Better outcome from arthroscopic partial meniscectomy than skin incisions only? A sham-controlled randomised trial in patients aged 35-55 years with knee pain and an MRI-verified meniscal tear

Abstract

Objective: Compare arthroscopic partial meniscectomy to a true sham intervention.

Methods: Sham-controlled superiority trial performed in three county hospitals in Denmark comparing arthroscopic partial meniscectomy to skin incisions only in patients aged 35-55 years with persistent knee pain and an MRI-confirmed medial meniscus lesion. A computer-generated table of random numbers generated two comparison groups. Participants and outcome assessors were blinded to group allocation. Exclusions were locking knees, high-energy trauma or severe osteoarthritis. Outcomes were collected at baseline, 3 and 24 months. We hypothesised no difference between groups. The primary outcome was the between-group difference in change from baseline to 2 years in the mean score across all five normalised Knee injury and Osteoarthritis Outcome Score (KOOS) subscales (KOOS₅).

Results: Forty-four patients (of the estimated 72) underwent randomisation; 22 in each group. Sixteen participants (36%) were non-blinded and eight participants (36%) from the sham group crossed over to the surgery group prior to the 2-year follow-up. At 2 years, both groups reported clinically relevant improvements (surgery 21.8, skin incisions only 13.6), the mean difference between groups was 8.2 in favour of surgery, which is slightly less than the cut-off of 10 prespecified to represent a clinically relevant difference; judged by the 95% CI (-3.4 to 19.8), a possibility of clinically relevant difference could not be excluded. In total, nine participants experienced 11 adverse events; six in the surgery group and three in the skin-incisions-only group.

Conclusion: We found greater improvement from arthroscopic partial meniscectomy compared with skin incisions only at 2 years, with the statistical uncertainty of the between-group difference including what could be considered clinically relevant. Because of the study being underpowered, nearly half in the sham group being non-blinded and one-third crossing over to surgery, the results cannot be generalised to the greater patient population.

Trial registration number: NCT01264991.

Keywords: adult orthopaedics; knee; musculoskeletal disorders; orthopaedic sports trauma.

Figure 1

Study flow.

Figure 2

Least square mean for each group over time for the primary outcome (KOOS₅) for intention-to-treat (A) and per-protocol (B) analyses. Solid lines represent the arthroscopic partial meniscectomy group and stipled lines the skin incision only group. KOOS₅, the mean score across all five normalised Knee injury and Osteoarthritis Outcome Score subscales.

Figure 3

Forest plot illustrating the contrast between the treatment arms after 2 years for intention-to-treat (A) and per-protocol (B) groups. ADL, Function, daily living; KOOS, Knee injury and Osteoarthritis Outcome Score; KOOS₅, the mean score across all five normalised KOOS subscales; MCS, Mental Component Score; PCS, Physical Component Score; QOL, quality of life; SF-36. Short-Form 36 items.