Arthroscopy for Knee Osteoarthritis: Not Recommended
Arthroscopic surgery should NOT be performed for degenerative knee osteoarthritis, even after failed conservative management with physical therapy, weight loss, and medications. 1
Strong Recommendation Against Arthroscopy
The BMJ clinical practice guideline provides a strong recommendation against arthroscopic knee surgery in patients with degenerative knee disease, regardless of whether they have:
- Imaging evidence of osteoarthritis 1
- Meniscal tears 1
- Mechanical symptoms like clicking or "giving way" 1
- Sudden or gradual symptom onset 1
This recommendation is based on high-quality evidence showing that arthroscopy provides no clinically meaningful benefit over conservative management for pain or function. 1
Why Arthroscopy Fails in Osteoarthritis
The evidence demonstrates that arthroscopic debridement and/or partial meniscectomy:
- Does not improve pain beyond what conservative management achieves 1
- Does not improve functional outcomes 1
- Requires 2-6 weeks recovery time and at least 1-2 weeks off work 1
- Carries surgical risks without corresponding benefits 1
A 2016 landmark randomized controlled trial found that among patients with degenerative medial meniscus tears, knee arthroscopy was no better than exercise therapy alone. 1
The Only Exception: True Mechanical Locking
Arthroscopic lavage and debridement should only be considered if the patient has:
- A clear history of persistent, objective mechanical locking of the knee 1
- NOT for "gelling" (stiffness after immobility) 1
- NOT for "giving way" symptoms 1
- NOT for x-ray evidence of loose bodies alone 1
This is an extremely narrow indication and does not apply to the vast majority of osteoarthritis patients with failed conservative management.
What Should Be Done Instead
Core Treatments That Must Be Optimized First
Before considering any surgical intervention, ensure the patient has received:
Non-pharmacological interventions:
- Structured exercise therapy focusing on local muscle strengthening and general aerobic fitness 2
- Weight loss interventions if overweight or obese 2
- Patient education to counter misconceptions about inevitable progression 2
- Appropriate footwear with shock-absorbing properties 2
- Assistive devices (walking aids) to reduce joint load 2
Pharmacological management:
- Paracetamol (acetaminophen) up to 4000 mg daily as first-line 2, 3
- Topical NSAIDs before oral NSAIDs 2
- Oral NSAIDs at lowest effective dose with proton pump inhibitor gastroprotection if topical agents fail 2, 3
- Intra-articular corticosteroid injection specifically for knee pain with effusion 2
When Surgery Is Appropriate
Total knee replacement is the only definitive surgical therapy for severe osteoarthritis and should be considered when: 1
- Joint symptoms substantially affect quality of life 1
- Symptoms remain refractory to comprehensive non-surgical treatment 1
- Referral should occur before prolonged and established functional limitation develops 1
Common Pitfalls to Avoid
Do not refer for arthroscopy based on:
- Patient frustration with persistent symptoms after conservative treatment 1
- Radiographic evidence of meniscal tears in the setting of osteoarthritis 1
- Mechanical symptoms like clicking, catching, or "giving way" 1
- The belief that "cleaning out" the joint will provide relief 1
Critical distinction: A 5-year retrospective study showed arthroscopy provided symptom relief only at 1-2 years but offered no benefit in decreasing or delaying eventual total knee arthroplasty compared to conservative treatment. 4 This temporary benefit does not justify the surgical risks and recovery burden when conservative management achieves similar outcomes without surgery.