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:

1. Patients with knee pain for more than 2 months without significant trauma (only the index knee will be included)
2. MRI-confirmed medial meniscus lesion (patients with a medial meniscus lesion AND a lateral lesion will also be included)
3. Age 35-55 years\*
4. Eligible for outpatient surgery - ASA score 1-2

Exclusion Criteria:

1. Patients in need of acute surgery e.g. locking knees, high-energy trauma
2. Symptoms associated with other musculoskeletal co-morbidities overriding the symptoms of the knee
3. Grade 3 or 4 knee OA on the Kellgren-Lawrence classification
4. Knee surgery within the last 2 years
5. Obese patients with BMI \> 35
6. Patients with ischemic heart disease
7. Patients with diabetic late-complications
8. Patients with thrombophilia
9. Pregnancy
10. Patients unable to speak Danish
11. Patients with drug or alcohol abuse
C: Inclusion Criteria:

1. Idiopathic or secondary osteoarthritis of the knee as diagnosed by Altman et al 2 classification tree -83 percent sensitivity, 93percent specificity
2. Grades 2 to 4 severity of OA by radiographic evaluation- modified Kellgren and Lawrence grading system
3. Age greater than 18.

Exclusion Criteria:

1. Inflammatory or post-infection arthritis of the knee
2. Previous arthroscopy for treatment of knee OA
3. Isolated medial compartment OA Grade 3-4 with greater than 5 degrees mechanical varus -ideal candidate for high tibial osteotomy
4. Isolated lateral compartment OA Grade III-IV with greater than 5 degrees mechanical valgus -ideal candidate for high tibial osteotomy or distal femoral osteotomy
5. Grade 4 OA in at least 2 compartments and over 60 years of age -ideal candidate for total knee arthroplasty
6. Cortico-steroid injection within the last three months.
7. Major neurological deficit
8. Major medical illness -life expectancy less than 2 years or with unacceptably high operative risk.
9. Pregnant
10. Unable to speak or read English
11. Psychiatric illness that limits informed consent
12. Unwilling to be followed for 2 years
D: 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.

Answer: D