Unfounded Concerns

The core statement of this review article (1) can be accepted: the benefit of arthroscopic surgery for degenerative meniscus lesions is questionable unless locking symptoms clearly indicate a mechanical problem in the knee. Therefore, this operation should no longer be considered as standard practice but rather as an exception (2). This conclusion is valid however for osteoarthritis in general, irrespective whether degenerative lesions are present in the meniscus, the cartilage, or both structures (3).

The problem presented by some patients changing treatment during the study (especially if it is in one direction—from the control group to the intervention group) could lead to consideration of treatment strategies, rather than treatment options, in the extreme case.

In the case presented here, having an immediate meniscus resection is compared to undergoing an initial (continued) conservative management strategy, which is followed by a subsequent operation only if necessary.

It does not seem plausible, however, to conclude that arthroscopy is beneficial based on the crossover of some study patients from conservative treatment to arthroscopically resective surgery. Rather, such a treatment crossover firstly shows how deeply rooted the belief in the efficacy of arthroscopy is, and how much effective treatment options are lacking momentarily. Even the statement that „patients with flap tears benefit from arthroscopic partial meniscectomy“ is not based on the available data.

Additionally, the Herrlin study reported that 8 of 13, and not “3 of 13,” switchers had flap tears. (Editor’s note: A correction for this has been published in issue 46/2015 of the German print version; the error had been spotted before the publication of the English language version of the article which is therefore correct).

We believe the concern that a low number of studies “may introduce a systematic bias” is unfounded. More importantly, the strong placebo effects of surgery should be considered. Therefore, if feasible, future studies should perform a sham operation in the comparison group.