Clinical features of the degenerate meniscus with the results of meniscectomy

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.

Translation, cross-cultural adaptation, reliability and validity of the Turkish version of the Western Ontario Meniscal Evaluation Tool (WOMET)

PURPOSE

The Western Ontario Meniscal Evaluation Tool (WOMET) is a questionnaire designed to evaluate quality of life related to the health (HRQOL) of patients with meniscus pathology. The purpose of this study was to translate and culturally adapt the WOMET into Turkish, and thereby to determine the reliability and validity of the translated version.

METHODS

The WOMET was translated into Turkish in accordance with the stages recommended by Guillemin. Ninety-six patients [35 male, 61 female; mean age: 43.6 ± 11.7 (23-71) years] with meniscal pathology were included in the study. The WOMET was completed twice at 3-7-day intervals. The inter-rater correlation coefficient was used for reliability, and Cronbach's α was used for internal consistency. Patients were asked to answer the Lysholm knee scale and the short form-36 (SF-36) for the validity of the estimation. The distribution of ceiling and floor effects was determined.

RESULTS

Mean and standard deviation of the first and second evaluations of the total WOMET were 1,048.9 ± 271.6 and 1,000.4 ± 255.2 (p = 0.03), respectively. The test-retest reliability of the total score, physical function, sports/work/lifestyle and emotion domains were 0.88, 0.78, 0.80 and 0.85, respectively. Cronbach's α was 0.89. WOMET was most strongly related to the physical function scale and the physical component score (ρ 0.54, ρ 0.60, respectively; p < 0.001). The weakest correlations between the WOMET and the SF-36 were for the mental component score and the emotional role functioning (ρ 0.11, ρ 0.03, respectively). We observed no ceiling and floor effects of the overall WOMET score, but 36.5 % of the patients showed floor effect in the question of "numbness", and 40.6 % of the patients showed ceiling effect in the question of "consciousness".

CONCLUSION

The Turkish version of the WOMET is valid and reliable. It can therefore be used for HRQOL of patients with meniscal pathology.

Updates in biological therapies for knee injuries: menisci

The preservation of meniscal tissue is paramount for long-term joint function, especially in younger patients who are athletically active. Many studies have reported encouraging results following the repair of meniscus tears, including both simple longitudinal tears located in the periphery and complex multiplanar tears that extend into the central third avascular region. However, most types of meniscal lesions are managed with a partial meniscectomy. Options to restore the meniscus range from an allograft transplantation to the use of synthetic and biological technologies. Recent studies have demonstrated good long-term outcomes with meniscal allograft transplantation, although the indications and techniques continue to evolve, and the long-term chondroprotective potential of this approach has yet to be determined. Several synthetic implants, most of which are approved in the European market, have shown some promise for replacing part of or the entire meniscus, including collagen meniscal implants, hydrogels, and polymer scaffolds. Currently, there is no ideal implant generated by means of tissue engineering. However, meniscus tissue engineering is a fast developing field that promises to develop an implant that mimics the histologic and biomechanical properties of a native meniscus.

Meniscus reconstruction: today's achievements and premises for the future

Injuries of the meniscus remain a burden for the development of premature cartilage degeneration and osteoarthritis. This review surveys all treatment options and focuses on the recent development of tissue engineering. Tissue engineering of the meniscus means a successful combination of cells, scaffolds and specific stimuli. Each element of the combination can be subject to variation. Studies investigating the optimum meniscus implant and previous steps in producing these implants are presented in this article. A comprehensive search of the English and German literature was performed in PubMed to retrieve appropriate manuscripts for review. Based on the literatures, autografts and allografts can delay the progress of osteoarthritis for a restricted time period, but several concerns persist. The biomechanical properties of the native meniscus are not copied entirely by the current existing autografts. Congruence, fixation, biocompatibility and potential infection will always remain as limitations for the users of allografts. Long-term results are still not available for meniscus prosthesis and even though it permits fast recovery, several aspects are questionable: bioincompatibility and a lack of cellular adhesion are likely to compromise their long-term fate. Currently, there is no ideal implant generated by means of tissue engineering. However, meniscus tissue engineering is a fast developing field, which promises to develop an implant that mimics histological and biomechanical properties of the native meniscus. At present several cell sources and scaffolds have been used successfully to grow 3-dimensional constructs. In future, optimal implants have to be developed using growth factors, modified scaffolds and stimuli that support cellular proliferation and differentiation to regenerate the native meniscus more closely.

Rapidly progressive osteoarthritis: biomechanical considerations

An underlying hypothesis for rapid cartilage loss in patients with osteoarthritis (OA) is that perturbation from normal joint mechanics produces locally high biomechanical strains that exceed the material properties of the tissue, leading to rapid destruction. Several imaging findings are associated with focally high biomechanical forces and thus are potential candidates for predictive biomarkers of rapid OA progression. This article focuses on 3 aspects of knee biomechanics that have potential magnetic resonance imaging correlates, and which may serve as prognostic biomarkers: knee malalignment, meniscal dysfunction, and injury of the osteochondral unit.

The role of biomechanics in the initiation and progression of OA of the knee

The knee is one of the most common joints affected by osteoarthritis (OA), frequently with clinical presentation by middle age or even earlier. Accumulating evidence supports that knee OA progression is often driven by biomechanical forces, and the pathological response of tissues to such forces leads to structural joint deterioration, knee symptoms and reduced function. Well-known biomechanical risk factors for progression include joint malalignment and meniscal tear. The high risk of OA after knee injury demonstrates the critical role of biomechanical factors also in incident disease in susceptible individuals. However, our knowledge of the contributing biomechanical mechanisms in the development of early disease and their order of significance is limited. Part of the problem is our current lack of understanding of early-stage OA, when it starts and how to define it.

The role of the meniscus in osteoarthritis genesis

The history of treating meniscal lesions has been characterized by firm belief in "radical" surgery, with serious long-term consequences for the individual and society. The menisci play a critical protective role for the knee joint through shock absorption and load distribution. Currently, the consensus in surgical treatment of meniscal tears is to preserve as much functional meniscal tissue as possible. Still, meniscal lesions are common, especially in the osteoarthritic knee. For health professionals, these lesions present a challenge in choosing the treatment that is best for the patient in both the short term and long term. A degenerative lesion, in the middle-aged or older patient, could suggest early-stage knee osteoarthritis and should be treated accordingly. Surgical resection of nonobstructive degenerate lesions may only remove evidence of the disorder while the osteoarthritis degradation proceeds. Well-designed randomized, controlled clinical trials are needed.

Risk factors for symptomatic knee osteoarthritis fifteen to twenty-two years after meniscectomy

OBJECTIVE

To evaluate the influence of age, sex, body mass index (BMI), extent of meniscal resection, cartilage status, and knee load on the development of radiographically evident osteoarthritis (OA) of the knee and knee symptoms after meniscal resection.

METHODS

We evaluated 317 patients with no cruciate ligament injury (mean +/- SD age 54 +/- 11 years) who had undergone meniscal resection 15-22 years earlier (followup rate 70%), with radiographic and clinical examination. The Knee injury and Osteoarthritis Outcome Score was used to quantify knee-related symptoms. Sixty-eight unoperated subjects identified from national population records were included as a reference group.

RESULTS

Symptomatic radiographic OA (corresponding to Kellgren/Lawrence grade > or =2) was present in 83 of 305 operated knees (27%) and 7 of 68 control knees (10%) (relative risk 2.6, 95% confidence interval [95% CI] 1.3-6.1). Patients who had undergone total meniscectomy and subjects with obesity (BMI > or =30) had a greater likelihood of tibiofemoral radiographic OA than those who had undergone partial meniscal resection and those with a BMI <25, respectively. Furthermore, degenerative meniscal tear, intraoperative cartilage changes, and lateral meniscectomy were associated with radiographic OA more frequently than were longitudinal tear, absence of cartilage changes, and medial meniscectomy, respectively. Symptomatic tibiofemoral or patellofemoral radiographic OA was associated with obesity, female sex, and degenerative meniscal tear.

CONCLUSION

Contributing risk factors for OA development after meniscal resection are similar to risk factors for common knee OA. Systemic factors and local biomechanical factors interact. Obesity, female sex, and preexisting early-stage OA are features associated with poor self-reported and radiographic outcome. Partial meniscal resection is associated with less radiographic OA over time than is total meniscectomy.

Meniscal tearing and rheumatoid arthritis

We report five cases of meniscal tears in patients who were subsequently found to have rheumatoid arthritis (RA) and discuss the management priorities with regard to symptom relief.

Arthroscopic management of degenerative meniscus tears in patients with degenerative arthritis

Frequently, meniscal pathology accompanies degenerative changes affecting the articular surface of the knee. The attritional changes in the meniscus lead to fragmentation of the meniscus and a variety of tears, usually of the posterior horn of the medial meniscus. A prospective study of the results of arthroscopic partial meniscectomy in the presence of at least Outerbridge Grade III chondromalacia of the accompanying joint surface was performed between 1980 and 1984. Eighty-seven knees in 84 patients were studied. The mean age was 62 (29-84) years. The right knee was involved in 44 patients, and 47 were men. Preoperative radiographs demonstrated osteoarthritis in 53 patients. The medial meniscus was involved in 82, while the lateral meniscus was affected in nine knees. Four knees had involvement of both menisci. In 72 knees, the most frequent lesion was a tear of the posterior horn of the medial meniscus. The most frequent configuration of the tears was a flap in 42. The morbidity was small with the use of ambulatory aids being 10 +/- 13 (mean +/- SD) days. Subsequent surgery was performed on six knees consisting of two total knee arthroplasties, two upper-tibial osteotomies, one repeat arthroscopic meniscectomy, and one popliteal cyst excision. Two patients had poor results related to progression of their arthritis and one developed osteonecrosis. Five patients were unchanged from their preoperative status. Subchondral sclerosis or osteophytes on the preoperative radiographs correlated with 72% compared to 90% satisfactory results in the absence of these findings (p less than 0.03). Complications consisted of superficial thrombophlebitis in three, hemarthrosis in one, and superficial infection in one patient.(ABSTRACT TRUNCATED AT 250 WORDS)

Arthroscopic partial medial meniscectomy: an analysis of unsatisfactory results

Results of 150 arthroscopic partial medial meniscectomies were analyzed by computer to identify the factors that lead to an unsatisfactory (fair or poor) outcome. The average follow-up for the group was 36 months (range 24-60 months). One-hundred ten men and 40 women were involved, with an average age of 48 years. The overall results were 58% excellent-good, 28% fair, and 14% poor. Most tears involved the posterior horn (76%). Bucket-handle, longitudinal, and flap tears were rated 88% excellent-good, whereas horizontal cleavage and degenerative and complex tears had only 45% excellent-good scores. The results were adversely affected by the severity of the chondromalacia, work-related injury, prior knee surgery, simultaneous lateral meniscectomy, and increased knee laxity. Because degenerative posterior horn tears had such a high percentage of unsatisfactory results, the question remains as to whether all these tears need to be removed.