Medial meniscal tears – surgery or physio or both?

30th July 2022, Dr Chee L Khoo

medial meniscal tear

I recently came across a trial comparing arthroscopic partial meniscectomy (APM) with physiotherapy (PT) in the management of medial meniscal tears in older patients. Older patients here mean patients that are older than 45 years who are supposed to have degenerated menisci. Now, meniscal tears (usually medial but sometimes can be lateral meniscal tear) in younger patients often require surgical intervention but in older patients, surgery is not necessarily better than conservative physiotherapy. The recent trial brought up more questions than answers.

When a middle-aged patient present with an acute painful swollen knee, investigations may review a torn medial meniscus. Traditionally, an APM is offered and some months later, the knee symptoms improved but over time, a significant number of these patients developed osteoarthritis of the knee. Some go on to have total knee replacements. The theory is that without the meniscus, the articular cartilage of the injured knee wears out faster and arthritis ensue years later.

Clinical symptoms routinely attributed to degenerative meniscus tears generally have a gradual onset and encompass localised knee pain and mechanical symptoms, such as occasional catching or locking of the knee. Common rationalisation for arthroscopic surgery is that the clinical symptoms are attributable to a mechanical problem, and that the degenerative meniscus tear is the cause of this mechanical problem. The sensitivity and specificity of the symptoms attributed to the degenerative meniscus tear in the osteoarthritic knee however, are low. Asymptomatic meniscus tears are highly prevalent amongst people with knee osteoarthritis [1-3]. These observations cast doubt on the rationalisation for the arthroscopic treatment of degenerative meniscus tears.

Another opposing theory is that the torn meniscal tear is a red herring. The discovery of the torn meniscus was incidental to the underlying knee osteoarthritis. Degenerative arthritis was coming any way. Whether an APM was performed, the knee would have improved in the short term only to succumb to full blown osteoarthritis in years to come.

Randomised clinical trials and systematic reviews show that arthroscopic partial meniscectomy is not clinically better than exercise therapy in patients with a degenerative meniscal tear in the first 2 years of follow-up (4-11). In a large randomised, controlled trial involving symptomatic patients 45 years of age or older with a meniscal tear and imaging evidence of mild-to-moderate knee osteoarthritis, there were no significant differences in the magnitude of improvement in functional status and pain after 6 and 12 months between patients assigned to arthroscopic partial meniscectomy with postoperative physical therapy and patients assigned to a standardised physical-therapy regimen. 35% of the patients who were randomised to physical therapy crossover to the surgical within 6 months of trial.

What about surgery plus exercise therapy?

Sonesson found that knee arthroscopic surgery combined with an exercise program provided no additional long-term benefit after 5 years compared with the exercise program alone in middle-aged patients with meniscal symptoms (12).

What about longer term outcomes?

In the original ESCAPE trial, physical therapy was non-inferior to early surgical treatment for non-locking medial meniscal tear over a 24-month follow-up (13). When these patients were followed up over 5 years, physical therapy remain non-inferior to arthroscopic meniscectomy (14).

What about development of OA in the longer term?

Sihvonen et al found that arthroscopic partial meniscectomy is associated with a slightly increased risk of radiographic knee OA compared with exercise therapy (15). Katz et al found a 5 times higher risk for total knee replacement after surgery vs exercise-based physical therapy (16). However, the trials by Berg et al (17), Herrlin et al (18) and Sonesson et al (12) that compared surgery with exercise therapy found no clinically relevant difference between the 2 treatments for OA progression.

Thus, older patients with medial meniscal tears can get better with physical therapy. They may developed osteoarthritis in the future but that is not dependent on whether arthroscopic meniscectomy is performed or not.

References:

  1. Boks SS, Vroegindeweij D, Koes BW, Hunink MM, Bierma-Zeinstra SM (2006) Magnetic resonance imaging abnormalities in symptomatic and contralateral knees: prevalence and associations with traumatic history in general practice. Am J Sports Med 34:1984–1991
  2. Englund M, Guermazi A, Gale D, Hunter DJ, Aliabadi P, Clancy M, Felson DT (2008) Incidental meniscal findings on knee MRI in middle-aged and elderly persons. N Engl J Med 359:1108–1115
  3. Zanetti M, Pfirrmann CW, Schmid MR, Romero J, Seifert B, Hodler J (2003) Patients with suspected meniscal tears: prevalence of abnormalities seen on MRI of 100 symptomatic and 100 contralateral asymptomatic knees. AJR Am J Roentgenol 181:635–641
  4. Gauffin  H, Tagesson  S, Meunier  A, Magnusson  H, Kvist  J.  Knee arthroscopic surgery is beneficial to middle-aged patients with meniscal symptoms: a prospective, randomised, single-blinded study. Osteoarthritis Cartilage. 2014;22(11):1808-1816. doi:10.1016/j.joca.2014.07.017
  5. Herrlin  S, Hållander  M, Wange  P, Weidenhielm  L, Werner  S.  Arthroscopic or conservative treatment of degenerative medial meniscal tears: a prospective randomised trial. Knee Surg Sports Traumatol Arthrosc. 2007;15(4):393-401. doi:10.1007/s00167-006-0243-2
  6. Katz  JN, Brophy  RH, Chaisson  CE,  et al.  Surgery versus physical therapy for a meniscal tear and osteoarthritis. N Engl J Med. 2013;368(18):1675-1684. doi:10.1056/NEJMoa1301408
  7. Kirkley  A, Birmingham  TB, Litchfield  RB,  et al.  A randomized trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2008;359(11):1097-1107. doi:10.1056/NEJMoa0708333
  8. Kise  NJ, Risberg  MA, Stensrud  S, Ranstam  J, Engebretsen  L, Roos  EM.  Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: randomised controlled trial with two year follow-up. BMJ. 2016;354:i3740. doi:10.1136/bmj.i3740
  9. van de Graaf  VA, Noorduyn  JCA, Willigenburg  NW,  et al; ESCAPE Research Group.  Effect of early surgery vs physical therapy on knee function among patients with non-obstructive meniscal tears: the ESCAPE randomized clinical trial. JAMA. 2018;320(13):1328-1337. doi:10.1001/jama.2018.13308
  10. Yim  JH, Seon  JK, Song  EK,  et al.  A comparative study of meniscectomy and nonoperative treatment for degenerative horizontal tears of the medial meniscus. Am J Sports Med. 2013;41(7):1565-1570. doi:10.1177/0363546513488518
  11. Abram  SGF, Hopewell  S, Monk  AP, Bayliss  LE, Beard  DJ, Price  AJ.  Arthroscopic partial meniscectomy for meniscal tears of the knee: a systematic review and meta-analysis. Br J Sports Med. 2020;54(11):652-663. doi:10.1136/bjsports-2018-100223
  12. Sonesson S, Kvist J, Yakob J, Hedevik H, Gauffin H. Knee Arthroscopic Surgery in Middle-Aged Patients With Meniscal Symptoms: A 5-Year Follow-up of a Prospective, Randomized Study. Orthop J Sports Med. 2020 Jan 27;8(1):2325967119893920. doi: 10.1177/2325967119893920. PMID: 32047825; PMCID: PMC6985975
  13. van de Graaf VA, Noorduyn JCA, Willigenburg NW, et al. Effect of Early Surgery vs Physical Therapy on Knee Function Among Patients With Nonobstructive Meniscal Tears: The ESCAPE Randomized Clinical Trial. JAMA. 2018;320(13):1328–1337. doi:10.1001/jama.2018.13308
  14. Noorduyn JCA, van de Graaf VA, Willigenburg NW, et al. Effect of Physical Therapy vs Arthroscopic Partial Meniscectomy in People With Degenerative Meniscal Tears: Five-Year Follow-up of the ESCAPE Randomized Clinical Trial. JAMA Netw Open. 2022;5(7):e2220394. doi:10.1001/jamanetworkopen.2022.20394
  15. Sihvonen  R, Paavola  M, Malmivaara  A,  et al; FIDELITY (Finnish Degenerative Meniscus Lesion Study) Investigators.  Arthroscopic partial meniscectomy for a degenerative meniscus tear: a 5 year follow-up of the placebo-surgery controlled FIDELITY (Finnish Degenerative Meniscus Lesion Study) trial.   Br J Sports Med. 2020;54(22):1332-1339. doi:10.1136/bjsports-2020-102813
  16. Katz  JN, Shrestha  S, Losina  E,  et al.  Five-year outcome of operative and non-operative management of meniscal tear in persons greater than 45 years old.   Arthritis Rheumatol. 2020;72(2):273-281. doi:10.1002/art.41082
  17. Berg  B, Roos  EM, Englund  M,  et al.  Development of osteoarthritis in patients with degenerative meniscal tears treated with exercise therapy or surgery: a randomized controlled trial.   Osteoarthritis Cartilage. 2020;28(7):897-906. doi:10.1016/j.joca.2020.01.020
  18. Herrlin  SV, Wange  PO, Lapidus  G, Hållander  M, Werner  S, Weidenhielm  L.  Is arthroscopic surgery beneficial in treating non-traumatic, degenerative medial meniscal tears? a five year follow-up.   Knee Surg Sports Traumatol Arthrosc. 2013;21(2):358-364. doi:10.1007/s00167-012-1960-3