Ayeni, Olufemi R.

Beavis, Cole

Coady, Catherine

Getgood, Alan

Hiemstra, Laurie

Litchfield, Robert

MacDonald, Peter B.

McCormack, Robert

Mohtadi, Nicholas

Outerbridge, Ross

Sheehan, Brendan

Volesky, Monika

Whelan, Daniel

Wong, Ivan

English

Scholarship@Western

Western University Scholarship@Western Bone and Joint Institute 2-22-2018 Position Statement of the Arthroscopy Association of Canada (AAC) Concerning Arthroscopy of the Knee Joint—September 2017 Ivan Wong Laurie Hiemstra Olufemi R. Ayeni Alan Getgood Cole Beavis See next page for additional authors Follow this and additional works at: https://ir.lib.uwo.ca/boneandjointpub  Part of the Medicine and Health Sciences Commons Citation of this paper: Wong, Ivan; Hiemstra, Laurie; Ayeni, Olufemi R.; Getgood, Alan; Beavis, Cole; Volesky, Monika; Outerbridge, Ross; Sheehan, Brendan; McCormack, Robert; Litchfield, Robert; Whelan, Daniel; Mohtadi, Nicholas; Coady, Catherine; and MacDonald, Peter B., "Position Statement of the Arthroscopy Association of Canada (AAC) Concerning Arthroscopy of the Knee Joint—September 2017" (2018). Bone and Joint Institute. 1521. https://ir.lib.uwo.ca/boneandjointpub/1521 Authors Ivan Wong, Laurie Hiemstra, Olufemi R. Ayeni, Alan Getgood, Cole Beavis, Monika Volesky, Ross Outerbridge, Brendan Sheehan, Robert McCormack, Robert Litchfield, Daniel Whelan, Nicholas Mohtadi, Catherine Coady, and Peter B. MacDonald This article is available at Scholarship@Western: https://ir.lib.uwo.ca/boneandjointpub/1521 Consensus StatementPosition Statement of the ArthroscopyAssociation of Canada (AAC) ConcerningArthroscopy of the Knee Joint—September 2017Arthroscopy Association of Canada*†Keywords: knee; arthroscopy; osteoarthritisThis position statement was prepared in response toincreased attention in the media and among health author-ities as to the role of arthroscopy in knees with and withoutradiographic evidence of osteoarthritis (OA). While recog-nizing the gap between scientific evidence and clinical prac-tice, this statement is intended to outline current bestpractice guidelines, taking into consideration the availableevidence as well as the clinical knowledge of experiencedsurgeons. It is meant to be a guideline for the practice ofarthroscopy while allowing for individual decision makingby the surgeon and patient after considering all risks andbenefits of any procedure.The position of the Arthroscopy Association of Canada(AAC) is virtually identical to that of the Australian Knee Soci-ety2 on arthroscopic surgery of the knee and consistent withconsensus statements published in Europe,3 by the HauteAutorité de Santé of France,8 and by the Deutschen Gesell-schaft für Orthopädie und Unfallchirurgie in Germany.4POSITION STATEMENTArthroscopic debridement and/or lavage of the knee joint hasnot been shown to have any beneficial effect on the naturalhistoryofOA, nor are theseprocedures indicated as a primarytreatment in the management of OA of the knee. However,this does not preclude the judicious use of arthroscopic sur-gery when indicated to manage symptomatic coexisting dis-ease or abnormality in the presence of OA or degeneration.These abnormalities include but are not limited to thefollowing: Known or suspected septic arthritis Symptomatic meniscal tear after an appropriate trial ofnonoperative treatment Symptomatic loose bodies Locked or locking knees Meniscal tears that require repair Inflammatory arthropathy requiring synovectomy Synovial pathologic condition requiring biopsyor resection Unstable chondral pathologic condition causingmechanical symptoms As an adjunct to and in combination with other surgicalprocedures as appropriate for OA (eg, high tibial osteot-omy and patellofemoral realignment) Diagnostic arthroscopy when the diagnosis is unclear onmagnetic resonance imaging (MRI) or when MRI is notpossible and the symptoms are not of OASUMMARY OF THE LITERATURE REVIEWThis position statement is based on a systematic reviewthat was recently performed by the Australian Knee Soci-ety2 on arthroscopic surgery of the knee as well as arecently published review in the Journal of ISAKOS.17Included in this review were 10 randomized clinical trialson knee arthroscopy: 4 trials in patients with medial menis-cal tear without evidence of OA and 6 trials in patients withunderlying OA. One of the studies included in the reviewwas performed in Canada11 and is perhaps more germaneto this response and the nuances of the current Canadianhealth care system. This study included patients withmoderate to advanced arthritis on radiography and an opti-mized comprehensive nonoperative management pathwayin both groups. At 2 years, the addition of arthroscopic sur-gery was not found to provide an advantage in terms ofhealth-related quality of life in patients treated within theconfines of the Canadian health care system.*Address correspondence to Ivan Wong, MD, MACM, FRCSC,DipSportMed, Dalhousie University, 2nd Floor, Room 2106, Camp HillVeteran’s Memorial Building, 5955 Veteran’s Memorial Lane, Halifax,Nova Scotia B3H 2E1 Canada (email: iw@drivanwong.com).†All authors are listed in the Authors section at the end of this article.The authors declared that they have no conflicts of interest in theauthorship and publication of this contribution.The Orthopaedic Journal of Sports Medicine, 6(2), 2325967118756597DOI: 10.1177/2325967118756597ª The Author(s) 20181This open-access article is published and distributed under the Creative Commons Attribution - NonCommercial - No Derivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits the noncommercial use, distribution, and reproduction of the article in any medium, provided the original author and source arecredited. You may not alter, transform, or build upon this article without the permission of the Author(s). For reprints and permission queries, please visit SAGE’s website athttp://www.sagepub.com/journalsPermissions.nav.Based on the evidence reported in these studies, thefollowing conclusions can be drawn.1. In patients with moderate to severe knee OA and in theabsence of loose bodies or locking, arthroscopic debride-ment provides no improvement in medium- to long-termoutcome compared with the control intervention.11,122. For patients with a degenerative medial meniscal tearand minimal to no OA, the majority will respond to non-operative intervention and will not likely require arthro-scopic medial meniscectomy.9,10,16,18,193. A subgroup of patients (up to 30%) with degenerativeknee disease will not gain adequate symptom relief afteran initial period of nonoperative management and mayrequire surgical intervention, irrespective of their age.104. Patients who failed nonoperative management and crossedinto the surgical arm of these trials had improvementof their symptoms after knee arthroscopy.9,105. In patients with medial meniscal tears, the role ofmechanical symptoms in the decision to performarthroscopy was unclear.186. The role of arthroscopic surgery in lateral meniscaltears has not been investigated.7. While preservation of the medial and lateral meniscusby repair of the body or root is recommended, it has notbeen subjected to a randomized controlled trial.8. No study investigated the role of diagnostic arthros-copy in situations where MRI was inconclusive orunable to be performed. The value of MRI in theinvestigation of atraumatic nonlocking knee symp-toms in the presence of OA remains uncertain.The decision to proceed with arthroscopy of the knee inthe presence of OA or degeneration should be made by thetreating orthopaedic surgeon only under all of the followingconditions: After careful review of the clinical scenario: particularlythe assessment of the relative contributions of the OA,and the arthroscopically treatable pathologic condition,to the patient’s symptoms With knowledge of the relevant evidence base, as listedin this document and including any new evidence thatmay present in the future After an appropriate trial of comprehensive, nonopera-tive treatment for 6 to 9 months After thoughtful discussion with the patient about therelative merits and risks of the procedure versus ongo-ing nonoperative treatmentDEFINITION OF DEGENERATIVEMENISCAL TEARDegenerative meniscal tears typically are slowly develop-ing lesions that occur secondary to wear or attrition. Thesetears are most often atraumatic, although patients mayhave a history of minor trauma associated with the onsetof knee pain.17 Degenerative change typically occurs in thebody and posterior horn; has a complex, oblique, orhorizontal cleavage configuration; and most commonlyinvolves the medial meniscus.15 On MRI, linear intrame-niscal signal is seen communicating with the inferior, supe-rior, or free edge of the meniscal surface on 2 consecutiveslices in a horizontal or complex pattern.6 Arthroscopically,degenerative tears have complex patterns, often with a hor-izontal cleavage component.17Degenerative meniscal lesions occur frequently in thegeneral population and are often incidental findings onknee MRI. These lesions are considered a marker ofearly degenerative change in the knee and are likelyan early sign of OA.3 Radiographic imaging that demons-trates joint space narrowing also implies a high likeli-hood of a meniscal tear in the narrowed compartment.The incidence of a meniscal tear is approximately 25% inpatients aged 50 to 59 years, 35% in patients aged 60 to69 years, and 45% in patients aged 70 to 79 years. Inpatients with knee OA, the incidence is approximately75% to 95%.3COMPREHENSIVE NONOPERATIVEMANAGEMENT OF OSTEOARTHRITISThe nonoperative management of OA includes a compre-hensive multidisciplinary approach designed to reducesymptoms in the knee. The following treatments shouldbe considered and undertaken for at least 6 to 9 monthsprior to considering arthroscopy and include but are notlimited to the following: Education Activity modification Physical therapy: strength, balance, core stability Weight loss Nutraceuticals Oral medications: nonsteroidal anti-inflammatorydrugs, acetaminophen Injections: cortisone, hyaluronic acid, platelet-richplasmaThe AAC recognizes that evidence for the use of thesetreatments and modalities continues to evolve. A thoroughreview of that literature, however, is beyond the scope ofthis position statement. Given that evidence is available tosupport the use of a comprehensive nonoperative strategyfor knee OA, the AAC believes that health authoritiesshould support the provision of this nonoperative treat-ment to patients who have OA.IMAGING OF THE ATRAUMATIC PAINFUL KNEE:ROLE OF RADIOGRAPHY AND MRIPlain radiography should be used as the first-line imagingtest when atraumatic knee pain is assessed in the middle-aged or older patient. Radiographs should include posterioranterior weightbearing views at 30 of knee flexion,5 lateralviews, and patellar skyline views.MRI can be a useful adjunct to plain radiographs but israrely necessary to make a diagnosis or treatment plan2 Arthroscopy Association of Canada The Orthopaedic Journal of Sports Medicinewhen degenerative changes are present on plain radio-graphs.13 MRI should be used judiciously in conjunctionwith plain radiographs to assess for additional pathologicconditions that may correlate with a patient’s symptomsand help guide treatment.1 MRI is both sensitive and spe-cific for the detection of meniscal abnormality14 but is asso-ciated with a high rate of incidental findings in middle-agedpatients.7 The treating physician must therefore interpretthe MRI findings carefully when formulating a treatmentplan. An MRI is not a criterion for referral to an orthopaedicsurgeon or another specialist.NEED FOR FUTURE RESEARCHCanada is a leader in the field of arthroscopy and in theperformance and implementation of rigorous clinicalresearch. At this time, there is a need for the specific indi-cations for knee arthroscopy to be clearly defined withhigh-quality, methodologically sound studies. The ground-work has been laid, with studies showing that kneearthroscopy is not indicated as the first-line treatment inpatients with OA and degenerative meniscal tears.10-12However, it is important not to make sweeping general-izations about these study results as they apply to a het-erogeneous population. Treatment of each patient must beappropriately considered, taking into account the uniquecharacteristics inherent to the clinical presentation.Research studies examining outcomes of the treatmentof OA, including arthroscopy, are the building blocks thatare needed to narrow the research questions and advanceour understanding of outcomes for patients withinthe entire range of severity of knee degeneration. Thehigh crossover rate in studies comparing nonoperativetreatment with knee arthroscopy demonstrates that a sig-nificant number of patients will fail nonoperative manage-ment. Therefore, it is also necessary to determine theappropriate duration of symptoms and timeline of nonop-erative treatment prior to considering arthroscopy. Deter-mining which patients will benefit from arthroscopy aswell as predicting which patients will fail nonoperativemanagement is the next challenge facing health care prac-titioners treating OA of the knee. The exploration of alter-native nonoperative treatments of OA needs to be ongoing.Finally, appropriate funding for comprehensive manage-ment strategies needs to be implemented by healthauthorities and insurance companies.The AAC is committed to continuing to pursue anddevelop evidence-based guidelines for knee arthroscopythat are appropriate for the Canadian population.AUTHORSIvan Wong, MD, MACM, FRCSC, DipSportMed (Depart-ment of Orthopaedics, Dalhousie University, Halifax, NovaScotia, Canada); Laurie Hiemstra, MD, PhD, FRCSC(Banff Sports Medicine, Banff, Alberta, Canada); OlufemiR. Ayeni, MD, MSc, PhD, FRCSC, DipSportMed (Depart-ment of Orthopaedic Surgery, McMaster University,Hamilton, Ontario, Canada); Alan Getgood, MD, FRCS(Tr&Orth), DipSEM (Fowler-Kennedy Sport MedicineClinic, London, Ontario, Canada); Cole Beavis, MD,FRCSC, DipSportMed (Department of Surgery, Universityof Saskatchewan, Saskatoon, Saskatchewan, Canada);Monika Volesky, MDCM, FRCSC, DipSportMed (Foot andAnkle Faculty, Department of Orthopaedics, JewishGeneral Hospital, Montreal, Quebec, Canada); Ross Outer-bridge, MD, FRCSC, DipSportMed (Sage Sport Institute,Kamloops, British Columbia, Canada); Brendan Sheehan,MD, FRCSC, DipSportMed (Department of Orthopaedics,Dalhousie University, Halifax, Nova Scotia, Canada);Robert McCormack, MD, FRCSC, DipSportMed (Depart-ment of Orthopaedics, University of British Columbia,New Westminster, British Columbia, Canada); Robert Litch-field, MD, FRCSC, DipSportMed (Fowler-Kennedy SportMedicine Clinic, London, Ontario, Canada); Daniel Whelan,MD, MSc, FRCSC, DipSportMed (Department of Orthopae-dics, St Michael’s Hospital, Toronto, Ontario, Canada);Nicholas Mohtadi, MD, MSc, FRCSC, DipSportMed (Univer-sity of Calgary Sport Medicine Centre, Calgary, Alberta,Canada); Catherine Coady, MD, FRCSC (Department ofOrthopaedics, Dalhousie University, Halifax, Nova Scotia,Canada); Peter B. MacDonald, MD, FRCSC, DipSportMed(University of Manitoba, Winnipeg, Manitoba, Canada).REFERENCES1. Adelani MA, Mall NA, Brophy RH, Halstead ME, Smith MV, WrightRW. The use of MRI in evaluating knee pain in patients aged 40 yearsand older. J Am Acad Orthop Surg. 2016;24(9):653-659.2. Australian Knee Society. Position statement from the Australian KneeSociety on arthroscopic surgery of the knee, including reference to thepresence of osteoarthritis or degenerative joint disease. https://www.aoa.org.au/docs/default-source/subspecialties/aks-aoa-arthoscopy-position-statement-final-oct-2016.pdf?sfvrsn¼2. Accessed January11, 2018.3. Beaufils P, Becker R. ESSKA meniscus consensus project. http://c.ymcdn.com/sites/www.esska.org/resource/resmgr/docs/2016-meniscus-consensus-proj.pdf? hhSearchTerms¼%22meniscusþandþproject%22. Accessed January 11, 2018.4. Becker R, Buchner M, Forster J, et al. S2k Leitlinie MeniskuserkrankungMethodenreport der Deutschen Gesellschaft für Orthopädie und Unfall-chirurgie. http://www.awmf.org/uploads/tx_szleitlinien/033-006m_S2k_Meniskuserkrankungen_2015-07.pdf. Accessed January 11, 2018.5. Davies AP, Calder DA, Marshall T, Glasgow MM. Plain radiography inthe degenerate knee: a case for change. J Bone Joint Surg Br. 1999;81(4):632-635.6. De Smet AA, Tuite MJ. Use of the “two-slice-touch” rule for the MRIdiagnosis of meniscal tears. AJR Am J Roentgenol. 2006;187:911-914.7. Englund M, Guermazi A, Gale D, et al. Incidental meniscal findings onknee MRI in middle-aged and elderly persons. N Engl J Med. 2008;359(11):1108-1115.8. Haute Autorité de Santé. Prise en charge thérapeutique des lésionsméniscales et des lésions isolées du ligament croisé antérieur du genouchez l’adulte. https://www.has-sante.fr/portail/upload/docs/application/pdf/2008-07/lesions_meniscales_et_du_ligament_croise_anterieur_-_recommandations.pdf. Accessed February 15, 2018.9. Herrlin SV, Wange PO, Lapidus G, Hallander M, Werner S, Weiden-hielm L. Is arthroscopic surgery beneficial in treating non-traumatic,degenerative medial meniscal tears? A five-year follow-up. Knee SurgSports Traumatol Arthrosc. 2013;21(2):358-364.The Orthopaedic Journal of Sports Medicine AAC Knee Scope Position Statement 310. Katz JN, Brophy RH, Chaisson CE, et al. Surgery versus physicaltherapy for a meniscal tear and osteoarthritis. N Engl J Med. 2013;368(18):1675-1684.11. Kirkley A, Birmingham TB, Litchfield RB, et al. A randomized trial ofarthroscopic surgery for osteoarthritis of the knee. N Engl J Med.2008;359(11):1097-1107.12. Moseley JB, O’Malley K, Petersen NJ, et al. A controlled trial of arthro-scopic surgery for osteoarthritis of the knee. N Engl J Med. 2002;347(2):81-88.13. Petron DJ, Greis PE, Aoki SK, et al. Use of knee magnetic resonanceimaging by primary care physicians in patients aged 40 years andolder. Sports Health. 2010;2(5):385-390.14. Phelan N, Rowland P, Galvin R, O’Byrne JM. A systematic review andmeta-analysis of the diagnostic accuracy of MRI for suspected ACLand meniscal tears of the knee. Knee Surg Sports Traumatol Arthrosc.2016;24(5):1525-1539.15. Poehling GG, Ruch DS, Chabon SJ. The landscape of meniscal inju-ries. Clin Sports Med. 1990;9(3):539-549.16. Sihvonen R, Paavola M, Malmivaara A, et al. Arthroscopic partialmeniscectomy versus sham surgery for a degenerative meniscal tear.N Engl J Med. 2013;369(26):2515-2524.17. Stone JA, Salzler M, Parker DA, Becker R, Harner CD. Degenera-tive meniscus tears—assimilation of evidence and consensusstatements across three continents: state of the art. J ISAKOS.2017;2:108-119.18. Yim JH, Seon JK, Song EK, et al. A comparative study of meniscec-tomy and nonoperative treatment for degenerative horizontal tears ofthe medial meniscus. Am J Sports Med. 2013;41(7):1565-1570.19. Vermesan D, Prejbeanu R, Laitin S, et al. Arthroscopic debride-ment compared to intra-articular steroids in treating degenerativemedial meniscal tears. Eur Rev Med Pharmacol Sci. 2013;17(23):3192-3196.4 Arthroscopy Association of Canada The Orthopaedic Journal of Sports Medicine

Position Statement of the Arthroscopy Association of Canada (AAC) Concerning Arthroscopy of the Knee Joint—September 2017

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Position Statement of the Arthroscopy Association of Canada (AAC) Concerning Arthroscopy of the Knee Joint—September 2017

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