Position Statement from the Australian Knee Society on Arthroscopic Surgery of the Knee, with particular reference to the presence of Osteoarthritis.
In preparing the following evidence based document, the Australian Knee Society, on behalf of the Australian Orthopaedic Association, has combined the individual clinical expertise of its members with the best available external clinical evidence from a systematic review of the literature. (references listed at end of document)
Arthroscopic debridement, and / or lavage, has been shown to have no beneficial effect on the natural history of osteoarthritis, nor is it indicated as a primary treatment in the management of osteoarthritis. However, this does not preclude the use of arthroscopic surgery, where indicated, to manage symptomatic coexisting pathology, in the presence of osteoarthritis.
Arthroscopic Surgery in the Presence of Osteoarthritis
There are certain clinical scenarios in which arthroscopic surgery, in the presence of osteoarthritis, may be appropriate – albeit after considered discussion with the patient. These include, but are not necessarily limited to, the following:
- known or suspected septic arthritis
- unstable meniscal tears after an appropriate trial of nonoperative treatment
- symptomatic loose bodies
- meniscal tears that require repair
- inflammatory arthropathy requiring synovectomy
- synovial pathology requiring biopsy or resection
- unstable chondral pathology causing mechanical symptoms
- as an adjunct to, and in combination with, other surgical procedures as appropriate for
- osteoarthritis: for example high tibial osteotomy and patellofemoral realignment
- diagnostic arthroscopy when the diagnosis is unclear on MRI
Definition of Osteoarthritis
Osteoarthritis, or degenerative joint disease, is a progressive 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 pathology in an otherwise normal joint, occurring more commonly in younger people. There is a spectrum of severity of osteoarthritis from minor partial thickness articular cartilage abnormalities to large areas of full thickness loss. Clinical decision making requires careful assessment of the degree of arthritis, its likely contribution to the symptoms, and the potential contribution of additional pathology to those symptoms.
Assessment and Interpretation of MRI Scanning
MRI is 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 pathology that may correlate with a patient’s symptoms. MRI reports should be interpreted carefully by the treating surgeon, in combination with direct review of the imaging, when determining the clinical relevance of the findings.
Arthroscopic Surgery in the Presence of Osteoarthritis
The decision to proceed with arthroscopic surgery in the presence of osteoarthritis should be made by the treating orthopaedic surgeon:
- after careful review of the clinical scenario: particularly the assessment of the relative contributions of the osteoarthritis, and the arthroscopically treatable pathology, to the patient’s symptoms
- with knowledge of the relevant evidence base, as listed in this document
- after an appropriate trial of nonoperative treatment
- and after thoughtful discussion with the patient about the relative merits of the procedure versus ongoing nonoperative treatment
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