Physical therapy non-inferior to knee arthroscopy for meniscal tears: RCT

Arthroscopic surgery should not be the first treatment in middle-aged and older patients with degenerative meniscal tears because it is no better than physical therapy, results from a European study have shown.

The latest trial evidence, from the Netherlands, adds to at least six other RCTs showing no benefit for early arthroscopic surgery over physical therapy or sham surgery for patients with nonobstructive meniscal tears, according to orthopaedic surgeons in a JAMA study.

In their non-inferiority trial, 321 patients with nonobstructive meniscal tears  (no locking of the knee joint) were randomly assigned to arthroscopic partial meniscectomy or a physical therapy program consisting of 16 sessions of exercise therapy over eight  weeks focused on coordination and strength exercises.

Over a 24-month follow-up period, knee function improved in the arthroscopy group by 26.2 points (from 44.8 to 71.5) and in the physical group by 20.4 points (from 46.5 to 67.7) on the International Knee Documentation Committee Subjective Knee Form. The overall between-group difference of 3.6 points at three, six 12 and 24 months was within the pre-defined non-inferiority margin of 8 points.

The results did not demonstrate noninferiority of physical therapy at the 12- and 24-month time points.

Overall, 289 (90%) of participants completed the trial and 29% of those assigned to physical therapy eventually had arthroscopy, presumably because they were not satisfied with the results of physical therapy, the study authors said.

Repeat surgery (three in the arthroscopy group and one in the physical therapy group) and additional outpatient visits for knee pain (six in the arthroscopy group and two in the physical therapy group) were the most frequent adverse events.

The study investigators noted that previous studies of arthroscopy for meniscal tears had been designed to assess superiority and had small sample sizes or short follow-up.

The latest study had a larger sample size and longer follow-up and showed non-inferiority for physical therapy overall despite a small benefit of [arthroscopy], at some time points, they wrote.

“The results of this trial support the recommendations from the current guidelines that physical may be considered an appropriate alternative to arthroscopic partial meniscectomy as first-line therapy for patients with meniscal tears,” they said.

An accompanying commentary noted that orthopaedic surgeons appeared to be ignoring evidence-based guidelines and continuing to do high volumes of arthroscopic surgery for degenerative meniscal tears.

“Orthopedic surgeons should recognise the value of [the] nonoperative approach and incorporate it into their treatment approach with the expectation that many patients will be treated successfully. The evidence clearly supports this approach,” it said.

“However, to change clinical practice, it may be necessary to establish a consortium of all groups involved in the management of this knee condition – orthopaedic surgeons, physiatrists, physical therapists, professional organisations, and insurance companies – to develop evidence-based treatment guidelines that each group can support. The guidelines should be focused on the best interests of the patients, rather than the clinicians, therapists, and other groups or entities who may gain from the different treatments for degenerative meniscal tears.”

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