Meniscal Tears: Arthroscopic Surgery vs. Physiotherapy

Meniscal Tears: Physio vs. Arthroscopic Surgery

Degen_meniscal_tear
Symptomatic osteoarthritis is generally acknowledged to be the commonest cause for middle-aged patients, presenting to medical care with knee pain. Within this same age group, meniscal “cartilage” tears are also common, present in roughly 35% of patients over 50 years of age, usually with minimal symptoms. Given that these conditions often occur together, it is sometimes quite challenging to sort out which is the principal cause for ongoing knee symptoms.

Arthroscopic knee surgery is generally considered to be ineffective for the treatment of osteoarthritis (wear and tear arthritis). There remains some belief that arthroscopy can be helpful for the treatment of meniscal (cartilage) tears.

A well designed, multi-centre randomized, controlled trial published yesterday in the New England Journal of medicine challenges the notion that arthroscopic surgery is any better than physiotherapy, for the treatment of knee pain in those with both arthritis and a meniscal tear. This study screened a large number of candidates, enrolling 351 patients that consented to participate. Patients over age 45 years of age, with both knee arthritis and meniscal tears had to meet strict study criteria to participate. Patients were then randomly assigned to treatment consisting either of physiotherapy alone or arthroscopic surgery followed by physiotherapy.

Arthroscopic Partial Meniscectomy (Surgical group)
Surgeons performed an arthroscopy with partial meniscectomy by trimming the damaged meniscus cartilage back to stable tissue. Surgeons also removed loose fragments of cartilage and bone (also known as debridement). Bracing was not used. Patients were then referred to physiotherapy for a postoperative program using the same protocol used in the physiotherapy group, described below.

Physiotherapy
The treatment group was based on literature supporting the effectiveness of land-based, individualized physiotherapy along with progressive home exercise for patients with knee osteoarthritis. The 3 stage protocol was designed to address issues typically present in arthritic knees. Patients were encouraged to attend physiotherapy sessions once or twice weekly and perform exercises at home. Pace and progress varied, with the program usually lasting about 6 weeks.
In both the arthroscopic-partial-meniscectomy and physiotherapy groups, patients were permitted to take acetaminophen and/or non-steroidal anti-inflammatory agents as needed. Some patients in both groups received cortisone shots over the course of the trial.

Looking at outcome scores for pain and overall function, both treatment groups showed similar improvement at both 6 and 12 months into the study. There were no significant differences regarding adverse outcomes. About one third of the physio patients chose to have surgery during the treatment period, presumably for nonresponsive symptoms. Similar numbers from both groups went on to have knee replacements over the relatively short period studied.

My take*…
These findings help us deal more objectively with the relatively common situation in which middle-aged present with both meniscal AND osteoarthritic findings. In the absence of mechanical locking, most patients should undergo a trial of physiotherapy and/or home exercise, before considering arthroscopic surgery. Surgery warrants consideration for patients that fail to respond to non-operative treatment, but patients should realize that results are by no means guaranteed. Further, well-designed scientific study is necessary to try and identify subgroups that would benefit more predictably from surgical intervention.

Full Scientific Article -link

K McKenzie MD
*The opinions expressed here are those of the writer, at the time this article was posted. These opinions are presented for education and discussion purposes only and are not meant to constitute direct medical advice. Individual patients/results may vary. Patients are strongly encouraged to seek professional medical advice before deciding on treatments options.

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