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Guideline for the management of knee and hip osteoarthritis

Recommendations

Surgical intervention

Guideline for the management of knee and hip osteoarthritis
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  3. Figures and tables
  4. Provided under licence

Last revised: 01 Jul 2018

Surgical interventions

Surgical intervention


 

Methylsulfonylmethane (MSM) – Knee and/or hip

Recommendation

We are unable to recommend either for or against the use of MSM for people with knee and/or hip OA.

Strength of recommendation

Conditional (neutral) recommendation

Quality of evidence

Very low

What is it? 

MSM is an organosulfur molecule that can be synthesised commercially from dimethylsulfoxide (DMSO). DMSO is a pungent solvent that has been used as an application for pain relief over arthritic joints. MSM has the advantage of being odourless, and can be easily taken orally in the form of a pill or a powder. The optimal dosing of MSM is not known, but 1–2 g twice a day is often offered in clinical practice. 

Rationale 

There are three trials with short study durations (12–13 weeks), and pooled data found statistically and clinically significant benefits in pain. Even larger effects were found in function, but with very serious inconsistent results and high heterogeneity across studies. One trial had a high risk of bias because of inappropriate randomisation technique; while the other had potential reporting bias (Appendix 5 of the Guideline for the management of knee and hip osteoarthritis: Technical document). The doses in the trials ranged from 1.5–6 g/day for 12 weeks. All of the studies were conducted in knee OA, so extrapolation to hip or other OA sites requires additional caution. 

The working group discussed the concerns in the literature of publication bias, effects being mostly driven by industrysponsored trials, and the overall poor quality of the positive trials. 

Harms 

The use of MSM for OA is relatively safe. Minor side effects were recorded, including gastrointestinal adverse events, fatigue and headaches; however, these were not statistically significant compared with placebo.

Arthroscopic, lavage and debridement, meniscectomy and cartilage repair – Knee

Recommendation

We do not recommend offering arthroscopic, lavage and debridement, meniscectomy and cartilage repair for people with knee osteoarthritis (OA) unless the person also has mechanical symptoms of a clinically locked knee as per Australian Knee Society’s ‘Arthroscopy position statement’.

Strength of recommendation

Strong against recommendation

Quality of evidence

Very low (lavage and debridement)
Low (meniscectomy)
Very low (cartilage repair)

What is it?

Arthroscopic surgery in people with knee OA is widely available and commonly occurs. It allows the surgeon to visualise the interior joint space. Arthroscopic joint lavage uses saline irrigation to remove particulate material, (eg cartilage fragments, calcium crystals). In arthroscopic debridement, whereby surgical instruments are used to smooth any rough articular surfaces. The goals of arthroscopic lavage and debridement are to decrease synovitis and improve joint motion. Arthroscopic meniscectomy is an outpatient, minimally invasive surgical procedure used to treat a torn meniscus cartilage in the knee.

Rationale

There is very low-quality evidence that there is no apparent benefit in terms of pain, function or quality of life (Appendix 5 of the Guideline for the management of knee and hip osteoarthritis: Technical document) for joint lavage, debridement and meniscectomy in the setting of knee OA. Arthroscopy occurs more commonly in the private hospital setting than public hospitals. It is important to note that arthroscopy rates in knee OA have been declining in the past few years.

In the context of an intervention where there is a debatable benefit, measurable costs and potentially serious harms, the working group strongly recommends against the use of arthroscopy for lavage and debridement in the setting of knee OA. The Australian Orthopaedic Association and the Knee Society position statement  strongly states that arthroscopy is not indicated for the treatment of knee OA. In the infrequent instance where exercise fails to release the locked knee, arthroscopy could be indicated.

Harms

Side effects from arthroscopic surgeries can include local pain and swelling, infection, prolonged drainage from the surgical site, bleeding into the joint, and thrombophlebitis. It is also associated with a number of potential harms, including deep venous thrombosis, premature joint replacement, and rarely, pulmonary embolism and death.

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