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Knee surgery no-no?

Arthroscopic surgery appears no better than nonoperative treatments in patients with degenerative meniscal tears without osteoarthritis, according to a meta-analysis in the Canadian Medical Association Journal.

The analysis included seven randomized trials in which just over 800 patients with degenerative meniscal tears and mild or no osteoarthritis were assigned to undergo either -arthroscopic meniscal debridement" or nonoperative treatment (e.g., exercise programs, steroid injections or sham surgery). Debridement refers to the medical removal of dead, damaged or infected tissue to improve the healing potential of remaining healthy tissue.

The researchers searched three medical databases for randomized controlled trials published from all the way back to January 1946 up to January 2014. They assessed risk of bias for all included studies and pooled outcomes using a random-effects model. The outcomes were based on function and pain relief, and divided into two sets, short-term (less than six months) and long-term (less than two years) data.

The pooled treatment effect of arthroscopic surgery did not show a significant or minimally important difference between treatments for long-term functional outcomes. Short-term functional outcomes between groups were significant but did not exceed the threshold for -minimally important difference." Arthroscopic surgery also did not result in a significant improvement in pain scores in the short term or in the long term.

Arthroscopic surgery therefore appeared to offer no meaningful benefit over the other treatments in terms of pain or function, either within six months or two years. The authors conclude that in this patient population, "There is moderate evidence to suggest that there is no benefit to arthroscopic meniscal debridement for degenerative meniscal tears in comparison with nonoperative or sham treatments..."

Arthroscopic surgery for degenerative meniscal tears is a commonly performed procedure, yet the role of conservative treatment for patients is not very clear. This systematic meta-analysis undermines the efficacy of arthroscopic meniscal debridement in comparison with nonoperative treatments in patients with knee pain, at least for middle-aged patients with mild or no concurrent knee osteoarthritis.

The benefits of non-surgical options like specific exercises and physical therapy are becoming increasingly known and understood. But the fact that in addition to these widely accepted treatments sham surgery fared as well as surgery is disconcerting. What not terribly long ago seemed a standard, almost inevitable option for countless athletes and recreational runners with knee problems now looks to be seriously under question. In any case, it is good to have moved firmly into an era where first-line treatment options almost always involve nonoperative management of injuries even as debilitating as meniscal tears.

CMAJ, August 25, 2014, doi: 10.1503/cmaj.140433, http://www.cmaj.ca/content/early/2014/08/25/cmaj.140433

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Publication:Running & FitNews
Geographic Code:1USA
Date:Sep 1, 2014
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