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21-03-2013 | Surgery | Article

Meniscal tear strategies questioned for osteoarthritis patients


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medwireNews: Trial findings support the use of physical therapy for the primary treatment of symptomatic meniscal tear in patients with mild-to-moderate knee osteoarthritis, with arthroscopic partial meniscectomy (APM) as a second-line option.

Intention-to-treat analysis showed no significant difference in the short-term outcomes of the 161 patients randomly assigned to receive APM immediately with postoperative physical therapy and the 169 patients who were initially given physical therapy alone, with the option of surgery at a later date. All patients were aged over 45 years.

At 6 months, the Western Ontario and McMaster Universities Osteoarthritis Index physical-function score was reduced by a significant 20.9 points in the surgery group and 18.5 points in the physical therapy group - this difference was not significant.

Pain scores on the Knee Injury and Osteoarthritis Outcome Scale were also comparable between the treatment groups at 6 months, with a significant 24.2- and 21.3-point decrease achieved in the APM and physical therapy groups, respectively.

These outcomes remained similar and comparable in the two groups 12 months after surgery, report Jeffrey Katz (Brigham and Women's Hospital, Boston, Massachusetts, USA) and co-authors.

Of note, 6% of patients assigned to receive surgery did not undergo APM and just 30% of patients initially given physical therapy crossed over to surgery in the first 6 months, rising to 35% at 12 months. The rate of adverse events did not significantly differ between the treatment groups. "These findings should help inform decision making by patients and their physicians," say Katz et al.

"Given that improvements in functional status and pain at 6 months did not differ significantly between patients assigned to [APM] and those assigned to physical therapy alone and that 70% of the patients in the physical therapy group did not undergo surgery, these data provide considerable reassurance regarding an initial nonoperative strategy," the researchers comment in TheNew England Journal of Medicine.

Katz et al now plan to investigate longitudinal imaging studies from the trial to determine whether patients who undergo APM have an increased risk for osteoarthritis progression compared with patients who did not receive surgery.

In an accompanying editorial, Rachelle Buchbinder (Monash University, Melbourne, Victoria, Australia) says that the efficacy and cost-effectiveness of physical therapy must be confirmed in clinical trials.

"These results should change practice," she writes. "They should also lead to reflection on the need for levels of high-quality evidence of the efficacy and safety of surgical procedures similar to those currently expected for nonoperative therapy."

By Lynda Williams, Senior medwireNews Reporter

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