New England Journal of Medicine Article Evaluating the Usefulness of Meniscectomy Is Flawed

doi:10.1016/j.arthro.2014.02.010

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Volume 30, Issue 5, May 2014, Pages 542-543

https://doi.org/10.1016/j.arthro.2014.02.010 Get rights and content

Abstract

A controversial article was recently published in the New England Journal of Medicine titled “Arthroscopic Partial Meniscectomy Versus Sham Surgery for a Degenerative Meniscal Tear” by Sihvonen et al. We believe that readers of this article should be careful about making sweeping generalizations regarding the study findings given several methodologic flaws inherent in the population studied. There are significant concerns regarding the generalizability of these data. The actual study sample group is exceedingly small as compared with the normal volume of meniscal surgery the authors are reported to routinely perform. The authors' definition of a sham procedure must be revisited. The authors' final conclusion that “arthroscopic partial meniscectomy is of no value” is simply not what the study found. We share the concerns that several other leading authorities have recently expressed about the societal implications of this work. Arthroscopic partial meniscectomy has revolutionized the way we are able to treat symptomatic meniscal pathology. However, this procedure, like all surgical procedures, must be properly indicated to truly benefit our patients.

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Cited by (51)

Medial Meniscus Posterior Root Tear Does Not Affect the Outcome of Medial Open-Wedge High Tibial Osteotomy
2021, Journal of Arthroplasty
Citation Excerpt :
Moreover, they suggested that realignment osteotomy could be considered as an additional treatment option in patient with varus malalignment to improve joint survival after partial meniscectomy for MMPRT [10]. Arthroscopic partial meniscectomy during MOWHTO would be helpful for reducing the posterior fallout and relieving the mechanical symptoms [8,9]. Current study showed that arthroscopic partial meniscectomy concomitant with MOWHTO in patients with MMPRT and varus malalignment provided significant pain relief and satisfactory functional outcomes in a mid-term to long-term follow-up.
This study aimed to verify whether the presence of medial meniscus posterior root tear (MMPRT) affects the clinical and radiographic outcomes of medial open-wedge high tibial osteotomy (MOWHTO) compared to the patients without MMPRT for over a midterm follow-up.
One hundred fifty-six knees were retrospectively enrolled that underwent MOWHTO and second-look arthroscopy concomitantly with a minimum 5 years of follow-up. Seventy-four knees with MMPRT (MMPRT group) were identified. Eighty-two knees with intact MMPR were assigned to another group (MMPRI group). All knees with torn medial meniscus with or without MMPRT had an arthroscopic partial meniscectomy during the MOWHTO. Clinical evaluation included range of motion, American Knee Society scores, and Western Ontario and McMaster Universities Osteoarthritis Index scores. Radiologically, the Kellgren-Lawrence grade was assessed preoperatively and at the latest follow-up. Cartilage status was also compared through the 2-stage arthroscopy according to the International Cartilage Repair Society grading.
Average age at operation was 55.8 years (range 42-67), and the average follow-up period was 82.2 months (range 60-148). There were no significant differences in clinical outcomes between the groups. Postoperative changes in Kellgren-Lawrence grade and arthroscopic cartilage status showed no significant differences between the groups. Resected MMPR was remodeled in 41.9% (31/74) of the MMPRT group through the second-look arthroscopy.
MMPRT does not affect the clinical and radiologic outcomes of MOWHTO compared to those patients without MMPRT over a mid-term follow-up.
Degenerative Meniscus Tear in Older Athletes
2020, Clinics in Sports Medicine
Degenerative tears of the posterior horn of the medial meniscus: correlation between MRI findings and outcome following intra-articular steroid/bupivacaine injection of the knee
2019, Clinical Radiology
Citation Excerpt :
Treatment options include watchful waiting, physiotherapy, medical treatment with acetaminophen and/or non-steroidal anti-inflammatory drugs [NSAIDs], intra-articular injection with corticosteroids or hyaluronic acid, arthroscopic partial meniscectomy, and ultimately total knee replacement.8,9,11 The surgical treatment of degenerative meniscal lesions is controversial.5–9 Based on favourable results from case series and anecdotal evidence, arthroscopic partial meniscectomy is a popular treatment for symptomatic meniscal lesions both with and without associated osteoarthritis12; however, randomised control trials have shown that this approach is no better than sham surgery or physical and medical therapy.13–20
To evaluate the response of symptomatic degenerative tears of the posterior horn of the medial meniscus to guided intra-articular knee steroid/bupivacaine injection and to correlate clinical outcomes with preprocedural findings at magnetic resonance imaging (MRI).
Sixty patients who had clinical and MRI evidence of a symptomatic degenerative tear of the posterior horn of the medial meniscus, isolated or accompanied by additional features of degenerative arthritis, who had failed conservative approaches (physiotherapy, non-steroidal anti-inflammatories, and 3 months rest/knee bracing) were included in the study. Patients underwent intra-articular knee steroid/bupivacaine injection and were followed clinically for a minimum of 6 months. Preprocedural MRI findings were correlated with duration of symptoms, clinical response to injection (recorded as complete, partial or no response) and duration of response to injection.
Forty-nine of 60 patients (82%) reported an improvement in symptoms following guided intra-articular knee steroid/bupivacaine injection (complete: 25 patients (42%), partial: 24 (40%) patients). Improvement was sustained in 32 of 60 patients (53%) at follow-up. Thirteen of 18 patients (72%) who had an isolated degenerative tear of the posterior horn of the medial meniscus recorded a complete resolution of symptoms. This was sustained at follow-up in 10 patients (56%).
Intra-articular steroid/bupivacaine knee joint injection reduced pain symptoms in the majority of patients (81.7%) with degenerative tears of the posterior horn of the medial meniscus, usually with a sustained response. Preprocedural MRI appearances correlate with response to injection. Patients with isolated tears are more likely to have a favourable outcome.
Are Orthopaedic Surgeons Performing Fewer Arthroscopic Partial Meniscectomies in Patients Greater Than 50 Years Old? A National Database Study
2019, Arthroscopy - Journal of Arthroscopic and Related Surgery
To report the trends in arthroscopic partial meniscectomy (APM) for degenerative meniscal tears in a large private insurance database among patients older than 50 years.
The Humana database between 2007 and 2015 was queried for this study. Patients meeting the inclusion criteria with degenerative meniscal tears who underwent APMs were identified by International Classification of Diseases, Ninth Revision codes, followed by Current Procedural Terminology codes. A linear regression analysis was performed with a significance level set at F < 0.05.
A total of 21,759 APMs were performed between 2007 and 2015 in patients older than 50 years. Normalized data for total yearly enrollment showed a significant increase in APMs performed from 2007 to 2010 (R² = 0.986, P = .007). The average percentage increase per year from 2007 to 2010 was 18.59%. However, there was a significant decrease in APMs performed from 2010 to 2015 (R² = 0.748, P = .026). The average percentage decrease per year from 2010 to 2015 was 7.74%. The percentage decrease overall from 2010 to 2015 was 71.68%. No difference in statistical significance was found when age was broken into 5-year age intervals. We found a significant difference in APM based on region (P < .001).
The rate of APMs in patients older than 50 years increased from 2007 until 2010. Since 2010, the rate of APMs in patients older than 50 years has significantly decreased. These trends are likely multifactorial. Regardless of cause, it appears that the orthopaedic surgery community is performing fewer APMs in this patient population.
Level III, retrospective database epidemiological study.
Arthroscopic debridement of the degenerative knee – Is there still a role?
2019, Asia-Pacific Journal of Sports Medicine, Arthroscopy, Rehabilitation and Technology
Citation Excerpt :
Supported by landmark articles by Mousley et al. and Kirkley et al. where they found no difference in outcomes in Mousley ‘s single blinded randomized controlled trial in 2002 comparing arthroscopic surgery versus sham surgery and again no difference in outcomes in Kirkley's randomized controlled trial in 2008 comparing arthroscopic surgery versus optimized medical and physical therapy, it may seem that the role of arthroscopic surgery in the degenerative knee is no longer justified.2,3 Interestingly, many specialists still remain convinced of the benefits of the procedure from their experience with several recent reports showing an increase in the incidence of arthroscopic knee surgery with meniscal resection in the past decade.4–11 In a randomized controlled trial by Katz et al., in 2013 comparing arthroscopic surgery versus physical therapy for symptomatic patients with meniscal tears and knee osteoarthritis, no significant difference in the frequency of adverse events was found between the groups.12
The role of arthroscopic debridement in the painful degenerative knee is controversial. Studies have shown that arthroscopic surgery for knee osteoarthritis provides no additional benefit to optimized physical and medical therapy. There are however, limited studies on the management of the subgroup of significantly symptomatic patients who remain refractory to maximal conservative treatment and are poor candidates for knee replacement surgery.
We propose that with careful patient selection, arthroscopic debridement can provide good symptomatic relief with sustained benefits in the degenerative knee.
We performed a retrospective, single-surgeon study of 180 consecutive knee arthroscopies performed in 169 patients, aged 40 years and above, who had mechanical symptoms affecting their daily lives and underwent arthroscopic debridement after failure of a minimum 2 months of optimized medical and physical therapy. Severity of the knee osteoarthritis on plain radiographs was assessed using the Kellgren-Lawrence classification.
Functional and satisfaction scores were assessed using Oxford Knee Score, Koos Knee Survey, Short Form-36, Numeric Pain Rating Scale, and questions adapted from the North American Spine Society Questionnaire.
Excellent functional outcomes and patient satisfaction were reported in the majority of patients over the follow-up timeframe of 2–8 years. The mean pre-operative Kellgren-Lawrence score was 2.02 (SD 0.580). Significant improvements compared to pre-operative scores were seen across all scoring systems tested. 90% of patients reported good to excellent results.
Arthroscopic knee debridement can provide good symptomatic relief and sustained benefits in significantly symptomatic patients with early degenerative knees who have failed conservative management. This is most useful in patients with mechanical symptoms secondary to degenerative meniscal tears or chondral flaps, and those with symptomatic patellofemoral osteoarthritis.
Arthroscopic Partial Meniscectomy Versus Physical Therapy for Degenerative Meniscus Lesions: How Robust Is the Current Evidence? A Critical Systematic Review and Qualitative Synthesis
2018, Arthroscopy - Journal of Arthroscopic and Related Surgery
The purpose of this systematic review was to investigate study quality and risk of bias for randomized trials comparing partial meniscectomy with physical therapy in middle-aged patients with degenerative meniscus tears.
A systematic review of Medline, Embase, Scopus, and Google Scholar was performed from 1990 through 2017. The inclusion criteria were at least 1 validated outcome score, and middle-aged patients (40 years and older) with a degenerative meniscus tear. Studies with a sham arm, and acute and concomitant injuries were excluded. Risk of bias was assessed with the Cochrane Risk of Bias Tool. The quality of studies was assessed with the Cochrane GRADE tool and quality assessment tool (Effective Public Health Practice Project). Publication bias was assessed by funnel plot and Egger’s test. The I² statistics was calculated a measure of statistical heterogeneity.
Six studies were included, and all were assessed as having a high risk of bias. There was no publication bias (P = .23). All studies were downgraded (low, n = 5; very low, n = 1). The Effective Public Health Practice Project assessed 1 study as strong, 2 as moderate, and 3 as weak. The overall results demonstrated moderate to low quality of the included studies. The I² statistic was 96.2%, demonstrating substantial heterogeneity between studies.
The results of this systematic review strongly suggest that there is currently no compelling evidence to support arthroscopic partial meniscectomy versus physical therapy. The studies evaluated here exhibited a high risk of bias, and the weak to moderate quality of the available studies, the small sample sizes, and the diverse study characteristics do not allow any meaningful conclusions to be drawn. Therefore, the validity of the results and conclusions of prior systematic reviews and meta-analyses must be viewed with extreme caution. The quality of the available published literature is not robust enough at this time to support claims of superiority for either alternative, and both arthroscopic partial meniscectomy or physical therapy could be considered reasonable treatment options for this condition.
Level II, systematic review of Level I and II studies.

View all citing articles on Scopus

: The authors report the following potential conflict of interest or source of funding: N.E. receives support from Arthrex. C.L. receives support from Genzyme, Ceterix, National Institutes of Health National Institute of Arthritis and Musculoskeletal and Skin Diseases. B.C. receives support from Arthrex, Zimmer, Regentis, DJ Ortho. Carticept, Regentis, Johnson & Johnson, Medipost.

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Level V EvidenceNew England Journal of Medicine Article Evaluating the Usefulness of Meniscectomy Is Flawed

Abstract

Arthroscopy

Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear

N Engl J Med

Finnish Degenerative Meniscal Lesion Study (FIDELITY): A protocol for a randomised, placebo surgery controlled trial on the efficacy of arthroscopic partial meniscectomy for patients with degenerative meniscus injury with a novel ‘RCT within-a-cohort’ study design

BMJ Open

Level V Evidence
New England Journal of Medicine Article Evaluating the Usefulness of Meniscectomy Is Flawed