This manuscript reported on the surgical outcomes of 146 patients over the course of 6 years who had either an arthroscopic partial medial meniscectomy or an arthroscopic washout procedure (which the authors called a “sham surgery”). Of note is that these patients had degenerative tears and there are no patients who had any type of traumatic event which caused a meniscus tear. Therefore, this was a very rare event as noted by the fact that over the course of 6 years, at 5 different centers, there were only 146 patients that were in the study.
First, I wish to congratulate Dr. Jarvinen for putting together this study. These types of studies are particularly very difficult to assemble, especially across multiple centers and do add to knowledge about the treatment of these problems.
In order to properly evaluate this study and ascertain as to its effects on arthroscopic surgery, one needs to read it and carefully evaluate the way the patients were chosen for the study and how they were followed. First, these types of studies are extremely difficult to isolate into a specific type of patients to enroll in the study. The authors were very careful to note that these patients had degenerative meniscus tears which were not due to a specific traumatic event. In addition, these patients did not have any evidence of any significant arthritis. Of note is that their patients did note an improvement with surgery for the first 2 months and the confidence intervals would indicate there is still some overall improvement with surgery at the 6-month interval. It was only at 1 year at which point there is no difference between the arthroscopic washout and the partial meniscectomy for degenerative tears which are not due to trauma. In addition, it was carefully noted that they only looked at medial meniscus tears, and the effects of lateral meniscus tears were not specifically evaluated.
Our published studies in the past on asymptomatic patients have noted that approximately 6% of patients that are less than 40 years of age do have an asymptomatic meniscus tear on MRI scans. This percentage probably increases as patients get older. I believe that the study would indicate that many of the patients in the study did have a meniscus tear which was present for some time prior to the surgery. One could easily interpret this from the fact that there was no trauma which caused these tears in the patients in the study. Therefore, one can interpret this data in that these tears were highly likely to have been asymptomatic up to the point of presentation, probably did not have any significant flaps or pieces that were catching in the joint like those with trauma frequently do, and it would greatly explain why many of the patents were not that much different than those who had the arthroscopic washout procedure.
The study also should add to information that we know about arthroscopic washout procedures. Since this was not a true sham surgery like the Mosely study in 2002, whereby only an incision was made in the knee, it could be interpreted that a simple washout of the knee could also have some benefit in improving patients outcomes at 1 year.
Overall, the authors should be congratulated for their study, but the overall interpretation of their findings needs to be qualified with a careful analysis of their study population. Overall, their study notes that patients who have a non-traumatic medial meniscus tear who have either an arthroscopic washout or an arthroscopic partial medial meniscectomy do equally well after 1 year. The surgical patients do better initially, which may be useful in returning people back to activities sooner. It is also important to recognize that the vast majority of arthroscopic partial medial meniscectomies are performed after a traumatic event, and this study certainly does not shed any light of the outcomes for these patients, which the authors are very careful to note in their study design.
Therefore, this study does validate that patient’s who may have a seemingly asymptomatic meniscus tear should trial physical therapy, injections, unloader braces, and other modalities initially to determine if their nontraumatic meniscus tear in the face of an otherwise nonarthritic knee should undergo an arthroscopic partial medial meniscectomy.
Robert F. LaPrade, MD, PhD
THE STEADMAN CLINIC
Complex Knee & Sports Medicine Surgeon
STEADMAN-PHILIPPON RESEARCH INSTITUTE
Chief Medical Officer
Deputy Director of the Sports Medicine Fellowship Program
Director of the International Research Scholar Program