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What's best for busted knees? -

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Norman Swan: For a long time there's been an ongoing controversy when you are middle-aged and have a torn knee cartilage and whether it's worse doing an arthroscopy, which is telescope surgery, minimal invasive surgery to actually trim the cartilage. You might have seen my Four Corners recently in September which actually dealt with partly this, it was more arthritis than torn meniscus or a torn cartilage. Anyway, there's been a fascinating study in the British Medical Journal of comparing exercise therapy to arthroscopy for people who have had a meniscal tear or a torn cartilage. And on the line from Martina Hansens hospital in Norway is orthopaedic surgeon Dr Nina Kise. Welcome to the Health Report.

Nina Kise: Hello to you.

Norman Swan: Tell me about this study.

Nina Kise: Yes, we had 140 patients, and half of them had gone through arthroscopic partial meniscectomy, and the other half has gone through exercise therapy. All patients had degenerative meniscal tears in their meniscus and had the pain in the joint line. And we took x-rays at baseline and only 4% of them had osteoarthritis evaluated by x-ray. So there had been some studies earlier comparing these patients doing exercise therapy or exercise therapy in addition to surgery, and the conclusion has been that surgery has no additional effect in these patients.

Norman Swan: So let's just double-back for a moment because you've given away the punchline very early, Nina, but thank you very much for doing that. So what I covered in fact recently was arthritis, so if you've got arthritis and your knee surgeon says, look, I'm going to clean it out with arthroscopy, there is no advantage to that versus…?

Nina Kise: No, there's not, not in the long-term.

Norman Swan: So when somebody has…some people say that a torn cartilage is in fact a normal phenomenon of ageing, but the people that you looked at, whether or not you've got symptoms or not, but the people that you looked at actually had symptoms.

Nina Kise: Yes, they had symptoms, they had pain in the knee, that's why they went to their doctors saying they had pain in the knee and then they were examined by MRI and they saw that it was a degenerative meniscal tear. And it has been practised the last 20, 30 years to do arthroscopy on these patients and removing meniscal tissue.

Norman Swan: So just doing a clean-up of the torn meniscus. And this was in 50-year-olds that you did this, so this is not young people with a sports tear, this is older people. And tell me about the exercise program that they went through as a comparison.

Nina Kise: The exercise program consisted of warming up exercises, strengthening exercises and neuromuscular exercises for balance.

Norman Swan: So the strengthening exercises presumably are to your quads, the muscles on the front of your knee?

Nina Kise: Yes, and the back, the hamstrings.

Norman Swan: And the neuromuscular ones, what do they do?

Nina Kise: They were standing at BOSU balls, do you know what that is?

Norman Swan: Yes.

Nina Kise: Doing knee bends and, yes, improving.

Norman Swan: So, functional, getting eccentric stimulation on that. And so when you compared the two at the end of the 12-week course, there was no difference in any symptoms?

Nina Kise: No, not after two years what is the main outcome of this study.

Norman Swan: But did they both get improvement?

Nina Kise: The exercise group improved in their muscle strength at three months and 12 months.

Norman Swan: Did they both improve with pain?

Nina Kise: Yes, they did.

Norman Swan: You allowed people after they had been in the exercise group to cross over. If they were unhappy they could go off and have knee surgery, go off and have knee arthroscopy, and one in five of them did. What happened to them?

Nina Kise: They were…at the two-year follow-up they were exactly like the other patients, so they did not lose anything by going through exercise therapy first.

Norman Swan: And the other way of looking at it is they didn't gain anything by having the extra surgery either.

Nina Kise: No, they didn't actually.

Norman Swan: So if I'm right, Nina, you are an orthopaedic surgeon?

Nina Kise: Yes.

Norman Swan: So are your colleagues talking to you anymore?

Nina Kise: Yes, they do!

Norman Swan: So they don't feel that you've undermined the knee surgery market in Norway?

Nina Kise: No, not at all. There has been a slow decrease in arthroscopy of these patients in the last two years in Norway, as also seen in Denmark and Sweden, and I think that is the result of the RCTs that have been published over the last years, that I mentioned earlier, and also the one from Finland who compared arthroscopy with meniscus resection with sham surgery, and no difference at one year in pain in the patients.

Norman Swan: So no doubt the physiotherapists or physical therapists and exercise physiologist are rejoicing at your study. But what you didn't do was do nothing. Have you got any sense of…you've got a meniscal tear, you've got a bit of pain, well, why bother doing anything. Do you know what the results are if you do nothing?

Nina Kise: No, I am sorry for that, I didn't do that, so that's a weakness that they had no group without treatment at all. That's a chance for me further on now to look at patients coming to our hospital and I will follow them and take them back after two or five years to see how they come on, if they have not done the exercise therapy, because most patients think it is hard to fulfil the exercise therapy program. So if they are not in a study I think many patients do not do all the exercises we suppose they are doing. So I will try to look into that.

Norman Swan: So not content with destroying the orthopaedic industry in Norway you're going to go after the physiotherapist and exercise physiologists. I'm glad to hear it! But no doubt the accountants in the Norwegian Department of Health are delighted with you. Nina Kise, thank you very much for joining us, it's been a delight talking to you and it has been fascinating for…we don't have a very middle-aged audience, they are very young but I'm sure one day when they are 50 years old they will be absolutely fascinated to know that information. Thank you very much indeed.

Nina Kise: Thank you.

Norman Swan: Nina Kise is an orthopaedic surgeon at Martina Hansens Hospital in Sandvika in Norway.

You're listening to the Health Report here on RN.


Guests
Dr Nina KiseOrthopaedic surgeon, Martina Hansens Hospital

Further Information
Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients

Credits
PresenterDr Norman Swan ProducerJoel Werner