12/28/2025
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๐๐ฒBetween Christmas and the beginning of the new year, we traditionally publish our โBest ofโ series featuring the most influential posts of the year that is coming to an end.
๐ฃ Today ๐ฅ # place 14 in 2025
๐๐ฎ๐ป ๐ฏ๐ฎ๐๐ฒ๐น๐ถ๐ป๐ฒ ๐ ๐ฅ๐ ๐ณ๐ถ๐ป๐ฑ๐ถ๐ป๐ด๐ ๐ถ๐ฑ๐ฒ๐ป๐๐ถ๐ณ๐ ๐๐ต๐ผ ๐ฟ๐ฒ๐๐ฝ๐ผ๐ป๐ฑ๐ ๐ฏ๐ฒ๐๐๐ฒ๐ฟ ๐๐ผ ๐ฒ๐ฎ๐ฟ๐น๐ ๐๐๐ฟ๐ด๐ฒ๐ฟ๐ ๐๐ฒ๐ฟ๐๐๐ ๐ฒ๐
๐ฒ๐ฟ๐ฐ๐ถ๐๐ฒ ๐ฎ๐ป๐ฑ ๐ฒ๐ฑ๐๐ฐ๐ฎ๐๐ถ๐ผ๐ป ๐ถ๐ป ๐๐ผ๐๐ป๐ด ๐ฝ๐ฎ๐๐ถ๐ฒ๐ป๐๐ ๐๐ถ๐๐ต ๐บ๐ฒ๐ป๐ถ๐๐ฐ๐ฎ๐น ๐๐ฒ๐ฎ๐ฟ๐ ?
Knee arthroscopy for meniscal injuries remains among the most frequently performed orthopedic procedures (https://pmc.ncbi.nlm.nih.gov/articles/PMC6584718/, https://pubmed.ncbi.nlm.nih.gov/21531866/, https://pubmed.ncbi.nlm.nih.gov/37434234/). Recent randomized controlled trials (RCTs) in young adults with meniscal tears found that early arthroscopic surgery did not provide superior patient-reported outcomes at 12 or 24 months compared to a strategy of exercise and education, with subsequent surgery if needed https://pubmed.ncbi.nlm.nih.gov/37879858/, https://pubmed.ncbi.nlm.nih.gov/38319181/, https://pubmed.ncbi.nlm.nih.gov/35676079/).
๐ details of the exercise prograhttps://www.bodyworkmovementtherapies.com/cms/10.1016/j.jbmt.2017.07.010/attachment/31656b55-b97c-4b6a-ac12-7ad51c95a933/mmc1.pdf
๐ However, certain patient subgroups may respond better to one treatment approach over the other (https://pubmed.ncbi.nlm.nih.gov/36878666/). Identifying these subgroups based on clinical characteristics that modify treatment effects (https://pubmed.ncbi.nlm.nih.gov/36244961/) could enhance patient counselling and support more personalized treatment decisions.
๐ A brand-new study by Clausen et al. (2025, https://www.jospt.org/doi/10.2519/jospt.2025.12994), a secondary subgroup analysis of the DREAM trial, investigated whether specific baseline MRI findings could predict which young patients with meniscal tears would benefit more from early surgery compared to exercise and education.
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Objectives of the Study
The study focused on three predefined MRI characteristics as potential effect modifiers:
1๏ธโฃ Type of meniscal tear โ categorized as simple (radial/longitudinal) or complex (bucket-handle, displaced, or complex tears, s. illustration, https://pubmed.ncbi.nlm.nih.gov/26724644/).
2๏ธโฃ Meniscus affected โ whether the tear was located in the medial or lateral meniscus.
3๏ธโฃ Presence of knee effusion/synovitis โ present in any knee recess versus no effusion/synovitis
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Methods
The study utilized data from the DREAM trial, a randomized controlled trial (RCT) comparing early meniscal surgery to a structured exercise program with patient education. The study population consisted of 121 patients aged 18โ40 years with MRI-confirmed meniscal tears, with 60 in the surgical group and 61 in the exercise group. Patients were followed for 12 months, and outcomes were assessed using the Knee Injury and Osteoarthritis Outcome Score (KOOS4).
A linear mixed model was used to analyse treatment effects, and an adjusted effect difference of โฅ10 points on KOOS4 was considered clinically relevant.
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Key Findings
๐ Knee Effusion/Synovitis as a Potential Modifier: Patients with knee effusion/synovitis showed a greater improvement in KOOS4 after early surgery compared to exercise therapy.
โถ๏ธ The mean improvement was 11.1 points in favour of early surgery (p=0.07), which was considered clinically significant.
โถ๏ธ This suggests that signs of persistent inflammation (inflammatory phenotype) of the knee may predict better outcomes with surgery.
๐ No Effect Modification by Tear Type: Contrary to expectations, patients with complex tears did not benefit more from early surgery than those with simple tears.
โถ๏ธ The difference between complex and simple tears was minimal (4.5 vs. 4.8 points on KOOS4, p=0.95), suggesting that both groups responded similarly to treatment.
๐ No Effect Modification by Meniscus Location: The study hypothesized that medial meniscus tears would respond better to surgery due to biomechanical forces acting more on the medial compartment.
โถ๏ธ However, the results showed the opposite trend, with lateral tears showing a greater response to surgery (9.6 points) than medial tears (4.6 points, p=0.47).
โถ๏ธ This unexpected finding challenges previous assumptions about meniscus biomechanics.
๐ก Discussion and Clinical Implications
โถ๏ธ Knee effusion/synovitis may be an MRI-defined effect modifier on patient-reported outcomes in favour of early meniscal surgery. These findings reinforce the importance of personalized treatment planning, considering MRI findings alongside patient symptoms (mechanical symptoms may be better improved by early surgery, https://pubmed.ncbi.nlm.nih.gov/36878666/) and patient preferences.
โถ๏ธ The lack of effect modification by tear type and location suggests that meniscal tear morphology alone should not determine treatment strategy.
โถ๏ธ The findings challenge the traditional assumption that medial meniscus tears are more problematic than lateral tears.
โถ๏ธ Exercise therapy remains a viable first-line treatment for most young adults with meniscal tears, given that complex tears did not significantly favour surgery.
โญ Limitations
โถ๏ธ The study was not powered to detect small subgroup differences, meaning that some trends may not have reached statistical significance due to the sample size.
โถ๏ธ MRI scans were conducted at multiple centers, which could introduce variability in image interpretation.
โถ๏ธ Long-term effects beyond 12 months were not analyzed, leaving uncertainty about the durability of the observed benefits.
Illustration: https://doi.org/10.1016/j.ejrad.2015.10.022
