Surgical management of degenerative meniscus lesions: the 2016 ESSKA meniscus consensus

Arthroscopic repair of degenerative medial meniscus tears in patients aged over 45 years resulted in favorable clinical outcomes and low clinical failure rates at a minimum 2-year follow-up

PURPOSE

This study aimed to investigate clinical and radiological results of arthroscopic repair for isolated medial degenerative meniscus tears (DMTs) in patients over 45 years old at a minimum 2-year follow-up.

METHODS

From 2013 to 2017, patients aged over 45 years with isolated medial DMT refractory to conservative management or with true mechanical symptoms who had undergone arthroscopic repair were retrospectively reviewed. Arthroscopic meniscus repair was performed using all-inside or all-inside and inside-out technique in combination with bone marrow venting procedure. Tear patterns were classified according to arthroscopic findings. Magnetic resonance imaging (MRI) and outcome evaluations, including Lysholm score, Tegner activity score, and International Knee Documentation Committee (IKDC) score, were evaluated preoperatively and at the final follow-up. International Cartilage Repair Society grades of the medial compartments and MRI signal at tear sites were assessed preoperatively and at the final follow-up. A grade 0 to 2 signal at the repair site suggested a healed meniscus, whereas a grade 3 signal suggested an unhealed meniscus. Clinical failure was determined according to Barrett criteria.

RESULTS

Twenty-seven patients (mean age, 57.7 ± 7.4 years) were enrolled. The mean follow-up was 52.0 ± 15.6 months. Among tear patterns, 48% were complex tears, 30% were horizontal tears, and 22% were other patterns. The mean Lysholm score and IKDC score significantly improved from 53 ± 25 to 89 ± 15 (p < 0.001) and 34 ± 24 to 72 ± 15 (p < 0.001) at the final follow-up, respectively. The median Tegner activity score significantly improved from 1 (range 1-4) to 4 (range 2-7, p < 0.001). Three (11%) patients were considered clinical failures, and five patients (19%) had cartilage lesion progression. At the final follow-up, MRI showed grade 0 in one (4%) patient, grade 1 in nine (33%) patients, grade 2 in six (22%) patients, and grade 3 in eleven (41%) patients.

CONCLUSION

Arthroscopic repair of isolated medial DMT refractory to conservative management or with true mechanical symptoms in patients aged over 45 years had good to excellent clinical outcomes with low clinical failure rates, despite unhealed menisci being observed on MRI in 41% of patients at a mean 4.3-year follow-up. Arthroscopic repair could be a treatment option for these patients.

LEVEL OF EVIDENCE

IV.

Variation in Patient-Reported Outcomes in Young and Old Patients Up to 4 to 6 Years After Arthroscopic Partial Meniscectomy

OBJECTIVE

To assess the variation in changes in patient-reported outcomes 4 to 6 years after arthroscopic partial meniscectomy (APM).

DESIGN

Prospective cohort study.

SETTING

Orthopedic departments at public hospitals.

PATIENTS

Patients (n = 447) from the Knee Arthroscopy Cohort Southern Denmark undergoing APM.

INTERVENTIONS

All patients underwent APM.

MAIN OUTCOME MEASURES

Change in KOOS4 scores from baseline before surgery to ∼5 years (range 4-6 years) after surgery. KOOS4 is the average aggregated score of 4 of 5 of the Knee injury and Osteoarthritis Outcome Score (KOOS) excluding the activities of daily living subscale (minimal clinical important improvement ∼10 points). A mixed linear model adjusted for sex and body mass index was used to assess change from baseline to ∼5-year follow-up. Change in KOOS4 was divided into 5 categories based on change from baseline to ∼5-year follow-up: <0 points, 0 to 9 points, 10 to 19 points, 20 to 29 points, and ≥30 points.

RESULTS

On average, patient-reported outcomes continued to improve from baseline to ∼5-year follow-up (mean KOOS4 change: 26, 95% CI, 24-28). Proportions in the different response groups were <0 points (12%), 0 to 9 points (13%), 10 to 19 points (16%), 20 to 29 points (19%), and ≥30 points (40%), with no difference between younger (≤40 years, n = 75) and older (>40 years, n = 337) patients (P = 0.898).

CONCLUSIONS

Patient-reported outcomes on average improved up to ∼5 years after APM; however, large variability was observed. The similar variability in younger and older patients questions the assumption that younger patients with traumatic injuries experience larger benefits from APM.

Patient's subjective knee function 3-5 years following partial meniscectomy or meniscus repair compared to a normal population: a retrospective cohort study

Purpose

Evaluate patient-reported knee function after arthroscopic partial meniscectomy (APM) and meniscus suture repair in two different age cohorts compared with a normal population.

Method

Arthroscopic meniscus surgery was performed on 421 patients at Skåne University Hospital from 2010 to 2014, with a mean (SD) follow-up of 4.2 (1.4) years. Patients and controls were divided into two age cohorts; 18-34 years (younger) and 35-54 years (middle-aged) as well as according to surgery performed; either solely meniscus surgery or with concurrent anterior cruciate ligament reconstruction (ACLR). The outcome is measured with the five subscales of the Knee and Osteoarthritis Outcome Score (KOOS).

Results

No significant difference in outcome after all studied types of meniscus surgeries between younger-aged and middle-aged patients.Younger patients with APM or meniscus suture repair, with or without, ACLR score lower than the normal population in all subscales of KOOS (p<0.001), except in Activities of Daily Living (ADL) for meniscus suture patients.Middle-aged patients with APM score lower in all subscales than the normal population (p≤0.009). Those with meniscus suture repair score lower than the normal population only for the subscales Sport/Rec and quality of life (p<0.001).Both younger-aged and middle-aged patients achieve better KOOS values after meniscus suture repair and ACLR than after all other combinations of surgery.

Conclusion

Patients with meniscus injuries do not reach the same KOOS score as the normal population, irrespective of age or type of meniscus surgery performed. However, combined with ACLR in younger-aged and middle-aged patients, meniscus suture gives a better subjective outcome than isolated meniscus surgery.

Clinical significance and management of meniscal extrusion in different knee pathologies: a comprehensive review of the literature and treatment algorithm

The menisci are crescent-shaped, fibrocartilaginous structures that play a crucial role in the load transition and distribution of the contact forces along the tibiofemoral articulation. Meniscal extrusion (ME) is a radiological finding, especially in magnetic resonance imaging (MRI) scans, for which there has been growing interest in recent years. ME, in the coronary plane, is defined as the maximum distance of the most distal end of the meniscus from the border of the tibial plateau, where the tibial eminences are the most prominent, without taking into account the osteophytes. Although there is still controversy in the literature in respect of the optimal cutoff value, a threshold of 3 mm is considered significant. ME has no specific clinical finding or sign and it is encountered in many knee pathologies. It is associated with either rapidly progressive knee osteoarthritis or early onset of knee osteoarthritis and increased morbidity. In this review, we delineate the clinical significance of ME in various knee pathologies, as well as when, why and how it should be managed. To the best of our knowledge, this is the first study to elaborate on these topics.

Second-look arthroscopy after meniscus repair and synovial mesenchymal stem cell transplantation to treat degenerative flaps and radial tears of the medial meniscus: A case report

BACKGROUND

The purpose of this study was to compare arthroscopic findings of a degenerative flap and radial tear of the medial meniscus (MM) before and one year after treatment by meniscus repair and synovial mesenchymal stem cell (MSC) transplantation.

METHODS

Patients with a degenerative flap and radial MM tear that would generally be treated by meniscectomy were included. The patients ranged in age from 45 to 62 years and all underwent meniscus repair and synovium harvest at time 0. The digested synovium was cultured with autologous serum for 12 days, and an average of 4 × 10⁷ MSCs were transplanted at two weeks. A second-look arthroscopy was performed at 52 weeks (n = 6). The average duration of symptoms was 24 months. For flap tears, arthroscopic findings were quantified in terms of the presence, stability, and smoothness of the meniscus at each zone and area. The Lysholm score was evaluated throughout the 52 week follow-up.

RESULTS

Four patients with MM flap tears showed deficiencies in the central area at the posterior junctional zone before treatment, but this zone was completely restored to a stable and smooth condition in two patients and partially restored in the other two patients. The arthroscopy score for a flap tear at the central area of the posterior junctional zone was 0.3 ± 0.5 before treatment and 4.3 ± 2.1 after treatment. The score was significantly higher after treatment (p < 0.05, n = 4). The original radial MM tears in two patients were healed one year after treatment. Lysholm scores were significantly higher at 4 and 52 weeks after treatment than before treatment (n = 6).

CONCLUSIONS

Arthroscopic findings for a degenerative flap and radial tear of the MM were improved at the central area of the posterior junctional zone one year after meniscus repair and MSC transplantation.

Effect of Physical Therapy vs Arthroscopic Partial Meniscectomy in People With Degenerative Meniscal Tears: Five-Year Follow-up of the ESCAPE Randomized Clinical Trial

IMPORTANCE

There is a paucity of high-quality evidence about the long-term effects (ie, 3-5 years and beyond) of arthroscopic partial meniscectomy vs exercise-based physical therapy for patients with degenerative meniscal tears.

OBJECTIVES

To compare the 5-year effectiveness of arthroscopic partial meniscectomy and exercise-based physical therapy on patient-reported knee function and progression of knee osteoarthritis in patients with a degenerative meniscal tear.

DESIGN, SETTING, AND PARTICIPANTS

A noninferiority, multicenter randomized clinical trial was conducted in the orthopedic departments of 9 hospitals in the Netherlands. A total of 321 patients aged 45 to 70 years with a degenerative meniscal tear participated. Data collection took place between July 12, 2013, and December 4, 2020.

INTERVENTIONS

Patients were randomly allocated to arthroscopic partial meniscectomy or 16 sessions of exercise-based physical therapy.

MAIN OUTCOMES AND MEASURES

The primary outcome was patient-reported knee function (International Knee Documentation Committee Subjective Knee Form (range, 0 [worst] to 100 [best]) during 5 years of follow-up based on the intention-to-treat principle, with a noninferiority threshold of 11 points. The secondary outcome was progression in knee osteoarthritis shown on radiographic images in both treatment groups.

RESULTS

Of 321 patients (mean [SD] age, 58 [6.6] years; 161 women [50.2%]), 278 patients (87.1%) completed the 5-year follow-up with a mean follow-up time of 61.8 months (range, 58.8-69.5 months). From baseline to 5-year follow-up, the mean (SD) improvement was 29.6 (18.7) points in the surgery group and 25.1 (17.8) points in the physical therapy group. The crude between-group difference was 3.5 points (95% CI, 0.7-6.3 points; P < .001 for noninferiority). The 95% CI did not exceed the noninferiority threshold of 11 points. Comparable rates of progression of radiographic-demonstrated knee osteoarthritis were noted between both treatments.

CONCLUSIONS AND RELEVANCE

In this noninferiority randomized clinical trial after 5 years, exercise-based physical therapy remained noninferior to arthroscopic partial meniscectomy for patient-reported knee function. Physical therapy should therefore be the preferred treatment over surgery for degenerative meniscal tears. These results can assist in the development and updating of current guideline recommendations about treatment for patients with a degenerative meniscal tear.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01850719.

Identification and diagnosis of meniscus tear by magnetic resonance imaging using a deep learning model

Objective

Meniscus tear is a common problem in sports trauma, and its imaging diagnosis mainly relies on MRI. To improve the diagnostic accuracy and efficiency, a deep learning model was employed in this study and the identification efficiency was evaluated.

Methods

Standard knee MRI images from 924 individual patients were used to complete the training, validation and testing processes. Mask regional convolutional neural network (R–CNN) was used to build the deep learning network structure, and ResNet50 was adopted to develop the backbone network. The deep learning model was trained and validated with a dataset containing 504 and 220 patients, respectively. Internal testing was performed based on a dataset of 200 patients, and 180 patients from 8 hospitals were regarded as an external dataset for model validation. Additionally, 40 patients who were diagnosed by the arthroscopic surgery were enrolled as the final test dataset.

Results

After training and validation, the deep learning model effectively recognized healthy and injured menisci. Average precision for the three types of menisci (healthy, torn and degenerated menisci) ranged from 68% to 80%. Diagnostic accuracy for healthy, torn and degenerated menisci was 87.50%, 86.96%, and 84.78%, respectively. Validation results from external dataset demonstrated that the accuracy of diagnosing torn and intact meniscus tear through 3.0T MRI images was higher than 80%, while the accuracy verified by arthroscopic surgery was 87.50%.

Conclusion

Mask R–CNN effectively identified and diagnosed meniscal injuries, especially for tears that occurred in different parts of the meniscus. The recognition ability was admirable, and the diagnostic accuracy could be further improved with increased training sample size. Therefore, this deep learning model showed great potential in diagnosing meniscus injuries.

Translational potential of this article

Deep learning model exerted unique effect in terms of reducing doctors’ workload and improving diagnostic accuracy. Injured and healthy menisci could be more accurately identified and classified based on training and learning datasets. This model could also distinguish torn from degenerated menisci, making it an effective tool for MRI-assisted diagnosis of meniscus injuries in clinical practice.

Patient beliefs and perceptions play a crucial role in the decision-making process when managing a meniscal tear. A qualitative systematic review of the literature

INTRODUCTION

There has been an increase in research on the effectiveness of treatment options for the management of meniscal tears. However, there is very little evidence about the patient experiences of meniscal tears.

AIM

To summarise the available qualitative evidence on patients' experiences and expectations of meniscal tears.

METHOD

A search of EMBASE, Medline, Sociofile and Web of Science up to November 2020 was performed to identify studies reporting patient experiences of meniscal tears. Studies were critically appraised using the CASP (Critical Appraisal Skills Program) checklist, and a meta-synthesis was performed to generate third-order constructs (new themes).

RESULTS

Two studies reporting semi-structured interviews from 34 participants (24 male; 10 female) were included. The mean interview length ranged from 16 to 45 min. Five themes were generated: (1) the imaging (MRI) results are a key driver in the decision-making process, (2) surgery is perceived to be the definitive and quicker approach, (3) physiotherapy and exercise is a slower approach which brought success over time, (4) patient perceptions and preferences are important in the clinical decision-making process and, (5) the impact on patient lives is a huge driver in seeking care and treatment decisions.

CONCLUSION

This is the first study to summarise the qualitative evidence on patient experiences with meniscal tears. The themes generated demonstrate the importance of patient perceptions of MRI findings and timing of treatment success as important factors in the decision-making process. This study demonstrates the need to strengthen our understanding of patients' experiences of meniscal tears.

Treatment, Return to Play, and Performance Following Meniscus Surgery

PURPOSE OF REVIEW

The standard of care in meniscal tear management is constantly evolving, especially for athletes and high-demand patients. Meniscus repairs, meniscus transplants, and partial meniscectomies are commonly performed, and rehabilitation methods following these operations are becoming more sophisticated. The ultimate goal of these procedures is returning patients to full activity with minimal risks. Return to play should be systematic, pathology dependent, and individualized to an athlete's needs, expectations, and level of play. This article provides a review of the current treatment modalities of meniscus tears, the rehabilitation protocols following each modality, and the return to play criteria that must be met before releasing the player to competition. In addition, it overviews articles that describe performance outcomes of patients that have undergone meniscus surgery.

RECENT FINDINGS

Current research shows high return to play rates for athletes that undergo meniscus surgery and describes effective rehabilitation protocols to facilitate recovery. There is an increased emphasis on meniscus preservation in recent literature. In addition, meniscus allograft transplantation has demonstrated its efficacy as a salvage procedure and has become a stronger consideration in the athlete with meniscus pathology. No standardized return to play protocol can be applied uniformly to all kinds of meniscal surgeries, and two athletes with the same pathology cannot be expected to follow identical paths towards full recovery. A multidisciplinary approach to care should be provided to the patients, and in the case of patients with high levels of athleticism, the road to recovery starts even before the injury itself.

Greater medial meniscus extrusion seen on ultrasonography indicates the risk of MRI-detected complete medial meniscus posterior root tear in a Japanese population with knee pain

To elucidate the association between medial meniscus extrusion measured on ultrasonography (MME_US) and the prevalence of medial meniscus posterior root tear detected on magnetic resonance imaging (MMPRT_MRI). We recruited 127 patients (135 knees; 90 females; mean age: 64.4 ± 8.7 years old; mean BMI: 25.5 ± 3.4 kg/m²) in this cross-sectional study. All participants had medial knee pain without a knee trauma or surgery history. Knee osteoarthritis (KOA) severity was evaluated using Kellgren-Lawrence grade (KLG) scores. Patients with KLG scores 0–1 and ≥ 2 were classified in non-radiographic (non-ROA) and radiographic KOA (ROA) groups, respectively. MME_US was measured with patients in the supine position. Based on fat-suppressed T2-weighted images, MMPRT_MRI was defined as the presence of “Ghost meniscus sign” and “Cleft/truncation sign”, indicating an abnormal high signal intensity of a completely disrupted posterior root. MME_US was compared between MMPRT+ and MMPRT– patients using a non-paired t-test. Receiver operating characteristic (ROC) curves were used to determine the optimal cut-off MME_US to predict MMPRT+. The prevalence of MMPRT+ was 31.3% (25/80 knees) and 29.1% (16/55 knees) in the non-ROA and ROA groups. The MME_US of MMPRT+ patients were significantly greater than that of MMPRT– patients in both the non-ROA (5.9 ± 1.4 mm vs. 4.4 ± 1.0 mm, P < 0.001) and ROA (7.8 ± 1.3 mm vs. 6.3 ± 1.3 mm, P < 0.001) groups. ROC curves demonstrated that 5-mm and 7-mm MME_US were the optimal cut-off values in non-ROA (adjusted odds ratio: 6.280; area under the curve [AUC]: 0.809; P < 0.001) and ROA (adjusted odds ratio: 15.003; AUC: 0.797; P = 0.001) groups. In both early non-radiographic and established radiographic KOA stages, a greater MME_US was associated with a higher MMPRT_MRI prevalence.

Large medial meniscus extrusion and varus are poor prognostic factors of arthroscopic partial meniscectomy for degenerative medial meniscus lesions

BACKGROUND

The indications and efficacy after arthroscopic partial meniscectomy (APM) for degenerative medial meniscus lesions (DMMLs) have been controversial. The purpose of this study was to identify predictors of unfavorable clinical and radiologic outcomes after APM for DMMLs and to choose appropriate indications and improve treatment efficacy.

METHODS

A total of 86 patients with DMMLs undergoing APM were retrospectively reviewed. The mean follow-up time was 32.1 months. Clinical outcomes (including Lysholm score) and radiographic results (including Kellgren-Lawrence grade (K-L grade: 0/1/2/3/4) were evaluated at preoperative and final follow-up. Preoperative prognostic factors, including gender, age, Body Mass Index (BMI), Hip-Knee-Ankle (HKA), Medial Posterior Tibial Slope (MPTS), Medial Meniscus Extrusion (MME), K-L grade, occupational kneeling, and cartilaginous condition (Outerbridge grade ≤ 2, VS ≥ 3), for relatively unfavorable (fair or poor grade) Lysholm and progression of K-L grade, were investigated by multivariate logistic regression analysis. Receiver operating characteristic curve was used to identify a cutoff point for the extent of medial meniscal extrusion that was associated with the final Lysholm score.

RESULTS

A significantly improved postoperative Lysholm score (84.5 ± 9.7) compared with the preoperative score (63.8 ± 9.3) (P < 0.001), but a progression of K-L grade (20/36/30/0/0-15/27/25/19/0) (P < 0.001). The adverse prognostic factor of Lysholm score was the advancing age (OR 1.109, P = 0.05) and HKA (OR 0.255, P < 0.001). The adverse prognostic factor of K-L grade progression was MME (OR 10.327, P < 0.001). The cutoff point for the relative value of preoperative medial meniscal extrusion associated with relatively unfavorable Lysholm scores was 2.05 mm (Area = 0.8668, P value < 0.0001, Sensitivity = 62.16%, Specificity = 93.88%).

CONCLUSIONS

Clinically, varus alignment, large MME, and older age were found to predict a poor prognosis after APM for DMMLs. The preoperative extent of MME can be used as a predictive factor for osteoarthritis in APM. Patients with varus and MME should avoid APM. High tibial osteotomy may be an effective treatment strategy.

Impact of job characteristics on return-to-work interval following arthroscopic partial meniscectomy

The aim of this paper was to investigate whether job characteristics are associated with time interval for return to former professional activity (return to work, RTW) after arthroscopic partial meniscectomy (APM). A retrospective study was carried out in a sample of 63 patients in working age who underwent an APM between July 2018 and July 2020. The following preoperative characteristics were assessed: age at surgery, meniscal side, sex, physical job demands (white versus blue collar worker), telework and work status (salaried versus self- employed). A linear regression analysis was used to study the association between job characteristics and RTW interval adjusted for socio-demographic and medical (meniscal side) factors. Telework was most strongly associated with interval for RTW (p <0,001, adjusted R Square: 20,8). The results suggested that telework supports early RTW independently of sociodemographic and medical factors. This study supported the need for a tailormade approach in the prescription of sick leave.

Platelet-rich plasma (PRP) augmentation does not result in more favourable outcomes in arthroscopic meniscal repair: a meta-analysis

Background

The efficacy and safety of platelet-rich plasma (PRP) augmentation for arthroscopic meniscal repair is controversial. This meta-analysis compared arthroscopic meniscal repair performed in isolation or augmented with PRP.

Methods

The present study was conducted according to PRISMA 2020 guidelines. Pubmed, Web of Science, Google Scholar and Embase were accessed in August 2021. All the clinical trials which compared arthroscopic meniscal repair performed in isolation or augmented with PRP were included.

Results

Eight hundred thirty-seven patients were included: 38% (318 of 837 patients) were women; the mean age of the patients was 35.6 (range, 20.8–64.3) years; the mean follow-up was 26.2 (range, 6–54) months. Similarity was found in analogue scale (VAS) (P = 0.5) and Lysholm (P = 0.9), and International Knee Documentation Committee (IKDC) scores (P = 0.9). Similarity was found in the rate of failure (P = 0.4) and rate of revision (P = 0.07).

Conclusion

The current published scientific evidence does not support PRP augmentation for arthroscopic meniscal repair.

Intraarticular injection of microfragmented adipose tissue plus arthroscopy in isolated primary patellofemoral osteoarthritis is clinically effective and not affected by age, BMI, or stage of osteoarthritis

Purpose

This study aimed to report the clinical and functional results of a series of patients with isolated primary patellofemoral osteoarthritis (PFOA) treated with intraarticular injection of microfragmented autologous adipose tissue plus knee arthroscopy. The results were also analyzed in relation to the age and body mas index (BMI) of patients, and to the stage of PFOA.

Methods

Twenty-three patients with early-to-moderate (stage 1–3 according to the Iwano classification system) PFOA who received this treatment were retrospectively analyzed, with a mean follow-up of 22.1 ± 4.2 months. Patients were assessed using the International Knee Society (IKS) knee and function and visual analog scale (VAS) scores, and relative to their capacity for climbing stairs. Differences in improvements of IKS and VAS scores in relation to age (< 60 versus ≥ 60 years), BMI (< 30 versus ≥ 30 kg/m²), and stage of PFOA (stages 1–2 versus stage 3) were finally analyzed.

Results

The mean IKS knee score significantly improved from 35.6 ± 14.9 points preoperatively to 61.9 ± 17.8 points at the latest follow-up, while the mean IKS function score significantly improved from 52.0 ± 14.7 points preoperatively to 82.3 ± 19.1 points at the latest follow-up. The mean VAS score significantly decreased from 8.7 ± 2.2 preoperatively to 5.2 ± 2.5 at the latest follow-up. A significant improvement in the capacity to climb stairs was found. No significant differences in improvements of IKS knee and function and VAS scores were found in relation to age, BMI, or stage of PFOA.

Conclusion

Intraarticular injection of microfragmented autologous adipose tissue following arthroscopic debridement significantly improved overall clinical and functional scores in patients with early or moderate isolated primary PFOA at a mean follow-up of almost 2 years. Improvements were not significantly affected by age, BMI, or stage of PFOA.

Level of evidence

Level IV, retrospective case series.

Isolated meniscus injuries in skeletally immature children and adolescents: state of the art

The prevalence of isolated meniscal injuries in children and adolescents is low; however, we see an increase mainly due to intensified sports-related activities at an early age. A meniscal repair should be attempted whenever possible as children present with increased meniscal healing potential. The diagnosis and management of meniscal tears involve both patient factors and tear characteristics: size, anatomical location and associated injuries. Special attention should be given to the feature of discoid menisci and related tears as they require a specific management plan. This state-of-the-art review highlights the most recent studies on clinical evaluation, surgical techniques, tips and tricks, pitfalls, outcomes, return-to-sports, geographical differences and future perspectives related to meniscal injuries in children and adolescents.

Mechanical symptoms and meniscal tear: a reappraisal

OBJECTIVE

To identify and summarize literature related to the association between mechanical symptoms (catching and locking of the knee), the presence of meniscal tear, and outcomes after arthroscopic surgery.

DESIGN

We searched PubMed and hand-searched reference lists for relevant articles and selected 38 for analysis.

RESULTS

Mechanical symptoms appear to have modest sensitivity (ranging 0.32-0.69), specificity (ranging 0.45-0.74) and positive predictive value (ranging 0.75-0.81) for meniscal tear. There is also very little evidence to suggest that those with mechanical symptoms experience better outcomes after arthroscopic surgery.

CONCLUSION

Our examination of the literature does not support the hypothesis that mechanical symptoms are related to the presence of meniscal tear or portend better outcomes after arthroscopic surgery.

Meniscus regeneration by 3D printing technologies: Current advances and future perspectives

Meniscal tears are a frequent orthopedic injury commonly managed by conservative strategies to avoid osteoarthritis development descending from altered biomechanics. Among cutting-edge approaches in tissue engineering, 3D printing technologies are extremely promising guaranteeing for complex biomimetic architectures mimicking native tissues. Considering the anisotropic characteristics of the menisci, and the ability of printing over structural control, it descends the intriguing potential of such vanguard techniques to meet individual joints’ requirements within personalized medicine. This literature review provides a state-of-the-art on 3D printing for meniscus reconstruction. Experiences in printing materials/technologies, scaffold types, augmentation strategies, cellular conditioning have been compared/discussed; outcomes of pre-clinical studies allowed for further considerations. To date, translation to clinic of 3D printed meniscal devices is still a challenge: meniscus reconstruction is once again clear expression of how the integration of different expertise (e.g., anatomy, engineering, biomaterials science, cell biology, and medicine) is required to successfully address native tissues complexities.

Clinical Outcome Measures in Arthroscopic Meniscectomy: Clinician versus Patient Completed Knee Scores

Objective  The aim of the present study was to investigate the difference between clinician-completed and patient-completed outcome scores in detecting improvement following arthroscopic meniscectomy in patients with meniscal tears of the knee. Methods  Thirty-four patients with meniscal tears were prospectively assessed using 9 clinical outcome measures. The five clinician-completed knee scores included the Tegner Activity Score, the Lysholm Knee Score, the Cincinnati Knee Score, the International Knee Documentation Committee (IKDC) Examination Knee Score, and the Tapper and Hoover Meniscal Grading Score. The four patient-completed knee scores included the IKDC Subjective Knee Score, the Knee Outcome Survey - Activities of Daily Living Scale (KOS-ADLS), the Short Form-12 Item Health Survey (SF-12), and the Knee Injury and Osteoarthritis Outcome Score (KOOS). Twenty-nine of the 34 patients underwent an arthroscopic meniscectomy and were reassessed with all 9 outcome scores upon their follow-up review. Results  A significant longitudinal improvement was observed in 4 of the 5 clinician-completed scores (Tegner [ p  < 0.001], Lysholm [ p  = 0.004], Cincinnati [p = 0.002] and Tapper and Hoover [ p  < 0.001], but not in the IKDC Examination [ p  = 0.332]. However, the IKDC Subjective score ( p  = 0.021) was the only patient-completed score to demonstrate significant improvement postoperatively. Conclusion  Overall, clinician-completed scoring systems were found to be inconsistent with those of patient-completed instruments. The mode of administering outcome measures can have a significant influence on the outcome results both for research and for clinical practice. A combination of both a clinician-completed with a patient-completed instrument may be a more balanced approach to assessing and quantifying meniscus tears and the outcome following arthroscopic meniscectomy.

Meniscectomy is still a frequent orthopedic procedure: a pending need for education on the meniscus treatment possibilities

PURPOSE

The purpose of this study was to evaluate the current status of education of polish surgeons in the subject of meniscus repair possibilities. The analysis of the possible correlations between the number of knee arthroscopy procedures performed by polish surgeons and their decision whether to remove or to repair the damaged meniscus has been performed.

METHODS

Two-hundred and five registered orthopedic surgeons took part in surveys. The questionnaire contained the description of 20 patients with different types of meniscus damage and three questions concerning the experience in knee arthroscopy (two questions) and a choice of the treatment method (one question). Comparisons were made between knee arthroscopy experts (> 100 arthroscopies performed per year) and non-experts (≤ 100 cases).

RESULTS

The questionnaire was completed by 194 knee surgeons from Poland with different levels in knee arthroscopy experience. For most cases, experts and non-experts agreed on the meniscus treatment method. Statistically significant differences in the recommended treatment between experts and non-experts were observed in 4 cases, where experts decided to repair the damage rather than to perform the meniscectomy.

CONCLUSIONS

Meniscectomy remains a frequent orthopedic procedure, despite meniscal sparing having been advocated for several decades now and despite the existence of meniscus repair technique which gives good clinical outcomes-augmentation of the damaged meniscus with a collagen membrane. Polish surgeons still need education on the meniscus treatment possibilities.

LEVEL OF EVIDENCE

V.

Bounding the Implications of Noncompliance in Randomized Controlled Trials in Orthopaedics: An Example in Arthroscopic Surgery

INTRODUCTION

Randomized controlled trials (RCTs) are not impervious to bias especially when there are substantial numbers of patients who cross over from the treatment assigned by randomization to another treatment group, leading to loss of confidence in study results. The goals of this study were to (1) quantify the effects of crossovers on RCTs, (2) describe the specific effects of crossovers on RCTs for arthroscopic meniscectomy for osteoarthritis of the knee (APM/OAK), and (3) assess the confidence in APM/OAK in which there have been substantial numbers of patients crossing over to another treatment group than that assigned.

METHODS

Studies were included that were RCTs of APM/OAK with intention-to-treat (ITT) analysis and illustrated the problem of crossovers on confidence in the analysis. Studies were excluded if they consisted of APM for conditions other than OAK or had unavailability of data needed for the analysis. For eligible RCTs, the ITT effect was calculated; bounds for the average treatment effect (ATE) and the complier ATE were assessed by estimating confidence intervals for the bound through robust Bayesian analysis.

RESULTS

The eligible studies had different comparators and, therefore, were analyzed individually. Data were not pooled. The most extreme point estimates (with 95% confidence interval) for ITT ranged from -0.01 to 0.04 (-0.16 to 0.16); for ATE with no assumptions, 0.38 (-0.58 to 0.43) to 0.62 (0.56 to 0.70); for ATE with minimum assumptions, -0.50 (-0.22 to 0.10) to 0.61 (0.53 to 0.57); and for complier ATE, -0.01 to 0.07 (-0.22 to 0.24).

DISCUSSION

These data suggest large bounds, crossing the threshold of "no effect," which indicates a high degree of uncertainty and low confidence in the RCTs studied. The results demonstrate that when there are crossovers, ITT analyses do not estimate the ATE and confidence in the results of these RCTs is low.

DATA AVAILABILITY

All analyzed data are provided in the article.

LEVEL OF EVIDENCE

Level I (therapeutic study = RCT).

Increased Vascularity in the Neonatal versus Adult Meniscus: Evaluation with Magnetic Resonance Imaging

Objective. Quantification of meniscus vascularity has been limited with previous techniques, and minimal data exist describing differential vascular zones in the skeletally immature meniscus. The objective of this study is to use quantitative contrast-enhanced magnetic resonance imaging (MRI) to compare meniscal vascularity in neonatal specimens with adults. We hypothesized that the developing meniscus has greater and more uniform vascularity throughout all zones. Design. Ten fresh-frozen human cadaveric knees (5 neonatal, age 0-6 months; 5 adult, 34-67 years) underwent gadolinium-enhanced MRI using an established vascularity quantification protocol. Regions of interest corresponding to peripheral and central zones of the meniscus were identified on pre-contrast coronal images, and signal enhancement within the same regions (normalized against background tissue) was compared between pre- and post-contrast images. Results. The medial and lateral menisci had similar distribution of perfusion (45.8% ± 8.1% medial vs. 54.2% ± 8.1% lateral in neonatal knees; 50.6% ± 11.3% medial vs. 49.4% ± 11.3% lateral in adult knees, P = 0.47). Increased perfusion was demonstrated in the periphery compared with the central zone (2.3:1 in neonatal knees and 3.25:1 in adult knees, P = 0.31). Neonatal specimens demonstrated 6.0-fold greater overall post-contrast meniscal signal enhancement compared with adults (P < 0.0001), with the 0-month specimen demonstrating the greatest proportional signal enhancement. Conclusions. While blood flow to the periphery is greater than to central zones in all menisci, younger menisci receive proportionally greater overall blood flow compared to adults, including to the central zone, suggesting that the immature meniscus is a more biologically active tissue than its adult counterpart.

The 50 Most Cited Articles on Meniscus Injuries and Surgery from 2000 to 2019 Focus on Arthroscopic Repair or Removal, Originate from Institutions Within the United States and Were Published Before 2010

Purpose

To identify the 50 most cited original articles on meniscus injury and surgery from 2000 to 2019, and to perform a bibliometric analysis of the identified articles.

Methods

A Clarivate Web of Science search, completed in June 2020, generated a list of the most cited articles related to meniscus research. Articles were sorted by number of times cited, and review articles or those unrelated to the meniscus were removed. Articles were classified as basic science or assigned the appropriate level of evidence. Extracted data included title, authors, journal, year of publication, country/institution of origin, total number of citations, and number of citations per year.

Results

The final list of 50 included articles with a range of 106 to 490 citations and a mean of 162.34 total or 11.91 citations per year. The most cited articles appeared in 8 of the most influential journals in the field per the Journal Citation Index. Twenty-nine (58%) originated from institutions within the United States, and only 13 (26%) were published in 2010 or later. Overall, 25 (50%) were classified as therapeutic, only 5 (10%) were therapeutic randomized controlled studies, and 17 (34%) were basic science. “Arthroscopic meniscal repair or meniscectomy” appeared most frequently, with 16 (32%) falling into this subclassification.

Conclusion

This study of the most cited meniscus articles showed a strong predominance for therapeutic studies, studies generated and published within the United States, and studies focused on topics of arthroscopic repair or removal. Overwhelmingly, included articles were published before 2010, affirming the criticism that bibliometric analysis favors older articles.

Clinical relevance

This study provides information about which articles are driving the field relating to meniscus injuries and meniscus surgery in the last two decades.

No decrease in incidence of arthroscopic meniscectomy in a Canadian province

PURPOSE

Arthroscopic meniscectomy (APM) is the most common procedure in orthopedic surgery, despite increasing evidence questioning its benefit over conservative management for treatment of degenerative meniscal tears. The purpose of this study is to determine the epidemiology and trends of APM in Saskatchewan, a Canadian province, over a 20 year period.

METHODS

Physician billing codes were used to identify patients who underwent APM in Saskatchewan between January 1, 1998 and December 31, 2017. Records were obtained from eHealth Saskatchewan, a provincial health database. Data was analyzed for overall incidence and age-specific trends of APM.

RESULTS

A total of 35,099 APMs were performed during the study period. The population of Saskatchewan ranged from 992,314 to 1,150,782 (median 1,017,368) during this time interval, with 81 orthopedic surgeons performing APM. Overall incidence rate of APM did not change significantly over time. No decrease was observed in patients presumed to have degenerative tears (≥ 50 years). The number of meniscectomies in patients ≥ 50 years was significantly greater during the second decade of study compared to the first (OR 1.48, p < 0.01). Conversely, the increase in incidence rate among older patients was not statistically significant (R² = 0.125, n.s.).

CONCLUSION

Overall incidence rate of APM in Saskatchewan has not decreased during the last 20 years. Furthermore, APM frequency increased over time for individuals ≥ 50 years. Several regional factors may have contributed to these findings, including the large proportion of Saskatchewan residents engaged in physically demanding work and barriers to accessing physiotherapy services. Given recent evidence disputing the benefit of APM over conservative measures, this study highlights the need for improved dissemination of evidence, as well as the importance of an individualized treatment plan to address patient-specific factors.

LEVEL OF EVIDENCE

Level IV.

Complex Meniscus Tears Treated with Collagen Matrix Wrapping and Bone Marrow Blood Injection: Clinical Effectiveness and Survivorship after a Minimum of 5 Years' Follow-Up

Purpose. To determine the 5-year success rate of the "all-inside" technique of arthroscopic meniscus suture and collagen membrane wrapping along with bone marrow blood injection, to evaluate the progression of degenerative changes and the impact of simultaneous anteriro cruciate ligament (ACL) reconstruction. Methods. Fifty-four consecutive patients with complex meniscal tears were treated with the previously described technique. The subjective scores (International Knee Documentation Committee 2000, Lysholm, EQ-5D-5L) and Barret clinical criteria of meniscal healing were recorded. Magnetic resonance images (MRIs) were assessed at 2 and 5 years postoperatively, using the Whole-Organ Magnetic Resonance Imaging Score (WORMS) criteria. Kaplan-Meier survival analyses were performed in order to assess the survivorship after the index procedure. Thirty-nine patients were divided into 2 groups: group A-isolated meniscus repair and group B-meniscus repair with concurrent ACL reconstruction. Results. Fifty-four patients were treated and 44 were available for analysis. There was a statistically significant improvement in subjective scores and clinical assessment between the preoperative, 2-year follow-up, and 5-year follow-up time points. EQ-5D-5L utility value was 0.9 ± 1 at final follow-up. The WORMS osteoarthritis severity grade had increased from 6.9 ± 5.0 points at the 2-year follow-up to 11.1 ± 9.6 points at the 5-year follow-up (P < 0.001). There was a significant difference between the groups after 60 months. The overall survival rate at final follow-up was 88%. Conclusions. The treatment option evaluated in this study has shown very good mid-term clinical and MRI-based outcomes as well as a favorable survival rate. Simultaneous ACL reconstruction is likely a factor for osteoarthritis progression.

Arthroscopic partial meniscectomy: did it ever work?

Arthroscopic partial meniscectomy (APM) is one the most common orthopedic surgical procedures. The most common indication for APM is a degenerative meniscal tear (DMT). High-quality evidence suggests that APM does not provide meaningful benefits in patients with DMTs and may even be harmful in the longer term. This narrative review focuses on a fundamental question: considering the history and large number of these surgeries, has APM ever actually worked in patients with DMT? A truly effective treatment needs a valid disease model that would biologically and plausibly explain the perceived treatment benefits. In the case of DMT, effectiveness requires a credible framework for the pain-generating process, which should be influenced by APM. Basic research, pathoanatomy, and clinical evidence gives no support to these frameworks. Moreover, treatment of DMT with an APM does not align with the traditional practice of medicine since DMT is not a reliable diagnosis for knee pain and no evidence-based indication exists that would influence patient prognosis from APM. A plausible and robust explanation supported by both basic research and clinical evidence is that DMTs are part of an osteoarthritic disease process and do not contribute to the symptoms independently or in isolation and that symptoms are not treatable with APM. This is further supported by the fact that APM as an intervention is paradoxical because the extent of procedure and severity of disease are both inversely associated with outcome. We argue that arthroscopic treatment of DMT is largely based on a logical fallacy: post hoc ergo propter hoc.

Radiographic Prognostic Factors Relevant to Surgical Outcomes of Arthroscopic Partial Medial Meniscectomy in Elderly Patients with Mild Osteoarthritis

The aim of this study was to investigate radiographic factors relevant to predict surgical outcomes of arthroscopic partial meniscectomy (APM) in elderly patients with mild osteoarthritis (Kellgren-Lawrence grades 1 and 2). Data of 172 consecutive patients aged >70 years who underwent arthroscopic meniscal surgery were reviewed retrospectively. The patients who met the inclusion criteria were classified into two groups based on the minimal clinically important difference value of the Lysholm knee scoring scale comparing the score of the last visit with that of the preoperative period: group 1 (with clinically significant improvement) and group 2 (without clinically important change). Radiographic factors assessed on X-ray and magnetic resonance images were evaluated using bivariate and logistic regression analyses. A total of 73 patients were included in this study. Bivariate analysis revealed that the extent of meniscus extrusion (p = 0.031), meniscus extrusion ratio (p = 0.001), and grade of meniscus degeneration (p = 0.019) were significantly different between the groups. Multivariate logistic regression analysis showed that the meniscus extrusion ratio was the most important independent predictive factor for surgical outcomes with clinically important changes (coefficient = 0.159, p = 0.009). On receiver operating characteristic (ROC) curve analysis, the cutoff point of the meniscus extrusion ratio discriminating the two groups was 34.2% (sensitivity: 79.3%; specificity: 68.6%; accuracy: 72.6%). Meniscus extrusion ratio was the most relevant predictive factor for discriminating patients with clinically important change. Meniscus extrusion ratio, with the cutoff point of 34.2%, could serve as a guide to determine whether to perform APM in elderly patients with mild osteoarthritis. This is a Level IV, therapeutic case series study.

A review of strategies for development of tissue engineered meniscal implants

The meniscus is a key stabilizing tissue of the knee that facilitates proper tracking and movement of the knee joint and absorbs stresses related to physical activity. This review article describes the biology, structure, and functions of the human knee meniscus, common tears and repair approaches, and current research and development approaches using modern methods to fabricate a scaffold or tissue engineered meniscal replacement. Meniscal tears are quite common, often resulting from sports or physical training, though injury can result without specific contact during normal physical activity such as bending or squatting. Meniscal injuries often require surgical intervention to repair, restore basic functionality and relieve pain, and severe damage may warrant reconstruction using allograft transplants or commercial implant devices. Ongoing research is attempting to develop alternative scaffold and tissue engineered devices using modern fabrication techniques including three-dimensional (3D) printing which can fabricate a patient-specific meniscus replacement. An ideal meniscal substitute should have mechanical properties that are close to that of natural human meniscus, and also be easily adapted for surgical procedures and fixation. A better understanding of the organization and structure of the meniscus as well as its potential points of failure will lead to improved design approaches to generate a suitable and functional replacement.

MRI findings of acute anterior instability of the knee in the absence of recent trauma

BACKGROUND

Anterior knee instability is usually encountered in the context of trauma, with the clinical examination and imaging focusing on anterior cruciate ligament (ACL) disruption. Limited data exist on magnetic resonance imaging (MRI) of acute anterior knee instability in the absence of recent trauma.

PURPOSE

To provide the first comprehensive account of MRI findings in acute anterior knee laxity in the absence of acute trauma and to evaluate predictors of ACL integrity and pain.

MATERIAL AND METHODS

A total of 84 consecutive patients with non-traumatic knee instability were prospectively studied. Instability was assessed with Lachman's, pivot shift, and Lelli's tests. MRI findings were recorded, and ACL integrity was surgically confirmed in all 24 cases of MRI suggesting tear and in 21/60 cases of MRI suggesting no tear. Binary logistic regression models were used to identify predictors of ACL tears and pain, and Mann-Whitney U test served for comparisons between continuous variables. The study was approved by the institutional review board.

RESULTS

Osteoarthritis and notch bony outgrowth (NBO) were present in 44% and 42.9% of all knees, respectively. NBO did not correlate with osteoarthritis (P = 0.606). NBO (odds ratio [OR] = 4.157; P = 0.016) and ACL grafts (OR = 9.277; P = 0.01) predisposed to non-traumatic ACL tears (torn in 28.6% of total cases). Presence of osteoarthritis was predictive of pain (OR = 17.671; P < 0.001).

CONCLUSION

We present a comprehensive analysis of MRI findings in clinically significant non-traumatic anterior instability, showing that NBO and ACL grafts predispose in non-traumatic ACL tears, whereas osteoarthritis is the only predictor of pain.

Image Enhancement Technology Based on Deep Trust Network Model in Clinical Treatment of Traumatology and Orthopedics

Fractures have brought great pain to patients, and treatment requires a lot of time and yield slow results, which seriously affect the production and life of people. Fractures are mostly treated with traditional conservative treatment methods. For orthopedic trauma, image enhancement technology has gradually played an important role in the clinical treatment of orthopedic trauma and has become a kind of suffering. It has become a new treatment method that attracts people's attention. In order to study the application of image enhancement technology based on the deep trust network model in the clinical treatment of trauma and orthopedics, this paper conducted a related survey of fracture patients in the city's first hospital, reviewed relevant literature, and interviewed professionals, and we collected relevant material, constructed case templates, and created clinical research models using comprehensive quantitative and qualitative analytical techniques. Studies have shown that the use of image enhancement techniques in the treatment of fractures has been successful, with healing efficiency approximately 20% faster than conservative treatment. In the clinical treatment of trauma and orthopedics, image enhancement technology can effectively reduce the incidence of complications in the prognosis of patients. Symptom Drop. This shows that the image enhancement technology of the deep trust network model can play an important role in the clinical treatment of trauma and orthopedics.

Meniscal repair: The current state and recent advances in augmentation

Meniscal injuries represent one of the most common orthopedic injuries. The most frequent treatment is partial resection of the meniscus, or meniscectomy, which can affect joint mechanics and health. For this reason, the field has shifted gradually towards suture repair, with the intent of preservation of the tissue. "Save the Meniscus" is now a prolific theme in the field; however, meniscal repair can be challenging and ineffective in many scenarios. The objectives of this review are to present the current state of surgical management of meniscal injuries and to explore current approaches being developed to enhance meniscal repair. Through a systematic literature review, we identified meniscal tear classifications and prevalence, approaches being used to improve meniscal repair, and biological- and material-based systems being developed to promote meniscal healing. We found that biologic augmentation typically aims to improve cellular incorporation to the wound site, vascularization in the inner zones, matrix deposition, and inflammatory relief. Furthermore, materials can be used, both with and without contained biologics, to further support matrix deposition and tear integration, and novel tissue adhesives may provide the mechanical integrity that the meniscus requires. Altogether, evaluation of these approaches in relevant in vitro and in vivo models provides new insights into the mechanisms needed to salvage meniscal tissue, and along with regulatory considerations, may justify translation to the clinic. With the need to restore long-term function to injured menisci, biologists, engineers, and clinicians are developing novel approaches to enhance the future of robust and consistent meniscal reparative techniques.

Injections in the osteoarthritic knee: a review of current treatment options

Knee osteoarthritis is a degenerative condition characterized by progressive cartilage degradation, subchondral damage, and bone remodelling. Among the approaches implemented to achieve symptomatic and functional improvements, injection treatments have gained increasing attention due to the possibility of intra-articular delivery with reduced side effects compared to systemic therapies.

In addition to well-established treatment options such as hyaluronic acid (HA), cortico-steroids (CS) and oxygen-ozone therapy, many other promising products have been employed in the last decades such as polydeoxyribonucleotide (PDRN) and biologic agents such as platelet-rich plasma (PRP) and mesenchymal stem cells (MSCs). Moreover, ultrasound-guided intra-meniscal injection and X-ray-guided subchondral injection techniques have been introduced into clinical practice.

Even when not supported by high evidence consensus, intra-articular CS and HA injections have gained precise indications for symptomatic relief and clinical improvement in OA. Biological products are strongly supported by in vitro evidence but there is still a lack of robust clinical evidence. PRP and MSCs seem to relieve OA symptoms through a regulation of the joint homeostasis, even if their capability to restore articular cartilage is still to be proved in vivo.

Due to increasing interest in the subchondral bone pathology, subchondral injections have been developed with promising results in delaying joint replacement. Nevertheless, due to their recent development and the heterogeneity of the injected products (biologic agents or calcium phosphate), this approach still lacks strong enough evidence to be fully endorsed.

Combined biological treatments, nano-molecular approaches, monoclonal antibodies and ‘personalized’ target therapies are currently under development or under investigation with the aim of expanding our armamentarium against knee OA.

Cite this article: EFORT Open Rev 2021;6:501-509. DOI: 10.1302/2058-5241.6.210026

Does practice of meniscus surgery change over time? A report of the 2021 'THE MENISCUS' Webinar

Purpose

The aim of this paper was to report the results presented in the session “Does practice of meniscus surgery change over time?” of the 2021 MENISCUS webinar held online on January 30^th 2021.

Method

During the 2021 MENISCUS webinar, an evaluation of meniscus surgery practices was performed by analyzing: (1) The presentation of the results of a survey conducted among ESSKA members and assessing their current practices in the field of meniscus surgery, (2) Four reports by national experts analyzing the trends in Arthroscopic Partial Meniscectomy (APM) and meniscus repair procedures in their respective countries (France, Belgium, Germany and Japan).

Results

(1) ESSKA Survey: Among the 461 respondents, 75% of surgeons claimed to perform more meniscus repairs and 85% less APM than 5 years ago. In ACL-associated meniscus injuries, a majority of surgeons (60%) indicated to perform a meniscal resection in less than 25% of cases. 25% declared to perform meniscus repair in ACL-associated meniscus injuries in less than 25% of cases and 37% in more than 50% of cases. Half of the respondents repair medial or lateral root tears in less than 25% of cases. Less than 20% of respondents were not familiar with the ESSKA consensus.

(2) National trends: In France, between 2005 and 2017, the APM rate decreased by 21.4%, while the repair rate increased by 320%. In Belgium, between 2007 and 2017, the APM rate decreased by 28.6%. In Germany, between 2010 and 2017 the number of APM decreased by 30%, while the number of repair procedures increased by 55%. Finally, in Japan, between 2011 and 2016, the APM ratio (APM/meniscus procedures) decreased by 16% from 91 to 75% while the repair ratio increased from 9 to 25%.

Conclusion

The 2021 ESSKA members' survey as well as statistics from 4 specifically examined countries (Belgium, France, Germany and Japan) suggest there has been a significant shift over the last years in the surgical management of meniscal lesions towards less APM and more conservative treatments.

Intrasubstance degeneration of medial meniscus horizontal cleavage tear in young patients is associated with increased joint line obliquity in the coronal plane of the knee

PURPOSE

To evaluate the effect of joint line obliquity of the knee on intrasubstance degeneration of isolated medial meniscus horizontal cleavage tear (HCT) in young patients.

METHODS

Sixty knees of 50 patients aged < 40 years (mean age, 33.3 ± 5.5 years old), who underwent arthroscopic partial meniscectomy (APM) for HCT, were retrospectively reviewed. The radiologic parameters of alignment, including mechanical hip-knee-ankle (mHKA) angle, posterior tibial slope, and joint line obliquity, were measured on preoperative long-standing whole-leg radiographs. The patients were classified into two groups, simple horizontal type (type 1) and complicated type (type 2), according to the presence of diffuse intrasubstance degeneration of the meniscus on preoperative magnetic resonance imaging. The risk factors for intrasubstance degeneration of HCT were analyzed using multiple logistic regression analysis. Medial joint space width (JSW) on weight-bearing 45° flexion posteroanterior radiographs and the mHKA were measured to evaluate the radiographic outcomes. The clinical outcomes were evaluated using the modified Lysholm score. Among patients followed-up for > 5 years, the clinical and radiologic outcomes were compared between the two groups.

RESULTS

The joint line obliquity was significantly greater in the type 2 group than in the type 1 group (2.9 ± 1.3 vs. 0.9 ± 1.4, P < 0.001), and a significant risk factor for diffuse intrasubstance degeneration (P < 0.001; odds ratio, 2.88; 95% confidence interval, 1.27-6.54). The relative changes in the JSW in the type 2 group were greater than those in the type 1 group during the mean follow-up period of 7.9 ± 2.5 years (26% vs 10%, P = 0.045). The modified Lysholm score was not significantly different between the two groups (n.s).

CONCLUSION

The diffuse intrasubstance degeneration of medial meniscus HCTs in young patients is associated with increased joint line obliquity of the knee joints. The radiologic outcomes after APM were inferior in the patients with diffuse intrasubstance degeneration. However, the clinical outcomes were not different during the mid-term follow-up.

LEVEL OF EVIDENCE

Level III.

Non-Surgical Treatment of Knee Osteoarthritis: Multidisciplinary Italian Consensus on Best Practice

The aim of this document is to provide a set of indications on the national best practice management of knee osteoarthritis based on an analysis of the existing literature and the contribution of experts in the field. During the first phase of the project, in agreement with the multidisciplinary panel of experts, the main guidelines on the topic were selected. Each guideline was assessed through the AGREEII system to identify their strong/weak points and a summary of the recommendations contained in the various documents was drawn up. The panel drew up a list of therapeutic options to be included in the document and some of these topics were selected for in-depth analysis and review. The search strategy for the required literature reviews was constructed using the PICOS approach. The results obtained from the literature reviews, the in-depth analyses conducted by the members of the scientific societies involved and the analysis of the existing guidelines enabled an initial draft of the consensus document to be elaborated. This document was examined at the consensus conference held on 28 May 2019, in the presence of a multidisciplinary group consisting of members of the various scientific societies involved. Single recommendations were discussed in work groups with a view to combining the indications given by the literature examined with the experience of the specialists involved. The recommendations discussed were then put to the vote in a plenary assembly. The final document contains 26 practice recommendations which leading specialists involved in the management of knee OA in Italy agree upon.

Editorial Commentary: Surgical Management of Degenerative Meniscus Lesions Is a Second- But Not a First-Line Treatment

The 20-year progression of osteoarthritis (OA) after arthroscopic partial meniscectomy (APM) in patients aged between 50 and 70 bears a long-term risk of conversion to total knee arthroplasty of 15.7%. Negative predictors at the time of surgery are the degree of knee OA, lateral meniscectomy, age at surgery, and malalignment. This confirms the evolution of the natural history of knee OA, but most importantly, it provides arguments to further restrain indications of APM in degenerative meniscus lesions (DMLs). An improved understanding of the consequences of APM for DMLs allows to increasingly limit the indications of this procedure, thus rendering it pertinent and efficient. Over the last years, the numbers of APM have been declining in several countries. This reduction required many surgeons to undergo a paradigm shift. This change cannot be induced by an anathema but by educational programs and guidelines based on broad consensus of the surgical communities, like the 2016 European Meniscus Consensus Project initiated by the European Society of Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA). It provided a reference frame for the management of DMLs, based both on scientific literature and balanced expert opinion. The proposed decisional algorithm introduced APM not as a first- but as a second-line treatment of DMLs in symptomatic patients. A recent survey presented earlier this month at the international conference "The Meniscus" among ESSKA members showed that a majority of the 460 respondents were familiar with the ESSKA consensus and that 66% of them changed their practice following its publication. Paradigm changes take time. The history of meniscus repair showed that it takes many years to develop medical and surgical practice. And there is a good reason for this. Paradigms are not fashionable that come and go with the seasons. The medical and orthopaedic communities need to get them right by improving clinical science and balancing discussions.

Editorial Commentary: Arthroscopic Partial Meniscectomy Is Not a First-Line Treatment for Degenerative Meniscus Tear: To Meniscectomize or Not to Meniscectomize?

A painful knee with a degenerative meniscal tear is a quite common problem in the middle-aged patient. Arthroscopic partial meniscectomy is too often used to alleviate pain and seems to work in the short-term. However, arthroscopic partial meniscectomy does not guarantee success, particularly in the long run, particularly in patients with greater grades of osteoarthritis, patients who are older than 60 years, female patients, patients with malalignment, and patients having lateral meniscectomy. There is a need for better science to recommend arthroscopic meniscectomy in those cases.

Outcomes at 20 Years After Meniscectomy in Patients Aged 50 to 70 Years

PURPOSE

To report the outcomes of arthroscopic meniscectomy (AM) at 20 years of follow-up through timing/rate of conversion to total knee replacement (TKR) and Knee Injury and Osteoarthritis Outcome Score (KOOS), focusing on detection of specific predictor variables for these outcomes, in patients 50 to 70 years old.

METHODS

We performed a retrospective study of 289 patients, ages at surgery 50 to 70 years, with diagnosis of degenerative meniscal tear who underwent arthroscopic meniscectomy. We collected the following baseline data: age, sex, injured meniscus (medial, lateral, or both), knee alignment, osteoarthritis (OA), associated lesion identified during arthroscopy, and associated procedure performed during arthroscopy. At 20 years of follow-up, we collected rate and timing of TKR conversion, and we evaluated clinical outcomes with KOOS.

RESULTS

Female sex (P < .01), older age (P < .01), lateral meniscectomy (P = .02), malalignment (P = .03), and advanced chondral lesion (P < .01) were found to be significantly related to subsequent TKR. No significant correlation was found between amount of resection and subsequent TKR (P = .26). Negative predictor factors to obtain equal or superior to age- and sex-adjusted KOOS scores were age 60 to 70 years at time of AM (P = .03) and lateral meniscectomy (P = .02).

CONCLUSIONS

We report a 15.7% conversion rate at 20 years from AM to TKR and a mean time between surgeries of 7 years. Subsequent TKR in the 20 years after AM for degenerative meniscus tears were significantly associated with preoperative OA and chondral lesion (Kellgren Lawrence 2; Outerbridge >2), lateral meniscectomy, age at surgery, female sex, and malalignment. Furthermore, age >60 years, lateral meniscectomy, and concurrent anterior cruciate ligament reconstruction were negative predictors for poor clinical outcomes at 20 years. Therefore, if patients present with negative predictor factors, the AM should not be proposed as second-line treatment, and nonoperative management should be continued until TKR is unavoidable.

LEVEL OF EVIDENCE

IV, case series.

Efficacy of Autologous Platelet-Rich Plasma Injections for Grade 3 Symptomatic Degenerative Meniscal Lesions: A 1-Year Follow-up Prospective Study

BACKGROUND

Platelet-rich plasma (PRP) injections have been proposed as a biologic option to provide symptomatic relief and delay surgery in patients with degenerative joint disease of osteoarthritis (OA). The efficacy of autologous PRP on symptomatic degenerative meniscal lesions (DMLs) has never been investigated.

HYPOTHESIS

We hypothesized that patients with symptomatic DMLs without OA undergoing autologous PRP injections experience a significant clinical improvement at 12 months.

STUDY DESIGN

Prospective case series.

LEVEL OF EVIDENCE

Level 4.

METHODS

A total of 69 patients with symptomatic DMLs without radiographic evidence of knee OA (Kellgren-Lawrence radiographic grading scale 0-1) received 4 autologous PRP injections once a week. Patients were prospectively evaluated before the injection and then at 1, 3, 6, and 12 months. Evaluation was based on Lysholm knee scoring scale (primary outcome), Western Ontario and McMaster Universities Arthritis Index (WOMAC), Tegner activity scale, and visual analogue scale scores.

RESULTS

Patients treated with PRP injections demonstrated an improving knee function and symptoms over the duration of the study. A significant improvement from baseline to 12 months was observed in all the outcome measures, and no patients experienced failure or required surgery during the follow-up. Patients younger than 50 years reported lower subjective level of pain and higher Tegner activity scale at baseline and had significantly better Lysholm knee scoring scale (P = 0.03) and WOMAC (P = 0.03) scores at 6 months, as well as better range of motion at 3, 6, and 12 months (P < 0.001). Thirty-three (47.8%) patients were very satisfied, 26 (37.7%) satisfied, 8 (11.6%) partially satisfied, and 2 (2.9 %) not satisfied, with 62 (89.8%) patients willing to repeat the same treatment. No patient was lost to follow-up and no patient experienced adverse reaction, infection, failure, recurrence or underwent further surgery.

CONCLUSION

PRP injections provide short-term benefits in symptomatic DMLs. Although promising results were evident at 12 months, this is a preliminary study and no definitive recommendation can be made based, for example, on longer follow-up.

CLINICAL RELEVANCE

This research supports the use of autologous PRP injections for symptomatic DMLs.

Development of a novel meniscal sheet scaffold and its effectiveness for meniscal regeneration in a rabbit defect model

This study evaluated the biomechanical strength of a novel two-layer meniscal sheet scaffold (MSS) consisting of polyglycolic acid and poly-Llactic acid/caprolactone and investigated meniscal healing using wrapping treatment for meniscal defect model in a rabbit. The ultimate failure load of the MSS was determined using a tensile testing machine, in vitro. A 2-mm cylindrical defects were created at the medial meniscus of rabbit knees (n = 40). Each knee was assigned to one of two groups. The defect group was not treated and the MSS group underwent wrapping treatment with MSS. Menisci were harvested at 2, 4, 8, and 12 weeks post-implantation. The regenerated meniscus and defect size were evaluated using macrophotographs. Ishida scores for regenerated tissue were determined using Safranin-O/Fast Green staining. Immunohistochemical analysis of Ki-67 for cell proliferation, anti-type I and II collagen antibodies for structure of the regenerated tissue was elucidated. Medial femoral cartilage was stained with Safranin-O/Fast Green and evaluated with Osteoarthritis Research Society International (OARSI) scores. The strength of MSS was maintained over 90% from initial time point to 4 weeks after hydrolysis and over 60% of the strength remained at 8 weeks. The surface area of the meniscus was larger and the defect size smaller in the MSS group than in the defect group at 8 and 12 weeks. Ishida scores revealed that the MSS group improved significantly compared to that of the defect group at all postsurgery time points evaluated. Ki-67 positive cell ratio was significantly higher in the MSS group. OARSI score of the defect group was significantly higher and the defect group showed progressive degeneration in the articular cartilage from 8 to 12 weeks. Overall, wrapping meniscus defects with MSS was useful for accelerating meniscal healing from an early stage and beneficial for tissue regeneration and promoting extracellular matrix maturation.

Outcomes at 20 years after meniscectomy in young patients

AIM

To define arthroscopic meniscectomy (AM) outcomes in young patients at 20 years follow up in terms of predictors of poor clinical results, rate and timing of conversion to total knee replacement (TKR).

METHODS

The following data were collected for 225 patients aged between 18 and 50 years with meniscal tear (MT) who underwent AM: age at surgery, gender, injured meniscus, knee alignment, associated lesions, amount of meniscal resection. At 20 years follow up, rate and timing of TKR conversion and clinical outcomes with Knee injury and Osteoarthritis Outcome Score (KOOS) score were reviewed.

RESULTS

Ten patients (4.4%) required TKR in the follow up period. The mean time from AM to TKR was 7.0 years (standard deviation 3.87). Age between 40 and 50 years at AM (P < 0.01), malalignment (P < 0.01), lateral meniscectomy (any size, P = 0.01), advanced chondral lesion (Outerbridge > 2, P < 0.01) and total meniscectomy (P < 0.01) were significantly related to subsequent TKR. Negative predicting factors to obtaining equal or superior to age/sex-adjusted KOOS score were age between 40 and 50 years old at time of AM (P < 0.01), female sex (P < 0.01), malalignment (P = 0.04), and advanced chondral lesion (Outerbridge > 2, P = 0.02).

CONCLUSIONS

Twenty years conversion rate to TKR after AM for MT is 4.4% and TKR was performed after a mean time of 7 years. Significant association between TKR surgery and advanced chondral lesion (Outerbridge > 2), total meniscectomy, lateral meniscectomy, age at surgery between 40 and 50 years old, and malalignment were found. Age between 40 and 50 years at time of AM, female, malalignment, advanced chondral lesion were all factors significantly related to poor clinical results.

Medial Meniscus Posterior Root Tear Does Not Affect the Outcome of Medial Open-Wedge High Tibial Osteotomy

BACKGROUND

This study aimed to verify whether the presence of medial meniscus posterior root tear (MMPRT) affects the clinical and radiographic outcomes of medial open-wedge high tibial osteotomy (MOWHTO) compared to the patients without MMPRT for over a midterm follow-up.

METHODS

One hundred fifty-six knees were retrospectively enrolled that underwent MOWHTO and second-look arthroscopy concomitantly with a minimum 5 years of follow-up. Seventy-four knees with MMPRT (MMPRT group) were identified. Eighty-two knees with intact MMPR were assigned to another group (MMPRI group). All knees with torn medial meniscus with or without MMPRT had an arthroscopic partial meniscectomy during the MOWHTO. Clinical evaluation included range of motion, American Knee Society scores, and Western Ontario and McMaster Universities Osteoarthritis Index scores. Radiologically, the Kellgren-Lawrence grade was assessed preoperatively and at the latest follow-up. Cartilage status was also compared through the 2-stage arthroscopy according to the International Cartilage Repair Society grading.

RESULTS

Average age at operation was 55.8 years (range 42-67), and the average follow-up period was 82.2 months (range 60-148). There were no significant differences in clinical outcomes between the groups. Postoperative changes in Kellgren-Lawrence grade and arthroscopic cartilage status showed no significant differences between the groups. Resected MMPR was remodeled in 41.9% (31/74) of the MMPRT group through the second-look arthroscopy.

CONCLUSION

MMPRT does not affect the clinical and radiologic outcomes of MOWHTO compared to those patients without MMPRT over a mid-term follow-up.

Synovial mesenchymal stem cells promote the meniscus repair in a novel pig meniscus injury model

Stem cell therapy has potential for the treatment of degenerative meniscus injuries; however, an optimal animal model has not been established. Basic and clinical research show that synovial mesenchymal stem cells (MSCs) promote meniscus repair. The purposes of this study were to create a novel meniscus injury model in microminipigs and to investigate the effectiveness of synovial MSCs on meniscus healing in this model. The posterior portion of the medial meniscus in microminipigs was punctuated 200 times with a 23G needle. Allogenic synovial MSC suspension was placed on the injury site for 10 min for transplantation. The meniscus was evaluated histologically and via sagittal magnetic resonance imaging (MRI), radial MRI reconstructed in three dimensional, and T2 mapping at 1 and 8 weeks. Proteoglycan content stained with safranin-o disappeared 1 week after treatment in both the MSC and control groups but increased at 8 weeks only in the MSC group. Histological scores at 8 weeks were significantly higher in the MSC group than in the control group (n = 6). At 8 weeks, the T2 values of the MSC group were significantly closer to those of a normal meniscus than were those of the control group. High signal intensity areas of the MRIs and positive areas stained with picrosirius red coincided with meniscal lesions. In conclusion, we created a novel meniscus injury model in microminipigs. Evaluation via histology, MRIs, and polarized microscopy showed that transplantation of synovial MSCs improved meniscus healing.

Degenerative meniscal lesions: Conservative versus surgical management

Degenerative meniscal lesions (DML) typically occur in middle-aged or elderly patients without any history of significant acute trauma. Its prevalence increases with age and are associated with knee osteoarthritis (OA). The most frequent orthopaedic treatment is arthroscopic partial meniscectomy (APM) to relieve pain and functional deficit associated with DML. Nevertheless, several randomised controlled clinical trials recommed against APM as the first-line treatment for managing knee pain in patients affected by DML and no radiographic knee OA that should be reserved for cases of failure after 3 month conservative therapy or earlier in patients with signficant knee mechanical symptoms.

Meniscal tears are more common than previously identified, however, less than a quarter of people with a tear undergo arthroscopy

PURPOSE

The management of meniscal tears is a widely researched and evolving field. Previous studies reporting the incidence of meniscal tears are outdated and not representative of current practice. The aim of this study was to report the current incidence of MRI confirmed meniscal tears in patients with a symptomatic knee and the current intervention rate in a large NHS trust.

METHODS

Radiology reports from 13,358 consecutive magnetic resonance imaging scans between 2015 and 2017, performed at a large UK hospital serving a population of 470,000, were assessed to identify patients with meniscal tears. The hospital database was interrogated to explore the subsequent treatment undertaken by the patient. A linear regression model was used to identify if any factors predicted subsequent arthroscopy.

RESULTS

1737 patients with isolated meniscal tears were identified in patients undergoing an MRI for knee pain, suggesting a rate of 222 MRI confirmed tears per 100,000 of the population aged 18 to 55 years old. 47% attended outpatient appointments and 22% underwent arthroscopy. Root tears [odds ratio (95% CI) 2.24 (1.0, 4.49); p = 0.049] and bucket handle tears were significantly associated with subsequent surgery, with no difference between the other types of tears. The presence of chondral changes did not significantly affect the rate of surgery [0.81 (0.60, 1.08); n.s].

CONCLUSION

Meniscal tears were found to be more common than previously described. However, less than half present to secondary care and only 22% undergo arthroscopy. These findings should inform future study design and recruitment strategies. In agreement with previous literature, bucket handle tears and root tears were significant predictors of subsequent surgery.

LEVEL OF EVIDENCE

III.

Successful treatment of degenerative medial meniscal tears in well-aligned knees with fibrin clot implantation

PURPOSE

The purpose of this study was to examine the results of meniscal repair performed for symptomatic degenerative medial meniscal tears.

METHODS

Twenty-four knees in 24 patients with symptomatic degenerative medial meniscal tears (mostly complex horizontal tears) who underwent isolated arthroscopic repair combined with autologous fibrin clot implantation were included in this study. The patients were followed up for a minimum of 2 years. The overall clinical outcome was evaluated using the Lysholm score, while the activity level was graded on the Tegner Activity Scale. The assessment of healing status at the repair site was based on clinical signs/symptoms and follow-up MRI examination results. In addition, the effects of the patient's clinical and radiological factors on healing of the repaired menisci were analyzed.

RESULTS

The mean age of the study subjects was 47.0 ± 8.1 years with a mean follow-up period of 39.3 ± 11.6 months. The Lysholm score significantly improved after surgery (P < 0.01). During the follow-up period, meniscal repairs were deemed to have failed in 6 of the 24 knees (25%). In the analysis of factors influencing meniscal healing, varus deformity (% of mechanical axis < 30%) was identified in all knees in the repair failure group, and the presence of varus deformity was shown to be a significant risk factor correlated with repair failure, while other factors did not significantly influence the healing status.

CONCLUSIONS

The short-term follow-up results showed that arthroscopic repair of degenerative medial meniscal tears combined with fibrin clot implantation attained clinical healing in 18 of 24 knees (75%) of patients, while 6 of the 24 knees (25%) of patients experienced clinical failure. The presence of varus deformity negatively affects the healing rate. In well-aligned knees, degenerative medial meniscal tears are successfully treated by isolated repair with fibrin clot implantation.

LEVEL OF EVIDENCE

IV.

Chondral lesions at the medial femoral condyle, meniscal degeneration, anterior cruciate ligament insufficiency, and lateral meniscal tears impair the middle-term results after arthroscopic partial meniscectomy

PURPOSE

The aim of the present study was to analyse which clinical, radiological and arthroscopic findings are able to predict the postoperative outcome after arthroscopic partial meniscectomy. Furthermore, the present study aimed to investigate the postoperative outcome after partial meniscectomy in patients with degenerative meniscal lesions.

METHODS

A total of 91 patients with a follow-up period of 34.7 ± 11.4 months after arthroscopic partial meniscectomy were included in this retrospective study. Clinical, radiological, and arthroscopic data were analysed at the time of follow-up. The multivariable linear regression analysis for postoperative outcome, based on the Western Ontario Meniscal Evaluation Tool (WOMET), included age, gender, body mass index, physical activity, presence of cartilage lesions, leg alignment, grade of radiographic osteoarthritis, location of meniscal lesions, meniscal extrusion, meniscal degeneration, presence of an anterior cruciate ligament tears as well as bone marrow lesions.

RESULTS

WOMET and WOMAC scores showed a significant improvement of 45.0 ± 48.1 points (CI 34.9-55.1; p ≤ 0.0001) and 75.1 ± 69.3 points (CI 60.6-89.6; p = 0.001) within the follow-up period. Multivariable linear regression analysis showed that poor preoperative WOMET scores (p = 0.001), presence of cartilage lesions at the medial femoral condylus (p = 0.001), meniscal degeneration (p = 0.008), the presence of an anterior cruciate ligament lesion (p = 0.005), and lateral meniscal tears (p = 0.039) were associated with worse postoperative outcomes. Patients with femoral bone marrow lesions had better outcome (p = 0.038).

CONCLUSION

Poor preoperative WOMET scores, presence of cartilage lesions at the medial femoral condylus, meniscal degeneration, concomitant anterior cruciate ligament lesions as well as lateral meniscal tears are correlated with worse postoperative outcomes after arthroscopic partial meniscectomy. Patients with femoral bone marrow lesions femoral are more likely to gain benefit from arthroscopic partial meniscectomy in the middle term. Despite justified recent restrictions in indication, arthroscopic partial meniscectomy seems to effectively reduce pain and alleviate symptoms in carefully selected patients with degenerative meniscal tears.

LEVEL OF EVIDENCE

III.

Arthroscopic anterior cruciate ligament reconstruction is a reliable option to treat knee instability in patients over 50 years old

PURPOSE

To evaluate return to sport and clinical outcomes with at least 2 years followup after arthroscopic reconstruction ACL in population over 50 years-old.

METHODS

eighty-one patients aged 50 years or older underwent isolated, primary ACL reconstruction with hamstring autograft between 2014 and 2016. In all patients, a period of conservative treatment had failed (minimum 6 months), and they complained of functional instability and/or limitation during daily activity. Patients were assessed preoperatively and at the latest follow-up with a physical examination, return to sports activity, the Lysholm score, the International Knee Documentation Committee scoring system, the Knee injury and Osteoarthritis Outcome Score, and the Tegner activity scale. Data regarding complications and revision surgeries were collected at 2-year follow-up.

RESULTS

At the last follow-up, significant improvement in outcome scores from pre- to postoperative assessments was found. The mean overall IKDC score increased from a preoperative mean of 54.4-82.9 (p < 0.001). Mean preoperative Lysholm score increased from a preoperative mean of 67.4-90.4 (p < 0.001). The mean overall KOOS score increased from a preoperative mean (p < 0.001). Median preoperative Tegner score was 5 (range 2-8) and median postoperative score was 5 (range 1-7). 86% of patients returned to the sport, 51% to their preinjury sports level. Tegner score, before accident, was the only positive influencing factor a return to pre-injury level of the sport.

CONCLUSION

Arthroscopic reconstruction ACL in patients over 50 years-old resulted in excellent functional outcomes, with most patients returning to sport and at the same level they had before the injury.

LEVEL OF EVIDENCE

Level IV.

Degenerative medial meniscus posterior root tear and non-root tear do not show differences in joint survival and clinical outcome after partial meniscectomy

PURPOSE

No comparative studies of outcomes between degenerative medial meniscus posterior root tear (MM PRT) and non-root tear (NRT) have been conducted. This study aimed to compare joint survival and clinical outcome between MM PRT and MM NRT after partial meniscectomy with proper control of confounding factors.

METHODS

One hundred and ten patients each in MM PRT and MM NRT groups who underwent arthroscopic partial meniscectomy were retrospectively evaluated through propensity score matching. Joint survival was assessed on the basis of surgical and radiographic failures. Clinical outcomes were assessed using the Lysholm score.

RESULTS

The confounding variables were well balanced between the groups, with standardized mean differences of < 0.2 after propensity score matching. Failures occurred in 30 (27.3%) and 35 patients (31.8%) in the MM PRT group and MM NRT group, respectively. The estimated mean survival times were 12.5 years (95% confidence interval [CI] 11.5-13.5) and 11.7 years (10.7-12.7), respectively. There were no significant differences in the overall survival rate and Lysholm score between the two groups (n.s.).

CONCLUSION

In middle-aged patients with degenerative MM PRT, joint survival and clinical outcome showed comparable results with those with MM NRT after partial meniscectomy. Arthroscopic partial meniscectomy is one of the effective treatments for MM PRT with consideration of various patient factors.

LEVEL OF EVIDENCE

III.