Early Surgery not superior to conservative management for Meniscal Tears in Young Adults

The meniscus is a C-shaped piece of tough, rubbery cartilage that acts as a shock absorber between your shinbone and thighbone. A torn meniscus is one of the most common knee injuries. Surgery is commonly used to treat meniscal tears; however, to our knowledge, no randomized controlled trials (RCTs) have compared surgery with nonsurgical alternatives in young adults.

A randomized control trial in New England Journal of Medicine, hypothesized that early meniscal surgery would be superior to a strategy of exercise and education with the option of surgery later if needed.

The pragmatic parallel-group DREAM TRIAL, Danish RCT on Exercise versus Arthroscopic Meniscal Surgery for Young Adults) trial , we enrolled young adults (18-40 years of age) with magnetic resonance imaging verified meniscal tears eligible for surgery from seven Danish hospitals. Patients were randomly assigned (1:1) to surgery (partial meniscectomy or meniscal repair) or 12-week supervised exercise therapy and education with the option of surgery later if needed. The primary outcome was the difference in change from baseline to 12 months in the mean score of four Knee Injury and Osteoarthritis Outcome Score (KOOS4) subscales covering pain, symptoms, function in sport and recreation, and quality of life, ranging from 0 (worst) to 100 (best).

The results of the trial were

• A total of 121 young adults, in total, 107 participants (88%) completed the 12-month follow-up; 16 participants (26%) from the exercise group crossed over to surgery, while 8 (13%) from the surgery group did not undergo surgery.

• Intention-to-treat analysis showed no statistically significant difference in change between groups from baseline to 12 months in KOOS4 scores (19.2 vs. 16.4 in the surgery vs. exercise groups; adjusted mean difference, 5.4 [95% confidence interval, −0.7 to 11.4]).

• No difference in serious adverse events was observed (four vs. seven in the surgery and exercise groups, respectively; P=0.40). Per-protocol and as-treated analyses yielded similar results.

Researchers concluded that "Our results suggest that among young, active adults with meniscal tears, a strategy of early meniscal surgery is not superior to a strategy of exercise and education with the option of later surgery. Both groups experienced clinically relevant improvements in pain, function, and quality of life at 12 months, and one of four from the exercise group eventually had surgery."

Reference: https://doi.org/10.1056/EVIDoa2100038