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PHYSICAL THERAPY AND SURGERY BOTH PROVIDE LONG-TERM PAIN RELIEF AFTER MENISCAL TEAR WITH OA
Newswise — CHICAGO – Patients with meniscal tears and osteoarthritic changes in their knee generally experience substantial pain relief over five years whether they receive physical therapy or arthroscopic partial meniscectomy, according to new research findings presented this week at the 2018 ACR/ARHP Annual Meeting (Abstract #1816).
Osteoarthritis, or OA, is a common, painful joint disease that most often affects people in middle age or later. OA affects the entire joint, involving the cartilage, joint lining, ligaments and bone. In osteoarthritis, the cartilage between the bones in the joint breaks down because of mechanical stress or biochemical changes, resulting in less protection of underlying bone and the onset of pain.
Recent studies of surgical and non-operative treatment of meniscal tears in OA patients have focused on short-term outcomes. In a new study, researchers at Brigham and Women’s Hospital and Harvard Medical School in Boston examined long-term outcomes for patients with OA-related knee pain and meniscal tear.
“These patients care about what happens over a longer time frame than one to two years,” said Jeffrey N. Katz, MD, MSc, Professor of Medicine and Orthopedic Surgery at Harvard Medical School, and the study’s co-author.
In this multi-center, randomized trial, researchers enrolled patients with knee pain, meniscal tear and OA changes on X-ray or magnetic resonance imaging (MRI), and compared outcomes after five years among patients randomized to physical therapy (PT) or to PT plus arthroscopic partial meniscectomy (APM). The primary outcome in the study was pain, using the Knee Osteoarthritis and Injury Outcome Score Pain Scale, where scores range from 0-100, with 100 being the worst pain. The secondary outcome was total knee replacement.
There were 351 study participants with a mean age of 58, and 57 percent were female. The authors compared results in three groups: 164 receiving APM immediately, 68 who were randomized to receive PT and crossed over to receive APM, and 109 who were randomized to and received PT. Ten participants were randomized too, but did not receive APM, and were excluded. Sixty-six percent of the participants completed nine or more of 12 follow-up questionnaires, with similar completion rates across all treatment groups.
The study’s findings showed similar pain improvement in the three treatment groups, with baseline Knee Osteoarthritis and Injury Outcome pain scores of 40-50 improving to 20-25 by six months, and showing little changes in pain scores between six and 60 months. Twenty-five patients in the study had a total knee replacement over the follow-up period. Ten percent of those who received APM (immediately or after cross over) had total knee replacement as compared with two percent who received PT and no surgery.
The researchers concluded that people with degenerative meniscal tears generally experience substantial pain relief over five years irrespective of their initial treatment. The greater risk of total knee replacement in those treated surgically will need to be examined further in other studies.
“For clinicians, these results suggest that patients with meniscal tear and osteoarthritic changes can be reassured that they are likely to experience improvement with either surgery or PT,” said Dr. Katz. “For researchers, the increased rates of knee replacement require more detailed study.”
This research is supported by the NIH’s National Institute of Arthritis and Musculoskeletal and Skin Diseases.
About the ACR/ARHP Annual Meeting
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About the American College of Rheumatology
The American College of Rheumatology is an international medical society representing over 9,400 rheumatologists and rheumatology health professionals with a mission to empower rheumatology professionals to excel in their specialty. In doing so, the ACR offers education, research, advocacy and practice management support to help its members continue their innovative work and provide quality patient care. Rheumatologists are experts in the diagnosis, management and treatment of more than 100 different types of arthritis and rheumatic diseases. For more information, visit www.rheumatology.org.
Abstract #: 1816
Five-Year Outcome of Operative and Nonoperative Management of Meniscal Tear in the Presence of Osteoarthritic Changes
Jeffrey N. Katz, Brigham & Women's Hospital and Harvard Medical School, Boston, MA, Swastina Shrestha, Brigham and Women's Hospital, Boston, MA, Elena Losina, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, Lisa A Mandl, Hospital for Special Surgery, New York, NY, Bruce Levy, Mayo Clinic, Rochester, MN, Kurt Spindler, Cleveland Clinic, Cleveland, OH and Jamie E. Collins, Orthopedic and Arthritis Center for Outcomes Research, Brigham and Women's Hospital, Boston, MA
Background/Purpose: While recent trials have examined short-term (~ 2 year) outcomes of surgical and nonoperative treatment of meniscal tear in the setting of osteoarthritis there has been little study of longer term outcomes of these treatments.
Methods: We examined 5-year outcomes of subjects in MeTeOR (Clintrials.gov NCT00597012), a multicenter randomized trial of physical therapy (PT) vs. PT plus arthroscopic partial meniscectomy (APM) for subjects with knee pain, meniscal tear and OA changes on xray or MRI. The primary outcome for this analysis was the Knee Osteoarthritis and Injury Outcome Score (KOOS) Pain Scale (0-100, 100 worst). Total knee replacement (TKR) was a secondary outcome. To address changes in KOOS Pain over 5 years, we used a piecewise linear mixed model, stratified by treatment group (randomized to and received APM; randomized to and received PT; randomized to PT but received APM during follow-up). The model censored subjects who had TKR and adjusted for age, sex, BMI, and mental health status. We used a pattern mixture model to assess whether the findings were biased by missing data due to TKR or losses to follow-up. We calculated the frequency of TKR over follow-up and used a Cox proportional hazards model to estimate the risk of TKR for treatment groups and KL grades, adjusting for baseline factors.
Results: The 351 subjects had mean age 58; 57% were female. 164 were randomized to and received APM; 109 were randomized to and received PT; 68 were randomized to PT and crossed over to receive APM. 10 subjects were randomized to but did not receive APM and were not analyzed. 66% of subjects completed ≥ 9 of 12 follow-up questionnaires, with similar completion rates across treatment groups. The piecewise linear model (Figure) showed similar pain improvement in the 3 treatment groups, with baseline KOOS Pain scores of 40-50 improving to 20-25 by 6 months and little change between 6 and 60 months. The pattern mixture models demonstrated similar patterns in pain scores as the main analysis, suggesting TKR and other losses to follow up did not bias these findings. Twenty five participants (7%) had TKR over follow-up. In the Cox model, the hazard of TKR was higher in those treated surgically (randomized to APM or crossed over) than those randomized to and receiving PT (HR 5.0, 95% CI: 1.2, 21.8), and in those with KL-3 radiographs vs. KL0-2 (HR 2.7, 95% CI 1.2, 6.4).
Conclusion: Pain relief was similar across treatment groups, while the few TKR’s were more common in those with KL3 and those receiving APM. These data suggest that persons with degenerative meniscal tear generally experience substantial pain relief over 5 years, irrespective of initial treatment. The greater risk of TKR in those treated with APM could reflect selection effects and/or faster progression of OA following surgery than following PT, and merits further study.
Fig: KOOS Pain (shaded 95% CI) stratified by treatment in piecewise linear model
- N. Katz, None. S. Shrestha, None. E. Losina, Samumed, 5, JBJS, 5 L. A. Mandl, None. B. Levy, Arthrex, 2, 5, 7, Smith and Nephew, 2, 5 K. Spindler, None. J. E. Collins, None.