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.).

Figure 1. Trial Enrollment and Follow-up

APM denotes arthroscopic partial meniscectomy, MRI magnetic resonance imaging, PT physical therapy, and TKR total knee replacement.

Figure 2. Scores on the WOMAC Physical-Function Scale and KOOS Pain Scale over the 12-Month Follow-up Period

Panel A shows the scores on the physical-function scale of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Panel B shows the scores on the pain scale of the Knee Injury and Osteoarthritis Outcome Scale (KOOS); scores on both scales range from 0 to 100, with higher scores indicating more severe symptoms. I bars indicate 95% confidence intervals. Panel C shows WOMAC physical-function scores in the APM group and in the PT group according to crossover status. The asterisk indicates that nine patients assigned to APM did not undergo surgery.