Written by Kevin Liu
Spoon Feed
Though confounded by high crossover, there were no outcome differences in patients with meniscal tears and knee osteoarthritis (OA) treated with arthroscopic surgery with post-operative physical therapy (PT) versus PT alone.
Use it or lose it; keep moving to improve the knee pain
Symptomatic, radiographically confirmed OA of the knee affects roughly 32.5 million Americans, with meniscal tears in 35% of patients over 50 and more prevalent in patients with OA. This landmark 2013 trial compared patients with symptomatic mild-to-moderate OA and meniscal tears treated with partial meniscectomies plus post-operative PT vs. PT alone to assess outcomes of physical function (WOMAC score) and pain (KOOS score).
In the intention-to-treat analysis, the mean improvement in the WOMAC score after 6 months was 20.9 points (95%CI 17.9 to 23.9) in the surgical group and 18.5 (95%CI 15.6 to 21.5) in the PT group, with no significant difference between groups. At 6 months, 51 study participants initially assigned to PT alone (30%) crossed over to surgery and 9 patients randomized to surgery (6%) had not undergone surgery. Outcomes at 12 months were similar to 6 months.
Limitations to the trial included no assessment of surgery or PT fidelity, the study being unblinded, and the high crossover, which also included a cohort that elected to have total knee replacements (5 patients in the surgical cohort and 3 in the PT alone).
How does this change my practice?
Since this article’s publication, there are now multiple treatment modalities for OA that include glucocorticoid injections, mesenchymal stem cells, allograft/autograft transplants, platelet rich plasma, hyaluronic acid injections, and even meniscal allograft transplants for meniscal tears. Currently, conservative management remains first-line for the treatment of both meniscal tears and knee OA, as meta-analyses of treatment modalities remains mixed. Until a definitive RCT demonstrates a clear benefit of one modality, my recommendation to myself and others is use or lose it; the most important treatment of knee pain is movement and PT.
Source
Surgery versus physical therapy for a meniscal tear and osteoarthritis. N Engl J Med. 2013 May 2;368(18):1675-84. doi: 10.1056/NEJMoa1301408. Epub 2013 Mar 18. Erratum in: N Engl J Med. 2013 Aug 15;369(7):683. PMID: 23506518
