Comparison of physical therapy and arthroscopic partial meniscectomy treatments in degenerative meniscus tears and the effect of combined hyaluronic acid injection with these treatments: A randomized clinical trial
Restricted accessResearch articleFirst published online September, 2021
Comparison of physical therapy and arthroscopic partial meniscectomy treatments in degenerative meniscus tears and the effect of combined hyaluronic acid injection with these treatments: A randomized clinical trial
Symptomatic degenerative meniscus tears are common in middle and old age. Arthroscopic partial meniscectomy (APM), physical therapy (PT) and hyaluronic acid injection (HAI) are the most commonly used treatment options.
OBJECTIVES:
The aim of our study is to compare the effectiveness of APM and PT in degenerative meniscus tears and to investigate the effect of HAI with a prospective, randomized, single-blind study.
METHODS:
The study included 192 patients with symptomatic degenerative meniscus tears. The patients were randomly divided into the four groups. The first group consisted of patients who underwent APM, the second group received HAI with APM, the third group received PT, and the fourth group received HAI with PT. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Visual Analog Scale (VAS) scores, and range of motion (ROM) values were used for evaluation.
RESULTS:
There was no difference between four groups according to age, gender, BMI, affected side, grade of osteoarthritis. In the 4 groups, WOMAC and VAS results at the 2nd and 6th months were better than pre-treatment. There was no difference between the groups in terms of WOMAC and VAS. In terms of ROM, the results were found better in PT group (Group 3, Group 4) at the 2nd and 6th months. However, the results were found worse in APM group (Group 1, Group 2). In addition, it was found that HAI applied with APM and PT had no effect on VAS, WOMAC, and ROM. It was determined that the increase of knee osteoarthritis negatively affected both the results of APM treatment and PT. VAS, WOMAC, and ROM results were found worse in patients with stage 3 osteoarthritis than grade 1 and 2, but there was no difference between grade 1 and 2.
CONCLUSIONS:
APM and PT give good results in terms of pain and functional results. However, ROM limitation develops after APM. Conversely, there is an increase in ROM after PT. Administration of HAI with these treatments has no effect on the results. PT is an easily applicable noninvasive method. Adding HAI to the treatment has no effect on the results and increases the cost.
Safran-NortonCESullivanJKIrrgangJJ, et al. A consensus-based process identifying physical therapy and exercise treatments for patients with degenerative meniscal tears and knee OA: the TeMPO physical therapy interventions and home exercise program. BMC Musculoskelet. Disord. 2019; 4; 20(1): 514.
2.
JeroschJCastroWHAssheuerJ. Age-related magnetic resonance imaging morphology of the menisci in asymptomatic individuals. Arch Orthop Trauma Surg. 1996; 115(3–4): 199–202.
3.
van de GraafVABloembergenCHWilligenburgNW, et al. Can even experienced orthopaedic surgeons predict who will benefit from surgery when patients present with degenerative meniscal tears? A survey of 194 orthopaedic surgeons who made 3880 predictions. Br J Sports Med. 2020; 54(6): 354–359.
4.
HerrlingSVWangePOLapidusG, et al. Is arthroscopic surgery beneficial in treating non-traumatic, degenerative medial meniscal tears? A five year follow-up. Knee Surg Sports Traumatol Arthrosc. 2013; 21(2): 358–64.
5.
Nina Jullum Kise, May Arna Risberg, Silje Stensrud, et al. Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: randomised controlled trial with two year follow-up. BMJ. 2016; 20; 354: 3740.
6.
HamiltonDFHowieCR. Knee arthroscopy: influence of systems for delivering healthcare on procedure rates. BMJ. 2015; 351: 4720.
7.
BergkvistDDahlbergLENeumanPEnglundM. Knee arthroscopies: who gets them, what does the radiologist report, and what does the surgeon find? Acta Orthop. 2016; 87(1): 12–6.
8.
RaineSMikaPAnttiM, et al. Arthroscopic partial meniscectomy versus placebo surgery for a degenerative meniscus tear: a 2-year follow-up of the randomised controlled trial. Ann Rheum Dis. 2018; 77(2): 188–195.
9.
MoseleyJBO’MalleyKPetersenNJ, et al. A controlled trial of ar thro scop ic surgery for osteoarthritis of the knee. N Engl J Med. 2002; 347: 81–8.
10.
KirkleyABirminghamTBLitchfieldRB, et al. A randomized trial of ar thro scop ic surgery for osteoarthritis of the knee. N Engl J Med. 2008; 359: 1097–107. [Erratum, N Engl J Med] 2009; 361: 2004.
11.
SalzlerMJLinAMillerCD, et al. Complications after arthroscopic knee surgery. Am J Sports Med. 2014; 42(2): 292–6.
12.
BertonALongoUGCandelaVGrecoFMartinaFMQuattrocchiCCDenaroV. Quantitative evaluation of meniscal healing process of degenerative meniscus lesions treated with hyaluronic acid: a clinical and MRI study. J. Clin. Med. 2020; 9(7): 2280.
13.
ShenDChenMChenKWangTLuLYangX. Efficacy of hyaluronic acid after knee arthroscopy: a systematic review and meta-analysis. J Rehabil Med. 2018 7; 50(10): 860–865.
14.
KellgrenJHLawrenceJS. Radiological assessment of osteo-arthrosis. Ann. Rheum. Dis. 2000; 16(4): 494–502.
15.
BaggaHBurkhardtDSambrookPMarchL. Longterm effects of intraarticular hyaluronan on synovial fluid in osteoarthritis of the knee. J Rheumatol. 2006; 33: 946–950.
16.
MiglioreAGiovannangeliFGranataMLaganàB. Hylan g-f 20: review of its safety and efficacy in the management of joint pain in osteoarthritis. Clin Med Insights Arthritis Musculoskelet Disord. 2010; 3: 55–68.
17.
Bahar Dernek, Fatma Nur Kesiktas, Tahir Mutlu Duymus, Demirhan Diracoglu, Cihan Aksoy. Therapeutic efficacy of three hyaluronic acid formulations in young and middle-aged patients with early-stage meniscal injuries. J. Phys. Ther. Sci. 2017; 29: 1148–1153.
18.
WaddellDDBertJM. The use of hyaluronan after arthroscopic surgery of the knee. Arthroscopy. 2010; 26(1): 105–111.
19.
Kenji Takahashi, Sanshiro Hashimoto, Hiromasa Kurosaki, Kazuo Kato, Tokifumi Majima, Yasuhiro Shindo, Hiroshi Watanabe, Yusuke Mochizuki, Shinro Takai. A pilot study comparing the efficacy of radiofrequency and microwave diathermy in combination with intra-articular injection of hyaluronic acid in knee osteoarthritis. J Phys Ther Sci. 2016; 28(2): 525–529.
20.
BellamyNBuchananWWGoldsmithCHCampbellJStittLW. Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J Rheumatol. 1988; 15: 1833–40.
21.
HuskissonEC. Measurement of pain. Lancet. 1974; 2: 1127–1131.
22.
EnglundMGuermaziALohmanderLS. The meniscus in knee osteoarthritis. Rheum Dis Clin North Am. 2009; 35: 579–590.
23.
JacksonRWDieterichsC. The results of arthroscopic lavage and debridement of osteoarthritic knees based on the severity of degeneration: a 4- to 6-year symptomatic follow-up. Arthroscopy. 2003; 19(1): 13–20.
24.
EnglundMGuermaziAGaleDHunterDJAliabadiPClancyMFelsonDT. Incidental meniscal findings on knee MRI in middle-aged and elderly persons. N Engl J Med. 2008; 359(11): 1108–1115.
25.
PereiraDPeleteiroBAraujoJBrancoJSantosRARamosE. The effect of osteoarthritis definition on prevalence and incidence estimates: a systematic review. Osteoarthritis Cartilage. 2011; 19(11): 1270–1285.
26.
ShannonFDevittAPoyntonAFitzpatrickPWalshM. Short-term benefit of arthroscopic washout in degenerative arthritis of the knee. International Orthopaedics. 2001; 25: 242–245.
Devdatta Suhas Neogi, Ashok Kumar, Laxman Rijal, Chandra Shekhar Yadav, Ashish Jaiman, Hira Lal Nag. Role of nonoperative treatment in managing degenerative tears of the medial meniscus posterior root. J Orthopaed Traumatol. 2013; 14: 193–199.
29.
Erik Hohmann, Vaida Glatt, Kevin Tetsworth, Mark Cote. Arthroscopic partial meniscectomy versus physical therapy for degenerative meniscus lesions: how robust is the current evidence? A critical systematic review and qualitative synthesis. Arthroscopy. 2018; 34(9): 2699–2708.
30.
LiJZhuWGaoXLiX. Comparison of arthroscopic partial meniscectomy to physical therapy following degenerative meniscus tears: a systematic review and meta-analysis. Biomed Res Int. 2020; 3: 1709415.
31.
KatzJNBrophyRHChaissonCEde ChavesLColeBJDahmDL, et al. Surgery versus physical therapy for a meniscal tear and osteoarthritis. N Engl J Med. 2013 2; 368(18): 1675–1684.
32.
Havard Østeras, Berit Østeras, Tom Arild Torstensen. Medical exercise therapy, and not arthroscopic surgery, resulted in decreased depression and anxiety in patients with degenerative meniscus injury. J Body Mov Ther. 2012; 16: 456–463.
33.
RaineSMikaPAnttiM, et al. Arthroscopic partial meniscectomy versus placebo surgery for a degenerative meniscus tear: a 2-year follow-up of the randomised controlled trial. Ann Rheum Dis. 2018; 77(2): 188–195.
34.
ThorlundJBJuhlCBRoosEMLohmanderLS. Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms. Br J Sports Med. 2015; 49(19): 1229–1235.
35.
HerrlinSVWangePOLapidusGHållanderM, et al. Is arthroscopic surgery beneficial in treating non-traumatic, degenerative medial meniscal tears? A five year follow-up. Knee Surgery, Sports Traumatology, Arthroscopy. 2013; 21: 358–364.
36.
MillerLEFredericsonMAltmanRD. Hyaluronic acid injections or oral nonsteroidal anti-inflammatory drugs for knee osteoarthritis: systematic review and meta-analysis of randomized trials. Orthop J Sports Med. 2020 27; 8(1): 2325967119897909.
37.
PettersonSCPlancherKD. Single intra-articular injection of lightly cross-linked hyaluronic acid reduces knee pain in symptomatic knee osteoarthritis: a multicenter, double-blind, randomized, placebo-controlled trial. Knee Surg Sports Traumatol Arthrosc. 2019; 27(6): 1992–2002.
38.
Francesca Salamanna, Gianluca Giavaresi, Annapaola Parrilli, Lucia Martini, Nicolò Nicoli Aldini, Giovanni Abatangelo, Antonio Frizziero, Milena Fini. Effects of intra-articular hyaluronic acid associated to Chitlac (arty-duo®) in a rat knee osteoarthritis model. J Orthop Res. 2019; 37(4): 867–876.
39.
HuskinJPVandekerckhoveBDelincéPVerdonkRDubucJ-EWillemsSHardyPBlancoFJCharroisOHandelbergF. Multicentre, prospective, open study to evaluate the safety and efficacy of hylan G-F 20 in knee osteoarthritis subjects presenting with pain following arthroscopic meniscectomy. Knee Surg Sports Traumatol Arthrosc. 2008; 16: 747–752.
40.
MathiesB. Effects of Viscoseal, a synovial fluid substitute, on recovery after arthroscopic partial meniscectomy and joint lavage. Knee Surg Sports Traumatol Arthrosc. 2006; 14: 32–39.
41.
Cağatay Uluçay, Faik Altintaş, Ender Ugutmen, Burak Beksaç. The use of arthroscopic debridement and viscosupplementation in knee osteoarthritis. Acta Orthop Traumatol Turc. 2007; 41(5): 337–42.
