Published online May 18, 2016. doi: 10.5312/wjo.v7.i5.287
Peer-review started: July 2, 2015
First decision: August 25, 2015
Revised: January 13, 2016
Accepted: January 27, 2016
Article in press: January 29, 2016
Published online: May 18, 2016
The role of arthroscopic partial meniscectomy (APM) in reducing pain and improving function in patients with meniscal tears remains controversial. Five recent high-quality randomized controlled trials (RCTs) compared non-operative management of meniscal tears to APM, with four showing no difference and one demonstrating superiority of APM. In this review, we examined the strengths and weaknesses of each of these RCTs, with particular attention to the occurrence of inadvertent biases. We also completed a quantitative analysis that compares treatment successes in each treatment arm, considering crossovers as treatment failures. Our analysis revealed that each study was an excellent attempt to compare APM with non-surgical treatment but suffered from selection, performance, detection, and/or transfer biases that reduce confidence in its conclusions. While the RCT remains the methodological gold standard for establishing treatment efficacy, the use of an RCT design does not in itself ensure internal or external validity. Furthermore, under our alternative analysis of treatment successes, two studies had significantly more treatment successes in the APM arm than the non-operative arm although original intention-to-treat analyses showed no difference between these two groups. Crossovers remain an important problem in surgical trials with no perfect analytical solution. With the studies available at present, no conclusion can be drawn concerning the optimal treatment modality for meniscal tears. Further work that minimizes significant biases and crossovers and incorporates sub-group and cost-benefit analyses may clarify therapeutic indications.
Core tip: Despite several recent high-quality randomized controlled trials, the efficacy of arthroscopic partial meniscectomy (APM) for meniscal tears remains controversial. In this review, we analyzed the five most important trials for potential inadvertent biases. Each study was found to have some combination of selection, performance, detection, and transfer biases that compromise its conclusion. We also completed an alternative analysis of their results that took into account the observed high crossover rates. This analysis suggested that two studies whose original conclusions showed no superiority of APM may in fact support APM.