article314

METEOR

"Arthroscopic Partial Meniscectomy versus Physical Therapy in Patients with Degenerative Meniscus Tears". The New England Journal of Medicine. Published: March 19, 2013, Updated: August 1, 2013.

Clinical Question

Does arthroscopic partial meniscectomy lead to better functional outcomes compared to nonoperative therapy in patients with meniscal tears and knee osteoarthritis?

Bottom Line

Arthroscopic partial meniscectomy did not result in significantly better functional outcomes than nonoperative therapy in patients aged 45 or older with meniscal tears and evidence of mild-to-moderate osteoarthritis.

Major Points

Meniscal tears and knee osteoarthritis are common in the population over 45 years of age. Whether surgical treatment for meniscal tears provides better functional outcomes than nonoperative therapy in these patients is uncertain. This multicenter, randomized, controlled trial evaluated this question and found no significant differences in improvement in functional status and pain between arthroscopic partial meniscectomy and standardized physical therapy.

Guidelines

As a result of this and similar studies, modern guidelines do not recommend the routine use of arthroscopic partial meniscectomy in patients with meniscal tears and concomitant degenerative knee disease.

Design

- Multicenter, randomized, controlled trial
- N=351 symptomatic patients aged ≥45 years with meniscal tear and mild-to-moderate osteoarthritis (per imaging)
- Intervention: Arthroscopic partial meniscectomy with postoperative physical therapy (n=174)
- Comparison: Standardized physical-therapy regimen alone (n=177)
- Follow-up: 6 and 12 months
- Primary Outcome: Change in WOMAC physical-function score at 6 months
- Funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases

Population

- Inclusion criteria: Symptomatic patients aged ≥45 years with a meniscal tear and evidence of mild-to-moderate osteoarthritis on imaging
- Exclusion Criteria: Detailed in the Supplementary Appendix

Interventions

- Arthroscopic partial meniscectomy with postoperative physical therapy including weight bearing as tolerated, no bracing
- Standardized physical therapy regimen focused on inflammation, range of motion, strength, aerobic conditioning, and functional mobility

Outcomes

- Primary outcome: Difference in the change of WOMAC physical-function score at 6 months; no significant difference found between the groups, the mean difference of 2.4 points favored arthroscopic meniscectomy but was not statistically significant (95% CI, -1.8 to 6.5)
- Secondary outcomes at 12 months: Similar to 6-month findings, with no significant differences in WOMAC physical-function and KOOS pain scores between surgical and nonoperative groups
- 30% of patients in the physical therapy group crossed over to surgery within 6 months, increasing to 35% by 12 months
- Adverse events did not differ significantly between the groups

Criticisms

- Only 26% of eligible patients were enrolled, so results may not generalize to all patients with meniscal tears and osteoarthritis
- Non-blinded treatment assignments could introduce bias
- Crossover from the physical therapy to surgery group complicates interpretation

Funding

- Grants from the National Institute of Arthritis and Musculoskeletal and Skin Diseases