated, to manage symptomatic coexisting pathology, in the presence of osteoarthritis or
degeneration.Partialmedialmeniscectomyisnotindicatedasaninitialtreatmentforatraumatic
tears of degenerative menisci, excluding bucket handle tears and surgeon assessed locked or
lockingknees.
ArthroscopicSurgeryinthePresenceofOsteoarthritisorDegeneration
Therearecertainclinicalscenariosinwhicharthroscopicsurgery,inthepresenceofosteoarthritis,may
beappropriate.Theseinclude,butarenotnecessarilylimitedto,thefollowing:
• knownorsuspectedsepticarthritis
• symptomatic non-repairable meniscal tears after failure of an appropriate trial of a
structuredrehabilitationprogram
• symptomaticloosebodies
• surgeonassessedlockedorlockingknees
• traumaticoratraumaticmeniscaltearsthatrequirerepair
• inflammatoryarthropathyrequiringsynovectomy
• synovialpathologyrequiringbiopsyorresection
• largeunstablechondralpathologycausingsurgeonassessedlockingorlockedknee
• asanadjunctto,andincombinationwith,othersurgicalproceduresasappropriatefor
osteoarthritis:forexamplehightibialosteotomyandpatello-femoralrealignment
• diagnosticarthroscopywhenthediagnosisisunclearonMRIorMRIisnotpossible,andthe
symptomsarenotofosteoarthritis
Thedecisiontoproceedwitharthroscopicsurgeryinthepresenceofosteoarthritisordegenerationshouldbe
madebythetreatingorthopaedicsurgeon:
• aftercarefulreviewoftheclinicalscenario:particularlytheassessmentoftherelativecontributions
oftheosteoarthritis,andthearthroscopicallytreatablepathology,tothepatient’ssymptoms• withknowledgeoftherelevantevidencebase,aslistedinthisdocument• afteranappropriatetrialofstructuredrehabilitation• andafterthoughtfuldiscussionwiththepatientabouttherelativemeritsoftheprocedureversus
ongoingnon-operativetreatment
Definitions
Osteoarthritis,ordegenerativejointdisease,isaprogressiveclinicaldisorderofjointscharacterizedby
gradualdiffuselossofarticularcartilage,effectsontheunderlyingbone,andsecondarycompromiseof
jointfunction.Thisshouldbedistinguishedfromfocalarticularcartilagepathologyinanotherwisenormal
joint.
Thereisaspectrumofseverityofosteoarthritisfromminorpartialthicknessarticularcartilageabnormalities
tolargeareasoffullthicknessloss.Clinicaldecisionmakingrequirescarefulassessmentofthedegreeof
arthritis,itslikelycontributiontothesymptoms,andthepotentialcontributionofadditionalpathologyto
thosesymptoms.Theconceptsofdegenerativeversustraumatic,inregardmeniscalpathologyandtearing,isarbitrary(1).No
universallyaccepteddefinitionofdegenerationordegenerativechangeexists,andcommonlyusedclinical
diagnosticdescriptorslackvalidity.
AssessmentandInterpretationofMRIScanning
Whilstplainradiography is thepreferred initial imagingmodality,MRIremainsexcellentadjunct
bothtoclinicaldecisionmaking,andtoguidingtheuseofsurgery. Inparticular,itcanbeusedto
moreaccuratelyassessthedegreeofarthritis,andtolookforand assessadditionalpathologythat
may correlate with a patient’s symptoms. MRI reports should be interpreted carefully by the
treatingsurgeon,incombinationwithdirectreviewoftheimaging, whendeterminingtheclinical
relevanceofthefindings.MRIdescriptionsofmeniscaltearing,degeneration,andpathologyinthe
absenceoftrauma,lackvalidity.Furtherinformationontheappropriateradiologicalinvestigation
of knee osteoarthritis can be obtained in the “Radiological Investigation Joint AKS-AMSIG
SubmissiontotheAustralianCommissiononQualityandSafetyinHealthcareontheRadiological
Investigationof KneeOsteoarthritis (http://www.kneesociety.org.au/resources/Joint-AKS-AMSIG-
submission-ACQSH-investigation-knee-osteoarthritis.pdf).
SystematicReview:ArthroscopicSurgeryinthePresenceofOsteoarthritis
Introduction
Ouraimwastoexaminetheevidenceofeffectiveness,inclusionandexclusioncriteria,theeffectsofageand
adverseevents,inexistingkneearthroscopyrandomizedcontrolledtrials,withaviewtotheformulationof
clinicalindicationguidelinesbasedonICD–10codesforkneearthroscopyinthepresenceofdegenerationor
osteoarthritis.
Methods
ThePRISMAstatementforsystematicreviewswasutilizedforthisreview(2).
LiteraturesearchandStudySelection
AsystematicsearchforclinicalindicationsinMedline,Embase,CINAHL,andtheCochraneCentralRegisterof
ControlledTrials(CENTRAL)inDecember2015wasundertaken.Thekeywords“arthroscopy”and“knee”,or
variationsofthemwereused.Limitationstoclinicaltrialsandhumanstudieswereapplied.Nosearch
restrictionsforfollow-uptime,studysize,ordateofpublicationwereset.
Eligibilitycriteria
Inclusioncriteria:1.Randomisedcontrolledtrials(RCT)assessingtheeffectivenessofarthroscopicsurgeryinvolvingmeniscal
surgery,debridement,chondroplasty,loosebodyremovaloranycombinations,withorwithoutclinicalor
radiographicosteoarthritis,comparedwithnon-surgicaltreatments,shamsurgeryorlavage.
2.Englishlanguagereports.
3.Publicationinapeerreviewedjournal.
Exclusioncriteria:
Allcriteriahadtobesatisfiedforinclusionandothersystematicreviewsormeta-analyseswereexcluded.
DataExtraction
Titlesand/orabstractsofstudiesthatwereretrievedusingthesearchstrategywerescreenedindependently
bytworeviewauthorstoidentifystudiesthatpotentiallymettheinclusioncriteria.Thefulltextsofthese
potentiallyeligiblestudieswereretrievedandindependentlyassessedforeligibilitybythetworeviewteam
members.Anydisagreementovertheeligibilityofaparticularstudywasresolvedthroughconsensuswiththe
additionofathirdreviewer.
Astandardisedformwasusedtoextractdatafromtheincludedstudiesforassessmentofstudyqualityand
evidencesynthesis.Extractedinformationincluded:studypopulation;primarydiagnosis,inclusioncriteria,
exclusioncriteria,detailsoftheintervention;detailsofthecomparator;studymethodology;outcomesand
timesofmeasurement,andpoweranalysis.Tworeviewauthorsextractedthedataindependently.
Iftwoseparatestudieswiththesameauthorsandthesameinterventionhadoverlappingdatesofpatient
enrolment,thenonlyonestudywasincluded.Inthissituation,thereviewerselectedthestudywiththe
longerfollow-up.Ifadifferentdataanalysisorsub-analysiswasundertaken,thenthesupplementalstudywas
included.
ICD10DiagnosisMatching
InternationalClassificationofDisease10thRevisionClinicalModification(ICD-10-CM)codesorProcedure
CodingSystem(ICD-10-PCS)codeswerematchedbytworeviewauthorstotheinclusion&exclusioncriteria
ofallmatchedstudies.ICD-10-CMcodesweredevelopedbytheCentersforDiseaseControlandPreventionin
conjunctionwiththeNationalCenterforHealthStatistics(NCHS),foroutpatientmedicalcodingand
reporting,aspublishedbytheWorldHealthOrganization.ICD-10-PCScodesweredevelopedbytheCenters
forMedicareandMedicaidServices(CMS)asasystemofclassificationofproceduralcodestoclassifyall
healthinterventionsbymedicalprofessionals(3).
Results
KneeArthroscopyOutcomesStudies
14RCTsofarthroscopickneesurgery(Table1)fulfilledthesearchcriteria(Figure1)inthreedifferentprimary
clinicalICD–10diagnosiscategories(Table2).Infourpapers,theprimaryclinicaldiagnosiswasosteoarthritis
(4)(5)(6)(7)(OAPapers)(ICD–10CodeM17.9).Inonepaper,Hubbardetal(8)theprimaryclinicaldiagnosis
wasofasinglemedialfemoralcondyledegenerativearticularlesion,howevernotenoughinformationwas
providedbytheauthorstoallowclassificationofthedegenerativechondrallesionasclinicalosteoarthritis.
In8paperstheprimaryclinicaldiagnosiswasasymptomaticdegenerativeatraumaticmedialmeniscaltear
(9)(1)(10)(11)(12)(13)(14)(15)(MMTPapers)(ICD-10CodeM23.2)inthepresenceofchondraldegeneration
ofvariousdegrees.Inonepaper,Kettunenetal(16)theprimaryclinicaldiagnosiswaspatellofemoralpain
(PFPainGroup)(ICD-10M22.4).
ThreeRCTswereassessedashavinginadequatepowerfortheprimaryoutcomesmeasure.Østeråsetal(15)
examinedarthroscopicpartialmedialmeniscectomyinthepresenceofkneeosteoarthritiscomparedto
physicaltherapy.Theyincludedapoweranalysis,howeverthefinalnumberofpatientsintheirstudywasless
thanstatedtoachieveadequatepower.Changetal(6)lackedapoweranalysis,howeveraPostHocPower
AnalysisusingG-Power(17)revealedthepaperwasinadequatelypowered(power<0.8)toconfirmtheself
describedmeaningfulimprovementofareductionof>1cmfromthebaselineVASscore.Sihvonenetal14)is
apost-hocsubgroupanalysisofpatientsfromtheiroriginal2013RCT(1)whosufferedself-described
mechanicalsymptoms,definedascatchingandclickingexcludinglockedorrecentlylockedknees.Theauthors
statethatthesub-groupanalysiswasunderpowered.
Threepapersfavoredarthroscopicinterventionatfinalfollow-up,twointheOA-ChondralDegeneration
Category(7)(8)andoneintheMMTCategory(9),theremaining11papersreportednooutcomedifference
comparedtothecontrolintervention.
RiskofBiasAssessment
StudieswereratedfortheirriskofbiasinTable3.Therewerenostudieswithalowriskofbiasinall7risk
domainsassessedintheOA-ChondralDegenerationCategoryandPatellofemoralPainCategory(7).InMMT
studies,therewasonlyonestudyoflowriskofbias(1)inalldomains.
MMTPapersExclusionsInthe8paperswithaprimaryclinicaldiagnosisofmedialmeniscaltearing,fivepapersexcludedsurgeon
assessedlockedorlockingknees(13)(1)(9)(15)(14)andoneexcludedloosebodies(18),withVermesanetal
notstatinganyexclusioncriteria(Table4).TheSihvonenetal(19)andSihvonenetal(14)trialprotocol
excludedsurgeonassessedlockedorrecentlylockedkneesandmajorchondralflapsbutincludedkneeswith
patientreportedcatchingandlockingsymptoms.Yimetal(11)&Katzeta(13)alsoincludedpatientswith
mechanicalsymptoms
AhistoryoftraumaticonsetwasanexclusioncriterioninsixMMTPaperspapers(15)(11)(1)(18)(14),with
Vermesanetal(20)notstatinganyexclusioncriteria.Nopaperincludedmeniscalrepairasamanagement
interventionandmeniscalrepairwasanexclusioncriteriainthreepapers(1)(11)(14).FiveoftheeightMMT
Papersreportedcross-overintothesurgicalgroupfromthecontrol,withratesofbetween2%-33%.
Nostudyincludeddiagnosticarthroscopy.Inflammatoryjointdisorderswereexcludedin4papers,ornotan
inclusioncriteriaintheremainder.
OAPapers-ExclusionCriteriaMerchanandGalindo(7)excludedpatientswithpaingreaterthansixmonths,maleswithaweightover85kg,
femalesgreater70kg,instabilityoranangulardeformitygreaterthan15degrees.Hubbardetal(8)excluded
anyotherintra-articularlesionexceptforsymptomaticmedialfemoralcondyledegenerativelesionsin
patientswithnoradiographicosteoarthritis.Moseleyetal(4)addedtheKellgrenandLawrencescoreforeach
compartmenttogether,excludingthepatientswithascoreofgreaterthannine.Kirkelyetal(5)excluded
patientswithlargemeniscaltears,buckethandletears,priormajorkneetrauma,inflammatoryorpost
infectiousarthritis,deformity>5degrees,priortraumaorKL4intwocompartments.
TypesofMedialMeniscalTear
Onlyonepaper,Kimetal(11),describedtheMMTpattern,theremaindergroupedallMMTpatternstogether
asatraumaticdegenerative.Sihvonenetal(1)describedanatraumaticsuddensymptomonsetsub-groupwho
didnobetterwithsurgicalintervention.
CrossOverIntoSurgicalGroup
NoneoftheOA/ChondralDegenerationpapersdescribedcrossoverintothesurgicalgroup.Sevenofthe
nineMMTPapersdescribedcross-overintothesurgicalgroupof0%(15),2%(11),2.5%(14),6.6%(1),
21.3%(9),30.2%(13),and33.3%(18).Reasonsforcrossoverintothesurgicalgroupwereeitherthoseof
persistentsymptoms(18)(1)(9)ornotgiven(11)(13).
HerrlinetalandKatzetalstatedthatpatientswhocrossedoverintothesurgicalgrouphadsignificantly
worsesymptomsthantheremainderofthecontrolgrouppriortocrossingover,howeverachievedsimilar
outcomestothecontrolandsurgicalgroup.
TheEffectofAge
Onlyonepaperspecificallyexaminedtheeffectofageonoutcome.Gauffinetal(9)reportedbetteroutcomes
forbothrehabilitationandarthroscopicinterventionfor55-64yearoldpatientscomparedtoyounger
patientsaged45-55years.
AdverseEvents
Nopaperdescribedagreaterrateofadverseeventsinthearthroscopicgroup.
LateralMeniscalTears
Nostudyexaminedoutcomesofpartialmeniscectomyasatreatmentforlateralmeniscaltears.
OutcomesofPatientswithAtraumaticMedialMeniscalTearsWhoHaveFailedNon-Operative
Management
Theinclusioncriteriaforfouroftheeightmeniscaltearsstudiesincludedfailureofclinicianassessednon-
specificnon-operativemanagementofbetween1&3months.Nomedialmeniscalstudyexaminedoutcomes
ofpatientswhohadundergonestructuredrehabilitationprogramandcontinuedtohavehadsevereself-
describedsymptomsafterbyrandomizationtooperativeversusnon-operativeintervention.
OutcomesofPatientsWhoHaveSelf-ReportedMechanicalSymptoms
Self-reportedmechanicalsymptomswerecommoninallpapers.Onepaper(14),asecondaryanalysisofa
previouslypublishedRCT,foundnodifferenceinpatientswithatraumaticself–describedmechanical
symptomswhounderwentmedialmeniscectomycomparedtoashamprocedure.Kirkelyetal(5)foundno
improvementinasub-groupofpatientswithosteoarthritisandself-describedmechanicalsymptoms
comparedtorehabilitation.
ProgressionofOsteoarthritisAfterPartialMeniscectomy
Onepaper,Herrlinetal(18),foundnodifferenceinosteoarthritisprogression5yearsafterpartialmedial
meniscectomycomparedtophysiotherapy.
ReviewConclusions
Allofthestudiesintheosteoarthritisgroupwereathighriskofbiasinatleastonedomain.
OneOAstudywasatlowriskofbiasfromblinding.Inthisstudy,patientswhowereassessedclinicallytohave
moderatetoseverekneeosteoarthritis,intheabsenceofloosebodiesorlocking,showednoadvantageof
arthroscopicdebridementoverlavageorshamsurgery.
Inastudywithahighriskofbias,patientswithisolatedmedialfemoralcondyledegenerativelesions
benefitedfromarthroscopicinterventioncomparedtorehabilitation.
Inastudywithahighriskofbias,arthroscopicpatellofemoralchondroplastydidnotbenefitpatients
comparedtonon-operativemanagement.
Inatraumaticmedialmeniscaltears,intheabsenceofsurgeonassessedlockingoralockedknee,ora
repairablemeniscustear,astudywithalowriskofbiasshowednoadvantageofarthroscopicpartial
meniscectomyovershamsurgery.
Inastudywithahighriskofbiasinonedomain,patientswithanatraumaticonsetofself–described
mechanicalsymptoms,inthepresenceofamedialmeniscaltear,otherthansurgeonassessedrecentlocking,
alockedkneeorsymptomaticloosebodies,therewasnoadvantagetoarthroscopicpartialmeniscectomy
overshamsurgery.
Theroleofarthroscopicsurgeryinlateralmeniscaltearsremainsuncertain,asithasnotbeensubjectedtoa
randomisedcontrolledtrial.
Theroleofsubchondraldrillingormicrofractureundertakenincombinationwithanosteotomyremains
uncertainasnorandomisedcontrolledstudiesexistcomparingittoosteotomyalone.
Preservationofthemedialorlateralmeniscusbyrepairofthebodyorroot,withorwithoutdegenerationof
thejoint,hasnotbeensubjectedtoarandomisedcontrolledtrial.
NostudyinvestigatedtheroleofdiagnosticarthroscopyinsituationswhereMRIwasinconclusiveorunableto
beperformed.ThevalueofMRIintheinvestigationofatraumaticnon-lockingkneesymptomsinpresenceof
osteoarthritisremainsuncertain.
Nomedialmeniscaltearstudyexaminedoutcomesofpatientswhofailedastructuredrehabilitationprogram
byrandomizationtooperativeversusnon-operativeintervention.
References
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Table1:ArthroscopicSurgeryOutcomesinRandomizedControlledTrialsAuthor&Year
PrimaryDx Rx Inclusions Ixx n Control %Notenrolled
MaxXROA
JointSpecificExclusions
%XOver
PA Notes Outcome
Osteoarthri=s&ChondralDegenera=veRCTs1 Merchan
and
Galindo8
1993
MildOAwithotherintra-
pathology
Synovectomy;débridement;APM,CPY,E/Oosteophytes&
PT
Painful“limited”OA,includingpaVentswithmeniscaltears,loosebodies&synoviVs.
XR 73 NSAID.AcVvity
modificaVon.
NS Ahlbach0-1,KL1-2
Duration of pain >6 months, patient body weight >85 kg in men and >70 kg in women, and history of previous surgery. Instability or an angular deformity > 15°.
Patellofemoral OA.
NA N OM=ModifiedHSSKScore.APMperformedin31/35.Power>0.8.
FavouredA/Sat1-3years(mean25
months)
2 Changetal171993
OsteoarthriVs
APM,CPY,Synovectomy
Painader3monthsaderrehabilitaVon
XR 32Pts
NeedleLavage
50 KL1-3 PriorKneesurgerywithin6months,TKA,
OAKLGradeIV.
NS N Inadequatepower.50%hadKLGrade3
Nodifferenceat12months.
3 Hubbard
etal9
1996
SymptomaVcsingleMFCdegeneraVvechondrallesionObCGrade3or4
Chondroplasty.NoAPM.
Symptoms>1yr,nolaxityornodeformity,fullROM,singleMedialFemoralCondyle
degeneraVvelesion,OBCGrade3or4,nootherintra-arVcularpathology,normalplainXR,modifiedLysholmscore<
38/70.
XR 76 A/SLavage NS KLO DegeneraVvelesionsonotherjointsurfaces,otherintra-arVcular
pathology,radiographiclossofjointspace,previousoperaVon,
steroidinjecVonforanyreason.MMTorVbial
degeneraVon.
NA N OM=Binaryself-describedpainpresence/absence&ModifiedLysholm.Power>0.8.
FavouredA/Sat1&5years
4 Moseley
etal5
2002
TricompartmentalOA
APM,
Chondroplasty,
<75years,moderateKneepainthathadfailed6months
medicalmanagementwithVASPainScore>3,failedmedicalMxanddiagnosisofOAbased
onACRdefiniVons
XR 180 Shamor
Lavage
44 KL3-4 Scoring>9byKLscoreaddiVoninthreecompartments
NA Y Threearmstudy.Inlavagegroup,
“mechanicallyimportant,unstabletears”were
debrided.Inshamgroup,jointnotentered.OM=bespokeKneeSpecificPainScale,AIMS2&SF
36PF
Nodifferenceat2yearsbetween3
groups.
5 Kirkleyet
al62008
SymptomaVcmoderatetosevereOA
Synovectomy;débridement;APM,CPY,E/Oosteophytes&
PT
Age>18yowithidiopathicorsecondaryOAKLGrade2-4.
XR&MRI
188 PT 16 KL0-4 Largemeniscaltears,buckethandletears,
priormajorkneetrauma,inflammatoryorpostinfecVousarthriVs,
deformity>5degrees,priortrauma,KL4intwo
compartments.
0% Y OM=WOMAC&SF36 Nodifferenceattwoyears.
Author&Year
PrimaryDx Rx Inclusions Ix n Control %Notenrolled
MaxXROA
JointSpecificExclusions %X-Over
PA Notes Outcome
MedialMeniscalTearRCTs1 Yimet
al122013SymptomaVchorizontaldegeneraVve
MMT
APM&PT
HorizontaldegeneraVveMedialMTonMRI&dailykneepainonthemedialsidewithmechanicalsymptoms,failednon-
surgicalMx
MRI 108 PT 30 KL0-1 Definitetrauma,ligamentdeficiency,systemicarthriVs,KL2-4andosteonecrosis,meniscalrepair,abrasionarthoplasty,
subchondraldrilling,cureqage.
2 Y Nomeniscalrepairsortotalmeniscectomyundertaken.Outcome
measures=VAS,LysholmandTegner
FavoredA/Sat3months.Nodifferenceat2years.MTpaqerndescribed.
2 Sihvonenetal12013
SymptomaVcDegeneraVve
MMTconfirmedonMRI&atAS
APM&PT
35to65y,kneepain>3monthsthatwasunresponsiveto
convenVonalconservaVvetreatmentandhadclinicalfindingsconsistentwitha
tearofthemedialmeniscus
XR&MRI
146 Shamsurgery&PT
12 KL0-1 Trauma-inducedonsetofsymptoms,lockedorrecently
lockingknee,decreasedrangeofmoVon,instability,pathology
otherthandegeneraVvekneediseaserequiringtreatment
otherthanarthroscopicparValmeniscectomy,Meniscalrepair,micro-fracturetochondral
defect,majorchondralflap,ClinicalOAbasedonACRCCR.Or
KL>1
6.6 Y Nochondroplastyundertaken.
OM=VAS,LysholmandWOMET.Blindedstudy.
MTpaqernnotdescribed.
Nodifferenceat12months.“resultsaredirectlyapplicableonlyto
paVentswithnon-traumaVcdegeneraVvemedialmeniscustears”
4 Katzetal142013
SymptomaVcDegeneraVve
MMTwithmildtomoderateOA
APM,CPY&PT
>45y&>1monthsymptoms,imagingevidenceofmild-to-moderateknee
osteoarthriVs,symptomsofthefollowing:clicking,catching,popping,givingway,painwithpivotortorque,painthatisepisodic,pain
thatisacuteandlocalizedtoonejointline),KL0-3.
XR&
MRI
330 PT 75 KL0-3 Chronicallylockedknee,KL4,clinicallysymptomaVc
chondrocalcinosis,bilateralsymptomaVcmeniscaltears,priorsurgeryonsameknee
30.2 Y SimilarimprovementinWOMACinfailedPTasAPMoncecrossedoverAPM,Treatmentsuccess
definedas>8pointimprovementonWOMACphysicalfuncVonscale.
MTpaqernnotdescribed.
Nodifferenceat12months.30%crossedovertoAPM.
Treatmentfailure25%inAPMGroupand49%inPTGroup.Sameadverse
eventsbetweengroups.
5 Herrlinetal192013
MRI-verifieddegeneraVveMMT&
radiographicAOGrade<2(Ahlback)
APM,CPY&PT
Age45-60,dailymedialpainover2-6months.
XR&
MRI
96 PT 55 Alback1
,ObBI-
IV
Historyoftrauma,OA>Alback1,RheumatoidArthriVs,Loosebodies,kneeinstability,osteochondraldefects&
tumours,TKA,priorkneesurgeryinlastyear
33 Y NodifferenceinOAprogressionnoted
between2Groups.OM=KOOS,Lysolm&VAS.
SimilarPROMsimprovementinPT&APM.MTpaqernnotdescribed.
Nodifferenceat2&5years.33%ofPTGroupcrossedoverintoAPMwithsimilarbenefittoAPMGroupandrestofPTgroupat2&5years.ThissubgrouphadsignificantlylowerPROMscoresthanrestofPT
GrouppriorAPM.6 Vermesa
netal132013
MRI-verifieddegeneraVve
medialmeniscustearandradio-
graphicosteoarthriVs
APM,CPY&PT
NontraumaVcsymptomaVckneeswithdegeneraVvelesions
medialcompartmentonMRI
MRI 120 CSI NS NS NS NS N OM=OxfordKneeScore.PostHocPowerAnalysis>
0.8(d=.0.3twotailed,p=0.05).MTpaqern
notdescribed.
Beqerscoresinsurgicalgroupat3months.Nodifferenceat12months.
Footnotes
AbbreviaVons:KOOS=KneeInjuryandOsteoarthriVsOutcomeScoreEQ5D=EuroQolPAS=PhysicalAcVvityScaleSSS=symptomsaVsfacVonscaleOA=OsteoarthriVsPT=PhysicalTherapyAS=ArthroscopicAPM=ArthroscopicParValMeniscectomyMRI=MagneVcResonanceImagingObC=OuterbridgeClassificaVon.
KL=KellengrenLawrenceOM–OutcomeMeasurePFJ=PatellofemoralJointROM=RangeofMoVonXR=Radiograph>=Lessthan<=GreaterthanPts=PaVentsMx=ManagementNS=NotstatedY=YesN=NoACRCCC=AmericanRheumatologyClinicalClassificaVonforOsteoarthriVsoftheKneePROM=PaVentRecordedOutcomeMeasures
7 Østerasetal162013
MRI-verifieddegeneraVve
MMTandradio-g=raphicOA
APM Age35-60 MRI 17 PT 12 KL0-2 ACLtears,acutetrauma,KL3-4,heamarthrosis,lockingknee
0 Y Inadequatepowerbasedonauthor’sownpoweranalysis.Outcome
measures=VAS&KOOS
Nodifferenceat3months.MTpaqernnotdescribed.
3 Gauffinetal102014
SymptomaVcMMT
APM,CPY
45-64,symptomsofMT>3monthsAhlback0PriorPT
XR,NoMRI
150 PT 2.8 Ahlbach0,KL1-2
Locked/lockingknee.RheumaVcdisease.
21.3 Y OM=KOOS,EQ5D,PAS&SSS.MTpaqernnot
described
FavoredA/Sat12months.
8 Sihvonenetal152016
SymptomaVcDegeneraVve
MMTconfirmedonMRI&atAS.Subgroupanalysis
oforiginalSihvonenetal20131paVentswithmechanical
symptoms
APM&PT
35to65y,kneepain>3monthsthatwasunresponsiveto
convenVonalconservaVvetreatmentandhadclinicalfindingsconsistentwitha
tearofthemedialmeniscuswithmechanical
symptoms
XR&MRI
69 Shamsurgery&PT
NS KL0-1 Trauma-inducedonsetofsymptoms,lockedorrecently
lockingknee,decreasedrangeofmoVon,instability,pathology
otherthandegeneraVvekneediseaserequiringtreatment
otherthanarthroscopicparValmeniscectomy,Meniscalrepair,micro-fracturetochondraldefect,meniscalrepair,majorchondralflap,ClinicalOAbased
onACRCCR.OrKL>1
2.5 N Nochondroplastyundertaken.
OM=VAS,LysholmandWOMET.Blindedstudy.
MTpaqernnotdescribed.
Nodifferenceat12months.
Authorsstate“Thissubgroupanalysisislikelytobeunderpowered…”
Posthocanalyses:ThestudyquesVonswerenotincludedaprioriasprimaryorsecondaryobjecVvesoftheoriginal
trial.
Author&Year
PrimaryDx Rx Inclusions Ix n Control %Notenrolled
MaxXROA
JointSpecificExclusions %X-Over
PA Notes Outcome
PatellofemoralPainRCT12 Kequnen
etal152012
PFJpainandsymptomslasVngatleast6months
PFJCPY
Age18–40yearsFemaleormale
SymptomslasVngatleast6months.
PFJpainduringkneeloadingphysicalacVvityorinprolongedflexion.
NA 56 PT 2% KL0 Priorkneesurgery,patelladislocaVon,OCD,Patella
tendinopathy,OsteoarthriVs,loosebodies,instability.
10 Y Outcomemeasures=Kujalascore&VAS
Nodifferenceat2&5years.
X-over=Cross-overIx=InvesVgaVonn=NumberofpaVentsCPY=Chondroplasty
CSI=CorVcosteroidinjecVonMFC=MedialFemoralCondyleRx=IntervenVonPA=PowerAnalysis
Table2:ArthroscopicKneeSurgeryRCTsInclusions&ExclusionsusingICD10Codes
ClinicalDiagnosesIncludedinRCTs
UnilateralOsteoarthri=sofKnee(9)(6)(7)M17.9OsteoarthriVsofknee,unspecifiedM17.0BilateralprimaryosteoarthriVsofkneeM17.1UnilateralprimaryosteoarthriVsofknee
Atrauma=cDegenerateTearstoMedialMeniscus(12)(1)(10)(14)(19)(22) M23.2Derangementofmeniscusduetooldtearorinjury M23.22Derangementofposteriorhornofmedialmeniscusduetooldtearorinjury M23.30Othermeniscusderangements,unspecifiedmeniscus M23.32Othermeniscusderangements,posteriorhornofmedialmeniscusPatellofemoralChondropathy(15)
M22.4Chondromalaciapatella===========================================================ClinicalDiagnosesExcludedfromRCTs*$
LockingorLockedKnee(7)(1)(10)(14) M23.40LooseBodyinKnee(21)(19)(15)M21.26Flexiondeformity,kneeM93.2OsteochondriVsdessicansM23.8OtherinternalderangementsofkneeS83.21ABucket-handletearofmedialmeniscus,currentinjury,iniValencounter(7)
S83.205AOthertearofunspecifiedmeniscus,currentinjury,unspecifiedknee,iniValencounter S83.22APeripheraltearofmedialmeniscus,currentinjury,iniValencounter S83.26APeripheraltearoflateralmeniscus,currentinjury,iniValencounter M25.669SVffnessofunspecifiedknee,notelsewhereclassifiedKneeInstability(12)(1)(19)(15) M23.60OtherspontaneousdisrupVonofunspecifiedligamentofknee M23.61OtherspontaneousdisrupVonofanteriorcruciateligamentofknee M23.62OtherspontaneousdisrupVonofposteriorcruciateligamentofkneeInternalDerangementsofthanMMT(1)(19)
M93.2OsteochondriVsdessicansM23.8OtherinternalderangementsofkneeM23.25Derangementofposteriorhornoflateralmeniscusduetooldtearorinjury
M23.26DerangementofotherlateralmeniscusduetooldtearorinjuryM23.35Othermeniscusderangements,posteriorhornoflateralmeniscusM23.23Derangementofothermedialmeniscusduetooldtearorinjury
M87.88OsteonecrosisMeniscalCysts(1) M23.0CysVcmeniscusNonOsteoarthri=sArthropathies(9)(7)(6)(12)(1)(10)(14)
M00.06StaphylococcalarthriVs,kneeM00.86ArthriVsduetootherbacteria,kneeM02.86OtherreacVvearthropathies,kneeM02.36Reiter'sdisease,kneeM05.76RheumatoidarthriVsofkneeM10.06Idiopathicgout,kneeM11.06HydroxyapaVtedeposiVondisease,kneeM12.26VillonodularsynoviVs(pigmented),knee
Trauma=cMeniscalInjury(7)(12)(1)(19)S83.2Tearofmeniscus,currentinjury S83.21ABucket-handletearofmedialmeniscus,currentinjury,iniValencounter S83.205AOthertearofunspecifiedmeniscus,currentinjury,unspecifiedknee,iniValencounter S83.22APeripheraltearofmedialmeniscus,currentinjury,iniValencounter S83.23AComplextearofmedialmeniscus,currentinjury,iniValencounter S83.24AOthertearofmedialmeniscus,currentinjury,iniValencounter S83.25ABucket-handletearoflateralmeniscus,currentinjury S83.26APeripheraltearoflateralmeniscus,currentinjury,iniValencounter S83.27AComplextearoflateralmeniscus,currentinjury,iniValencounter S83.28AOthertearoflateralmeniscus,currentinjury,iniValencounterTrauma=corSecondaryOsteoarthri=sofKnee(7)
M17.2Bilateralpost-traumaVcosteoarthriVsofkneeM17.3Unilateralpost-traumaVcosteoarthriVsofkneeM17.4OtherbilateralsecondaryosteoarthriVsofkneeM17.5OtherunilateralsecondaryosteoarthriVsofknee
MeniscalRepair(12)(1) 0SQC4ZZRepairRightKneeJoint,PercutaneousEndoscopicApproach 0SQD4ZZRepairLedKneeJoint,PercutaneousEndoscopicApproach
*”ClinicalDiagnosesExcludedfromRCTs”doesnotincludenon-traumaVcosteoarthriVsinstudieswithaprimaryclinicaldiagnosisotherthanosteoarthriVs.$DiagnosesofcondiVonsexternaltothekneejointnotincluded.OsteoarthriVsasdefinedbytheACR
Table3:RiskofBiasAssessment
RamdonSequenceGeneration
AllocationConcealment
BlindingofParticpants
BlindingofOutcome
Assessment
IncompleteOutcomeof
DataSelectiveReporting OtherBias
Merchan&Galindo1993 LowRisk Unclear HighRisk HighRisk Lowrisk Lowrisk LowriskChang1993 Unclear Unclear HighRisk HighRisk Unclear Lowrisk Lowrisk
Hubbard1996 LowRisk Lowrisk HighRisk HighRisk Unclear Unclear LowriskMoseley2002 Unclear Lowrisk Lowrisk Lowrisk HighRisk Lowrisk LowriskKirkley2008 LowRisk Unclear HighRisk HighRisk Unclear Lowrisk LowriskYim2013 Unclear LowRisk HighRisk HighRisk HighRisk Lowrisk Lowrisk
Sihvonenetal2013 Low Lowrisk Lowrisk Lowrisk Lowrisk Lowrisk LowriskGauffin2014 Unclear Lowrisk HighRisk HighRisk Low Lowrisk LowriskKatz2013 Low Lowrisk HighRisk HighRisk Low Lowrisk Lowrisk
Herrlin2013 Unclear Unclear HighRisk HighRisk Low Low LowriskVersmesan2013 Unclear Unclear HighRisk HighRisk Unclear Unclear LowriskKettunen2012 Lowrisk Lowrisk HighRisk HighRisk Unclear Lowrisk LowriskØsteras2013 Unclear Unclear HighRisk HighRisk Lowrisk Unclear Lowrisk
Sihvonenetal2016 Lowrisk Lowrisk Lowrisk Lowrisk Lowrisk HighRisk Lowrisk
Table4:ExclusionsofMedialMeniscalTearRandomisedControlledTrials
Lockingorlocked
Hxoftrauma
MeniscalRepair
Loosebodies
MajorChonralFlap
OtherNonMeniscalPathology
Yim2013 NS Yes Yes NS NS YesSihvonenetal2013 Yes Yes Yes NS Yes Yes
Gauffin2014 Yes NS NS NS NS YesKatz2013 Yes NS NS NS NS Yes
Herrlin2013 Yes Yes NS Yes NS YesVersmesan2013 NS NS NS NS NS YesØsteras2013 Yes Yes NS NS NS Yes
Sihvonenetal2016 Yes Yes Yes NS Yes Yes• NS=NotStated
Figure1: PRISMAFlowDiagram
Recordsidentifiedthroughdatabasesearching
(n=2876)
Screen
ing
Inclu
ded
Eligibility
Iden
tifica
tion
Additionalrecordsidentifiedthroughothersources
(n=11)
Recordsafterduplicatesremoved(n=2329)
Recordsscreened(n=2329)
Recordsexcluded(n=2262)
Full-textarticlesassessedforeligibility(n=67)
Full-textarticlesexcluded,withreasons(n=53)
Studiesincludedinqualitativesynthesis
(n=14)