Australian Rheumatology Association
Recommendations from the Australian Rheumatology Association on arthroscopy, ANA testing, imaging, ultrasound and anti-dsDNA antibodies. The ARA supports and educates members and other practitioners in the musculoskeletal field to enable provision of best possible management for patients. It fosters excellence in the diagnosis and management of musculoskeletal and inflammatory conditions through training, professional development, research and advocacy.
1.
Do not perform arthroscopy with lavage and/or debridement or partial meniscectomy for patients with symptomatic osteoarthritis of the knee and/or degenerate meniscal tear.
There is consistent evidence to indicate that arthroscopic lavage and/or debridement to treat people for symptomatic knee osteoarthritis, and/or partial meniscectomy for patients with a degenerate meniscal tear (with or without underlying osteoarthritis), is no more effective than placebo surgery or non-operative alternatives.
There appears to be a high rate of conversion from knee arthroscopy to total knee arthroplasty, which rises with increased age, further suggesting arthroscopic surgery should be avoided in people over the age of 50 years. Additionally, arthroscopy is associated with peri- and post-operative risks and considerable cost.
Supporting evidence
- Buchbinder R, Richards B, Harris I. Knee osteoarthritis and role for surgical intervention: lessons learned from randomized clinical trials and population-based cohorts. Curr Opin Rheumatol 2014; 26:138-44.
- Fedorka CJ, Cerynik DL, Tauberg B, et al. The relationship between knee arthroscopy and arthroplasty in patients under 65 years of age. J Arthroplasty 2014; 29:335-38.
- Khan M, Evaniew N, Bedi A, et al. Arthroscopic surgery for degenerative tears of the meniscus: a systematic review and meta-analysis. CMAJ 2014; 186:1057-64.
- Katz JN, Brophy RH, Chaisson CE, et al. Surgery versus physical therapy for a meniscal tear and osteoarthritis. N Engl J Med 2013; 368:1675-84.
- Sihvonen R, Paavola M, Malmivaara A, et al. Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. N Engl J Med 2013; 369:2515-24.
- Thorlund JB, Juhl CB, Roos EM, et al. Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms. BMJ 2015; 350:h2747.
- Wai EK, Kreder HJ, Williams JI. Arthroscopic débridement of the knee for osteoarthritis in patients fifty years of age or older: utilization and outcomes in the Province of Ontario. J Bone Joint Surg Am 2002; 84-A:17-22.
How this list was made
An ARA Evolve working group comprising 19 rheumatologists and 3 advanced rheumatology trainees was established after a call for interest. The group agreed that items should be included if they were either primarily a rheumatologist issue or an issue that rheumatologists should advocate for on behalf of their patients.
A preliminary list of low-value clinical practices was created based upon the working group’s clinical experiences, as well as consideration of potentially relevant items identified from a review of other lists generated. This list was refined into 12 items and small teams for each topic were formed to review the evidence pertaining to these items and their relevance to Australian healthcare.
Brief summaries of the evidence were written based on NHMRC evidence review standards. An anonymous online survey was created based on these summaries and all ordinary (356 rheumatologists) and associate (72 rheumatology trainees) ARA members were invited to participate. Survey participants were asked to select the five recommendations for which they considered the evidence to be the strongest. The survey attracted a 50% response rate and based on its results, the ARA top five recommendations were formulated.
- 1 Do not perform arthroscopy with lavage and/or debridement or partial meniscectomy for patients with symptomatic osteoarthritis of the knee and/or degenerate meniscal tear.
- 2 Do not order antinuclear antibody (ANA) testing without symptoms and/or signs suggestive of a systemic rheumatic disease.
- 3 Do not undertake imaging for low back pain in patients without indications of a serious underlying condition.
- 4 Do not use ultrasound guidance to perform injections into the subacromial space as it provides no additional benefit in comparison to landmark-guided injection.
- 5 Do not order anti-double stranded (ds) DNA antibodies in ANA negative patients unless clinical suspicion of systemic lupus erythematosus (SLE) remains high.