MENISCAL SURGERY FLOPS IN ANOTHER STUDY
It's the most common orthopedic procedure performed, even though studies show it does nothing
Straight Healthcare
August 2022
The meniscus is a cartilage pad in the knee that serves as a cushion between the femur and tibia bones. It may become torn through acute trauma or normal wear-and-tear (meniscal illustration). Meniscal tears can cause pain and mechanical symptoms described as popping, locking, and catching. To address these symptoms, orthopedic surgeons often perform arthroscopic surgery, where they attempt to suture or remove the torn meniscus. Because of blood supply and tear patterns, less than 10% of meniscal tears can be sewn back together (repair), and the rest are treated with excision of the damaged cartilage (meniscectomy). About one million arthroscopic meniscectomies are performed in the U.S. annually to the tune of 4 billion dollars. Given these numbers, there's no question orthopedic surgeons like the procedure, but what about the patients? Are they better off, or is the primary beneficiary the surgeon's bottom line?
To evaluate the effects of meniscal surgery, patients must be divided into those with and without accompanying osteoarthritis (OA). Arthroscopic meniscal surgery used to be a common procedure in patients with OA. Then in 2002, a study was published that compared arthroscopy to a sham procedure in patients with OA. The study found no benefit of surgery, and arthroscopy in OA patients declined rapidly. [PubMed abstract] While OA patients were getting less meniscal surgery, patients without OA were steadily getting more, which suggests it benefits younger, more active patients. This assumption has now been tested in several studies. The first and most substantial study was the FIDELITY study, which like its predecessor in OA patients, was a groundbreaking sham-controlled trial. FIDELITY randomized 146 patients with symptomatic meniscal tears to meniscectomy or sham surgery. At 12 months, there was no significant difference in pain or function outcomes. A two-year follow-up analysis also found no difference. [SH review] One critique of FIDELITY was that the average age in the study was 58 years, meaning younger active patients weren't represented. This issue was addressed in the recently published DREAM study, where 121 young adults (mean age 29 years) with meniscal tears were randomized to meniscal surgery or physical therapy. After one year, there was no significant difference between the groups for pain and function outcomes. The physical therapy group had a 26% crossover rate, but per-protocol and as-treated analyses also showed no effect. [SH review]
One argument proponents use to support arthroscopy is the theory that mechanical symptoms (e.g. locking, catching) are caused by loose or torn cartilage, which is removed during surgery. In the FIDELITY study, a post hoc analysis found no significant difference in the subgroup of patients with mechanical symptoms (N=69), and in the DREAM study, more than half the patients had mechanical symptoms at baseline.
Does meniscal surgery offer some benefit in a small subgroup of patients (e.g. elite athletes)? It's possible, but the vast majority of people should avoid this procedure.
To evaluate the effects of meniscal surgery, patients must be divided into those with and without accompanying osteoarthritis (OA). Arthroscopic meniscal surgery used to be a common procedure in patients with OA. Then in 2002, a study was published that compared arthroscopy to a sham procedure in patients with OA. The study found no benefit of surgery, and arthroscopy in OA patients declined rapidly. [PubMed abstract] While OA patients were getting less meniscal surgery, patients without OA were steadily getting more, which suggests it benefits younger, more active patients. This assumption has now been tested in several studies. The first and most substantial study was the FIDELITY study, which like its predecessor in OA patients, was a groundbreaking sham-controlled trial. FIDELITY randomized 146 patients with symptomatic meniscal tears to meniscectomy or sham surgery. At 12 months, there was no significant difference in pain or function outcomes. A two-year follow-up analysis also found no difference. [SH review] One critique of FIDELITY was that the average age in the study was 58 years, meaning younger active patients weren't represented. This issue was addressed in the recently published DREAM study, where 121 young adults (mean age 29 years) with meniscal tears were randomized to meniscal surgery or physical therapy. After one year, there was no significant difference between the groups for pain and function outcomes. The physical therapy group had a 26% crossover rate, but per-protocol and as-treated analyses also showed no effect. [SH review]
One argument proponents use to support arthroscopy is the theory that mechanical symptoms (e.g. locking, catching) are caused by loose or torn cartilage, which is removed during surgery. In the FIDELITY study, a post hoc analysis found no significant difference in the subgroup of patients with mechanical symptoms (N=69), and in the DREAM study, more than half the patients had mechanical symptoms at baseline.
Does meniscal surgery offer some benefit in a small subgroup of patients (e.g. elite athletes)? It's possible, but the vast majority of people should avoid this procedure.
