Resentment around arthroscopic surgery

Ardern and co-workers proposed five reasons which would explain the declining worldwide arthroscopic meniscectomy rates (see my previous post on this topic). Among other things they wrote:

If one cannot congratulate the funders for limiting arthroscopy, perhaps a broad-based, international consensus on the need for medical reversal was responsible? One might expect such a consensus to be driven by medical specialty societies. However, many international arthroscopy societies have done exactly the opposite—they have published consensus statements and clinical practice guidelines that endorse knee and shoulder arthroscopy for middle-aged and older patients.

Apparently this statement upset some people. An editorial was published in the KSSTA journal which can be considered a “response”. Authors of that piece write:

It therefore appears that this editorial is scientifically questionable and should even be regarded as dangerous in its form for the medical world. Authors refer to their own guideline: Moreover, we all agree that, on the basis of solid scientific studies, the first-line treatment should be non-surgical in most middle-aged and older patients. A strong message is, however, conveyed by the recommendations resulting from a large, scientifically based consensus project, which was organised by ESSKA in 2013 and published in 2017 and 2019 [2]. The publication in 2017 proposed APM in degenerative meniscal lesions in the event of the failure of initial non-surgical treatment and the persistence of mechanical symptoms. Early APM was only recommended in specific, clearly depicted and very carefully selected situations.

Here are some takes from that guideline:

What is a degenerative meniscus lesion? A degenerative meniscus lesion is a slowly developing lesion, typically involving a horizontal cleavage of the meniscus in a middle-aged or older person. Such meniscus lesions are frequent in the general population and are often incidental findings on knee MRI (Fig. 2). The pathogenesis is not fully understood.

Do degenerative meniscus lesions cause knee symptoms? There is very limited evidence that pain in the degenerative knee is directly attributable to a degenerative meniscus lesion even if the lesion is considered to be unstable.

What outcomes can be expected after arthroscopic partial meniscectomy (APM)? 1. Improvement of functional outcomes can be expected after APM (Grade A). 2. Most of the RCTs found no difference in terms of clinical outcomes after surgery compared to non-operative treatment (Grade A). 3. When surgical treatment is proposed after a non-operative treatment failure, APM will result in similar but not superior results than successful non-operative treatment (Grade A).

When should arthroscopic partial meniscectomy (APM) be proposed? 1. Surgery should not be proposed as a first line of treatment of DMLs (Grade A). 2. APM may be proposed after 3 months and persistent pain and/or mechanical symptoms related to a DML with normal X-rays but an abnormal MRI (Grade III meniscus lesion). The patient has to be informed about chances of successful outcomes and risks of either method (Grade B).

At least for me all this seems quite confusing. Based on the first two takes, a degenerative meniscus lesions are often incidental findings in the knee MRI without known pathogenesis and the evidence is very scarce which would show that these lesions caused any pain. Based on all this, what is the rationale to offer an APM for the patient even after certain period of physiotherapy or watchful waiting? If this is not endorsement what is it then?

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