Why Surgery Isn’t Always the Best Answer for Knee Injuries
Knee injuries are in general one of the most common types of injuries we see as clinicians, the majority of these suspected to have some form of underlying meniscus pathology in nature. In the United States alone, arthroscopic partial menisectomies are the most commonly performed orthopaedic surgery with 700, 000 performed annually resulting in estimated direct medical costs of $4 billion. But is surgery the best answer to these types of injuries? Sihvonen et al. conducted a multicenter, randomized, double-blind, sham-controlled trial to compare outcomes between two groups who presented with suspected medial meniscus injuries. One group received an arthroscopic partial menisectomy, while the other group received a sham surgical procedure.
146 patients were selected for the study between the ages of 35 to 65 years old all of whom had knee symptoms consistent with a degenerative medial meniscus tear and no knee osteoarthritis. Patients were then randomly assigned to either arthroscopic partial meniscectomy or sham surgery. The surgeon asked a research nurse to open an envelope containing the study-group assignment and reveal it to the surgeon; the assignment was not revealed to the patient.
During the arthroscopic partial meniscectomy, the damaged and loose parts of the meniscus were removed. For the sham surgery, a standard arthroscopic partial meniscectomy was simulated and the patient was kept in the operating room for the amount of time required to perform an actual arthroscopic partial meniscectomy.
The primary outcomes were changes in the Lysholm and Western Ontario Meniscal Evaluation Tool (WOMET) scores and in knee pain after exercise at 12 months after the procedure. The results of the study showed that outcomes after arthroscopic partial meniscectomy were no better than those after a sham surgical procedure.
Clinical implications for us as clinicians are to encourage and promote conservative management of suspected medial meniscus injuries through both physiotherapy and exercise based treatment. Education also plays a fundamental role in recovery and can easily be done through educating patients and other health care professionals on current evidence based practices.
Sihvonen, R., Paavola, M., Malmivaara, A., Itala, A., Joukainen, A., Nurmi, H. et al, Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. N Engl J Med. 2013;369:2515–2524.