Changing our treatment of degenerative meniscal tears

Abstract

Arthroscopic partial meniscectomy has been the most performed surgical procedure in orthopaedics for long. This thesis compares physical therapy to APM for degenerative meniscal tears and shows that in patients >45 years old, physical therapy is cheaper and noninferior for patient reported knee function. Unfortunately, 29% of patients initially treated with physical therapy had an inadequate treatment response and received surgery. This indicates that 71% of patients initially treated with physical therapy do not require surgery. However, APMs are still frequently performed. One of the most common reasons is a surgeon’s belief in being able to identify who will and will not benefit from physical therapy. Therefore, we conducted a survey among almost 200 orthopaedic surgeons to determine their ability to predict the treatment outcome of patients treated for a meniscal tear. Only 50% of the predictions were correct, which was similar to prediction expected by chance alone, with no difference between experienced knee surgeons and other surgeons. These results indicate that orthopaedic surgeons are unable to identify whether a patient with a meniscal tear is better off with surgery. Therefore, the results of this thesis suggest that physical therapy is appropriate as the first-line therapy in patients >45 years old with a meniscal tear.

Key findings per chapter: Chapter 2. Pooling data of previous RCTs revealed that partial meniscectomy has only a short-term small benefit of unknown clinical importance over non- surgical treatment in patients with degenerative meniscal tears. Chapter 3. The IKDC ‘Subjective Knee Form’ is a reliable and valid measurement instrument when evaluating treatment outcome in patients with a meniscal tear. Chapter 4. We designed and initiated a multicentre randomised clinical trial and published the trial protocol to improve transparency for our healthcare and research community. Chapter 5. In our randomised clinical trial, we found that supervised exercise therapy is non-inferior to partial meniscectomy for improving patient-reported knee function in patients with degenerative meniscal tears. Chapter 6. Supervised exercise therapy is more cost-effective than arthroscopic partial meniscectomy in the treatment of degenerative meniscal tears. Chapter 7. The IKDC ‘Subjective Knee Form’ is a responsive measurement instrument when evaluating treatment outcome in patients with a meniscal tear. Chapter 8. Even experienced orthopaedic surgeons are unable to predict outcomes of partial meniscectomy and supervised exercise therapy.

Conclusion Supervised exercise therapy, compared to arthroscopic partial meniscectomy, provides better value for money in the initial treatment of degenerative meniscal tears.