Meniscus--friend or foe: epidemiologic observations and surgical implications

Effect of arthroscopic partial meniscectomy on structural degeneration of the knee - A 5-year MRI-based follow-up of the placebo-surgery controlled FIDELITY (Finnish Degenerative Meniscus Lesion Study) trial

OBJECTIVE

To assess the 5-year effects of arthroscopic partial meniscectomy (APM) vs. placebo-surgery on the development of the structural changes of the knee by MRI.

DESIGN

This multicentre, randomized, participant- and outcome-assessor-blinded, placebo-surgery-controlled trial was carried out in Finland. We randomized 146 adults, mean age 52 years (range 35 to 65) to undergo either APM or placebo surgery. The subjects had symptoms of degenerative medial meniscus tear, a tear verified in MRI and arthroscopy, and no advanced osteoarthritis at baseline. We compared the baseline and 5-year follow-up MRIs using MRI Osteoarthritis Knee Score (MOAKS) scoring to derive subregional data on cartilage damage, osteophytes and bone marrow lesions (BMLs). Progression of structural cartilage changes analysed per subregion was the main outcome, that of osteophytes and BMLs secondary outcomes. We analysed the progression with multilevel logistic regression model on subregion level data, adjusted for randomization stratification factors, and using robust standard errors.

RESULTS

Sixty-three (90%) subjects in the APM and 73 (96%) in the placebo-surgery group had MRI at both time points. The adjusted odds ratio (APM vs. placebo-surgery) was 1.31 (95% confidence interval 0.81, 1.94) for progression of cartilage damage, 2.86 (1.16, 6.21) for osteophytes, and 1.43 (0.84, 2.43) for BMLs.

CONCLUSIONS

We found a slightly greater risk for progression of osteophytes in the APM group compared to the placebo-surgery group at 5 years after surgery.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT01052233 and NCT00549172).

Compositional Variation and Functional Mechanism of Exosomes in the Articular Microenvironment in Knee Osteoarthritis

Osteoarthritis (OA) is a major cause of disability worldwide with increasing age. Knee OA (KOA) is the most prevalent type of OA. Recently, it is considered that KOA is a whole joint disease, including articular cartilage, subchondral bone, synovium, ligaments, joint capsules, and muscles around the joint. Exosomes in knee joint are mainly secreted by articular chondrocytes and synoviocytes. They participate in cell and tissue cross-talk by carrying a complex cargo of proteins, lipids, nucleic acids, etc. Under normal conditions, exosomes maintain the microenvironmental homeostasis of the joint cavity. Under pathological conditions, the composition and function of exosomes changes, which in turn, disrupts the balance of anabolism and catabolism of articular chondrocyte and facilitates inflammatory responses, thus accelerating KOA progression. As a regenerative medicine, mesenchymal stem cells (MSCs) are promised to facilitate repair of degenerated cartilage and decelerate OA process. The therapeutic function of MSC mainly depends on MSC-derived exosomes, which can restore the homeostasis of the articular microenvironment. In the future, the specific mechanism of exosomes for OA treatment needs further elucidation, and the treatment effect of exosomes for long-term and/or severe OA needs further exploration.

Assessment of changes in the meniscus and subchondral bone in a novel closed-joint impact and surgical reconstruction lapine model

Despite reconstruction surgery to repair a torn anterior cruciate ligament (ACL), patients often still show signs of post-traumatic osteoarthritis (PTOA) years following the procedure. The goal of this study was to document changes in the meniscus and subchondral bone due to closed-joint impact and surgical reconstruction in a lapine model. Animals received insult to the joint followed by surgical reconstruction of the ACL and partial meniscectomy. Following euthanasia of the animals at 1, 3, and 6-months post-impact, meniscal tissue was assessed for changes in morphology, mechanical properties and proteoglycan content. Femurs and tibias were scanned via micro-computed tomography to determine changes in bone quality, morphometry, and formation of osteophytes. Both the lateral and medial menisci showed severe degradation and tearing at all-time points, with higher degree of degeneration being observed at 6-months. Decreases in both the instantaneous and equilibrium modulus were documented in both menisci. Minimal changes were found in bone quality and morphometry, with most change documented in the tibia. Bones from the reconstructed limbs showed large volumes of osteophyte formations, with an increase in volume over time. The initial changes that were representative of PTOA may have been limited to the meniscus, but at later time points consistent changes due to the disease were seen in both tissues. This study, which builds on a previous study by this laboratory, suggests that the addition of surgical reconstruction of the ACL to our model was not sufficient to prevent the development of PTOA.

Meniscal Regenerative Scaffolds Based on Biopolymers and Polymers: Recent Status and Applications

Knee menisci are structurally complex components that preserve appropriate biomechanics of the knee. Meniscal tissue is susceptible to injury and cannot heal spontaneously from most pathologies, especially considering the limited regenerative capacity of the inner avascular region. Conventional clinical treatments span from conservative therapy to meniscus implantation, all with limitations. There have been advances in meniscal tissue engineering and regenerative medicine in terms of potential combinations of polymeric biomaterials, endogenous cells and stimuli, resulting in innovative strategies. Recently, polymeric scaffolds have provided researchers with a powerful instrument to rationally support the requirements for meniscal tissue regeneration, ranging from an ideal architecture to biocompatibility and bioactivity. However, multiple challenges involving the anisotropic structure, sophisticated regenerative process, and challenging healing environment of the meniscus still create barriers to clinical application. Advances in scaffold manufacturing technology, temporal regulation of molecular signaling and investigation of host immunoresponses to scaffolds in tissue engineering provide alternative strategies, and studies have shed light on this field. Accordingly, this review aims to summarize the current polymers used to fabricate meniscal scaffolds and their applications in vivo and in vitro to evaluate their potential utility in meniscal tissue engineering. Recent progress on combinations of two or more types of polymers is described, with a focus on advanced strategies associated with technologies and immune compatibility and tunability. Finally, we discuss the current challenges and future prospects for regenerating injured meniscal tissues.

A single dose of P188 prevents cell death in meniscal explants following impact injury

OBJECTIVE

To determine the efficacy of single and multiple administrations of Poloxamer 188 (P188) in saving meniscal cells following an injurious impact.

METHODS

Meniscal explants were harvested from both the lateral and medial menisci of Flemish Giant rabbits. After a 24-h incubation period, explants were subjected to 50% impact strain to simulate traumatic joint injury, and the explants were then placed in media with or without supplemented P188. Temporal administrations of P188 over a 14-day period were given based on one of 6 different treatments regimes. Over the 14-day period, explants were cyclically loaded to 10% strain at 1 Hz for 1 h per day, five days a week. Cell viability was assessed on day 14, with the remainder of the tissue being fixed to determine cell apoptosis levels and proteoglycan changes via histology.

RESULTS

The injurious impact proved to produce significant levels of cell death in meniscal explants. The ability of P188 to prevent cell death was not affected by the number of P188 doses (single versus multiple). P188 treatment proved to maintain cell viability levels comparable to those from unimpacted explants. There were no significant changes in cell apoptosis or proteoglycan coverage in the tissues over a 14-day period for any group, all treatment groups were statistically similar to the unimpacted explants.

CONCLUSION

A single dose of P188 following impact is all that is necessary to inhibit cell death in the meniscus following a traumatic impact. Thus, orthopaedic surgeons may choose to administer P188 in addition to treating any other acute damage due to a traumatic load to the knee, such as anterior cruciate ligament rupture, although more in depth in vivo studies are necessary.

Risk of opportunistic infections in patients with rheumatoid arthritis initiating abatacept: cumulative clinical trial data

BACKGROUND

To evaluate incidence of opportunistic infections (OIs) in patients with rheumatoid arthritis (RA) treated with abatacept in clinical trials.

METHODS

This pooled analysis of 16 randomized, double-blind/open-label trials, with ≥ 1 abatacept (intravenous or subcutaneous) arm, and with/without placebo control covered cumulative (controlled short-term and open-label long-term) abatacept exposure periods. OIs were analyzed separately in controlled (abatacept and placebo individually) and cumulative periods. OIs were identified using a prespecified list; events were independently adjudicated. Unadjusted incidence rates (IRs; per 100 patient-years) with 95% confidence intervals (CIs) were calculated.

RESULTS

In cumulative periods, 7044 patients received abatacept, with a mean (standard deviation) duration of exposure of 36.9 (26.2) months (21,274 patient-years of exposure). IRs (95% CIs) of OIs were 0.17 (0.05-0.43) for abatacept and 0.56 (0.22-1.15) for placebo during the controlled periods and 0.21 (0.15-0.28) for abatacept during the cumulative periods. There was 1 case of tuberculosis in both the abatacept (IR [95% CI] 0.04 [0.00-0.24]) and placebo (IR [95% CI] 0.08 [0.00-0.44]) groups during the controlled periods; 13 verified tuberculosis cases (IR [95% CI] 0.06 [0.03-0.10]) were reported in the cumulative period. Herpes zoster was reported numerically more often with abatacept (IR 1.9 [1.4-2.5]), versus placebo (1.7 [1.1-2.6]) in the controlled periods; within the cumulative period, herpes zoster IR (95% CI) was 1.53 (1.36-1.71) for abatacept-treated patients.

CONCLUSION

In controlled periods of the clinical trials, abatacept-treated patients had similarly low rates of OIs compared with placebo-treated patients. Overall, OI rates were similar among abatacept-treated patients in the controlled and cumulative periods and consistent with the ranges reported in the literature.

Arthroscopic partial meniscectomy for a degenerative meniscus tear: a 5 year follow-up of the placebo-surgery controlled FIDELITY (Finnish Degenerative Meniscus Lesion Study) trial

Objectives

To assess the long-term effects of arthroscopic partial meniscectomy (APM) on the development of radiographic knee osteoarthritis, and on knee symptoms and function, at 5 years follow-up.

Design

Multicentre, randomised, participant- and outcome assessor-blinded, placebo-surgery controlled trial.

Setting

Orthopaedic departments in five public hospitals in Finland.

Participants

146 adults, mean age 52 years (range 35–65 years), with knee symptoms consistent with degenerative medial meniscus tear verified by MRI scan and arthroscopically, and no clinical signs of knee osteoarthritis were randomised.

Interventions

APM or placebo surgery (diagnostic knee arthroscopy).

Main outcome measures

We used two indices of radiographic knee osteoarthritis (increase in Kellgren and Lawrence grade ≥1, and increase in Osteoarthritis Research Society International (OARSI) atlas radiographic joint space narrowing and osteophyte sum score, respectively), and three validated patient-relevant measures of knee symptoms and function (Western Ontario Meniscal Evaluation Tool (WOMET), Lysholm, and knee pain after exercise using a numerical rating scale).

Results

There was a consistent, slightly greater risk for progression of radiographic knee osteoarthritis in the APM group as compared with the placebo surgery group (adjusted absolute risk difference in increase in Kellgren-Lawrence grade ≥1 of 13%, 95% CI −2% to 28%; adjusted absolute mean difference in OARSI sum score 0.7, 95% CI 0.1 to 1.3). There were no relevant between-group differences in the three patient-reported outcomes: adjusted absolute mean differences (APM vs placebo surgery), −1.7 (95% CI −7.7 to 4.3) in WOMET, −2.1 (95% CI −6.8 to 2.6) in Lysholm knee score, and −0.04 (95% CI −0.81 to 0.72) in knee pain after exercise, respectively. The corresponding adjusted absolute risk difference in the presence of mechanical symptoms was 18% (95% CI 5% to 31%); there were more symptoms reported in the APM group. All other secondary outcomes comparisons were similar.

Conclusions

APM was associated with a slightly increased risk of developing radiographic knee osteoarthritis and no concomitant benefit in patient-relevant outcomes, at 5 years after surgery.

Trial registration

ClinicalTrials.gov (NCT01052233 and NCT00549172).

Comparison of Arthroscopic Partial Meniscectomy to Physical Therapy following Degenerative Meniscus Tears: A Systematic Review and Meta-analysis

Objective

To compare the effectiveness of arthroscopic partial meniscectomy (APM) and physical therapy (PT) for degenerative meniscus tears.

Method

We conducted a literature search through PubMed, Embase, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov. Randomized controlled trials in adults with degenerative meniscal tears without symptoms of locking were considered for inclusion. Two researchers independently performed the literature search, assessed the risk of bias, and selected eligible studies. The primary outcome was function at different follow-up time points and the secondary outcome was pain at different follow-up time points.

Results

We included 6 randomized controlled trials, with a total of 1006 participants, among which 495 were in the APM group and 511 were in the PT group. We found a small benefit in functional outcomes in the APM group until the 12 months follow-up time point (SMD = 0.20; 95%CI = 0.0-0.33; p = 0.002; I ² = 34%), but no significant differences in function between groups at the 24-month follow-up time point (SMD = 0.12; 95%CI = -0.04 - 0.28; p = 0.002; I ² = 34%), but no significant differences in function between groups at the 24-month follow-up time point (SMD = 0.12; 95%CI = -0.04 - 0.28; p = 0.002; I ² = 34%), but no significant differences in function between groups at the 24-month follow-up time point (SMD = 0.12; 95%CI = -0.04 - 0.28; p = 0.002; I ² = 34%), but no significant differences in function between groups at the 24-month follow-up time point (SMD = 0.12; 95%CI = -0.04 - 0.28.

Conclusion

In the treatment of degenerative meniscus tears, APM yielded better functional and pain outcomes compared with physical therapy in the short term until 12 months, but there were comparable results for pain and functional outcomes between the groups at the 24 months follow-up time point.

Statistical analysis plan for the 5-year and 10-year follow-up assessments of the FIDELITY trial

Background

The research objectives of the 5-year and 10-year assessments in the Finnish degenerative meniscal lesion study (FIDELITY) are twofold: (1) to assess the long-term efficacy of arthroscopic partial meniscectomy (APM) in adults (age 35 to 65 years) with a degenerative meniscus tear and (2) to determine the respective effects of APM and degenerative meniscus tear on the development of radiographic and clinical knee osteoarthritis (OA).

Methods and design

FIDELITY is an ongoing multi-center, randomized, participant and outcome assessor blinded, placebo-surgery-controlled trial in 146 patients. This statistical analysis plan (SAP) article describes the overall principles for analysis of long-term outcomes (5-year and 10-year follow up), including how participants will be included in each analysis, the primary and secondary outcomes and their respective analyses, adjustments for covariates, and the presentation of the results. In addition, we will present the planned sensitivity and subgroup analyses.

Discussion

To assess the long-term efficacy of APM on knee symptoms and function we are carrying out a long-term (5-year and 10-year) follow up of our placebo-surgery-controlled FIDELITY trial according to statistical principles outlined in detail in this document. As our second primary objective, whether APM (resection of torn meniscus tear) accelerates or delays the development of knee osteoarthritis in patients with an arthroscopically verified degenerative tear of the medial meniscus, a pre-registered follow-up is also carried out.

Trial registration

ClinicalTrials.gov, NCT00549172 (Arthroscopy in the Treatment of Degenerative Medial Meniscus Tear). Registered on 25 October 2007 (NCT00549172). ClinicalTrials.gov, NCT01052233 (Development of Knee Osteoarthritis After Arthroscopic Partial Resection of Degenerative Meniscus Tear). Registered on 20 January 2010.

Rates of knee arthroplasty within one-year of undergoing arthroscopic partial meniscectomy in England: temporal trends, regional and age-group variation in conversion rates

OBJECTIVE

The aim of this study was to determine the proportion of patients undergoing arthroscopic partial meniscectomy (APM) then subsequently receiving a knee arthroplasty within one or two years, with focus on patients over the age of 60 years and regional variation.

METHODS

Patients undergoing APM in England over 20-years (01-April-1997 to 31-March 2017) were identified in the national Hospital Episode Statistics (HES). The proportion of patients undergoing arthroplasty in the same knee within one or two years of APM was determined and trends were analysed over time nationally and by NHS Clinical Commissioning Group (CCG) region.

RESULTS

806,195 APM patients were eligible for analysis with at least one-year of follow up and 746,630 with two-years. The odds of arthroplasty conversion within one year increased over the study period (odds ratio [OR] 3.10 within 1-year in 2014 vs 2000; 95% confidence interval [CI] 2.75-3.50). For patients undergoing APM aged 60 years or older in 2015-16, 9.9% (1689/17,043; 95% CI 9.5-10.4) underwent arthroplasty within 1-year and, in 2014-15, 16.6% (3100/18,734; 95% CI 16.0-17.1) underwent arthroplasty within 2-years. There was greater than 10-fold variation by CCG.

CONCLUSIONS

Over the study period, the proportion of patients undergoing arthroplasty within one-year of APM increased. In 2015-16, of patients aged 60 years or older who underwent APM, 10% subsequently underwent knee arthroplasty within one year (17% within two years in 2014-15) and there was a high level of regional variation in this outcome. The development and adoption of national treatment guidance is recommended to improve and standardise treatment selection.

T2 mapping of the meniscus is a biomarker for early osteoarthritis

Purpose

To evaluate in vivo T₂ mapping as quantitative, imaging-based biomarker for meniscal degeneration in humans, by studying the correlation between T₂ relaxation time and degree of histological degeneration as reference standard.

Methods

In this prospective validation study, 13 menisci from seven patients with radiographic knee osteoarthritis (median age 67 years, three males) were included. Menisci were obtained during total knee replacement surgery. All patients underwent pre-operative magnetic resonance imaging using a 3-T MR scanner which included a T₂ mapping pulse sequence with multiple echoes. Histological analysis of the collected menisci was performed using the Pauli score, involving surface integrity, cellularity, matrix organization, and staining intensity. Mean T₂ relaxation times were calculated in meniscal regions of interest corresponding with the areas scored histologically, using a multi-slice multi-echo postprocessing algorithm. Correlation between T₂ mapping and histology was assessed using a generalized least squares model fit by maximum likelihood.

Results

The mean T₂ relaxation time was 22.4 ± 2.7 ms (range 18.5–27). The median histological score was 10, IQR 7–11 (range 4–13). A strong correlation between T₂ relaxation time and histological score was found (r_s = 0.84, CI 95% 0.64–0.93).

Conclusion

In vivo T₂ mapping of the human meniscus correlates strongly with histological degeneration, suggesting that T₂ mapping enables the detection and quantification of early compositional changes of the meniscus in knee OA.

Key Points

• Prospective histology-based study showed that in vivo T₂mapping of the human meniscus correlates strongly with histological degeneration.

• Meniscal T₂mapping allows detection and quantifying of compositional changes, without need for contrast or special MRI hardware.

• Meniscal T₂mapping provides a biomarker for early OA, potentially allowing early treatment strategies and prevention of OA progression.

Electronic supplementary material

The online version of this article (10.1007/s00330-019-06091-1) contains supplementary material, which is available to authorized users.

Arthroscopic partial meniscectomy for meniscal tears of the knee: a systematic review and meta-analysis

OBJECTIVE

To assess the benefit of arthroscopic partial meniscectomy (APM) in adults with a meniscal tear and knee pain in three defined populations (taking account of the comparison intervention): (A) all patients (any type of meniscal tear with or without radiographic osteoarthritis); (B) patients with any type of meniscal tear in a non-osteoarthritic knee; and (C) patients with an unstable meniscal tear in a non-osteoarthritic knee.

DESIGN

Systematic review and meta-analysis.

DATASOURCES

A search of MEDLINE, Embase, CENTRAL, Scopus, Web of Science, Clinicaltrials.gov and ISRCTN was performed, unlimited by language or publication date (inception to 18 October 2018).

ELIGIBILITYCRITERIA

Randomised controlled trials performed in adults with meniscal tears, comparing APM versus (1) non-surgical intervention; (2) pharmacological intervention; (3) surgical intervention; and (4) no intervention.

RESULTS

Ten trials were identified: seven compared with non-surgery, one pharmacological and two surgical. Findings were limited by small sample size, small number of trials and cross-over of participants to APM from comparator interventions. In group A (all patients) receiving APM versus non-surgical intervention (physiotherapy), at 6-12 months, there was a small mean improvement in knee pain (standardised mean difference [SMD] 0.22 [95% CI 0.03 to 0.40]; five trials, 943 patients; I² 48%; Grading of Recommendations Assessment, Development and Evaluation [GRADE]: low), knee-specific quality of life (SMD 0.43 [95% CI 0.10 to 0.75]; three trials, 350 patients; I² 56%; GRADE: low) and knee function (SMD 0.18 [95% CI 0.04 to 0.33]; six trials, 1050 patients; I² 27%; GRADE: low). When the analysis was restricted to people without osteoarthritis (group B), there was a small to moderate improvement in knee pain (SMD 0.35 [95% CI 0.04 to 0.66]; three trials, 402 patients; I² 58%; GRADE: very low), knee-specific quality of life (SMD 0.59 [95% CI 0.11 to 1.07]; two trials, 244 patients; I² 71%; GRADE: low) and knee function (SMD 0.30 [95% CI 0.06 to 0.53]; four trials, 507 patients; I² 44%; GRADE: very low). There was no improvement in knee pain, function or quality of life in patients receiving APM compared with placebo surgery at 6-12 months in group A or B (pain: SMD 0.08 [95% CI -0.24 to 0.41]; one trial, 146 patients; GRADE: low; function: SMD -0.08 [95% CI -0.41 to 0.24]; one trial, 146 patients; GRADE: high; quality of life: SMD 0.05 [95% CI -0.27 to 0.38]; one trial; 146 patients; GRADE: high). No trials were identified for people in group C.

CONCLUSION

Performing APM in all patients with knee pain and a meniscal tear is not appropriate, and surgical treatment should not be considered the first-line intervention. There may, however, be a small-to-moderate benefit from APM compared with physiotherapy for patients without osteoarthritis. No trial has been limited to patients failing non-operative treatment or patients with an unstable meniscal tear in a non-arthritic joint; research is needed to establish the value of APM in this population.

PROTOCOL REGISTRATION NUMBER

PROSPERO CRD42017056844.

The TeMPO trial (treatment of meniscal tears in osteoarthritis): rationale and design features for a four arm randomized controlled clinical trial

BACKGROUND

Meniscal tears often accompany knee osteoarthritis, a disabling condition affecting 14 million individuals in the United States. While several randomized controlled trials have compared physical therapy to surgery for individuals with knee pain, meniscal tear, and osteoarthritic changes (determined via radiographs or magnetic resonance imaging), no trial has evaluated the efficacy of physical therapy alone in these subjects.

METHODS

The Treatment of Meniscal Tear in Osteoarthritis (TeMPO) Trial is a four-arm multi-center randomized controlled clinical trial designed to establish the comparative efficacy of two in-clinic physical therapy interventions (one focused on strengthening and one containing placebo) and two protocolized home exercise programs.

DISCUSSION

The goal of this paper is to present the rationale behind TeMPO and describe the study design and implementation strategies, focusing on methodologic and clinical challenges.

TRIAL REGISTRATION

The TeMPO Trial was first registered at clinicaltrials.gov with registration No. NCT03059004 . on February 14, 2017.

Temporal trends and regional variation in the rate of arthroscopic knee surgery in England: analysis of over 1.7 million procedures between 1997 and 2017. Has practice changed in response to new evidence?

OBJECTIVES

We investigated trends and regional variation in the rate of arthroscopic knee surgery performed in England from 1997-1998 to 2016-2017.

DESIGN

Cross-sectional study of the national hospital episode statistics (HES) for England.

METHODS

All hospital episodes for patients undergoing a knee arthroscopy between 1 April 1997 and 31 March 2017 were extracted from HES by procedure code. Age and sex-standardised rates of surgery were calculated using Office for National Statistic population data as the denominator. Trends in the rate of surgery were analysed by procedure both nationally and by Clinical Commissioning Group (CCG).

RESULTS

A total of 1 088 872 arthroscopic partial meniscectomies (APMs), 326 600 diagnostic arthroscopies, 308 618 knee washouts and 252 885 chondroplasties were identified (1 759 467 hospital admissions; 1 447 142 patients). The rate of APM increased from a low of 51/100 000 population (95% CI 51 to 52) in 1997-1998 to a peak at 149/100 000 (95% CI 148 to 150) in 2013-2014; then, after 2014-2015, rates declined to 120/100 000 (95% CI 119 to 121) in 2016-2017. Rates of arthroscopic knee washout and diagnostic arthroscopy declined steadily from 50/100 000 (95% CI 49 to 50) and 47/100 000 (95% CI 46 to 47) respectively in 1997-1998, to 4.8/100 000 (95% CI 4.6 to 5.0) and 8.1/100 000 (95% CI 7.9 to 8.3) in 2016-2017. Rates of chondroplasty have increased from a low of 3.2/100 000 (95% CI 3.0 to 3.3) in 1997-1998 to 51/100 000 (95% CI 50.6 to 51.7) in 2016-2017. Substantial regional and age-group variation in practice was detected. In 2016-2017, between 11% (22/207) and 16% (34/207) of CCGs performed at least double the national average rate of each procedure.

CONCLUSIONS

Over the last 20 years, and likely in response to new evidence, rates of arthroscopic knee washout and diagnostic arthroscopy have declined by up to 90%. APM rates increased about 130% overall but have declined recently. Rates of chondroplasty increased about 15-fold. There is significant variation in practice, but the appropriate population intervention rate for these procedures remains unknown.

National consensus on the definition, investigation, and classification of meniscal lesions of the knee

BACKGROUND

The aim of this study was to deliver standardised terminology for the identification and stratification of patients with meniscal lesions of the knee.

METHODS

A national group of expert surgeons was convened by the British Association for Surgery of the Knee (BASK) and a formal consensus process was undertaken following a validated methodology. A combination of nominal group techniques and an iterative Delphi process was used to develop and refine relevant definitions. Where appropriate, definitions were placed into categories to facilitate use in clinical practice and guideline development.

RESULTS

A degenerative meniscus develops progressively with degradation of meniscal tissue and this may be revealed by intra-meniscal high signal on magnetic resonance imaging (MRI). A meniscal tear was defined as a defect or split in the meniscocapsular complex, which can occur in a degenerative or non-degenerative meniscus. Degenerative meniscal lesions (high signal or tear) are frequent in the general population and are often incidental findings on knee MRI. Symptoms were defined and classified into three groups: (1) strongly suggestive of a treatable meniscal lesion, (2) potentially suggestive of a treatable meniscal lesion, (3) osteoarthritic. A strategy for radiological imaging (radiograph ± MRI) was agreed for the investigation of the patients with a possible meniscal tear. Meniscal lesions and tear patterns on MRI imaging were defined and classified with reference to potential treatability: (1) target, (2) possible target, (3) no target.

CONCLUSIONS

The agreed terminology will enable patients with meniscal lesions to be identified and stratified consistently in clinical practice, research and guideline development.

Meniscal extrusion and degeneration during the course of osteoarthritis in the Murine collagenase-induced osteoarthritis model

Meniscal damage is, despite its major role in knee osteoarthritis (OA), often neglected in OA animal models. We evaluated structural meniscal degeneration during the course of OA in the murine collagenase-induced OA (CIOA) model. To investigate this, OA was induced in the knee joints of 33 male C57BL/6 mice by an intra-articular injection of 10U collagenase. The mice were sacrificed after 1, 3, 7, 14, 28, and 56 days, and the knees were harvested and processed for histological analysis. As control, six knees were obtained from 16-week-old mice in which no OA was induced. Meniscal damage, meniscal extrusion, and articular cartilage damage were evaluated on thionin-stained sections. Associations between parameters of interest were evaluated with Spearman rho correlation tests. When compared to non-OA knees, meniscal extrusion was visible from day 1 onwards and meniscal degeneration had a tendency to increase over time. The meniscus damage appeared around the same time as articular cartilage damage (day 14-28) and was statistically significantly more pronounced anterior than posterior, and no differences were seen between medial and lateral menisci. Meniscus and articular cartilage damage were moderately associated in the CIOA knees (ρ = 0.57; 95%CI [0.23-0.78]). Our findings suggest that the CIOA model is a valuable model to study the role of meniscal damage during OA progression and can support the development of future preventative treatment strategies. © 2018 The Authors. Journal of Orthopaedic Research® Published by Wiley Periodicals, Inc. on behalf of the Orthopaedic Research Society. J Orthop Res 36:2416-2420, 2018.

Dynamic compression of human and ovine meniscal tissue compared with a potential thermoplastic elastomer hydrogel replacement

Understanding how human meniscal tissue responds to loading regimes mimetic of daily life as well as how it compares to larger animal models is critical in the development of a functionally accurate synthetic surrogate. Seven human and eight ovine cadaveric meniscal specimens were regionally sectioned into cylinders 5 mm in diameter and 3 mm thick along with 10 polystyrene-b-polyethylene oxide block copolymer-based thermoplastic elastomer (TPE) hydrogels. Samples were compressed to 12% strain at 1 Hz for 5000 cycles, unloaded for 24 h, and then retested. No differences were found within each group between test one and test two. Human and ovine tissue exhibited no regional dependency (p < 0.05). Human samples relaxed quicker than ovine tissue or the TPE hydrogel with modulus values at cycle 50 not significantly different from cycle 5000. Ovine menisci were found to be similar to human menisci in relaxation profile but had significantly higher modulus values (3.44 MPa instantaneous and 0.61 MPa after 5000 cycles compared with 1.97 and 0.11 MPa found for human tissue) and significantly different power law fit coefficients. The TPE hydrogel had an initial modulus of 0.58 MPa and experienced less than a 20% total relaxation over the 5000. Significant differences in the magnitude of compressive modulus between human and ovine menisci were observed, however the relaxation profiles were similar. Although statistically different than the native tissues, modulus values of the TPE hydrogel material were similar to those of the human and ovine menisci, making it a material worth further investigation for use as a synthetic replacement. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part A: 105A: 2722-2728, 2017.

A Cohort Study on Meniscal Lesions among Airport Baggage Handlers

Meniscal lesions are common and may contribute to the development of knee arthrosis. A few case-control and cross-sectional studies have identified knee-straining work as risk factors for meniscal lesions, but exposure-response relations and the role of specific exposures are uncertain, and previous results may be sensitive to reporting and selection bias. We examined the relation between meniscal lesions and cumulative exposure to heavy lifting in a prospective register-based study with complete follow-up and independent information on exposure and outcome. We established a cohort of unskilled men employed at Copenhagen Airport or in other companies in the metropolitan Copenhagen area from 1990 to 2012 (the Copenhagen Airport Cohort). The cohort at risk included 3,307 airport baggage handlers with heavy lifting and kneeling or squatting work tasks and 63,934 referents with a similar socioeconomic background and less knee-straining work. Baggage handlers lifted suitcases with an average weight of approximately 15 kg, in total approximately five tonnes during a 9-hour workday. The cohort was followed in the National Patient Register and Civil Registration System. The outcome was a first time hospital diagnosis or surgery of a meniscal lesion. Baggage handlers had a higher incidence of meniscal lesions than the referents. Within baggage handlers spline regression showed that the incidence rate ratio was 1.91 (95% confidence interval: 1.29-2.84) after five years as a baggage handler and then decreased slowly to reach unity after approximately 30 years, adjusted for effects of potential confounders. This relation between baggage handling and meniscal lesions was present for work on the apron which involves lifting in a kneeling or squatting position, but not in the baggage hall, which only involves lifting in standing positions. The results support that long-term heavy lifting in a kneeling or squatting position is a risk factor for the development of symptomatic meniscal lesions.

Partial meniscectomy is associated with increased risk of incident radiographic osteoarthritis and worsening cartilage damage in the following year

OBJECTIVES

To assess whether partial meniscectomy is associated with increased risk of radiographic osteoarthritis (ROA) and worsening cartilage damage in the following year.

METHODS

We studied 355 knees from the Osteoarthritis Initiative that developed ROA (Kellgren-Lawrence grade ≥ 2), which were matched with control knees. The MR images were assessed using the semi-quantitative MOAKS system. Conditional logistic regression was applied to estimate risk of incident ROA. Logistic regression was used to assess the risk of worsening cartilage damage in knees with partial meniscectomy that developed ROA.

RESULTS

In the group with incident ROA, 4.4 % underwent partial meniscectomy during the year prior to the case-defining visit, compared with none of the knees that did not develop ROA. All (n = 31) knees that had partial meniscectomy and 58.9 % (n = 165) of the knees with prevalent meniscal damage developed ROA (OR = 2.51, 95 % CI [1.73, 3.64]). In knees that developed ROA, partial meniscectomy was associated with an increased risk of worsening cartilage damage (OR = 4.51, 95 % CI [1.53, 13.33]).

CONCLUSIONS

The probability of having had partial meniscectomy was higher in knees that developed ROA. When looking only at knees that developed ROA, partial meniscectomy was associated with greater risk of worsening cartilage damage.

KEY POINTS

• Partial meniscectomy is a controversial treatment option for degenerative meniscal tears. • Partial meniscectomy is strongly associated with incident osteoarthritis within 1 year. • Partial meniscectomy is associated with increased risk of worsening cartilage damage.

Epidemiology of meniscal injuries in US high school athletes between 2007 and 2013

PURPOSE

Knowledge of epidemiologic trends of meniscal injuries in young active populations is limited. Better awareness of injury patterns is a first step to lowering injury rates. Our hypothesis was that meniscal injuries in high school athletes would vary by gender, sport, and type of exposure.

METHODS

During the 2007/2008 and 2012/2013 academic years, a large nationally disperse sample of US high schools reported athlete exposure and injury data for 22 sports by having certified athletic trainers complete an internet-based data collection tool.

RESULTS

One thousand and eighty-two meniscal injuries were reported during 21,088,365 athlete exposures for an overall injury rate of 5.1 per 100,000 athlete exposures. The overall rate of injury was higher in competition (11.9) than practice (2.7) (RR = 4.4; 95% CI 3.9-5.0), and 12/19 sports showed significantly higher injury rates in competition compared to practice. Of all injuries, 68.0% occurred in boys, yet among the gender-comparable sports of soccer, basketball, track and field, lacrosse, and baseball/softball injury rates were higher for girls than boys (5.5 and 2.5, respectively, RR = 2.2; 95% CI 1.8-2.7). Contact injury represented the most common mechanism (55.9%). Surgery was performed for the majority of injuries (63.8%), and 54.0% of athletes had associated intra-articular knee pathology.

CONCLUSIONS

Meniscal injury patterns among high school athletes vary by gender, sport, and type of exposure. Our study is clinically relevant because recognition of distinct differences in these injury patterns will help drive evidence-based, targeted injury prevention strategies and efforts.

LEVEL OF EVIDENCE

III.

Zonal differences in meniscus MR relaxation times in response to in vivo static loading in knee osteoarthritis

This study assessed the effects of static loading on MRI relaxation times of menisci in individuals with and without radiographic knee OA. High-resolution fast spin-echo (FSE) and T(1ρ)/T(2) relaxation time MR sequences were obtained with and without loading at 50% body weight in 124 subjects. T(1ρ)/T(2) relaxation times were calculated in menisci, and meniscus lesions were assessed through clinical grading. Student's t-test compared OA and control unloaded relaxation times as well as within-group changes with loading, Generalized Linear Models evaluated zonal variation, and ANCOVA compared loading response between groups. Unloaded T(1ρ) and T(2) in the middle and inner zones of the lateral anterior horn and outer zone of the medial posterior horn were significantly higher in OA and suggest that meniscal OA change occurs unevenly. Zonal T(1ρ) and T(2) showed differing patterns between anterior and posterior horns, suggesting differences in macromolecular organization. Significant increases with loading were seen largely in the T(2) of controls and less frequently in subjects with OA. In the medial posterior horn, T(1ρ) and T(2) decreased with loading in OA but changed negligibly in controls; these significantly different loading responses between groups may indicate load transmission failure in OA menisci.

Analysis of Gene Expression and Ultrastructure of Stifle Menisci from Juvenile and Adult Pigs

The origin of the age-associated degenerative processes in meniscal tissue is poorly understood and may be related to an imbalance of anabolic and catabolic metabolism. The aim of the current study was to compare medial menisci isolated from juvenile pigs and degenerated medial menisci from adult pigs in terms of gene expression profile and ultrastructure. Medial menisci were isolated from the knee joints of juvenile and adult pigs (n = 8 for each group). Degeneration was determined histologically according to a scoring system. In addition, the gene expression profiles of 14 genes encoding extracellular matrix proteins, catabolic matrix metalloproteinases and mediators of inflammation were analyzed. Changes in the ultrastructure of the collagen network of the meniscal tissue were analyzed by using transmission electron microscopy. The histologic analysis of menisci showed significantly higher grade of degeneration in tissue isolated from adult porcine knee joints compared with menisci isolated from juvenile knee joints. In particular, destruction of the collagen network was greater in adult menisci than in juvenile menisci. Degenerated menisci showed significantly decreased gene expression of COL1A1 and increased expression of MMP2, MMP13, and IL8. The menisci from adult porcine knee joints can serve as a model for meniscal degeneration. Degenerative changes were manifested as differences in histopathology, gene expression and ultrastructure of collagen network.

The Treatment of Non-Traumatic Meniscus Lesions

BACKGROUND

Most meniscus lesions are of non-traumatic origin. The indications for partial meniscectomy are controversial.

METHODS

We systematically searched the literature for randomized controlled trials (RCTs) comparing partial meniscectomy with non-surgical treatment.

RESULTS

Of 6870 articles retrieved by the literature search, we were able to include six in this systematic review. Five trials showed no difference between the clinical outcomes of patients who underwent arthroscopic partial meniscectomy and those who underwent control treatment (arthroscopic lavage, physiotherapy, glucocorticoids). In three trials, however, symptoms improved in 21-30% of the patients in the physiotherapy group only after they underwent arthroscopic partial meniscectomy (crossover design). In two trials, the percentage of patients who crossed over from one treatment arm to the other was markedly lower; in one, the frequency of crossing over was not reported. In one RCT, the patients who underwent arthroscopic partial meniscectomy had significantly less pain and other symptoms. Five of the six trials had acceptable scores for method, but all had weaknesses. These mainly concerned the description of the surgical techniques and the failure to take account of analgesic use-in particular, the use of non-steroidal antiinflammatory drugs (NSAIDs).

CONCLUSION

For most patients with non-traumatic meniscus lesions, surgical and non-surgical treatments seem to be of equal value; only one of the six included trials revealed lower pain and symptom scores after arthroscopic partial meniscectomy. In multiple trials, however, the crossover analysis showed that non-surgical treatment fails for some patients. These patients may benefit from arthroscopic partial meniscectomy. Further trials are needed to better define this subgroup of patients.

Effect of exercise therapy compared with arthroscopic surgery on knee muscle strength and functional performance in middle-aged patients with degenerative meniscus tears: a 3-mo follow-up of a randomized controlled trial

OBJECTIVE

The aim of this study was to compare the effect of a 12-wk exercise therapy program and arthroscopic partial meniscectomy on knee strength and functional performance in middle-aged patients with degenerative meniscus tears.

DESIGN

A total of 82 patients (mean age, 49 yrs; 35% women) with a symptomatic, unilateral, magnetic resonance imaging-verified degenerative meniscus tear and no or mild radiographic osteoarthritis were randomly assigned to a supervised neuromuscular and strength exercise program or arthroscopic partial meniscectomy. Outcomes assessed 3 mos after intervention initiation were isokinetic knee muscle strength, lower extremity performance, and self-reported global rating of change.

RESULTS

Mean difference in isokinetic knee extension peak torque between the two groups was 16% (95% confidence interval, 7.1-24.0) (P < 0.0001), favoring the exercise group. Patients in the exercise group improved isokinetic knee extension peak by a mean of 25 Nm (range, 18-33 Nm) from baseline to follow-up. Furthermore, patients assigned to exercise therapy showed statistically significant improvements (P ≤ 0.002) in all other measured variables, with moderate to large effect sizes (0.5-1.3). Patients reported a similar and positive effect of both interventions.

CONCLUSION

A 12-wk supervised exercise therapy program yielded clinically relevant and statistically significant improvement in isokinetic quadriceps strength immediately after completion of the program, as compared with treatment with arthroscopic partial meniscectomy.

Meniscus tissue engineering using a novel combination of electrospun scaffolds and human meniscus cells embedded within an extracellular matrix hydrogel

Meniscus injury and degeneration have been linked to the development of secondary osteoarthritis (OA). Therapies that successfully repair or replace the meniscus are, therefore, likely to prevent or delay OA progression. We investigated the novel approach of building layers of aligned polylactic acid (PLA) electrospun (ES) scaffolds with human meniscus cells embedded in extracellular matrix (ECM) hydrogel to lead to formation of neotissues that resemble meniscus-like tissue. PLA ES scaffolds with randomly oriented or aligned fibers were seeded with human meniscus cells derived from vascular or avascular regions. Cell viability, cell morphology, and gene expression profiles were monitored via confocal microscopy, scanning electron microscopy (SEM), and real-time polymerase chain reaction (PCR), respectively. Seeded scaffolds were used to produce multilayered constructs and were examined via histology and immunohistochemistry. Morphology and mechanical properties of PLA scaffolds (with and without cells) were influenced by fiber direction of the scaffolds. Both PLA scaffolds supported meniscus tissue formation with increased COL1A1, SOX9, and COMP, yet no difference in gene expression was found between random and aligned PLA scaffolds. Overall, ES materials, which possess mechanical strength of meniscus and can support neotissue formation, show potential for use in cell-based meniscus regeneration strategies.

Subcutaneous abatacept for the treatment of rheumatoid arthritis: longterm data from the ACQUIRE trial

OBJECTIVE

Assess longterm tolerability, safety, and efficacy of subcutaneous (SC) abatacept (ABA) in methotrexate-refractory patients with rheumatoid arthritis (RA).

METHODS

The phase III, multinational Abatacept Comparison of Sub[QU]cutaneous Versus Intravenous in Inadequate Responders to MethotrexatE (ACQUIRE) trial comprised a 6-month, randomized, double-blind (DB) period, in which patients received intravenous (IV) or SC ABA, plus MTX, followed by an open-label, longterm extension (LTE), in which patients received SC ABA, 125 mg/week. Safety and efficacy from the LTE (∼3.5 yrs of exposure) are reported.

RESULTS

Patients who completed the DB period (1372/1385, 99.1%) entered the LTE; 1134 patients (82.7%) kept taking the treatment at time of reporting. Mean (SD) was 31.9 months (6.8); median (range) exposure was 33.0 (8-44) months. Patients entering the LTE had longstanding, moderate-to-severe disease [mean 7.6 (7.9) yrs and DAS28 (C-reactive protein) 6.2 (0.9)]. Incidence rates (events/100 patient-yrs) were reported for serious adverse events (8.76, 95% CI 7.71, 9.95), infections (44.80, 95% CI 41.76, 48.01), serious infections (1.72, 95% CI 1.30, 2.27), malignancies (1.19, 95% CI 0.86, 1.66), and autoimmune events (1.31, 95% CI 0.95, 1.79). Twenty-seven patients (2%) experienced injection-site reactions; all except 1 were mild. American College of Rheumatology 20, 50, and 70 responses achieved during the DB period were maintained through the LTE, and on Day 981 were 80.2% (95% CI 77.2, 83.2), 63.5% (95% CI 58.2, 68.9), and 39.5% (95% CI 34.0, 44.9) for patients who kept taking SC ABA, and 80.0% (95% CI 77.0, 83.0), 63.2% (95% CI 57.8, 68.7), and 39.2% (95% CI 33.7, 44.7) for those who switched from IV to SC ABA.

CONCLUSION

These findings support SC ABA as a well-tolerated and efficacious longterm treatment for patients with RA and inadequate response to MTX (ClinicalTrials.gov identifier NCT00559585).

Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear

BACKGROUND

Arthroscopic partial meniscectomy is one of the most common orthopedic procedures, yet rigorous evidence of its efficacy is lacking.

METHODS

We conducted a multicenter, randomized, double-blind, sham-controlled trial in 146 patients 35 to 65 years of age who had knee symptoms consistent with a degenerative medial meniscus tear and no knee osteoarthritis. Patients were randomly assigned to arthroscopic partial meniscectomy or sham surgery. The primary outcomes were changes in the Lysholm and Western Ontario Meniscal Evaluation Tool (WOMET) scores (each ranging from 0 to 100, with lower scores indicating more severe symptoms) and in knee pain after exercise (rated on a scale from 0 to 10, with 0 denoting no pain) at 12 months after the procedure.

RESULTS

In the intention-to-treat analysis, there were no significant between-group differences in the change from baseline to 12 months in any primary outcome. The mean changes (improvements) in the primary outcome measures were as follows: Lysholm score, 21.7 points in the partial-meniscectomy group as compared with 23.3 points in the sham-surgery group (between-group difference, -1.6 points; 95% confidence interval [CI], -7.2 to 4.0); WOMET score, 24.6 and 27.1 points, respectively (between-group difference, -2.5 points; 95% CI, -9.2 to 4.1); and score for knee pain after exercise, 3.1 and 3.3 points, respectively (between-group difference, -0.1; 95% CI, -0.9 to 0.7). There were no significant differences between groups in the number of patients who required subsequent knee surgery (two in the partial-meniscectomy group and five in the sham-surgery group) or serious adverse events (one and zero, respectively).

CONCLUSIONS

In this trial involving patients without knee osteoarthritis but with symptoms of a degenerative medial meniscus tear, the outcomes after arthroscopic partial meniscectomy were no better than those after a sham surgical procedure. (Funded by the Sigrid Juselius Foundation and others; ClinicalTrials.gov number, NCT00549172.).

Transcriptome analysis of injured human meniscus reveals a distinct phenotype of meniscus degeneration with aging

OBJECTIVE

Meniscus tears are associated with a heightened risk of osteoarthritis. This study aimed to advance our understanding of the metabolic state of injured human meniscus at the time of arthroscopic partial meniscectomy through transcriptome-wide analysis of gene expression in relation to the patient's age and degree of cartilage chondrosis.

METHODS

The degree of chondrosis of knee cartilage was recorded at the time of meniscectomy in symptomatic patients without radiographic osteoarthritis. RNA preparations from resected menisci (n = 12) were subjected to transcriptome-wide microarray and QuantiGene Plex analyses. Variations in the relative changes in gene expression with age and chondrosis were analyzed, and integrated biologic processes were investigated computationally.

RESULTS

We identified a set of genes in torn menisci that were differentially expressed with age and chondrosis. There were 866 genes that were differentially regulated (≥1.5-fold difference and P < 0.05) with age and 49 with chondrosis. In older patients, genes associated with cartilage and skeletal development and extracellular matrix synthesis were repressed, while those involved in immune response, inflammation, cell cycle, and cellular proliferation were stimulated. With chondrosis, genes representing cell catabolism (cAMP catabolic process) and tissue and endothelial cell development were repressed, and those involved in T cell differentiation and apoptosis were elevated.

CONCLUSION

Differences in age-related gene expression suggest that in older adults, meniscal cells might dedifferentiate and initiate a proliferative phenotype. Conversely, meniscal cells in younger patients appear to respond to injury, but they maintain the differentiated phenotype. Definitive molecular signatures identified in damaged meniscus could be segregated largely with age and, to a lesser extent, with chondrosis.

Finnish Degenerative Meniscal Lesion Study (FIDELITY): a protocol for a randomised, placebo surgery controlled trial on the efficacy of arthroscopic partial meniscectomy for patients with degenerative meniscus injury with a novel 'RCT within-a-cohort' study design

INTRODUCTION

Arthroscopic partial meniscectomy (APM) to treat degenerative meniscus injury is the most common orthopaedic procedure. However, valid evidence of the efficacy of APM is lacking. Controlling for the placebo effect of any medical intervention is important, but seems particularly pertinent for the assessment of APM, as the symptoms commonly attributed to a degenerative meniscal injury (medial joint line symptoms and perceived disability) are subjective and display considerable fluctuation, and accordingly difficult to gauge objectively.

METHODS AND ANALYSIS

A multicentre, parallel randomised, placebo surgery controlled trial is being carried out to assess the efficacy of APM for patients from 35 to 65 years of age with a degenerative meniscus injury. Patients with degenerative medial meniscus tear and medial joint line symptoms, without clinical or radiographic osteoarthritis of the index knee, were enrolled and then randomly assigned (1 : 1) to either APM or diagnostic arthroscopy (placebo surgery). Patients are followed up for 12 months. According to the prior power calculation, 140 patients were randomised. The two randomised patient groups will be compared at 12 months with intention-to-treat analysis. To safeguard against bias, patients, healthcare providers, data collectors, data analysts, outcome adjudicators and the researchers interpreting the findings will be blind to the patients' interventions (APM/placebo). Primary outcomes are Lysholm knee score (a generic knee instrument), knee pain (using a numerical rating scale), and WOMET score (a disease-specific, health-related quality of life index). The secondary outcome is 15D (a generic quality of life instrument). Further, in one of the five centres recruiting patients for the randomised controlled trial (RCT), all patients scheduled for knee arthroscopy due to a degenerative meniscus injury are prospectively followed up using the same protocol as in the RCT to provide an external validation cohort. In this article, we present and discuss our study design, focusing particularly on the internal and external validity of our trial and the ethics of carrying out a placebo surgery controlled trial.

ETHICS AND DISSEMINATION

The protocol has been approved by the institutional review board of the Pirkanmaa Hospital District and the trial has been duly registered at ClinicalTrials.gov. The findings of this study will be disseminated widely through peer-reviewed publications and conference presentations.

TRIAL REGISTRATION

ClinicalTrials.gov, number NCT00549172.

Closing the gap between bench and bedside research for early arthritis therapies (EARTH): report from the AOSSM/NIH U-13 Post-Joint Injury Osteoarthritis Conference II

This report summarizes the 2010 AOSSM/NIH (American Orthopaedic Society for Sports Medicine/National Institutes of Health) U13 Post-Joint Injury Osteoarthritis II Conference to include the discussion concerning potential study cohorts, assessment considerations, and research priorities. There was strong consensus and enthusiasm for approaching the development of disease-modifying treatments for osteoarthritis through study of "pre-osteoarthritic" cohorts, particularly human subjects under 30 years of age following acute anterior cruciate ligament injuries. Clinical study of acute treatment strategies initiated within a few days after injury will need development of recruitment pathways and short-term proof-of-concept outcome measures that are specific to the intervention being studied. For example, measures of joint inflammation can be used in short-term prospective randomized controlled trials to determine whether an anti-inflammatory intervention was effective in decreasing early inflammation. These short-term clinical trials will need to be followed by longer-term evaluation of the clinical cohorts for joint and cartilage degeneration to determine if the acute intervention affected later development of osteoarthritis. Research priorities were identified in several disciplines, particularly regarding development and validation of quantitative imaging, biomechanics, and biomarker measures of joint structure, composition, and function that predict the accelerated development of osteoarthritis. Systematic study of posttraumatic osteoarthritis is anticipated to advance understanding and treatment of all forms of osteoarthritis.

Development and preliminary validation of a meniscal symptom index

OBJECTIVE

In diagnosing symptomatic meniscal tear, clinicians often query patients with a "checklist" of symptoms such as "popping" or "catching." There has been little research on the reliability or diagnostic value of these terms.

METHODS

We developed questions to elicit the presence of 11 checklist symptoms associated with meniscal tear and administered a survey with both "checklist" and expanded descriptions to study subjects. We examined the reliability of the checklist and expanded versions of each item. Validity was evaluated in relation to the clinical diagnosis of symptomatic meniscal tear, which consisted of the clinical impression of the treating orthopedic surgeon based upon physical examination, history, and magnetic resonance imaging. We developed a Meniscal Symptom Index, calculated as the sum of those expanded descriptive items that were independently associated with symptomatic meniscal tear in multivariate logistic regression.

RESULTS

A total of 300 individuals (mean±SD age 52±12 years, 67% women) completed the survey. One hundred twenty-one had symptomatic meniscal tear. Test-retest reliability was higher for expanded descriptions than for checklist items. The Meniscal Symptom Index consisted of 4 expanded items: localized pain, clicking, catching, and giving way. Among the subjects with none of these symptoms, 16% (95% confidence interval [95% CI] 2%, 30%) had symptomatic meniscal tear, whereas among those with all 4 symptoms, 76% (95% CI 63%, 88%) had symptomatic meniscal tear (P for trend = 0.0001).

CONCLUSION

Clinicians should use expanded symptom definitions when querying patients about meniscal symptoms. A newly developed Meniscal Symptom Index holds promise as a diagnostic tool and merits further validation.