METEOR

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Katz JN, et al. "Surgery versus Physical Therapy for a Meniscal Tear and Osteoarthritis". The New England Journal of Medicine. 2013. 368(18):1675-1684.
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Clinical Question

Among patients with symptomatic mild-to-moderate osteoarthritis and meniscal tear, does arthroscopic partial meniscectomy improve symptoms when compared to physical therapy alone?

Bottom Line

Physical therapy did not provide better symptom improvement than arthroscopic partial meniscectomy in patients with symptomatic mild-to-moderate osteoarthritis and meniscal tear. However, the trial is limited by high crossover to surgery.

Major Points

Radiographic evidence of osteoarthritis (OA) and meniscal tears are both common in the adult population and are often asymptomatic. The Moseley Trial (2002) demonstrated no difference between arthoscopic debridement and a sham surgery in individuals with symptomatic knee OA. The efficacy of meniscal surgery compared to physical therapy (PT) in individuals with knee pain and radiographic evidence of meniscal tear and osteoarthritis is unclear.

The 2013 Meniscal Tear in Osteoarthritis Research (METEOR) trial randomized 330 adults with symptomatic OA to arthoscopic meniscetomy followed by PT or PT alone in an unblinded fashion. At 6 months both groups had similar symptomatic improvements, though 30% of the PT group crossed over to surgery. This trial supports PT as an initial treatment modality for those with symptomatic OA and meniscal tear.[1]

Guidelines

As of April 2015, no guidelines have been published that reflect the results of this trial.

Design

  • Multicenter, prospective, randomized, open-label, comparative trial
  • N=330
    • Meniscetomy (n=161)
    • PT (n=169)
  • Setting: 7 centers in the US
  • Enrollment: 2008-2011
  • Follow-up: 1 year (primary outcome was calculated 6 months)
  • Analysis: Intention-to-treat
  • Primary outcome: Between-group difference in WOMAC physical function score at 6 months

Population

Inclusion Criteria

  • Age ≥45 years with meniscal tear and OA on imaging (MRI or radiography)
  • ≥1 symptom consistent with meniscal tear persisting for ≥4 weeks despite pharmacologic therapy, PT, or activity limitation
  • Willingness to be randomized

Exclusion Criteria

  • Chronically locked knee
  • Kellgren-Lawrence radiographic scale grade 4
  • Inflammatory arthritis
  • Symptomatic chondrocalcinosis
  • Viscosupplementation injection in affected knee in previous 4 weeks
  • Contraindication to PT or surgery
  • Bilateral symptomatic meniscal tears
  • Prior surgery in affected knee

Baseline Characteristics

From the meniscectomy group.

  • Demographics: Age 59.0 years, male 44.1%, White race 85.7%, Black race 9.3%, Hispanic 1.2%
  • Health data: BMI 30.0 kg/m2
  • Disease-specific:
    • Involved knee: right 43.5%, left 56.5%
    • Kellgren-Lawrence radiologic OA assessment grade (out of 4, higher indicates more evidence of disease on radiography):
      • 0: 21.1%
      • 1: 16.1%
      • 2: 23.0%
      • 3: 28.0%
    • WOMAC physical function scale: 37.1 (out of 100, higher indicates more limited function)
    • KOOS pain scsore: 46.0 (out of 100, high indicates more pain)
    • Mental Health Index 5 score: 44.3 (out of 100, higher indicates better mental health)
    • SF-36 physical activity score: 44.3 (out of 100, higher indicates greater physical activity)

Interventions

  • Randomization to one of two interventions:
    • Meniscectomy - Arthroscopic trimming damaged meniscus to stable rim and removal of loose cartilage and bone fragments
    • PT - No surgery
  • Both groups underwent post-intervention three-staged structured physical therapy addressing inflammation, ROM, strength, muscle-length restriction, aerobic conditioning, functional mobility, proprioception, and balance
  • Both groups were treated with acetaminophen, NSAIDS, and intraarticular glucocorticoid injections

Outcomes

Presented as meniscectomy vs. PT. Outcomes are at 6 months except where specified. Improvement is defined as a reduction in the score for WOMAC and KOOS scales and is presented as a positive number.

Primary Outcome

WOMAC physical function score
14.7 vs. 19.0 (NS)
Improvement from baseline: 20.9 vs. 18.5 (NS)
Between-group difference from baseline: 2.4 (95% CI -1.8 to 6.5; NS)
Above line is the primary outcome. Other related data are presented in this section.
At 12 months: 0.7 (95% CI -3.5 to 4.9; NS)

Secondary Outcomes

KOOS pain score
21.1 vs. 25.2 (NS)
Improvement from baseline: 24.2 vs. 21.3 (NS)
Between-group difference from baseline: 2.9 (95% CI -1.2 to 7.0; NS)
At 12 months: -0.4 (95% CI -4.8 to 4.0; NS)
SF-36 physical activity score
69.2 vs. 66.1 (NS)
Improvement from baseline: 24.2 vs. 23.1 (NS)
Between-group difference from baseline: 1.1 (95% CI -4.4 to 6.6; NS)
At 12 months: -3.0 (95% CI -8.8 to 2.7; NS)
Treatment outcome
Success: 67% vs. 44% (P=0.001)
Defined as improvement in WOMAC score ≥8 without crossover
Failure: 25% vs. 49% (no statistics given)
WOMAC improvement <8 and no crossover: 80% vs. 38%
Crossover: 20% vs. 62%
Crossover, entire group: 5% vs. 30%

Adverse Events

Serious
Any: 3 vs. 2
Fatal PE: 1 vs. 0
MI: 1 vs. 0
Sudden death: 0 vs. 1
Stroke: 0 vs. 1
Hypoxemia: 1 vs. 0
Non-serious
Any: 15 vs. 13
DVT: 2 vs. 0

Criticisms

  • Not blinded
  • Only 26% of eligible patients enrolled
  • The use of academic medical centers limits generalization to community hospitals
  • No assessment of surgeon or PT fidelity
  • No sham procedure[1]
  • The more specific Lysholm score or the International Knee Documentation Committee score may have been more appropriate tools than the WOMAC score for the primary outcome as they are more specifica for meniscal function[2]
  • Plain films may have missed cartilage damage that may have been picked up by arthroscopy or more sensitive imaging modalities like MRI[2]

Funding

  • National Institute of Arthritis and Musculoskeletal and Skin Diseases at the National Institutes of health
  • Authors with multiple disclosures

Further Reading

  1. 1.0 1.1 Buchbinder, R. "Editorial: Meniscetomy in patients with knee osteoarthritis and a meniscal tear?" The New England Journal of Medicine. 2013;368:1740-1741.
  2. 2.0 2.1 Holzer LA. "Correspondence: Surgery versus physical therapy for meniscal tear and osteoarthritis." The New England Journal of Medicine. 2013;369:677-678.