Arthroscopic Partial Meniscectomy versus Sham Surgery for a Degenerative Meniscal Tear

Sihvonen, Raine; Paavola, Mika; Malmivaara, Antti; Itälä, Ari; Joukainen, Antti; Nurmi, Heikki; Kalske, Juha; Act, Abstr

doi:10.1056/nejmoa1305189

Cited by 721 publications

(733 citation statements)

References 36 publications

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“…We are currently witnessing a notable shift in the indications for knee arthroscopy. 7 high-quality randomized controlled trials assessing the benefit of arthroscopic partial meniscectomy for patients with degenerative meniscal tears were recently published (Østerås et al 2012, Herrlin et al 2013, Katz et al 2013, Sihvonen et al 2013, Yim et al 2013, Gauffin et al 2014, Stensrud et al 2015). Only 1 of these trials (Gauffin et al 2014) provided any support for surgery of the degenerative knee.…”

Section: Discussionmentioning

confidence: 99%

Changes in rates of arthroscopy due to degenerative knee disease and traumatic meniscal tears in Finland and Sweden

et al. 2015

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Background and purposeKnee arthroscopy is commonly performed to treat degenerative knee disease symptoms and traumatic meniscal tears. We evaluated whether the recent high-quality randomized control trials not favoring arthroscopic surgery for degenerative knee disease affected the procedure incidence and trends in Finland and Sweden.Patients and methodsWe conducted a bi-national registry-based study including all adult (aged ≥18 years) inpatient and outpatient arthroscopic surgeries performed for degenerative knee disease (osteoarthritis (OA) and degenerative meniscal tears) and traumatic meniscal tears in Finland between 1997 and 2012, and in Sweden between 2001 and 2012.ResultsIn Finland, the annual number of operations was 16,389 in 1997, reached 20,432 in 2007, and declined to 15,018 in 2012. In Sweden, the number of operations was 9,944 in 2001, reached 11,711 in 2008, and declined to 8,114 in 2012. The knee arthroscopy incidence for OA was 124 per 105 person-years in 2012 in Finland and it was 51 in Sweden. The incidence of knee arthroscopies for meniscal tears coded as traumatic steadily increased in Finland from 64 per 105 person-years in 1997 to 97 per 105 person-years in 2012, but not in Sweden.InterpretationThe incidence of arthroscopies for degenerative knee disease declined after 2008 in both countries. Remarkably, the incidence of arthroscopy for degenerative knee disease and traumatic meniscal tears is 2 to 4 times higher in Finland than in Sweden. Efficient implementation of new high-quality evidence in clinical practice could reduce the number of ineffective surgeries.

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Section: Discussionmentioning

confidence: 99%

Changes in rates of arthroscopy due to degenerative knee disease and traumatic meniscal tears in Finland and Sweden

et al. 2015

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“…Several randomized controlled trials designed to evaluate the effect of arthroscopy on middle-aged patients with knee pain with or without OA have, however, not shown any beneficial effect of surgery over placebo surgery or physiotherapy. (Moseley et al 2002, Herrlin et al 2007, Kirkley et al 2008, Katz and Losina 2013, Sihvonen et al 2013, Yim et al 2013). Only 1 study has indicated a slightly better effect of knee arthroscopy with partial meniscectomy than of physiotherapy alone, but this study did not include any sham operation (so a stronger placebo effect in surgery patients cannot be excluded) (Gauffin et al 2014).…”

Section: Discussionmentioning

confidence: 99%

“…The treatment of patients with degenerative meniscal tear with minor evidence of OA has been controversial (Aaron et al 2006, Spahn et al 2006, Herrlin et al 2007, Herrlin et al 2013). However, a recent double-blind, sham-controlled study did not show any advantage over placebo arthroscopy and arthroscopic partial meniscectomy in medial atraumatic degenerative meniscus tears also in knees without radiographic OA (Sihvonen et al 2013). …”

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confidence: 99%

Knee arthroscopies: who gets them, what does the radiologist report, and what does the surgeon find?

et al. 2015

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Background and purposeSeveral randomized controlled trials have not shown any added benefit of arthroscopy over placebo surgery or physiotherapy in middle-aged patients with knee symptoms without trauma. We studied the characteristics of the knee arthroscopies performed in southern Sweden.Patients and methodsFrom the orthopedic surgical records from 2007–2009 in the Skåne region of Sweden (with a population of 1.2 million), we retrieved ICD-10 diagnostic codes and selected all 4,096 arthroscopies that were diagnosed peroperatively with code M23.2 (derangement of meniscus due to old tear or injury) or code M17 (knee osteoarthritis). We extracted information on cartilage and meniscus status at arthroscopy, and we also randomly sampled 502 of these patients from the regional archive of radiology and analyzed the preoperative prevalence of radiographic or magnetic resonance imaging (MRI)-defined osteoarthritis.Results2,165 (53%) of the 4,096 arthroscopies had the diagnostic code M23.2 or M17. In this subgroup, 1,375 cases (64%) had typical findings consistent with degenerative meniscal tear (i.e. that correspond to a degenerative meniscal tear in at least a third of all arthroscopies). Of the randomly sampled patients, the preoperative prevalence of radiological knee osteoarthritis was 46%.InterpretationThere is a discrepancy between evidence-based medicine treatment guidelines and clinical practice regarding the amount of knee arthroscopies performed in patients with symptoms of degenerative knee disease.

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“…In order to mimick the sounds, surgeons were required to talk through the procedure steps 46 , ask for instruments 47, 48 , use suction 48 or ask for a laser or other device to be activated, even though it was not used in the placebo group 49– 53 .…”

Section: Strategies Used To Maintain Blinding In Interventional Placementioning

confidence: 99%

“…Surgeons also attempted to immitate sensory cues, for example by manipulating the knee as if the actual arthroscopy were performed 48 , injecting saline to imitate tidal irrigation 14 , or by splashing saline on the knee to simulate lavage 45 . In a trial on meniscectomy, surgeons used a mechanised shaver (without the blade) pushing it firmly against the patella to simulate the sensations the patient would experience during the surgery 48 .…”

Section: Strategies Used To Maintain Blinding In Interventional Placementioning

confidence: 99%

Blinding in trials of interventional procedures is possible and worthwhile

2017

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In this paper, we have used evidence from our earlier review of surgical randomised controlled trials with a placebo arm to show that blinding in trials of interventional procedures is feasible, and that many creative methods can be used to make the active and the placebo procedure as similar as possible. We give examples of ingenious strategies used to simulate the active procedure and make the placebo control indistinguishable from the active treatment. We discuss why it is important to blind of patients, assessors, and caregivers and the types of bias that may occur in interventional trials. Finally, we describe the benefits of blinding, from the obvious ones such as avoiding bias, as well as less evident benefits such as avoiding patient drop out in the control arm.

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Arthroscopic Partial Meniscectomy versus Sham Surgery for a Degenerative Meniscal Tear

Cited by 721 publications

References 36 publications

Changes in rates of arthroscopy due to degenerative knee disease and traumatic meniscal tears in Finland and Sweden

Changes in rates of arthroscopy due to degenerative knee disease and traumatic meniscal tears in Finland and Sweden

Knee arthroscopies: who gets them, what does the radiologist report, and what does the surgeon find?

Blinding in trials of interventional procedures is possible and worthwhile

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