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Nonoperative Management of Degenerative Meniscus Tears Is Worth a Try

Published:December 06, 2019DOI:https://doi.org/10.1016/j.arthro.2019.11.128

      Abstract

      Clinical trials comparing arthroscopy and physical therapy for degenerative meniscal tears show no significant difference. Methodologically, these trials have flaws. Intention-to-treat analysis allows therapy patients to crossover to surgery, and outcomes of these surgically treated patients are paradoxically reported in the therapy group. In contrast, it is impossible for surgery patients to crossover. Nevertheless, initial nonoperative management of degenerative meniscal tears is worth a try.
      Clinical trials comparing arthroscopy and physical therapy for degenerative meniscal tears show no significant difference. Methodologically, these trials have flaws. That said, nonoperative management of degenerative meniscus tears is worth a try.
      The classic study by Katz et al.
      • Katz J.N.
      • Brophy R.H.
      • Chaisson C.E.
      • et al.
      Surgery versus physical therapy for a meniscal tear and osteoarthritis.
      included patients with degenerative meniscus tears plus osteoarthritis. Katz et al. found no significant difference between arthroscopy and physical therapy and found that “30% of the patients who were assigned to physical therapy alone underwent surgery within 6 months.” Because the study methods were “intention-to-treat analysis,”
      • Katz J.N.
      • Brophy R.H.
      • Chaisson C.E.
      • et al.
      Surgery versus physical therapy for a meniscal tear and osteoarthritis.
      the outcomes of these surgically treated patients were, paradoxically, reported in the physical therapy (PT) group. Additional PT patients probably required arthroscopy after 6 months. In contrast, it is impossible for surgery patients to “crossover”
      • Katz J.N.
      • Brophy R.H.
      • Chaisson C.E.
      • et al.
      Surgery versus physical therapy for a meniscal tear and osteoarthritis.
      to the physical therapy group. Obviously, if a trial of PT does not work, you can have a knee scope, but you can’t “un-have” surgery.
      The study by Katz et al. was well performed, and the conclusion was appropriately measured and qualified. Initial nonoperative management of degenerative meniscus tears is worth a try.
      What rubs us the wrong way is that interpretation of the medical literature is nuanced, and some practitioners and payers, as well as the lay press, misinterpret. To cite an example from the New York Times, and in a headline no less, the “newspaper of record” calls knee arthroscopy “Useless” with a capital “U.”
      • Kolata G.
      Why ‘Useless’ surgery is still popular.
      (As an addendum, Dr. Katz was quoted in the Times article,
      • Kolata G.
      Why ‘Useless’ surgery is still popular.
      where he clarified the nuances, but with regard to the headline, his explanations were to little avail.)
      Bearing all this in mind, we call readers attention to an article and an editorial commentary of substantial interest. First, following up on our 2018 Editorial, “Expert Opinion Is Necessary: Delphi Panel Methodology Facilitates a Scientific Approach to Consensus,”
      • Hohmann E.
      • Brand J.C.
      • Rossi M.J.
      • Lubowitz J.H.
      Expert opinion is necessary: Delphi panel methodology facilitates a scientific approach to consensus.
      Associate Editor Hohmann pulls together an authoritative panel to realize agreement in an article in the current issue, “Degenerative Meniscus Lesions: An Expert Consensus Statement Using the Modified Delphi Technique.”
      • Hohmann E.
      • Richard Angelo R.
      • Arciero R.
      • et al.
      Degenerative meniscus lesions: An expert consensus statement using the modified Delphi technique.
      Then, in Editorial Commentary, Jeffery Katz shares his content expertise and puts Hohmann et al. in considered context.
      • Katz J.N.
      Degenerative meniscal tear: Sojourn to the oracle.
      Among many interesting points, Katz broadens our understanding by advising that expanding future sources of expert input could result in a wider and more comprehensive perspective.
      Investigate the article. Explore the commentary.
      Time, like water under a bridge, also reshapes our view. Looking back at their 2013 study,
      • Katz J.N.
      • Brophy R.H.
      • Chaisson C.E.
      • et al.
      Surgery versus physical therapy for a meniscal tear and osteoarthritis.
      Katz et al. faced some reproach for their findings regarding meniscus tear treatment. In retrospect, and to their credit, the work of Katz and others
      • Katz J.N.
      • Brophy R.H.
      • Chaisson C.E.
      • et al.
      Surgery versus physical therapy for a meniscal tear and osteoarthritis.
      ,
      • Katz J.N.
      • Wright J.
      • Spindler K.P.
      • et al.
      Predictors and outcomes of crossover to surgery from physical therapy for meniscal tear and osteoarthritis: A randomized trial comparing physical therapy and surgery.
      • Kise N.J.
      • Risberg M.A.
      • Stensrud S.
      • et al.
      Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: Randomized controlled trial with two year follow-up.
      • Sihvonen R.
      • Paavola M.
      • Malmivaara A.
      • Itälä A.
      • Joukainen A.
      • Nurmi H.
      • Kalske J.
      • Järvinen T.L.
      Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear.
      • Moseley J.B.
      • O’Malley K.
      • Petersen N.J.
      • et al.
      A controlled trial of arthroscopic surgery for osteoarthritis of the knee.
      may have contributed to the highest aspiration of medical research by instigating a change in clinical practice to the benefit of patients. As Hohmann et al.
      • Hohmann E.
      • Richard Angelo R.
      • Arciero R.
      • et al.
      Degenerative meniscus lesions: An expert consensus statement using the modified Delphi technique.
      concur, not all degenerative meniscus tears cause symptoms, and when symptomatic, initial treatment should be nonoperative.
      Nonoperative management of degenerative meniscus tears is worth a try.
      As we know and as we have always known, knee arthroscopy is not a cure for osteoarthritis, nor is knee arthroscopy useless. You can’t undo surgery. Knee arthroscopy is always an option when nonsurgical treatment is ineffective.

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        Expert opinion is necessary: Delphi panel methodology facilitates a scientific approach to consensus.
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        Degenerative meniscus lesions: An expert consensus statement using the modified Delphi technique.
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