Letter to the Editor: The New AAOS Guidelines on Knee Arthroscopy for Degenerative Meniscus Tears are a Step in the Wrong Direction.

Abstract

To the Editor, I read the thought-provoking January Editorial by Seth S. Leopold MD [5] with great interest. In the piece, Dr. Leopold points to serious problems with the updated American Academy of Orthopaedic Surgery (AAOS) guidelines on knee osteoarthritis (OA) [1], specifically with respect to the use of arthroscopic surgery in patients who have this diagnosis. He argues that the new guidelines are a step in the wrong direction. I agree with him. The previous guideline, published in 2013, offered inconclusive evidence regarding the role of arthroscopic partial meniscectomy in the treatment of knee OA [2]. After 8 years and numerous trials, this inconclusive evidence evolved to a weak recommendation favoring arthroscopic partial meniscectomy in knee OA [1]. I also agree with Dr. Leopold that we need a paradigm shift in our field as it relates to guidelines involving arthroscopic partial meniscectomy in the treatment of OA. To do this, we must accept that science, medicine, and orthopaedic surgery are not static processes, but rather dynamic, constantly evolving systems. As new evidence emerges, old traditions and practices should change. Arthroscopic partial meniscectomy is no exception. Although once established as a routine treatment, we should embrace the fact that arthroscopic partial meniscectomy, based on the evidence, does not provide a benefit for most patients with OA and degenerative meniscus tears. In fact, it is inaccurate to suggest that some patients benefit from arthroscopic partial meniscectomy when degenerative tears are considered. I believe that no such group of responders exists, and if it does, no one has provided clear evidence in support of that contention [8]. As Dr. Leopold writes [5], it makes no “biologic or anatomic sense” how arthroscopic partial meniscectomy could even, in theory, relieve symptoms in patients with knee OA and degenerative tears. Atraumatic tears are early signs of OA, and no biological mechanism explains how these tears could cause symptoms treatable with arthroscopic partial meniscectomy. Moreover, degenerative tears cannot be diagnosed clinically with any reasonable degree of certainty, and because of this, there is no established indication for arthroscopic partial meniscectomy [6]. In his editorial, Dr. Leopold writes that it is time to accept that some patients’ knees will hurt [5]. A vast majority of those knees will have degenerative joint disease, a progressive and fluctuating disease for which we have minimal means to help surgically other than with arthroplasty, which is not appropriate for all patients, particularly earlier in the course of the disease. Because of this, we need to educate patients about OA in ways that help guide their outlook, so they can live more effectively with the condition. There are, of course, instances when arthroscopic partial meniscectomy is indicated. Some tears can be treated with this technique, such as parrot beak and bucket-handle tears. But these tear types are rare in patients who are in middle adulthood and beyond. Despite the rarity of lesions appropriate for arthroscopic partial meniscectomy, the incidence of this technique remains several hundred surgeries per 100,000 people annually. Meaning that millions are performed per year around the world [3, 4]. This is a tremendous amount of low-value care [7], and I should note, it’s not just about the money. A small but nonzero proportion of these patients will have serious complications of surgery—mainly infections or life-threatening thromboembolic events—and when multiplied by millions, that represents many lives harmed by an intervention with no plausible benefit. If we want to be ethical and honest with our patients, we should admit that basic research and high-quality clinical evidence point to only one clear direction: arthroscopic partial meniscectomy is of no use in most of our patients who have knee complaints. It is saddening that the recent AAOS guideline says otherwise.