Purpose: Knee injury, including meniscal tear, is a major risk factor for developing osteoarthritis. Although surgery is a common treatment of meniscal tears, no randomized controlled trials (RCTs) have compared surgery with non-surgical alternatives in young adults with a meniscal tear. We aimed to determine whether a strategy of early meniscal surgery was superior to a strategy of exercise and education with the option of surgery later in young adults with a meniscal tear in terms of pain, function, and quality of life.
Methods: This was a pragmatic, parallel-group, multicenter, RCT recruiting young adults (18-40 years) with MRI-verified meniscal tears eligible for meniscal surgery from seven Danish hospitals between January 26, 2017 through to December 4, 2019 (ClinicalTrials.gov NCT02995551). Primary endpoint was at 12 months with additional follow-ups at 3 and 6 months. Patients were randomized (1:1, by central study coordinator, stratified by hospital and sex) to surgery (partial meniscectomy or meniscal repair) or a strategy of 12-weeks supervised exercise therapy (two 60-90-minute sessions weekly) and 30-45min of patient education with the option of surgery later if needed. The primary outcome was difference in change from baseline to 12 months in the mean score of four Knee Injury and Osteoarthritis Outcome Score subscales, covering pain, symptoms, function in sport and recreation, and quality of life (KOOS4 scale: 0 (worst) to 100 (best). Intention-to-treat and per-protocol analysis were conducted. Per-protocol analysis excluded patients randomized to exercise therapy but participating in <18 of 24 exercise sessions or crossing over to surgery, and patients not having surgery in the surgery group.
Results: Out of the 121 young adults enrolled (mean age 29.7 years, 28% women, 60 allocated to surgery group), 107 patients (88%) completed the 12-month follow-up, 16 (26%) from the exercise group had meniscal surgery, while 8 (13%) from the surgery group did not have surgery. In total, 36 (59%) patients attended 18 or more of 24 exercise sessions. Both treatment groups experienced clinically relevant improvements (10 points or more on KOOS4). The intention-to-treat analysis did not demonstrate a statistically significant difference in change between groups from baseline to 12 months in KOOS4 (19.2 vs. 16.4 in surgery vs. exercise group; adjusted mean difference, 5.4 [95% CI, -0.7 to 11.4]; Figure 1A), with similar results in the per-protocol analysis (Figure 1B). No difference in serious adverse events was observed (4 in surgery vs. 7 in exercise group, p=0.40).
Conclusions: In a group of young, active adults with meniscal tears, our results suggest that a strategy of early meniscal surgery was not superior to a strategy of exercise and education with the option of later surgery. Both groups experienced clinically relevant improvements and one in four patients from the exercise group underwent surgery, suggesting that both treatment strategies could be viable and effective options in clinical practice. Our study therefore highlights that decisions on treatment of meniscal tears in young adults should include patient preferences and values.
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