Original Title: Rapport vedrørende behandling af vedvarende symptomer som følge af menisklæsion

Authors' objectives: The Danish national clinical guideline for meniscal pathology states that surgery may be considered as a treatment option for patients with meniscal lesions who experience treatment failure, defined as persistent symptoms despite having completed at least three months of exercise therapy. Despite this, there are currently no clear recommendations regarding the optimal management of these patients. The Danish Health Technology Council wished to assess the current evidence on the treatment alternatives for patients over the age of 40 who experience persistent symptoms of a meniscal lesion, i.e. patients who have been diagnosed with a meniscal lesion through orthopedic evaluation and have completed at least three months of professionally guided exercise therapy aimed at alleviating symptoms and improving physical function. The potential secondary treatment alternatives include continued professionally guided exercise therapy, surgical intervention, or no further treatment.

Authors' results and conclusions: Clinical effect and safety: The analysis evaluates the clinical effectiveness and safety of three treatment options for patients over 40 who experience persistent symptoms due to meniscal lesions, despite completing at least three months of professionally guided exercise therapy. The compared interventions include 1) continued professionally guided exercise therapy, 2) surgical treatment (primarily arthroscopic partial meniscectomy, APM), and 3) no treatment (represented by sham surgery in the identified literature). Outcomes assessed include health-related quality of life, pain levels, functional status, treatment success, and complications such as osteoarthritis. Two randomized controlled trials form the evidence base: one comparing continued professionally guided exercise therapy with surgery, and another comparing surgery with sham surgery. No direct evidence was found comparing continued professionally guided exercise therapy with no treatment. The minimal clinically relevant differences for several effect measures were identified by consensus by the expert committee, for which reason comparison to these cut-off values should be interpreted with caution. Nonetheless, across both comparisons, no clinically relevant differences were identified between the treatment alternatives. The quality of evidence, assessed using GRADE, was rated as “very low” or “low” across all outcomes, limiting confidence in the findings. The expert committee concludes that no treatment option can be deemed superior based on current evidence, but emphasizes caution due to limited data, potential selection bias, and lack of representativeness for Danish clinical practice. Patient perspective: A systematic literature review and empirical data collection were planned with the purpose of exploring patient expectations and experiences with the different treatment alternatives. However, the latter failed due to recruitment issues. Only one study was identified in the literature, focusing solely on experiences with APM. The expert committee found this insufficient to represent the broader patient perspective across all three treatment alternatives. The expert committee notes that many of the clinical outcomes—such as quality of life, pain, function, and treatment success—are patient-reported and thus reflect elements of patient experience. The committee therefore refers to the clinical effectiveness and safety results as indirect indicators of patients’ experiences with the treatment alternatives. Organizational implications: An interview study with ten orthopedic surgeons, supported by six research articles, explored factors influencing whether patients are offered APM or additional exercise therapy. Key determinants include the nature of the lesion (traumatic vs. degenerative), prior training outcomes, clinical history, physical examination, MRI findings, and specific meniscal injuries. Surgeons also cited patient pressure, age, weight, osteoarthritis severity, occupation, and lifestyle as influential. While there is general agreement on relevant factors, individual interpretations and preferences vary widely. This leads to inconsistent treatment recommendations from the surgeons, with some surgeons offering APM frequently and others rarely. Thus, treatment decisions depend not only on clinical indicators but also on the evaluating surgeon. Consequently, both referral practices and patient pathways are organized differently across hospitals. The scientific literature shows no clear subgroups that benefit more from APM than training, and even experienced surgeons appear to struggle with predicting outcomes reliably. The expert committee finds that individualized assessments are appropriate, given the complexity of cases, but highlights unequal access to rehabilitation services across regions as an issue. The committee concludes that while variation in clinical judgment is acceptable, disparities in access to publicly funded rehabilitation are problematic and contribute to unequal healthcare provision. Health economics: The health economic analysis compares two treatment strategies for patients over 40 with persistent meniscal symptoms: 1) additional exercise therapy with the option of later APM, and 2) immediate APM. Other surgical procedures and the “no treatment” alternative were excluded due to lack of data. Over a lifetime horizon, APM resulted in higher costs (DKK 18,224) and lower effectiveness (–0.16 quality-adjusted life years), making additional exercise therapy the dominant treatment alternative. Given the uncertainty associated with the data inputs, there was a 72% probability that APM is likely more costly and less effective than additional exercise therapy. The expert committee notes that since the difference in QALYs is partly driven by data on the development of osteoarthritis, which is subject to significant uncertainty, no long-term difference in effectiveness between the two treatment alternatives can be expected. Budget impact analysis suggests that recommending additional exercise therapy could double referrals for this treatment option and save DKK 25 million over five years from the perspective of the Danish regions. The expert committee emphasizes that the budget impact analysis represents an incomplete expenditure profile as it excludes key cost components, including effectively all costs associated with additional exercise therapy and rehabilitation following APM, which are funded by the Danish municipalities.

Project Status: Completed

Year Published: 2025

URL for published report: https://www.sundk.dk/media/fmtf2znf/anbefaling_behandling_af_menisklaesion.pdf

English language abstract: There is no English language summary available

Publication Type: Not Assigned

Country: Denmark

Organisation Name: The Danish Health Technology Council

Contact Address: Niels Jernes Vej 6a, 9220 Aalborg