PositionStatementfromtheAustralianKneeSocietyonArthroscopic
SurgeryoftheKnee,includingreferencetothepresenceof
OsteoarthritisorDegenerativeJointDisease
UpdatedOctober2016
Inpreparingthefollowingevidencebaseddocument,theAustralianKneeSociety,onbehalfoftheAustralian
OrthopaedicAssociation,hascombinedtheindividualclinicalexpertiseofitsmemberswithpublishedrandomized
controlledtrialsfromasystematicreviewoftheliterature.
PositionStatement
Arthroscopic debridement, and / or lavage, has been shown to have no beneficial effect on 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,butare notnecessarilylimitedto,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
Whilstplainradiographyisthepreferredinitialimagingmodality,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
Investigation of Knee Osteoarthritis (http://www.kneesociety.org.au/resources/Joint-AKS-AMSIGsubmission-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.
MMTPapersExclusions
Inthe8paperswithaprimaryclinicaldiagnosisofmedialmeniscaltearing,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-ExclusionCriteria
MerchanandGalindo(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
Theinclusioncriteriaforfouroftheeightmeniscaltearsstudiesincludedfailureofclinicianassessednonspecificnon-operativemanagementofbetween1&3months.Nomedialmeniscalstudyexaminedoutcomes
ofpatientswhohadundergonestructuredrehabilitationprogramandcontinuedtohavehadsevereselfdescribedsymptomsafterbyrandomizationtooperativeversusnon-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:ArthroscopicSurgeryOutcomesinRandomizedControlledTrials
Author& PrimaryDx
Year
Rx
Inclusions
Ixx
n
Control
%Not MaxXR
enrolled
OA
JointSpecific
Exclusions
%X
Over
PA
Notes
Outcome
FavouredA/Sat1-
3years(mean25
months)
Osteoarthri=s&ChondralDegenera=veRCTs
1
Merchan
MildOA
withother
and
intraGalindo8
pathology
Synovectomy;
débridement;
APM,CPY,E/O
osteophytes&
PT
Changet OsteoarthriV
al171993
s
APM,CPY,
Synovectomy
1993
2
Painful“limited”OA,including XR
paVentswithmeniscaltears,
loosebodies&synoviVs.
Painader3monthsader
rehabilitaVon
XR
73
NSAID.
AcVvity
modificaVo
n.
NS
Ahlbach
0-1,KL
1-2
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=ModifiedHSSK
Score.APMperformed
in31/35.Power>0.8.
32
Pts
Needle
Lavage
50
KL1-3
PriorKneesurgery
within6months,TKA,
OAKLGradeIV.
NS
N
Inadequatepower.50% Nodifferenceat12
hadKLGrade3
months.
DegeneraVvelesionson
otherjointsurfaces,
otherintra-arVcular
pathology,radiographic
lossofjointspace,
previousoperaVon,
steroidinjecVonforany
reason.MMTorVbial
degeneraVon.
Scoring>9byKLscore
addiVoninthree
compartments
NA
N
OM=BinaryselfFavouredA/Sat1&
describedpainpresence/
5years
absence&Modified
Lysholm.Power>0.8.
NA
Y
Largemeniscaltears,
buckethandletears,
priormajorkneetrauma,
inflammatoryorpost
infecVousarthriVs,
deformity>5degrees,
priortrauma,KL4intwo
compartments.
0%
Y
Threearmstudy.In
Nodifferenceat2
lavagegroup,
yearsbetween3
“mechanicallyimportant,
groups.
unstabletears”were
debrided.Inshamgroup,
jointnotentered.OM=
bespokeKneeSpecific
PainScale,AIMS2&SF
36PF
OM=WOMAC&SF36 Nodifferenceattwo
years.
3
Hubbard SymptomaV Chondroplasty. Symptoms>1yr,nolaxityorno XR
csingleMFC
NoAPM.
deformity,fullROM,single
etal9
degeneraVve
MedialFemoralCondyle
1996
chondral
degeneraVvelesion,OBCGrade
lesionObC
3or4,nootherintra-arVcular
Grade3or4
pathology,normalplainXR,
modifiedLysholmscore<
38/70.
76 A/SLavage
NS
KLO
4
Moseley Tricompartm
APM,
<75years,moderateKneepain XR
entalOA
thathadfailed6months
5
etal Chondroplasty,
medicalmanagementwithVAS
2002
PainScore>3,failedmedical
MxanddiagnosisofOAbased
onACRdefiniVons
180
44
KL3-4
16
KL0-4
5
Kirkleyet SymptomaV
al62008 cmoderate
tosevereOA
Synovectomy;
débridement;
APM,CPY,E/O
osteophytes&
PT
Age>18yowithidiopathicor XR& 188
secondaryOAKLGrade2-4. MRI
Shamor
Lavage
PT
Author
&Year
PrimaryDx
1
Yimet
al122013
SymptomaVc
horizontal
degeneraVve
MMT
2
4
Rx
Inclusions
Ix
n
Control %Not MaxXR
enrolled
OA
JointSpecificExclusions
%X- PA
Ove
r
Notes
Outcome
MedialMeniscalTearRCTs
5
6
APM HorizontaldegeneraVve MRI
&PT MedialMTonMRI&daily
kneepainonthemedial
sidewithmechanical
symptoms,failednon-
surgicalMx
108
PT
30
KL0-1
Definitetrauma,ligament
deficiency,systemicarthriVs,KL
2-4andosteonecrosis,meniscal
repair,abrasionarthoplasty,
subchondraldrilling,cureqage.
Sihvonen
SymptomaVc
etal1
DegeneraVve
2013
MMTconfirmed
onMRI&atAS
APM 35to65y,kneepain>3 XR&
&PT
monthsthatwas
MRI
unresponsiveto
convenVonalconservaVve
treatmentandhadclinical
findingsconsistentwitha
tearofthemedial
meniscus
146
Sham
surgery
&PT
12
KL0-1
Katzet
al142013
>45y&>1month
symptoms,imaging
evidenceofmild-tomoderateknee
osteoarthriVs,symptoms
ofthefollowing:clicking,
catching,popping,giving
way,painwithpivotor
torque,painthatis
episodic,pain
thatisacuteandlocalized
toonejointline),KL0-3.
APM Age45-60,dailymedial
,CPY painover2-6months.
&PT
330
PT
75
KL0-3
Trauma-inducedonsetof
6.6
symptoms,lockedorrecently
lockingknee,decreasedrangeof
moVon,instability,pathology
otherthandegeneraVve
kneediseaserequiringtreatment
otherthanarthroscopic
parValmeniscectomy,Meniscal
repair,micro-fracturetochondral
defect,majorchondralflap,
ClinicalOAbasedonACRCCR.Or
KL>1
Chronicallylockedknee,KL4, 30.2
clinicallysymptomaVc
chondrocalcinosis,bilateral
symptomaVcmeniscaltears,
priorsurgeryonsameknee
96
PT
55
120
CSI
NS
SymptomaVc
APM,
DegeneraVve
CPY
MMTwithmildto &PT
moderateOA
Herrlin
etal19
2013
MRI-verified
degeneraVve
MMT&
radiographicAO
Grade<2
(Ahlback)
Vermesa
netal13
2013
MRI-verified
APM,
NontraumaVc
degeneraVve
CPY symptomaVckneeswith
medialmeniscus &PT
degeneraVvelesions
tearandradio-
medialcompartmenton
graphic
MRI
osteoarthriVs
XR&
MRI
XR&
MRI
MRI
2
Alback1 Historyoftrauma,OA>Alback1, 33
RheumatoidArthriVs,Loose
,ObBIbodies,kneeinstability,
IV
osteochondraldefects&
tumours,TKA,priorkneesurgery
inlastyear
NS
NS
NS
Y
Nomeniscalrepairsor FavoredA/Sat3months.Nodifference
totalmeniscectomy
at2years.MTpaqerndescribed.
undertaken.Outcome
measures=VAS,Lysholm
andTegner
Y
Nochondroplasty
undertaken.
OM=VAS,Lysholmand
WOMET.Blindedstudy.
MTpaqernnotdescribed.
Nodifferenceat12months.
“resultsaredirectlyapplicableonlyto
paVentswithnon-traumaVc
degeneraVvemedialmeniscustears”
Y
Similarimprovementin
WOMACinfailedPTas
APMoncecrossedover
APM,Treatmentsuccess
definedas>8point
improvementonWOMAC
physicalfuncVonscale.
MTpaqernnotdescribed.
Nodifferenceat12months.30%
crossedovertoAPM.
Treatmentfailure25%inAPMGroup
and49%inPTGroup.Sameadverse
eventsbetweengroups.
Y
NodifferenceinOA
Nodifferenceat2&5years.
progressionnoted
33%ofPTGroupcrossedoverinto
between2Groups.OM=
APMwithsimilarbenefittoAPM
KOOS,Lysolm&VAS.
GroupandrestofPTgroupat2&5
SimilarPROMs
years.Thissubgrouphadsignificantly
improvementinPT&APM. lowerPROMscoresthanrestofPT
MTpaqernnotdescribed.
GrouppriorAPM.
N OM=OxfordKneeScore.
Beqerscoresinsurgicalgroupat3
PostHocPowerAnalysis> months.Nodifferenceat12months.
0.8(d=.0.3two
tailed,p=0.05).MTpaqern
notdescribed.
7
Østeras
etal16
2013
MRI-verified
degeneraVve
MMTandradio-
g=raphicOA
3
Gauffinet
al102014
SymptomaVc
MMT
8
MRI
17
PT
12
KL0-2
ACLtears,acutetrauma,KL3-4,
heamarthrosis,lockingknee
0
Y
Inadequatepowerbased Nodifferenceat3months.MTpaqern
onauthor’sownpower
notdescribed.
analysis.Outcome
measures=VAS&KOOS
XR,
No
MRI
150
PT
2.8
Ahlbach
0,KL1-2
Locked/lockingknee.
RheumaVcdisease.
21.3
Y
OM=KOOS,EQ5D,PAS&
SSS.MTpaqernnot
described
FavoredA/Sat12months.
Sihvonen
SymptomaVc
APM 35to65y,kneepain>3 XR&
etal15
DegeneraVve
&PT
monthsthatwas
MRI
2016
MMTconfirmed
unresponsiveto
onMRI&atAS.
convenVonalconservaVve
Subgroupanalysis
treatmentandhadclinical
oforiginal
findingsconsistentwitha
Sihvonenetal
tearofthemedial
20131paVents
meniscuswithmechanical
withmechanical
symptoms
symptoms
69
Sham
surgery
&PT
NS
KL0-1
Trauma-inducedonsetof
2.5
symptoms,lockedorrecently
lockingknee,decreasedrangeof
moVon,instability,pathology
otherthandegeneraVve
kneediseaserequiringtreatment
otherthanarthroscopic
parValmeniscectomy,Meniscal
repair,micro-fracturetochondral
defect,meniscalrepair,major
chondralflap,ClinicalOAbased
onACRCCR.OrKL>1
N
Nochondroplasty
undertaken.
OM=VAS,Lysholmand
WOMET.Blindedstudy.
MTpaqernnotdescribed.
Nodifferenceat12months.
Author
&Year
Ix
n
NA
56
PrimaryDx
APM
Age35-60
APM, 45-64,symptomsofMT
CPY
>3months
Ahlback0
PriorPT
Rx
Inclusions
Control %Not MaxXR
enrolled
OA
JointSpecificExclusions
Authorsstate“Thissubgroupanalysis
islikelytobeunderpowered…”
Posthocanalyses:ThestudyquesVons
werenotincludedaprioriasprimary
orsecondaryobjecVvesoftheoriginal
trial.
%X- PA
Ove
r
Notes
Outcome
Outcomemeasures=
Kujalascore&VAS
Nodifferenceat2&5years.
PatellofemoralPainRCT
12
Kequnen
etal15
2012
PFJ Age18–40yearsFemale
PFJpainand
symptomslasVng CPY
ormale
atleast6months
SymptomslasVngatleast
6months.
PFJpainduringknee
loadingphysicalacVvityor
inprolongedflexion.
Footnotes
AbbreviaVons:
KOOS=KneeInjuryandOsteoarthriVsOutcomeScore
EQ5D=EuroQol
PAS=PhysicalAcVvityScale
SSS=symptomsaVsfacVonscale
OA=OsteoarthriVs
PT=PhysicalTherapy
AS=Arthroscopic
APM=ArthroscopicParValMeniscectomy
MRI=MagneVcResonanceImaging
ObC=OuterbridgeClassificaVon.
PT
2%
KL0
Priorkneesurgery,patella
dislocaVon,OCD,Patella
tendinopathy,OsteoarthriVs,
loosebodies,instability.
10
Y
KL=KellengrenLawrence
OM–OutcomeMeasure
PFJ=PatellofemoralJoint
ROM=RangeofMoVon
XR=Radiograph
>=Lessthan
<=Greaterthan
Pts=PaVents
Mx=Management
NS=Notstated
Y=Yes
N=No
ACRCCC=AmericanRheumatologyClinicalClassificaVonforOsteoarthriVsoftheKnee
PROM=PaVentRecordedOutcomeMeasures
X-over=Cross-over
Ix=InvesVgaVon
n=NumberofpaVents
CPY=Chondroplasty
CSI=CorVcosteroidinjecVon
MFC=MedialFemoralCondyle
Rx=IntervenVon
PA=PowerAnalysis
Table2:ArthroscopicKneeSurgeryRCTsInclusions&ExclusionsusingICD10Codes
ClinicalDiagnosesIncludedinRCTs
UnilateralOsteoarthri=sofKnee(9)(6)(7)
M17.9OsteoarthriVsofknee,unspecified
M17.0BilateralprimaryosteoarthriVsofknee
M17.1UnilateralprimaryosteoarthriVsofknee
Atrauma=cDegenerateTearstoMedialMeniscus(12)(1)(10)(14)(19)(22)
M23.2Derangementofmeniscusduetooldtearorinjury
M23.22Derangementofposteriorhornofmedialmeniscusduetooldtearor
injury
M23.30Othermeniscusderangements,unspecifiedmeniscus
M23.32Othermeniscusderangements,posteriorhornofmedialmeniscus
PatellofemoralChondropathy(15)
M22.4Chondromalaciapatella
===========================================================
ClinicalDiagnosesExcludedfromRCTs*$
LockingorLockedKnee(7)(1)(10)(14)
M23.40LooseBodyinKnee(21)(19)(15)
M21.26Flexiondeformity,knee
M93.2OsteochondriVsdessicans
M23.8Otherinternalderangementsofknee
S83.21ABucket-handletearofmedialmeniscus,currentinjury,iniValencounter(7)
S83.205AOthertearofunspecifiedmeniscus,currentinjury,unspecifiedknee,
iniValencounter
S83.22APeripheraltearofmedialmeniscus,currentinjury,iniValencounter
S83.26APeripheraltearoflateralmeniscus,currentinjury,iniValencounter
M25.669SVffnessofunspecifiedknee,notelsewhereclassified
KneeInstability(12)(1)(19)(15)
M23.60OtherspontaneousdisrupVonofunspecifiedligamentofknee
M23.61OtherspontaneousdisrupVonofanteriorcruciateligamentofknee
M23.62OtherspontaneousdisrupVonofposteriorcruciateligamentofknee
InternalDerangementsofthanMMT(1)(19)
M93.2OsteochondriVsdessicans
M23.8Otherinternalderangementsofknee
M23.25Derangementofposteriorhornoflateralmeniscusduetooldtearorinjury
M23.26Derangementofotherlateralmeniscusduetooldtearorinjury
M23.35Othermeniscusderangements,posteriorhornoflateralmeniscus
M23.23Derangementofothermedialmeniscusduetooldtearorinjury
M87.88Osteonecrosis
MeniscalCysts(1)
M23.0CysVcmeniscus
NonOsteoarthri=sArthropathies(9)(7)(6)(12)(1)(10)(14)
M00.06StaphylococcalarthriVs,knee
M00.86ArthriVsduetootherbacteria,knee
M02.86OtherreacVvearthropathies,knee
M02.36Reiter'sdisease,knee
M05.76RheumatoidarthriVsofknee
M10.06Idiopathicgout,knee
M11.06HydroxyapaVtedeposiVondisease,knee
M12.26VillonodularsynoviVs(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,iniValencounter
Trauma=corSecondaryOsteoarthri=sofKnee(7)
M17.2Bilateralpost-traumaVcosteoarthriVsofknee
M17.3Unilateralpost-traumaVcosteoarthriVsofknee
M17.4OtherbilateralsecondaryosteoarthriVsofknee
M17.5OtherunilateralsecondaryosteoarthriVsofknee
MeniscalRepair(12)(1)
0SQC4ZZRepairRightKneeJoint,PercutaneousEndoscopicApproach
0SQD4ZZRepairLedKneeJoint,PercutaneousEndoscopicApproach
*”ClinicalDiagnosesExcludedfromRCTs”doesnotincludenon-traumaVcosteoarthriVsin
studieswithaprimaryclinicaldiagnosisotherthanosteoarthriVs.
$DiagnosesofcondiVonsexternaltothekneejointnotincluded.
OsteoarthriVsasdefinedbytheACR
Table3:RiskofBiasAssessment
Merchan&Galindo1993
Chang1993
Hubbard1996
Moseley2002
Kirkley2008
Yim2013
Sihvonenetal2013
Gauffin2014
Katz2013
Herrlin2013
Versmesan2013
Kettunen2012
Østeras2013
Sihvonenetal2016
Ramdon
Sequence
Generation
LowRisk
Unclear
LowRisk
Unclear
LowRisk
Unclear
Low
Unclear
Low
Unclear
Unclear
Lowrisk
Unclear
Lowrisk
Allocation
Concealment
Unclear
Unclear
Lowrisk
Lowrisk
Unclear
LowRisk
Lowrisk
Lowrisk
Lowrisk
Unclear
Unclear
Lowrisk
Unclear
Lowrisk
Blindingof
Particpants
HighRisk
HighRisk
HighRisk
Lowrisk
HighRisk
HighRisk
Lowrisk
HighRisk
HighRisk
HighRisk
HighRisk
HighRisk
HighRisk
Lowrisk
Blindingof
Outcome
Assessment
HighRisk
HighRisk
HighRisk
Lowrisk
HighRisk
HighRisk
Lowrisk
HighRisk
HighRisk
HighRisk
HighRisk
HighRisk
HighRisk
Lowrisk
Incomplete
Outcomeof
Data
Lowrisk
Unclear
Unclear
HighRisk
Unclear
HighRisk
Lowrisk
Low
Low
Low
Unclear
Unclear
Lowrisk
Lowrisk
Selective
Reporting
Lowrisk
Lowrisk
Unclear
Lowrisk
Lowrisk
Lowrisk
Lowrisk
Lowrisk
Lowrisk
Low
Unclear
Lowrisk
Unclear
HighRisk
OtherBias
Lowrisk
Lowrisk
Lowrisk
Lowrisk
Lowrisk
Lowrisk
Lowrisk
Lowrisk
Lowrisk
Lowrisk
Lowrisk
Lowrisk
Lowrisk
Lowrisk
Table4:ExclusionsofMedialMeniscalTearRandomisedControlledTrials
Yim2013
Sihvonenetal2013
Gauffin2014
Katz2013
Herrlin2013
Versmesan2013
Østeras2013
Sihvonenetal2016
• NS=NotStated
Lockingor Hxof
locked
trauma
NS
Yes
Yes
Yes
Yes
NS
Yes
NS
Yes
Yes
NS
NS
Yes
Yes
Yes
Yes
Meniscal
Repair
Yes
Yes
NS
NS
NS
NS
NS
Yes
Loose
bodies
NS
NS
NS
NS
Yes
NS
NS
NS
Major
Chonral
Flap
NS
Yes
NS
NS
NS
NS
NS
Yes
OtherNon
Meniscal
Pathology
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Figure1: PRISMAFlowDiagram
Recordsidentifiedthrough
databasesearching
(n=2876)
Additionalrecordsidentified
throughothersources
(n=11)
Recordsscreened
(n=2329)
Recordsexcluded
(n=2262)
Eligibility
Recordsafterduplicatesremoved
(n=2329)
Full-textarticlesassessed
foreligibility
(n=67)
Full-textarticlesexcluded,
withreasons
(n=53)
Included
Screening
Identification
Studiesincludedin
qualitativesynthesis
(n=14)