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Based on criteria for selecting "articles most likely to change clinical practice," one article of significant interest was selected by the DynaMed Editorial Team.

Initial Treatment with Physical Therapy for Meniscal Tear Associated with Functional Improvement Similar to Surgery and May Lower Surgery Rates in Patients with Knee Osteoarthritis
Reference: N Engl J Med 2013 Mar 18 early online, (level 2 [mid-level] evidence)

Meniscal tears are common in patients with osteoarthritis of the knee, and symptomatic tears are frequently treated with arthroscopic surgery. Existing data from randomized trials show arthroscopic debridement is not effective for treating knee osteoarthritis (N Engl J Med 2008 Sep 11;359(11):1097, N Engl J Med 2002 Jul 11;347(2):81), but these trials have not specifically addressed meniscal tears. A new trial compared initial physical therapy vs. initial arthroscopic surgery for symptomatic meniscal tears in this population.

A total of 351 patients with mild-to-moderate osteoarthritis and symptomatic meniscal tear were randomized to 1 of 2 treatments and followed for 1 year. The first group began treatment with a standardized physical therapy regimen but had the option for surgery at the discretion of patient and surgeon. The second group had immediate arthroscopic partial meniscectomy followed by the same standardized physical therapy. The physical therapy regimen for both groups included interventions to address inflammation, range of motion, muscle strength, aerobic conditioning, functional mobility, and balance. There were 1 or 2 weekly sessions plus home exercises for approximately 6 weeks depending on patient progress. All patients could have acetaminophen or NSAIDs as needed, and intraarticular glucocorticoid injections were permitted. The primary outcome was change in physical function measured by the Western Ontario and McMaster Universities Osteoarthritis Index scale (WOMAC score, 0-100 scale with higher scores indicating more severe symptoms). The mean WOMAC scores at baseline were 37.5 in physical therapy group and 37.1 in surgery group. A change in score of 8 points was considered clinically meaningful.

Patients who did not complete follow-up (6% at 6 months and 9% at 1 year) were excluded from the analyses. Both groups showed significant improvement in physical function by WOMAC score at 6 months (decrease in score 18.5 vs. 20.9) and 1 year (decrease in score 22.8 vs. 23.5). There were no significant differences in improvement between groups at either time point. 30% of the physical therapy group crossed over to surgical treatment in the first 6 months (surgery was performed in 94% of the surgery group). In the physical therapy group, 44% had clinically relevant improvement at 6 months without crossing over, compared to 67% in the surgery group (p < 0.001). There were no significant differences in adverse events or pain at 6 or 12 months.

Most of the patients in the physical therapy group who had surgery in the first 6 months had little functional improvement prior to crossover. However, their 1-year outcomes were similar to those of the immediate surgery group, suggesting that delaying surgery did not have a detrimental effect. It should be noted that the WOMAC questionnaire is a valid measure of physical function during basic activities of daily living, but it does not assess high-level function as may be required for work or sports. Nevertheless, these results suggest that physical therapy may be an appropriate first option for many patients with osteoarthritis and meniscal tears and that it may be possible to reserve surgery for those who do not benefit from physical therapy alone.

For more information, see the Meniscus tears topic in DynaMed.

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Massachusetts Academy of Family Physicians (MassAFP) 2013 Spring CME Refresher, April 12 – 13, 2013
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