BOA/BASK response to media reports regarding knee arthroscopy

Articles in the Independent, Telegraph and the Daily Mail suggest that keyhole knee surgery for the middle-aged does more harm than good.

Joint statement from the British Orthopaedic Association and the British Association for Surgery of the Knee.

The Independent, Telegraph and Daily Mail all published an article this week (17th June 2015) regarding a study published in the BMJ on arthroscopic surgery for degenerative knee. We are publishing a statement, to provide our members and their patients with a background to this and a BOA and BASK perspective.

Early direct access to MRI scanning of the knee has become commonplace, believing that performance of this investigation replaces the traditional medical skills of history taking and physical examination of the patient by a clinician specialising in that field. The first investigation after an adequate history and appropriate exam should be a weight bearing x-ray of the knee in the “middle aged” group referred to in this study. If this investigation shows arthritic change then MRI scanning should not be done. If MRI scanning is performed too early in the investigative pathway then over diagnosis of meniscus lesions predominates. Very often the arthritic knee has an associated and often irrelevant meniscus tear. The MRI scan result then triggers referral to an orthopaedic surgeon with the expectation by the patient that the knee problem can be “cured” by a knee arthroscopy.

• A knee with no arthritis and an acute meniscus tear causing pain for more than six weeks (often without locking or giving way) will not settle with watchful waiting, pain killers, exercise or physiotherapy. It would be correct to offer knee arthroscopy to this group of patients regardless of their age;
• Patients with advanced bone on bone arthritis should not generally be treated with arthroscopy. They need conservative treatment and when that is no longer efficacious, joint replacement is often appropriately advised;
• The grey area is the patient with some degree of arthritis but with acute on chronic pain and evidence of mechanical symptoms due to a meniscus tear. The decision on whether to operate in that circumstance is a finely balanced clinical decision. Some patients benefit and some do not.

The patient may well not be in severe enough pain for a joint replacement so apart from a steroid injection, weight loss, analgesics and modification of lifestyle (again primary care interventions), a knee arthroscopy would be the next step.

Any operation, including arthroscopy, is not without a degree of risk and it should not be recommended lightly. Informed consent, discussing risks and benefits, always need to be discussed with the patient and the decision to do a knee arthroscopy is a joint process between the patient and surgeon.

The BOA will be addressing this issue at the Annual Congress in September where Stefan Lohmander (Lund University) is the Presidential Guest Speaker.

The full article can be downloaded here - www.bmj.com/content/350/bmj.h2747