Please select the eligibility criteria that correspond to the clinical trial below.
Title: Cost-effectiveness of Early Surgery Versus Conservative Treatment With Optional Delayed Meniscectomy in Older Patients. A Randomized Controlled Trial.
Brief Summary: The purpose of this study is to determine the effectiveness of both arthroscopic knee surgery and physical therapy in the treatment of non-obstructive meniscal injuries in older patients.

The investigators assume equal improvement of physical function in both groups and reduced costs with conservative treatment.


Options:
A: Inclusion Criteria:

* OA symptoms lasting at least 1 month and managed with medications, activity limitations, and/or physical therapy
* At least one symptom consistent with a torn meniscus. Symptoms may include clicking, catching, popping, giving way, pain with pivot or torque, episodic pain, and/or pain that is acute and localized to one joint line.
* Available knee X-ray (within 6 months) and MRI (within 3 years)
* Evidence of osteophyte formation or cartilage fissure, tear, or loss on a knee MRI OR plain radiographic evidence of osteophyte formation or joint space narrowing
* Evidence of a meniscal tear (tear extending to surface of meniscus) on a knee MRI
* Willingness to undergo random assignment and sign an informed consent

Exclusion Criteria:

* Chronically locked knee
* Kellgren-Lawrence Grade IV status, indicating advanced OA and usually the need for total knee replacement
* Contraindication to MRI
* Radiographic chondrocalcinosis (a condition in which there are deposits of calcium pyrophosphate dihydrate \[CPPD\] crystals in one or more joints that eventually result in damage to the affected joints) AND acute symptomatic pseudogout
* Inflammatory diseases (e.g., rheumatoid arthritis, psoriatic arthritis, systemic lupus erythematosus, gout, pseudogout)
* Injection with viscosupplementation in the affected knee in the 4 weeks before study entry
* Any medical contraindications to surgery or physical therapy
* Both knees are symptomatic for meniscal tears and a candidate for bilateral APMs
* Prior surgery on an affected knee
* Pregnancy or possible pregnancy
* Claim filed for worker's compensation
* Unable or unwilling to give informed consent
* Unable or unwilling to attend physical therapy sessions at designated locations or in the community
B: Inclusion Criteria:

* Patients between 45 and 70 years of age at presentation.
* A meniscal tear visualized on MRI. The meniscal tear can either be isolated or combined with a partial asymptomatic Anterior Cruciate Ligament (ACL) injury or an asymptomatic degenerative ACL shown on MRI with no abnormal clinical findings (a negative Lachman test and Pivot Shift).
* Mental Competence.
* Willingness to comply with follow up schedule.
* Written informed consent.

Exclusion Criteria:

* Knee locking or trauma leading to acute surgery.
* One of the following associated injuries on the index knee:

  1. A symptomatic partial ACL rupture or any total ACL rupture determined by clinical examination (positive Lachman test and/or positive Pivot Shift) and shown on MRI;
  2. A complete Posterior Cruciate Ligament (PCL) injury;
  3. Cartilage change down to bone; grade 4 of the Kellgren Lawrence Grading Scale for Osteoarthritis visualized on X-ray;
  4. An injury to the lateral/posterolateral ligament complex with significantly increased laxity.
* A history of knee surgery other than diagnostic arthroscopy on the index knee.
* Tumors on MRI suspected for a malignancy.
* Obese patients with Body Mass Index (BMI) \> 35.
* ASA 4-5 patients which can severely interfere with rehabilitation.
* General disease that effects physical function or systemic medication/abuse of steroids (e.g., rheumatoid arthritis, psoriatic arthritis, systemic lupus erythematosus, gout, pseudogout)
* Any other medical condition or treatment interfering with the completion or assessment of the trial, e.g. contraindications to MRI or surgery.
* Drugs or alcohol abuse.
* Patients unable to speak or read Dutch.
C: Inclusion Criteria:

* All (consecutive) patients referred to the orthopaedic department in Linköping for a suspected meniscal injury
* Age:45-64 years old
* No gonarthrosis (Ahlbäck=0) on standing radiographs

Exclusion Criteria:

* Rheumatic disease
* Patellofemoral arthrosis
* Fibromyalgia
* A knee or hip replacement
* A neurologic disorder including stroke
* A contraindication for an operation
* Catching or locking for more than 2 seconds more than once a week
* A permanent extension deficit
* Patients who cannot understand instructions in Swedish
D: Inclusion Criteria:

* Age 35-60 years
* Knee pain for more than 2 months without a significant trauma
* Medial meniscal tear on MRI
* Eligible for arthroscopic partial meniscectomy
* Grade 0-2 radiographic severity (specification after Kellgren Lawrence)

Exclusion Criteria:

* Those requiring acute trauma surgeries, including those treated as acute cases in the ER
* Ligament injuries
* Tumours (MRI)
* Pain or other musculoskeletal comorbidities severely affecting lower extremity muscle function overriding the symptoms from the knee
* Grade 3 or 4 radiographic severity (specification after Kellgren Lawrence)
* Comorbidities excluding physical activities and exercise.
* Previous knee surgery within two years
* Not able to speak or read Norwegian, drug abuse or mental problems

Answer: B