Comparison of Quality of Life in Patients Operated for Knee Surgery via Conventional Method and Arthroscopy: An Original Research

ABSTRACT

Introduction:

To assess physical activity and knee function, the two methods of conventional supervised exercise and the arthroscopic partial meniscectomy trailed by exercise were evaluated after a nontraumatic meniscal (medial) tear that was confirmed on magnetic resonance imaging (MRI).

Materials and Methods:

One hundred adult subjects were assessed for the current prospective research. The pain in the knee was assessed using the Knee Injury and Osteoarthritis Outcome Score (KOOS), Lysholm Knee Scoring Scale (LKSS), Tegner Activity Scale (TAS), and Visual Analogue Scale (VAS). All the parameters were compared at the start of the study and 2 and 6 months after the intervention. All the data were compared using the analysis of variance (ANOVA) with P < 0.05 considered as significant.

Results:

According to the outcome scores, exercising by itself did not result in a larger improvement than an arthroscopic partial medial meniscectomy. There was a significant reduction in discomfort, improved function, and satisfaction for subjects in the two groups (P < 0.0001). After six months, 40% of the subjects reported that the activity levels were similar to the incidence of the injury.

Conclusion:

The quality of life was reported to be comparable in the arthroscopy subjects and the conventional group subjects. Hence, arthroscopy can be delayed for the meniscal tear in the adult subjects who are best managed by the conservatively managed.

INTRODUCTION

Many people who report knee’s inability to function, swelling of knee, and discomfort are usually middle and senior adults with progressive tears of the meniscus. Many meniscal rips in physically active people and elderly people happen without trauma and may be a symptom of early osteoarthritis. Magnetic resonance imaging (MRI) was used by Battacharyya et al.[1] to demonstrate that medial or lateral meniscal tears were frequently discovered in patients who had not suffered osteoarthritis. The majority were middle-aged and had a meniscal tear, and even the tear was discovered in the subjects who were considered as controls in their study. The likelihood that an injured meniscus may negatively impact the joint cartilage rises if the injury results in unstable knees and impaired knee function.[1-5] Patients with meniscal injuries frequently undergo a partial arthroscopic meniscectomy. Following arthroscopy, many patients report improvement, particularly in terms of decreased knee pain, increased knee function, and improved quality of life. According to ChatainF et al.,[2] 91% of patients who underwent arthroscopic medial meniscectomy 11.5 years prior believed that their knees were normal or nearly normal. Matsusue et al.,[3] concluded that the subjects who underwent surgery had good functional ability after the time interval of a year. Roos et al.[4] in contrary to the above research studies have stated that the function worsened after the surgery. Exercise has been recommended as a management technique for the effective control of pain in these meniscal injury patients.[6-10] Previous studies show that physical activity improves functionality and quality of life in patients suffering from osteoarthritis by reducing symptoms and improving muscle strength.[10] Exercising three times per week for four months could enhance knee function by more than 35%.[11] Numerous studies (such as these) have demonstrated that quadriceps weakness results from knee discomfort. After an arthroscopic partial meniscectomy and six weeks of training, muscle strength was gained for the leg muscles; however, the strength was not comparable to that of the uninjured leg.[12] The purpose of therapy is to improve knee function by regaining adequate control of the knee, range of motion (ROM), muscle strength, and flexibility. Concentric and eccentric activities should be included in the workout regimen to promote both neuromuscular function and muscle hypertrophy.[5] After degenerative meniscal tears, there are numerous therapeutic options. There is still disagreement over the best course of action. Hence, the current research assessed physical activity and knee function, and the two methods of conventional supervised exercise and the arthroscopic partial meniscectomy trailed by exercise were evaluated after a nontraumatic meniscal (medial) tear.

MATERIALS AND METHODS

The current research was piloted following the approval of the ethical committee. The consent was obtained from the included subjects. The subjects included were adults who were between 46 and 65 years, positive pain with or without a history of any accident, positive signs of the meniscal tear as confirmed by the MRI, and a grade 1 or 0 of osteoarthritis. All the subjects who had not consented to the study and those who had any systemic conditions that precluded the outcome of the surgery were excluded.

A hundred subjects were finalized for the study who were equally grouped to receive the arthroscopy followed by the exercise and those who had conservative treatment. The study was then explained to them over the phone at that point. They were randomly assigned to one of two treatments—supervised exercise alone or an arthroscopically assisted partial meniscectomy—after providing written informed consent. Two skilled physiotherapists conducted a clinical evaluation. Information was gathered together with data on the patient’s weight, number of days taken off work due to illness, amount of medication taken, level of pain, type of work, and potential physical activity.

Questionnaires

All patients completed Knee Injury and Osteoarthritis Outcome Score (KOOS),[13] Lysholm Knee Scoring Scale (LKSS),[14] and Tegner Activity Scale (TAS)[15] questionnaires before the intervention and eight weeks later. These questionnaires were given out by administrative employees after 8 weeks and by test leaders before the study. After six months, the three questionnaires were given to the patients via regular mail to record their responses as well as their medicine consumption, sick time, and the potential severity of knee pain.

KOOS

The KOOS has five patient-related values that are assessed separately: “quality of life (four items), sport and recreational function (five items), activities of daily living (17 items), pain (nine items), and symptoms (7 items).” Each question has five potential answers with an ascending severity of 0–4. The results are converted to a scale of 0 to 100, with 100 denoting no knee-related issues. It has been used as a good tool to estimate the QOL.[13]

LKSS

There are eight components to the LKSS, such as “pain, swelling, instability, locking, limping, stair climbing, support, and squatting.” An unhampered knee means a perfect mark of hundred. An excellent knee function without problems during any exercise is advised to be more than 91 points.[14] Similar to the KOOS, the LKSS is also the most followed and reliable.

TAS

The TAS measures both daily activities and athletic activity at 10 different levels. Levels 1–6 display amateur sports, whereas Levels 7–10 display professional sports. Level 0 refers to a sick absence for knee issues. Before the injury, at the beginning of the intervention, and at the end of 8 weeks and 6 months, questions were asked of the patients regarding their level of activity. The TAS’s key benefit is the ability to monitor variations in functionality in the same patient before and after interventions.

Workout program

Each patient followed a standardized workout program with the option for individual adaptation twice or a week for 2 months. The exercise program’s objectives were to lessen discomfort, restore complete range of motion, and enhance knee functionality. It included activities to enhance balance and proprioception as well as muscle strength, endurance, and flexibility. Patients were instructed to apply some effort throughout the exercises, but to do so practically painlessly and without having an adverse effect on the injured knee the next day. If the subjects were able to do the exercise without experiencing any issues, they were performed using heavier weights and more resistance. Additionally, a home schedule was followed twice a week. It involved three sets of 10 repetitions of a stepdown exercise and one minute of one-legged standing. The patients recorded their participation in supervised and unsupervised workouts along with other exercises in a diary.

VAS

The 10-point VAS was employed to gauge the potential severity of knee pain over the previous week, both when resting and when bearing weight.[16] Zero represents no discomfort, and 10 represents the greatest amount of pain.

Arthroscopy

Two skilled surgeons performed arthroscopies on all 50 subjects considered for the first group, and all the protocols were followed.

Statistics

All the subjects were evaluated for the values of the above scales at the time of surgery, at 2 months, and at the end of 6 months. Statistical analysis was performed after data were collected using the mean and standard deviations for all the intended parameters. The intergroup variations were confirmed using the ANOVA tests. IBM Corporation’s SPSS was used to conduct the statistical analysis, Version 25.0 of IBM SPSS Statistics for Windows (IBM Corp., Armonk, New York). The chosen level of significance was <0.05.

RESULTS

KOOS

In all five parameters that were evaluated, no significant variance was found between the arthroscopic and conventional groups. However, when the individual items were compared in both groups it was observed that a significant increase in the scale values was between the start of the research and the end of 2 and 6 months (P = 0.001). There was no significant variance when the two time intervals of 2 and 6 months were compared (P > 0.05). It is noteworthy that there was no significant variance when the two groups were associated with each other (P > 0.05) [Table 1].

Table 1.

Comparison of the two groups for the KOOS at different time intervals

Parameters	Arthroscopy	Conventional	P
Beginning of the study
ADL	67	78	0.31
Pain	55	61	0.07
QOL	30	37	0.66
Sport/Rec	21	29	0.08
Symptom	63	70	0.15
After 2 months
ADL	92	95	0.52
Pain	88	85	0.89
QOL	61	62	0.58
Sport/Rec	71	69	0.11
Symptoms	85	88	0.47
After 6 months
ADL	83	95	0.55
Pain	88	85	0.41
QOL	68	62	0.60
Sport/Rec	69	64	0.79
Symptoms	88	85	0.93
Comparison of the significance levels of the individual parameters for various time intervals
ADL	Beginning vs 2 months=0.001	Beginning vs 2 months=0.001
	Beginning vs 6 months=0.001	Beginning vs 6 months=0.001
	2 months vs 6 months=0.124	2 months vs 6 months=0.11
Pain	Beginning vs 2 months=0.001	Beginning vs 2 months=0.001
	Beginning vs 6 months=0.001	Beginning vs 6 months=0.001
	2 months vs 6 months=0.11	2 months vs 6 months=0.124
QOL	Beginning vs 2 months=0.001	Beginning vs 2 months=0.001
	Beginning vs 6 months=0.001	Beginning vs 6 months=0.001
	2 months vs 6 months=0.58	2 months vs 6 months=0.89
Sport/Rec	Beginning vs 2 months=0.001	Beginning vs 2 months=0.001
	Beginning vs 6 months=0.001	Beginning vs 6 months=0.001
	2 months vs 6 months=0.163	2 months vs 6 months=0.85
Symptom	Beginning vs 2 months=0.001	Beginning vs 2 months=0.001
	Beginning vs 6 months=0.001	Beginning vs 6 months=0.001
	2 months vs 6 months=0.74	2 months vs 6 months=0.56

ADL=Activities of daily living, QOL=Quality of life

LKSS

It was evident that the scores of the subjects in the arthroscopy group were lower than that in the conventional group. No statistically significant variance was found between the arthroscopic and conventional groups when assessed. The scale values from the beginning of the research and the conclusion of 2 and 6 months, however, showed a substantial increase when the individual items in both groups were compared (P = 0.001). When the two time intervals of 2 and 6 months were examined, there was no discernible variance (P > 0.05). Notably, there was no discernible variance between the two groups when they were compared to one another (P > 0.05) [Table 2].

Table 2.

Comparison of the two groups for the LKSS, VAS, and TAS at different time intervals

Review time	LKSS		VAS (Function)		VAS (Rest)		TAS
	a	c	a	c	a	c	a	c
Beginning	61	73	6	5	2	1	3	3
After 2 months	88	90	1	1	0	0	3	3
After 6 months	84	85	1	1	0	0	3	3
P
Beginning vs 2 months	0.04	0.05	0.001	0.001	<0.001	<0.001	-	-
Beginning vs 6 months	0.021	0.01	0.001	0.001	<0.001	<0.001	-	-
2 months vs 6 months	0.321	0.45	0.85	0.36	-	-	-	-

TAS

Of the 100 subjects in the arthroscopy group, 71% and 69% in the conventional group reported that their physical activity was reduced when they had knee pain. Before any intervention, the TAS score was 4, whereas after the interventions the score was consistent and was 3 for both groups. A greater percentage of the subjects revived to pre-injury levels in the conventional group than in the arthroscopy group [Table 2].

VAS

After 2 months of consistent exercise in both interventional subjects, pain levels were significantly lower on both the outcome scores and the VAS (P 0.001). At the beginning of the trial, both groups’ median pain ratings on the VAS during physical exercise were 5.5. They received a 1.0 score after two and six months [Table 2].

Arthroscopy

All the subjects responded well to the arthroscopy and were uneventful. No postoperative complications were noted. In 80% of patients, degenerative lesions were found. A partial resection was performed for the meniscal tear.

DISCUSSION

In this study, two therapies for middle-aged people with a meniscal rupture of nontraumatic origin were compared. Both group subjects followed the supervised exercises with one group after the arthroscopy. Both groups significantly improved after 8 weeks of exercise, as measured by various outcome surveys. Exercise as a therapeutic alternative for meniscal injuries has not been adequately researched. Orthopedic injury rehabilitation has been shown to benefit from resistance exercise.[15] Aichroth[17] suggests using mobility and strengthening exercises along with gradually increasing resistance training to address meniscal injuries that were seen on an MRI. It can be emphasized that the significance of exercise programs is customized for each subject to get the optimum therapeutic effect, as have previous studies.[4,15] Additionally, to improve the performance of the exercises with core stability and knee control and to create the workouts in accordance with the subject’s prior experience, the clinical impression of this study suggested beginning with supervised training sessions. The majority of research articles discuss rehabilitation following arthroscopy. According to some,[17-19] the patients receiving arthroscopy demonstrated that supervised exercise could aid in a quick recovery and better satisfaction. Goodwin and Morrissey[20] and Goodyear-Smith and Arroll[21] conducted critical analyses of clinical trials, but they were unable to find sufficient proof that physical therapy following arthroscopy would benefit patients under the age of 40 in terms of functional improvements. After a straightforward arthroscopic partial meniscectomy, they advise patients to follow a home exercise program and verbal instructions.

Small sample numbers and brief follow-ups were, nevertheless, defining characteristics of the recommended clinical trials. The lack of employing standardized outcome scores, particularly ones that include subscales of quality of life, may be the cause of the discrepancy between the results from past research and this study after training sessions. The improvement was less in the KOOS study than in the current trial, where the patients had additional postoperative knee training. A third group that received only arthroscopy after medial meniscal excision may have enhanced the study because there is insufficient confirmation to support the benefits of exercise after arthroscopy.[17,19] In line with other researchers, we also discovered that, particularly in individuals with degenerative knee abnormalities, sports participation decreased or stopped following arthroscopic meniscectomy.[13,22]

According to the research cited, the patients in this study reduced their physical movements by a few grades. After 6 months, 59% of the subjects had not resumed their pre-injured level. When supervised therapy following surgery was more widespread than it is now, 20 years ago, there was a higher incidence of patients who did not return to sports. Particularly in those without articular cartilage injury, arthroscopy can be a successful short-term and long-term treatment.[3,5,16] A meniscal tear in the periphery can be successfully cured.[1] Exercise therapy over a few weeks could be suggested as the initial option because people older than 40 are at a greater risk of developing radiographic tibiofemoral osteoarthritis after arthroscopic meniscectomy.

The KOOS formula, LKSS, and TAS are the foundations upon which current findings are found. For patients who are young or middle-aged and have a variety of knee problems, such as meniscal pathology, the KOOS has been validated.[13] The excellent correlation between KOOS and LKSS may indicate that the formulas are equivalent for evaluating subjective knee issues in meniscal tear patients. According to reports, patients with meniscal tears respond most sensitively to the LKSS, which was created for the diagnosis of knee ligament injuries.[6] The scale could not be sensitive enough to changes over time, as seen by the arthroscopy–lower group’s overall Lysholm score after 6 months.[14] The patients in this study were on average 56 years old. The majority of patients said that their level of activity was recreational. Because they are not engaging in activities that place a significant strain on the knees, people who restrict their activity may score higher on the LKSS.

Current findings lead in a different direction. The median score of LKSS for both groups after 8 weeks of knee-taxing exercise was almost 89/100; however, after 6 months of reduced regular exercise, the median score was a little lower at 84. Even though all KOOS subscales showed significant recovery and the LKSS score was high, only 40% had reached their pre-injury level of activity at six months.

According to radiological examination results, there is little evidence linking knee discomfort to osteoarthritis. Before pursuing more expensive studies, a conservative treatment may be beneficial if clinical testing shows possible knee deterioration. We observed a few group differences at the beginning of the investigation despite randomization. To find a ten-point average KOOS difference between the groups, a power analysis was carried out. Before surgery, the arthroscopy–KOOS group’s scores were all numerically lower than those of the conventional group. For ADL and sport/recreation, the disparities were 11 and 10, respectively. Despite this, there were no statistically significant differences between the groups at the beginning of KOOS for ADL and sport/recreation. The postoperative ratings for the two groups were equal in size. This initial difference may have had an impact on the outcomes, particularly for patients in the arthroscopy group. This could support the idea that patients in the arthroscopic exercise group improved slightly more than those in the exercise group, at least according to their subjective assessments. The current sample proportions may have been small to detect potential differences between the groups. A longer follow-up period may also be required to identify variations in the groups.

CONCLUSION

Within the constraints of the current research, it can be concluded that among the subjects of middle age with meniscal damage, the arthroscopy in combination with the supervised exercises did not yield better outcomes compared with the conventional treatment of conservative therapy. However, further research is suggested to corroborate the current findings.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.