I have my doubts when it comes to operating a degenerative meniscus (see my previous post) and in an amazing Finnish multicenter RCT it seems that my doubts have been confirmed. Sihvonen et al. managed to randomize 146 patients to arthroscopic meniscal or sham surgery where none of the outcomes differed between the groups.
They included 35-65 years old patients with findings consistent of a meniscal tear and symptoms for > 3 months. They excluded any signs of osteoarthritis, only MRI-verified medial meniscal tears (the most common one) were included. In summary – a group commonly considered for arthroscopy.
The randomization was performed during a diagnostic arthroscopy where the MRI-findings were confirmed. The blinding was elegantly performed where the operating surgeons were only participating during surgery, thereby minimizing surgeon preference bias.
They measured knee pain after exercise, Lysholm score, and WOMET without finding any notable differences at 1 year. They also performed subgroup analysis but could not identify any benefit from surgery.
A few random thoughts
- Out of 205 patient screened ¾ actually participated and only 24 declined participation. Failure to include is often a major issue with randomized studies – if a large proportion declines participation the results may not generalize to the source population.
- Good job in getting the article into NEJM, a top-ranking journal. A pity that so few orthopaedic papers reach this high – we have so many controversial topics to share with the medical community.
- I’m thoroughly impressed by the Finnish orthopaedic community – two quality articles within the last few months, wow! (See my previous post on rotator cuff tears).
R. Sihvonen, M. Paavola, A. Malmivaara, A. Itälä, A. Joukainen, H. Nurmi, J. Kalske, and T. L. N. Järvinen, “Arthroscopic Partial Meniscectomy versus Sham Surgery for a Degenerative Meniscal Tear,” New England Journal of Medicine, vol. 369, no. 26, pp. 2515–2524, 2013.