Functional Outcomes of Surgery and Physical Therapy in Meniscal Tear and Osteoarthritis

Frank J. Domino, MD

Review

Katz JN, et al. Surgery versus physical therapy for a meniscal tear and osteoarthritis. N Engl J Med. 2013. 2013 May 2;368(18):1675-84. http://www.nejm.org/doi/full/10.1056/NEJMoa1301408.

Study Methods

This was a randomized controlled multicenter trial of 351 adults located in urban and suburban areas of the US.

Patient Demographics

All patients were at least 45 years old and had a meniscal tear, as well as evidence of mild-to-moderate osteoarthritis on imaging.

Intervention and Control

Surgical intervention and postoperative physical therapy were compared to a standardized physical therapy regimen with the option to cross over to surgery left at the discretion of the patient and surgeon.

Results and Outcomes

The differences between the 2 groups in terms of patient symptom and quality of life scores 6 months after randomization were measured with a standard tool known as the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) physical-function score, which ranges from zero to 100 with higher scores indicating more severe symptoms.

Using an intention-to-treat analysis, the mean improvement in the WOMAC score at 6 months was 20.9 points [95% confidence interval (CI), 17.9 to 23.9] in the surgical group and 18.5 points (95% CI, 15.6 to 21.5) in the physical-therapy group (mean difference, 2.4 points; 95% CI, −1.8 to 6.5), which was a non-statistically significant difference.

At 6 months, 30% of patients in the physical therapy arm had undergone surgery, while 6% of patients assigned to surgery had not undergone the procedure.

Similar results were recorded at 12 months, and there also were no differences in WOMAC scores, which implied no difference in symptoms or quality of life. Additionally, the frequency of adverse events did not significantly differ between the 2 groups.

Conclusion

In terms of functional improvement at 6 and 12 months after randomization, no significant differences were seen between the physical therapy group and the surgery with physical therapy group. However, 30% of patients who were only assigned to physical therapy underwent surgery within 6 months.

Commentary

Getting old isn’t easy. After age 50, more than 30% of men and roughly 20% of women have torn menisci. After age 70, the prevalence of torn menisci rises to more than 50% of all geriatric adults. As the risk of osteoarthritis increases with torn meniscus, their presence can herald significant morbidity.

Patients with meniscal tears often present with knee pain that occurs after engaging in some activity, though the patients' recollection of injury isn't often present. The activity can involve a rotary movement of the lower leg, such as pivoting while playing basketball. On exam, there may be some effusion, and on palpation, there may be tenderness along the joint line. The medial meniscus is typically affected, which produces the medial knee deformity that’s commonly associated with osteoarthritis. Included in the differential of medial knee pain are anserine bursitis and injury to the medial collateral ligament.

Managing meniscal tears is often left to the clinician’s prerogative, and this study helps inform both the evaluation and management of the disease. If a patient’s history and physical exam suggest a meniscal tear, then consider X-rays to rule out a fracture. If it is negative, then treat the knee conservatively by referring for aggressive physical therapy. If the patient fails, then consider MRI and referral to a surgeon.

Encourage patients by reminding them that successful rehabilitation will prevent — or at least delay — the need for surgery. Remind them that if they ultimately need surgery, then physical rehabilitation will be needed postoperatively, so recommend that they invest time and energy before the surgery, as they’re going to need it either way.

Taking that approach will not only empower patients to manage their health without surgery, but it will also lower morbidity. Although it wasn’t seen in this study, deep vein thrombosis is a major concern following any lower leg surgery, and its risk increases with age. Educating patients on the topic may also help them develop a lifelong approach to exercise, as appropriate exercise and physical therapy are first-line treatments for osteoarthritis of the knee.

About the Author

Frank J. Domino, MD, is Professor and Pre-Doctoral Education Director for the Department of Family Medicine and Community Health at the University of Massachusetts Medical School in Worcester, MA. Domino is Editor-in-Chief of the 5-Minute Clinical Consult series (Lippincott Williams & Wilkins). Additionally, he is Co-Author and Editor of the Epocrates LAB database, and author and editor to the MedPearls smartphone app. He presents nationally for the American Academy of Family Medicine and serves as the Family Physician Representative to the Harvard Medical School’s Continuing Education Committee.