Surgery vs. physiotherapy in patients with meniscal tears
When treating patients with nonobstructive meniscal tears, Physiotherapy (PT) and arthroscopic partial meniscectomy (APM) result in comparable overall outcomes.
Over a 24-month period, patient-reported knee function did not differ much between patients who received PT or underwent APM; PT may therefore very well be an appropriate and cost-effective alternative to surgery in this specific group of patients.
APM is one of the most common procedures in orthopaedic surgery, but its advantages are subject to discussion: a large portion of the population above 50 years of age has degenerative meniscal tears but no symptoms, and PT also does a good job in improving pain and function in the short-term in patients with knee osteoarthritis (OA).
In this study, 289 subjects with nonobstructive meniscal tears who were randomly allocated to either APM (n = 159) or PT (n = 162) completed 24 months of follow up. Those who were randomised to APM underwent surgery and received a home exercise program. Subjects in the PT group received 16 30-minute PT sessions over a period of 8 weeks.
The primary outcome was self-reported knee function as measured by the Subjective Knee Form of the International Knee Documentation Committee (IKDC). Other outcome measures included knee pain during weightbearing, general health, progression of OA and activity level. Questionnaires were completed at baseline and 3, 6, 12 and 24 months of follow up.
It was shown that overall, outcomes of PT treatment were similar to those of APM. However, when analysing data collected at each separate moment, only the between-group differences at 3 and 6 months demonstrated noninferiority of PT and those at 12 and 24 months did not.
It is concluded that clinical practice guidelines recommending PT as a plausible alternative to APM are supported by the results of this study, and that further studies with longer periods of follow up will shed light on the effect of time on differences between treatments.
Read an interesting comment on this study and the authors' in-depth reply here.
Expert opinion by Willem-Paul Wiertz
Based on the findings of this study, it seems justified to conclude that APM and PT result in similar outcomes, but this should be nuanced a little bit. First, as stated in the paper, overall outcomes of PT were noninferior to APM, but at 12 and 24 months of follow up, noninferiority could not be demonstrated.
Second, since this is a noninferiority trial, the as-treated analysis is also presented in the paper. Even though in this analysis – which basically groups and analyses subjects according to the treatment they actually received – differences between the PT and APM group at 12 and 24 months are smaller, they remain apparent.
On the other hand, the smallest detectable change (SDC) for the IKDC has been used as the noninferiority margin, but the SDC does not necessarily equal the minimal clinically important difference (MCID); using another margin can also shed another light on the present results.
> From: Van de Graaf et al., JAMA 320 (2018) 1328-1337. All rights reserved to American Medical Association. Click here for the online summary.