Knee Arthroscopies or “Clean Outs” are a very common operation performed on people with knee pain of all ages, but are they really a good idea? This is a topic that has been researched extensively over the last few years and the results may surprise you.
To answer this question first we need to break people with knee pain into two groups:
- Those without Knee Arthritis
- Those with Knee Arthritis
A rough guide of 35 years old generally splits these two groups, although a plain weight bearing X-ray would give a specific patient a good idea if they have arthritic knees.
A recent clinical guidelines review by the British Journal of Sports Medicine has come to this conclusions (The Summary).
- We make a strong recommendation against the use of arthroscopy in nearly all patients with degenerative knee disease, based on linked systematic reviews; further research is unlikely to alter this recommendation
- This recommendation applies to patients with or without imaging evidence of osteoarthritis, mechanical symptoms, or sudden symptom onset
- Healthcare administrators and funders may use the number of arthroscopies performed in patients with degenerative knee disease as an indicator of quality care.
- Knee arthroscopy is the most common orthopaedic procedure in countries with available data
- This Rapid Recommendation package was triggered by a randomised controlled trial published in The BMJ in June 2016 which found that, among patients with a degenerative medial meniscus tear, knee arthroscopy was no better than exercise therapy
The strong recommendation against knee arthroscopy is a reflection of the strongest point FOR having the operation:
Less than 15% of people wll have a small or very small improvement in short term pain and function that does not even persist to one year post operatively, but they also have a higher risk of the burden, postoperative limitations, and rare serious adverse effects associated with the operation.
Perhaps my favourite line of the review is:
The recommendation is not applicable to patients who do not share these values (that is, those who place a high value on a small, uncertain, and transient reduction in pain and function, and a low value on avoiding the burden and postoperative limitation associated with arthroscopy).
In other words, if you like the sounds of a 1 in 7 chance of a very small decrease in pain up to only three months after the operation and don’t care about the significant risks with it, then you might want the op!
Dont forget cost to the healthcare system:
- The panel focused on the patient perspective rather than that of society when formulating the recommendation. However, implementation of this recommendation will almost certainly result in considerable cost savings for health funders.
- A rigorous economic analysis found that knee arthroscopy for degenerative knee disease is not close to cost effective by traditional standards, even in extreme scenarios that assume a benefit with arthroscopy.
Who don’t we have a clear reason to recommend against a Knee Arthroscopy:
- Patients who are objectively unable to fully extend their knee or who have persistent, severe, and frequent mechanical symptoms? – We just don’t know yet.
- Patients under 35 years old with acute/ traumatic knee injuries – current evidence suggests a menisectomy in this group is effective.
Our Recommendation for people over the age of 35 with degenerative knee pain:
On current evidence there are only three things strongly supported when it comes to conservative care:
- Weight Loss
- Increasing Strength
- Anti-Inflammatories during an acute flare up (after a consultation with your GP)
If this fails to give someone adequate relief, then a good Orthopaedic Knee Specialist opinion should be used to help guide operative management if necessary.
If you have any questions about how to manage your knee pain, or you would like an assessment of your knee to work out the best way to manage your pain, call us at Gymea Physio focus on 9526 6686, or Cronulla Physio focus at 9544 4884.
You can find the full clinical guidelines research paper here: Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline
