Predictors and Outcomes of Crossover to Surgery from Physical Therapy for Meniscal Tear and Osteoarthritis

Katz, Jeffrey N.; Wright, John; Spindler, Kurt P.; Mandl, Lisa A.; Safran‐Norton, Clare E.; Reinke, Emily K.; Levy, Bruce A.; Wright, Rick W.; Jones, Morgan H.; Martin, Scott D.; Marx, Robert G.; Losina, Elena

doi:10.2106/jbjs.15.01466

Cited by 46 publications

(73 citation statements)

References 27 publications

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“…Subjects who crossed over from PT to APM had higher baseline pain and slower initial clinical improvement. Since these factors may be associated with more rapid structural progression, we did not include the crossovers in the primary analysis . We performed a secondary as‐treated analysis, also mechanistic in focus, in which subjects crossing over from PT to APM within 6 months of randomization were analyzed in the surgical group.…”

Section: Methodsmentioning

confidence: 99%

Early Magnetic Resonance Imaging–Based Changes in Patients With Meniscal Tear and Osteoarthritis: Eighteen‐Month Data From a Randomized Controlled Trial of Arthroscopic Partial Meniscectomy Versus Physical Therapy

Collins

Losina

Marx

et al. 2020

Arthritis Care & Research

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Objective. The present study was undertaken to evaluate changes in knee magnetic resonance imaging (MRI) findings over the course of 18 months in subjects with osteoarthritic change and meniscal tear treated with arthroscopic partial meniscectomy (APM) or nonoperatively with physical therapy (PT).Methods. We used 18-month follow-up data from the Meniscal Tear in Osteoarthritis Research Trial. MRI results were read with reference to the MRI Osteoarthritis Knee Score. We focused on 18-month change in bone marrow lesions (BMLs), cartilage thickness, cartilage surface area, osteophyte size, effusion-synovitis, and Hoffa-synovitis. We used multinomial logistic regression to assess associations between MRI-based changes in each feature and treatment type.Results. A total of 351 subjects were randomized, and 225 had both baseline and 18-month MRI results. In both treatment groups, patients experienced substantial changes in several MRI-based markers. In 60% of the APM group, versus 33% of the PT group, cartilage surface area damage advanced in ≥2 subregions (adjusted odds ratio 4.2 [95% confidence interval 2.0-9.0). Patients who underwent APM also had greater advancement in scores for osteophytes and effusion-synovitis. We did not find significant associations between treatment type and change in cartilage thickness, BMLs, or Hoffa-synovitis.Conclusion. This cohort of patients with meniscal tear and osteoarthritis showed marked advancement in MRI-based features over 18 months. Patients treated with APM showed more advancement in some features compared to those treated nonoperatively. The clinical relevance of these early findings is unknown and requires further study.Recent estimates suggest that 14 million adults in the US have knee osteoarthritis (OA), including 8 million individuals under 65 years of age (1). Of these, ~80% have a concomitant meniscal tear (2). Nonoperative treatment of symptomatic meniscal tear typically includes a physical therapy (PT) regimen (muscle strengthening, endurance, flexibility, and balance training). Surgical treatment ClinicalTrials.gov identifier: NCT00597012.

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Section: Methodsmentioning

confidence: 99%

Early Magnetic Resonance Imaging–Based Changes in Patients With Meniscal Tear and Osteoarthritis: Eighteen‐Month Data From a Randomized Controlled Trial of Arthroscopic Partial Meniscectomy Versus Physical Therapy

Collins

Losina

Marx

et al. 2020

Arthritis Care & Research

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“… 19–21 These findings have been interpreted as evidence that APM should be performed after failed conservative treatment. 22 Although such hypotheses might well be true, an alternative accounting can explain the number of crossovers and the beneficial treatment effects of surgery after failed conservative treatment: lack of blinding (participants’ knowledge of not having undergone surgery) may drive conservatively treated patients to request surgery and also make them feel more content with the outcome once having undergone surgery. 23 24 …”

Section: Introductionmentioning

confidence: 99%

Arthroscopic partial meniscectomy versus placebo surgery for a degenerative meniscus tear: a 2-year follow-up of the randomised controlled trial

Sihvonen¹,

et al. 2017

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ObjectiveTo assess if arthroscopic partial meniscectomy (APM) is superior to placebo surgery in the treatment of patients with degenerative tear of the medial meniscus.MethodsIn this multicentre, randomised, participant-blinded and outcome assessor-blinded, placebo-surgery controlled trial, 146 adults, aged 35–65 years, with knee symptoms consistent with degenerative medial meniscus tear and no knee osteoarthritis were randomised to APM or placebo surgery. The primary outcome was the between-group difference in the change from baseline in the Western Ontario Meniscal Evaluation Tool (WOMET) and Lysholm knee scores and knee pain after exercise at 24 months after surgery. Secondary outcomes included the frequency of unblinding of the treatment-group allocation, participants' satisfaction, impression of change, return to normal activities, the incidence of serious adverse events and the presence of meniscal symptoms in clinical examination. Two subgroup analyses, assessing the outcome on those with mechanical symptoms and those with unstable meniscus tears, were also carried out.ResultsIn the intention-to-treat analysis, there were no significant between-group differences in the mean changes from baseline to 24 months in WOMET score: 27.3 in the APM group as compared with 31.6 in the placebo-surgery group (between-group difference, −4.3; 95% CI, −11.3 to 2.6); Lysholm knee score: 23.1 and 26.3, respectively (−3.2; −8.9 to 2.4) or knee pain after exercise, 3.5 and 3.9, respectively (−0.4; −1.3 to 0.5). There were no statistically significant differences between the two groups in any of the secondary outcomes or within the analysed subgroups.ConclusionsIn this 2-year follow-up of patients without knee osteoarthritis but with symptoms of a degenerative medial meniscus tear, the outcomes after APM were no better than those after placebo surgery. No evidence could be found to support the prevailing ideas that patients with presence of mechanical symptoms or certain meniscus tear characteristics or those who have failed initial conservative treatment are more likely to benefit from APM.

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“…Orthopaedic surgeons have expressed concerns about the generalisability of the trial results and point out that the study samples are not representative of the subjects they select for surgery in their day-to-day clinical practice 18–24. The common perception by most surgeons is that there are subgroups of patients that do need the procedure to improve 8.…”

Section: Introductionmentioning

confidence: 99%

Arthroscopic meniscectomy versus non-surgical or sham treatment in patients with MRI confirmed degenerative meniscus lesions: a protocol for an individual participant data meta-analysis

Wijn¹,

Rovers²,

Rongen³

et al. 2020

BMJ Open

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IntroductionArthroscopic partial meniscectomy (APM) after degenerative meniscus tears is one of the most frequently performed surgeries in orthopaedics. Although several randomised controlled trials (RCTs) have been published that showed no clear benefit compared with sham treatment or non-surgical treatment, the incidence of APM remains high. The common perception by most orthopaedic surgeons is that there are subgroups of patients thatdoneed APM to improve, and they argue that each study sample of the existing trials is not representative for the day-to-day patients in the clinic. Therefore, the objective of this individual participant data meta-analysis (IPDMA) is to assess whether there are subgroups of patients with degenerative meniscus lesions who benefit from APM in comparison with non-surgical or sham treatment.Methods and analysisAn existing systematic review will be updated to identify all RCTs worldwide that evaluated APM compared with sham treatment or non-surgical treatment in patients with knee symptoms and degenerative meniscus tears. Time and effort will be spent in contacting principal investigators of the original trials and encourage them to collaborate in this project by sharing their trial data. All individual participant data will be validated for missing data, internal data consistency, randomisation integrity and censoring patterns. After validation, all datasets will be combined and analysed using a one-staged and two-staged approach. The RCTs’ characteristics will be used for the assessment of clinical homogeneity and generalisability of the findings. The most important outcome will be the difference between APM and control groups in knee pain, function and quality of life 2 years after the intervention. Other outcomes of interest will include the difference in adverse events and mental health.Ethics and disseminationAll trial data will be anonymised before it is shared with the authors. The data will be encrypted and stored on a secure server located in the Netherlands. No major ethical concerns remain. This IPDMA will provide the evidence base to update and tailor diagnostic and treatment protocols as well as (international) guidelines for patients for whom orthopaedic surgeons consider APM. The results will be submitted for publication in a peer-reviewed journal.PROSPERO registration numberCRD42017067240.

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Predictors and Outcomes of Crossover to Surgery from Physical Therapy for Meniscal Tear and Osteoarthritis

Cited by 46 publications

References 27 publications

Early Magnetic Resonance Imaging–Based Changes in Patients With Meniscal Tear and Osteoarthritis: Eighteen‐Month Data From a Randomized Controlled Trial of Arthroscopic Partial Meniscectomy Versus Physical Therapy

Early Magnetic Resonance Imaging–Based Changes in Patients With Meniscal Tear and Osteoarthritis: Eighteen‐Month Data From a Randomized Controlled Trial of Arthroscopic Partial Meniscectomy Versus Physical Therapy

Arthroscopic partial meniscectomy versus placebo surgery for a degenerative meniscus tear: a 2-year follow-up of the randomised controlled trial

Arthroscopic meniscectomy versus non-surgical or sham treatment in patients with MRI confirmed degenerative meniscus lesions: a protocol for an individual participant data meta-analysis

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