title: Predictors and Outcomes of Crossover to Surgery from Physical Therapy for Meniscal Tear and Osteoarthritis: A Randomized Trial Comparing Physical Therapy and Surgery.
abstract: BACKGROUND
  Arthroscopic partial meniscectomy (APM) combined with physical therapy (PT) have yielded pain relief similar to that provided by PT alone in randomized trials of subjects with a degenerative meniscal tear. However, many patients randomized to PT received APM before assessment of the primary outcome. We sought to identify factors associated with crossing over to APM and to compare pain relief between patients who had crossed over to APM and those who had been randomized to APM.
  
  
  METHODS
  We used data from the MeTeOR (Meniscal Tear in Osteoarthritis Research) Trial of APM with PT versus PT alone in subjects ≥45 years old who had mild-to-moderate osteoarthritis and a degenerative meniscal tear. We assessed independent predictors of crossover to APM among those randomized to PT. We also compared pain relief at 6 months among those randomized to PT who crossed over to APM, those who did not cross over, and those originally randomized to APM.
  
  
  RESULTS
  One hundred and sixty-four subjects were randomized to and received APM and 177 were randomized to PT, of whom 48 (27%) crossed over to receive APM in the first 140 days after randomization. In multivariate analyses, factors associated with a higher likelihood of crossing over to APM among those who had originally been randomized to PT included a baseline Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Pain Score of ≥40 (risk ratio [RR] = 1.99; 95% confidence interval [CI] = 1.00, 3.93) and symptom duration of <1 year (RR = 1.74; 95% CI = 0.98, 3.08). Eighty-one percent of subjects who crossed over to APM and 82% of those randomized to APM had an improvement of ≥10 points in their pain score at 6 months, as did 73% of those who were randomized to and received only PT.
  
  
  CONCLUSIONS
  Subjects who crossed over to APM had presented with a shorter symptom duration and greater baseline pain than those who did not cross over from PT. Subjects who crossed over had rates of surgical success similar to those of the patients who had been randomized to surgery. Our findings also suggest that an initial course of rigorous PT prior to APM may not compromise surgical outcome.
  
  
  METHODS
  Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
authors.affiliation: Brigham and Women's Hospital, Boston, Massachusetts jnkatz@partners.org.
authors.forename: Jeffrey N
authors.initials: JN
authors.lastname: Katz
authors.affiliation: Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: John
authors.initials: J
authors.lastname: Wright
authors.affiliation: Cleveland Clinic Sports Health Center, Garfield Heights, Ohio.
authors.forename: Kurt P
authors.initials: KP
authors.lastname: Spindler
authors.affiliation: Hospital for Special Surgery, New York, NY.
authors.forename: Lisa A
authors.initials: LA
authors.lastname: Mandl
authors.affiliation: Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Clare E
authors.initials: CE
authors.lastname: Safran-Norton
authors.affiliation: Vanderbilt Orthopaedic Institute, Medical Center East, Nashville, Tennessee.
authors.forename: Emily K
authors.initials: EK
authors.lastname: Reinke
authors.affiliation: Mayo Clinic, St. Paul, Minnesota.
authors.forename: Bruce A
authors.initials: BA
authors.lastname: Levy
authors.affiliation: Washington University, St. Louis, Missouri.
authors.forename: Rick W
authors.initials: RW
authors.lastname: Wright
authors.affiliation: Cleveland Clinic Sports Health Center, Garfield Heights, Ohio.
authors.forename: Morgan H
authors.initials: MH
authors.lastname: Jones
authors.affiliation: Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Scott D
authors.initials: SD
authors.lastname: Martin
authors.affiliation: Hospital for Special Surgery, New York, NY.
authors.forename: Robert G
authors.initials: RG
authors.lastname: Marx
authors.affiliation: Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Elena
authors.initials: E
authors.lastname: Losina
mesh_terms: D000203:Activities of Daily Living; D000368:Aged; D018592:Cross-Over Studies; D005260:Female; D006801:Humans; D007719:Knee Joint / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D019637:Orthopedic Procedures / Q000379:methods*; D020370:Osteoarthritis, Knee / Q000601:surgery / Q000628:therapy*; D010147:Pain Measurement; D026741:Physical Therapy Modalities; D011379:Prognosis; D020127:Recovery of Function / Q000502:physiology; D000070600:Tibial Meniscus Injuries / Q000601:surgery / Q000628:therapy*; D016896:Treatment Outcome