Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: randomised controlled trial with two year follow-upBMJ 2016; 354 doi: https://doi.org/10.1136/bmj.i3740 (Published 20 July 2016) Cite this as: BMJ 2016;354:i3740
- Nina Jullum Kise, orthopaedic surgeon1,
- May Arna Risberg, physiotherapist and professor2 3 4,
- Silje Stensrud, physiotherapist2,
- Jonas Ranstam, independent statistician and professor5,
- Lars Engebretsen, orthopaedic surgeon and professor3 6 7,
- Ewa M Roos, physiotherapist and professor8
- 1Department of Orthopaedic Surgery, Martina Hansens Hospital, PO box 823, N-1306 Sandvika, Norway
- 2Norwegian Research Centre for Active Rehabilitation, Oslo, Norway
- 3Division of Orthopaedic Surgery, Oslo University Hospital, Norway
- 4Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
- 5Department of Orthopaedics, Clinical Sciences Lund, Lund University, Sweden
- 6Faculty of Medicine, University in Oslo
- 7Oslo Sports Trauma Research Centre, Norwegian School of Sport Sciences, Oslo, Norway
- 8Research Unit for Musculoskeletal Function and Physiotherapy, Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
- Correspondence to: N J Kise
- Accepted 26 June 2016
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 (KOOS4), 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 KOOS4 at two years (0.9 points, 95% confidence interval −4.3 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.
We thank the patients for their participation; research coordinators Kristin Bølstad and Emilie Jul-Larsen for the organisation of the participants; physiotherapists Marte Lund, Karin Rydevik, and Christian Vilming for assistance with data collection; the Norwegian Sports Medicine Clinic (NIMI), Oslo, Norway, for supporting the Norwegian Research Center for Active Rehabilitation (NAR) with rehabilitation facilities and research staff (NAR is a collaboration between the Norwegian School of Sports Sciences, Department of Orthopaedic Surgery, Oslo University Hospital, and NIMI); and the Department of Orthopaedic Surgery, Oslo University Hospital and the Department of Orthopaedic Surgery, Martina Hansens Hospital, Bærum, for accessibility to the outpatient and surgical clinics.
Contributors: EMR, MAR, and SS conceived and designed the study. SS, LE, and NJK collected the data. SS trained most participants. LE and NJK operated on most participants. NJK and EMR drafted the article. Jonas Ranstam performed the statistical analyses. All authors participated in the analysis and interpretation of the data, revision of the article, and final approval of the version to be published. EMR is the guarantor. All authors had full access to all of the data including statistical reports and tables in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Funding: This study was funded by Sophies Minde Ortopedi AS, Swedish Rheumatism Association, Swedish Scientific Council, Region of Southern Denmark, Danish Rheumatism Association, and the Health Region of South-East Norway. The researchers were independent from the funder.
Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any company for the submitted work; no relationships with any company that might have an interest in the submitted work in the previous three years; their spouses, partners, or children have no financial relationships that may be relevant to the submitted work; and they have no non-financial interests that may be relevant to the submitted work.
Ethical approval: This study was approved by the regional ethics committee of the Health Region of South-East Norway (reference No 2009/230).
Data sharing: Anonymised data will be shared on reasonable request.
Transparency: The lead author (NJK) affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained. Data sharing: we agree to share anonymised data upon reasonable request.
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