- Email: [email protected]
Nonoperative Management of Degenerative Meniscus Tears Is Worth a Try
Journal Pre-proof Nonoperative Management of Degenerative Meniscus Tears is Worth a Try James H. Lubowitz, M.D, Editor-in-Chief, Jefferson C. Brand, M.D, Assistant Editor-inChief, Michael J. Rossi, M.D., M.S, Assistant Editor-in-Chief PII:
S0749-8063(19)31169-7
DOI:
https://doi.org/10.1016/j.arthro.2019.11.128
Reference:
YJARS 56707
To appear in:
Arthroscopy: The Journal of Arthroscopic and Related Surgery
Received Date: 26 November 2019 Accepted Date: 26 November 2019
Please cite this article as: Lubowitz JH, Brand JC, Rossi MJ, Nonoperative Management of Degenerative Meniscus Tears is Worth a Try, Arthroscopy: The Journal of Arthroscopic and Related Surgery (2020), doi: https://doi.org/10.1016/j.arthro.2019.11.128. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier on behalf of the Arthroscopy Association of North America
Editorial Nonoperative Management of Degenerative Meniscus Tears is Worth a Try 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.1 included patients with degenerative meniscus tears plus osteoarthritis. Katz et al. found no significant difference between arthroscopy and physical therapy, and also 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,”1 the outcomes of these surgically treated patients were, paradoxically, reported in the physical therapy group. Additional physical therapy (PT) patients probably required arthroscopy after 6 months. In contrast, it is impossible for surgery patients to
“crossover”1 to the physical therapy group. Obviously, if a trial of PT doesn’t 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.”2 (As an addendum, Dr. Katz was quoted in the Times article,2 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 in this issue of substantial interest. First though, following up on our 2018 Editorial, “Expert Opinion Is Necessary: Delphi Panel Methodology Facilitates a Scientific Approach to Consensus,”3 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.”4 Then, in Editorial Commentary, Jeffery Katz shares his content expertise and puts Hohmann et al. in considered context.5 Among many interesting points, Katz broadens our understanding by advising that expanding future sources of expert input could result in a broader and more comprehensive perspective. Investigate the article. Explore the commentary.
Time, like water under a bridge, also broadens our view. Looking back at their 2013 study,1 Katz et al. faced some reproach for their findings regarding meniscus tear treatment. In retrospect, and to their credit, the work of Katz and others1,6-9 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.4 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. James H. Lubowitz, M.D. Editor-in-Chief Jefferson C. Brand, M.D. Assistant Editor-in-Chief Michael J. Rossi, M.D., M.S. Assistant Editor-in-Chief
REFERENCES
1. Katz JN, Brophy RH, Chaisson CE, et al. Surgery versus physical therapy for a meniscal tear and osteoarthritis. N Engl J Med 2013;368:1675-1684. 2. Kolata G. Why ‘useless’ surgery is still popular. New York Times August 3, 2016. Accessed November 16, 2019. Available at: https://www.nytimes.com/2016/08/04/upshot/the-right-to-know-that-an-operationis-next-to-useless.html. 3. Hohmann E, Brand JC, Rossi MJ, Lubowitz JH. Expert opinion is necessary: Delphi panel methodology facilitates a scientific approach to consensus. Arthroscopy 2018;34:349-351. 4. Hohmann E, Richard Angelo R, Arciero R, et al. Degenerative meniscus lesions: An expert consensus statement using the modified Delphi technique. Arthroscopy 2020;36:XXX-XXX. 5. Katz JN. Degenerative meniscal tear: Sojourn to the oracle. Arthroscopy 2020;36:XXX-XXX. 6. Katz JN, Wright J, Spindler KP, 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. J Bone Joint Surg Am 2016;22:18901896. 7. Kise NJ, Risberg MA, 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. BMJ 2016;354:i3740.
8. Sihvonen R, Paavola M, Malmivaara A, Itälä A, Joukainen A, Nurmi H, Kalske J, Järvinen TL. Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. N Engl J Med 2013;369:2515-2524. 9. Moseley JB, O’Malley K, Petersen NJ, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med 2002;347:81-88.
S0749-8063(19)31169-7
DOI:
https://doi.org/10.1016/j.arthro.2019.11.128
Reference:
YJARS 56707
To appear in:
Arthroscopy: The Journal of Arthroscopic and Related Surgery
Received Date: 26 November 2019 Accepted Date: 26 November 2019
Please cite this article as: Lubowitz JH, Brand JC, Rossi MJ, Nonoperative Management of Degenerative Meniscus Tears is Worth a Try, Arthroscopy: The Journal of Arthroscopic and Related Surgery (2020), doi: https://doi.org/10.1016/j.arthro.2019.11.128. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier on behalf of the Arthroscopy Association of North America
Editorial Nonoperative Management of Degenerative Meniscus Tears is Worth a Try 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.1 included patients with degenerative meniscus tears plus osteoarthritis. Katz et al. found no significant difference between arthroscopy and physical therapy, and also 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,”1 the outcomes of these surgically treated patients were, paradoxically, reported in the physical therapy group. Additional physical therapy (PT) patients probably required arthroscopy after 6 months. In contrast, it is impossible for surgery patients to
“crossover”1 to the physical therapy group. Obviously, if a trial of PT doesn’t 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.”2 (As an addendum, Dr. Katz was quoted in the Times article,2 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 in this issue of substantial interest. First though, following up on our 2018 Editorial, “Expert Opinion Is Necessary: Delphi Panel Methodology Facilitates a Scientific Approach to Consensus,”3 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.”4 Then, in Editorial Commentary, Jeffery Katz shares his content expertise and puts Hohmann et al. in considered context.5 Among many interesting points, Katz broadens our understanding by advising that expanding future sources of expert input could result in a broader and more comprehensive perspective. Investigate the article. Explore the commentary.
Time, like water under a bridge, also broadens our view. Looking back at their 2013 study,1 Katz et al. faced some reproach for their findings regarding meniscus tear treatment. In retrospect, and to their credit, the work of Katz and others1,6-9 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.4 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. James H. Lubowitz, M.D. Editor-in-Chief Jefferson C. Brand, M.D. Assistant Editor-in-Chief Michael J. Rossi, M.D., M.S. Assistant Editor-in-Chief
REFERENCES
1. Katz JN, Brophy RH, Chaisson CE, et al. Surgery versus physical therapy for a meniscal tear and osteoarthritis. N Engl J Med 2013;368:1675-1684. 2. Kolata G. Why ‘useless’ surgery is still popular. New York Times August 3, 2016. Accessed November 16, 2019. Available at: https://www.nytimes.com/2016/08/04/upshot/the-right-to-know-that-an-operationis-next-to-useless.html. 3. Hohmann E, Brand JC, Rossi MJ, Lubowitz JH. Expert opinion is necessary: Delphi panel methodology facilitates a scientific approach to consensus. Arthroscopy 2018;34:349-351. 4. Hohmann E, Richard Angelo R, Arciero R, et al. Degenerative meniscus lesions: An expert consensus statement using the modified Delphi technique. Arthroscopy 2020;36:XXX-XXX. 5. Katz JN. Degenerative meniscal tear: Sojourn to the oracle. Arthroscopy 2020;36:XXX-XXX. 6. Katz JN, Wright J, Spindler KP, 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. J Bone Joint Surg Am 2016;22:18901896. 7. Kise NJ, Risberg MA, 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. BMJ 2016;354:i3740.
8. Sihvonen R, Paavola M, Malmivaara A, Itälä A, Joukainen A, Nurmi H, Kalske J, Järvinen TL. Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. N Engl J Med 2013;369:2515-2524. 9. Moseley JB, O’Malley K, Petersen NJ, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med 2002;347:81-88.