Treatment of Degenerative Meniscal Tears in Middle-Aged Patients

Background: In orthopedic surgery, new knowledge has contributed to change of treatment algorithms. For patients with degenerative meniscal tears, the usual treatment has been arthroscopic partial meniscectomy (APM), but studies have shown similar results after exercise therapy (ET) or sham surgery. Aim: The overall aim of this thesis was to determine if ET was superior to APM on knee function after 2 years. Secondary aims were to identify prognostic factors for outcomes. Methods: 140 patients aged 35-60 years with degenerative meniscal tears were treated with either ET or APM. Main outcomes were 2-year KOOS4 score (mean score of 4 of 5 subscales from the Knee injury and Osteoarthritis Outcome Score) and 3-month thigh strength. Secondary outcomes were KOOS subscales and knee performance. In subgroups, prognostic factors of knee function, knee performance and activity level at baseline and meniscal tear characteristics, on 1- and 2-year outcomes were explored. Results: Both treatment groups had clinically and statistically significant improvements for all KOOS outcomes at 2 years, and there were no between-group differences. After 3 and 12 months, the ET group had significantly better muscle strength. A better 6-meter timed hop test result at baseline was associated with better 2-year outcomes. Complex meniscal tears, meniscal extrusion, cartilage injury and larger meniscal excisions were associated with worse outcomes. Conclusions: No differences in 2-year results for treatment of degenerative meniscal tears with ET or APM. Better knee function at baseline was a significant prognostic factor for better outcomes. Complex meniscal tears, meniscal extrusion, cartilage injury and larger excisions of meniscal tissue were prognostic factors for inferior outcomes. This implicates that ET should be recommended, at least as the primary treatment. Patients should be informed that better knee performance is a prognostic factor for better outcomes after 2 years

The 6-m timed hop test is a prognostic factor for outcomes in patients with meniscal tears treated with exercise therapy or arthroscopic partial meniscectomy: a secondary, exploratory analysis of the Odense–Oslo meniscectomy versus exercise (OMEX) trial

Purpose: To identify the prognostic factors for 2-year patient-reported outcomes in middle-aged patients with degenerative meniscal tears treated with exercise therapy (ET) or arthroscopic partial meniscectomy (APM). Methods: One hundred and seven patients, with mean age 49.6 (SD 6.2) years and BMI 25.7 (SD 3.7), were included in this analysis of data from the OMEX trial (http://www.clinicaltrials.gov NCT01002794). Linear and Poisson regression models were built to explore the associations between potential prognostic factors (patient characteristics, knee function-related and disease-related factors) and 2-year patient-reported outcomes: the Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales Pain, Symptoms, ADL, Sport/Rec, QoL and 5-point Global Rating of Change scales for knee pain (GRC Pain) and function (GRC Function). Analyses were performed for the whole cohort and for the two treatment groups (n = 55 and 52) with adjustments for age, sex, BMI and baseline KOOS. Results: For the whole cohort, a 1-s better baseline 6-m timed hop test result was associated with 3.1–7.1 points better 2-year scores for all KOOS subscales (95% CIs 1.1–5.2 to 4.1–10.1 points). A 1.61–2.80 s better test was associated with scores equivalent to previously calculated clinical relevant differences for each KOOS subscale. For the groups of patients treated with ET and APM, respectively, 2.09–3.60 s and 0.63–1.99 s better tests were associated with clinical relevant differences. For the whole cohort, a 1-s better test was associated with 26% (95% CI 15–38%) and 22% (95% CI 11–34%) higher possibility for better or much better GRC Pain and Function scores. Patients treated with ET had 17% (95% CI 2–33%) increased possibility for better or much better GRC Pain score, and patients treated with APM had 65% (95% CI 32–108%) and 70% (95% CI 38–109%) increased possibility for better or much better GRC Pain and Function scores. Conclusions: The 6-m timed hop test result was a significant prognostic factor for 2-year patient-reported outcomes in middle-aged patients with degenerative meniscal tears, especially in those treated with APM

The 6-m timed hop test is a prognostic factor for outcomes in patients with meniscal tears treated with exercise therapy or arthroscopic partial meniscectomy: a secondary, exploratory analysis of the Odense–Oslo meniscectomy versus exercise (OMEX) trial

Purpose: To identify the prognostic factors for 2-year patient-reported outcomes in middle-aged patients with degenerative meniscal tears treated with exercise therapy (ET) or arthroscopic partial meniscectomy (APM). Methods: One hundred and seven patients, with mean age 49.6 (SD 6.2) years and BMI 25.7 (SD 3.7), were included in this analysis of data from the OMEX trial (http://www.clinicaltrials.gov NCT01002794). Linear and Poisson regression models were built to explore the associations between potential prognostic factors (patient characteristics, knee function-related and disease-related factors) and 2-year patient-reported outcomes: the Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales Pain, Symptoms, ADL, Sport/Rec, QoL and 5-point Global Rating of Change scales for knee pain (GRC Pain) and function (GRC Function). Analyses were performed for the whole cohort and for the two treatment groups (n = 55 and 52) with adjustments for age, sex, BMI and baseline KOOS. Results: For the whole cohort, a 1-s better baseline 6-m timed hop test result was associated with 3.1–7.1 points better 2-year scores for all KOOS subscales (95% CIs 1.1–5.2 to 4.1–10.1 points). A 1.61–2.80 s better test was associated with scores equivalent to previously calculated clinical relevant differences for each KOOS subscale. For the groups of patients treated with ET and APM, respectively, 2.09–3.60 s and 0.63–1.99 s better tests were associated with clinical relevant differences. For the whole cohort, a 1-s better test was associated with 26% (95% CI 15–38%) and 22% (95% CI 11–34%) higher possibility for better or much better GRC Pain and Function scores. Patients treated with ET had 17% (95% CI 2–33%) increased possibility for better or much better GRC Pain score, and patients treated with APM had 65% (95% CI 32–108%) and 70% (95% CI 38–109%) increased possibility for better or much better GRC Pain and Function scores. Conclusions: The 6-m timed hop test result was a significant prognostic factor for 2-year patient-reported outcomes in middle-aged patients with degenerative meniscal tears, especially in those treated with APM

Middle-aged patients with an MRI-verified medial meniscal tear report symptoms commonly associated with knee osteoarthritis : A cross-sectional study of 199 patients

Background and purpose — No consensus exists on when to perform arthroscopic partial meniscectomy in patients with a degenerative meniscal tear. Since MRI and clinical tests are not accurate in detecting a symptomatic meniscal lesion, the patient’s symptoms often play a large role when deciding when to perform surgery. We determined the prevalence and severity of self-reported knee symptoms in patients eligible for arthroscopic partial meniscectomy due to a degenerative meniscal tear. We investigated whether symptoms commonly considered to be related to meniscus injury were associated with early radiographic signs of knee osteoarthritis. Patients and methods — We included individual baseline items from the Knee injury and Osteoarthritis Outcome Score collected in 2 randomized controlled trials evaluating treatment for an MRI-verified degenerative medial meniscal tears in 199 patients aged 35–65 years. Each item was scored as no, mild, moderate, severe, extreme, and at least “mild” considering the symptoms present. Early radiographic signs of osteoarthritis, defined as a Kellgren and Lawrence grade of at least 1, were seen in 70 patients. Results — At least monthly knee pain, pain during stair walking and when twisting on the knee, and lack of confidence in knee was present in at least 80% of the patients. Median severity was at least moderate for knee pain, pain when twisting on the knee, pain walking on stairs, lack of confidence in knee, and clicking. Mechanical symptoms such as catching were rare. Early radiographic signs of osteoarthritis were associated with an increased risk of self-reported swelling, catching, and stiffness later in the day; the odds ratio was 2.4 (95% CI 1.2–4.9), 2.3 (1.2–4.3), and 2.3 (1.1–5.0), respectively. Interpretation — Middle-aged patients with a degenerative medial meniscus tear reported symptoms commonly associated with knee osteoarthritis. Frequent knee pain, presence of lack of confidence in the knee, and clicking did not distinguish those with a meniscal tear alone from those with early radiographic knee OA. Our findings support the notion that symptoms reported by those with a degenerative meniscal tear represent early signs of knee osteoarthritis

Muscle strength and osteoarthritis progression after surgery or exercise for degenerative meniscal tears: Secondary analyses of a randomized trial

Objective: To evaluate muscle strength changes following partial meniscectomy or exercise therapy for degenerative meniscal tears and the relationship between baseline muscle strength and osteoarthritis progression. Methods: Secondary analysis of a randomized trial (n = 140 participants). Isokinetic quadriceps and hamstrings strength (peak torque [Nm/kg] and total work [J/kg]) were assessed at baseline, 3-month, 12-month, and 5-year follow-up. Between-group differences were analyzed using intent-to-treat linear mixed models. The relationship between baseline muscle strength and osteoarthritis progression (Kellgren/Lawrence ≥1 grade increase) were assessed using logistic regression models. Results: We found statistically significant between-group differences favoring exercise therapy at 3 months (quadriceps –0.30 Nm/kg [95% confidence interval (95% CI) –0.40, –0.20]; hamstrings –0.10 Nm/kg [95% CI –0.15, –0.04]) and 12 months (quadriceps –0.13 Nm/kg [95% CI –0.23, –0.03]; hamstrings –0.08 Nm/kg [95% CI –0.14, –0.03]). At 5 years, between-group differences were –0.10 Nm/kg (95% CI –0.21, 0.01) for quadriceps and –0.07 Nm/kg (95% CI –0.13, –0.01) for hamstrings. Quadriceps muscle weakness at baseline was associated with knee osteoarthritis progression over 5 years, with adjusted odds ratio of 1.40 for every 0.2 Nm/kg decrease (95% CI 1.15, 1.71). The adjusted odds ratio for hamstrings was 1.14 (95% CI 0.97, 1.35) for every 0.1 Nm/kg decrease. Conclusion: Exercise therapy was effective in improving muscle strength at 3- and 12-month follow-up compared to partial meniscectomy, but the effect was attenuated at 5 years. Quadriceps muscle weakness at baseline was associated with higher odds of osteoarthritis progression over 5 years

Complex Tears, Extrusion, and Larger Excision Are Prognostic Factors for Worse Outcomes 1 and 2 Years After Arthroscopic Partial Meniscectomy for Degenerative Meniscal Tears: A Secondary Explorative Study of the Surgically Treated Group From the Odense-Oslo Meniscectomy Versus Exercise (OMEX) Trial

Background: Few studies have examined morphological findings from preoperative magnetic resonance imaging (MRI) and arthroscopic findings as prognostic factors for outcomes 1 and 2 years after arthroscopic partial meniscectomy (APM). Purpose/Hypothesis: The purpose was to evaluate prognostic factors of preoperative findings from MRI and arthroscopic evaluation on lower extremity performance at 1 year and patient-reported outcomes at 1 to 2 years after APM. The hypothesis was that medial compartment abnormalities would be prognostic for 1- and 2-year functional outcomes. Study Design: Cohort study; Level of evidence, 2. Methods: This secondary analysis from the OMEX (Odense-Oslo Meniscectomy Versus Exercise) trial included 40 patients treated surgically. Regression analyses with adjustments for age, sex, and body mass index explored associations between MRI findings (tear complexity and extrusion), arthroscopic findings (tear length, cartilage injury, and amount of excised meniscal tissue), and the following: lower extremity performance tests and thigh muscle strength at 1 year and the 5 Knee injury and Osteoarthritis Outcome Score (KOOS) subscales at 1 and 2 years. Results: A complex meniscal tear was a significant and clinically relevant prognostic factor for worse KOOS Symptoms subscores at 2 years (mean, 14.1 points [95% CI, 6.1-22.2]). Meniscal extrusion of at least 11%, 25%, and 20% were significant and clinically relevant prognostic factors for worse KOOS Activities of Daily Living (ADL) subscores at 1 year and worse KOOS Sports and Recreation (Sports/Rec) subscores at 1 and 2 years, respectively. Tear lengths of at least 7.0 mm, 6.7 mm, and 6.5 mm were significant and clinically relevant prognostic factors for better KOOS Symptoms subscores at 1 year and better KOOS Sports/Rec subscores at 1 and 2 years, respectively. A cartilage injury in the medial compartment was a significant and clinically relevant prognostic factor for worse KOOS ADL and Quality of Life (QoL) subscores at 2 years (mean, 10.4 and 19.4 points, respectively [95% CI, 3.4-17.4 and 7.7-31.1, respectively]). More than 20% meniscal tissue excised was a significant and clinically relevant prognostic factor for worse KOOS Pain, Symptoms, ADL, and Sports/Rec subscores at 1 and 2 years (mean, 8.9-41.5 points [95% CI, 2.2-15.5 to 21.0-62.0]) and worse KOOS QoL subscores at 2 years (mean, 25.3 points [95% CI, 13.6-37.0]). Conclusion: Complex meniscal tears, larger extrusion, cartilage injuries, and larger meniscal excision were significant and clinically relevant prognostic factors for worse outcomes 1 and 2 years after APM

Muscle strength and osteoarthritis progression after surgery or exercise for degenerative meniscal tears: Secondary analyses of a randomized trial

Objective: To evaluate muscle strength changes following partial meniscectomy or exercise therapy for degenerative meniscal tears and the relationship between baseline muscle strength and osteoarthritis progression. Methods: Secondary analysis of a randomized trial (n=140 participants). Isokinetic quadriceps and hamstrings strength (peak torque [N·m/kg] and total work [J/kg]) were assessed at baseline, three-, 12-month, and five-year follow-up. Between-group differences were analyzed using intention-to-treat linear mixed models. The relationship between baseline muscle strength and osteoarthritis progression (Kellgren and Lawrence, ≥1 grade increase) were assessed using logistic regression models. Results: We found statistically significant between-group differences favoring exercise therapy at three months (quadriceps: -0.30 N·m/kg, 95% CI -0.40, -0.20; hamstrings: -0.10 N·m/kg, 95% CI -0.15, -0.04) and 12 months (quadriceps: -0.13 N·m/kg, 95% CI -0.23, -0.03; hamstrings: -0.08 N·m/kg, 95% CI -0.14, -0.03). At five years, between-group differences were -0.10 N·m/kg (95% CI -0.21 to 0.01) for quadriceps and -0.07 N·m/kg (95% CI -0.13 to -0.01) for hamstrings. Quadriceps muscle weakness at baseline was associated with knee osteoarthritis progression over five years: adjusted odds ratio of 1.40 for every 0.2 N·m/kg decrease (95% CI 1.15 to 1.71). The adjusted odds ratio for hamstrings was 1.14 (95% CI 0.97-1.35) for every 0.1 N·m/kg decrease. Conclusion: Exercise therapy was effective in improving muscle strength at three and 12-month follow-up compared to partial meniscectomy, but the effect was attenuated at five years. Quadriceps muscle weakness at baseline was associated with higher odds of osteoarthritis progression over five years

Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients : Randomised controlled trial with two year follow-up

Objective To determine if exercise therapy is superior to arthroscopic partial meniscectomy for knee function in middle aged patients with degenerative meniscal tears. Design Randomised controlled superiority trial. Setting Orthopaedic departments at two public hospitals and two physiotherapy clinics in Norway. Participants 140 adults, mean age 49.5 years (range 35.7-59.9), with degenerative medial meniscal tear verified by magnetic resonance imaging. 96% had no definitive radiographic evidence of osteoarthritis. Interventions 12 week supervised exercise therapy alone or arthroscopic partial meniscectomy alone. Main outcome measures Intention to treat analysis of between group difference in change in knee injury and osteoarthritis outcome score (KOOS 4), defined a priori as the mean score for four of five KOOS subscale scores (pain, other symptoms, function in sport and recreation, and knee related quality of life) from baseline to two year follow-up and change in thigh muscle strength from baseline to three months. Results No clinically relevant difference was found between the two groups in change in KOOS 4 at two years (0.9 points, 95% confidence interval4.3 to 6.1; P=0.72). At three months, muscle strength had improved in the exercise group (P≤0.004). No serious adverse events occurred in either group during the two year follow-up. 19% of the participants allocated to exercise therapy crossed over to surgery during the two year follow-up, with no additional benefit. Conclusion The observed difference in treatment effect was minute after two years of follow-up, and the trial's inferential uncertainty was sufficiently small to exclude clinically relevant differences. Exercise therapy showed positive effects over surgery in improving thigh muscle strength, at least in the short term. 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. Trial registration www.clinicaltrials.gov (NCT01002794)

Development of osteoarthritis in patients with degenerative meniscal tears treated with exercise therapy or surgery: a randomized controlled trial

Objective: To evaluate progression of individual radiographic features 5 years following exercise therapy or arthroscopic partial meniscectomy as treatment for degenerative meniscal tear. Design: Randomized controlled trial including 140 adults, aged 35–60 years, with a magnetic resonance image verified degenerative meniscal tear, and 96% without definite radiographic knee osteoarthritis. Participants were randomized to either 12-weeks of supervised exercise therapy or arthroscopic partial meniscectomy. The primary outcome was between-group difference in progression of tibiofemoral joint space narrowing and marginal osteophytes at 5 years, assessed semi-quantitatively by the OARSI atlas. Secondary outcomes included incidence of radiographic knee osteoarthritis and symptomatic knee osteoarthritis, medial tibiofemoral fixed joint space width (quantitatively assessed), and patient-reported outcome measures. Statistical analyses were performed using a full analysis set. Per protocol and as treated analysis were also performed. Results: The risk ratios (95% CI) for progression of semi-quantitatively assessed joint space narrowing and medial and lateral osteophytes for the surgery group were 0.89 (0.55–1.44), 1.15 (0.79–1.68) and 0.77 (0.42–1.42), respectively, compared to the exercise therapy group. In secondary outcomes (full-set analysis) no statistically significant between-group differences were found. Conclusion: The study was inconclusive with respect to potential differences in progression of individual radiographic features after surgical and non-surgical treatment for degenerative meniscal tear. Further, we found no strong evidence in support of differences in development of incident radiographic knee osteoarthritis or patient-reported outcomes between exercise therapy and arthroscopic partial meniscectomy