Letter to Editor: Editorial: Appropriate Use? Guidelines on Arthroscopic Surgery for Degenerative Meniscus Tears Need Updating

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To the editor,
We read your editorial [14] with great interest and agree with your conclusions that the American Academy of Orthopaedic Surgeons guidelines and its accompanying appropriate-use criteria need to be updated. Arthroscopic partial meniscectomy is the most-frequently performed orthopaedic procedure. Its indication is not always perfectly defined, particularly when it comes to degenerative meniscal lesions. Partial meniscectomy is therefore probably too frequently performed, given that all but one [8] recently published randomized clinical trials [10-13, 15, 18, 19] demonstrated no additional benefit of arthroscopic partial meniscectomy in comparison to nonoperative treatment. These publications generated an intense and controversial debate through editorials and letters [3, 6], as well as a critical reconsideration of the indication for arthroscopy in degenerative meniscus lesions.
There are various reasons for the discrepancy between high-level scientific evidence and clinical practice, including a general resistance to change among clinicians, as well as the fact that patients included in randomized clinical trials may not be fully representative of those presenting with knee pain in the daily practice [4, 5]. Katz and colleagues [12], for example, identified only 2.4% of all patients of a multicenter study fulfilling the inclusion criteria. Sihvonen and colleagues [17] included only 146 patients from five orthopaedic clinics during a period of 5 years. Additionally, a number of patients required arthroscopy after failed nonoperative treatment, despite the highly selective inclusion criteria. In a similar approach on surgery for cartilage defects, Engen and colleagues [7] demonstrated that patients qualifying for inclusion in randomized clinical trials represented only 4% of those presenting in their cartilage clinic.
Although randomized clinical trials represent the highest available scientific level, it remains difficult to directly transfer their conclusions into daily clinical practice. Therefore, the surgical community needs a more uniform and clear message, perhaps balancing these two controversial options with nonoperative treatment on one end and arthroscopic partial meniscectomy on the other end of our therapeutic armamentarium.
In an editorial published in 2015, we wrote: “The necessity of a consensual process becomes clear, founded on the independence of the organizers and with the participation of all interested parties to produce the most exhaustive critical analysis of the literature possible. Work of this kind will permit a probable reduction in the number of arthroscopic meniscal resections in our countries in favor of abstention and meniscal repair and an improved nosological definition of the meniscectomy, rendering it pertinent and efficient” [2]. It appeared that a consensus should therefore not only be based on highest scientific level, but also on clinical expertise [16]. With that in mind, the European Society for Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA), developed the ESSKA Meniscus Consensus Project. This project, chaired by two authors of this letter (PB, RB), followed the strict Formal Consensus Process [9] and involved 84 physicians or scientists from 22 European countries [1].
The two main messages of the consensus are as follows (Fig. 1):
Considering Europe's diversity in terms of medical culture and healthcare systems, finding a consensus was not easy. Although the countries are different, our patients remain the same, and so our practice should not be adapted to a specific healthcare system, but rather, the healthcare systems should be adapted to our best clinical practice.
The first agreement of the European Consensus statement was the primary conservative treatment of a degenerative meniscal lesion.
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