Arthroscopic Partial Menisectomy versus Sham Surgery for a Degenerative Meniscal Tear
Sihvonen R, Paavola M, Malmivaara A, Itala A, Joukainen A, Nurmi H, Kalske J, & Jarvinen T. The New England Journal of Medicine 369;26. December 26, 2013.
Take Home Message: Patients aged 35 to 65 with a degenerative medial meniscus tear but no radiographic knee osteoarthritis report similar improvements in knee symptoms and quality of life after arthroscopic meniscectomy or placebo surgery.
Within the past 15 years, there has been a steady decline in the use of arthroscopic surgical procedures for the treatment of knee osteoarthritis. Two independent studies conducted by Kirkley et al and Moseley et al have been credited for this trend. These studies suggested that arthroscopic intervention of knee osteoarthritis with or without meniscal pathology is not clinically efficacious, but yet the number of arthroscopic partial meniscectomies has increased by 50% over the past 15 years. The authors of this randomized clinical trial evaluated if arthroscopic surgery would be beneficial among patients with a degenerative medial meniscus tear but no radiographic knee osteoarthritis. The authors conducted a multicenter, randomized, double-blind, placebo-controlled trial with 146 participants who were 35 to 65 years of age, had knee pain (duration: 3 months to 4 years) that was most consistent with a degenerative medial meniscus tear, and had no radiographic evidence of knee osteoarthritis. The orthopaedic surgeon confirmed the presence of a degenerative meniscus tear during the arthroscopy. The authors randomly assigned the participants to arthroscopic partial meniscectomy or sham arthroscopic surgery. The participants reported their outcomes at baseline and 2, 6, and 12 months after surgery via changes in knee symptoms (Lysholm), quality of life (Western Ontario Meniscal Evaluation Tool [WOMET]), and knee pain after exercise on a visual analog scale 0 to 10 (0 denoting the absence of pain). While both groups improved in all three outcome measures the authors found no differences between the groups between baseline and 12 months: average Lysholm score change, 21.7 points in the partial-menisectomy group vs. 23.3 points in the sham-surgery group; average WOMET score change, 24.6 and 27.1 points respectively; and average change in knee pain after exercise, 3.1 and 3.3 points respectively.
With the Affordable Care Act (ACA) in its infancy and the high cost of medical care coming under increasing scrutiny, a study such as this could be cited by policymakers when attempting to reduce unnecessary medical procedures and their attendant medical costs. The intent of this study was to dispel the notion that arthroscopic intervention is an efficacious treatment approach to degenerative medial meniscal tears. As noted above, the results of earlier studies by Moseley and Kirkley independently refute the benefits of arthroscopic intervention for knee osteoarthritis. This was the first sham surgery trial that attempted to determine if arthroscopic intervention for a degenerative meniscus tear in the absence of radiographic osteoarthritis is effective. Consensus opinion amongst practitioners of musculoskeletal care is that patients with a meniscus tear by MRI and sharp, well-localized discomfort in the absence of arthritis are likely to benefit from arthroscopic intervention. On the other hand, patients with a meniscus tear in the setting of dull, achy discomfort and radiographic osteoarthritis generally have less than satisfactory results from arthroscopic intervention. This trial would suggest that even in the former situation, arthroscopic partial meniscectomy results in no better outcomes than sham surgery. One should also consider that in this study, evaluations were completed 12 months post-operatively. This allowance of time offered the participants an opportunity to heal possibly altering the obtained results. Introducing a third group that had no arthroscopic surgery, to serve as a control for time, would elucidate whether this influenced the outcome. This study will surely generate discussion in orthopaedic surgery circles.
Questions for Discussion: How do you decide which of patients with degenerative meniscus tears will benefit from arthroscopic partial meniscectomy? What non-operative treatment modalities do you favor in your approach to patients with degenerative mensicus tears?
Written by: Andrew W. Albano, Jr. DO and Marc I. Harwood, MD
Reviewed by: Jeffrey Driban