Background
Arthroscopic knee surgery is a common treatment for symptomatic knee osteoarthritis, even for meniscus tears due to degenerative processes, despite guidelines that advise against its use. This Cochrane review is an update of a non-Cochrane systematic review that was published in 2017.
Goals
To assess the benefits and harms of arthroscopic surgery, including debridement, partial meniscectomy, or both, compared with placebo surgery or non-surgical treatment in people with degenerative knee disease (osteoarthritis, degenerative meniscus tears, or both). ).
Search methods
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and two trials registers up to 16 April 2021, without language restrictions.
Selection criteria
We included randomized controlled trials (RCTs), or trials using quasi-randomised methods of participant allocation, that compared arthroscopic surgery with placebo surgery or non-surgical interventions (e.g. exercise, injections, non-arthroscopic lavage/irrigation, pharmacological treatment and supplements and complementary therapies) in people with symptomatic degenerative knee disease (osteoarthritis or degenerative meniscus tears or both).
The main outcomes were pain, function, self-reported treatment success, knee-specific quality of life, serious adverse events, total adverse events, and knee surgery (replacement or osteotomy).
Data collection and analysis
Two review authors independently selected studies for inclusion, extracted data, and assessed risk of bias and certainty of evidence using GRADE. The main comparison was arthroscopic surgery compared with placebo surgery for outcomes measuring the benefits of surgery, but data from all control groups were combined to assess harms and knee surgery (replacement or osteotomy).
Main results
Sixteen trials (2105 participants) met the inclusion criteria. The average age of the participants ranged from 46 to 65 years, and 56% of the participants were women. Four trials (380 participants) compared arthroscopic surgery with placebo surgery.
In the remaining trials, arthroscopic surgery was compared with exercise (eight trials, 1371 participants), a single intra-articular injection of glucocorticoids (one trial, 120 participants), non-arthroscopic lavage (one trial, 34 participants), non-arthroscopic anti-inflammatories. steroids (one trial, 80 participants) and weekly injections of hyaluronic acid for five weeks (one trial, 120 participants).
Most trials without a placebo control were susceptible to bias: in particular, selection (56%), performance (75%), detection (75%), attrition (44%) and selective reporting biases. (75%).
Placebo-controlled trials were less susceptible to bias and none were at risk of performance or detection bias. This review is limited to reporting on the main comparison, arthroscopic surgery versus placebo surgery.
High-certainty evidence indicates that arthroscopic surgery results in little or no difference in pain or function at three months after surgery, moderate-certainty evidence indicates that there is probably little or no improvement in surgery-specific quality of life. knee at three months after surgery and low-certainty evidence suggests that arthroscopic surgery may result in little or no difference in participant-reported success up to five years, compared with placebo surgery.
The mean postoperative pain in the placebo group was 40.1 points on a scale of 0 to 100 (with a lower score indicating less pain) compared with 35.5 points in the arthroscopic surgery group, a difference of 4 .6 points better (95% confidence interval (CI): 0.02 best to 9 better; I2 = 0%; four trials, 309 participants).
The mean postoperative functionality in the placebo group was 75.9 points on a rating scale of 0 to 100 (with a higher score indicating better functionality) compared with 76 points in the arthroscopic surgery group, a difference of 0 .1 point better (95% CI: 3.2 worse to 3.4 better; I2 = 0%; three trials, 302 participants).
The mean knee-specific health-related quality of life in the placebo group was 69.7 points on a rating scale of 0 to 100 (with a higher score indicating better quality of life) compared to 75.3 points in the arthroscopic surgery group, a difference of 5.6 points better (95% CI: 0.36 better to 10.68 better; I2 = 0%; two trials, 188 participants). The quality of this evidence has been downgraded to moderate certainty, as the 95% confidence interval does not rule out or recognize a clinically important change.
After surgery, 74 out of 100 people reported treatment success with placebo and 82 out of 100 people reported treatment success with arthroscopic surgery up to five years (risk ratio [RR] 1.11, 95% CI). %: 0.66 to 1.86; I2 = 53%; three trials, 189 participants).
The quality of this evidence has been reduced to low certainty due to the significant existence of indirect measures (diversity in the definition and timing of outcomes measurement) and the serious imprecision (small number of events).
It is unclear whether the risk of serious or total adverse events was increased with arthroscopic surgery compared with placebo or nonsurgical interventions.
In eight trials, serious adverse events were reported in six out of 100 people in the control groups and eight out of 100 people in the arthroscopy groups (RR 1.35, 95% CI 0.64 to 2.83, I2 = 47%; eight trials, 1206 participants).
Fifteen out of 100 people reported adverse events with control interventions, and 17 out of 100 people with surgery up to five years (RR 1.15, 95% CI 0.78 to 1.70, I2 = 48% ; nine trials, 1326 participants).
The certainty of the evidence was low, downgraded two-fold due to serious imprecision (small number of events) and possible reporting bias (incomplete reporting of outcomes in studies).
Serious adverse events included death, pulmonary embolism, acute myocardial infarction, deep vein thrombosis, and deep infection.
Posterior knee surgery (replacement or high tibial osteotomy) was reported in two out of 100 people in the control groups and four out of 100 people in the arthroscopic surgery groups up to five years in four trials (RR 2.63; 95% CI: 0.94 to 7.34; I2 = 11%; four trials, 864 participants). The certainty of the evidence was low, reduced two-fold due to the small number of events.
Authors’ conclusions Arthroscopic surgery results in little or no clinically important benefit on pain or function, probably has no clinically important benefit on knee-specific quality of life, and may not improve treatment success compared with an intervention. placebo. It could result in little or no difference, or a slight increase, in total and serious adverse events compared with control, but the evidence is of low certainty. It remains to be determined whether arthroscopic surgery results in a slightly higher number of subsequent knee surgeries (replacement or osteotomy) compared to control. |
Key results
Compared with placebo surgery, arthroscopic surgery had few beneficial effects:
- Pain (lower scores mean less pain). The improvement in pain was 4.6 points (0.02 points better to 9 points better) on a scale of 0 to 100 points with arthroscopic surgery than with placebo, at three months after surgery.
- People who underwent arthroscopic surgery rated their postoperative pain at 35.5 points.
- People who underwent placebo surgery rated their postoperative pain at 40.1 points.
Knee functionality (higher scores mean better functionality).
- Improvement in knee function was 0.1 point better (3.2 worse to 3.4 better) on a scale of 0 to 100 points with arthroscopic surgery than with placebo, at three months after surgery .
- People who underwent arthroscopic surgery rated their postoperative knee function at 76.0 points.
- People who underwent placebo surgery rated their postoperative knee function at 75.9 points.
Knee-specific quality of life (higher scores mean better quality of life).
- The improvement in knee-specific quality of life was 5.6 points (0.4 better to 10.7 better) on a scale of 0 to 100 points with arthroscopic surgery than with placebo, at three months after Surgery.
- People who underwent arthroscopic surgery rated their postoperative quality of life at 75.3 points.
- People who underwent placebo surgery rated their postoperative quality of life at 69.7 points.
Treatment success (rated by participants)
- 8% more people rated the treatment as successful (25% less to 63% more), that is, eight more people out of every 100, up to five years after surgery.
- 82 out of 100 people reported treatment success with arthroscopic surgery.
- 74 out of 100 people reported treatment success with placebo surgery.
Serious adverse events
- 2% more people (2% less to 10% more) had serious adverse events, that is, two more people in 100, up to five years after surgery.
- Eight out of 100 people reported serious adverse events with arthroscopic surgery.
- Six out of 100 people reported serious adverse events with placebo surgery.
Total adverse events
- 2% more people (3% less to 11% more) had adverse events, that is, two more people out of every 100, up to five years after surgery.
- 17 out of 100 people reported adverse events with arthroscopic surgery.
- 15 out of 100 people reported adverse events with placebo surgery.
Posterior knee surgery
- 2% more people (0.1% less to 9% more) had subsequent knee surgery, that is, two more people in every 100, up to the age of five.
- Four out of every 100 people had a knee replacement or osteotomy (knee surgery that reshapes the bone) with arthroscopic surgery.
- Two in 100 people had a knee replacement or osteotomy with placebo surgery.
