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Commentary & Perspective

Indications for Knee Arthroscopy in Patients with Osteoarthritis
Commentary on an article by Alex Gu, MD, et al.: “Comparison of Revision Risk Based on Timing of Knee Arthroscopy Prior to Total Knee
Arthroplasty”

Morgan H. Jones, MD, MPH

Total knee arthroplasty (TKA) improves the quality of life of patients with osteoarthritis and is one of the most effective procedures
in all of medicine. To help surgeons and their patients avoid adverse outcomes, multiple investigators have tried to identify
modifiable factors that predict adverse events after TKA, many of them by using large insurer databases. For example, a recent
systematic review showed that intra-articular injection of either corticosteroids or hyaluronic acid in the 90 days prior to TKA
increased the odds of periprosthetic joint infection (PJI)1.
In their study, Gu et al. examined the association between knee arthroscopy prior to TKA and adverse events following the
TKA. They show that the prevalences of revision surgery and PJI are higher in patients who had knee arthroscopy closer to the time
of subsequent TKA, and they recommend an interval of at least 36 weeks between the procedures to minimize this risk. However,
even when this guidance was followed—when TKA was performed between 36 weeks and 1 year after arthroscopy—the risk of
manipulation under anesthesia was higher. These findings are important and should impact practice, but not just by increasing the
interval between knee arthroscopy and TKA. They should make the reader consider the indications for arthroscopy for patients
with severe knee osteoarthritis in the first place.
The investigators included 130,128 patients who had TKA between 2006 and 2017, and they identified 6,105 patients (4.7%)
who had knee arthroscopy within 1 year prior to the TKA. They excluded arthroscopic procedures other than meniscectomy or
chondroplasty, and they adjusted for factors known to increase the risk of revision surgery and PJI, including age, sex, body mass
index, smoking status, and comorbidities. While the database did not record the severity of osteoarthritis in these patients, one must
assume that it was severe at the time of knee arthroscopy in many of them.
This high percentage of patients underwent knee arthroscopy prior to TKA despite randomized controlled trials
by Moseley et al. in 2002 and Kirkley et al. in 2008 showing that arthroscopy had no efficacy for treatment of osteoarthritis
of the knee2,3. Some might argue that these patients were being treated for “mechanical symptoms,” but trials of arthroscopic
partial meniscectomy for meniscal tears and osteoarthritis usually exclude patients with radiographic evidence of severe
osteoarthritis; also, these trials showed just a small benefit from arthroscopy even in patients with mild-to-moderate
osteoarthritis4.
The article by Gu et al. adds to the body of work that identifies modifiable risk factors for preventing complications after TKA
and should encourage clinicians to postpone TKA in patients who have recently had knee arthroscopy. In addition, the high rate of
knee arthroscopy prior to TKA should provide clinicians with another reminder of the importance of avoiding knee arthroscopy in
patients with severe osteoarthritis.
Morgan H. Jones, MD, MPH1
1
Cleveland Clinic Sports Medicine, Cleveland, Ohio
Email address: JONESM7@ccf.org

ORCID iD for M.H. Jones: 0000-0002-5466-0624

Disclosure: The author indicated that no external funding was received for any aspect of this work. On the Disclosure of Potential Conflicts of Interest form, which
is provided with the online version of the article, the author checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena
outside the submitted work (http://links.lww.com/JBJS/G363).

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References
1. Richardson SS, Schairer WW, Sculco TP, Sculco PK. Comparison of infection risk with corticosteroid or hyaluronic acid injection prior to total knee arthroplasty. J Bone Joint
Surg Am. 2019 Jan 16;101(2):112-8.
2. Moseley JB, O’Malley K, Petersen NJ, Menke TJ, Brody BA, Kuykendall DH, Hollingsworth JC, Ashton CM, Wray NP. A controlled trial of arthroscopic surgery for osteoarthritis
of the knee. N Engl J Med. 2002 Jul 11;347(2):81-8.
3. Kirkley A, Birmingham TB, Litchfield RB, Giffin JR, Willits KR, Wong CJ, Feagan BG, Donner A, Griffin SH, D’Ascanio LM, Pope JE, Fowler PJ. A randomized trial of arthroscopic
surgery for osteoarthritis of the knee. N Engl J Med. 2008 Sep 11;359(11):1097-107.
4. Brignardello-Petersen R, Guyatt GH, Buchbinder R, Poolman RW, Schandelmaier S, Chang Y, Sadeghirad B, Evaniew N, Vandvik PO. Knee arthroscopy versus conservative
management in patients with degenerative knee disease: a systematic review. BMJ Open. 2017 May 11;7(5):e016114.