Arthroscopic partial meniscectomy combined with medical exercise therapy versus isolated medical exercise therapy for degenerative meniscal tear: A meta-analysis of randomized controlled trials

Long-term effects of exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear: A meta-analysis of randomized controlled trials

BACKGROUND

Degenerative meniscal tear (DMT) is common in the elderly population. However, there has been controversy over the treatment of DMT regarding whether to adopt arthroscopic partial meniscectomy (APM) or exercise therapy (ET). In order to compare the long-term outcomes between the two treatment methods, we conducted a meta-analysis of randomized controlled trials (RCTs) with long-term follow-up.

METHODS

PubMed, Cochrane Library, Embase, and Web of Science were last searched on 16 April 2023 for studies on DMT that compared the clinical outcomes between APM and ET. The subjective outcomes of the comparison include the Knee Injury and Osteoarthritis Outcome Score (KOOS), which consists of five sub-scales: pain, symptoms, activities of daily living (ADL), sport and recreation (Sport/recreation), and quality of life (QOL). The objective outcome includes knee osteoarthritis progression.

RESULTS

We identified 6 potentially eligible trials, including 1078 participants, from the literature search. ET showed a lower risk of knee osteoarthritis progression than APM (RR, 1·27; 95%CI 1·05 to 1·53). There were no statistically significant differences in the KOOS-pain, KOOS-symptoms, KOOS-ADL, KOOS-Sport/recreation, and KOOS-QOL between the two treatment methods.

CONCLUSION

For the treatment of DMT, ET showed a lower risk of knee osteoarthritis progression than APM. ET and APM had comparable effects on subjective outcomes including pain management and knee function. Therefore, it is not recommended to use APM but rather recommended to use ET for treating APM.

Physical Therapist Interventions Versus or Combined With Surgical Treatment in Nontraumatic Degenerative Meniscal Pathology: A Systematic Review and Network Meta-Analysis

OBJECTIVE

This study aimed to synthesize the evidence from randomized clinical trials in people with nontraumatic degenerative meniscal pathology by comparing physical therapist interventions versus or combined with arthroscopic partial meniscectomy (APM).

METHODS

Seven electronic databases were searched. Methodological quality was evaluated using the Physiotherapy Evidence Database scale. Data synthesis was performed with random-effects network meta-analysis, and results were summarized using the standardized mean differences.

RESULTS

From 2103 studies, 10 randomized clinical trials comprising 1411 individuals were included. Ninety percent of the selected randomized clinical trials were classified as good quality according to the Physiotherapy Evidence Database scale. All interventions (physical therapist interventions, APM, and APM plus physical therapist interventions) showed reduced pain and physical impairments at 3-month follow-up. However, when a physical therapist intervention was included, greater reductions in pain at rest (APM vs physical therapist interventions: 0.73 [95% CI = 0.20 to 1.26]; APM vs APM plus physical therapist interventions: 0.59 [95% CI = 0.15 to 1.03]) and greater increases in the strength of knee extensor muscles (APM vs physical therapist interventions: 0.44 [95% CI = 0.07 to 0.80]; APM vs APM plus physical therapist interventions: 0.73 [95% CI = 0.29 to 1.16]) were observed at 3 months. By contrast, no differences were found between treatments beyond 3 months.

CONCLUSION

Physical therapist interventions based on exercise programs demonstrate superior short-term outcomes in pain reduction and knee extensor strength compared to surgical treatment.

IMPACT

For nontraumatic degenerative meniscal pathology, conservative treatment utilizing a physical therapist intervention approach should be prioritized as the first choice over surgical treatment. It offers comparable or superior short-term pain reduction and strength improvements, with a lower risk of side effects. In cases where surgery is deemed necessary, including postsurgical, physical therapist interventions are highly recommended to enhance muscle strength and alleviate pain.

Comparing Surgical Techniques for Meniscal Tears: A Systematic Review of Radiographic and Functional Outcomes

Meniscal tears are a common orthopedic injury. The management approaches for meniscal tears include both surgical and non-surgical procedures; however, the majority of the surgeons opt for various surgical interventions. This systematic review aimed to compare the outcomes of different surgical techniques for meniscal tears. The systemic search was carried out in various databases including PubMed, Web of Science, CINAHL, and Scopus. Studies that investigated surgical techniques for meniscal repair and published between 2010 to 2023 were included. Out of the 7,421 potential studies identified from databases and Google Scholar search, only 17 studies were included in our systemic review. The follow-up periods ranged from 6 weeks to 123 months. Adverse effects were reported in some studies, including joint line tenderness, swelling, and loss of flexion, while others reported no significant adverse events. Pull-out repair and refixation techniques demonstrated better clinical outcomes and slower arthritic progression than partial meniscectomy. Mason-Allen stitches and simple stitches yielded comparable results, and both inside-out and all-inside techniques had similar clinical and functional outcomes. This systematic review provides valuable insights into the outcomes of different surgical techniques for meniscal tears. Further studies with longer follow-up periods may help assess the long-term effectiveness of these surgical techniques.

Chronic pain and functional impairment after arthroscopic surgery for a knee injury

Arthroscopic interventions are widely used to treat the consequences of the meniscus and anterior cruciate ligament (ACL) injuries. However, the long-term consequences of these surgeries are not always favorable and not in all cases allow to avoid the development of chronic pain and posttraumatic osteoarthritis.Objective: to evaluate the incidence of persistent postoperative pain and the persistence of functional disorders in patients undergoing arthroscopic interventions on the menisci and ACL.Material and methods. The study group consisted of 147 patients (60 women and 87 men, mean age 38.8±12.5 years) who underwent arthroscopic surgery on the knee joint (KJ) in the traumatology and orthopedic department of V.A. Nasonova Research Institute of Rheumatology in 2018– 2021. The condition of patients was assessed by telephone survey and/or online questionnaire. The pain and fatigue levels were assessed on numerical rating scale (NRS, 0–10), as well as the severity of functional disorders on the Lysholm scale (LS).Results and discussion. Moderate or intense knee pain and increased fatigue (≥4 according to NRS) were noted in 11.3% and 14.7% of respondents, respectively. The state of the KJ according to LS in 35.3% of patients was assessed as excellent (95–100 points), in 29.3% – as good (84–94 points), in 21.3% – as satisfactory (65–83 points) and 14.0% – as unsatisfactory (≤64 points).Conclusion. More than 10% of patients after arthroscopic operations on the knee joint experience moderate or severe pain and fatigue, satisfactory and unsatisfactory functional results are observed in 35.4% of cases.

Cost-Effectiveness of Arthroscopic Partial Meniscectomy and Physical Therapy for Degenerative Meniscal Tear

OBJECTIVE

We examined the cost-effectiveness of treatment strategies for concomitant meniscal tear and knee osteoarthritis (OA) involving arthroscopic partial meniscectomy surgery and physical therapy (PT).

METHODS

We used the Osteoarthritis Policy Model, a validated Monte Carlo microsimulation, to compare three strategies, 1) PT-only, 2) immediate surgery, and 3) PT + optional surgery, for participants whose pain persists following initial PT. We modeled a cohort with baseline meniscal tear, OA, and demographics from the Meniscal Tear in Osteoarthritis Research (MeTeOR) trial of arthroscopic partial meniscectomy versus PT. We estimated risks and costs of arthroscopic partial meniscectomy complications and accounted for heightened OA progression post surgery using published data. We estimated surgery use rates and treatment efficacies using MeTeOR data. We considered a 5-year time horizon, discounted costs, and quality-adjusted life-years (QALYs) 3% per year and conducted sensitivity analyses. We report incremental cost-effectiveness ratios.

RESULTS

Relative to PT-only, PT + optional surgery added 0.0651 QALY and $2,010 over 5 years (incremental cost-effectiveness ratio = $30,900 per QALY). Relative to PT + optional surgery, immediate surgery added 0.0065 QALY and $3080 (incremental cost-effectiveness ratio = $473,800 per QALY). Incremental cost-effectiveness ratios were sensitive to optional surgery efficacy in the PT + optional surgery strategy. In the probabilistic sensitivity analysis, PT + optional surgery was cost-effective in 51% of simulations at willingness-to-pay thresholds of both $50,000 per QALY and $100,000 per QALY.

CONCLUSION

First-line arthroscopic partial meniscectomy has a prohibitively high incremental cost-effectiveness ratio. Under base case assumptions, second-line arthroscopic partial meniscectomy offered to participants with persistent pain following initial PT is cost-effective at willingness-to-pay thresholds between $31,000 and $473,000 per QALY. Our analyses suggest that arthroscopic partial meniscectomy can be a high-value treatment option for patients with meniscal tear and OA when performed following an initial PT course and should remain a covered treatment option.

Effectiveness of exercise versus arthroscopic partial meniscectomy plus exercise in the management of degenerative meniscal tears at 5-year follow-up: a systematic review and meta-analysis

INTRODUCTION

There are no meta-analytical data in the long term for comparing surgery and exercise for meniscal tear. The aim of this study is to compare the effectiveness of exercise versus arthroscopic partial meniscectomy (APM) plus exercise for degenerative meniscal tears (DMT) in knee function at 5-year follow-up.

MATERIALS AND METHODS

A systematic search of Medline, EMBASE, Web of Science, SciELO, SPORTDiscus, Scopus, and Cochrane Library was performed. The studies were included if they were randomized controlled trials performed in patients aged ≥ 18 years with DMT, that compared physical therapy to APM at 5-year follow-up, and reported at least one outcome measure of knee function/disability. Risk of bias was analyzed with the Cochrane RoB-2 tool and certainty of evidence with GRADE recommendations. A random effects model meta-analysis was performed.

RESULTS

3743 articles were identified and 4 met the criteria. Three had low risk of bias and one had some concerns. There were no significant between-group differences, in within-group changes from baseline to 5-year, on the Knee Injury and Osteoarthritis Outcome Score pain (- 2.28; 95% CI - 5.41 to 0.84), symptoms (- 0.24; 95% CI - 4.13 to 3.64), activities of daily living (- 2.16; 95% CI - 6.16 to 1.83) and quality of life (- 3.98; 95% CI - 9.05 to 1.10). There was a significant difference in support of APM plus exercise for sport/recreation (- 9.28; 95% CI - 18.28 to - 0.29). Leave-one-out sensitivity analysis revealed a non-significant difference in sport/recreation (- 5.05; 95% CI - 12.04 to 1.94). There were no differences in other patient-reported outcome measures.

CONCLUSION

Moderate certainty of evidence suggests that the addition of APM to an exercise program adds no benefits in knee function at 5-year follow-up.

No evidence in support of arthroscopic partial meniscectomy in adults with degenerative and nonobstructive meniscal symptoms: a level I evidence-based systematic review

PURPOSE

It is unclear whether the results of arthroscopic partial meniscectomy (APM) are comparable to a structured physical therapy (PT). This systematic review investigated efficacy of APM in the management of symptomatic meniscal damages in middle aged patients. Current available randomised controlled trials (RCTs) which compared APM performed in isolation or combined with physical therapy versus sham arthroscopy or isolated physical therapy were considered in the present systematic review.

METHODS

This systematic review was conducted according to the 2020 PRISMA statement. All the level I RCTs which investigated the efficacy of AMP were accessed. Studies which included elderlies with severe OA were not eligible, nor were those in which APM was combined with other surgical intervention or in patients with unstable knee or with ligaments insufficiency. The risk of bias was assessed using the software Review Manager 5.3 (The Nordic Cochrane Collaboration, Copenhagen). To rate the quality of evidence of collected outcomes, the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) was used.

RESULTS

Data from 17 studies (2037 patients) were collected. 48.5% (988 of 2037 patients) were women. The mean age of the patients was 52.7 ± 3.9 years, the mean BMI 27.0 ± 1.3 kg/m². The current evidence suggests no difference in functional PROMs (quality of the evidence: high), clinical PROMs (quality of the evidence: high), pain (quality of the evidence: high), quality of life (quality of the evidence: high), physical performance measures (quality of the evidence: moderate), and OA progression (quality of the evidence: moderate).

CONCLUSIONS

The benefits of APM in adults with degenerative and nonobstructive meniscal symptoms are limited. The current evidence reports similarity in the outcome between APM and PT. Further long-term RCTs are required to investigate whether APM and PT produce comparable results using validated and reliable PROMs. Moreover, future RCTs should investigate whether patients who might benefit from APM exist, clarifying proper indications and outcomes. High quality investigations are strongly required to establish the optimal PT regimes.

LEVEL OF EVIDENCE

Level I.

Arthroscopic surgery for degenerative knee disease (osteoarthritis including degenerative meniscal tears)

BACKGROUND

Arthroscopic knee surgery remains a common treatment for symptomatic knee osteoarthritis, including for degenerative meniscal tears, despite guidelines strongly recommending against its use. This Cochrane Review is an update of a non-Cochrane systematic review published in 2017.

OBJECTIVES

To assess the benefits and harms of arthroscopic surgery, including debridement, partial menisectomy or both, compared with placebo surgery or non-surgical treatment in people with degenerative knee disease (osteoarthritis, degenerative meniscal tears, or both).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and two trials registers up to 16 April 2021, unrestricted by language.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), or trials using quasi-randomised methods of participant allocation, comparing arthroscopic surgery with placebo surgery or non-surgical interventions (e.g. exercise, injections, non-arthroscopic lavage/irrigation, drug therapy, and supplements and complementary therapies) in people with symptomatic degenerative knee disease (osteoarthritis or degenerative meniscal tears or both). Major outcomes were pain, function, participant-reported treatment success, knee-specific quality of life, serious adverse events, total adverse events and knee surgery (replacement or osteotomy).

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, extracted data, and assessed risk of bias and the certainty of evidence using GRADE. The primary comparison was arthroscopic surgery compared to placebo surgery for outcomes that measured benefits of surgery, but we combined data from all control groups to assess harms and knee surgery (replacement or osteotomy).

MAIN RESULTS

Sixteen trials (2105 participants) met our inclusion criteria. The average age of participants ranged from 46 to 65 years, and 56% of participants were women. Four trials (380 participants) compared arthroscopic surgery to placebo surgery. For the remaining trials, arthroscopic surgery was compared to exercise (eight trials, 1371 participants), a single intra-articular glucocorticoid injection (one trial, 120 participants), non-arthroscopic lavage (one trial, 34 participants), non-steroidal anti-inflammatory drugs (one trial, 80 participants) and weekly hyaluronic acid injections for five weeks (one trial, 120 participants). The majority of trials without a placebo control were susceptible to bias: in particular, selection (56%), performance (75%), detection (75%), attrition (44%) and selective reporting (75%) biases. The placebo-controlled trials were less susceptible to bias and none were at risk of performance or detection bias. Here we limit reporting to the main comparison, arthroscopic surgery versus placebo surgery. High-certainty evidence indicates arthroscopic surgery leads to little or no difference in pain or function at three months after surgery, moderate-certainty evidence indicates there is probably little or no improvement in knee-specific quality of life three months after surgery, and low-certainty evidence indicates arthroscopic surgery may lead to little or no difference in participant-reported success at up to five years, compared with placebo surgery. Mean post-operative pain in the placebo group was 40.1 points on a 0 to 100 scale (where lower score indicates less pain) compared to 35.5 points in the arthroscopic surgery group, a difference of 4.6 points better (95% confidence interval (CI) 0.02 better to 9 better; I² = 0%; 4 trials, 309 participants). Mean post-operative function in the placebo group was 75.9 points on a 0 to 100 rating scale (where higher score indicates better function) compared to 76 points in the arthroscopic surgery group, a difference of 0.1 points better (95% CI 3.2 worse to 3.4 better; I² = 0%; 3 trials, 302 participants). Mean post-operative knee-specific health-related quality of life in the placebo group was 69.7 points on a 0 to 100 rating scale (where higher score indicates better quality of life) compared with 75.3 points in the arthroscopic surgery group, a difference of 5.6 points better (95% CI 0.36 better to 10.68 better; I² = 0%; 2 trials, 188 participants). We downgraded this evidence to moderate certainty as the 95% confidence interval does not rule in or rule out a clinically important change. After surgery, 74 out of 100 people reported treatment success with placebo and 82 out of 100 people reported treatment success with arthroscopic surgery at up to five years (risk ratio (RR) 1.11, 95% CI 0.66 to 1.86; I² = 53%; 3 trials, 189 participants). We downgraded this evidence to low certainty due to serious indirectness (diversity in definition and timing of outcome measurement) and serious imprecision (small number of events). We are less certain if the risk of serious or total adverse events increased with arthroscopic surgery compared to placebo or non-surgical interventions. Serious adverse events were reported in 6 out of 100 people in the control groups and 8 out of 100 people in the arthroscopy groups from eight trials (RR 1.35, 95% CI 0.64 to 2.83; I² = 47%; 8 trials, 1206 participants). Fifteen out of 100 people reported adverse events with control interventions, and 17 out of 100 people with surgery at up to five years (RR 1.15, 95% CI 0.78 to 1.70; I² = 48%; 9 trials, 1326 participants). The certainty of the evidence was low, downgraded twice due to serious imprecision (small number of events) and possible reporting bias (incomplete reporting of outcome across studies). Serious adverse events included death, pulmonary embolism, acute myocardial infarction, deep vein thrombosis and deep infection. Subsequent knee surgery (replacement or high tibial osteotomy) was reported in 2 out of 100 people in the control groups and 4 out of 100 people in the arthroscopy surgery groups at up to five years in four trials (RR 2.63, 95% CI 0.94 to 7.34; I² = 11%; 4 trials, 864 participants). The certainty of the evidence was low, downgraded twice due to the small number of events.

AUTHORS' CONCLUSIONS

Arthroscopic surgery provides little or no clinically important benefit in pain or function, probably does not provide clinically important benefits in knee-specific quality of life, and may not improve treatment success compared with a placebo procedure. It may lead to little or no difference, or a slight increase, in serious and total adverse events compared to control, but the evidence is of low certainty. Whether or not arthroscopic surgery results in slightly more subsequent knee surgery (replacement or osteotomy) compared to control remains unresolved.

Predictors of the outcome of physiotherapy following a meniscus tear: A systematic review

BACKGROUND

Physiotherapy is indicated for treatment of a painful degenerative knee meniscus tear. Predicting the outcome remains uncertain.

OBJECTIVE

The purpose of this systematic review was to identify which predictive factors are associated with the outcome of physiotherapy for degenerative knee meniscus tear.

METHODS

A systematic electronic literature search was undertaken of PubMed, CINAHL, Medline with AMED and EMBASE via Ovid from inception to July 2021. Studies of adults receiving physiotherapy which presented data on the association of baseline variables and the treatment outcome were included. Study quality was assessed using CASP (Critical Appraisal Skills Programme) tools. Data were narratively analysed.

RESULTS

1051 titles were retrieved and screened for eligibility. Fifteen studies met the inclusion criteria. Nine studies investigated just degenerative tears. The evidence-base was of low/moderate quality. Across all studies, seven and five studies (100%) reported no association between mechanical symptoms or gender respectively (p > 0.05). There was no association with osteoarthritis in 80%, age in 71%, or body mass index in 60% of studies (p > 0.05). Four studies (80%) reported that higher baseline pain was associated with cross-over to surgery, greater improvement with surgery or less improvement in pain score (p > 0.05).

CONCLUSION

Patient demographic characteristics provide minimal association with outcome following physiotherapy for degenerative meniscus tear. The evidence-base is limited in size and quality. A large adequately powered prospective cohort study investigating a broad range of predictive factors is warranted to develop a predictive model to better stratify those most likely to benefit from physiotherapy.

No decrease in incidence of arthroscopic meniscectomy in a Canadian province

PURPOSE

Arthroscopic meniscectomy (APM) is the most common procedure in orthopedic surgery, despite increasing evidence questioning its benefit over conservative management for treatment of degenerative meniscal tears. The purpose of this study is to determine the epidemiology and trends of APM in Saskatchewan, a Canadian province, over a 20 year period.

METHODS

Physician billing codes were used to identify patients who underwent APM in Saskatchewan between January 1, 1998 and December 31, 2017. Records were obtained from eHealth Saskatchewan, a provincial health database. Data was analyzed for overall incidence and age-specific trends of APM.

RESULTS

A total of 35,099 APMs were performed during the study period. The population of Saskatchewan ranged from 992,314 to 1,150,782 (median 1,017,368) during this time interval, with 81 orthopedic surgeons performing APM. Overall incidence rate of APM did not change significantly over time. No decrease was observed in patients presumed to have degenerative tears (≥ 50 years). The number of meniscectomies in patients ≥ 50 years was significantly greater during the second decade of study compared to the first (OR 1.48, p < 0.01). Conversely, the increase in incidence rate among older patients was not statistically significant (R² = 0.125, n.s.).

CONCLUSION

Overall incidence rate of APM in Saskatchewan has not decreased during the last 20 years. Furthermore, APM frequency increased over time for individuals ≥ 50 years. Several regional factors may have contributed to these findings, including the large proportion of Saskatchewan residents engaged in physically demanding work and barriers to accessing physiotherapy services. Given recent evidence disputing the benefit of APM over conservative measures, this study highlights the need for improved dissemination of evidence, as well as the importance of an individualized treatment plan to address patient-specific factors.

LEVEL OF EVIDENCE

Level IV.