Exercise as Effective as Surgery for Meniscal Tears

Marcia Frellick

July 21, 2016

Exercise is as effective as knee surgery for middle-aged patients with degenerative meniscal tears, according to a study published July 20 in the BMJ.

Nina Jullum Kise, MD, from the Department of Orthopedic Surgery, Martina Hansens Hospital, Sandvika, Norway, and colleagues conducted a randomized controlled trial that included 140 adults, average age 49.5 years, with degenerative medial meniscal tear verified by magnetic resonance imaging. Only 4% of the patients showed definitive radiographic evidence of osteoarthritis.

Half the patients received a supervised 12-week exercise program (two to three sessions each week), and half received arthroscopic surgery followed by daily at-home exercises.

The researchers tested thigh muscle strength at 3 and 12 months and recorded patient-reported knee function at 2 years.

The authors found no differences at 2 years between the groups in knee function (0.9 points; 95% confidence interval, −4.3 to 6.1 points; P = .72) and found greater muscle strength in the exercise group at 3 months (P ≤ .04) and 12 months (P < .03).

Those in the exercise group also reported significantly fewer symptoms such as mechanical problems, swelling, and decreased range of motion.

Nineteen percent of the participants crossed over from the exercise group to the surgery group during the 2-year follow-up, with no additional benefit.

"Our results should encourage clinicians and middle aged patients with degenerative meniscal tear and no definitive radiographic evidence of osteoarthritis to consider supervised exercise therapy as a treatment option," the authors write.

2 Million Surgeries a Year

Every year, about 2 million people worldwide undergo knee arthroscopy, but compiled evidence suggests the surgery offers little benefit for most patients.

Previous studies have used insufficient exercise programs, the authors say, and have found only a slight benefit during a short period.

"In a recent meta-analysis, the authors concluded that a small but inconsequential benefit is seen from treatment interventions that involve arthroscopy," the authors write. "This small effect is of short duration and absent one year after surgery. Only one in five randomised controlled trials found greater pain relief one year after partial meniscectomy compared with non-surgical treatment."

Those results, added to the newly reported data from Dr Kise and colleagues, raise the question of why the surgery continues to be so widely performed when the evidence of benefit is not there.

In an accompanying editorial, Teppo L. N. Järvinen, MD, PhD, professor in the Department of Orthopaedics and Traumatology, University of Helsinki, and Helsinki University Central Hospital in Finland, and Gordon H. Guyatt, MD, distinguished professor in the Department of Clinical Epidemiology and Biostatistics, McMaster University in Hamilton, Ontario, Canada, say: "Essentially, good evidence has been widely ignored."

They point to a series of rigorous trials, summarized in two recent systematic reviews and meta-analyses, that conclude that arthroscopic knee surgery offers little benefit for most patients with knee pain: the analysis cited by Dr Kise and colleagues and another from 2014.

Surgeons Would Argue Trials Are Not Real Life

They acknowledge that orthopedic surgeons would disagree the surgeries are unnecessary and that surgeons would argue that trials do not reflect the real world, but Dr Järvinen and Dr Guyatt remain unconvinced.

"We are at the point where any careful scrutiny, by, for instance, public health administrators or officials of an insurance company, would conclude that the estimated two million arthroscopic partial meniscectomies undertaken globally each year at a cost of several billion US dollars is potentially nothing but medical waste," they write.

The most common serious adverse event with arthroscopic knee surgery is deep vein thrombosis, with 4.13 events per 1000 procedures (95% confidence interval, 1.78 - 9.60 events per 1000 procedures), Dr Kise and colleagues note. However, no serious adverse events occurred in either treatment group in the current study.

The authors note that one limitation of the trial was the lack of a sham surgery control.

This study was funded by Sophies Minde Ortopedi AS, the Swedish Rheumatism Association, the Swedish Scientific Council, the Region of Southern Denmark, the Danish Rheumatism Association, and the Health Region of South-East Norway. The authors and editorialists have disclosed no relevant financial relationships.

BMJ. 2016;354:i3740. Article full text, Editorial full text

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