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Large Joints Feature

Knee Scope / Courtesy: FXRX Orthopaedics & Bracing
Knee Scope / Courtesy: FXRX Orthopaedics & Bracing

Sham Surgery as Good as Partial Meniscectomy

Walter Eisner • Fri, December 27th, 2013

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Sham surgery is just as effective as an arthroscopic partial meniscectomy in diminishing knee pain.

That’s the result of a trial from the University of Helsinki, Finland involving 146 patients reported in the December 16, 2013 issue of the New England Journal of Medicine (NEJM). None of the patients had knee osteoarthritis but had symptoms of a degenerative medial meniscus tear. The outcomes after arthroscopic partial meniscectomy were no better than those after a sham surgical procedure.

The experiment involved volunteers whose knee pain appeared to be caused by wear and tear of the meniscus. After 12 months, the average improvement among the people who received real surgery and those who got the sham surgery was essentially the same, reported the research team, and led by Teppo Jarvinen, M.D., Ph.D.

There was no significant improvement in knee pain after exercise and no sizable improvement in the likelihood that a patient would require subsequent knee surgery.

However, according to Craig Bennett, M.D., chief of sports medicine at the University of Maryland Medical Center, the findings should not be over-generalized. One problem, he told Reuters Health in a telephone interview, is that sham surgery is, in fact, a surgical procedure with potential benefit.

People with knee pain who seem to be candidates for meniscal repair may be suffering because of debris in a swollen knee joint. “If you scope the knee (without touching the cushion), that will often help even if you don’t completely address the torn meniscus issue,” he said.

The researchers conducted a multicenter, randomized, double-blind, sham-controlled trial in the patients 35 to 65 years of age who had knee symptoms consistent with a degenerative medial meniscus tear and no knee osteoarthritis. Patients were randomly assigned to arthroscopic partial meniscectomy or sham surgery.

The primary outcomes were changes in the Lysholm and Western Ontario Meniscal Evaluation Tool (WOMET) scores (each ranging from 0 to 100, with lower scores indicating more severe symptoms) and in knee pain after exercise (rated on a scale from 0 to 10, with 0 denoting no pain) at 12 months after the procedure.

In the intention-to-treat analysis, according to the NEJM article, there were no significant between-group differences in the change from baseline to 12 months in any primary outcome. The mean changes (improvements) in the primary outcome measures were as follows:

  • Lysholm score, 21.7 points in the partial-meniscectomy group as compared with 23.3 points in the sham-surgery group (between-group difference, −1.6 points; 95% confidence interval [CI], −7.2 to 4.0);
  • WOMET score, 24.6 and 27.1 points, respectively (between-group difference, −2.5 points; 95% CI, −9.2 to 4.1); and score for knee pain after exercise, 3.1 and 3.3 points, respectively (between-group difference, −0.1; 95% CI, −0.9 to 0.7).

There were no significant differences between groups in the number of patients who required subsequent knee surgery (two in the partial-meniscectomy group and five in the sham-surgery group) or serious adverse events (one and zero, respectively).

Because about 700,000 such surgeries are done in the U.S. each year at a cost of $4 billion, the new findings “will not be welcomed with open arms,” Dr. Jarvinen predicted in a phone interview reported by Reuters.

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One Response to “Sham Surgery as Good as Partial Meniscectomy”

  1. http://www.sfexaminer.com/sanfrancisco/surgery-and-physical-therapy-important-in-meniscus-injury-recovery/Content?oid=2664674

    Recently, a comparative study compared sham knee surgery to a partial resection of the meniscus in 45- to 60-year-old people and noted no difference at one year. In other words, the study seems to suggest that people who just thought they had experienced arthroscopic knee surgery fared just as well as the people who really did have the surgery. If this is the case, you may well be asking yourself: “Is this particular procedure necessary?” If you’ve had this procedure done yourself, how do you know if it really worked or if it was all a placebo?
    The first thing to clarify is that the subgroup of people who volunteered to take part in this study did not experience an injury that resulted in an acute meniscus tear. Their meniscus damage was the result of wear and tear over a period of time. Second and more importantly, the fact is that physical therapy alone helps all patients with knee injuries for some period of time. So it is not surprising to me that these patients all seem to be doing well after a year. The difference comes later.

    Unfortunately, the data is overwhelming that even small losses of meniscus tissue lead to big changes in force concentration on the tibia (shin bone) and eventually arthritis.

    So if the recent study had followed the patients longer, researchers would have realized the disservice done to the patients whose torn meniscus cartilages are ignored. The meniscus is the key shock absorber in the knee. A torn meniscus produces intermittent pain and catching in the knee. The old approach was to tell patients to live with pain until they could not stand it any longer and would eventually have to have a knee replacement.

    The new approach is based on the fact that we now have the skills to repair, regenerate and replace the meniscus cartilage. These improved techniques mean that the development of arthritis may not be a fait accompli. The knee mechanics can be restored. The patients can return to full activities without damaging the joint surfaces if the meniscus tissue is anatomically replaced.

    So what are the new techniques? If the meniscus is torn, a successful repair depends on stabilizing the tissue and bringing in a new blood supply with repair cells. Improved suture techniques and devices are now available that permit stabilizing even complex tears extending into the root of the meniscus. Growth factors and cell injections provide a stimulus to healing even in the areas without blood vessels. Collagen scaffolds are used to both re-grow the meniscus if segments are missing and to hold cells and blood clots into horizontal splits in the tissue. Partial and complete meniscus allografts (donor tissue) are used to replace the meniscus in pristine knees and even in the setting of advanced arthritis. The new meniscus provides a pain relieving shock absorber permitting the running and impact sports that artificial knees do not allow.

    For my patients, I always use physical therapy to optimize the outcome of a knee injury. But I recommend surgery when I know that it will help avoid arthritis and other knee problems in the future. The long-term results count. So when you hear press reports that meniscus surgery is no better than physical therapy alone, think about it; evolution preserved the key meniscus structure for a reason, without its full structure, the knee degrades and life does, too.

    Dr. Kevin R. Stone is an orthopedic surgeon at The Stone Clinic and chairman of the Stone Research Foundation in San Francisco. He pioneers advanced orthopedic surgical and rehabilitation techniques to repair, regenerate and replace damaged cartilage and ligaments. For more info, visit http://www.stoneclinic.com.

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