PositionStatementfromtheAustralianKneeSocietyonArthroscopicSurgeryoftheKnee,includingreferencetothepresenceof

OsteoarthritisorDegenerativeJointDiseaseUpdatedOctober2016

Inpreparingthefollowingevidencebaseddocument,theAustralianKneeSociety,onbehalfoftheAustralianOrthopaedicAssociation,hascombinedtheindividualclinicalexpertiseofitsmemberswithpublishedrandomized

controlledtrialsfromasystematicreviewoftheliterature.

PositionStatement

Arthroscopicdebridement, and /or lavage,hasbeen shown tohavenobeneficial effecton the

naturalhistoryofosteoarthritis,norisitindicatedasaprimarytreatmentinthemanagement of

osteoarthritis. However, this does not preclude the judicious use of arthroscopic surgery,when

indicated, to manage symptomatic coexisting pathology, in the presence of osteoarthritis or

degeneration.Partialmedialmeniscectomyisnotindicatedasaninitialtreatmentforatraumatic

tears of degenerative menisci, excluding bucket handle tears and surgeon assessed locked or

lockingknees.

ArthroscopicSurgeryinthePresenceofOsteoarthritisorDegeneration

Therearecertainclinicalscenariosinwhicharthroscopicsurgery,inthepresenceofosteoarthritis,may

beappropriate.Theseinclude,butarenotnecessarilylimitedto,thefollowing:

• knownorsuspectedsepticarthritis

• symptomatic non-repairable meniscal tears after failure of an appropriate trial of a

structuredrehabilitationprogram

• symptomaticloosebodies

• surgeonassessedlockedorlockingknees

• traumaticoratraumaticmeniscaltearsthatrequirerepair

• inflammatoryarthropathyrequiringsynovectomy

• synovialpathologyrequiringbiopsyorresection

• largeunstablechondralpathologycausingsurgeonassessedlockingorlockedknee

• asanadjunctto,andincombinationwith,othersurgicalproceduresasappropriatefor

osteoarthritis:forexamplehightibialosteotomyandpatello-femoralrealignment

• diagnosticarthroscopywhenthediagnosisisunclearonMRIorMRIisnotpossible,andthe

symptomsarenotofosteoarthritis

Thedecisiontoproceedwitharthroscopicsurgeryinthepresenceofosteoarthritisordegenerationshouldbe

madebythetreatingorthopaedicsurgeon:

• aftercarefulreviewoftheclinicalscenario:particularlytheassessmentoftherelativecontributions

oftheosteoarthritis,andthearthroscopicallytreatablepathology,tothepatient’ssymptoms• withknowledgeoftherelevantevidencebase,aslistedinthisdocument• afteranappropriatetrialofstructuredrehabilitation• andafterthoughtfuldiscussionwiththepatientabouttherelativemeritsoftheprocedureversus

ongoingnon-operativetreatment

Definitions

Osteoarthritis,ordegenerativejointdisease,isaprogressiveclinicaldisorderofjointscharacterizedby

gradualdiffuselossofarticularcartilage,effectsontheunderlyingbone,andsecondarycompromiseof

jointfunction.Thisshouldbedistinguishedfromfocalarticularcartilagepathologyinanotherwisenormal

joint.

Thereisaspectrumofseverityofosteoarthritisfromminorpartialthicknessarticularcartilageabnormalities

tolargeareasoffullthicknessloss.Clinicaldecisionmakingrequirescarefulassessmentofthedegreeof

arthritis,itslikelycontributiontothesymptoms,andthepotentialcontributionofadditionalpathologyto

thosesymptoms.Theconceptsofdegenerativeversustraumatic,inregardmeniscalpathologyandtearing,isarbitrary(1).No

universallyaccepteddefinitionofdegenerationordegenerativechangeexists,andcommonlyusedclinical

diagnosticdescriptorslackvalidity.

AssessmentandInterpretationofMRIScanning

Whilstplainradiography is thepreferred initial imagingmodality,MRIremainsexcellentadjunct

bothtoclinicaldecisionmaking,andtoguidingtheuseofsurgery. Inparticular,itcanbeusedto

moreaccuratelyassessthedegreeofarthritis,andtolookforand assessadditionalpathologythat

may correlate with a patient’s symptoms. MRI reports should be interpreted carefully by the

treatingsurgeon,incombinationwithdirectreviewoftheimaging, whendeterminingtheclinical

relevanceofthefindings.MRIdescriptionsofmeniscaltearing,degeneration,andpathologyinthe

absenceoftrauma,lackvalidity.Furtherinformationontheappropriateradiologicalinvestigation

of knee osteoarthritis can be obtained in the “Radiological Investigation Joint AKS-AMSIG

SubmissiontotheAustralianCommissiononQualityandSafetyinHealthcareontheRadiological

Investigationof KneeOsteoarthritis (http://www.kneesociety.org.au/resources/Joint-AKS-AMSIG-

submission-ACQSH-investigation-knee-osteoarthritis.pdf).

SystematicReview:ArthroscopicSurgeryinthePresenceofOsteoarthritis

Introduction

Ouraimwastoexaminetheevidenceofeffectiveness,inclusionandexclusioncriteria,theeffectsofageand

adverseevents,inexistingkneearthroscopyrandomizedcontrolledtrials,withaviewtotheformulationof

clinicalindicationguidelinesbasedonICD–10codesforkneearthroscopyinthepresenceofdegenerationor

osteoarthritis.

Methods

ThePRISMAstatementforsystematicreviewswasutilizedforthisreview(2).

LiteraturesearchandStudySelection

AsystematicsearchforclinicalindicationsinMedline,Embase,CINAHL,andtheCochraneCentralRegisterof

ControlledTrials(CENTRAL)inDecember2015wasundertaken.Thekeywords“arthroscopy”and“knee”,or

variationsofthemwereused.Limitationstoclinicaltrialsandhumanstudieswereapplied.Nosearch

restrictionsforfollow-uptime,studysize,ordateofpublicationwereset.

Eligibilitycriteria

Inclusioncriteria:1.Randomisedcontrolledtrials(RCT)assessingtheeffectivenessofarthroscopicsurgeryinvolvingmeniscal

surgery,debridement,chondroplasty,loosebodyremovaloranycombinations,withorwithoutclinicalor

radiographicosteoarthritis,comparedwithnon-surgicaltreatments,shamsurgeryorlavage.

2.Englishlanguagereports.

3.Publicationinapeerreviewedjournal.

Exclusioncriteria:

Allcriteriahadtobesatisfiedforinclusionandothersystematicreviewsormeta-analyseswereexcluded.

DataExtraction

Titlesand/orabstractsofstudiesthatwereretrievedusingthesearchstrategywerescreenedindependently

bytworeviewauthorstoidentifystudiesthatpotentiallymettheinclusioncriteria.Thefulltextsofthese

potentiallyeligiblestudieswereretrievedandindependentlyassessedforeligibilitybythetworeviewteam

members.Anydisagreementovertheeligibilityofaparticularstudywasresolvedthroughconsensuswiththe

additionofathirdreviewer.

Astandardisedformwasusedtoextractdatafromtheincludedstudiesforassessmentofstudyqualityand

evidencesynthesis.Extractedinformationincluded:studypopulation;primarydiagnosis,inclusioncriteria,

exclusioncriteria,detailsoftheintervention;detailsofthecomparator;studymethodology;outcomesand

timesofmeasurement,andpoweranalysis.Tworeviewauthorsextractedthedataindependently.

Iftwoseparatestudieswiththesameauthorsandthesameinterventionhadoverlappingdatesofpatient

enrolment,thenonlyonestudywasincluded.Inthissituation,thereviewerselectedthestudywiththe

longerfollow-up.Ifadifferentdataanalysisorsub-analysiswasundertaken,thenthesupplementalstudywas

included.

ICD10DiagnosisMatching

InternationalClassificationofDisease10thRevisionClinicalModification(ICD-10-CM)codesorProcedure

CodingSystem(ICD-10-PCS)codeswerematchedbytworeviewauthorstotheinclusion&exclusioncriteria

ofallmatchedstudies.ICD-10-CMcodesweredevelopedbytheCentersforDiseaseControlandPreventionin

conjunctionwiththeNationalCenterforHealthStatistics(NCHS),foroutpatientmedicalcodingand

reporting,aspublishedbytheWorldHealthOrganization.ICD-10-PCScodesweredevelopedbytheCenters

forMedicareandMedicaidServices(CMS)asasystemofclassificationofproceduralcodestoclassifyall

healthinterventionsbymedicalprofessionals(3).

Results

KneeArthroscopyOutcomesStudies

14RCTsofarthroscopickneesurgery(Table1)fulfilledthesearchcriteria(Figure1)inthreedifferentprimary

clinicalICD–10diagnosiscategories(Table2).Infourpapers,theprimaryclinicaldiagnosiswasosteoarthritis

(4)(5)(6)(7)(OAPapers)(ICD–10CodeM17.9).Inonepaper,Hubbardetal(8)theprimaryclinicaldiagnosis

wasofasinglemedialfemoralcondyledegenerativearticularlesion,howevernotenoughinformationwas

providedbytheauthorstoallowclassificationofthedegenerativechondrallesionasclinicalosteoarthritis.

In8paperstheprimaryclinicaldiagnosiswasasymptomaticdegenerativeatraumaticmedialmeniscaltear

(9)(1)(10)(11)(12)(13)(14)(15)(MMTPapers)(ICD-10CodeM23.2)inthepresenceofchondraldegeneration

ofvariousdegrees.Inonepaper,Kettunenetal(16)theprimaryclinicaldiagnosiswaspatellofemoralpain

(PFPainGroup)(ICD-10M22.4).

ThreeRCTswereassessedashavinginadequatepowerfortheprimaryoutcomesmeasure.Østeråsetal(15)

examinedarthroscopicpartialmedialmeniscectomyinthepresenceofkneeosteoarthritiscomparedto

physicaltherapy.Theyincludedapoweranalysis,howeverthefinalnumberofpatientsintheirstudywasless

thanstatedtoachieveadequatepower.Changetal(6)lackedapoweranalysis,howeveraPostHocPower

AnalysisusingG-Power(17)revealedthepaperwasinadequatelypowered(power<0.8)toconfirmtheself

describedmeaningfulimprovementofareductionof>1cmfromthebaselineVASscore.Sihvonenetal14)is

apost-hocsubgroupanalysisofpatientsfromtheiroriginal2013RCT(1)whosufferedself-described

mechanicalsymptoms,definedascatchingandclickingexcludinglockedorrecentlylockedknees.Theauthors

statethatthesub-groupanalysiswasunderpowered.

Threepapersfavoredarthroscopicinterventionatfinalfollow-up,twointheOA-ChondralDegeneration

Category(7)(8)andoneintheMMTCategory(9),theremaining11papersreportednooutcomedifference

comparedtothecontrolintervention.

RiskofBiasAssessment

StudieswereratedfortheirriskofbiasinTable3.Therewerenostudieswithalowriskofbiasinall7risk

domainsassessedintheOA-ChondralDegenerationCategoryandPatellofemoralPainCategory(7).InMMT

studies,therewasonlyonestudyoflowriskofbias(1)inalldomains.

MMTPapersExclusionsInthe8paperswithaprimaryclinicaldiagnosisofmedialmeniscaltearing,fivepapersexcludedsurgeon

assessedlockedorlockingknees(13)(1)(9)(15)(14)andoneexcludedloosebodies(18),withVermesanetal

notstatinganyexclusioncriteria(Table4).TheSihvonenetal(19)andSihvonenetal(14)trialprotocol

excludedsurgeonassessedlockedorrecentlylockedkneesandmajorchondralflapsbutincludedkneeswith

patientreportedcatchingandlockingsymptoms.Yimetal(11)&Katzeta(13)alsoincludedpatientswith

mechanicalsymptoms

AhistoryoftraumaticonsetwasanexclusioncriterioninsixMMTPaperspapers(15)(11)(1)(18)(14),with

Vermesanetal(20)notstatinganyexclusioncriteria.Nopaperincludedmeniscalrepairasamanagement

interventionandmeniscalrepairwasanexclusioncriteriainthreepapers(1)(11)(14).FiveoftheeightMMT

Papersreportedcross-overintothesurgicalgroupfromthecontrol,withratesofbetween2%-33%.

Nostudyincludeddiagnosticarthroscopy.Inflammatoryjointdisorderswereexcludedin4papers,ornotan

inclusioncriteriaintheremainder.

OAPapers-ExclusionCriteriaMerchanandGalindo(7)excludedpatientswithpaingreaterthansixmonths,maleswithaweightover85kg,

femalesgreater70kg,instabilityoranangulardeformitygreaterthan15degrees.Hubbardetal(8)excluded

anyotherintra-articularlesionexceptforsymptomaticmedialfemoralcondyledegenerativelesionsin

patientswithnoradiographicosteoarthritis.Moseleyetal(4)addedtheKellgrenandLawrencescoreforeach

compartmenttogether,excludingthepatientswithascoreofgreaterthannine.Kirkelyetal(5)excluded

patientswithlargemeniscaltears,buckethandletears,priormajorkneetrauma,inflammatoryorpost

infectiousarthritis,deformity>5degrees,priortraumaorKL4intwocompartments.

TypesofMedialMeniscalTear

Onlyonepaper,Kimetal(11),describedtheMMTpattern,theremaindergroupedallMMTpatternstogether

asatraumaticdegenerative.Sihvonenetal(1)describedanatraumaticsuddensymptomonsetsub-groupwho

didnobetterwithsurgicalintervention.

CrossOverIntoSurgicalGroup

NoneoftheOA/ChondralDegenerationpapersdescribedcrossoverintothesurgicalgroup.Sevenofthe

nineMMTPapersdescribedcross-overintothesurgicalgroupof0%(15),2%(11),2.5%(14),6.6%(1),

21.3%(9),30.2%(13),and33.3%(18).Reasonsforcrossoverintothesurgicalgroupwereeitherthoseof

persistentsymptoms(18)(1)(9)ornotgiven(11)(13).

HerrlinetalandKatzetalstatedthatpatientswhocrossedoverintothesurgicalgrouphadsignificantly

worsesymptomsthantheremainderofthecontrolgrouppriortocrossingover,howeverachievedsimilar

outcomestothecontrolandsurgicalgroup.

TheEffectofAge

Onlyonepaperspecificallyexaminedtheeffectofageonoutcome.Gauffinetal(9)reportedbetteroutcomes

forbothrehabilitationandarthroscopicinterventionfor55-64yearoldpatientscomparedtoyounger

patientsaged45-55years.

AdverseEvents

Nopaperdescribedagreaterrateofadverseeventsinthearthroscopicgroup.

LateralMeniscalTears

Nostudyexaminedoutcomesofpartialmeniscectomyasatreatmentforlateralmeniscaltears.

OutcomesofPatientswithAtraumaticMedialMeniscalTearsWhoHaveFailedNon-Operative

Management

Theinclusioncriteriaforfouroftheeightmeniscaltearsstudiesincludedfailureofclinicianassessednon-

specificnon-operativemanagementofbetween1&3months.Nomedialmeniscalstudyexaminedoutcomes

ofpatientswhohadundergonestructuredrehabilitationprogramandcontinuedtohavehadsevereself-

describedsymptomsafterbyrandomizationtooperativeversusnon-operativeintervention.

OutcomesofPatientsWhoHaveSelf-ReportedMechanicalSymptoms

Self-reportedmechanicalsymptomswerecommoninallpapers.Onepaper(14),asecondaryanalysisofa

previouslypublishedRCT,foundnodifferenceinpatientswithatraumaticself–describedmechanical

symptomswhounderwentmedialmeniscectomycomparedtoashamprocedure.Kirkelyetal(5)foundno

improvementinasub-groupofpatientswithosteoarthritisandself-describedmechanicalsymptoms

comparedtorehabilitation.

ProgressionofOsteoarthritisAfterPartialMeniscectomy

Onepaper,Herrlinetal(18),foundnodifferenceinosteoarthritisprogression5yearsafterpartialmedial

meniscectomycomparedtophysiotherapy.

ReviewConclusions

Allofthestudiesintheosteoarthritisgroupwereathighriskofbiasinatleastonedomain.

OneOAstudywasatlowriskofbiasfromblinding.Inthisstudy,patientswhowereassessedclinicallytohave

moderatetoseverekneeosteoarthritis,intheabsenceofloosebodiesorlocking,showednoadvantageof

arthroscopicdebridementoverlavageorshamsurgery.

Inastudywithahighriskofbias,patientswithisolatedmedialfemoralcondyledegenerativelesions

benefitedfromarthroscopicinterventioncomparedtorehabilitation.

Inastudywithahighriskofbias,arthroscopicpatellofemoralchondroplastydidnotbenefitpatients

comparedtonon-operativemanagement.

Inatraumaticmedialmeniscaltears,intheabsenceofsurgeonassessedlockingoralockedknee,ora

repairablemeniscustear,astudywithalowriskofbiasshowednoadvantageofarthroscopicpartial

meniscectomyovershamsurgery.

Inastudywithahighriskofbiasinonedomain,patientswithanatraumaticonsetofself–described

mechanicalsymptoms,inthepresenceofamedialmeniscaltear,otherthansurgeonassessedrecentlocking,

alockedkneeorsymptomaticloosebodies,therewasnoadvantagetoarthroscopicpartialmeniscectomy

overshamsurgery.

Theroleofarthroscopicsurgeryinlateralmeniscaltearsremainsuncertain,asithasnotbeensubjectedtoa

randomisedcontrolledtrial.

Theroleofsubchondraldrillingormicrofractureundertakenincombinationwithanosteotomyremains

uncertainasnorandomisedcontrolledstudiesexistcomparingittoosteotomyalone.

Preservationofthemedialorlateralmeniscusbyrepairofthebodyorroot,withorwithoutdegenerationof

thejoint,hasnotbeensubjectedtoarandomisedcontrolledtrial.

NostudyinvestigatedtheroleofdiagnosticarthroscopyinsituationswhereMRIwasinconclusiveorunableto

beperformed.ThevalueofMRIintheinvestigationofatraumaticnon-lockingkneesymptomsinpresenceof

osteoarthritisremainsuncertain.

Nomedialmeniscaltearstudyexaminedoutcomesofpatientswhofailedastructuredrehabilitationprogram

byrandomizationtooperativeversusnon-operativeintervention.

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Table1:ArthroscopicSurgeryOutcomesinRandomizedControlledTrialsAuthor&Year

PrimaryDx Rx Inclusions Ixx n Control %Notenrolled

MaxXROA

JointSpecificExclusions

%XOver

PA Notes Outcome

Osteoarthri=s&ChondralDegenera=veRCTs1 Merchan

and

Galindo8

1993

MildOAwithotherintra-

pathology

Synovectomy;débridement;APM,CPY,E/Oosteophytes&

PT

Painful“limited”OA,includingpaVentswithmeniscaltears,loosebodies&synoviVs.

XR 73 NSAID.AcVvity

modificaVon.

NS Ahlbach0-1,KL1-2

Duration of pain >6 months, patient body weight >85 kg in men and >70 kg in women, and history of previous surgery. Instability or an angular deformity > 15°.

Patellofemoral OA.

NA N OM=ModifiedHSSKScore.APMperformedin31/35.Power>0.8.

FavouredA/Sat1-3years(mean25

months)

2 Changetal171993

OsteoarthriVs

APM,CPY,Synovectomy

Painader3monthsaderrehabilitaVon

XR 32Pts

NeedleLavage

50 KL1-3 PriorKneesurgerywithin6months,TKA,

OAKLGradeIV.

NS N Inadequatepower.50%hadKLGrade3

Nodifferenceat12months.

3 Hubbard

etal9

1996

SymptomaVcsingleMFCdegeneraVvechondrallesionObCGrade3or4

Chondroplasty.NoAPM.

Symptoms>1yr,nolaxityornodeformity,fullROM,singleMedialFemoralCondyle

degeneraVvelesion,OBCGrade3or4,nootherintra-arVcularpathology,normalplainXR,modifiedLysholmscore<

38/70.

XR 76 A/SLavage NS KLO DegeneraVvelesionsonotherjointsurfaces,otherintra-arVcular

pathology,radiographiclossofjointspace,previousoperaVon,

steroidinjecVonforanyreason.MMTorVbial

degeneraVon.

NA N OM=Binaryself-describedpainpresence/absence&ModifiedLysholm.Power>0.8.

FavouredA/Sat1&5years

4 Moseley

etal5

2002

TricompartmentalOA

APM,

Chondroplasty,

<75years,moderateKneepainthathadfailed6months

medicalmanagementwithVASPainScore>3,failedmedicalMxanddiagnosisofOAbased

onACRdefiniVons

XR 180 Shamor

Lavage

44 KL3-4 Scoring>9byKLscoreaddiVoninthreecompartments

NA Y Threearmstudy.Inlavagegroup,

“mechanicallyimportant,unstabletears”were

debrided.Inshamgroup,jointnotentered.OM=bespokeKneeSpecificPainScale,AIMS2&SF

36PF

Nodifferenceat2yearsbetween3

groups.

5 Kirkleyet

al62008

SymptomaVcmoderatetosevereOA

Synovectomy;débridement;APM,CPY,E/Oosteophytes&

PT

Age>18yowithidiopathicorsecondaryOAKLGrade2-4.

XR&MRI

188 PT 16 KL0-4 Largemeniscaltears,buckethandletears,

priormajorkneetrauma,inflammatoryorpostinfecVousarthriVs,

deformity>5degrees,priortrauma,KL4intwo

compartments.

0% Y OM=WOMAC&SF36 Nodifferenceattwoyears.

Author&Year

PrimaryDx Rx Inclusions Ix n Control %Notenrolled

MaxXROA

JointSpecificExclusions %X-Over

PA Notes Outcome

MedialMeniscalTearRCTs1 Yimet

al122013SymptomaVchorizontaldegeneraVve

MMT

APM&PT

HorizontaldegeneraVveMedialMTonMRI&dailykneepainonthemedialsidewithmechanicalsymptoms,failednon-

surgicalMx

MRI 108 PT 30 KL0-1 Definitetrauma,ligamentdeficiency,systemicarthriVs,KL2-4andosteonecrosis,meniscalrepair,abrasionarthoplasty,

subchondraldrilling,cureqage.

2 Y Nomeniscalrepairsortotalmeniscectomyundertaken.Outcome

measures=VAS,LysholmandTegner

FavoredA/Sat3months.Nodifferenceat2years.MTpaqerndescribed.

2 Sihvonenetal12013

SymptomaVcDegeneraVve

MMTconfirmedonMRI&atAS

APM&PT

35to65y,kneepain>3monthsthatwasunresponsiveto

convenVonalconservaVvetreatmentandhadclinicalfindingsconsistentwitha

tearofthemedialmeniscus

XR&MRI

146 Shamsurgery&PT

12 KL0-1 Trauma-inducedonsetofsymptoms,lockedorrecently

lockingknee,decreasedrangeofmoVon,instability,pathology

otherthandegeneraVvekneediseaserequiringtreatment

otherthanarthroscopicparValmeniscectomy,Meniscalrepair,micro-fracturetochondral

defect,majorchondralflap,ClinicalOAbasedonACRCCR.Or

KL>1

6.6 Y Nochondroplastyundertaken.

OM=VAS,LysholmandWOMET.Blindedstudy.

MTpaqernnotdescribed.

Nodifferenceat12months.“resultsaredirectlyapplicableonlyto

paVentswithnon-traumaVcdegeneraVvemedialmeniscustears”

4 Katzetal142013

SymptomaVcDegeneraVve

MMTwithmildtomoderateOA

APM,CPY&PT

>45y&>1monthsymptoms,imagingevidenceofmild-to-moderateknee

osteoarthriVs,symptomsofthefollowing:clicking,catching,popping,givingway,painwithpivotortorque,painthatisepisodic,pain

thatisacuteandlocalizedtoonejointline),KL0-3.

XR&

MRI

330 PT 75 KL0-3 Chronicallylockedknee,KL4,clinicallysymptomaVc

chondrocalcinosis,bilateralsymptomaVcmeniscaltears,priorsurgeryonsameknee

30.2 Y SimilarimprovementinWOMACinfailedPTasAPMoncecrossedoverAPM,Treatmentsuccess

definedas>8pointimprovementonWOMACphysicalfuncVonscale.

MTpaqernnotdescribed.

Nodifferenceat12months.30%crossedovertoAPM.

Treatmentfailure25%inAPMGroupand49%inPTGroup.Sameadverse

eventsbetweengroups.

5 Herrlinetal192013

MRI-verifieddegeneraVveMMT&

radiographicAOGrade<2(Ahlback)

APM,CPY&PT

Age45-60,dailymedialpainover2-6months.

XR&

MRI

96 PT 55 Alback1

,ObBI-

IV

Historyoftrauma,OA>Alback1,RheumatoidArthriVs,Loosebodies,kneeinstability,osteochondraldefects&

tumours,TKA,priorkneesurgeryinlastyear

33 Y NodifferenceinOAprogressionnoted

between2Groups.OM=KOOS,Lysolm&VAS.

SimilarPROMsimprovementinPT&APM.MTpaqernnotdescribed.

Nodifferenceat2&5years.33%ofPTGroupcrossedoverintoAPMwithsimilarbenefittoAPMGroupandrestofPTgroupat2&5years.ThissubgrouphadsignificantlylowerPROMscoresthanrestofPT

GrouppriorAPM.6 Vermesa

netal132013

MRI-verifieddegeneraVve

medialmeniscustearandradio-

graphicosteoarthriVs

APM,CPY&PT

NontraumaVcsymptomaVckneeswithdegeneraVvelesions

medialcompartmentonMRI

MRI 120 CSI NS NS NS NS N OM=OxfordKneeScore.PostHocPowerAnalysis>

0.8(d=.0.3twotailed,p=0.05).MTpaqern

notdescribed.

Beqerscoresinsurgicalgroupat3months.Nodifferenceat12months.

Footnotes

AbbreviaVons:KOOS=KneeInjuryandOsteoarthriVsOutcomeScoreEQ5D=EuroQolPAS=PhysicalAcVvityScaleSSS=symptomsaVsfacVonscaleOA=OsteoarthriVsPT=PhysicalTherapyAS=ArthroscopicAPM=ArthroscopicParValMeniscectomyMRI=MagneVcResonanceImagingObC=OuterbridgeClassificaVon.

KL=KellengrenLawrenceOM–OutcomeMeasurePFJ=PatellofemoralJointROM=RangeofMoVonXR=Radiograph>=Lessthan<=GreaterthanPts=PaVentsMx=ManagementNS=NotstatedY=YesN=NoACRCCC=AmericanRheumatologyClinicalClassificaVonforOsteoarthriVsoftheKneePROM=PaVentRecordedOutcomeMeasures

7 Østerasetal162013

MRI-verifieddegeneraVve

MMTandradio-g=raphicOA

APM Age35-60 MRI 17 PT 12 KL0-2 ACLtears,acutetrauma,KL3-4,heamarthrosis,lockingknee

0 Y Inadequatepowerbasedonauthor’sownpoweranalysis.Outcome

measures=VAS&KOOS

Nodifferenceat3months.MTpaqernnotdescribed.

3 Gauffinetal102014

SymptomaVcMMT

APM,CPY

45-64,symptomsofMT>3monthsAhlback0PriorPT

XR,NoMRI

150 PT 2.8 Ahlbach0,KL1-2

Locked/lockingknee.RheumaVcdisease.

21.3 Y OM=KOOS,EQ5D,PAS&SSS.MTpaqernnot

described

FavoredA/Sat12months.

8 Sihvonenetal152016

SymptomaVcDegeneraVve

MMTconfirmedonMRI&atAS.Subgroupanalysis

oforiginalSihvonenetal20131paVentswithmechanical

symptoms

APM&PT

35to65y,kneepain>3monthsthatwasunresponsiveto

convenVonalconservaVvetreatmentandhadclinicalfindingsconsistentwitha

tearofthemedialmeniscuswithmechanical

symptoms

XR&MRI

69 Shamsurgery&PT

NS KL0-1 Trauma-inducedonsetofsymptoms,lockedorrecently

lockingknee,decreasedrangeofmoVon,instability,pathology

otherthandegeneraVvekneediseaserequiringtreatment

otherthanarthroscopicparValmeniscectomy,Meniscalrepair,micro-fracturetochondraldefect,meniscalrepair,majorchondralflap,ClinicalOAbased

onACRCCR.OrKL>1

2.5 N Nochondroplastyundertaken.

OM=VAS,LysholmandWOMET.Blindedstudy.

MTpaqernnotdescribed.

Nodifferenceat12months.

Authorsstate“Thissubgroupanalysisislikelytobeunderpowered…”

Posthocanalyses:ThestudyquesVonswerenotincludedaprioriasprimaryorsecondaryobjecVvesoftheoriginal

trial.

Author&Year

PrimaryDx Rx Inclusions Ix n Control %Notenrolled

MaxXROA

JointSpecificExclusions %X-Over

PA Notes Outcome

PatellofemoralPainRCT12 Kequnen

etal152012

PFJpainandsymptomslasVngatleast6months

PFJCPY

Age18–40yearsFemaleormale

SymptomslasVngatleast6months.

PFJpainduringkneeloadingphysicalacVvityorinprolongedflexion.

NA 56 PT 2% KL0 Priorkneesurgery,patelladislocaVon,OCD,Patella

tendinopathy,OsteoarthriVs,loosebodies,instability.

10 Y Outcomemeasures=Kujalascore&VAS

Nodifferenceat2&5years.

X-over=Cross-overIx=InvesVgaVonn=NumberofpaVentsCPY=Chondroplasty

CSI=CorVcosteroidinjecVonMFC=MedialFemoralCondyleRx=IntervenVonPA=PowerAnalysis

Table2:ArthroscopicKneeSurgeryRCTsInclusions&ExclusionsusingICD10Codes

ClinicalDiagnosesIncludedinRCTs

UnilateralOsteoarthri=sofKnee(9)(6)(7)M17.9OsteoarthriVsofknee,unspecifiedM17.0BilateralprimaryosteoarthriVsofkneeM17.1UnilateralprimaryosteoarthriVsofknee

Atrauma=cDegenerateTearstoMedialMeniscus(12)(1)(10)(14)(19)(22) M23.2Derangementofmeniscusduetooldtearorinjury M23.22Derangementofposteriorhornofmedialmeniscusduetooldtearorinjury M23.30Othermeniscusderangements,unspecifiedmeniscus M23.32Othermeniscusderangements,posteriorhornofmedialmeniscusPatellofemoralChondropathy(15)

M22.4Chondromalaciapatella===========================================================ClinicalDiagnosesExcludedfromRCTs*$

LockingorLockedKnee(7)(1)(10)(14) M23.40LooseBodyinKnee(21)(19)(15)M21.26Flexiondeformity,kneeM93.2OsteochondriVsdessicansM23.8OtherinternalderangementsofkneeS83.21ABucket-handletearofmedialmeniscus,currentinjury,iniValencounter(7)

S83.205AOthertearofunspecifiedmeniscus,currentinjury,unspecifiedknee,iniValencounter S83.22APeripheraltearofmedialmeniscus,currentinjury,iniValencounter S83.26APeripheraltearoflateralmeniscus,currentinjury,iniValencounter M25.669SVffnessofunspecifiedknee,notelsewhereclassifiedKneeInstability(12)(1)(19)(15) M23.60OtherspontaneousdisrupVonofunspecifiedligamentofknee M23.61OtherspontaneousdisrupVonofanteriorcruciateligamentofknee M23.62OtherspontaneousdisrupVonofposteriorcruciateligamentofkneeInternalDerangementsofthanMMT(1)(19)

M93.2OsteochondriVsdessicansM23.8OtherinternalderangementsofkneeM23.25Derangementofposteriorhornoflateralmeniscusduetooldtearorinjury

M23.26DerangementofotherlateralmeniscusduetooldtearorinjuryM23.35Othermeniscusderangements,posteriorhornoflateralmeniscusM23.23Derangementofothermedialmeniscusduetooldtearorinjury

M87.88OsteonecrosisMeniscalCysts(1) M23.0CysVcmeniscusNonOsteoarthri=sArthropathies(9)(7)(6)(12)(1)(10)(14)

M00.06StaphylococcalarthriVs,kneeM00.86ArthriVsduetootherbacteria,kneeM02.86OtherreacVvearthropathies,kneeM02.36Reiter'sdisease,kneeM05.76RheumatoidarthriVsofkneeM10.06Idiopathicgout,kneeM11.06HydroxyapaVtedeposiVondisease,kneeM12.26VillonodularsynoviVs(pigmented),knee

Trauma=cMeniscalInjury(7)(12)(1)(19)S83.2Tearofmeniscus,currentinjury S83.21ABucket-handletearofmedialmeniscus,currentinjury,iniValencounter S83.205AOthertearofunspecifiedmeniscus,currentinjury,unspecifiedknee,iniValencounter S83.22APeripheraltearofmedialmeniscus,currentinjury,iniValencounter S83.23AComplextearofmedialmeniscus,currentinjury,iniValencounter S83.24AOthertearofmedialmeniscus,currentinjury,iniValencounter S83.25ABucket-handletearoflateralmeniscus,currentinjury S83.26APeripheraltearoflateralmeniscus,currentinjury,iniValencounter S83.27AComplextearoflateralmeniscus,currentinjury,iniValencounter S83.28AOthertearoflateralmeniscus,currentinjury,iniValencounterTrauma=corSecondaryOsteoarthri=sofKnee(7)

M17.2Bilateralpost-traumaVcosteoarthriVsofkneeM17.3Unilateralpost-traumaVcosteoarthriVsofkneeM17.4OtherbilateralsecondaryosteoarthriVsofkneeM17.5OtherunilateralsecondaryosteoarthriVsofknee

MeniscalRepair(12)(1) 0SQC4ZZRepairRightKneeJoint,PercutaneousEndoscopicApproach 0SQD4ZZRepairLedKneeJoint,PercutaneousEndoscopicApproach

*”ClinicalDiagnosesExcludedfromRCTs”doesnotincludenon-traumaVcosteoarthriVsinstudieswithaprimaryclinicaldiagnosisotherthanosteoarthriVs.$DiagnosesofcondiVonsexternaltothekneejointnotincluded.OsteoarthriVsasdefinedbytheACR

Table3:RiskofBiasAssessment

RamdonSequenceGeneration

AllocationConcealment

BlindingofParticpants

BlindingofOutcome

Assessment

IncompleteOutcomeof

DataSelectiveReporting OtherBias

Merchan&Galindo1993 LowRisk Unclear HighRisk HighRisk Lowrisk Lowrisk LowriskChang1993 Unclear Unclear HighRisk HighRisk Unclear Lowrisk Lowrisk

Hubbard1996 LowRisk Lowrisk HighRisk HighRisk Unclear Unclear LowriskMoseley2002 Unclear Lowrisk Lowrisk Lowrisk HighRisk Lowrisk LowriskKirkley2008 LowRisk Unclear HighRisk HighRisk Unclear Lowrisk LowriskYim2013 Unclear LowRisk HighRisk HighRisk HighRisk Lowrisk Lowrisk

Sihvonenetal2013 Low Lowrisk Lowrisk Lowrisk Lowrisk Lowrisk LowriskGauffin2014 Unclear Lowrisk HighRisk HighRisk Low Lowrisk LowriskKatz2013 Low Lowrisk HighRisk HighRisk Low Lowrisk Lowrisk

Herrlin2013 Unclear Unclear HighRisk HighRisk Low Low LowriskVersmesan2013 Unclear Unclear HighRisk HighRisk Unclear Unclear LowriskKettunen2012 Lowrisk Lowrisk HighRisk HighRisk Unclear Lowrisk LowriskØsteras2013 Unclear Unclear HighRisk HighRisk Lowrisk Unclear Lowrisk

Sihvonenetal2016 Lowrisk Lowrisk Lowrisk Lowrisk Lowrisk HighRisk Lowrisk

Table4:ExclusionsofMedialMeniscalTearRandomisedControlledTrials

Lockingorlocked

Hxoftrauma

MeniscalRepair

Loosebodies

MajorChonralFlap

OtherNonMeniscalPathology

Yim2013 NS Yes Yes NS NS YesSihvonenetal2013 Yes Yes Yes NS Yes Yes

Gauffin2014 Yes NS NS NS NS YesKatz2013 Yes NS NS NS NS Yes

Herrlin2013 Yes Yes NS Yes NS YesVersmesan2013 NS NS NS NS NS YesØsteras2013 Yes Yes NS NS NS Yes

Sihvonenetal2016 Yes Yes Yes NS Yes Yes• NS=NotStated

Figure1: PRISMAFlowDiagram

Recordsidentifiedthroughdatabasesearching

(n=2876)

Screen

ing

Inclu

ded

Eligibility

Iden

tifica

tion

Additionalrecordsidentifiedthroughothersources

(n=11)

Recordsafterduplicatesremoved(n=2329)

Recordsscreened(n=2329)

Recordsexcluded(n=2262)

Full-textarticlesassessedforeligibility(n=67)

Full-textarticlesexcluded,withreasons(n=53)

Studiesincludedinqualitativesynthesis

(n=14)