Лечебная физкультура или менискэктомия предпочтительней для пациентов с разрывом мениска и остеоартритом коленного сустава?
В опубликованном в 2013 году в New England Journal of Medicine исследовании METEOR, 350 пациентов с разрывом мениска и остеоартритом (ОА) коленного сустава от легкой до умеренной степени тяжести, были рандомизированы на две группы: в 1- ю группу вошли пациенты, которым в качестве лечения была назначена только лечебная физкультура (ЛФ); во 2-ю группу вошли пациенты, лечение которых состояло из менискэктомия с последующей ЛФ.
Дальнейший анализ показал, что функция коленного сустава и интенсивность боли были одинаковыми в обеих группах через 6 и 12 месяцев наблюдения. Однако у 30% пациентов после лечения только ЛФ всё-таки было проведено оперативное вмешательство через 6 месяцев, и у еще 5% пациентов - через 12 месяцев.
Результаты 5-летнего наблюдения за пациентами той же популяции, опубликованные в журнале Arthritis & Rheumatology в 2019 году, показали, что стандартизированные оценки боли при ОА улучшились в обеих группах в течение первых 24 месяцев и были стабильными через 24–60 месяцев. 25 (или 7%) пациентов перенесли полную замену коленного сустава в течение 5 лет. Пациенты, ранее перенесшие менискэктомию, гораздо чаще подвергались данному вмешательству, чем те, кто лечился только ЛФ - 10% и 2% соответственно.
Исследователи считают, что у пациентов с ОА легкой или умеренной степени тяжести и разрывом мениска имеет смысл начинать терапию с ЛФ. А к хирургическому лечению коленного сустава стоит прибегать лишь в случаях, когда ЛФ была не эффективна.
Surgery versus physical therapy for a meniscal tear and osteoarthritis
Katz JN et al
BACKGROUND:
Whether arthroscopic partial meniscectomy for symptomatic patients with a meniscal tear and knee osteoarthritis results in better functional outcomes than nonoperative therapy is uncertain.
METHODS:
We conducted a multicenter, randomized, controlled trial involving symptomatic patients 45 years of age or older with a meniscal tear and evidence of mild-to-moderate osteoarthritis on imaging. We randomly assigned 351 patients to surgery and postoperative physical therapy or to a standardized physical-therapy regimen (with the option to cross over to surgery at the discretion of the patient and surgeon). The patients were evaluated at 6 and 12 months. The primary outcome was the difference between the groups with respect to the change in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) physical-function score (ranging from 0 to 100, with higher scores indicating more severe symptoms) 6 months after randomization.
RESULTS:
In the intention-to-treat analysis, the mean improvement in the WOMAC score after 6 months was 20.9 points (95% confidence interval [CI], 17.9 to 23.9) in the surgical group and 18.5 (95% CI, 15.6 to 21.5) in the physical-therapy group (mean difference, 2.4 points; 95% CI, -1.8 to 6.5). At 6 months, 51 active participants in the study who were assigned to physical therapy alone (30%) had undergone surgery, and 9 patients assigned to surgery (6%) had not undergone surgery. The results at 12 months were similar to those at 6 months. The frequency of adverse events did not differ significantly between the groups.
CONCLUSIONS:
In the intention-to-treat analysis, we did not find significant differences between the study groups in functional improvement 6 months after randomization; however, 30% of the patients who were assigned to physical therapy alone underwent surgery within 6 months. (Funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases; METEOR ClinicalTrials.gov number, NCT00597012.).
Five-Year Outcome of Operative and Nonoperative Management of Meniscal Tear in Persons Older Than Forty-Five Years.
Katz JN et al
OBJECTIVE:
To determine the 5-year outcome of treatment for meniscal tear in osteoarthritis.
METHODS:
We examined 5-year follow-up data from the Meniscal Tear in Osteoarthritis Research trial (METEOR) of physical therapy versus arthroscopic partial meniscectomy. We performed primary intent-to-treat (ITT) and secondary as-treated analyses. The primary outcome measure was the Knee Injury and Osteoarthritis Outcome Score (KOOS) pain scale; total knee replacement (TKR) was a secondary outcome measure. We used piecewise linear mixed models to describe change in KOOS pain. We calculated 5-year cumulative TKR incidence and used a Cox model to estimate hazard ratios (HRs) for TKR, with 95% confidence intervals (95% CIs).
RESULTS:
Three hundred fifty-one participants were randomized. In the ITT analysis, the KOOS pain scores were ~46 (scale of 0 [no pain] to 100 [most pain]) at baseline in both groups. Pain scores improved substantially in both groups over the first 3 months, continued to improve through the next 24 months (to ~18 in each group), and were stable at 24-60 months. Results of the as-treated analyses of the KOOS pain score were similar. Twenty-five participants (7.1% [95% CI 4.4-9.8%]) underwent TKR over 5 years. In the ITT model, the HR for TKR was 2.0 (95% CI 0.8-4.9) for subjects randomized to the arthroscopic partial meniscectomy group, compared to those randomized to the physical therapy group. In the as-treated analysis, the HR for TKR was 4.9 (95% CI 1.1-20.9) for subjects ultimately treated with arthroscopic partial meniscectomy, compared to those treated nonoperatively.
CONCLUSION:
Pain improved considerably in both groups over 60 months. While ITT analysis revealed no statistically significant differences following TKR, greater frequency of TKR in those undergoing arthroscopic partial meniscectomy merits further study.