Each year in the United States, more than 300,000 knee arthroscopies are performed for patients who have both a meniscal tear and osteoarthritis in the same compartment of the knee. Yet the frequency with which this treatment is performed belies significant uncertainty surrounding outcomes associated with its use.
Mayo orthopedic surgeon Bruce A. Levy, MD, explains that the challenge starts in the consult room, when a patient presents with, for example, medial-sided knee pain. "But if they have a medial meniscus tear and concomitant medial compartment osteoarthritis, it is almost impossible to figure out what is generating the pain," Dr Levy says. "Is it the meniscal tear? Or is it the osteoarthritis in the medial compartment?"
This ambiguity over the identity of pain origin and generation is problematic because meniscal tears and osteoarthritis tend to respond differently to arthroscopy. Data show that arthroscopy is very effective in treating meniscal tears without osteoarthritis — and highly ineffective for treating advanced osteoarthritis of the knee.
But what is the best course of treatment when both conditions are present? Currently physicians tell this subset of patients who are contemplating treatment that knee arthroscopy is unpredictable in the setting of meniscal tear and concomitant osteoarthritis.
A new federal study, however, is generating comparative effectiveness research (CER) data that will help answer the question. Notes Diane L. Dahm, MD, one of Dr Levy's Mayo co-investigators in the Meniscal Tear With Osteoarthritis Research (MeTeOR) study: "That is why we are so excited to be one of 7 advanced orthopedic specialty centers in the U.S. involved in MeTeOR. The data will clarify indications for arthroscopy vs nonoperative treatment in this subset of patients by giving us the highest quality of evidence from a large, randomized, multicenter trial sponsored by the National Institutes of Health (NIH)."
Adds Dr Levy: "At the end of the day, we expect to be able to identify which knee symptoms, clinical, and intraoperative variables are predictors of bad outcomes from arthroscopy, and which are predictors of good outcomes in the form of improvement of functional status."
MeTeOR is the first study of its size to evaluate patients who have both a symptomatic meniscal tear characterized by mechanical symptoms such as knee catching, locking, or buckling, as well as mild to moderate osteoarthritis. Arthritic pain is typically described in nonmechanical terms, such as dull and achy. But those distinctions are also problematic. Says Dr Levy: "Patients often report both types of pain, so that is part of what we need clarified by MeTeOR as well."
MeTeOR aims to enroll 340 patients > 45 years old with these 2 knee comorbidities who are otherwise healthy. It randomizes them to 1 of 2 arms of the trial to evaluate effects of arthroscopy compared to nonoperative treatment such as standard physical therapy.
To eliminate bias, specialists follow a strict and standard protocol at the 7 centers participating in the study, which is led by principal investigator Jeffrey N. Katz, MD, MS, at Brigham and Women's Hospital, Boston.
Mayo Clinic's 3 investigators, Dr Levy, Dr Dahm, and Michael J. Stuart, MD, are excited and optimistic about the potential of MeTeOR to improve patient care. Says Dr Levy: "This is the type of trial that will change clinical practice because of the sheer volume of the procedures done for this particular problem, and the fact that it has never been studied this effectively."
|MeTeOR at a glance|
Enrollment goal: 340 by February 2011
Main exclusion criteria < age 45:
Crossover option available? In selected cases, after 6 months of nonoperative participation patients may be allowed to cross over to the surgical arm.