Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: randomised controlled trial with two year follow-up

Abstract

Objective: To determine if exercise therapy is superior to arthroscopic partial meniscectomy for knee function in middle aged patients with degenerative meniscal tears.

Design: Randomised controlled superiority trial.

Setting: Orthopaedic departments at two public hospitals and two physiotherapy clinics in Norway.

Participants: 140 adults, mean age 49.5 years (range 35.7-59.9), with degenerative medial meniscal tear verified by magnetic resonance imaging. 96% had no definitive radiographic evidence of osteoarthritis.

Interventions: 12 week supervised exercise therapy alone or arthroscopic partial meniscectomy alone.

Main outcome measures: Intention to treat analysis of between group difference in change in knee injury and osteoarthritis outcome score (KOOS4), defined a priori as the mean score for four of five KOOS subscale scores (pain, other symptoms, function in sport and recreation, and knee related quality of life) from baseline to two year follow-up and change in thigh muscle strength from baseline to three months.

Results: No clinically relevant difference was found between the two groups in change in KOOS4 at two years (0.9 points, 95% confidence interval -4.3 to 6.1; P=0.72). At three months, muscle strength had improved in the exercise group (P≤0.004). No serious adverse events occurred in either group during the two year follow-up. 19% of the participants allocated to exercise therapy crossed over to surgery during the two year follow-up, with no additional benefit.

Conclusion: The observed difference in treatment effect was minute after two years of follow-up, and the trial's inferential uncertainty was sufficiently small to exclude clinically relevant differences. Exercise therapy showed positive effects over surgery in improving thigh muscle strength, at least in the short term. Our results should encourage clinicians and middle aged patients with degenerative meniscal tear and no definitive radiographic evidence of osteoarthritis to consider supervised exercise therapy as a treatment option.Trial registration www.clinicaltrials.gov (NCT01002794).

Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any company for the submitted work; no relationships with any company that might have an interest in the submitted work in the previous three years; their spouses, partners, or children have no financial relationships that may be relevant to the submitted work; and they have no non-financial interests that may be relevant to the submitted work.

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Figures

Fig 1 Flow chart of participants through study. KOOS4=mean of knee injury and osteoarthritis outcome score subscales for pain, other symptoms, function in sport and recreation, and knee related quality of life

Fig 2 Primary patient reported outcome: intention to treat analysis of change in mean score for knee injury and osteoarthritis outcome subscale (KOOS4) scores for pain, symptoms, function in sports and recreation, and knee related quality of life in exercise therapy group and arthroscopic partial meniscectomy group, from baseline to three month, 12 month, and two year follow-ups. Whiskers represent 95% confidence intervals

Fig 3 Forest plots of intention to treat analyses of differences between groups in thigh muscle strength (peak torque (Nm) and total work (J) for knee extension and knee flexion, respectively) at three (primary endpoint) and 12 months

Fig 4 Lower extremity performance tests: one leg hop test (cm), 6 m timed hop test (sec), and number of knee bends in 30 seconds (n) at three and 12 months. Whiskers represent 95% confidence intervals

Fig 5 Forest plots showing intention to treat analyses of between group differences in changes in primary patient reported outcome (mean score for knee injury and osteoarthritis outcome score (KOOS) subscales for pain, other symptoms, function in sport and recreation, and knee related quality of life (KOOS4)), and secondary outcomes for KOOS subscales and SF-36 physical component summary (PCS) and mental component summary (MCS) from baseline to two year follow-up. Whiskers represent 95% confidence intervals. QOL=quality of life; ADL=activities of daily living