Are you familiar with your meniscus? Or menisci, to be more precise? The term most often refers to the two pieces of cartilage sandwiched between the femur and the tibia inside your knee joint, and for some they are troublesome indeed. That's because they are prone to tear, either traumatically or as a result of wear and tear, and the usual method for dealing with that is to arthroscopically clean up the frayed parts, often in conjunction with or following other types of management such as steroid injections, physical therapy, and weight loss. Now comes a study published in the New England Journal of Medicine that Rick and I discuss on PodMed this week showing no benefit to surgery. As I rather sarcastically remark to Rick, surprise!
The study took place in Finland, where such studies can be undertaken because there's less threat of litigation, in a modest 146 patients. All of the subjects were between 35 and 65 years of age, had no evidence of osteoarthritis in the knee joint, but did have symptoms consistent with a tear in the medical meniscus, and who did not respond over three months duration to conservative conventional treatment. MRI was performed on all participants to confirm the presence of a tear; final confirmation was performed at arthroscopy. At arthroscopy, patients were randomized to either partial meniscectomy or elaborate sham surgery, completely simulating the meniscectomy without actually removing tissue. Patients were blinded to their assignment, as were all providers outside of the surgeon and OR staff.
Study subjects were followed for 12 months with a primary outcome measure of knee pain and a couple of other measures, including quality of life. Here's what the authors write, "Although marked improvement from baseline to 12 months was seen in the three primary outcomes in both study groups, there were no significant between-group differences in the change from baseline to 12 months in any of these measures." Well. Guess that sums it up nicely, and fits well with much of the data from numerous studies demonstrating clearly that surgical interventions for a variety of conditions are not superior to time in pain reduction or improving function. The caveat must be emphasized however, that all subjects in this study underwent a graded exercise program following their procedure and this no doubt improved function and stabilization of the knee joint.
A few statistics are worth repeating here: partial arthroscopic meniscectomy is the most common orthopedic procedure performed in the United States, with an annual outlay of direct medical costs of approximately $4 billion dollars. In this era of cost containment the procedure is clearly worth scrutinizing for efficacy. As with so many conditions people develop, prevention is also worth a close look: would more regular physical activity and weight control reduce the number of folks who would develop this condition to begin with? For now, Rick and I agree, it's worth advocating for the 'tincture of time.'
Other topics this week include eating nuts during pregnancy in JAMA Pediatrics, BRCA screening recommendations in Annals of Internal Medicine, and dietary supplements and liver disease, in the New York Times. Until next week, y'all live well.