Commissioners were reviewing how best to manage patients with meniscal tears. Information appraising the effectiveness of treating this with physiotherapy and/or knee arthroscopy was needed. They requested an evidence review to help decision-making.
The commissioners were planning the most effective care pathway for patients with meniscal tears. The current model was for patients to be offered physiotherapy and non-steroidal anti-inflammatory drugs (NSAIDs) as first line treatment before consideration for surgery.
PICO was used to structure the search.
P: Patients with a meniscal tear
I: Pre-operative physiotherapy
C: Knee arthroscopy
O: Reduced need for surgery and improved outcomes
The local Public Health Evidence Assistant was asked to conduct the search and write a report of her findings.
The research question was defined as:
“Does physiotherapy prior to knee arthroscopy for meniscal tear a) reduce the need for
surgery; b) improve outcomes of those having surgery?”
Her search strategy was to use the following databases and websites:
Cochrane Database of Systematic Reviews (including CRD DARE, NHS EED, HTA, and CENTRAL)
•NICE Evidence (EMBASE, MEDLINE)
•Google and Google Scholar search engines
The following combination of index terms and free‐text: were used:
meniscal, meniscal tear, traumatic, degenerative, exercise, exercise therapy, physiotherapy, pre-operative, arthroscopy, surgery
Systematic reviews (SRs) are generally considered the strongest form of evidence. One was found. It included a meta-analysis of 7 randomised clinical trials (RCTs) and compared arthroscopic meniscal debridement (with or without concurrent articular debridement) to non-operative treatments including physiotherapy.
The results from the SR, other relevant RCTs, a prospective longitudinal study and retrospecive case series were graded for bias and summarised. Reliability was graded according to the type of study and methodology used.
All evidence reviewed was cited in the report so the commissioners could access the original full text articles if required.
The Evidence Assistant found evidence which she considered reliable. It showed that for patients with degenerative meniscal tears: physiotherapy alone leads to the same outcomes in long-term functionality and pain scores, at upto 5 year-follow-ups, as knee arthroscopy.
No studies were identified that focused on traumatic meniscal tears.These are caused, for example, by falls or twisting the knee whilst exercising.
The review was discussed with the locally commsissioned provider. Current practice was found to be compliant with the findings so no further action was needed.
This review is available in the locality it was developed, upon request via firstname.lastname@example.org