American Academy of Orthopaedic Surgeons

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Released May 15, 2020

Avoid routinely performing arthroscopy with lavage and/or debridement in patients with a primary diagnosis of symptomatic osteoarthritis of the knee.

None of the evidence we examined specifically included patients who had a primary diagnosis of meniscal tear, loose body, or other mechanical derangement, with concomitant diagnosis of osteoarthritis of the knee. The present recommendation does not apply to such patients.

There were three studies that met the inclusion criteria for this recommendation. The Kirkley et. al and Kalunian et. al studies comparing arthroscopic lavage to placebo were rated as moderate strength and the Moseley et al. study comparing arthroscopic lavage to sham arthroscopic surgery was rated as a high strength study.

Kirkley et al. reported that a large number of patients were not eligible for participation in their study (38%) largely due to the exclusion criteria of substantial knee malalignment. In some cases, patients declined participation. Kirkely et al. compared arthroscopic surgery to lavage and debridement combined with usual physical therapy and medical treatment, usual care. The authors used the pain, functional status and other symptoms subscales of the Arthritis Self-Efficacy Scale (ASES) and the McMaster-Toronto Arthritis Patient Preference Disability Questionnaire (MACTAR) at multiple time points (ranging from three months to two years). Out of 20 outcomes, only two were statistically significant in favor of surgery with lavage. Differences in AIMS pain were statistically significant at three months and differences in AIMS-Other Arthritis Symptoms subscale scores remained significant after two years. In summary, this randomized controlled trial demonstrated no benefit of arthroscopic surgery compared to physical therapy and medical treatment for osteoarthritis of the knee.

Kalunian et al. included a large number of enrolled patients from one institution with intraarticular crystals in their knee. They compared arthroscopic lavage with 3,000 ml saline to lavage with 250 ml saline. There were not any statistically significant differences in VAS and WOMAC pain scores between the two treatment groups.

The Moseley et al. study raised questions regarding its limited sampling (mostly male veterans) as well as the number of potential study participants who declined randomization into a treatment group. In this RCT, the effects of arthroscopy with debridement or lavage were not statistically significant in the vast majority of patient-oriented outcome measures for pain and function, at multiple time points from one week to two years following surgery.

Collectively all three included studies did not demonstrate clinical benefit of arthroscopic debridement or lavage. The work group also considered the potential risks to patients (anesthesia intolerance, infection, and venous thrombosis) associated with surgical intervention.

It was agreed that the lacking evidence for treatment benefit and increased risks from surgery were sufficient reasons to recommend against arthroscopic debridement and/or lavage in patients with a primary diagnosis of osteoarthritis of the knee.


These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

How The List Was Created

(1–5) The American Academy of Orthopaedic Surgeons (AAOS) routinely develops evidence-based clinical practice guidelines as valuable tools to advance the physician-patient communications process and enhance the diagnosis and treatment of musculoskeletal conditions. AAOS physician volunteer work groups develop evidence-based clinical practice guidelines to serve as an educational tool based on an assessment of the current scientific and clinical information and accepted approaches to treatment. The most recent approved clinical practice guidelines have been published in the Journal of Bone and Joint Surgery. AAOS staff, led by the medical director, conducted a review of the approved clinical practice guidelines previously developed by the work groups and selected a variety of topics frequently used in orthopaedic surgical practice. After input from the orthopaedic specialty society leaders and approval from the AAOS Presidential Leadership and Board of Directors, the final five topics were selected for this campaign. The AAOS disclosure and conflict of interest policy can be found at www.aaos.org.

(6-10) The American Academy of Orthopaedic Surgeons (AAOS) routinely develops evidence-based clinical practice guidelines as valuable tools to advance the physician-patient communications process and enhance the diagnosis and treatment of musculoskeletal conditions. AAOS physician volunteer workgroups develop evidence-based clinical practice guidelines to serve as an educational tool based on an assessment of the current scientific and clinical information and accepted approaches to treatment. AAOS staff methodologists conducted a review of the approved clinical practice guidelines previously developed by the workgroups and selected a variety of topics frequently used in orthopaedic surgical practice. After input and approval from the AAOS Committee on Evidence-Based Quality and Value, followed by the approval from the AAOS, Council on Research and Quality and AAOS Board of Directors, the final five topics were selected for this campaign. The AAOS disclosure and conflict of interest policy can be found at www.aaos.org/quality.

Sources

Kirkley A, Birmingham TB, Litchfield RB et al. A randomized trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med 2008;359(11):1097-1107. PM:18784099

Kalunian KC, Moreland LW, Klashman DJ et al. Visually-guided irrigation in patients with early knee osteoarthritis: a multicenter randomized, controlled trial. Osteoarthritis Cartilage 2000;8(6):412-418. PM:11069725

Moseley JB, O’Malley K, Petersen NJ et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med 2002;347(2):81-88. PM:12110735