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Research

Arthroscopic surgery for degenerative tears of the meniscus: a systematic review and meta-analysis

Moin Khan, Nathan Evaniew, Asheesh Bedi, Olufemi R. Ayeni and Mohit Bhandari
CMAJ October 07, 2014 186 (14) 1057-1064; DOI: https://doi.org/10.1503/cmaj.140433
Moin Khan
Division of Orthopaedic Surgery (Khan, Evaniew, Ayeni, Bhandari), Department of Surgery, McMaster University, Hamilton, Ont.; MedSport, Department of Orthopaedic Surgery (Bedi), University of Michigan, Ann Arbor, Mich.; Department of Clinical Epidemiology and Biostatistics (Bhandari), McMaster University, Hamilton, Ont.
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  • For correspondence: moinkhanmd@gmail.com
Nathan Evaniew
Division of Orthopaedic Surgery (Khan, Evaniew, Ayeni, Bhandari), Department of Surgery, McMaster University, Hamilton, Ont.; MedSport, Department of Orthopaedic Surgery (Bedi), University of Michigan, Ann Arbor, Mich.; Department of Clinical Epidemiology and Biostatistics (Bhandari), McMaster University, Hamilton, Ont.
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Asheesh Bedi
Division of Orthopaedic Surgery (Khan, Evaniew, Ayeni, Bhandari), Department of Surgery, McMaster University, Hamilton, Ont.; MedSport, Department of Orthopaedic Surgery (Bedi), University of Michigan, Ann Arbor, Mich.; Department of Clinical Epidemiology and Biostatistics (Bhandari), McMaster University, Hamilton, Ont.
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Olufemi R. Ayeni
Division of Orthopaedic Surgery (Khan, Evaniew, Ayeni, Bhandari), Department of Surgery, McMaster University, Hamilton, Ont.; MedSport, Department of Orthopaedic Surgery (Bedi), University of Michigan, Ann Arbor, Mich.; Department of Clinical Epidemiology and Biostatistics (Bhandari), McMaster University, Hamilton, Ont.
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Mohit Bhandari
Division of Orthopaedic Surgery (Khan, Evaniew, Ayeni, Bhandari), Department of Surgery, McMaster University, Hamilton, Ont.; MedSport, Department of Orthopaedic Surgery (Bedi), University of Michigan, Ann Arbor, Mich.; Department of Clinical Epidemiology and Biostatistics (Bhandari), McMaster University, Hamilton, Ont.
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  • Representing Clinical Important Benefits in the Systematic Review and Meta-Analysis of Arthroscopic Surgery for Degenerative Meniscal Tears
    Jan O. Friedrich
    Posted on: 24 November 2014
  • : Study design does not always allow a simple conclusion
    Ewa M Roos
    Posted on: 02 September 2014
  • Posted on: (24 November 2014)
    Page navigation anchor for Representing Clinical Important Benefits in the Systematic Review and Meta-Analysis of Arthroscopic Surgery for Degenerative Meniscal Tears
    Representing Clinical Important Benefits in the Systematic Review and Meta-Analysis of Arthroscopic Surgery for Degenerative Meniscal Tears
    • Jan O. Friedrich, Assistant Professor

    In their recently published article "Arthroscopic surgery for degenerative tears of the meniscus: a systematic review and meta- analysis" Khan et al (1) report a statistically significant increase in short-term functional outcomes of surgical vs conservative treatment of +0.25 (95% confidence interval [CI] 0.02 to 0.48) pooled standardized mean difference (SMD) units, but none in long-term functional outcomes +0.07 (95%...

    Show More

    In their recently published article "Arthroscopic surgery for degenerative tears of the meniscus: a systematic review and meta- analysis" Khan et al (1) report a statistically significant increase in short-term functional outcomes of surgical vs conservative treatment of +0.25 (95% confidence interval [CI] 0.02 to 0.48) pooled standardized mean difference (SMD) units, but none in long-term functional outcomes +0.07 (95% CI -0.10 to 0.23) SMD. They argue that the statistically significant short-term functional outcome increase is not a clinically important improvement because it is less than a change of 10 in the Knee Injury and Osteoarthritis Outcome Score (KOOS) used to measure functional outcome, which corresponds to 0.5 SMD using the KOOS median standard deviation.

    Given mean scores ranging from around 40 to just over 90 in the included studies an increase of 10 would correspond to an approximate 10-25% increase in KOOS being clinically important. For clinicians unfamiliar with SMD, a change of +0.25 falls between what is typically considered a small (0.2 SMD) and medium (0.5 SMD) treatment effect (2). An alternative method pools the ratio of means (RoM), i.e. the mean value in the surgical group divided by the mean value in the conservative treatment group, for each trial (3,4). Replotting data in Figures 3 and 4 in the meta-analysis (1) using the same RevMan 5.2 software but replacing SMD by RoM (4) greatly reduces heterogeneity and yields a value of 1.06 (95% CI 1.03- 1.08) corresponding to a statistically significant 6% increase in short- term outcomes for the surgical group, and an even smaller and non- statistically significant 1% increase in long-term outcomes (see accompanying figure). Clinicians may find it easier to interpret and accept that a 6% improvement in a short-term functional outcome measure is unlikely to be clinically important than an increase of 0.25 SMD.

    Sincerely,

    Jan O Friedrich, MD DPhil FRCPC
    Assistant Professor of Medicine , University of Toronto Medical Director,
    Medical-Surgical Intensive Care Unit, and Li Ka Shing Knowledge Institute,
    St. Michael's Hospital
    Toronto, Ontario

    References:

    1) Khan M, Evaniew N, Bedi A, Ayeni OR, Bhandari M. Arthroscopic surgery for degenerative tears of the meniscus: a systematic review and meta-analysis. CMAJ 2014; 186(14): 1057-1064.
    2) Cohen J. Statistical power analysis for the behavioral sciences. 2nd edition. Hillside, NJ: Lawrence Erlbaum Associates, 1988: 24-27.
    3) Friedrich JO, Adhikari NKJ, Beyene J. The ratio of means method as an alternative to mean differences for analyzing continuous outcome variables in meta-analysis: a simulation study. BMC Med Res Method 2008; 8:32.
    4) Friedrich JO, Adhikari NKJ, Beyene J. Ratio of means for analyzing continuous outcomes in meta-analysis performed as well as mean difference methods. J Clin Epidemiol 2011; 64: 556-564.

    Conflict of Interest:

    Co-developer of ratio of means method (see references 3 and 4)

    Show Less
    Competing Interests: None declared.
  • Posted on: (2 September 2014)
    Page navigation anchor for : Study design does not always allow a simple conclusion
    : Study design does not always allow a simple conclusion
    • Ewa M Roos, Professor and Head of Research Unit
    • Other Contributors:

    A systematic review and meta-analysis of arthroscopic surgery for degenerative tears of the meniscus was recently published online in Canadian Medical Association Journal.1 We commend the authors for their timely work summarizing the available scientific evidence up until January 20, 2014.

    The authors state in their aim that they "evaluate the efficacy of arthroscopic meniscal debridement in comparison with nono...

    Show More

    A systematic review and meta-analysis of arthroscopic surgery for degenerative tears of the meniscus was recently published online in Canadian Medical Association Journal.1 We commend the authors for their timely work summarizing the available scientific evidence up until January 20, 2014.

    The authors state in their aim that they "evaluate the efficacy of arthroscopic meniscal debridement in comparison with nonoperative or sham treatments". This is correct for the study comparing arthroscopic surgery to a sham surgery procedure,2 the study comparing arthroscopic surgery to steroid injection,3 and the study comparing arthroscopic surgery to medical exercise therapy.4 However, this aim is incorrectly stated for the studies by Herrlin,5 Katz,6 and Yim7 where exercise was a component of treatment provided to both groups. These three latter studies, together contributing the majority of patients, 522 out of 805, included in this meta-analysis, actually studied the additional effect derived from a combination of arthroscopic surgery and exercise in comparison with exercise alone. Thus, a comparison of the effects from arthroscopic surgery alone to exercise alone is not possible from these three studies. A more correct interpretation of the results from the meta-analysis would therefore be "There is moderate evidence to suggest that there is no additional benefit of arthroscopic meniscal debridement for degenerative meniscal tears compared to exercise, and no benefit in comparison with sham surgery or injection therapy".

    References

    1. Khan M, Evaniew N, Bedi A, Ayeni OR, Bhandari M. Arthroscopic surgery for degenerative tears of the meniscus: a systematic review and meta- analysis. CMAJ 2014.

    2. Sihvonen R, Paavola M, Malmivaara A, et al. Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. N Engl J Med 2013; 369(26): 2515-24.

    3. Vermesan D, Prejbeanu R, Laitin S, et al. Arthroscopic debridement compared to intra-articular steroids in treating degenerative medial meniscal tears. European review for medical and pharmacological sciences 2013; 17(23): 3192-6.

    4. Osteras H, Osteras B, Torstensen TA. Medical exercise therapy, and not arthroscopic surgery, resulted in decreased depression and anxiety in patients with degenerative meniscus injury. Journal of bodywork and movement therapies 2012; 16(4): 456-63.

    5. Herrlin 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(4): 393-401.

    6. Katz JN, Brophy RH, Chaisson CE, et al. Surgery versus physical therapy for a meniscal tear and osteoarthritis. N Engl J Med 2013; 368(18): 1675- 84.

    7. Yim 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(7): 1565-70.

    Conflict of Interest:

    None declared

    Show Less
    Competing Interests: None declared.
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Canadian Medical Association Journal: 186 (14)
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Vol. 186, Issue 14
7 Oct 2014
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Arthroscopic surgery for degenerative tears of the meniscus: a systematic review and meta-analysis
Moin Khan, Nathan Evaniew, Asheesh Bedi, Olufemi R. Ayeni, Mohit Bhandari
CMAJ Oct 2014, 186 (14) 1057-1064; DOI: 10.1503/cmaj.140433

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Arthroscopic surgery for degenerative tears of the meniscus: a systematic review and meta-analysis
Moin Khan, Nathan Evaniew, Asheesh Bedi, Olufemi R. Ayeni, Mohit Bhandari
CMAJ Oct 2014, 186 (14) 1057-1064; DOI: 10.1503/cmaj.140433
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