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

Related Posts:

Sihvonen R, Paavola M, Malmivaara A, Itälä A, Joukainen A, Nurmi H, Kalske J, Järvinen TL, & Finnish Degenerative Meniscal Lesion Study (FIDELITY) Group (2013). Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. The New England Journal of Medicine, 369 (26), 2515-24 PMID: 24369076