OBJECTIVE: To determine if exercise therapy is superior to arthroscopic partial meniscectomy for knee function in middle aged patients with degenerative meniscal tears.
DESIGN: Randomised controlled superiority trial.
SETTING: Orthopaedic departments at two public hospitals and two physiotherapy clinics in Norway.
PARTICIPANTS: 140 adults, mean age 49.5 years (range 35.7-59.9), with degenerative medial meniscal tear verified by magnetic resonance imaging. 96% had no definitive radiographic evidence of osteoarthritis.
INTERVENTIONS: 12 week supervised exercise therapy alone or arthroscopic partial meniscectomy alone.
MAIN OUTCOME MEASURES: Intention to treat analysis of between group difference in change in knee injury and osteoarthritis outcome score (KOOS4), defined a priori as the mean score for four of five KOOS subscale scores (pain, other symptoms, function in sport and recreation, and knee related quality of life) from baseline to two year follow-up and change in thigh muscle strength from baseline to three months.
RESULTS: No clinically relevant difference was found between the two groups in change in KOOS4 at two years (0.9 points, 95% confidence interval -4.3 to 6.1; P=0.72). At three months, muscle strength had improved in the exercise group (P≤0.004). No serious adverse events occurred in either group during the two year follow-up. 19% of the participants allocated to exercise therapy crossed over to surgery during the two year follow-up, with no additional benefit.
CONCLUSION: The observed difference in treatment effect was minute after two years of follow-up, and the trial's inferential uncertainty was sufficiently small to exclude clinically relevant differences. Exercise therapy showed positive effects over surgery in improving thigh muscle strength, at least in the short term. Our results should encourage clinicians and middle aged patients with degenerative meniscal tear and no definitive radiographic evidence of osteoarthritis to consider supervised exercise therapy as a treatment option.Trial registration www.clinicaltrials.gov (NCT01002794).
OBJECTIVE: The aim of this study was to compare the effect of a 12-wk exercise therapy program and arthroscopic partial meniscectomy on knee strength and functional performance in middle-aged patients with degenerative meniscus tears.
DESIGN: A total of 82 patients (mean age, 49 yrs; 35% women) with a symptomatic, unilateral, magnetic resonance imaging-verified degenerative meniscus tear and no or mild radiographic osteoarthritis were randomly assigned to a supervised neuromuscular and strength exercise program or arthroscopic partial meniscectomy. Outcomes assessed 3 mos after intervention initiation were isokinetic knee muscle strength, lower extremity performance, and self-reported global rating of change.
RESULTS: Mean difference in isokinetic knee extension peak torque between the two groups was 16% (95% confidence interval, 7.1-24.0) (P < 0.0001), favoring the exercise group. Patients in the exercise group improved isokinetic knee extension peak by a mean of 25 Nm (range, 18-33 Nm) from baseline to follow-up. Furthermore, patients assigned to exercise therapy showed statistically significant improvements (P ≤ 0.002) in all other measured variables, with moderate to large effect sizes (0.5-1.3). Patients reported a similar and positive effect of both interventions.
CONCLUSION: A 12-wk supervised exercise therapy program yielded clinically relevant and statistically significant improvement in isokinetic quadriceps strength immediately after completion of the program, as compared with treatment with arthroscopic partial meniscectomy.
OBJECTIVES: Virtually all early cases of knee osteoarthritis have degenerative medial meniscus lesions accompanying the chondral defects on MRI. It is difficult to determine if the symptoms are caused by the unstable meniscus or by osteoarthritis, hence unclear guidance towards treatment. We, therefore, aimed to determine the clinical improvement following arthroscopic meniscectomy compared to intraarticular administration of corticosteroids for degenerative ruptures of the medial meniscus in the presence of early stage medial compartment knee osteoarthritis.
PATIENTS AND METHODS: We included 120 consecutive cases of nontraumatic symptomatic knees which had degenerative lesions of the medial compartment (cartilage and meniscus) on MRI's. They were randomized to receive either intraarticular steroid injection or arthroscopic debridement. We also analyzed the correlation between BMI, age, gender, MRI, intraoperative aspect of the meniscus and cartilage and clinical improvement using the Oxford Knee Score up to one year. At one month there was significant improvement of the scores for all the examined cases. Also at one month, the arthroscopic group performed better in terms of symptom improvement. This was maintained for 79% of the knees in the arthroscopic group and 61% in the intraarticular steroid injection respectively, out of those available for follow up at one year.
RESULTS: At one month, symptoms reappeared for 12 patients in the steroid group and 7 in the arthroscopy respectively. Gender and age did not correlate with treatment, whereas extrusion of the meniscus, bone marrow edema, duration of the clinical symptoms, obesity and a low preoperative score were negative prognostic factors.
CONCLUSIONS: Degenerative medial meniscal tears, in the presence of osteoarthritis, can only marginally benefit from arthroscopic debridement over intraarticular steroid injections in short term follow up. When considering individual cases, factors become more predictive when analyzed in group.
BACKGROUND: Arthroscopic partial meniscectomy is one of the most common orthopedic procedures, yet rigorous evidence of its efficacy is lacking.
METHODS: We conducted a multicenter, randomized, double-blind, sham-controlled trial in 146 patients 35 to 65 years of age who had knee symptoms consistent with a degenerative medial meniscus tear and no knee osteoarthritis. Patients were randomly assigned to arthroscopic partial meniscectomy or sham surgery. The primary outcomes were changes in the Lysholm and Western Ontario Meniscal Evaluation Tool (WOMET) scores (each ranging from 0 to 100, with lower scores indicating more severe symptoms) and in knee pain after exercise (rated on a scale from 0 to 10, with 0 denoting no pain) at 12 months after the procedure.
RESULTS: In the intention-to-treat analysis, there were no significant between-group differences in the change from baseline to 12 months in any primary outcome. The mean changes (improvements) in the primary outcome measures were as follows: Lysholm score, 21.7 points in the partial-meniscectomy group as compared with 23.3 points in the sham-surgery group (between-group difference, -1.6 points; 95% confidence interval [CI], -7.2 to 4.0); WOMET score, 24.6 and 27.1 points, respectively (between-group difference, -2.5 points; 95% CI, -9.2 to 4.1); and score for knee pain after exercise, 3.1 and 3.3 points, respectively (between-group difference, -0.1; 95% CI, -0.9 to 0.7). There were no significant differences between groups in the number of patients who required subsequent knee surgery (two in the partial-meniscectomy group and five in the sham-surgery group) or serious adverse events (one and zero, respectively).
CONCLUSIONS: In this trial involving patients without knee osteoarthritis but with symptoms of a degenerative medial meniscus tear, the outcomes after arthroscopic partial meniscectomy were no better than those after a sham surgical procedure. (Funded by the Sigrid Juselius Foundation and others; ClinicalTrials.gov number, NCT00549172.).
PURPOSE: The aim of this prospective randomized intervention study was to evaluate the outcome at a 2 and 5 year follow-up whether combined arthroscopic surgery followed by exercise therapy was superior to the same exercise therapy alone when treating non-traumatic, degenerative medial meniscal tears.
METHODS: Ninety-six middle-aged patients with MRI-verified degenerative medial meniscus tear and radiographic osteoarthritis grade ≤1 (Ahlbäck) participated in the study. Radiographic examination was done before randomization and after 5 years. The patients were randomly assigned to either arthroscopic treatment followed by exercise therapy for 2 months or to the same exercise therapy alone. At the start of the study and at the follow-ups at 24 and 60 months the patients answered three questionnaires KOOS, Lysholm Knee Scoring Scale and Tegner Activity Scale and made pain ratings on the Visual Analogue Scale (VAS).
RESULTS: Both groups showed highly significant clinical improvements from baseline to the follow-ups at 24 and 60 months on all subscales of KOOS, Lysholm Knee Scoring Scale and VAS (p < 0.0001). No group differences were found at any of the testing occasions. One third of the patients that were treated with exercise therapy alone did not feel better after the treatment but were improved after arthroscopic surgery. According to radiographic findings two patients from each group had a slight progression of their osteoarthritis after 5 years.
CONCLUSION: The findings indicate that arthroscopic surgery followed by exercise therapy was not superior to the same exercise therapy alone for this type of patients. Consequently, exercise therapy can be recommended as initial treatment. However, one third of the patients from the exercise group still had disabling knee symptoms after exercise therapy but improved to the same level as the rest of the patients after arthroscopic surgery with partial meniscectomy.
LEVEL OF EVIDENCE: I.
BACKGROUND: It is still debated whether a degenerative horizontal tear of the medial meniscus should be treated with surgery.
HYPOTHESIS: The clinical outcomes of arthroscopic meniscectomy will be better than those of nonoperative treatment for a degenerative horizontal tear of the medial meniscus.
STUDY DESIGN: Randomized controlled trial; Level of evidence, 1.
METHODS: A total of 102 patients with knee pain and a degenerative horizontal tear of the posterior horn of the medial meniscus on magnetic resonance imaging were included in this study between January 2007 and July 2009. The study included 81 female and 21 male patients with an average age of 53.8 years (range, 43-62 years). Fifty patients underwent arthroscopic meniscectomy (meniscectomy group), and 52 patients underwent nonoperative treatment with strengthening exercises (nonoperative group). Functional outcomes were compared using a visual analog scale (VAS) for pain, Lysholm knee score, Tegner activity scale, and patient subjective knee pain and satisfaction. Radiological evaluations were performed using the Kellgren-Lawrence classification to evaluate osteoarthritic changes.
RESULTS: In terms of clinical outcomes, meniscectomy did not provide better functional improvement than nonoperative treatment. At the final follow-up, the average VAS scores were 1.8 (range, 1-5) in the meniscectomy group and 1.7 (range, 1-4) in the nonoperative group (P = .675). The average Lysholm knee scores at 2-year follow-up were 83.2 (range, 52-100) and 84.3 (range, 58-100) in the meniscectomy and nonoperative groups, respectively (P = .237). In addition, the average Tegner activity scale and subjective satisfaction scores were not significantly different between the 2 groups. Although most patients initially had intense knee pain with mechanical symptoms, both groups reported a relief in knee pain, improved knee function, and a high level of satisfaction with treatment (P < .05 for all values). Two patients in the meniscectomy group and 3 in the nonoperative group with Kellgren-Lawrence grade 1 progressed to grade 2 at the 2-year follow-up.
CONCLUSION: There were no significant differences between arthroscopic meniscectomy and nonoperative management with strengthening exercises in terms of relief in knee pain, improved knee function, or increased satisfaction in patients after 2 years of follow-up.
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.).
The purpose of this pilot study was to compare the effectiveness of conservative therapy involving medical exercise therapy (MET) versus arthroscopic surgery in patients with knee pain, with MRI-verified degenerative meniscus. The patients were randomly assigned either to MET (n = 9) or to arthroscopic surgery (n = 8). Patients receiving MET had 3 treatments a week for 3 months, a total of 36 treatments. The arthroscopy consisted of meniscectomy with no structured conservative therapy after surgery. Assessment of pain, function, anxiety and depression were performed at inclusion and after 3 months. At the end of treatment, which was 3 months after inclusion, there were no statistical differences between the two groups regarding pain and function. However, anxiety and depression were significantly reduced in the MET group compared with the patients receiving arthroscopic surgery. Bearing in mind the low number of included patients in this pilot study, arthroscopy was found to be no better than MET regarding knee pain and overall daily function. The results from this pilot study are similar to other clinical studies, thereby demonstrating that conservative therapy is just as effective as surgery.
To determine if exercise therapy is superior to arthroscopic partial meniscectomy for knee function in middle aged patients with degenerative meniscal tears.
DESIGN:
Randomised controlled superiority trial.
SETTING:
Orthopaedic departments at two public hospitals and two physiotherapy clinics in Norway.
PARTICIPANTS:
140 adults, mean age 49.5 years (range 35.7-59.9), with degenerative medial meniscal tear verified by magnetic resonance imaging. 96% had no definitive radiographic evidence of osteoarthritis.
Intention to treat analysis of between group difference in change in knee injury and osteoarthritis outcome score (KOOS4), defined a priori as the mean score for four of five KOOS subscale scores (pain, other symptoms, function in sport and recreation, and knee related quality of life) from baseline to two year follow-up and change in thigh muscle strength from baseline to three months.
RESULTS:
No clinically relevant difference was found between the two groups in change in KOOS4 at two years (0.9 points, 95% confidence interval -4.3 to 6.1; P=0.72). At three months, muscle strength had improved in the exercise group (P≤0.004). No serious adverse events occurred in either group during the two year follow-up. 19% of the participants allocated to exercise therapy crossed over to surgery during the two year follow-up, with no additional benefit.
CONCLUSION:
The observed difference in treatment effect was minute after two years of follow-up, and the trial's inferential uncertainty was sufficiently small to exclude clinically relevant differences. Exercise therapy showed positive effects over surgery in improving thigh muscle strength, at least in the short term. Our results should encourage clinicians and middle aged patients with degenerative meniscal tear and no definitive radiographic evidence of osteoarthritis to consider supervised exercise therapy as a treatment option.Trial registration www.clinicaltrials.gov (NCT01002794).
