Early surgery or exercise and education for meniscal tears in young adults

Key points

1. 01No statistically significant difference in the primary knee outcome (KOOS4) between surgery and exercise groups at 12 months (adjusted mean difference 5.4 points, 95% CI -0.7 to 11.4).
2. 02Both groups improved by a clinically relevant margin: surgery group +19.2 points, exercise group +16.4 points on KOOS4 (0-100 scale).
3. 0326% of patients assigned to exercise crossed over to surgery within 12 months; 13% assigned to surgery chose not to have it.
4. 04Serious adverse event rates were similar: 4 events in the surgery group vs. 7 in the exercise group (P=0.40).
5. 05This is the first RCT comparing surgery vs. non-surgical treatment exclusively in adults aged 40 or younger with meniscal tears.

How it was conducted

Design

Pragmatic, comparative effectiveness, multicenter, parallel-group RCT (1:1 allocation), 7 Danish hospitals

Participants

121 adults aged 18-40 years with MRI-confirmed meniscal tear eligible for surgery; mean age 29.7 years, 28% female, 74% moderate-to-high activity level pre-injury

Groups

Early surgery (arthroscopic partial meniscectomy or repair, n=60) vs. 12-week supervised neuromuscular and strengthening exercise therapy plus patient education with option of later surgery (n=61)

Primary outcome

Change in KOOS4 (mean of pain, symptoms, function in sport/recreation, and quality of life subscales; 0-100) from baseline to 12 months

Follow-up

3, 6, and 12 months

What they found

• Primary outcome KOOS4: surgery group improved 19.2 points (95% CI, 14.4 to 24.0); exercise group improved 16.4 points (95% CI, 11.9 to 21.0); adjusted between-group difference 5.4 points (95% CI, -0.7 to 11.4) - not statistically significant.
• KOOS Pain: surgery +15.1 (95% CI 9.8 to 20.4), exercise +13.3 (95% CI 9.0 to 17.7); adjusted between-group difference 6.0 (95% CI 0.4 to 11.7).
• KOOS Symptoms: surgery +13.8 (95% CI 8.8 to 18.8), exercise +11.0 (95% CI 6.5 to 15.5); adjusted between-group difference 5.1 (95% CI 0.0 to 10.2).
• WOMET score: surgery +24.0 (95% CI 17.5 to 30.5), exercise +18.8 (95% CI 12.7 to 25.0); adjusted between-group difference 9.4 (95% CI 1.7 to 17.0).
• Responders improving >=20% in KOOS4: 76% surgery vs. 64% exercise; adjusted odds ratio 1.80 (95% CI 0.76 to 4.27).
• Responders improving >=50% in KOOS4: 57% surgery vs. 38% exercise; adjusted odds ratio 2.18 (95% CI 0.98 to 4.83).
• Serious adverse events: 4 in surgery group vs. 7 in exercise group (P=0.40). Non-serious adverse events: 30 vs. 29 (P=0.85).
• Per-protocol and as-treated analyses yielded results consistent with the intention-to-treat analysis.

Limitations

• The 95% CI of the primary outcome (-0.7 to 11.4) included the pre-defined clinically meaningful threshold of 10 points in favor of surgery, so a small true benefit of surgery cannot be excluded.
• Differential loss to follow-up between groups (82% completion in surgery group vs. 95% in exercise group) introduces potential bias of unknown direction.
• No sham surgery control group; placebo effects of both surgery and exercise may inflate within-group improvements.
• The pragmatic design allowed crossovers, which reflect real-world practice but complicate interpretation of treatment-specific effects.

Why it matters

For patients

Young adults with a meniscal tear can expect meaningful pain relief and functional improvement whether they choose surgery now or start with supervised exercise, and most who try exercise first do not need surgery within a year.

For clinicians

Early arthroscopic meniscal surgery should not be presented as clearly superior to supervised exercise and education in active patients aged 18-40; shared decision-making incorporating patient preference is appropriate.

For readers

This is the first RCT focused exclusively on young adults with meniscal tears, filling a critical evidence gap, though a modest benefit of surgery remains possible given the confidence interval width.