No significant benefit found between arthroscopic partial meniscectomy, placebo surgery

Sihvonen R, et al. Ann Rheum Dis. 2017;doi:10.1136/annrheumdis-2017-211172.

June 7, 2017

Recently published results showed patients with a degenerative meniscal tear who underwent arthroscopic partial meniscectomy had no significant benefit over placebo surgery.

“As the evidence started to mount that arthroscopic partial meniscectomy (APM), the most common orthopedic procedure, offers little more than just placebo for the patients, the frontline practitioners have consistently argued that there are certain patients more likely to benefit from APM,” Teppo L. N. Järvinen, MD, PhD, told “Those with presence of mechanical symptoms or certain meniscus tear characteristics or those who have failed initial conservative treatment have been the most commonly asserted ‘optimal candidates’ for APM. The results of our 2-year follow-up of the FIDELITY trial refute such assertions.”

Järvinen and colleagues randomly assigned 146 patients with degenerative medial meniscus tears and no knee osteoarthritis (OA) to undergo either APM or placebo surgery, in which the sounds and sensations of APM were mimicked. The between-group difference in the change from baseline in the Western Ontario Meniscal Evaluation Tool and Lysholm knee scores, as well as knee pain after exercise at 24 months after surgery, was identified as the primary outcome. Researchers included the frequency of unblinding of the treatment-group allocation, participants’ satisfaction, impression of change, return to normal activities, the incidence of serious adverse events and the presence of meniscal symptoms in clinical examination as secondary outcomes. Researchers also performed two subgroup analyses that assessed the outcomes of patients with meniscal symptoms and patients with unstable meniscus tears.

Results showed the Western Ontario Meniscal Evaluation Tool, Lysholm knee score and knee pain after exercise had no significant between-group differences in the mean changes from baseline to 24 months. Researchers also noted no statistically significant differences in any of the secondary outcomes or within the analyzed subgroups between the two groups. According to results, most patients in the APM group and placebo surgery group reported being satisfied with their outcomes. – by Casey Tingle

Disclosure: The researchers report no relevant financial disclosures.

Even with a multicenter study, it took the authors 7 years to obtain a sufficient number of cases to be included in this study. This suggests that a multitude of patient cases cannot be included and illustrates the paucity of cases with the described pathology, meaning it is seen relatively rarely in the day-to-day orthopedic practice

The value of the treatment, whether APM or conservative treatment, is therefore only applicable to a few individuals.

The 3-month delay after the onset of symptoms used in the study is the waiting period that is suggested by the European Society of Sports Traumatology, Knee Surgery & Arthroscopy (ESSKA) meniscal study group, but that is not even mentioned in the paper’s list of references.

Another key point is there are still a number of cross-over individuals who wanted surgery after they failed conservative treatment. In addition, no mention is made about the alignment of the lower legs of the patients included in the study. Radiographs were taken to illustrate the absence of OA, but no evaluation was done of limb alignment, such as with full-leg anteroposterior films. This is a major shortcoming of the clinical approach that the authors suggested for this line of “pathology.”

At any rate, recommendations by the ESSKA group suggest indeed to refrain from surgery in the first 3 months after the onset of complaints. This suggests the ESSKA-suggested approach to managing this condition is similar to what was presented in the study.

René Verdonk, MD, PhD
Orthopaedics Today Europe Editorial Board member

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