Potential harms of isolated arthroscopic partial meniscectomy
Authors: Kim L Bennell, Jeffrey N Katz
Journal: The Lancet (2018)

Meniscal tears are common in middle-aged and older adults,1Englund M Guermazi A Gale D et al.Incidental meniscal findings on knee MRI in middle-aged and elderly persons.N Engl J Med. 2008; 359: 1108-1115Crossref PubMed Scopus (663) Google Scholar and most patients with osteoarthritis have concomitant meniscal tears. When a meniscal tear is judged to be a source of symptoms, arthroscopic partial meniscectomy is often done to remove the damaged meniscal tissue. This procedure is the most common orthopaedic surgery in countries with available data.2Cullen KA Hall MJ Golosinskiy A Ambulatory surgery in the United States 2006.Natl Health Stat Report. 2009; 11: 1-25PubMed Google Scholar In The Lancet, Simon G F Abram and colleagues3Abram SGF Judge A Beard DJ Price AJ Adverse outcomes after arthroscopic partial meniscectomy: a study of 700 000 procedures in the national Hospital Episode Statistics database for England.Lancet. 2018; (published online Sept 24.)http://dx.doi.org/10.1016/S0140-6736(18)31269-8Scopus (49) Google Scholar report the findings of a study of the risk of serious complications within 90 days of isolated arthroscopic partial meniscectomy. They used routinely collected hospital data for all arthroscopic partial meniscectomies done in public hospitals in England between 1997 and 2017. 699 965 procedures were included, and surgery was most commonly done in patients aged 40–59 years. The risk of serious complications was low: 2218 serious complications were recorded (0·317% [95% CI 0·304–0·330]). The risk was greater in patients who were older (adjusted odds ratio [OR] 1·247 per decade [95% CI 1·208–1·288]) and had more comorbidities (adjusted OR 1·860 per 10 units on the Charlson comorbidity index [95% CI 1·708–2·042]), and lower in women than in men (adjusted OR 0·640 [95% CI 0·580–0·705]). The risks of mortality, myocardial infarction, and stroke were lower in the trial population than in the general population, probably because patients who are offered and choose to undergo arthroscopic partial meniscectomy are healthier than age-matched patients in the general population. Within 90 days, pulmonary embolism occurred in roughly one in every 1282 cases (0·078% [95% CI 0·072–0·085]) and further surgery for infection was done in roughly one in every 742 cases (0·135% [95% CI 0·126–0·144]). Both of these complications were more common in the study population than in the general population. On the basis of these data, the authors estimated that for every 1500 fewer arthroscopic partial meniscectomies done, roughly one pulmonary embolism and two knee joint infections could be prevented. Similarly, one death from pulmonary embolism could be prevented with 77 519 fewer procedures (95% CI 45 455–261 097). Abram and colleagues' study has several strengths. It is the largest reported cohort study of arthroscopic partial meniscectomies. The authors focused on isolated arthroscopic partial meniscectomy and excluded more complex procedures such as ligamentous reconstruction, which enabled assessment of harms with increased accuracy. The data included were complete, from a national source, and covered the full range of major perioperative complications. Finally, the likelihood of harm was contextualised through comparison of risks in the study population to those in the general population. A minor limitation of the study was the restriction to public hospitals, which could limit generalisability. Furthermore, although this study provides robust data for short-term complications, it does not address long-term risks, such as the potential for structural damage, after arthroscopic partial meniscectomy. Abram and colleagues' findings3Abram SGF Judge A Beard DJ Price AJ Adverse outcomes after arthroscopic partial meniscectomy: a study of 700 000 procedures in the national Hospital Episode Statistics database for England.Lancet. 2018; (published online Sept 24.)http://dx.doi.org/10.1016/S0140-6736(18)31269-8Scopus (49) Google Scholar can be used to remind clinicians and patients contemplating arthroscopic partial meniscectomy that even simple and generally safe surgical procedures carry a risk of serious adverse outcomes. The more complex issue complementing this study of surgical complications is the efficacy of arthroscopic partial meniscectomy—after all, potential harms need to be weighed against potential benefits. The efficacy of the procedure for middle-aged and older patients with persistent knee pain and meniscal tears is controversial, and the published work informing this debate is complex, with differences between studies in terms of patient selection criteria, surgical procedures, and crossover rates, and contrasting results of intention-to-treat and as-treated analyses. A systematic review and meta-analysis4Thorlund JB Juhl CB Roos EM Lohmander LS Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms.BMJ. 2015; 350: h2747Crossref PubMed Scopus (220) Google Scholar of nine randomised controlled trials of the effect of knee arthroscopic surgery involving partial menisectomy or debridement, or both, in middle-aged and older patients with or without osteoarthritis showed small but clinically insignificant improvements in intention-to-treat analyses favouring arthroscopic surgery over control (exercise therapy or sham) for pain at 3 and 6 months, but not at 24 months. Guidelines vary in recommendations of arthroscopic partial meniscectomy for patients with or without evidence of osteoarthritis, with some against, some supportive, and some making no comment.5Siemieniuk RAC Harris IA Agoritsas T et al.Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline.BMJ. 2017; 357: j1982Crossref PubMed Scopus (132) Google Scholar Because overall both exercise therapy and arthroscopic partial meniscectomy seem to produce substantial but similar benefits,6Katz JN Brophy RH Chaisson CE et al.Surgery versus physical therapy for a meniscal tear and osteoarthritis.N Engl J Med. 2013; 368: 1675-1684Crossref PubMed Scopus (439) Google Scholar, 7Herrlin S Hallander M Wange P Weidenhielm L Werner S Arthroscopic or conservative treatment of degenerative medial meniscal tears: a prospective randomised trial.Knee Surg Sports Traumatol Arthrosc. 2007; 15: 393-401Crossref PubMed Scopus (268) Google Scholar, 8Gauffin H Tagesson S Meunier A Magnusson H Kvist J Knee arthroscopic surgery is beneficial to middle-aged patients with meniscal symptoms: a prospective, randomised, single-blinded study.Osteoarthritis Cartilage. 2014; 22: 1808-1816Summary Full Text Full Text PDF PubMed Scopus (140) Google Scholar, 9Yim JH Seon JK Song EK et al.A comparative study of meniscectomy and nonoperative treatment for degenerative horizontal tears of the medial meniscus.Am J Sports Med. 2013; 41: 1565-1570Crossref PubMed Scopus (239) Google Scholar, 10Osteras H Osteras B Torstensen TA Medical exercise therapy, and not arthroscopic surgery, resulted in decreased depression and anxiety in patients with degenerative meniscus injury.J Bodyw Mov Ther. 2012; 16: 456-463Summary Full Text Full Text PDF PubMed Scopus (62) Google Scholar clinicians generally offer non-operative intervention as a reasonable initial strategy. Thus, decisions to subsequently undergo arthroscopic partial meniscectomy will be preference based and follow a shared decision-making discussion between patients, their families, and clinicians. In this context, the robust data for harms associated with arthroscopic partial meniscectomy reported by Abram and colleagues will help to ensure meaningful discussions of the benefits and harms of the procedure and fully informed consent. JNK receives support for a research project from Samumed, outside the area of work commented on here. KLB declares no competing interests. Adverse outcomes after arthroscopic partial meniscectomy: a study of 700 000 procedures in the national Hospital Episode Statistics database for EnglandOverall, the risk associated with undergoing arthroscopic partial meniscectomy was low. However, some rare but serious complications (including pulmonary embolism and infection) are associated with the procedure, and the risks have not fallen with time. In view of uncertainty about the effectiveness of arthroscopic partial meniscectomy, an appreciation of relative risks is crucial for patients and clinicians. Our data provide a basis for decision making and consent. Full-Text PDF Open Access