Sports Medicine Research: In the Lab & In the Field: Is Exercise Just as Effective as Surgery for Degenerative Meniscal Tears? (Sports Med Res)
Monday, April 23, 2012

Is Exercise Just as Effective as Surgery for Degenerative Meniscal Tears?

Is arthroscopic surgery beneficial in treating non-traumatic, degenerative medial meniscal tears? A five year follow-up.

Herrlin SV, Wange PO, Lapidus G, HÃ¥llander M, Werner S, Weidenhielm L. Knee Surg Sports Traumatol Arthrosc. 2012 Mar 23. [Epub ahead of print]

Middle-aged patients with knee pain and impaired knee function of unclear cause often get magnetic resonance imaging (MRI) of their knee that shows a meniscal tear. Treatment of non-traumatic, degenerative medial meniscal tears is controversial, particularly in patients with underlying arthritic changes of the knee. It poses the question of whether or not conservative treatment (rest, NSAID’s, physical therapy, injection therapy, etc) versus arthroscopic surgery right away is more appropriate. The authors studied whether patients with minimal knee osteoarthritis would demonstrate differences in clinical outcomes or radiographic results between arthroscopic surgery with post-operative therapy versus exercise therapy alone for non-traumatic, degenerative medial meniscal tears. Ninety-six middle-aged patients with a degenerative medial meniscal tear on MRI and radiographic osteoarthritis (Ahlback grade 1 or less) participated in the study. Patients were randomly assigned to arthroscopic treatment followed by exercise therapy for 2 months or to the same exercise therapy alone. The patients answered three questionnaires at the start of the study, and at 2, 6, 24, and 60 months, with the primary outcome measure being the Knee injury and Osteoarthritis Outcome Score (KOOS). Radiographic examination was done before randomization and after 5 years, using the Ahlback classification. The exercise therapy consisted of a 2-month supervised exercise program that was supervised by two experienced physical therapists (twice a week) after onset of the study. Forty-seven patients underwent primary arthroscopic surgery and 13 (27%) patients in the exercise only group (49 participants) underwent late arthroscopy between 2 and 14 months due to worsening symptoms. The authors did not find any significant group differences in the clinical outcomes determined with KOOS. Both groups showed significant improvements from the start of the study to 24 months, while the improvements from 24 to 60 months were unchanged. The 13 patients from the exercise-only group that underwent late arthroscopy had significant differences at 2 months that led to the arthroscopy, but at 24 and 60 months had similar KOOS scores to the other groups. Only 4 out of 88 patients showed progression of osteoarthritis in radiographic findings after 5 years.

This study lends support to both clinicians and patients in facilitating decisions that may help lower health care costs and avoid unnecessary surgeries when conservative treatments could potentially be just as effective. Certainly patients with significant mechanical symptoms (e.g., locking) should be considered for early arthroscopy. However, a decision to initially pursue conservative treatment may be more appropriate for patients experiencing only pain and not “true” mechanical symptoms. The authors mention a limitation of not having a natural history group, but another group that would have been beneficial would be a group of patients undergoing treatment with a corticosteroid injection. Corticosteroid injection therapy is a common treatment for middle-aged patients with knee pain and no mechanical symptoms before undergoing a surgical procedure. Another possible healthcare saving approach is to decide if an MRI is needed for every middle-aged patient with knee pain before trying several weeks of conservative therapy. Convincing patients of this fact can frequently be a difficult task. One argument against early surgical intervention is that removing any part of the meniscus could alter the biomechanical pressure loads within the knee enough to hasten the progression of osteoarthritis. In this study, only a small percentage of patients from the arthroscopic surgery group showed a progression in radiographic findings, which goes against this thought. As the authors point out, more studies such as this one are needed to find methods of picking patients that would benefit most from early surgical intervention. What are your recommendations for patients that fit this study’s criteria?

Written by: Kris Fayock, MD and Peter Vitanzo, MD
Reviewed by: Jeffrey Driban

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Herrlin SV, Wange PO, Lapidus G, HÃ¥llander M, Werner S, & Weidenhielm L (2012). Is arthroscopic surgery beneficial in treating non-traumatic, degenerative medial meniscal tears? A five year follow-up. Knee Surgery, Sports Traumatology, Arthroscopy PMID: 22437659

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