Abstract
Objective
Patients with meniscal tears reporting “meniscal symptoms” such as catching or locking, have traditionally undergone arthroscopy. We investigated whether patients with meniscal tears who report “meniscal symptoms” have greater improvement with arthroscopic partial meniscectomy (APM) than physical therapy (PT).
Methods:
We used data from the Meniscal Tear in Osteoarthritis Research (MeTeOR) trial, which randomized participants with knee osteoarthritis (OA) and meniscal tear to APM or PT. The frequency of each “meniscal symptom” (clicking, catching, popping, intermittent locking, giving way, swelling) was measured at baseline and 6-months. We used linear regression models to determine whether the difference in improvement in KOOS Pain at 6-months between those treated with APM versus PT was modified by the presence of each “meniscal symptom”. We also determined the percent of participants with resolution of “meniscal symptoms” by treatment group.
Results:
We included 287 participants. The presence (vs. absence) of any of the “meniscal symptoms” did not modify the improvement in KOOS Pain between APM vs. PT by more than 0.5 SD (all p-interaction >0.05). APM led to greater resolution of intermittent locking and clicking than PT (locking 70% vs 46%, clicking 41% vs 25%). No difference in resolution of the other “meniscal symptoms” was observed.
Conclusion:
“Meniscal symptoms” were not associated with improved pain relief. Although symptoms of clicking and intermittent locking had a greater reduction in the APM group, the presence of “meniscal symptoms” in isolation should not inform clinical decisions surrounding APM vs. PT in patients with meniscal tear and knee OA.
Introduction
Symptomatic knee osteoarthritis (OA) affects an estimated 14 million individuals in the United States, with up to 91% of patients with knee OA demonstrating a meniscal tear on magnetic resonance imaging (MRI).1,2 Knee symptoms such as catching, popping or locking elicited in young persons with acute injuries were have been considered “mechanical symptoms.” Historically, these “mechanical symptoms” along with symptoms such as pain with twisting have been grouped together as “meniscal symptoms” and attributed to meniscal tear or to other internal derangements. These patients were often referred to orthopedic surgeons for consideration of arthroscopic diagnosis and management. However, in the current era of advanced imaging, meniscal tear can be visualized on magnetic resonance imaging (MRI), obviating the need for direct surgical visualization.
Middle aged and older patients with knee OA frequently report “meniscal symptoms”; clinicians continue to suspect symptomatic meniscal tear in these patients, even though there is little evidence that “meniscal’ symptoms” stem from meniscal pathology in older patients with degenerative (rather than traumatic) meniscal tears.3 In fact prior evidence suggests that meniscal tears were seen in a similar proportion of asymptomatic and symptomatic knees.4
Randomized trials comparing surgical treatment versus conservative therapy for patients with degenerative meniscal tears have found that both strategies reduce pain.5–8 Though “meniscal symptoms” may not be specific to meniscal damage, many clinicians feel that patients with “meniscal symptoms” may represent a subgroup with a favorable response to APM9, as resection of the torn meniscus is thought to aid in restoring smooth joint motion. Therefore, there is considerable interest in whether patients with “meniscal symptoms” might benefit more from surgery than those without these symptoms.
Our group previously developed a more comprehensive list of commonly considered “meniscal symptoms” based on input from physicians, physical therapists and patients. While the original list included several pain parameters here we focus on the traditional “mechanical” or “meniscal symptoms” including clicking, catching, popping, intermittent locking, giving way, and swelling of the knee.10 We sought to evaluate whether patients reporting any of these expanded “meniscal symptoms” had greater improvement with APM than with PT using data from the Meniscal Tear in Osteoarthritis Research (MeTeOR) trial, a randomized trial of APM versus PT in patients with knee OA and meniscal tear.6 We evaluated the association between these expanded “meniscal symptoms”, treatment group (APM, PT), and patient improvement. Here we test the null hypothesis that in patients with osteoarthritis, the association between treatment group and 6-month change in pain will not be different for those with vs. without baseline “meniscal symptoms”.
Methods
Study Sample
We used data from participants in the MeTeOR trial; details of this trial have been previously published.6,11 Three hundred and fifty-one subjects were recruited from 7 academic centers from 2008 through 2011. Participants included males and females 45 years or older who had at least 4 weeks of knee pain and an MRI with evidence of a meniscal tear extending to the meniscal surface in at least 2 consecutive slices. Included participants also had evidence of mild to moderate osteoarthritic change (Kellgren-Lawrence (KL) grade ≤ 3) as determined by osteophyte and/or joint space narrowing on plain radiographs, or full-thickness articular cartilage defect on at least one tibial or femoral surface on MRI. We excluded patients with a chronically locked knee (e.g. subject unable to flex or extend knee on exam), inflammatory arthritis, prior surgery on the index knee, KL grade 4 OA, and contraindication to MRI. Participants reporting locking, but able to flex and extend the knee on exam were included and are designated as ‘intermittent locking’ in our analyses. Participants were randomized either to PT or to APM followed by the PT regimen. The surgical intervention was APM with resection of the damaged meniscus back to a stable rim. Meniscal repairs were not permitted as part of the trial.
All participants provided consent and the study was approved by the Partners HealthCare Human Research Committee (2005P000440). This trial is registered at clinicaltrials.gov (NCT00597012).
Data Elements
We collected data on age, sex and body mass index (BMI, kg/m2) at baseline. The frequency of patient-reported “meniscal symptoms” was obtained at baseline and 6-month follow up. “Meniscal symptoms” included clicking, catching, popping, intermittent locking, giving way, and knee swelling. Questionnaires assessed frequency of each meniscal symptom as follows: none; once/week; 2–6 times/week; 1–2 times/day; and several times/day. Based on the distribution of the categorical responses, all “meniscal symptoms” were dichotomized to ‘none’ versus any. Radiographic severity of OA was measured at baseline using the Kellgren-Lawrence grade.12
Outcome and Assessment
The primary outcome of interest was change in patient-reported pain from baseline to 6-months follow-up, assessed with the Knee Injury and Osteoarthritis Outcome Score (KOOS) Pain Scale.13 We transformed KOOS Pain to a 0–100 scale with 0 being least amount of pain and 100 the greatest with negative change indicative of improvement.
Statistical Analysis
We described baseline characteristics of the cohort using means and percentages. For the primary analysis, we excluded the participants crossing over from PT to APM prior to 6 months, as these participants could be early in the recovery process at the 6-month assessment as well as participants randomized to APM who did not undergo the surgery. The participants crossing over from PT to APM after 6-months were included in the PT arm. Participants missing either baseline or 6-month KOOS Pain scores were excluded. We built separate multivariable linear regressions for each “meniscal symptom” (clicking, catching, popping, intermittent locking, giving way, and swelling), with the dichotomous symptom variable as the independent variable and change in KOOS Pain score from baseline to 6-months as the dependent variable. We examined the interaction between each “meniscal symptom” and treatment type (APM, PT) on change in KOOS Pain. All models were adjusted for age, sex, BMI and baseline KOOS Pain score.
In a second set of models we also adjusted for KL grade to account for radiographic OA severity. In another sensitivity analysis, we dichotomized “meniscal symptoms” as less than daily (none; once/week; 2–6 times/week) vs. daily (1–2 times/day and several times/day) to allow investigation of participants with more frequent “meniscal symptoms”. The original MeTeOR trial was not powered to detect these interactions; thus, these analyses are intended to be hypothesis generating.
To address potential bias due to the exclusion of cross-overs from the primary analysis, we assessed whether including cross-overs in the APM arm or the PT arm altered results through two sensitivity analyses. In the first we used an intention to treat approach, in which we included participants crossing over from PT to APM prior to 6-months and participants crossing over from PT to APM after 6-months in the PT arm. The second analysis used an as-treated approach including participants crossing over from APM to PT prior to 6-months in the APM arm. (The participants crossing over after 6 months were kept in the PT arm as the primary outcome was at 6 months).
As a secondary analysis we investigated resolution of “meniscal symptoms” from baseline to 6-month follow-up. From the subset of participants reporting any “meniscal symptoms” at baseline we defined ‘resolution’ as those participants reporting none at follow-up. We investigated differences in this outcome across each treatment category, APM and PT. In this analysis, we included participants crossing-over from PT to APM after 6 months in the PT arm, and excluded patients crossing over between arms during the first 6 months. Participants with missing 6-month meniscal symptom data were considered ‘non-resolvers’ rather than omitted as this was felt to be the most conservative analytic approach. We used contingency tables and the Chi square test to assess for statistically significant differences in percent improvement among the treatment groups.
For all analyses p<0.05 was considered statistically significant. All analyses were performed using SAS 9.4 statistical software (SAS Institute Inc., Cary, NC).
Results
Of the 351 participants,164 (47%) participants were randomized to and received APM. One hundred and nine (31%) were randomized to PT and did not cross-over; 14 (4%) participants were randomized to PT but crossed over after 6 months and were therefore included in the PT arm. Ten (3%) participants were randomized to APM but did not have the procedure and 54 (15%) were randomized to PT but received APM within 6 months and were excluded from analysis. The primary analysis included the 287 (82%) participants who were randomized to and received APM or were randomized to and received PT in the first 6 months. Mean age and BMI was similar among the treatment groups. Clicking, catching, popping and giving way were present in 48–67% of participants at baseline. Twenty-seven to 31% of participants reported intermittent locking, and 71–75% reported swelling. The percent of participants reporting each meniscal symptom by treatment group at baseline is outlined in Table 1.
Table 1:
Baseline characteristics by treatment group
| Arthroscopic partial meniscectomy (n=164) |
Physical Therapy (n=123) |
P value | |
|---|---|---|---|
| Age, mean (SD) | 59 (8) | 58 (6) | 0.08 |
| BMI, mean (SD) | 30 (6) | 30 (6) | 0.99 |
| Female n, (%) | 94 (57) | 67 (54) | 0.63 |
| KOOS Pain, mean (SD) | 46 (16) | 46 (16) | 0.74 |
| Kellgren-Lawrence grade n, (%) | |||
| 0 | 14 (9) | 10 (8) | 0.29 |
| 1 | 31 (19) | 34 (28) | |
| 2 | 63 (38) | 37 (30) | |
| 3 | 56 (34) | 42 (34) | |
| “Meniscal symptoms” n, (%) | |||
| Clicking | 106 (66) | 80 (67) | 0.81 |
| Catching | 81 (51) | 62 (52) | 0.86 |
| Popping | 79 (50) | 61 (51) | 0.85 |
| Intermittent Locking | 43 (27) | 37 (31) | 0.42 |
| Giving Way | 77 (48) | 64 (54) | 0.27 |
| Swelling | 114 (71) | 90 (75) | 0.49 |
SD; standard deviation, BMI; body mass index, KOOS; Knee injury and Osteoarthritis Outcome Score.
Of the 287 participants data were missing on 0–6% for each baseline characteristic
Primary Analysis
In the primary analysis, participants randomized to and receiving APM were considered in the APM group (n=164) and those randomized to PT who remained in the PT group at least until 6-months were considered in the PT group (n=123). Six-month change in KOOS Pain was missing in 23 participants in the APM group and 20 participants in the PT group, thus the final analysis included 141 in the APM group and 103 in the PT group. Overall, regardless of “meniscal symptoms” at baseline, those undergoing APM had slightly greater improvement in KOOS Pain scores at 6 months compared to PT. In the individual models for “meniscal symptoms” after adjustment for age, sex, BMI and baseline KOOS Pain, participants without clicking, catching, popping, or locking and with giving way and swelling had a small but greater improvement in KOOS Pain after APM than PT. Assuming the standard deviation of KOOS Pain is 1514, the differences correspond to an effect size of 0.3–0.5. Participants with clicking, catching, popping or locking and without giving way and swelling had minimal differences in KOOS Pain between APM and PT. All interaction p values were > 0.09 (Table 2). Further adjusting models for KL grade did not alter results. The results of this analysis did not change when “meniscal symptoms” were considered as ‘daily’ versus ‘less than daily’, aside from swelling where those with ‘daily’ and ‘less than daily’ swelling had a 3 and 5-point greater improvement with APM respectively. (Appendix 1). As in the primary analysis, the effect of each meniscal symptom on change in KOOS Pain over 6 months was not modified by treatment (p-value for interaction >0.05 for each symptom).
Table 2:
Change in KOOS Pain for APM and PT by presence of “meniscal symptom”
| Mean change in KOOS Pain from baseline to 6-months (95% CI)* | |||||
|---|---|---|---|---|---|
| Physical Therapy | Arthroscopic Partial meniscectomy | P value | Difference** | P value for interaction | |
| Clicking | 18.9 (14.7, 23.2) | 22.2 (18.6, 25.8) | 0.24 | −3.3 (−8.8, 2.2) | 0.58 |
| No clicking | 21.9 (16.4, 27.4) | 27.8 (22.9, 32.7) | 0.11 | −5.9 (−13.1, 1.4) | |
| Catching | 20.1 (15.3, 24.8) | 21.9 (17.8, 25.9) | 0.56 | −1.8 (−8.0, 4.3) | 0.37 |
| No catching | 20.6 (15.9, 25.4) | 26.5 (22.2, 30.7) | 0.07 | −5.8 (−12.1, 0.4) | |
| Popping | 18.9 (13.9, 23.8) | 21.2 (17.1, 25.2) | 0.47 | −2.3 (−8.7, 4.0) | 0.41 |
| No popping | 21.6 (17.0, 26.1) | 27.6 (23.5, 31.6) | 0.05 | −6.0 (−12.0, 0.04) | |
| Intermittent locking | 21.2 (15.2, 27.1) | 21.5 (15.7, 27.3) | 0.94 | −0.3 (−8.6, 7.9) | 0.32 |
| No intermittent locking | 19.9 (15.9, 24.0) | 25.2 (21.8, 28.5) | 0.05 | −5.2 (−10.5, −0.02) | |
| Giving way | 17.8 (13.0, 22.5) | 25.7 (21.5, 29.8) | 0.01 | −7.9 (−14.1, −1.7) | 0.09 |
| No giving way | 22.7 (17.8, 27.5) | 22.9 (19.0, 26.9) | 0.93 | −0.3 (−6.4, 5.9) | |
| Swelling | 19.8 (16.0, 23.7) | 25.9 (22.4, 29.3) | 0.02 | −6.0 (−11.1, −0.9) | 0.12 |
| No swelling | 22.5 (15.7, 29.3) | 20.6 (15.1, 26.1) | 0.66 | 1.9 (−6.7, 10.4) | |
KOOS; Knee injury and Osteoarthritis Outcome Score
APM; Arthroscopic partial meniscectomy
PT; Physical therapy
CI: confidence interval
Adjusted for age, sex, BMI and baseline KOOS Pain
Negative values favor APM and positive values favor PT
Sensitivity Analyses
In the sensitivity analysis, using an intention to treat approach, 177 participants were categorized as PT and 164 as APM. Change in KOOS Pain over 6 months was missing in 26 participants in the PT group and 23 in the APM group. At baseline the cross-over group had a higher percent of female participants at 65%, versus 57% for APM and 54% for PT. Mean baseline KOOS Pain was also greater in the cross-over participants at 51, versus 46 for both APM and PT. (Appendix 3). Results were analogous to the primary analysis and the presence or absence of each meniscal symptom and treatment type did not clinically or statistically significantly modify the change in KOOS Pain at 6 months. (‘Intention to treat’ Appendix 3). In the second sensitivity analysis including those crossing over from PT to APM prior to 6-months in the APM arm, 218 were categorized as APM and 123 as PT. Change in KOOS Pain over 6 months was missing in 29 participants in the APM arm and 20 participants in the PT arm. Again, the results were similar to the primary analysis. (‘As treated’ Appendix 3).
Secondary Outcome
In this analysis participants crossing over from PT to APM after six months were included in the PT arm, while those crossing over before 6 months were excluded. For each meniscal symptom 14 to 32 participants did not provide 6-month data, missingness did not vary between treatment. At 6-months the percent of participants with resolution (reporting any meniscal symptom at baseline and none at 6-month follow up) for clicking, catching, popping, intermittent locking, and giving way was greater in those undergoing APM. Among those undergoing PT, clicking resolved in 25%; catching in 50%; popping in 38%; locking in 46%, and giving way in 55%. Improvement in swelling was greater in the PT group than in those receiving APM. (Table 3). The greater extent of resolution in intermittent locking and clicking in the APM group as compared with the PT group was statistically significant (p<0.05).
Table 3.
Proportion of participants with resolution of “meniscal symptoms” over 6-months by each treatment category
| Clicking | Catching | Popping | Locking | Giving Way | Swelling | |
|---|---|---|---|---|---|---|
| APM, n (%) | 43 (41)* | 48 (59) | 39 (49) | 30 (70)* | 44 (57) | 43 (38) |
| PT, n (%) | 20 (25)* | 31 (50) | 23 (38) | 17 (46)* | 35 (55) | 36 (40) |
| Relative Risk (95% CI) | 1.62 (1.04,2.53) | 1.19(0.87,1.61) | 1.31 (0.88,1.94) | 1.52 (1.02,2.27) | 1.04(0.78,1.40) | 0.94(0.67,1.33) |
APM: arthroscopic partial meniscectomy; PT: physical therapy
Relative risk >1 favors APM
‘Resolution’ reflects participants with any symptom at baseline and none at 6-month follow up, if data missing at 6-months regarded as ‘no resolution’
p<0.05 for difference in resolution between APM and PT groups
Discussion
Our study suggests that in general, individuals with OA and “meniscal symptoms” do not have greater clinically meaningful improvement in pain after APM compared with PT. The differences in 6-month change KOOS Pain between APM and PT did not exceed 7.9 points, as the minimal clinically important difference for KOOS pain is 8–1515,16 points, these differences are unlikely to be clinically meaningful.15 In separate analyses for each symptom, the presence of clicking, catching, popping, intermittent locking, and swelling at baseline did not demonstrate a statistically significant or clinically greater improvement in 6-month pain outcomes with APM than with PT. Only with presence of giving way did the difference between APM and PT reach an effect size of 0.5 indicating a moderate effect. While a greater proportion of participants undergoing APM reported improvement in clicking, catching, popping, giving way and intermittent locking over 6-months, only intermittent locking and clicking showed statistically significant differences in improvement among the treatment groups. This suggests that APM may offer greater relief of clicking and intermittent locking “meniscal symptoms” than PT, despite not offering greater relief of pain.
Our findings are comparable to two recent studies. Sihvonen et al analyzed data from the FIDELITY trial, in which participants with meniscal tear without knee OA were randomized to APM versus sham surgery, to evaluate whether participants with “meniscal symptoms” (sensation of catching or locking) had greater improvement with APM. Results demonstrated no significant difference in the prevalence of “meniscal symptoms” after APM versus sham surgery at 2, 6, or 12 months.16 Our study differs in that we found that APM was more likely to relieve intermittent locking and clicking than PT. But, like Sihvonen et al, we also found that relief in overall pain was not influenced by “meniscal symptoms”.17
Gauffin et al included patients with meniscal tear and Ahlbäck grade 0 knee OA (< 50% joint space narrowing) randomized to exercise versus APM. Secondary analyses of this study showed no effect of “meniscal symptoms” (catching or locking for more than 2 seconds) or interaction between “meniscal symptoms” and treatment on change in KOOS Pain at 3-year follow up.18 Similar results were seen in the main trial with 1- year follow-up.19 However, the 3-year as-treated data also found that participants with “meniscal symptoms” had less improvement in KOOS Pain with APM. The 5-year follow-up data from this study again demonstrated a statistically significant greater reduction in KOOS Pain for those without “meniscal symptoms” in the APM group.20 As noted by Gauffin et al, “meniscal symptoms” may be non-specific and not necessarily reflect meniscal pathology.18 Regardless, our study adds to this body of literature by evaluating a broader range of “meniscal symptoms” and again suggests that traditional “meniscal symptoms” do not clearly relate to meniscal pathology in patients with osteoarthritis, as assessed by response to partial meniscal resection.
Orthopedic surgeons generally assert that the decision to refer a patient with meniscal tear for surgical evaluation should not be based on the presence of “meniscal symptoms” alone, but be grounded in the surgeon’s clinical judgement and patient preference. We acknowledge the wide range of views on this important topic and encourage additional research, such as ours, to clarify unresolved questions regarding the nature of meniscal symptoms and their role in selecting patients for treatment.19,21–23 Prior work from our group using MeTeOR data has shown that patients with fewer osteoarthritic changes on MRI (bone marrow lesions and cartilage damage) have greater improvement of pain with APM than with PT, while those with more substantial OA changes have similar outcomes regardless whether they undergo APM or PT.24 Therefore clinical features such as extent of underlying OA and tear type may be more salient to the initial surgical decision than the presence or frequency of “meniscal symptoms”.24,25 In our study, adjusting for KL grade, a radiographic marker of OA severity, did not alter results. However, it is likely KL grade is not sensitive enough to capture underlying pathology. Overall, studies on the use of APM for treatment of meniscal tear have not found APM to be superior to PT6,7,26,27, though Gauffin et al19 found benefit to APM and PT compared with PT alone. Based on the current evidence there are no widely accepted criteria for identifying patients more likely to improve from APM than from PT.
Our study has several limitations. Thirty-one percent (54) of the participants randomized to PT crossed-over to APM over 6-months. To address bias from excluding these participants we included them in intention to treat and as-treated analyses. The results of these analyses were similar to the primary analysis. We excluded participants without complete 6-month KOOS Pain data which may introduce bias. As this study is a secondary analysis of MeTeOR data, we have limited power to detect interactions. We did not correct for multiple comparisons and thus recommend caution in interpretation. The follow-up period was 6-months, therefore we are unable to assess if these results are durable. “Meniscal symptoms” including intermittent locking fluctuate over time, we cannot rule out that any observed improvement was due to chance or natural disease course instead of treatment and additional confirmatory studies are warranted. Lastly, as all patients had OA changes in addition to meniscal tear we are unable to ascertain whether the etiology of the “meniscal symptoms” was indeed the meniscus or other sources such as damage to cartilage or surrounding structures. Finally, we cannot use this data to draw conclusions regarding younger patients with traumatic type tears.
In summary, our results suggest that in our patients with mild to moderate knee OA and meniscal tear, the presence of self-reported clicking, catching, popping, intermittent locking, or swelling does not identify a subgroup that is more likely to have pain relief following APM. Although symptoms of clicking and intermittent locking had a greater reduction in the APM group, the presence of “meniscal symptoms” in isolation is not sufficient to make a clinical decision regarding APM vs. PT for the reduction of pain in this patient population, and further clinical data points must be considered including patient characteristics, physical examination and imaging findings.
Supplementary Material
Significance and Innovation.
We leveraged data from a randomized control trial to evaluate the association between “meniscal symptoms” and knee pain after surgery versus physical therapy for meniscal tear
The presence or absence of “meniscal symptoms” was not associated with differential pain outcomes after surgery versus physical therapy
Knee symptoms such as clicking and catching have historically been ascribed to meniscal pathology. This data casts further doubt on the ability of “meniscal symptoms” to help direct management of meniscal tear.
Source of funding:
R01 AR05557, T32 AR055885, K24 AR 057827; P30AR072577, Rheumatology Research Foundation SDA.
Disclosures:
Dr. Lindsey MacFarlane receives research support from Samumed. Heidi Yang- nothing to disclose. Dr. Jamie Collins consults for BICL LLC (<10,000). Dr. Robert Brophy- nothing to disclose. Dr. Brian Cole reports other from Aesculap, NIH, Operative Techniques in Sports Medicine, Smith and Nephew, Bandgrip Inc., Acumed LLC, Encore Medical, LP, GE Healthcare, Merck Sharp & Dohme Corporation, SportsTek Medical, Inc, and Vericel Corporation Elsevier publishing, personal fees from Ossio, personal fees and other from Regentis, grants, personal fees. (all <10,000). He also reports personal fees and other from Arthrex Inc (>10,000). Dr Kurt Spindler consults for the NFL, Service Excellence, Mitek, Flexion Therapeutics, Samumed and Novopeds (all <10,000). Dr. Ali Guermazi reports personal fees from BICL LLC, and is a consultant for TissueGene (>10,000), Pfizer (>10,000), AstraZeneca (<10,000), MerckSerono (>10,000), Galapagos (<10,000), and Roche (<10,000). Dr. Morgan Jones receives personal fees from Samumed and the Journal of Bone and Joint Surgery, research support from Flexion Therapeutics, and consults for Regeneron (<10,000). Dr. Lisa Mandl receives royalties from Uptodate, research support from Regeneron (all <10,000) and is an editor at Annals of Internal Medicine. Dr. Scott Martin- nothing to disclose. Dr. Robert Marx is an editor for the Journal of Bone and Joint Surgery (>10,000), received royalties from Springer and Demos Health and reports personal fees from MEND Nutrition Inc. (all <10,000). Dr. Bruce Levy reports consulting fees from Arthrex and Smith and Nephew (all <10,000) and is on the editorial board of KSSTA and the Journal of Knee Surgery. Dr. Michael Stuart receives research support from Arthrex and Stryker, consulting fees and royalties from Arthrex (>$10,000). Dr. Clare Safran- Norton is a shareholder of Merck and Johnson and Johnson. Dr. John Wright is employed at Johnson & Johnson. Dr. Rick Wright reports royalties and personal fees from Responsive Arthroscopy (<10,000). Dr. Losina receives research support from Flexion Therapeutics, Samumed and Pfizer and consults for Pfizer (<10,000). Dr. Katz receives research support from Flexion Therapeutics, Samumed and Pfizer.
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