Diagnostic Validity of Combining History Elements and Physical Examination Tests for Traumatic and Degenerative Symptomatic Meniscal Tears

Arthroscopic surgery or exercise therapy for degenerative meniscal lesions: a systematic review of systematic reviews

BACKGROUND

Arthroscopic partial meniscectomy (APM) is widely applied for the treatment of degenerative meniscal lesions in middle-aged patients; however, such injury is often associated with mild or moderate osteoarthritis and has been reported by MRI in asymptomatic knees. Previous studies suggested, in most patients, a lack of benefit of surgical approach over conservative treatment, yet many controversies remain in clinical practice. Our aims were to assess the functional and pain scores between exercise therapy and arthroscopic surgery for degenerative meniscal lesions and to evaluate the methodological quality of the most recent systematic reviews (SRs).

METHODS

Two authors independently searched PubMed and Google Scholar for SRs comparing the outcome (in knee pain and functionality) of arthroscopic treatment and exercise therapy or placebo for degenerative meniscal lesions. The timeframe set was from 2009 to 2019 included.

RESULTS

A total of 13 SRs were selected. Two reviewers independently assessed the methodological quality of each paper using the AMSTAR 2 tool: seven scored as "moderate," four obtained a "low" grade while the remaining two were evaluated as "critically low." SRs agreed that in middle-aged patients with degenerative meniscal lesions arthroscopic surgery appears to grant no long-term improvement in pain and function over exercise therapy or placebo.

CONCLUSIONS

Conservative treatment based on physical therapy should be the first-line management. However, most SRs revealed subgroups of patients that fail to improve after conservative treatment and find relief when undergoing surgery. In the future, randomized controlled trials, evidence should be looked for that APM can be successful in case of the unsatisfactory results after physical therapy.

Arthroscopic partial meniscectomy: did it ever work?

Arthroscopic partial meniscectomy (APM) is one the most common orthopedic surgical procedures. The most common indication for APM is a degenerative meniscal tear (DMT). High-quality evidence suggests that APM does not provide meaningful benefits in patients with DMTs and may even be harmful in the longer term. This narrative review focuses on a fundamental question: considering the history and large number of these surgeries, has APM ever actually worked in patients with DMT? A truly effective treatment needs a valid disease model that would biologically and plausibly explain the perceived treatment benefits. In the case of DMT, effectiveness requires a credible framework for the pain-generating process, which should be influenced by APM. Basic research, pathoanatomy, and clinical evidence gives no support to these frameworks. Moreover, treatment of DMT with an APM does not align with the traditional practice of medicine since DMT is not a reliable diagnosis for knee pain and no evidence-based indication exists that would influence patient prognosis from APM. A plausible and robust explanation supported by both basic research and clinical evidence is that DMTs are part of an osteoarthritic disease process and do not contribute to the symptoms independently or in isolation and that symptoms are not treatable with APM. This is further supported by the fact that APM as an intervention is paradoxical because the extent of procedure and severity of disease are both inversely associated with outcome. We argue that arthroscopic treatment of DMT is largely based on a logical fallacy: post hoc ergo propter hoc.

Higher psychological distress in patients seeking care for a knee disorder is associated with diagnostic discordance between health care providers: a secondary analysis of a diagnostic concordance study

Background

Knee disorders are highly prevalent and may be a disabling condition. An accurate diagnosis is necessary to guide toward a rapid and efficient management of knee disorders. However, the ability to make a valid diagnosis is often complex for clinicians and evidence is mainly focused on clinician cognitive biases or errors produced during clinical reasoning. The aim of this secondary exploratory analysis is to identify patient-specific characteristics associated with diagnostic discordance between health care providers in making a diagnosis for a new knee disorder.

Methods

We performed a secondary analysis of a diagnostic study comparing the diagnostic ability of a physiotherapist to medical musculoskeletal specialists. Patients’ socio-demographic, psychosocial and clinical characteristics were compared between the concordant and discordant diagnostic groups. Psychosocial symptoms were evaluated using the validated Kessler 6 (K6) questionnaire. We performed multivariable logistic regressions using the Bayesian Information Criterion to identify the most probable model including patients’ characteristics associated with diagnostic discordance. Overall probability of identified variables to explain diagnostic discordance and associated odd ratios (OR) with 95% credibility intervals (95% CrI) were calculated.

Results

Overall, 279 participants were evaluated by a physiotherapist and medical musculoskeletal specialists. The mean age of the participants was 49.1 ± 15.8 years and 57.7% were female. The most common disorder was osteoarthritis (n = 117, 18.8% of cases were discordant). The most probable model explaining diagnostic discordance (11.13%) included having depressive symptoms, which was associated with an increased probability of diagnostic discordance (OR: 3.9; 95% CrI: 1.9 – 8.0) and having a higher number of comorbidities, which was associated with a decreased probability of diagnostic discordance (OR: 0.6; 95% CrI: 0.5 – 0.9). The depression item of the K6 questionnaire had a 99.4% chance to be included in a model explaining diagnostic discordance. Other variables taken separately had less than 50% chance to be included in a model explaining diagnostic discordance and cannot be considered significant.

Conclusion

Our results suggest that depressive symptoms may increase the risk of knee diagnostic discordance. Clinicians may be more likely to make diagnostic errors and should be more cautious when evaluating patients with knee disorders suffering from psychological distress.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04534-9.