WHAT’S NEW
Recommend physical therapy, exercise instead of surgery
Previous studies of arthroscopic partial meniscectomy to treat degenerative meniscal tears in patients with knee OA found no benefit.6,8 This study specifically examined patients without OA and found arthroscopic partial meniscectomy offered no benefit over sham surgery.
In addition to fewer referrals for meniscectomy, these findings could lead to another change in practice: Clinicians may be less likely to order MRI to confirm the diagnosis of a medial meniscal tear, since doing so will not change their therapeutic approach. This approach centers on recommending that patients with a degenerative meniscal tear start and stick with physical therapy and their designated exercise regimen.
CAVEATS
Surgery might be effective for more active patients
This study, as well as previous research, did not look at surgery for an acute medial meniscus tear following a traumatic incident, such as a fall or direct blow. Additionally, these results are based on improved outcomes in activities of daily living, and may not extend to patients who engage in high-level functioning, such as sports or strenuous work. The sham surgery group received lavage, which could be considered an active treatment, although a previous trial found lavage had no benefit over conservative treatment in patients with knee OA.4
CHALLENGES TO IMPLEMENTATION
It might be hard to convince patients they don’t need surgery
Some patients expect immediate intervention with surgery. It may be difficult to convince such patients that active participation in physical therapy can lead to the same outcomes as surgery. Spending time with your patient to explain the injury, what happens during surgery, and the evidence that shows a lack of difference in outcomes can lead to fewer surgeries. Most patients and clinicians will want to do an MRI after three months of persistent pain to determine the diagnosis, although some may be comfortable with continuing conservative treatment.
References
1. Sihvonen R, Paavola M, Malmivaara A, et al; Finnish Degenerative Meniscal Lesion Study (FIDELITY) Group. Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. N Engl J Med. 2013; 369:2515-2524.
2. American Academy of Orthopaedic Surgeons. Treatment of Osteoarthritis of the Knee. Evidence-Based Guideline. 2nd ed. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2013.
3. Knee disorders. In: Hegmann KT, ed. Occupational Medicine Practice Guidelines. Evaluation and Management of Common Health Problems and Functional Recovery in Workers. 3rd ed. Elk Grove Village, IL: American College of Occupational and Environmental Medicine; 2011:1-503.
4. Kirkley A, Birmingham TB, Litchfield RB, et al. A randomized trial for arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2008; 359:1097-1107.
5. Katz JN, Brophy RH, Chaisson CE, et al. Surgery versus physical therapy for a meniscal tear and osteoarthritis. N Engl J Med. 2013;368:1675-1684.
6. Cullen KA, Hall MJ, Golosinskiy A. Ambulatory surgery in the United States, 2006. Natl Health State Report. 2009;11:1-25.
7. Salzler MJ, Lin A, Miller CD, et al. Complications after arthroscopic knee surgery. Am J Sports Med. 2014;42:292-296.
8. Moseley JB, O’Malley K, Petersen NJ, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2002; 347:81-88.
Acknowledgement
The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center For Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center For Research Resources or the National Institutes of Health.
Copyright © 2014. The Family Physicians Inquiries Network. All rights reserved.
Reprinted with permission from the Family Physicians Inquiries Network and The Journal of Family Practice. 2014;63(9):534-536.