STUDY COMPARES MENISCAL TEAR TREATMENT - PHYSICAL THERAPY (PT) VS SURGERY (MAR 2013)
The meniscus is a cartilage pad that sits on top of the tibia bone. It forms a rim of cartilage that the femur sits in where the two bones articulate (knee joint).
Meniscal tears have been observed in up to 35% of people aged 50 years and older, and two-thirds of these tears do not cause symptoms. Meniscal tears are often treated surgically in a
procedure where the tear is trimmed away. In the U.S., more than 465,000 meniscal repairs are performed annually.
- A study in the NEJM compared surgical meniscal repair to physical therapy in 351 patients with a meniscal tear and signs of osteoarthritis.
- Main inclusion criteria: ≥ 45 years old, symptoms for 4 weeks, symptoms of torn meniscus (at least one of the following: clicking, catching, popping, giving way, pain with
pivot or torque, episodic pain, pain that is acute and localized to one joint line), evidence of osteoarthritis on X-ray or MRI, meniscal tear on MRI
- Main exclusion criteria: Severe osteoarthritis, locked knee
- Patients were randomized to one of two groups:
- Surgical group - Surgical meniscal repair followed by PT (174 patients)
- Physical therapy (PT) and watch - Physical therapy with option for later surgical meniscal repair if needed (177 patients)
- PRIMARY OUTCOME: Difference between groups in change in score from baseline on the WOMAC Index (measure of knee function) at 6 months
- After 6 months, the following was seen:
- There was no significant difference in the change from baseline in the WOMAC physical-function index between the two groups
- There was no significant difference in pain scores between the two groups
- In the PT group, 30% of the patients eventually had surgery (crossovers)
- In the Surgery group, 5.6% of patients had not undergone surgery
- An as-treated analysis found no difference between the two groups at 6 and 12 months
- At 12 months, there was no significant difference between the two groups for the 6 month outcomes
- This study is pertinent for the following reasons:
- It supports a "physical therapy and watch" approach to meniscal tears in older individuals with mild-to-moderate osteoarthritis
- By one year, 35% of the patients in the PT group had crossed over and had surgery. This means 65% of patients who are treated with PT will likely never need surgery.
- This study has the following limitations:
- The study population was older (average age 58 years), and patients had mild-to-moderate osteoarthritis. These results cannot be extrapolated to younger, more active patients without
- The crossover rate was high (30-35%). High crossover rates will often bias a study toward the null (no difference).
- The as-treated analysis found no significant difference, but this analysis is subject to bias and loss of randomization