A study from Finland caught my attention. This study probably also caught the attention of third party reimbursers.
In this trial involving patients without knee osteoarthritis but with symptoms of a degenerative medial meniscus tear, the outcomes after arthroscopic partial meniscectomy were no better than those after a sham surgical procedure.
Approximately 700,000 arthroscopic partial meniscectomies are performed annually in the United States alone, with annual direct medical costs estimated at $4 billion. A recent randomized trial showed that arthroscopic partial meniscectomy combined with physical therapy provides no better relief of symptoms than physical therapy alone in patients with a meniscal tear plus knee osteoarthritis.
This study wanted to address patients without knee osteoarthritis. Its rationale was that arthroscopic partial meniscectomy in patients with osteoarthirits might be addressing the pathology too late.
The researchers enrolled patients 35 to 65 years of age who had knee pain (for >3 months) that was unresponsive to conventional conservative treatment and had clinical findings consistent with a tear of the medial meniscus. Patients with an obvious traumatic onset of symptoms or with knee osteoarthritis as defined with the use of clinical criteria (American College of Rheumatology) or radiographic criteria (Kellgren–Lawrence grade >1) were excluded.
Every patient had diagnostic knee arthroscopy. Half the patients also had partial meniscectomy. The other half had a “simulated” meniscectomy. The description of the simulation is fascinating:
To mimic the sensations and sounds of a true arthroscopic partial meniscectomy, the surgeon asked for all instruments, manipulated the knee as if an arthroscopic partial meniscectomy was being performed, pushed a mechanized shaver (without the blade) firmly against the patella (outside the knee), and used suction. The patient was also kept in the operating room for the amount of time required to perform an actual arthroscopic partial meniscectomy.
Both groups had significant improvements in two outcome measures at 12 months. The two primary outcomes were Lysholm knee score and knee pain after exercise. There were no significant differences between groups.
Note: Each group failed conservative management. And regardless of the technique, each group improved after the surgery – meniscectomy or sham surgery.
While some might conclude that no surgery should be performed in such patients, others will conclude the opposite. Remember, each group improved. Sham surgery, while characterized as a placebo control, is not the same as swallowing a sugar pill.
I’m certain we’ve not heard the last word on this. It will be interesting to see what third party payers say about reimbursing for arthroscopic meniscectomies.
The other question is what orthopaedic surgeons should tell patients regarding studies like this. In terms of documentation and informed consent, consideration should be given to proactively referencing the study. If there’s a complication, this advance discussion will demonstrate that the patient was informed vis a vis expectations – and that each group in the study did improve compared to baseline. And the complication rate was quite low for patients who underwent this procedure compared to expected benefit.
Sometimes the more we learn, the less we really know.