Glucosamine Sulfate for creaky knees

DISCUSSION
In this seven-center randomized, controlled trial involving symptomatic patients 45 years of age or older with a meniscal tear and imaging evidence of mild-to-moderate knee osteoarthritis, there were no significant differences in the magnitude of improvement in functional status and pain after 6 and 12 months between patients assigned to arthroscopic partial meniscectomy with postoperative physical therapy and patients assigned to a standardized physical-therapy regimen. These results were achieved with a 30% rate of crossover to arthroscopic partial meniscectomy at 6 months. At 12 months, among 169 participants (not all of whom provided data at the 1-year evaluation), the rate of crossover to surgery was 35%.

In a prior small, single-center, randomized, controlled trial comparing arthroscopic partial meniscectomy with standardized physical therapy for symptomatic patients with a meniscal tear and knee osteoarthritis, the two groups had similar functional outcomes at 6 months, and the similarity between the groups persisted through 5 years of follow-up.8,9 To our knowledge, this is the first large, multicenter, randomized, controlled trial to examine the efficacy of arthroscopic partial meniscectomy as compared with a standardized physical-therapy regimen.

Surgical randomized, controlled trials present methodologic challenges, including crossover from one group to the other.24,25 To account for crossovers, we defined an additional outcome a priori in which patients were deemed to have a successful treatment response if they had improvement of at least 8 points on the WOMAC physical-function scale (a clinically important difference) and they did not cross over from their assigned treatment. A total of 67% of patients assigned to arthroscopic partial meniscectomy met this threshold for success, as compared with 44% of patients treated with physical therapy alone. We acknowledge, however, that because the treatment assignments were not blinded, and because crossover could not occur in the arthroscopic-partial-meniscectomy group once the surgery had been performed, this secondary analysis was vulnerable to bias.

Several limitations of the study warrant discussion. First, because we enrolled only 26% of eligible patients, our findings must be generalized cautiously. The most frequent reason that patients declined enrollment was a strong preference for one treatment or the other. Since patients' preferences may be associated with treatment outcome, our trial may be vulnerable to selection bias. Participating surgeons may not have referred potentially eligible patients because they were uncomfortable randomly assigning these patients to treatment; this form of selective enrollment may also create bias.26 Second, because the trial was conducted in academic referral centers, the findings should be generalized carefully to community settings. Third, we did not formally assess the fidelity of the physical therapists or surgeons to the standard intervention protocols. Finally, our study was not blinded, since our investigative group did not consider a sham comparison group feasible.

These limitations notwithstanding, the results of our trial may help guide management in the care of patients with knee symptoms, a meniscal tear, and imaging evidence of osteoarthritis. Our findings suggest that both arthroscopic partial meniscectomy and referral to physical therapy — with an opportunity to consider arthroscopic partial meniscectomy if substantial improvements are not achieved — are likely to result in considerable improvement in functional status and knee pain over a 6-to-12-month period.

Given that improvements in functional status and pain at 6 months did not differ significantly between patients assigned to arthroscopic partial meniscectomy and those assigned to physical therapy alone and that 70% of the patients in the physical-therapy group did not undergo surgery, these data provide considerable reassurance regarding an initial nonoperative strategy. It is uncertain whether patients who undergo arthroscopic partial meniscectomy are at greater risk for progression of underlying osteoarthritis than patients treated nonoperatively.27-30 Longitudinal assessment of imaging studies in our trial is planned to address this question.

In summary, symptomatic patients with a meniscal tear and imaging evidence of mild-to-moderate osteoarthritis who were randomly assigned to arthroscopic partial meniscectomy with postoperative physical therapy had improvements in functional status and pain at 6 months that did not differ significantly from the improvements in patients randomly assigned to a standardized physical-therapy regimen alone. However, 30% of patients assigned to the physical-therapy group crossed over to surgery in the first 6 months.

These findings should help inform decision making by patients and their physicians.