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

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

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

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?

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

Related Posts:

Herrlin SV, Wange PO, Lapidus G, Hållander 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