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Meniscectomy & Nonoperative treatment in degenerative horizontal medial meniscus tears
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October 2013
Meniscectomy & Nonoperative treatment in degenerative horizontal medial meniscus tears
Study Type:Therapy
OE Level Evidence:2
Journal Level of Evidence:N/A
A Comparative Study of Meniscectomy and Nonoperative Treatment for Degenerative Horizontal Tears of the Medial Meniscus
Am J Sports Med. 2013 Jul;41(7):1565-70. doi: 10.1177/0363546513488518. Epub 2013 May 23Did you know you're eligible to earn 0.5 CME credits for reading this report? Click Here
Synopsis
One hundred and eight patients with knee pain and a degenerative horizontal tear of the posterior horn of the medial meniscus were randomized to be treated either with arthroscopic meniscectomy or conservative treatment (strength training). The aim of the trial was to evaluate if the surgical procedure provided superior clinical outcomes, measured by Visual Analog Scale (VAS) pain, Lysholm knee score, Tegner activity scale, patient subjective knee pain and satisfaction. After 2 years of evaluation, the treatments did not differ in terms of keen pain relief, knee function, or satisfaction.
Publication Funding Details
+
Funding:
Not Reported
Conflicts:
None disclosed
Was the allocation sequence adequately generated?
Was allocation adequately concealed?
Blinding Treatment Providers: Was knowledge of the allocated interventions adequately prevented?
Blinding Outcome Assessors: Was knowledge of the allocated interventions adequately prevented?
Blinding Patients: Was knowledge of the allocated interventions adequately prevented?
Was loss to follow-up (missing outcome data) infrequent?
Are reports of the study free of suggestion of selective outcome reporting?
Were outcomes objective, patient-important and assessed in a manner to limit bias (ie. duplicate assessors, Independent assessors)?
Was the sample size sufficiently large to assure a balance of prognosis and sufficiently large number of outcome events?
Was investigator expertise/experience with both treatment and control techniques likely the same (ie.were criteria for surgeon participation/expertise provided)?
Yes = 1
Uncertain = 0.5
Not Relevant = 0
No = 0
The Reporting Criteria Assessment evaluates the transparency with which authors report the methodological and trial characteristics of the trial within the publication. The assessment is divided into five categories which are presented below.
3/4
Randomization
3/4
Outcome Measurements
3/4
Inclusion / Exclusion
4/4
Therapy Description
4/4
Statistics
Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65
The Fragility Index is a tool that aids in the interpretation of significant findings, providing a measure of strength for a result. The Fragility Index represents the number of consecutive events that need to be added to a dichotomous outcome to make the finding no longer significant. A small number represents a weaker finding and a large number represents a stronger finding.
Why was this study needed now?
Horizontal tears of the meniscus often occur in a middle aged population due to degenerative changes. Surgical treatments have proven to be difficult and propose an increased risk of osteoarthritis. Little is currently know about the comparative efficacy of operative treatment and non-operative management due a lack of previous studies. Hence, this RCT aimed to compare the clinical outcomes of arthroscopic meniscectomy with nonoperative treatment for degenerative horizontal tears in the posterior horn of the medial meniscus.
What was the principal research question?
Will the 2 year postoperative clinical outcomes of arthroscopic meniscectomy be comparable to nonoperative treatment for degenerative horizontal tears of the medial meniscus?
Study Characteristics
-
Population:
108 patients with knee pain and a degenerative horizontal tear of the posterior horn of the medial meniscus (Mean age: 56.8 years; Range: 43-62 years) (n=102 patients completed follow-up)
Intervention:
Meniscectomy Group: Patients underwent arthroscopic meniscectomy using a 5.5-mm, 30 degree arthroscope and a pressure-controlled irrigation system. Only resection with limited debridement of the articular surface lesion was performed. Analgesics or NSAIDs were permitted for the first 2 weeks, and then patients underwent a home exercise program for 8 weeks (same as nonoperative group) (Mean age: 54.9 +/- 10.3) (n=54; 50 completed follow-up)
Comparison:
Nonoperative Group: Patients were prescribed analgesics, nonsteroidal anti-antiinflammatory drugs (NSAIDs), or muscle relaxants for the first 2 weeks. They also undertook supervised exercises to improve muscle strength, endurance and flexibility, 60 min per session, 3x a week for 3 weeks. Afterwards they underwent a home exercise program for 8 weeks, consisting of isometric and isotonic muscle exercises (the full routine can be found in the original publication) (Mean age: 57.6 +/- 11.0) (n=54; 52 completed follow-up)
Outcomes:
Outcomes were Visual Analog Scale (VAS) pain, Lysholm knee score, Tegner activity scale, and patient subjective knee pain and satisfaction. Osteoarthritic changes were radiologically evaluated by Kellgren-Lawrence classification.
Methods:
RCT
Time:
2 years
What were the important findings?
- The most common symptoms reported by patients before treatments were knee pain at high flexion (92%) and tenderness at the posteromedial joint line (84%).
- The meniscectomy group and non-operative group demonstrated similar VAS scores at 2 year follow up (Meniscectomy: 1.8 (range 1-5); Nonoperative group: 1.7 (range 1-4) (P = 0.675). The surgical treatment group experienced improvement 6 months after the procedure, while symptoms lasted longer in non-operative group.
- The meniscectomy group had knee pain with mechanical symptoms completely relieved in 34 patients, improved in 13, and remained in 3 at 2 year follow up. In the nonoperative group, knee pain was completely relieved in 35, improved in 12, and remained in 5 patients. No statistical differences were observed between the treatments (P = 0.652).
- The nonoperative treatment had 17 patients very satisfied, 29 satisfied and 6 dissatisfied, while meniscectomy group had 18 very satisfied, 28 satisfied, and 4 dissatisfied (P = 0.357 between groups)
- Lysholm scores improved in both groups, average scores of 83.2 (range, 52-100) in meniscectomy group and 84.3 (range, 58-100) in nonoperative groups at 2 years (P = 0.237). The only difference, favoring meniscectomy, was seen at 3 months (P = 0.031)
- Tegner scores improved at 2 years from 4.2 (range, 0-6) to 5.1 (range, 0-8) in the meniscectomy group and from 4.1 (range, 0-6) to 4.9 (range, 0-8) in the nonoperative group. No differences were found between the treatments (P = 0.522).
- OA progression by >1 grade was seen in 2 patients in meniscetomy group (ages 59 to 62 years) and 3 in the nonoperative group (ages 57, 67, and 74 years) at 2 years. The difference compared to pre-treatment was not significant (both p>0.05)
What should I remember most?
In the treatment of horizontal tears of the posterior horn of the medial meniscus of the knee joint, meniscectomy and nonoperative management both indicated similar knee pain relief, improved knee function, and increased patient satisfaction at 2 years.
How will this affect the care of my patients?
The study suggested that non-operative treatment with exercises and analgesics provides similar clinical results as surgical treatment. Similar trials still need to be conducted to replicate results before definitive conclusion can be made. Additionally, complications should be reported in detail and a cost effectiveness assessment should be considered in the future.
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