Surgery versus Physical Therapy for a Meniscal Tear and Osteoarthritis

Abstract

BACKGROUND Whether arthroscopic partial meniscectomy for symptomatic patients with a meniscal tear and knee osteoarthritis results in better functional outcomes than nonoperative therapy is uncertain. METHODS We conducted a multicenter, randomized, controlled trial involving symptomatic patients 45 years of age or older with a meniscal tear and evidence of mild-to-moderate osteoarthritis on imaging. We randomly assigned 351 patients to surgery and postoperative physical therapy or to a standardized physical-therapy regimen (with the option to cross over to surgery at the discretion of the patient and surgeon). The patients were evaluated at 6 and 12 months. The primary outcome was the difference between the groups with respect to the change in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) physical-function score (ranging from 0 to 100, with higher scores indicating more severe symptoms) 6 months after randomization. RESULTS In the intention-to-treat analysis, the mean improvement in the WOMAC score after 6 months was 20.9 points (95% confidence interval [CI], 17.9 to 23.9) in the surgical group and 18.5 (95% CI, 15.6 to 21.5) in the physical-therapy group (mean difference, 2.4 points; 95% CI, −1.8 to 6.5). At 6 months, 51 active participants in the study who were assigned to physical therapy alone (30%) had undergone surgery, and 9 patients assigned to surgery (6%) had not undergone surgery. The results at 12 months were similar to those at 6 months. The frequency of adverse events did not differ significantly between the groups. CONCLUSIONS In the intention-to-treat analysis, we did not find significant differences between the study groups in functional improvement 6 months after randomization; however, 30% of the patients who were assigned to physical therapy alone underwent surgery within 6 months. (Funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases; METEOR ClinicalTrials.gov number, NCT00597012.)

Changes in rates of arthroscopy due to degenerative knee disease and traumatic meniscal tears in Finland and Sweden

“…We are currently witnessing a notable shift in the indications for knee arthroscopy. 7 high-quality randomized controlled trials assessing the benefit of arthroscopic partial meniscectomy for patients with degenerative meniscal tears were recently published (Østerås et al 2012, Herrlin et al 2013, Katz et al 2013, Sihvonen et al 2013, Yim et al 2013, Gauffin et al 2014, Stensrud et al 2015). Only 1 of these trials (Gauffin et al 2014) provided any support for surgery of the degenerative knee.…”

Total Knee Arthroplasty After Previous Knee Surgery

“…Given the high incidence of meniscal tears in older patient populations 12 , magnetic resonance imaging (MRI) is not indicated in patients over the age of fifty years without mechanical complaints, unless specifically ruling out osteonecrosis. It is imperative to make weight-bearing radiographs in this population prior to arthroscopic partial meniscectomy, which will not be efficacious with substantial joint space narrowing, although a recent prospective, multicenter study demonstrated that arthroscopic partial meniscectomy can be an effective treatment for patients over the age of forty years with a meniscal tear and mild to moderate degenerative changes 13 . Knee arthroscopy is not an effective treatment for knee osteoarthritis 14,15 and patients should be advised of the low expectation for improvement.…”

Not the Last Word: Choosing Wisely

“…This result confirms the findings of previous randomized controlled trials of patients with varying degrees of knee osteoarthritis and degenerative meniscal tears. These trials showed that combined arthroscopic surgery and exercise therapy is not more effective than exercise therapy alone [22,23,25,37]. These results are further backed up by a subgroup analysis of patients with mechanical symptoms of catching or locking in a randomized trial of arthroscopic surgery for osteoarthritis of the knee by Kirkley and colleagues [26].…”