Knee Surgery: No Benefit for Those With Mild Osteoarthritis

Jennifer Garcia

August 27, 2014

Arthroscopic surgery for middle-aged patients with degenerative meniscal tears and mild or no osteoarthritis provided no benefit when compared with nonoperative management, according to a new systematic review and meta-analysis. These results were published online August 25 in CMAJ.

The review included 7 randomized controlled trials that compared arthroscopic meniscal debridement with nonoperative or sham treatments. The studies included data on 805 patients (811 knees) who had knee pain secondary to degenerative meniscal tears with mild or no concurrent osteoarthritis. The mean age of the patients was 56 years.

The review authors, led by Moin Khan, MD, from the Division of Orthopedic Surgery at McMaster University, Hamilton, Ontario, Canada, used pooled standardized mean differences of study outcomes and converted these to the Knee Injury and Osteoarthritis Outcome Score for comparison. This scoring system, which evaluates patient outcomes such as pain and difficulty with activities of daily living, allowed reviewers to determine the minimal important difference (MID) among study outcomes. The MID was defined as "the smallest difference that an informed patient would perceive as important enough to justify a change in management."

Arthroscopic debridement did result in improvement in short-term function (standardized mean difference, 0.25; 95% confidence interval [CI], 0.02 - 0.48) but failed to exceed MID. Among the 5 trials that evaluated long-term function, there was no significant improvement in function (standardized mean difference, 0.07; 95% CI, −0.10 to 0.23), and outcomes "failed to exceed the threshold of patient importance based on the MID."

Among the 4 trials that evaluated short-term pain, there was no significant improvement in pain scores (mean difference, 0.20; 95% CI, −0.67 to 0.26) when compared with nonoperative management. Results were similar among the 3 trials that evaluated long-term pain (mean difference, −0.06; 95% CI, −0.28 to 0.15) when compared with nonoperative management.

"Arthroscopic surgery for degenerative meniscal tears in the setting of mild or no concurrent osteoarthritis in middle-aged patients may have little, if any, effect on short-term (< 6 mo) and long-term (< 2 yr) outcomes in comparison with nonoperative management," write Dr. Khan and colleagues.

The review authors note that all but 1 of the included trials had an uncertain to high risk for bias and that the use of MIDs may not be applicable in all settings. They note, however, that this is a supplementary tool that may be useful in determining whether a therapeutic intervention will have a meaningful clinical effect for the patient. The reviewers also acknowledge that statistical heterogeneity was low to moderate in the reviewed studies.

Nonetheless, given these findings, "[a] trial of nonoperative management should be the first-line treatment" for patients in this setting, the authors note.

When asked to comment on these findings, Frederick M. Azar, MD, president of the American Academy of Orthopedic Surgeons and chief of staff of the Campbell Clinic in Memphis, Tennessee, said: "This study will likely not have an impact on the decision making of orthopedic surgeons when considering whether or not to offer surgical treatment to a patient for a symptomatic meniscal tear because we rarely perform surgery on degenerative tears."

In addition, Dr. Azar noted various study limitations including the combination of various outcome measures in the pooled analysis, the lack of a subgroup analysis, and the fact that only 1 study was from the United States, so results may therefore not represent the heterogenous US population. The length of follow-up also raised concern with Dr. Azar, who noted that "4 of the 7 studies included in the review had follow-up less than 6 months."

In conclusion, Dr. Azar said that "arthroscopy of the knee remains a safe, minimally invasive, successful, relatively low-cost procedure," and that "the decision to offer a patient arthroscopy for a meniscal tear should be individualized."

One of the study authors has received consultancy payments from Smith & Nephew, Stryker, Amgen, Zimmer, Moximed, and Bioventus and grant support from Smith & Nephew, DePuy, Eli Lilly, and Bioventus. Dr. Azar has received royalties and financial or material support from Elsevier and owns stock in Pfizer.

CMAJ. 2014. Published online August 25, 2014. Full text

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