Is surgery the only option for meniscal tear and osteoarthritis?

Many middle age and older adults have disabling knee pain due to a tear in the meniscus, an important supporting structure in the knee that is often damaged in patients with underlying knee osteoarthritis.

In the United States, more than 450,000 arthroscopic meniscal surgeries are performed each year to treat meniscal tears. However, there is little data available to clinicians who must decide with their patients whether it is best to treat tears with surgery or with physical therapy.

Now, new research from Brigham and Women's Hospital (BWH), suggests that physical therapy (PT) may prove just as effective as surgery for some patients. These findings are presented at the annual meeting of the American Academy of Orthopedic Surgeons and simultaneously published online in the New England Journal of Medicine.

“Since both the patients who received physical therapy and those who received surgery had similar and considerable improvements in function and pain, our research shows that there is no single “best” treatment,” said Jeffrey N. Katz, MD, MSc, principal investigator for the trial. “Patients who wish to avoid surgery can be reassured that physical therapy is a reasonable option, although they should recognize that not everyone will improve with physical therapy alone.
In this study, one third of patients who received physical therapy ultimately chose to have surgery, often because they did not improve with PT,” added Katz, who is director of the Orthopedic and Arthritis Center for Outcomes Research at BWH and Professor of Medicine and Orthopedic Surgery at Harvard Medical School.

These findings are from the MeTeOR (Meniscal Tear in Osteoarthritis Research) Trial, a multicenter study designed by a research team at BWH that involved 351 patients who were over 45 years old with knee pain, meniscal tear and knee osteoarthritis. The patients were randomized to receive arthroscopic meniscal surgery or physical therapy. Those subjects assigned to the physical therapy arm had the opportunity to undergo surgery later in the course of the trial if they wished. Researchers assessed their improvement in functional status using standardized functional status scores after six and twelve months.

The researchers report that subjects assigned to physical therapy and those assigned to surgery both had substantial and similar improvements in functional status. However, researchers also note that these results were achieved in part because one-third of subjects assigned to the physical therapy arm elected to undergo surgery over the course of the study. The remaining two-thirds of patients in the physical therapy group did achieve similar improvements in pain and physical function compared to the surgical group, but without undergoing surgery.

“We hope these findings will help physicians and their patients with knee pain, meniscal tear and osteoarthritis to discuss the likely outcomes of surgery and physical therapy and make informed treatment decisions,” said senior author, Elena Losina, PhD, co-director of the Orthopaedic and Arthritis Center for Outcomes Research at BWH and Associate Professor of Orthopedic Surgery Harvard Medical School.

“These results are extremely valuable and will enable us to work with patients and their families to identify the treatment that is best aligned with patients' preferences,” said John Wright, MD, an orthopedic surgeon at BWH and lead orthopedist on the study.

Participating study sites included Cleveland Clinic, Hospital for Special Surgery, Mayo Clinic, Rush University, Vanderbilt University and Washington University. The Boston University School of Public Health Data Coordinating Center provided data management for the trial.

This research was supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases of the National Institutes of Health (NIH NIAMS grants: R01 AR 055557, K24 AR 057827, P60 AR 047782).

Brigham and Women's Hospital(BWH) is a 793-bed nonprofit teaching affiliate of Harvard Medical School and a founding member of Partners HealthCare. BWH has more than 3.5 million annual patient visits, is the largest birthing center in New England and employs more than 15,000 people. The Brigham's medical preeminence dates back to 1832, and today that rich history in clinical care is coupled with its national leadership in patient care, quality improvement and patient safety initiatives, and its dedication to research, innovation, community engagementand educating and training the next generation of health care professionals. Through investigation and discovery conducted at its Biomedical Research Institute (BRI), BWH is an international leader in basic, clinical and translational research on human diseases, involving nearly 1,000 physician-investigators and renowned biomedical scientists and faculty supported by $640 million in funding. For the last 19 years, BWH ranked second in research funding from the National Institutes of Health (NIH) among independent hospitals. BWH continually pushes the boundaries of medicine, including building on its legacy in organ transplantation by performing the first face transplants in the U.S. in 2011. BWH is also home to major landmark epidemiologic population studies, including the Nurses' and Physicians' Health Studies, OurGenes and the Women's Health Initiative. For more information and resources, please visit BWH's online newsroom.