Functional Outcomes of Arthroscopic Partial Meniscectomy Versus Physical Therapy for Degenerative Meniscal Tears Using a Patient-Specific Score: A Randomized Controlled Trial

Abstract

Background: It is unknown whether the treatment effects of partial meniscectomy and physical therapy differ when focusing on activities most valued by patients with degenerative meniscal tears. Purpose: To compare partial meniscectomy with physical therapy in patients with a degenerative meniscal tear, focusing on patients’ most important functional limitations as the outcome. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: This study is part of the Cost-effectiveness of Early Surgery versus Conservative Treatment with Optional Delayed Meniscectomy for Patients over 45 years with non-obstructive meniscal tears (ESCAPE) trial, a multicenter noninferiority randomized controlled trial conducted in 9 orthopaedic hospital departments in the Netherlands. The ESCAPE trial included 321 patients aged between 45 and 70 years with a symptomatic, magnetic resonance imaging–confirmed meniscal tear. Exclusion criteria were severe osteoarthritis, body mass index >35 kg/m2, locking of the knee, and prior knee surgery or knee instability due to an anterior or posterior cruciate ligament rupture. This study compared partial meniscectomy with physical therapy consisting of a supervised incremental exercise protocol of 16 sessions over 8 weeks. The main outcome measure was the Dutch-language equivalent of the Patient-Specific Functional Scale (PSFS), a secondary outcome measure of the ESCAPE trial. We used crude and adjusted linear mixed-model analyses to reveal the between-group differences over 24 months. We calculated the minimal important change for the PSFS using an anchor-based method. Results: After 24 months, 286 patients completed the follow-up. The partial meniscectomy group (n = 139) improved on the PSFS by a mean of 4.8 ± 2.6 points (from 6.8 ± 1.9 to 2.0 ± 2.2), and the physical therapy group (n = 147) improved by a mean of 4.0 ± 3.1 points (from 6.7 ± 2.0 to 2.7 ± 2.5). The crude overall between-group difference showed a –0.6-point difference (95% CI, –1.0 to –0.2; P = .004) in favor of the partial meniscectomy group. This improvement was statistically significant but not clinically meaningful, as the calculated minimal important change was 2.5 points on an 11-point scale. Conclusion: Both interventions were associated with a clinically meaningful improvement regarding patients’ most important functional limitations. Although partial meniscectomy was associated with a statistically larger improvement at some follow-up time points, the difference compared with physical therapy was small and clinically not meaningful at any follow-up time point. Registration: NCT01850719 ( ClinicalTrials.gov identifier) and NTR3908 (the Netherlands Trial Register).

In patients eligible for meniscal surgery who first receive physical therapy, multivariable prognostic models cannot predict who will eventually undergo surgery

“…The efficacy of physical therapy was not investigated in this study. However, given the absence of a clinically relevant benefit of surgery over conservative treatment [ 2 , 4 – 7 , 9 , 12 , 16 , 17 , 21 , 25 ], and the lack of clear prognostic characteristics for treatment outcomes [ 13 ], clinicians should rely more on the current guidelines recommending physical therapy as the first-line treatment in patients with degenerative meniscal tears. [ 15 , 19 ]…”

“…Current guidelines state that physical therapy is the preferred first-line treatment in patients over 45 years of age with a degenerative meniscal tear [ 15 , 19 ]. These guidelines are based on several randomized clinical trials (RCT) which demonstrated no clinically superiority of meniscal surgery over physical therapy in this population [ 2 , 4 – 7 , 9 , 12 , 16 , 17 , 21 , 25 ]. However, not all patients experience beneficial results from physical therapy.…”

Editorial Commentary: Arthroscopic Partial Meniscectomy Is Not a First-Line Treatment for Degenerative Meniscus Tear: To Meniscectomize or Not to Meniscectomize?

“…That is probably the basis for APM not being superior to physiotherapy in that setting, as has been shown in several investigations. 3,4 In addition, APM has been associated with an increased risk of radiographic knee osteoarthritis progression without a clear benefit for knee symptoms or function when compared with sham surgery. 5,6 However, APM in DMTs continues to be one of the most widely practiced interventions in orthopaedics.…”

Treatment of post-meniscectomy knee symptoms with medial meniscus replacement results in greater pain reduction and functional improvement than non-surgical care

“…Evidence from randomized controlled trials (RCT) has suggested that partial meniscectomy may not be superior to non-surgical care alone or sham surgery, but some trials had important study design limitations and high cross-over rates [1,7,27,32,33,35,36]. Nonetheless, expert consensus statements and professional societies recommend partial meniscectomy for patients with irreparable meniscus tears and mechanical knee symptoms that are refractory to at least 3 months of non-surgical care [5,19].…”

“…The principal goals of partial meniscectomy are to relieve knee pain and functional limitations through the surgical removal of loose, unstable meniscal fragments and smoothing of frayed edges to prevent additional tearing. Evidence from randomized controlled trials (RCT) has suggested that partial meniscectomy may not be superior to non-surgical care alone or sham surgery, but some trials had important study design limitations and high cross-over rates [ 1 , 7 , 27 , 32 , 33 , 35 , 36 ]. Nonetheless, expert consensus statements and professional societies recommend partial meniscectomy for patients with irreparable meniscus tears and mechanical knee symptoms that are refractory to at least 3 months of non-surgical care [ 5 , 19 ].…”