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Gold standard for the management of degenerative knee conditions?

15th Aug, 2022

Key Points

  1. There is a strong recommendation against knee arthroscopy surgery in patients with degenerative knee disease.
  2. Surgical management is not practical due to its minute improvement in pain.  
  3. Arthroscopic surgery and conservative management of knee degeneration are both able to reduce pain and increase knee function.

Surgery for degenerative knee conditions?

Is there a right way to treat degenerative knee conditions? Well, there might not be a right way, but there might be a best method of treatment. The common mode of treatment for degenerative knee conditions used to be arthroscopic surgery. However, evidence now suggests that exercise therapy is able to provide the same benefits as arthroscopic surgery. 

This clinical practice guideline shares recommendations for degenerative knee conditions, and why it strongly suggests against arthroscopic surgery. Produced by a panel of experts, these guidelines are based on systematic reviews comparing arthroscopic surgery to exercise therapy.

Current treatment for degenerative knee conditions 

Some of the current management options for knee degenerative conditions include:

  1. Interventions led by Physiotherapists
  2. Exercise therapy
  3. Watchful waiting i.e. Monitoring the progression of your knee and deciding when it is necessary to take action
  4. Weight loss for patients who are overweight
  5. Oral or topical pain medications like Non-Steroidal Anti-Inflammatory drugs (NSAIDS)
  6. Intra-articular corticosteroid or other injections
  7. Surgery
    1. Arthroscopic knee surgery
    2. Knee replacement surgery
    3. Osteotomy

Background of arthroscopic knee surgeries

Arthroscopic knee surgery for degenerative knee conditions is a common orthopaedic procedure and incurs high costs for the country. Despite recommendations against arthroscopic surgery for knee degeneration, the positive responses to surgery and financial incentives may explain why this surgery continues to be so common. It is also thought to be a last resort for patients who are frustrated with their symptoms, having exhausted other less invasive management strategies.

But if so many patients continue to experience improvements in their knee after surgery, why is it discouraged by experts? This may be because the improvements may be erroneously contributed by placebo effects or co-interventions rather than the procedure itself!

What are the latest recommendations for degenerative knee conditions? 

The expert panel strongly suggests conservative management over surgery, and discourage patients from getting arthroscopy if they only have radiographic evidence of osteoarthritis (OA). These recommendations were made based on several reasonings:

  1. Practicality
    1. Recovery from surgery generally takes 2-6 weeks
    2. Recovery involves pain, swelling, and limits function
    3. Most patients will not be able to fully weight-bear in the first week after surgery
    4. Driving and physical activity are limited during the period of recovery
  2. Values and preferences
    1. The expert panel prioritises value in avoiding:
      1. Burden, post-operative limitations, and rare but serious adverse effects of surgery
    2. The side-effects associated with surgery are for small improvements in short term pain and function that do not even sustain for 1 year
  3. Cost and resources, a society impact
    1. It is cost saving for health funders

In addition, degenerative knee conditions are chronic, and their symptoms tend to fluctuate. With professional help and advice, the pain generally tends to improve over time, hence why the strong recommendations against surgery. 

What are the gains after knee surgery?

Based on studies done, arthroscopic surgery reduces pain and increases knee function after surgery for approximately 3 months, but this improvement does not persist to a year. It also does not seem to result in improvement of long term pain or function in the knee.

Should surgery be considered? 

A small percentage of patients may see small improvements in pain and function 3 months after surgery, but arthroscopic knee surgery generally does not improve knee pain or function in the long term. The improvements seen after surgery have been suggested to be a placebo effect or attributed to co-interventions post-operation. In fact, most patients will experience marked improvements in pain and function without undergoing arthroscopy. Therefore, non-invasive interventions such as exercise therapy are strong recommendations made by the expert panel of this clinical practice guideline

The expert panel included 3 patients who live with OA, one of whom had knee arthroscopy. They contributed to recommendations against having arthroscopic knee surgery as they discussed that patients with degenerative knee conditions hold a high importance to reducing pain. To elaborate, they argued that a small improvement in knee function with no reduction in pain would be irrelevant to a patient suffering from knee pain and limited function.

So…surgery for degenerative knee conditions…yay or nay?

The recommendations were made based on the evidence that non-invasive interventions bring more benefit to knee pain and function than arthroscopic surgery, with improvements that persist more than 1 year. In addition, there is no recovery time necessary for conservative management.

Ultimately, this must be advised by your health professional. While the recommendations are made based on evidence, your health provider would be able to recommend interventions based on what your needs are.

Unsure of what to do? Contact us to speak to our Rehab Centre Physiotherapist who will be able to ascertain the source of pain and discuss with you the various options available to you! 

DISCLAIMER: These advice or exercises should not replace the need for a consultation with a Physiotherapist especially if your condition doesn’t improve. Therapeutic exercise should be carefully selected to suit your condition.

Ref: 
Siemieniuk, R., Harris, I., Agoritsas, T., Poolman, R., Brignardello-Petersen, R., & Van de Velde, S. et al. (2017). Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline. BMJ, j1982. https://doi.org/10.1136/bmj.j1982

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