Arthroscopic Surgery for Degenerative Knee?
Arthroscopic Surgery for Degenerative Knee?
The literature search yielded 1789 reports after exclusion of duplicates. Of these, 18 were considered for inclusion after review of title and abstract. After full text review, six reports were excluded because of no or insufficient data on patient reported pain or physical function, and two were excluded because they were not clinical trial reports. We included 10 reports on nine different trials in the systematic review (supplementary figure A http://www.bmj.com/content/bmj/suppl/2015/06/16/bmj.h2747.DC1/thoj023058.ww1_default.pdf). One report was not included in the final meta-analysis as it was a secondary trial report and the only one providing five year follow-up data.
Study Characteristics. The nine included trials had randomly allocated 1270 patients to interventions including arthroscopic surgery with partial meniscectomy, debridement, or both or a variety of control treatments ranging from placebo surgery to exercise (supplementary table A http://www.bmj.com/content/bmj/suppl/2015/06/16/bmj.h2747.DC1/thoj023058.ww1_default.pdf). Mean age of patients in the individual trials ranged from 49.7 to 62.8 years. Mean baseline pain in the included studies ranged from 36 to 63 mm on a 0–100 mm visual analogue scale. In two trials, all patients had radiographic knee osteoarthritis (Kellgren and Lawrence grade 2 or more); in five trials, some of the patients had radiographic knee osteoarthritis; and in two trials, no patients had radiographic knee osteoarthritis. The follow-up time for the primary endpoint in the trials varied between three and 24 months.
Synthesis of Results. Our primary analysis for pain, combining the individual trials' primary endpoints ranging from three to 24 months, showed a small but statistically significant benefit for interventions including knee arthroscopy compared with control treatments (effect size 0.14, 95% confidence interval 0.03 to 0.26; I=0.0%) (fig 1 and supplementary table B http://www.bmj.com/content/bmj/suppl/2015/06/16/bmj.h2747.DC1/thoj023058.ww1_default.pdf). This effect size corresponds to a difference of 2.4 (95% confidence interval 0.4 to 4.3) mm between treatment groups on a 0–100 mm visual analogue scale. Evaluation of between group differences at different postoperative time points showed a statistically significant benefit in favour of interventions including knee arthroscopy at three months (effect size 0.27, 0.14 to 0.41; I=20.6%) and six months (0.18, 0.05 to 0.30; I=0.0%) but not at later postoperative times (fig 2 and supplementary table B http://www.bmj.com/content/bmj/suppl/2015/06/16/bmj.h2747.DC1/thoj023058.ww1_default.pdf).
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Figure 1.
Results of primary analysis on benefit on patient reported pain of interventions including arthroscopic knee surgery compared with control interventions (follow-up time range: 3–24 months)
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Figure 2.
Effect of interventions including arthroscopic knee surgery compared with control interventions on patient reported pain presented as difference in mm on 0–100 mm visual analogue scale, with 95% confidence interval error bars. Table below shows number of studies and patients included in analyses at different follow-up time points, with estimated difference between interventions calculated as effect size and estimates of heterogeneity (I). Data from 2 months' follow-up from Osteraas et al and Sihvonen et al are included in 3 month estimate
For physical function, we found no significant difference between interventions including knee arthroscopy and control treatments (effect size 0.09, −0.05 to 0.24; I=11.9%) (fig 3). When evaluating physical function over time, we found no between group differences at any of the analysed time points (fig 4).
(Enlarge Image)
Figure 3.
Results of main analysis on benefit on patient reported physical function of interventions including arthroscopic knee surgery compared with control interventions (follow-up time range: 3–24 months)
(Enlarge Image)
Figure 4.
Effect of interventions including arthroscopic knee surgery compared with control interventions on patient reported physical function presented as difference in mm on 0–100 mm visual analogue scale, with 95% confidence interval error bars. Table below shows number of studies and patients included in analyses at the different follow-up time points, with estimated difference between interventions calculated as effect size and estimates of heterogeneity (I)
Risk of Bias. Agreement between assessors on risk of bias ranged from 78% to 100% (that is, κ values ranging from 0.53 to 1.00). Only one included report was assessed as "adequate" on all domains (supplementary table C http://www.bmj.com/content/bmj/suppl/2015/06/16/bmj.h2747.DC1/thoj023058.ww1_default.pdf), and only two reports were assessed as "adequate" for blinding. The remaining studies were not blinded.
Subgroup Analysis. Analysis of the effect of risk of bias showed no differences between studies scored as adequate, unclear, or inadequate on any of the domains investigated (fig 5 and supplementary figure B http://www.bmj.com/content/bmj/suppl/2015/06/16/bmj.h2747.DC1/thoj023058.ww1_default.pdf). We also did subgroup analyses on the primary endpoint analysis of pain and physical function for the osteoarthritis status of the study population (ranging from no radiographic osteoarthritis at all via a mixed population to all having radiographic osteoarthritis) and for type of surgery (partial meniscectomy with or without concomitant debridement) (fig 6 and supplementary figure C http://www.bmj.com/content/bmj/suppl/2015/06/16/bmj.h2747.DC1/thoj023058.ww1_default.pdf). These analyses did not change the interpretation of the results from the primary analyses. Subgroup analysis stratified for presence/absence of mechanical symptoms was not possible owing to lack of data. In a further subgroup analysis to evaluate the influence of study design, we found no differences between studies with different control interventions (fig 6 and supplementary figure C http://www.bmj.com/content/bmj/suppl/2015/06/16/bmj.h2747.DC1/thoj023058.ww1_default.pdf).
(Enlarge Image)
Figure 5.
Evaluation of risk of bias in primary analysis of pain. P value indicates difference between studies dependent on risk of bias scoring (that is, adequate, inadequate, and unclear)
(Enlarge Image)
Figure 6.
Subgroup analysis on primary analysis of pain stratified by study population knee osteoarthritis status, surgery type, and study design. P value indicates difference between different subgroups
We screened titles and abstracts of 2330 reports after exclusion of duplicates; of these, 37 were reviewed as full text. This resulted in exclusion of 28 reports, leaving nine reports for meta-analysis (supplementary figure A http://www.bmj.com/content/bmj/suppl/2015/06/16/bmj.h2747.DC1/thoj023058.ww1_default.pdf).
Study Characteristics. Two randomised trials and seven observational/registry studies reported on adverse events (supplementary table D http://www.bmj.com/content/bmj/suppl/2015/06/16/bmj.h2747.DC1/thoj023058.ww1_default.pdf). Quality of reporting of adverse events was frequently low in both observational studies and randomised clinical trials, and only two of nine arthroscopy trials provided useful information on adverse events.
Synthesis of Results. Deep venous thrombosis was the most frequently reported symptomatic adverse event associated with arthroscopic meniscectomy, with 4.13 (95% confidence interval 1.78 to 9.60) events per 1000 procedures, followed by infection, pulmonary embolism, and death (Table 1 and supplementary table B http://www.bmj.com/content/bmj/suppl/2015/06/16/bmj.h2747.DC1/thoj023058.ww1_default.pdf). Heterogeneity of all the estimates was high (Table 1).
Risk of Bias. Only one study was assessed as "adequate" on all three domains (supplementary table E http://www.bmj.com/content/bmj/suppl/2015/06/16/bmj.h2747.DC1/thoj023058.ww1_default.pdf). All reports sufficiently described the surgical intervention, but seven of nine studies reported only a few types of adverse events in the same report (supplementary table D http://www.bmj.com/content/bmj/suppl/2015/06/16/bmj.h2747.DC1/thoj023058.ww1_default.pdf).
Results
Benefits
The literature search yielded 1789 reports after exclusion of duplicates. Of these, 18 were considered for inclusion after review of title and abstract. After full text review, six reports were excluded because of no or insufficient data on patient reported pain or physical function, and two were excluded because they were not clinical trial reports. We included 10 reports on nine different trials in the systematic review (supplementary figure A http://www.bmj.com/content/bmj/suppl/2015/06/16/bmj.h2747.DC1/thoj023058.ww1_default.pdf). One report was not included in the final meta-analysis as it was a secondary trial report and the only one providing five year follow-up data.
Study Characteristics. The nine included trials had randomly allocated 1270 patients to interventions including arthroscopic surgery with partial meniscectomy, debridement, or both or a variety of control treatments ranging from placebo surgery to exercise (supplementary table A http://www.bmj.com/content/bmj/suppl/2015/06/16/bmj.h2747.DC1/thoj023058.ww1_default.pdf). Mean age of patients in the individual trials ranged from 49.7 to 62.8 years. Mean baseline pain in the included studies ranged from 36 to 63 mm on a 0–100 mm visual analogue scale. In two trials, all patients had radiographic knee osteoarthritis (Kellgren and Lawrence grade 2 or more); in five trials, some of the patients had radiographic knee osteoarthritis; and in two trials, no patients had radiographic knee osteoarthritis. The follow-up time for the primary endpoint in the trials varied between three and 24 months.
Synthesis of Results. Our primary analysis for pain, combining the individual trials' primary endpoints ranging from three to 24 months, showed a small but statistically significant benefit for interventions including knee arthroscopy compared with control treatments (effect size 0.14, 95% confidence interval 0.03 to 0.26; I=0.0%) (fig 1 and supplementary table B http://www.bmj.com/content/bmj/suppl/2015/06/16/bmj.h2747.DC1/thoj023058.ww1_default.pdf). This effect size corresponds to a difference of 2.4 (95% confidence interval 0.4 to 4.3) mm between treatment groups on a 0–100 mm visual analogue scale. Evaluation of between group differences at different postoperative time points showed a statistically significant benefit in favour of interventions including knee arthroscopy at three months (effect size 0.27, 0.14 to 0.41; I=20.6%) and six months (0.18, 0.05 to 0.30; I=0.0%) but not at later postoperative times (fig 2 and supplementary table B http://www.bmj.com/content/bmj/suppl/2015/06/16/bmj.h2747.DC1/thoj023058.ww1_default.pdf).
(Enlarge Image)
Figure 1.
Results of primary analysis on benefit on patient reported pain of interventions including arthroscopic knee surgery compared with control interventions (follow-up time range: 3–24 months)
(Enlarge Image)
Figure 2.
Effect of interventions including arthroscopic knee surgery compared with control interventions on patient reported pain presented as difference in mm on 0–100 mm visual analogue scale, with 95% confidence interval error bars. Table below shows number of studies and patients included in analyses at different follow-up time points, with estimated difference between interventions calculated as effect size and estimates of heterogeneity (I). Data from 2 months' follow-up from Osteraas et al and Sihvonen et al are included in 3 month estimate
For physical function, we found no significant difference between interventions including knee arthroscopy and control treatments (effect size 0.09, −0.05 to 0.24; I=11.9%) (fig 3). When evaluating physical function over time, we found no between group differences at any of the analysed time points (fig 4).
(Enlarge Image)
Figure 3.
Results of main analysis on benefit on patient reported physical function of interventions including arthroscopic knee surgery compared with control interventions (follow-up time range: 3–24 months)
(Enlarge Image)
Figure 4.
Effect of interventions including arthroscopic knee surgery compared with control interventions on patient reported physical function presented as difference in mm on 0–100 mm visual analogue scale, with 95% confidence interval error bars. Table below shows number of studies and patients included in analyses at the different follow-up time points, with estimated difference between interventions calculated as effect size and estimates of heterogeneity (I)
Risk of Bias. Agreement between assessors on risk of bias ranged from 78% to 100% (that is, κ values ranging from 0.53 to 1.00). Only one included report was assessed as "adequate" on all domains (supplementary table C http://www.bmj.com/content/bmj/suppl/2015/06/16/bmj.h2747.DC1/thoj023058.ww1_default.pdf), and only two reports were assessed as "adequate" for blinding. The remaining studies were not blinded.
Subgroup Analysis. Analysis of the effect of risk of bias showed no differences between studies scored as adequate, unclear, or inadequate on any of the domains investigated (fig 5 and supplementary figure B http://www.bmj.com/content/bmj/suppl/2015/06/16/bmj.h2747.DC1/thoj023058.ww1_default.pdf). We also did subgroup analyses on the primary endpoint analysis of pain and physical function for the osteoarthritis status of the study population (ranging from no radiographic osteoarthritis at all via a mixed population to all having radiographic osteoarthritis) and for type of surgery (partial meniscectomy with or without concomitant debridement) (fig 6 and supplementary figure C http://www.bmj.com/content/bmj/suppl/2015/06/16/bmj.h2747.DC1/thoj023058.ww1_default.pdf). These analyses did not change the interpretation of the results from the primary analyses. Subgroup analysis stratified for presence/absence of mechanical symptoms was not possible owing to lack of data. In a further subgroup analysis to evaluate the influence of study design, we found no differences between studies with different control interventions (fig 6 and supplementary figure C http://www.bmj.com/content/bmj/suppl/2015/06/16/bmj.h2747.DC1/thoj023058.ww1_default.pdf).
(Enlarge Image)
Figure 5.
Evaluation of risk of bias in primary analysis of pain. P value indicates difference between studies dependent on risk of bias scoring (that is, adequate, inadequate, and unclear)
(Enlarge Image)
Figure 6.
Subgroup analysis on primary analysis of pain stratified by study population knee osteoarthritis status, surgery type, and study design. P value indicates difference between different subgroups
Harms
We screened titles and abstracts of 2330 reports after exclusion of duplicates; of these, 37 were reviewed as full text. This resulted in exclusion of 28 reports, leaving nine reports for meta-analysis (supplementary figure A http://www.bmj.com/content/bmj/suppl/2015/06/16/bmj.h2747.DC1/thoj023058.ww1_default.pdf).
Study Characteristics. Two randomised trials and seven observational/registry studies reported on adverse events (supplementary table D http://www.bmj.com/content/bmj/suppl/2015/06/16/bmj.h2747.DC1/thoj023058.ww1_default.pdf). Quality of reporting of adverse events was frequently low in both observational studies and randomised clinical trials, and only two of nine arthroscopy trials provided useful information on adverse events.
Synthesis of Results. Deep venous thrombosis was the most frequently reported symptomatic adverse event associated with arthroscopic meniscectomy, with 4.13 (95% confidence interval 1.78 to 9.60) events per 1000 procedures, followed by infection, pulmonary embolism, and death (Table 1 and supplementary table B http://www.bmj.com/content/bmj/suppl/2015/06/16/bmj.h2747.DC1/thoj023058.ww1_default.pdf). Heterogeneity of all the estimates was high (Table 1).
Risk of Bias. Only one study was assessed as "adequate" on all three domains (supplementary table E http://www.bmj.com/content/bmj/suppl/2015/06/16/bmj.h2747.DC1/thoj023058.ww1_default.pdf). All reports sufficiently described the surgical intervention, but seven of nine studies reported only a few types of adverse events in the same report (supplementary table D http://www.bmj.com/content/bmj/suppl/2015/06/16/bmj.h2747.DC1/thoj023058.ww1_default.pdf).
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