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• The orthopedic community does not oppose non-operative treatment of degenerative meniscal lesions
  Romain Seil, Philippe Beaufils, Roland Becker and Jacques Menetrey
  Published on: 30 November 2020

• Published on: 30 November 2020

  The orthopedic community does not oppose non-operative treatment of degenerative meniscal lesions

  • Romain Seil, President ESSKA office Centre Médical |
  • Other Contributors:
    • Philippe Beaufils, MD
    • Roland Becker, MD
    • Jacques Menetrey, MD

  “When taking a step back is a veritable leap forward. Reversing decades of arthroscopy for managing joint pain: five reasons that could explain declining rates of common arthroscopic surgeries.” Ardern CL, Paatela T, Mattila V, et al. Br J Sports Med 2020;54:1311-1313.

  We have read your editorial with curiosity. Meniscal preservation is a major challenge for modern orthopaedics (1, 2). And when middle-aged patients have knee pain from degenerative meniscus lesions or incipient osteoarthritis, their first treatment should be non-surgical. We are all agreed about that. It was a clear conclusion from ESSKA’s (European Society of Sports Traumatology, Knee Surgery and Arthroscopy) recent consensus project based on strict and transparent methodology (3).

  Unfortunately, your editorial overlooked our exhaustive analysis and was, at times, more assertive than empirical. It seemed to assume that orthopaedic surgeons and their societies will oppose non-operative treatments, simply because they are surgeons. This animus is unhelpful: it stigmatises our community; it creates mistrust amongst our patients, and it risks more and disruptive regulations. And we have already been here, with combative publications (4,5) inviting combative replies (6,7). It was to avoid these immature polemics that ESSKA intervened.

  We would note that ESSKA’s investigation — and the subsequent Consensus Statement —involved 21 countries (3) and has been disseminated, in their mother tongue...

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  “When taking a step back is a veritable leap forward. Reversing decades of arthroscopy for managing joint pain: five reasons that could explain declining rates of common arthroscopic surgeries.” Ardern CL, Paatela T, Mattila V, et al. Br J Sports Med 2020;54:1311-1313.

  We have read your editorial with curiosity. Meniscal preservation is a major challenge for modern orthopaedics (1, 2). And when middle-aged patients have knee pain from degenerative meniscus lesions or incipient osteoarthritis, their first treatment should be non-surgical. We are all agreed about that. It was a clear conclusion from ESSKA’s (European Society of Sports Traumatology, Knee Surgery and Arthroscopy) recent consensus project based on strict and transparent methodology (3).

  Unfortunately, your editorial overlooked our exhaustive analysis and was, at times, more assertive than empirical. It seemed to assume that orthopaedic surgeons and their societies will oppose non-operative treatments, simply because they are surgeons. This animus is unhelpful: it stigmatises our community; it creates mistrust amongst our patients, and it risks more and disruptive regulations. And we have already been here, with combative publications (4,5) inviting combative replies (6,7). It was to avoid these immature polemics that ESSKA intervened.

  We would note that ESSKA’s investigation — and the subsequent Consensus Statement —involved 21 countries (3) and has been disseminated, in their mother tongues, to orthopaedic surgeons across Europe (English, Italian, French, Spanish, German, and more). It began with recommendations of the French orthopaedic community (8) and was followed by new UK guidelines (9). As a result, there have been changes to British regulations (which proves just how useful a scientific society can be, as a driver of efficient clinical best-practice). By contrast, your editorial was limited to a few countries, and a small number of references.

  It is clear that Arthroscopic Partial Meniscectomies (APM) have been declining, and in many countries (10,11), but not as fast as we might have expected. And we can usefully ask why this is — why there is an apparent lag between the scientific data and the everyday-practice (that is, between what actually does happen, and what we think should be happening)?

  The answer is that we all work within a Scientific Paradigm. We are scientists, but also practical men/women. We are trained in a paradigm, because it seems to offer the best and most efficient way. And we continue within that paradigm, until the results prove it wrong (or less efficient). So, although we broadly agree with the various pressure groups developed in your editorial, such as surgeons, patients, and regulatory systems — we fundamentally disagree with your proposed solution. Our reasons are as follows:
  - The acceptability of RCTs may be questioned. Any RCT has weaknesses and limitations which should be recognised, particularly in the field of functional surgery (12). Selection bias is one of the main arguments. Patients in a study involving sham-surgery cannot possibly claim to represent the general populations of other countries. This raises the question of the external validity of this type of study. This problem goes far beyond our discipline, and affects all medical specialties, urging some authors to a return to so-called “real-life” studies (13). Our ESSKA Meniscus Consensus was a valuable contribution, in this regard, because it allowed for the real diversity of cultures and approaches but managed to find a common path.
  - As we have already said, surgeons work within a paradigm, unless or until that paradigm is proven incompetent (at which point they will adapt and change). And, as surgeons, they are trained to consider surgery first (14). This cannot be otherwise, and therefore every surgical study should be scrutinized for confirmation bias or prejudice (15, 16). Anathemas do not help, but educational programmes do, if they are properly supported. This is where universities and scientific societies are important, because they can reform an inefficient paradigm.
  - Patient expectations are also important because they also reflect a paradigm, and one which may be out-of-date. What patients demand from their surgeons differs from country to country. In many countries, patients with months of pain may despair of non-operative treatment, and urge a surgeon for something more active. This is a mistake on their part, of course, but it is one which RCTs ignore. Here again, consensus and “real life” studies are valuable, because they alone can correct such mistakes.
  - Then there is the diversity amongst healthcare systems which makes any global approach very difficult. The type of healthcare-professionals, their availability, and their pay, these all vary from country to country. Coercion may not be the best way to limit the number of APMs. We would prefer consultation, on the basis of proper and agreed data.
  - Finally, it all takes time. The history of Meniscus Repair (17,18), shows that it takes many years to develop medical and surgical practice. And there is a good reason for this. Paradigms are not fashions, that come and go with the seasons. They are much more important. So we need to get them right.

  In conclusion: meniscus preservation is a major issue. For Degenerative Meniscus Lesions, the first-line treatment must be non-operative. But this does not exclude APM for selected cases, in accord with international recommendations. The surgical community is not opposed to reducing APM in this context. It is only through education and consultation, and accepting the cultural differences between countries, that such a common goal can be achieved.
  Needless confrontation, does not help.

  References
  1.Pujol N, Beaufils P. Save the meniscus again! Knee Surg Sports Traumatol Arhrosc. 2019;27(2):341-342.
  2.Seil R, Becker R. Time for a paradigm change in meniscal repair: save the meniscus! Knee Surg Sports Traumatol Arthrosc. 2016;24(5):1421-3.
  3.Beaufils P, Becker R, Kopf S, et al. Surgical management of degenerative meniscus lesions: the 2016 ESSKA meniscus consensus. Knee Surg Sports Traumatol Arthrosc. 2017;25(2):335-346.
  4.Lohmander LS, Thorlund JB, Roos EM. Routine knee arthroscopic surgery for the painful knee in middle-aged and old patients--time to abandon ship. Acta Orthop. 2016 ;87(1):2-4.
  5.Thorlund JB, Juhl CB, Roos EM, et al. Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms. BMJ. 2015 16;350:h2747
  6.Lubowitz JH, et al. Could the New England Journal of Medicine be biased against arthroscopic knee surgery? Part 2. Arthroscopy. 2014. 30(6):654-5
  7.Bollen SR Is arthroscopy of the knee completely useless? Meta-analysis--a reviewer's nightmare. Bone Joint J. 2015 Dec;97-B(12):1591-2.
  8.Beaufils P, Hulet C, Dhénain M,et al. Clinical practice guidelines for the management of meniscal lesions and isolated lesions of the anterior cruciate ligament of the knee in adults. Orthop Traumatol Surg Res. 2009 ;95(6):437-42
  9.Siemieniuk RAC, Harris IA, Agoritsas T, et al. Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline. Br J SportsMed 2018;52:313.
  10.Jacquet C, Pujol N, Pauly V, et al. Analysis of the trends in arthroscopic meniscectomy and meniscus repair procedures in France from 2005 to 2017.Orthop Traumatol Surg Res. 2019;105(4):677-682
  11.Benjamin R Parker 1, Shepard Hurwitz 2, Jeffrey Spang 3, et al. Surgical Trends in the Treatment of Meniscal Tears: Analysis of Data From the American Board of Orthopaedic Surgery Certification Examination Database. Am J Sp Med. 2016;44(7):1717-23.
  12.Reeves M. EPI-546 : Fundamentals of Epidemiology and Biostatistics. Course Notes – Lecture 7 The RCT.https://learn.chm.msu.edu/epi/Coursepack/EPI546_Lecture_7_course_notes.pdf
  13.Saturni S, Bellini F, Braido F, et al. Randomized Controlled Trials and real life studies. Approaches and methodologies: a clinical point of view. Pulm Pharmacol Ther. 2014;27(2):129-38.
  14.Becker R, Kopf S, Seil R, et al. From meniscal resection to meniscal repair: a journey of the last decade. Knee Surg Sports Traumatol Arthrosc. 2020;28(11):3401-3404.
  15.Elston DM. Confirmation bias in medical decision-making. J Am Acad Dermatol. 2020;82(3):572
  16.Reider B Editorial : To Cut … or Not? Am J Sports Med 2015;43(10):2365-7.
  17.Beaufils P, Becker R, Verdonk R, et al. Focusing on results after meniscus surgery. Knee Surg Sports Traumatol Arthrosc. 2015;23(1):3-7.
  18.Seil R, Karlsson J, Beaufils P, et al. The difficult balance between scientific evidence and clinical practice: the 2016 ESSKA meniscus consensus on the surgical management of degenerative meniscus lesions. Knee Surg Sports Traumatol Arthrosc. 2017;25(2):333-334

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  Conflict of Interest:
  None declared.

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