Journal»Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association
PURPOSE: We aimed to determine if the randomized controlled trials (RCTs) evaluated in the most recent meta-analysis on arthroscopic surgery for degenerative knee arthritis included documented trials of appropriate conservative treatment prior to randomization.
METHODS: We selected all RCTs of the most recent meta-analysis by Brignardello-Petersen and recorded for each RCT, if physiotherapy prior to randomization was mandatory. We compared the treatment effect of arthroscopy in studies in which physiotherapy prior to randomization was mandatory versus studies in which it was not. This review was registered in the PROSPERO database (CRD42017070091).
RESULTS: Of the 13 RCTs in the meta-analysis, there were 2 in which physiotherapy prior to randomization was mandatory. In 1 additional multicenter RCT, prior conservative treatment was mentioned as mandatory in the publication, but not in the protocol. The treatment effects attributed to arthroscopy in terms of short-term pain (P = .0037), short-term function (P = .0309), and long-term function (P = .0012) were larger in studies in which prior physiotherapy was mandatory.
CONCLUSIONS: Although the most recent meta-analysis claims that it is based "on patients who do not respond to conservative treatment," physiotherapy was mandatory prior to randomization only in 2 of the 13 studies. As several orthopaedic guidelines recommend that the first line of treatment in patients with degenerative arthritis of the knee should be conservative, for instance with physiotherapy, and the question of performing arthroscopy arises once conservative treatment fails, 11 of the 13 RCTs failed to adhere to these accepted guidelines. Therefore, patient selection in these 11 studies may not represent the typical indications for arthroscopy, where patients have tried conservative management prior to being offered surgery. When comparing studies where prior physiotherapy was mandatory to studies in which it was not mandatory, there were statistically significant effects favoring arthroscopy in terms of pain in the short term, and for function both in the short and the long term. These findings suggest that the treatment effects attributed to arthroscopy were higher when prior physiotherapy was mandatory. Given these findings, the external validity of most of these RCTs, and the resulting "strong recommendation against the use of arthroscopy in nearly all patients with degenerative knee disease," is called into question.
LEVEL OF EVIDENCE: Level II, systematic review of Level I and II studies.
Knee arthroscopy has historically been a common treatment for knee osteoarthritis. A Cochrane review of the literature up to 2006 has resulted in guidance that arthroscopy is not effective in knee osteoarthritis. It cited that deficiencies in the evidence base prevented widespread acceptance of the recommendations. The aim of this review is to update the evidence base for the efficacy of arthroscopy in knee osteoarthritis. The authors searched CINHAL, EMBASE, MEDLINE, and CENTRAL for randomised controlled trials that compared arthroscopic surgery in knee osteoarthritis with a control group (e.g. lavage, best medical care). The primary outcome measure was patient reported functional outcome. The study methodology was registered on Prospero, a systematic review register: Registration number CRD42012002891. Five randomised controlled trials included 516 patients, almost double the 271 episodes contained in previous reviews. Two high quality studies, according to the Jadad classification, published since the Cochrane review, addressed many of the methodological flaws criticised in previous reviews. However, certain subgroup analyses (e.g. patients with meniscal tears and mechanical symptoms) are still underpowered.
BACKGROUND: Patients with knee pain as a result of osteoarthritis or degenerative meniscal injury may seek treatment through arthroscopic surgery. How effective arthroscopic debridement with or without meniscectomy is for relieving pain and improving patients' functional outcomes is uncertain.
OBJECTIVES: To conduct an evidence update of an evidence-based analysis (EBA) conducted in 2005 to determine if arthroscopic debridement for osteoarthritis of the knee or for meniscal injury from degenerative causes improve patient outcomes.
DATA SOURCES: A literature search was performed using Ovid MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, Embase, and all EBM databases, for studies published from January 1, 2005, to February 4, 2014.
REVIEW METHODS: A systematic review of the literature was conducted, limited to randomized controlled trials (RCTs) that examined the effectiveness of arthroscopic debridement with or without meniscectomy. Quality assessment of the body of literature was conducted using Grading of Recommendations Assessment, Development, and Evaluation (GRADE).
RESULTS: A total of 8 RCTs were identified, 2 from the original EBA plus 6 that were published since that time. The studies included patients with a range of indications for treatment and severity of osteoarthritis. Moderate-quality evidence showed no statistically significant difference in pain or functional status between patients who received arthroscopic treatment versus placebo (e.g., sham surgery). Low-quality evidence showed no statistically significant difference in pain or functional status between patients who received arthroscopic treatment versus usual care (e.g., physical therapy).
LIMITATIONS: Heterogeneity across the study populations, interventions, and reported measures limited the ability to calculate a summary effect estimate; however, all studies demonstrated consistency in their findings.
CONCLUSIONS: The evidence does not show the superiority of arthroscopic debridement with or without meniscectomy in patients with osteoarthritis of the knee or with meniscal injury from degenerative causes.
PURPOSE: Knee osteoarthritis is one of the most common orthopaedic diseases. Therapeutic options for this disease include conservative treatments and arthroscopic debridement and partial or complete replacement. This meta-analysis aimed to collect and analyse the available information on the effects of arthroscopic joint debridement related to the clinical outcomes, the required conversion to replacement and the factors for patient selection.
METHODS: A search for publications was performed in the PubMed, Cochrane and EMBASE medical databases. The primary search resulted in a total of 1,512 citations. The results from 30 papers were included in this study. The extracted dates were listed in a standardised protocol. The statistical evaluation was performed using Comprehensive Meta-analysis software (V2 Biostat, Englewood, NJ, USA).
RESULTS: No randomised study that compared conservative and arthroscopic treatments for knee osteoarthritis was found. Most studies reported middle-term results after arthroscopic operations. The results of these studies showed excellent or good outcomes in more than 60 % of all patients. These results were correlated with a significant increase in the knee scores from baseline to follow-up; the standardised difference in means was 2.3 (CI 95 % 1.5-3.0, p < 0.001). The required conversion rate to replacement increased as the follow-up interval increased. The rates were as follows: 1 year-6.1 % (CI 95 %, 2.1-16.6 %), 2 years-16.8 % (CI 95 %, 10.2-26.3 %), 3 years-21.7 % (CI 95 %, 15.5-29.1 %) and 4 years-34.1 % (CI 95 %, 22.8-47.6 %). The mean survival time was 42.7 (CI 95 %, 14.5-71.1) months. Numerous factors influenced the outcome, including the radiological stage of the osteoarthritis and individual patient factors (e.g. time of history of osteoarthritis, weight and smoking). The local knee findings, such as axial dysalignment, missing effusion and massive crepitus, were also correlated with patient outcome.
CONCLUSION: Arthroscopic joint debridement is a potential and sufficient treatment for knee osteoarthritis in a middle-term time interval. This procedure results in an excellent or good outcome in approximately 60 % of patients in approximately 5 years.
LEVEL OF EVIDENCE: Systematic review of studies, Level III.
BACKGROUND AND PURPOSE: The optimal treatment for isolated patellofemoral osteoarthritis is unclear at present. We systematically reviewed the highest level of available evidence on the nonoperative and operative treatment of isolated patellofemoral osteoarthritis to develop an evidenced-based discussion of treatment options. METHODS: A systematic computerized database search (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, MEDLINE (PubMed), and EMBASE) was performed in March 2009. The quality of the studies was assessed independently by two authors using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. RESULTS: We extracted data from 44 articles. The best available evidence for treatment of isolated patellofemoral osteoarthritis is sparse and of generally low methodological quality. Nonoperative treatment using physiotherapy (GRADE.: high quality, weak recommendation for use), taping (GRADE.: moderate quality, weak recommendation for use), or injection therapy (GRADE.: very low quality, weak recommendation for use) may result in short-term relief. Joint-preserving surgical treatment may result in insufficient, unpredictable, or only short-term improvement (GRADE.: low quality, weak recommendation against use). Total knee replacement with patellar resurfacing results in predictable and good, durable results (GRADE.: low quality, weak recommendation for use). Outcome after patellofemoral arthroplasty in selected patients is good to excellent (GRADE.: low quality, weak recommendation for use). INTERPRETATION: Methodologically good quality comparative studies, preferably using a patient-relevant outcome instrument, are needed to establish the optimal treatment strategy for patients with isolated patellofemoral osteoarthritis.
We aimed to determine if the randomized controlled trials (RCTs) evaluated in the most recent meta-analysis on arthroscopic surgery for degenerative knee arthritis included documented trials of appropriate conservative treatment prior to randomization.
METHODS:
We selected all RCTs of the most recent meta-analysis by Brignardello-Petersen and recorded for each RCT, if physiotherapy prior to randomization was mandatory. We compared the treatment effect of arthroscopy in studies in which physiotherapy prior to randomization was mandatory versus studies in which it was not. This review was registered in the PROSPERO database (CRD42017070091).
RESULTS:
Of the 13 RCTs in the meta-analysis, there were 2 in which physiotherapy prior to randomization was mandatory. In 1 additional multicenter RCT, prior conservative treatment was mentioned as mandatory in the publication, but not in the protocol. The treatment effects attributed to arthroscopy in terms of short-term pain (P = .0037), short-term function (P = .0309), and long-term function (P = .0012) were larger in studies in which prior physiotherapy was mandatory.
CONCLUSIONS:
Although the most recent meta-analysis claims that it is based "on patients who do not respond to conservative treatment," physiotherapy was mandatory prior to randomization only in 2 of the 13 studies. As several orthopaedic guidelines recommend that the first line of treatment in patients with degenerative arthritis of the knee should be conservative, for instance with physiotherapy, and the question of performing arthroscopy arises once conservative treatment fails, 11 of the 13 RCTs failed to adhere to these accepted guidelines. Therefore, patient selection in these 11 studies may not represent the typical indications for arthroscopy, where patients have tried conservative management prior to being offered surgery. When comparing studies where prior physiotherapy was mandatory to studies in which it was not mandatory, there were statistically significant effects favoring arthroscopy in terms of pain in the short term, and for function both in the short and the long term. These findings suggest that the treatment effects attributed to arthroscopy were higher when prior physiotherapy was mandatory. Given these findings, the external validity of most of these RCTs, and the resulting "strong recommendation against the use of arthroscopy in nearly all patients with degenerative knee disease," is called into question.
LEVEL OF EVIDENCE:
Level II, systematic review of Level I and II studies.
