KNEE
CARTILAGE (Meniscus) NEWS
From CHICAGO, Illinois — Patients with knee osteoarthritis
and a meniscal tear who received physical therapy without surgery had good
functional improvement 6 months later, and outcomes did not differ
significantly from patients who underwent arthroscopic partial meniscectomy, a
new clinical trial shows.
In
the Meniscal Tear in Osteoarthritis Research (METEOR) trial, both groups of
patients improved substantially in function and pain.
This finding,
presented here at the American Academy of Orthopaedic Surgeons 2013 Annual
Meeting and published online simultaneously in the New England Journal of Medicine,
provides "considerable reassurance regarding an initial nonoperative
strategy," the investigators report.
Patients with a
meniscal tear and osteoarthritis pose a treatment challenge because it is not
clear which condition is causing their symptoms," principal investigator
Jeffrey Katz, MD, from Brigham and Women's Hospital in Boston, Massachusetts,
told Mediscape Medical
News.
"These data
suggest that there are 2 reasonable pathways for patients with knee arthritis
and meniscal tear," Dr. Katz explained. "We hope physicians will use
these data to help patients understand their choices."
In an accompanying
editorial, clinical epidemiologist Rachelle Buchbinder, PhD, from
the Monash University School of Public Health and Preventive Medicine in
Victoria, Australia, said that "these results should change practice.
Currently, millions of people are being exposed to potential risks associated
with a [surgical] treatment that may or may not offer specific benefit, and the
costs are substantial."
These results
should change practice.
The METEOR trial
enrolled 351 patients from 7 medical centers in the United States. Eligible
patients were older than 45 years, had osteoarthritic cartilage change
documented with magnetic resonance imaging, and had at least 1 symptom of
meniscal tear, such as knee clicking or giving way, that lasted at least 1
month despite drug treatment, physical therapy, or limited activity.
In this
intent-to-treat analysis, investigators randomly assigned 174 patients to
arthroscopic partial meniscectomy plus postoperative physical therapy and 177
to physical therapy alone.
The physical therapy
in both regimens was a standardized 3-stage program that allowed patients to
advance to the next intensity level at their own pace, Dr. Katz explained. The
program involved 1 or 2 sessions a week for about 6 weeks and home exercises.
The average number of physical therapy visits was 7 in the surgery group and 8
in the nonsurgery group.
Investigators
evaluated patients 6 and 12 months after randomization. The primary outcome was
the between-group difference in change in physical function score from baseline
to 6 months, assessed using the Western Ontario and McMaster Universities
Osteoarthritis Index (WOMAC). At baseline, demographic characteristics and
WOMAC physical function scores were similar in the 2 groups.
At 6 months,
improvement in the WOMAC function score was comparable in the 2 groups. The
mean between-group difference of 2.4 points was not statistically significant
after analysis of covariance. There was also no significant difference between
groups in pain improvement or frequency of adverse events.
METEOR: Mean
Improvement in Osteoarthritis Index at 6 Months
|
Treatment Group
|
Mean Improvement (Points)
|
95% Confidence Interval
|
|
Surgery plus physical therapy
|
20.9
|
17.9–23.9
|
|
Physical therapy
|
18.5
|
15.6–21.5
|
There was 1 death in
each group, and 8 patients in the nonsurgery group and 13 in the surgery group
withdrew in the first 6 months of the study.
Patients in the
nonsurgery group were allowed to cross over to the surgical group at any time.
Within 6 months, 30% of patients did so.
"They were not
doing very well," Dr. Katz said. His team is still analyzing the reasons
these patients did not benefit from intensive physical therapy.
The 12-month results
were similar to the 6-month results. In addition, by 12 months, outcomes for
the crossover patients and for those in the original surgery group were
similar.
Meeting delegate John
Mays, MD, an orthopaedic surgeon practicing in Bossier City, Louisiana, who was
asked by Medscape
Medical News to comment on the findings, said most patients
don't choose physical therapy. "In the real world, most people want a
quick fix" and choose surgery, he noted.
Dr. Mays said he
would have liked to have seen a group of patients who underwent surgery but did
not receive postoperative physical therapy. He explained that his patients with
osteoarthritis and meniscal tear rarely get physical therapy after arthroscopic
meniscectomy; they most often do home-based exercises.
He added that
"most insurance plans have limits on the number of physical therapy
sessions they allow."
This study is funded
by the National Institute of Arthritis and Musculoskeletal and Skin Diseases.
Dr. Katz, Dr. Buchbinder, and Dr. Mays have disclosed no relevant financial
relationships.
