Position Statement From the Australian Knee Society on Arthroscopic Surgery of the Knee, Including Reference to the Presence of Osteoarthritis or Degenerative Joint Disease: Updated October 2016

摘要

Arthroscopic debridement and/or lavage has been shown to have no beneficial effect on the natural history of osteoarthritis (OA), nor is it indicated as a primary treatment in the management of OA. However, this does not preclude the judicious use of arthroscopic surgery, when indicated, to manage symptomatic coexisting abnormalities in the presence of OA or degeneration. Partial medial meniscectomy is not indicated as an initial treatment for atraumatic tears of degenerative menisci, excluding bucket-handle tears and surgeon-assessed locked or locking knees. Arthroscopic Surgery in the Presence of Osteoarthritis or Degeneration There are certain clinical scenarios in which arthroscopic surgery, in the presence of OA, may be appropriate. These include, but are not necessarily limited to, the following: known or suspected septic arthritis; symptomatic nonrepairable meniscal tears after the failure of an appropriate trial of a structured rehabilitation program; symptomatic loose bodies; surgeon-assessed locked or locking knees; traumatic or atraumatic meniscal tears that require repair; inflammatory arthropathy requiring synovectomy; synovial abnormalities requiring biopsy or resection; large unstable chondral abnormalities causing surgeon-assessed locking or locked knees; as an adjunct to, and in combination with, other surgical procedures as appropriate for OA (eg, high tibial osteotomy and patellofemoral realignment); and diagnostic arthroscopic surgery when the diagnosis is unclear on magnetic resonance imaging (MRI) or MRI is not possible and the symptoms are not of OA. The decision to proceed with arthroscopic surgery in the presence of OA or degeneration should be made by the treating orthopaedic surgeon: after a careful review of the clinical scenario, particularly the assessment of the relative contributions of OA and the arthroscopically treatable abnormality, to the patient’s symptoms; with knowledge of the relevant evidence base, as listed in this work; after an appropriate trial of structured rehabilitation; and after a thoughtful discussion with the patient about the relative merits of the procedure versus ongoing nonoperative treatment. Definitions OA, or degenerative joint disease, is a progressive clinical disorder of joints characterized by gradual diffuse loss of articular cartilage, effects on the underlying bone, and secondary compromise of joint function. This should be distinguished from focal articular cartilage abnormalities in an otherwise normal joint. There is a spectrum of severity of OA from minor partial-thickness articular cartilage abnormalities to large areas of full-thickness loss. Clinical decision making requires a careful assessment of the degree of arthritis, its likely contribution to the symptoms, and the potential contribution of additional abnormalities to those symptoms. The concept of degenerative versus traumatic, in regard to meniscal lesions and tearing, is arbitrary.~( 15 )No universally accepted definition of degeneration or degenerative change exists, and commonly used clinical diagnostic descriptors lack validity. Assessment and Interpretation of MRI While plain radiography is the preferred initial imaging modality, MRI remains an excellent adjunct both to clinical decision making and to guiding the use of surgery. In particular, it can be used to more accurately assess the degree of arthritis and to look for and assess additional abnormalities that may correlate with a patient’s symptoms. MRI scans should be interpreted carefully by the treating surgeon, in combination with direct review of the imaging, when determining the clinical relevance of the findings. MRI descriptions of meniscal tearing, degeneration, and lesions in the absence of trauma lack validity. Further information on the appropriate radiological investigation of knee OA can be obtained from the statement, “Joint AKS-AMSIG Submission to the Australian Commission on Quality and Safety in Healthcare on the Radiological Investigation of Knee Osteoarthritis” ( http://www.kneesociety.org.au/resources/Joint-AKS-AMSIG-submission-ACQSH-investigation-knee-osteoarthritis.pdf ). Systematic Review: Arthroscopic Surgery in the Presence of Osteoarthritis Introduction Our aim was to examine the evidence of effectiveness, inclusion and exclusion criteria, effects of age, and adverse events in existing knee arthroscopic surgery randomized controlled trials (RCTs), with a view to the formulation of clinical indication guidelines based on International Classification of Diseases–10th Revision (ICD-10) codes for knee arthroscopic surgery in the presence of degeneration or OA. Methods The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement for systematic reviews was utilized for this work.~( 11 ) Literature Search and Study Selection In December 2015, a systematic search for clinical indications in Medline, Embase, CINAHL, and the Cochrane Central Register of Controlled Trials