Surgery versus physical therapy for a meniscal tear and osteoarthritis

Katz JN, Brophy RH, Chaisson CE, de Chaves L, Cole BJ, Dahm DL, Donnell-Fink LA, Guermazi A, Haas AK, Jones MH, Levy BA, Mandl LA, Martin SD, Marx RG, Miniaci A, Matava MJ, Palmisano J, Reinke EK, Richardson BE, Rome BN, Safran-Norton CE, Skoniecki DJ, Solomon DH, Smith MV, Spindler KP, Stuart MJ, Wright J, Wright RW, Losina E · The New England Journal of Medicine

WOMAC physical function improved 20.9 points (95% CI 17.9 to 23.9) in the surgical group versus 18.5 (95% CI 15.6 to 21.5) with physical therapy, a between-group difference of 2.4 points (95% CI -1.8 to 6.5); KOOS pain improved 24.2 versus 21.3 (difference 2.9; 95% CI -1.2 to 7.0). By 6 months 51 patients assigned to physical therapy (30.2%) had crossed over to surgery, and their 12-month function then matched the surgical group's. Crossover ranged from 0.0% to 59.5% across centres.

Population

351 symptomatic patients aged 45 or older with a meniscal tear and mild-to-moderate osteoarthritis on imaging, across seven US centres — 14,430 screened, 1,330 eligible

Intervention

Arthroscopic partial meniscectomy with postoperative physical therapy

Comparator

A standardised physical-therapy regimen, with the option to cross over to surgery

Limitations

Not blinded and not placebo-controlled, so the surgical arm carries the whole non-specific effect of an operation. The 30% crossover pulls the intention-to-treat comparison towards the null; the crossover patients had not improved before crossing, which is the reading that keeps a subgroup argument alive. Population is meniscal tear with established osteoarthritis, which is a different question from FIDELITY's.