Confused on a higher level – the haunted degenerative meniscus

Where is the evidence actually pointing? The image has been kindly provided by Rinna-Ranna.
Where is the evidence actually pointing? The image has been kindly provided by Rinna-Ranna.

One, never-ending thread on this blog seems to be the degenerative meniscus. Gauffin et al. recently published a randomized controlled trial comparing surgery vs physiotherapy with favorable results for surgery regarding pain. Could this be the turnaround for one of the most controversial, but common orthopaedic procedures?

Participants

The patients were recruited from Linköpings University hospital and the inclusion criteria were:

  • Age 45–64
  • Symptom duration more than 3 months
  • Standing X-ray with less than 50% reduction of the joint space (no OA)
  • Undergone prior physiotherapy

There were some exclusions, but in general it was a rather representative material for typical degenerative meniscal injuries.

Interventions

The physiotherapy program was basically training twice a week with little supervision. The surgery in turn was not MRI-based, but based on arthroscopic diagnostics where “a surgeon judged, according to their experience, whether a meniscal resection or any other surgical treatment was indicated”. There was no blinding.

Results

The patients with surgery had a 10 points better pain score according to the KOOS-instrument, both at the 3 and 12 month follow-up. Interestingly all the measurements, the other KOOS-scales, the EQ-5D index, and the EQ VAS, were better among those with surgery. This indicates a homogeneous improvement among those with surgery.

A few thoughts

The study resembles my own clinical experience, and it is nice to see a study that goes in the other direction. A little controversy is always good for a subject, it shows how difficult these issues are in real life settings.

My main objections are:

  • Lack of blinding – it is a pity that no blinding occurred although it does more resemble every day clinic.
  • Poor physiotherapy program – I’m not convinced that the program was top-notch. I’ve found that self-supervised programs have a rather low compliance. Although, this is probably also the case with many of my own physiotherapy referrals. Good physiotherapy is expensive, time consuming, and requires patient commitment.
  • Lack of imputation – there were some patients that were dropped simply because of failure to return the forms on time, and only 87% returned the form at 12 months. In a randomized study with only 1 year follow-up, I’m not that impressed by the rigor; it should at least have been analyzed using some imputation methodology.

Summary

A nice study that will most likely spur more (still needed) research.

H. Gauffin, S. Tagesson, A. Meunier, H. Magnusson, och J. Kvist, ”Knee arthroscopic surgery is beneficial to middle-aged patients with meniscal symptoms: a prospective, randomised, single-blinded study”, Osteoarthritis and Cartilage, vol 22, num 11, ss 1808–1816, nov 2014.

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