Symptomatic osteoarthritis
is generally acknowledged to be the commonest cause for middle-aged patients,
presenting to medical care with knee pain. Within this same age group, meniscal “cartilage” tears are
also common, present in roughly 35% of patients over 50 years of age, usually
with minimal symptoms. Given that these conditions often occur together, it is
sometimes quite challenging to sort out which is the principal cause for
ongoing knee symptoms.
Arthroscopic knee surgery
is generally considered to be ineffective for the treatment of osteoarthritis
(wear and tear arthritis). There remains some belief that arthroscopy can be
helpful for the treatment of meniscal (cartilage) tears.
A well designed,
multi-centre randomized, controlled trial published yesterday in the New
England Journal of medicine challenges the notion that arthroscopic surgery is
any better than physiotherapy, for the treatment of knee pain in those with
both arthritis and a meniscal tear.
This study screened a large number of candidates, enrolling 351 patients
that consented to participate.
Patients over age 45 years of age, with both knee arthritis and meniscal
tears had to meet strict study criteria to participate. Patients were then
randomly assigned to treatment consisting either of physiotherapy alone or
arthroscopic surgery followed by physiotherapy.
Arthroscopic Partial
Meniscectomy (Surgical group)
Surgeons performed an
arthroscopy with partial meniscectomy by trimming the damaged meniscus cartilage
back to stable tissue. Surgeons also removed loose fragments of cartilage and
bone (also known as debridement). Bracing
was not used. Patients were then referred to physiotherapy for a postoperative program
using the same protocol used in the physiotherapy group, described below.
The treatment group was based on literature
supporting the effectiveness of land-based, individualized physiotherapy along
with progressive home exercise for patients with knee osteoarthritis. The 3 stage protocol was designed to address
issues typically present in arthritic knees. Patients were encouraged to attend physiotherapy sessions
once or twice weekly and perform exercises at home. Pace and progress varied,
with the program usually lasting about 6 weeks.
In both the arthroscopic-partial-meniscectomy and
physiotherapy groups, patients were permitted to take acetaminophen and/or non-steroidal
anti-inflammatory agents as needed. Some patients in both groups received
cortisone shots over the course of the trial.
Looking at outcome scores for pain and overall
function, both treatment groups showed similar improvement at both 6 and 12
months into the study. There were
no significant differences regarding adverse outcomes. About one third of the
physio patients chose to have surgery during the treatment period, presumably
for nonresponsive symptoms. Similar numbers from both groups went on to have
knee replacements over the relatively short period studied.
My take*…
These findings help us deal more objectively with
the relatively common situation in which middle-aged present with both meniscal
AND osteoarthritic findings. In
the absence of mechanical locking, most patients should undergo a trial of
physiotherapy and/or home exercise, before considering arthroscopic
surgery. Surgery warrants
consideration for patients that fail to respond to non-operative treatment, but
patients should realize that results are by no means guaranteed. Further, well-designed scientific study
is necessary to try and identify subgroups that would benefit more predictably
from surgical intervention.
Full Scientific Article -link
K McKenzie MD
*The opinions expressed here are those of the
writer, at the time this article was posted. These opinions are presented for education and discussion
purposes only and are not meant to constitute direct medical advice. Individual patients/results may
vary. Patients are strongly
encouraged to seek professional medical advice before deciding on treatments
options.
