11 Feb Partial Meniscectomy Doesn’t Reduce Mechanical Knee Symptoms Any Better Than Sham Procedure
MedicalResearch.com Interview with:
Dr. Teppo Järvinen
Teppo L N Järvinen MD PhD
Sports Medicine, Orthopedic Surgery, Clinical Trials
University of Helsinki, Helsinki
MedicalResearch: What is the background for this study? What are the main findings?
Dr. Järvinen: When the primary analysis of the FIDELITY trial was published in the New England Journal of Medicine (http://www.nejm.org/doi/full/10.1056/NEJMoa1305189), showing that arthroscopic partial meniscectomy (APM) is no better than sham/placebo surgery in relieving knee pain and improving knee function in patients with a degenerative meniscus tear and no knee OA, the study was met with unprecedented criticism, even hostility. The advocates of APM (which was at the time and probably still is the most common orthopedic procedure in the US and most other “western” countries) argued – despite the fact that our study only confirmed what several other high-quality RCTs had suggested – that arthroscopic partial meniscectomy is a highly beneficial procedure in the “right” patients. Among the subgroups of patients allegedly having a favourable response to APM, those experiencing “mechanical symptoms” — sensations of knee catching or locking — represented the most obvious group who would benefit from arthroscopic partial meniscectomy surgery. This assertion is plausible because knee catching or locking is believed to result from a mechanical blocking mechanism in the knee – a piece of the joint structure lodging between the articular surfaces. Because degenerative meniscal tears are very common pathologic alterations found by arthroscopy in the knee joints of patients with degenerative knee disease, trimming the torn meniscus should, in theory at least, improve the apparent mechanical derangement.
Against this background, it is somewhat unusual that no study has yet specifically tested whether arthroscopic partial meniscectomy is effective in alleviating these symptoms. Mechanical symptoms are usually thought to be a solid indication for arthroscopic knee surgery. This is what we set out to examine in our secondary analysis of our sham-surgery controlled FIDELITY trial.
Our key finding: arthroscopic partial meniscectomy (partial resection of a torn meniscus) does not reduce or alleviate mechanical symptoms any better than a sham surgical procedure.
MedicalResearch: What should clinicians and patients take away from your report?
Dr. Järvinen: As noted, mechanical symptoms have previously been attributed to a mechanical derangement. Such mechanistic (biological) rationale is actually very common in medicine. However, our findings re-iterate the need to occasionally re-examine existing theories and scrutinize them closely even if they seem so obvious that it almost feels unnecessary to study them.
MedicalResearch: What recommendations do you have for future research as a result of this study?
Dr. Järvinen: It is important to note that our analyses were done post hoc as the FIDELITY trial was not originally designed to address this question. Also, the results are only generalizable to knee catching and occasional locking (the “milder end” of the mechanical symptom spectrum), because few patients reported other types of mechanical symptoms. Given this, I urge other researchers to conduct similar, sham-surgery controlled trials designed specifically to address this question – to either corroborate or refute our findings. Having said that, I still feel that until new evidence is published, our study is by far the best answer so far on this issue and it does not support the existing practice of carrying out arthroscopic partial meniscectomy for people with a degenerative knee disease and mechanical symptoms.
Citation:
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Dr. Teppo L.N. Jarvinen (2016). Arthroscopic Partial Meniscectomy Doesn’t Reduce Mechanical Knee Symptoms Any Better Thean Sham Procedure
Last Updated on February 11, 2016 by Marie Benz MD FAAD