Letter to the Editor

Authors’ Reply

We aimed to determine if the randomized controlled trials (RCTs) evaluated in the most recent meta-analysis on arthroscopic surgery for degenerative knee arthritis included documented trials of appropriate conservative treatment prior to randomization.

We selected all RCTs of the most recent meta-analysis by Brignardello-Petersen and recorded for each RCT, if physiotherapy prior to randomization was mandatory. We compared the treatment effect of arthroscopy in studies in which physiotherapy prior to randomization was mandatory versus studies in which it was not. This review was registered in the PROSPERO database (CRD42017070091).

Of the 13 RCTs in the meta-analysis, there were 2 in which physiotherapy prior to randomization was mandatory. In 1 additional multicenter RCT, prior conservative treatment was mentioned as mandatory in the publication, but not in the protocol. The treatment effects attributed to arthroscopy in terms of short-term pain (P = .0037), short-term function (P = .0309), and long-term function (P = .0012) were larger in studies in which prior physiotherapy was mandatory.

Although the most recent meta-analysis claims that it is based “on patients who do not respond to conservative treatment,” physiotherapy was mandatory prior to randomization only in 2 of the 13 studies. As several orthopaedic guidelines recommend that the first line of treatment in patients with degenerative arthritis of the knee should be conservative, for instance with physiotherapy, and the question of performing arthroscopy arises once conservative treatment fails, 11 of the 13 RCTs failed to adhere to these accepted guidelines. Therefore, patient selection in these 11 studies may not represent the typical indications for arthroscopy, where patients have tried conservative management prior to being offered surgery. When comparing studies where prior physiotherapy was mandatory to studies in which it was not mandatory, there were statistically significant effects favoring arthroscopy in terms of pain in the short term, and for function both in the short and the long term. These findings suggest that the treatment effects attributed to arthroscopy were higher when prior physiotherapy was mandatory. Given these findings, the external validity of most of these RCTs, and the resulting “strong recommendation against the use of arthroscopy in nearly all patients with degenerative knee disease,” is called into question.

Level II, systematic review of Level I and II studies.

Randomized controlled studies have a high level of evidence. However, some patients are not treated in the manner to which they were randomized and actually switch to the alternative treatment (crossover). In such cases, “intent-to-treat” statistical methods require that such a switch be ignored, resulting in bias. Thus, the study conclusions could be wrong. This bias is a common problem in the knee meniscus literature.

Superior labrum from anterior to posterior (SLAP) lesions are a slap in the face to the revered trinity of history, physical examination, and imaging. SLAP lesions are difficult to diagnose, and arthroscopy is not only the gold standard, but the current method on which expert arthroscopic shoulder subspecialists rely.

This article provides a broad overview of the clinical nonpharmacologic treatment options for managing acute and chronic pain. Physical therapy and modalities, interventional techniques, emerging regenerative medicine, and cognitive behavioral paradigms of treatment are presented. Recommendations are evidence-based and are a practical resource for the musculoskeletal pain and sports medicine practitioner.

In contrast to the AAOS knee osteoarthritis guidelines, systematic review of overlapping meta-analyses shows that viscosupplementation with intra-articular hyaluronic acid injection reduces knee osteoarthritis pain and improves function according to the highest level of evidence.