Long-term outcomes similar for operative vs. nonoperative meniscal tear management

CHICAGO — Patients with degenerative meniscal tear who underwent arthroscopic partial meniscectomy had substantial and similar improvements in pain compared with patients who only received physical therapy, according to 5-year data presented at the ACR/ARHP 2018 Annual Meeting.

However, the results also showed that patients who were surgically treated were more likely to undergo total knee replacement (TKR) after arthroscopic partial meniscectomy (APM).

During a plenary session, Jeffrey N. Katz, MD, MSc, director of the Orthopedic and Arthritis Center for Outcomes Research in the department of orthopedic surgery and division of rheumatology, immunology and allergy at Brigham and Women’s Hospital, reported that more than 400,000 APM procedures are performed in the United States each year. Several randomized controlled trials have previously examined the short-term outcomes of patients who undergo APM vs. physical therapy (PT).

“These trials have documented marked and similar improvements in both groups in intention-to-treat analyses,” Katz said. “Although, as many as 30% of patients have crossed over from PT to surgery in some of the trials. Therefore, longer-term data are needed to better inform treatment decisions in middle-aged and older persons with knee pain and meniscal tear.”

To gather more long-term data, Katz and colleagues assessed the 5-year outcomes of APM and PT among patients aged 45 years and older enrolled in the MeTeOR trial.

For the MeTeOR trial, patients with knee pain and meniscal tear were randomly assigned to APM with PT — a strengthening-based, 3-month outpatient program — or PT alone.

For the current analysis, Katz and colleagues evaluated the outcomes of 340 patients who received APM (n = 164); who were assigned to PT alone but crossed over to APM (n = 67); and who were assigned to PT and did not cross over to APM (n = 109). The researchers reviewed medical records and questionnaires completed every 6 months. The primary outcome was KOOS Pain Score.

Improvements in pain

At baseline, average KOOS Pain Scores were 46 in both the APM group and the PT alone group, and 50 in the APM crossover group. During the trial, pain improvement was similar in the three treatment groups, with baseline KOOS Pain Scores ranging from 20 to 25 by 6 months.

“The crossover APM group had a less immediate improvement, as they were doing poorly, crossed over, then joined their counterparts,” Katz noted.

Improvements in pain and function were sustained throughout the 5-year study period. Overall, Katz said the results support both APM and PT, with the option of delaying APM, as pain levels were similar at 12 to 60 months.

TKR higher among surgically-treated patients

In other results, 25 patients underwent a total knee replacement (TKR) during the trial. Approximately 10% of patients in the APM group and in the crossover to APM group underwent TKR vs. 1.8% of patients in the PT alone group (adjusted HR = 4.7; 95% CI, 1.1-20), which Katz said was “unexplained, concerning and requires further study.” These findings are consistent with previous research from the Osteoarthritis Initiative, which also showed that patients with meniscal tear who underwent APM were more likely to require TKR.

Katz offered two potential explanations for the higher prevalence of TKR among patients who undergo APM.

“One is accelerated structural damage,” he said. “Our group has some preliminary evidence of this in MRIs from the MeTeOR group.”

The other potential reason could be that patients who undergo APM are more familiar with surgeons.

“Whatever the explanation, this finding should be discussed by patients and clinicians who are contemplating treatment for knee pain and meniscal tear,” Katz concluded. – by Stephanie Viguers

References:

Katz JN, et al. Abstract 1816. Presented at: ACR/ARHP Annual Meeting, Oct. 20-24, 2018; Chicago.

Disclosure: Katz reports no relevant financial disclosures.