Summary of intervention
Arthroscopy of the knee is a surgical technique where a camera and instruments are inserted into the knee through small incisions, usually under general anaesthesia. Following a detailed systematic assessment of the important structures within the knee joint a surgical procedure is performed which can involve repair or resection of meniscal tissue, with or without other associated procedures such as ligament reconstruction or repair of articular cartilage lesions. The British Association for surgery of the Knee (BASK) recently published guidelines for the use of arthroscopic surgery to treat degenerate meniscal tears.
This guidance applies to adults and children.
Number of interventions 2018/19
The use of arthroscopic surgery to treat degenerate meniscal tears should follow published BASK guidelines.
Rationale for recommendation
Meniscal tears in the knee are a common finding and in many cases are not related to any significant symptoms. They are often associated with degenerative articular cartilage change and osteoarthritis within the knee. A significant number of patients who present with persistent and often mechanical symptoms within the knee have a meniscal tear, which may be noted with an MRI scan.
The vast majority of patients with a meniscal tear should be initially treated non-operatively and should not have arthroscopic meniscectomy as a firstline treatment. Non-operative treatment is highly effective with patient education using verbal and written materials, physiotherapy and weight loss interventions. Exercise should comprise both local muscle strengthening and general aerobic fitness. Paracetamol and topical NSAIDs should be firstline pharmacological pain management strategies. Many patients treated this way will improve and do not require surgery.
There are a number of occasions when arthroscopic meniscal surgery can be considered as a first-line treatment. Firstly, patients who have a locked knee need urgent assessment. If a bucket handle tear of the meniscus is present, most cases need arthroscopic repair or resection of the meniscus.
Secondly where the patient has had an acute injury and an MRI scan reveals a potentially repairable meniscus tear, an arthroscopic meniscal repair should be considered.
Where symptoms have not settled after three months of non-operative treatment an MRI scan should be considered. In these cases with an unstable meniscal tear on MRI, arthroscopic meniscal surgery may be indicated. Recent systematic review evidence has suggested that in these cases where there are persistent symptoms, there can be improvement with this procedure.
Patients considering arthroscopic knee surgery should go through a shared decision-making process and have a good understanding of the risks of surgery. The procedure is a relatively safe intervention but does carry a low a low risk of infection and deep vein thrombosis, both of which are serious complications.
Routine use of arthroscopy for degenerative knee disease, where no specific target pathology has been identified (e.g. proven meniscal tear and persistent symptoms), is not recommended. Use of arthroscopy in patients with generic degenerative knee disease and no specific target pathology has not been found to be clinically beneficial and is unlikely to be cost-effective. Using agreed guidelines for employing arthroscopic surgery to treat meniscal tear pathology and avoiding indiscriminative use will reduce unwarranted variation in clinical care.