Mechanical symptoms as an indication for knee arthroscopy in patients with degenerative meniscus tear: a prospective cohort study

Knee arthroscopy has limited effects on relieving local symptoms of knee osteoarthritis: an analysis of data from the Osteoarthritis Initiative

BACKGROUND

Knee arthroscopy's efficacy in symptom improvement for knee osteoarthritis remains debated. In this study, we analyzed a multicenter database to investigate local symptom improvement.

METHODS

We extracted and analyzed the data of 163 patients from the Osteoarthritis Initiative cohort who underwent unilateral knee arthroscopy (UKA) and were followed up for at least 24 months. UKA patients were matched to non-UKA patients (n = 163) according to sex, age, abdominal circumference, and Kellgren-Lawrence grade. The verified KOOS questionnaires (knee catching, locking, grinding, or clicking) and common local symptoms (frequent knee pain, aching, or stiffness) were set as outcomes. Furthermore, we built a binary logistic regression model to examine the relationship between UKA and local symptom improvement and new-onset symptoms, adjusting for conservative therapeutic covariables (injection of steroids or transparent acid into the knee joint, oral chondroitin sulfate, amino glucose, or analgesics).

RESULT

Analysis showed that the UKA and non-UKA groups showed no obvious difference in the three knee symptoms, but the probability of new-onset grinding or clicking, and frequent knee pain, aching, or stiffness symptoms in the UKA group were respectively 5.82 and 5.65-fold higher than that in the non-UKA group. After analyzing conservative treatment data using a multiple imputation method, the results were consistent with previous regression analyses.

CONCLUSION

Compared to the non-UKA group, the UKA group showed no noticeable differences in the improvement of the three knee symptoms and showed an increased the probability of new-onset grinding or clicking and frequent knee pain, aching, or stiffness symptoms. Key Points • Knee arthroscopy may increase the probability of new-onset grinding or clicking and frequent knee pain, aching, or stiffness symptoms. • We found no difference in the improvement of local knee symptoms (knee catching, locking, grinding, clicking or frequent pain, aching, or stiffness) improvement between the two groups with or without knee arthroscopy.

Editorial Commentary: We Should Be Cautious About Using Catching and Locking as an Indication for Knee Arthroscopy: Mechanical Symptoms May Be Multifactorial in Their Causes

Knee arthroscopy may be offered as a treatment for mechanical (catching/locking, grinding/clicking) and meniscal (pain with twisting/pivoting) symptoms. Recent studies have found that mechanical symptoms, particularly catching/locking, may be multifactorial in their causes (chondral lesions, meniscal tears, loose bodies) and less responsive to arthroscopic meniscectomy. Surgeons should be aware of this evidence and adjust their surgical indications appropriately.

Grinding, Clicking, and Pivot Pain Resolve in Most Patients After Knee Arthroscopy

PURPOSE

To determine whether knee arthroscopy alleviates the symptom constellation of knee grinding/clicking, catching/locking, and pivot pain.

METHODS

One-year follow-up data from 584 consecutive subjects who underwent knee arthroscopy from August 2012 to December 2019 were collected prospectively. Subjects reported frequency of knee grinding/clicking, catching/locking, and/or pivot pain preoperatively and 1 and 2 years postoperatively. A single surgeon performed each procedure and documented all intraoperative pathology. We measured the postoperative resolution or persistence of these symptoms and used multivariable regression models to identify preoperative demographic and clinical variables that predicted symptom persistence. We also assessed changes in the Pain, Activities of Daily Living, and Quality of Life subscales of the Knee Injury and Osteoarthritis Outcome Score (KOOS).

RESULTS

Postoperative symptom resolution was more likely for grinding/clicking (65.6%) and pivot pain (67.8%) than for catching/locking (44.1%). Smoking status, overweight/obesity, absence of meniscal tear, and number of compartments with focal cartilage lesions predicted persistence of 1 or more patient-reported knee symptoms. KOOS subscale scores consistently improved by at least one standard deviation. Individuals who had resolution of patient-reported knee symptoms exhibited roughly 2-fold improvements in KOOS Pain, ADL and Quality of Life scores compared with those whose symptoms persisted. Persistence of pivot pain was associated with the least improvement of the 3 KOOS subscales.

CONCLUSIONS

Two in three patients with grinding/clicking or pivot pain experience symptom resolution after knee arthroscopy, although catching/locking is more likely to persist. Smoking status, overweight/obesity, absence of meniscal tear, and number of compartments with focal cartilage lesions predict symptom persistence after knee arthroscopy.

LEVEL OF EVIDENCE

Therapeutic Level IV, retrospective cohort analysis of prospective data.

Treatment of the syndrome of knee pain and meniscal tear in middle-aged and older persons: A narrative review

Objective:

Design:

Results:

Conclusion:

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.

Isolated Arthroscopic Partial Meniscectomy Is More Effective at Improving Meniscal Symptoms in Comparison With Mechanical Symptoms in Patients With Concomitant Untreated Chondral Lesions

PURPOSE

To rank Knee Injury and Osteoarthritis Outcome Score (KOOS) questions from most to least improvement after arthroscopic partial meniscectomy (APM) and compare improvement of meniscal versus mechanical symptoms.

METHODS

A secondary analysis of the Chondral Lesions and Meniscus Procedures (ChAMP) Trial was performed. Inclusion criteria were age 30 years or older with degenerative meniscal tear failing nonoperative management, with or without associated unstable chondral lesions. No chondral debridement was performed. Responses to the 42 KOOS questions ranged from 0 (extreme problems) to 4 (no problems), and were answered preoperatively and at 1 year after isolated APM. The 1-year mean change, or delta (Δ), was calculated for each KOOS question and the Δ for meniscal and mechanical symptoms were statistically compared.

RESULTS

Greatest improvement in 135 eligible patients was observed for questions about (1) awareness of knee problems (Δ = 1.93, standard deviation [SD] = 1.38), (2) frequency of knee pain (Δ = 1.93, SD = 1.29), (3) degree of difficulty while twisting/pivoting on the injured knee (Δ = 1.88, SD = 1.13), (4) degree of difficulty while running (Δ = 1.67, SD = 1.30), and (5) being troubled by lack of confidence in the knee (Δ = 21.67, SD = 1.11). Least improvement was observed for questions about: (1) degree of difficulty while getting on/off the toilet (Δ = 0.94, SD = 0.96), (2) feel grinding or hear clicking when the knee moves (Δ= 0.90, SD = 1.25), 3) degree of difficulty while getting in/out of the bath (Δ= 0.88, SD = 1.00), (4) knee catches/hangs up during movement (Δ= 0.80, SD = 1.09), and (5) the ability to straighten the knee fully (Δ= 0.54, 1.44). There was greater improvement for the KOOS questions pertaining to meniscal versus mechanical symptoms (P < .00001).

CONCLUSIONS

KOOS symptoms as reported by subjects' responses to the questions pertaining to the frequency of knee pain, twisting/pivoting, running, squatting, and jumping showed the most improvement 1 year after isolated APM, whereas those relating to mechanical symptoms improved the least. Focusing on meniscal rather than mechanical symptoms may help surgeons better identify patients expected to benefit from APM.

LEVEL OF EVIDENCE

IV, retrospective analysis of prospectively collected data.

Medium-term efficacy of arthroscopic debridement vs conservative treatment for knee osteoarthritis of Kellgren-Lawrence grades I-III

BACKGROUND

Arthroscopic debridement is a mature treatment for knee osteoarthritis (KOA). Due to the differences in the research subjects, methods, and efficacy evaluation indexes, there are great differences in the surgical efficacy reported in the literature.

AIM

To compare the medium-term efficacy of arthroscopic debridement and conservative treatment for KOA of Kellgren-Lawrence grades I-III.

METHODS

Patients with KOA of Kellgren-Lawrence grades I-III who were admitted to the orthopedic clinic of our hospital from July 2018 to December 2018 and agreed to undergo arthroscopic surgery were included in an arthroscopic debridement group, and those who refused surgical treatment were included in a conservative treatment group. Gender, age, body mass index (BMI), side of KOA, American hospital for special surgery knee score (HSS score) before treatment, visual analogue scale (VAS) score during walking and rest before treatment, conservative treatment content, and surgical procedure were recorded. Outpatient visits were conducted at the 1^st, 3^rd, 6^th, 12^th, and 24^th mo after treatment in the two groups. The changes of HSS score and VAS score in each group before and after treatment were statistically analyzed, and the differences of HSS score and VAS score in different treatment stages between the two groups were also compared.

RESULTS

In the conservative treatment group, there were 80 patients with complete follow-up data, including 20 males and 60 females, aged 58.75 ± 14.66 years old. And in the knee arthroscopic debridement group, there were 98 patients with complete follow-up data, including 24 males and 74 females, aged 59.27 ± 14.48 years old. There was no statistically significant difference in the general data (gender, age, BMI, side of KOA, Kellgren-Lawrence grade distribution, HSS score, and VAS score) between the two groups before treatment. The HSS scores of the conservative treatment group at the 1^st, 3^rd, 6^th, 12^th, and 24^th mo after treatment were significantly higher than that before treatment (P < 0.05). There was no statistical difference in HSS score of the conservative treatment group among the 1^st, 3^rd, 6^th, 12^th, and 24^th mo (P > 0.05). The HSS score of the knee arthroscopic debridement group at the 1^st mo after surgery was significantly higher than that before surgery (P < 0.05). HSS scores of the knee arthroscopic debridement group at the 3^rd, 6^th, 12^th, and 24^th mo were significantly higher than those before surgery and at the 1^st mo after surgery (P < 0.05). There were no statistically significant differences in HSS scores at the 3^rd, 6^th, 12^th, and 24^th mo after surgery (P > 0.05). HSS scores at the 3^rd, 6^th, 12^th, and 24^th mo were significantly higher in the arthroscopic debridement group than in the conservative treatment group (P < 0.05). There was no statistical difference in HSS scores between the two groups before treatment and at the 1^st mo of follow-up (P > 0.05). VAS scores during walking and rest were significantly decreased in both groups, and the VAS score during rest was significantly lower in the arthroscopic debridement group than in the conservative treatment group, but there was no significant difference in the VAS score during walking between the two groups after treatment.

CONCLUSION

Compared with conservative treatment, arthroscopic debridement can significantly improve the knee resting pain and knee functional status of patients with KOA of Kellgren-Lawrence grades I-III within 2 years after treatment.

Meniscal and Mechanical Symptoms Are Associated with Cartilage Damage, Not Meniscal Pathology

BACKGROUND

Traditionally defined "meniscal" and "mechanical" symptoms are thought to arise from meniscal tears. Yet meniscal tears and cartilage damage commonly coexist in symptomatic knees. To better characterize the primary driver of these symptoms, we investigated whether the presence of preoperative patient-reported knee symptoms (PRKS), including knee catching/locking, grinding/clicking/popping, and pain with pivoting, are associated with various intra-articular pathological conditions diagnosed at knee arthroscopy.

METHODS

We collected prospective data from 565 consecutive patients who underwent knee arthroscopy from 2012 to 2019 and had PRKS collected via the Knee injury and Osteoarthritis Outcome Score (KOOS) questionnaire. The diagnosis of meniscal pathology and concomitant cartilage damage was confirmed and classified intraoperatively. We used multivariable regression models, adjusting for possible confounders, to examine the association of specific pathological conditions of the knee with the presence of preoperative PRKS.

RESULTS

Tricompartmental cartilage damage was strongly associated with significantly worse PRKS, with an increase of 0.33 point (95% confidence interval [CI] = 0.08 to 0.58; p = 0.01) on a 0 to 4-point scale. We did not observe an association between meniscal pathology and preoperative PRKS.

CONCLUSIONS

Contrary to current dogma, this study demonstrates that traditionally defined "meniscal" and "mechanical" knee symptoms are strongly associated with the burden and severity of underlying cartilage damage rather than with specific meniscal pathology.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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).

Revisiting Arthroscopic Partial Meniscectomy for Degenerative Tears in Knees With Mild or No Osteoarthritis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

The purpose of this systematic review and meta-analysis was to evaluate the efficacy of arthroscopic partial meniscectomy (APM) for symptomatic degenerative meniscal tear (DMT) in knees with mild or no osteoarthritis.

STUDY DESIGN

A systematic review and meta-analysis.

METHODS

MEDLINE, EMBASE, and Cochrane databases were systematically searched. The inclusion criteria were as follows: (1) English language; (2) randomized controlled trial (RCT); (3) comparison between APM and other treatment modalities as a primary objective; and (4) complete DMT in knees with mild or no osteoarthritis. Mild or no arthritis was defined as Kellgren-Lawrence grade 0 to 2 or Ahlbäck 0 to 1 on radiography. Statistical analysis of functional activity and pain after APM and conservative treatment or sham operation was performed using R version 3.3.1.

RESULTS

Five articles were included in the final analysis, and they were all RCTs. Four studies compared clinical results of APM with those for physical therapy, and one study compared APM with sham operation. The functional activity was not better in the APM group (296 cases) than in the conservative treatment or sham operation group (284 cases) (I: 0%, small level of heterogeneity). Pain was not reduced significantly in the APM group compared with that in the conservative treatment or sham operation group (I: 0∼90%, high level of heterogeneity).

CONCLUSIONS

This systematic review and meta-analysis of high-quality literature provides relatively strong evidence that APM did not improve functional activity or reduce pain compared with the results with conservative treatment or sham operation in knees with mild or no osteoarthritis.

Degenerative Meniscus Lesions: An Expert Consensus Statement Using the Modified Delphi Technique

PURPOSE

The purpose of this study was to perform an evidence-based, expert consensus survey using the Delphi panel methodology to develop recommendations for the treatment of degenerative meniscus tears.

METHODS

Twenty panel members were asked to respond to 10 open-ended questions in rounds 1 and 2. The results of the first 2 rounds served to develop a Likert-style questionnaire for round 3. In round 4, the panel members outside consensus were contacted and asked to either change their score in view of the group's response or argue their case. The level of agreement for round 4 was defined as 80%.

RESULTS

There was 100% agreement on the following items: insidious onset, physiological part of aging, tears often multiplanar, not all tears cause symptoms, outcomes depend on degree of osteoarthritis, obesity is a predictor of poor outcome, and younger patients (<50 years) have better outcomes. There was between 90% and 100% agreement on the following items: tears are nontraumatic, radiographs should be weightbearing, initial treatment should be conservative, platelet-rich plasma is not a good option, repairable and peripheral tears should be repaired, microfracture is not a good option for chondral defects, the majority of patients obtain significant improvement and decrease in pain with surgery but results are variable, short-term symptoms have better outcomes, and malalignment and root tears have poor outcomes.

CONCLUSIONS

This consensus statement agreed that degenerative meniscus tears are a normal part of aging. Not all tears cause symptoms and, when symptomatic, they should initially be treated nonoperatively. Repairable tears should be repaired. The outcome of arthroscopic partial meniscectomy depends on the degree of osteoarthritis, the character of the meniscus lesion, the degree of loss of joint space, the amount of malalignment, and obesity. The majority of patients had significant improvement, but younger patients and patients with short-term symptoms have better outcomes.

LEVEL OF EVIDENCE

Level V - expert opinion.

Knee Arthroscopic Surgery in Middle-Aged Patients With Meniscal Symptoms: A 5-Year Follow-up of a Prospective, Randomized Study

Background:

Arthroscopic meniscal surgery is a common orthopaedic procedure in middle-aged patients, but the efficacy of this procedure has been questioned. In this study, we followed up the only randomized controlled trial that has shown a 1-year benefit from knee arthroscopic surgery with an exercise program compared with an exercise program alone.

Purpose:

To (1) evaluate whether knee arthroscopic surgery combined with an exercise program provided an additional 5-year benefit compared with an exercise program alone in middle-aged patients with meniscal symptoms, (2) determine whether baseline mechanical symptoms affected the outcome, and (3) compare radiographic changes between treatment groups.

Study Design:

Randomized controlled trial; Level of evidence, 1.

Methods:

Of 179 eligible patients aged 45 to 64 years, 150 were randomized to either a 3-month exercise program (nonsurgery group) or to the same exercise program plus knee arthroscopic surgery (surgery group) within 4 weeks. Radiographs were assessed, according to the Kellgren-Lawrence grade, at baseline and at the 5-year follow-up. The primary outcome was the change in Knee injury and Osteoarthritis Outcome Score (KOOS)–Pain (KOOS_PAIN) subscore from baseline to the 5-year follow-up. We performed an as-treated analysis.

Results:

A total of 102 patients completed the 5-year questionnaire. At the 5-year follow-up, both groups had significant improvement in KOOS_PAIN subscores, although there was no significant change from the 3-year scores. There was no between-group difference in the change in the KOOS_PAIN subscore from baseline to 5 years (3.2 points [95% CI, –6.1 to 12.4]; adjusted P = .403). In the surgery group, improvement was greater in patients without mechanical symptoms than in those with mechanical symptoms (mean difference, 18.4 points [95% CI, 8.7 to 28.1]; P < .001). Radiographic deterioration occurred in 60% of patients in the surgery group and 37% of those in the nonsurgery group (P = .060).

Conclusion:

Knee arthroscopic surgery combined with an exercise program provided no additional long-term benefit after 5 years compared with the exercise program alone in middle-aged patients with meniscal symptoms. Surgical outcomes were better in patients without mechanical symptoms than in patients with mechanical symptoms during the preoperative period. Radiographic changes did not differ between treatment groups.

Registration:

NCT01288768 (ClinicalTrials.gov identifier).

Effect of medial meniscus extrusion on arthroscopic surgery outcome in the osteoarthritic knee associated with medial meniscus tear: a minimum 4-year follow-up

Background:

The potential benefit of arthroscopic surgery for osteoarthritic knee associated with medial meniscus tear is controversial. This study was conducted to determine the effect of pre-operative medial meniscus extrusion (MME) on arthroscopic surgery outcomes in the osteoarthritic knee associated with medial meniscus tear during a minimum 4-year follow-up.

Methods:

This was a retrospective review of a total of 131 patients diagnosed with osteoarthritic knee associated with medial symptomatic degenerative meniscus tear who underwent arthroscopic surgery from January 2012 to December 2014 and were observed for more than 4 years. Patients were classified into two groups: MME ≥3 mm (major MME group, n = 54) and MME <3 mm (non-major MME group, n = 77). Clinical assessments, including the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, and radiographic assessments, including the Kellgren-Lawrence (K-L) grade and medial joint space width (JSW), were evaluated pre-operatively and at final follow-up. The longitudinal changes of clinical and radiographic parameters (WOMAC and the medial JSW change, K-L grade progression) were compared between groups unadjusted and adjusted for age, sex, and body mass index. Four-year survival rates (without progression to knee replacement [KR]) were also evaluated using a log-rank test and Cox proportional hazard regression model.

Results:

Major MME was present in 41% of patients. After a minimum 4-year follow-up, the mean WOMAC total and pain scores improved significantly in both groups. However, the medial JSW and K-L grade worsened significantly. Patients with pre-operative major MME worsened more in WOMAC total (adjusted mean difference [MD] 3.800, 95% confidence interval [CI]: 0.900, 11.400; P = 0.037) and function (adjusted MD 3.100, 95% CI: 0.700, 6.300; P = 0.038) scores than patients with pre-operative non-major MME, and no significant difference was observed in WOMAC pain and stiffness score between groups. The group with major MME had significantly higher joint space narrowing (adjusted MD −0.630, 95% CI: −1.250, −0.100; P = 0.021) and K-L rate progression (adjusted mean relative risk [RR] 1.310, 95% CI: 1.100, 1.600; P = 0.038) than the group with non-major MME. There was a significantly more KR progression in patients with major MME compared with those with non-major MME (adjusted RR 3.100, 95% CI: 1.100, 9.200; P = 0.042 and adjusted hazard ratio 3.500, 95% CI 1.100, 9.500; P = 0.022).

Conclusions:

Osteoarthritic knee patients associated with medial meniscus tear with non-major MME are more responsive to arthroscopic surgery in terms of the clinical and radiologic outcomes and survival for at least 4-year follow-up; however, in terms of pain relief, arthroscopic surgery in patients with major MME is also beneficial as well as in patients with non-major MME.

Subgroups of patients with osteoarthritis and medial meniscus tear or crystal arthropathy benefit from arthroscopic treatment

PURPOSE

The purpose of this study was to perform a systematic review of prospective randomized controlled trials comparing arthroscopic treatment for knee osteoarthritis (OA) with either other therapeutic interventions or sham treatment.

METHODS

A systematic search for randomized controlled trials (RCT) about arthroscopic treatment (AT) for knee OA was performed according to the PRISMA guidelines. Arthroscopic treatment included procedures such as lavage, debridement and partial meniscectomy of the knee. Data source was PubMed central.

RESULTS

Fourteen articles could be included. Five studies compared interventive AT with either sham surgery, lavage or diagnostic arthroscopy. Nine trials compared AT with another active intervention (exercise, steroid injection, hyaluronic acid injection). In ten trials, the clinical scores improved after arthroscopic treatment of knee OA in comparison to the baseline. In seven trials, there was a significant difference in the final clinical outcome with higher scores for patients after arthroscopic OA treatment in comparison to a control group. In four trials, the intention to treat analysis revealed no significant difference between arthroscopic OA treatment and the control group. In one of those trials, which compared arthroscopic partial meniscectomy (APM) with exercise, the cross over rate from exercise to AT was 34.9%. The clinical scores of cross-over patients improved after APM. In one study, the subgroup analysis revealed that patients with tears of the anterior two-thirds of the medial meniscus or any lateral meniscus tear had a higher probability of improvement after arthroscopic surgery than did patients with other intraarticular pathology. There was no difference in the side effects between patients with AT and the control group. Despite acceptable scores in the methodological quality assessment, significant flaws could be found in all studies. These flaws include bad description of the exact surgical technique or poor control of postoperative use of non-steroidal anti-inflammatory drugs (NSAID).

CONCLUSION

Results of RCTs comparing AT with other treatment options were heterogeneous. AT in OA patients is not useless because there is evidence that a subgroup of patients with non-traumatic flap tears of the medial meniscus or patients with crystal arthropathy benefit from arthroscopy. This topic has a high relevance because several health insurances do not reimburse arthroscopy for patients with OA anymore. The results of these randomized studies, however, should be interpreted with care because in many studies, the use of other therapeutic variables such as pain killers or NSAIDs was not controlled or reported.

LEVEL OF EVIDENCE

I.

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.

Arthroscopic Partial Meniscectomy Versus Physical Therapy for Degenerative Meniscus Lesions: How Robust Is the Current Evidence? A Critical Systematic Review and Qualitative Synthesis

PURPOSE

The purpose of this systematic review was to investigate study quality and risk of bias for randomized trials comparing partial meniscectomy with physical therapy in middle-aged patients with degenerative meniscus tears.

METHODS

A systematic review of Medline, Embase, Scopus, and Google Scholar was performed from 1990 through 2017. The inclusion criteria were at least 1 validated outcome score, and middle-aged patients (40 years and older) with a degenerative meniscus tear. Studies with a sham arm, and acute and concomitant injuries were excluded. Risk of bias was assessed with the Cochrane Risk of Bias Tool. The quality of studies was assessed with the Cochrane GRADE tool and quality assessment tool (Effective Public Health Practice Project). Publication bias was assessed by funnel plot and Egger's test. The I² statistics was calculated a measure of statistical heterogeneity.

RESULTS

Six studies were included, and all were assessed as having a high risk of bias. There was no publication bias (P = .23). All studies were downgraded (low, n = 5; very low, n = 1). The Effective Public Health Practice Project assessed 1 study as strong, 2 as moderate, and 3 as weak. The overall results demonstrated moderate to low quality of the included studies. The I² statistic was 96.2%, demonstrating substantial heterogeneity between studies.

CONCLUSIONS

The results of this systematic review strongly suggest that there is currently no compelling evidence to support arthroscopic partial meniscectomy versus physical therapy. The studies evaluated here exhibited a high risk of bias, and the weak to moderate quality of the available studies, the small sample sizes, and the diverse study characteristics do not allow any meaningful conclusions to be drawn. Therefore, the validity of the results and conclusions of prior systematic reviews and meta-analyses must be viewed with extreme caution. The quality of the available published literature is not robust enough at this time to support claims of superiority for either alternative, and both arthroscopic partial meniscectomy or physical therapy could be considered reasonable treatment options for this condition.

LEVEL OF EVIDENCE

Level II, systematic review of Level I and II studies.

Conundrum of mechanical knee symptoms: signifying feature of a meniscal tear?

Background

Mechanical knee symptoms are often considered important in the decision to perform knee arthroscopy on the suspicion of a meniscal tear. We investigated if presence of a meniscal tear at knee arthroscopy in adults is associated with presence of preoperative self-reported mechanical knee symptoms.

Methods

We used data from Knee Arthroscopy Cohort Southern Denmark (KACS). KACS consists of patients aged 18 years or older referred to knee arthroscopy on the suspicion of a meniscal tear at four recruiting hospitals between 1 February 2013 and 31 January 2015. Of 1259 invited patients, 908 (72%) replied to the baseline questionnaire. With 91 patients excluded, the study sample consisted of 641 and 176 patientswithandwithouta meniscal tear confirmed at surgery, respectively. Exposure was meniscal tear as determined by the knee surgeon during arthroscopy. Main outcomes were preoperative mechanical knee symptoms defined as self-reported catching/locking or self-reported inability to straighten knee fully.

Results

55% of all patients reported symptoms of catching/locking and 47% were unable to straighten their knee fully. Preoperative mechanical symptoms were equally prevalent in patientswithandwithouta meniscal tear (prevalence ratio catching/locking 0.89, 95% CI 0.77 to 1.03, and inability to straighten knee fully, prevalence ratio 1.02, 95% CI 0.84 to 1.23).

Interpretation

Patient-reported mechanical symptoms were equally common irrespective of presence or absence of a meniscal tear in patients undergoing arthroscopy for suspicion of a meniscal tear. Our findings suggest that mechanical knee symptoms have a limited value when considering indication for meniscal surgery.

Trial registration number

NCT01871272; Results.

Change in patient-reported outcomes in patients with and without mechanical symptoms undergoing arthroscopic meniscal surgery: A prospective cohort study

OBJECTIVE

Patients with degenerative or traumatic meniscal tears are at high risk of developing knee osteoarthritis. We investigated if younger (≤40 years) and older (>40 years) patients with preoperative mechanical symptoms (MS) improved more in patient-reported outcomes after meniscal surgery than those without MS.

DESIGN

Patients from Knee Arthroscopy Cohort Southern Denmark (KACS) undergoing arthroscopic surgery for a meniscal tear completed online questionnaires before surgery, and at 12 and 52 weeks follow-up. Questionnaires included self-reported presence of MS (i.e., sensation of catching and/or locking) and the Knee injury and Osteoarthritis Outcome Score (KOOS). We analyzed between-group differences in change in KOOS₄ from baseline to 52 weeks, using an adjusted mixed linear model.

RESULTS

150 younger patients (mean age 31 (SD 7), 67% men) and 491 older patients (mean age 54 (SD 9), 53% men) constituted the baseline cohorts. Patients with MS generally had worse self-reported outcomes before surgery. At 52 weeks follow-up, younger patients with preoperative MS had improved more in KOOS₄ scores than younger patients without preoperative MS (adjusted mean difference 10.5, 95% CI: 4.3, 16.6), but did not exceed the absolute postoperative KOOS₄ scores observed for those without MS. No difference in improvement was observed between older patients with or without MS (adjusted mean difference 0.7, 95% CI: -2.6, 3.9).

CONCLUSIONS

Younger patients (≤40 years) with preoperative MS experienced greater improvements after arthroscopic surgery compared to younger patients without MS. Our observational study result needs to be confirmed in randomized trials.

KNEES-ACL has superior responsiveness compared to the most commonly used patient-reported outcome measures for anterior cruciate ligament injury

PURPOSE

For clinical trials, it is essential that measures are sensitive to change. The aim of this study was to conduct a head-to-head comparison of responsiveness of four PROMs used to measure outcome after anterior cruciate ligament (ACL) reconstruction. The PROMs compared were the knee injury osteoarthritis outcome score (KOOS), the international knee documentation committee subjective form (IKDC), the Lysholm score, and the knee numeric-entity evaluation score (KNEES-ACL). We hypothesized that KNEES-ACL would be more responsive than the other PROMs, as KNEES-ACL was created based on patient interviews and validated using Rasch analysis.

METHODS

One-hundred and sixty-six consecutive adults completed the four PROMs before and 3, 6, and 12 months after ACL-reconstructive surgery. Responsiveness was calculated as Cohen's Effect Size and Standardized Response Means. Bootstrapping was used to generate 95% confidence intervals for comparisons of responsiveness across PROMs. Repeated-measures ANOVA was also computed for each PROM.

RESULTS

The largest effect sizes at 12 months were seen for KNEES-ACL_{Sports-Behaviour} (1.35, p < 0.001) and KNEES-ACL_{Sports-Physical} (1.19, p < 0.001), the smallest for KOOS_ADL (0.35, p < 0.001) and KOOS_Symptoms (0.39, p < 0.001). IKDC and Lysholm lay between these with IKDC slightly more responsive. Head-to-head comparisons of similar subscales of KOOS and KNEES-ACL showed substantial differences in effect size in the domains of symptoms (0.69, p < 0.001), daily activities (0.31, p = 0.005), and Sports activity (0.63, p = 0.013) all in favour of KNEES-ACL.

CONCLUSION

These results demonstrate superior responsiveness for KNEES-ACL, which is the only PROM that has been constructed through exhaustive patient feedback and validated for patients with ACL deficiency using the most stringent psychometric methods (Rasch analysis). KNEES-ACL is the most precise and accurate PROM for patients with ACL injury and the most trustworthy instrument for clinicians and clinical researchers.

LEVEL OF EVIDENCE

Prospective cohort study, Level II.

Patient-reported symptoms and changes up to 1 year after meniscal surgery

Background and purpose - Detailed information on the symptoms and limitations that patients with meniscal tears experience is lacking. This study was undertaken to map the most prevalent self-reported symptoms and functional limitations among patients undergoing arthroscopic meniscal surgery and investigate which symptoms and limitations had improved most at 1 year after surgery. Patients and methods - Patients aged 18-76 years from the Knee Arthroscopy Cohort Southern Denmark (KACS) undergoing arthroscopic meniscal surgery were included in this analysis of individual subscale items from the Knee Injury and Osteoarthritis Outcome Score and 1 question on knee stability. Severity of each item was scored as none, mild, moderate, severe, or extreme. Improvements were evaluated using Wilcoxon's signed-rank test and effect size (ES). Results - The most common symptoms were knee grinding and clicking, knee pain in general, pain when twisting and bending the knee and climbing stairs (88-98%), while the most common functional limitations were difficulty bending to the floor, squatting, twisting, kneeling, and knee awareness (97-99%). Knee pain in general and knee awareness improved most 1 year after meniscal surgery (ES -0.47 and -0.45; p < 0.001), while knee instability and general knee difficulties improved least (ES 0.10 and -0.08; p < 0.006). Interpretation - Adults undergoing surgery for a meniscal tear commonly report clinical symptoms and functional limitations related to their daily activities. Moderate improvements were observed in some symptoms and functional limitations and small to no improvement in others at 1 year after surgery. These findings can assist the clinical discussion of symptoms, treatments, and patients' expectations.

Meniscal allograft transplantation using a novel all-arthroscopic technique with specifically designed instrumentation

The present study describes a novel all-arthroscopic technique for medial and lateral meniscal allograft transplantation (MAT). Surgical instruments were specifically designed to assist in the all-arthroscopic approach for MAT. The bone plug attachment technique, either the arthroscopic-assisted or all-arthroscopic approach, attaches bone plugs to the anterior and posterior horns. In the present study, two sets of surgical implements were designed: One to produce bone plugs of predefined sizes in the anterior and posterior horns of the allograft meniscus (bone plug implements) and a second to create bone tunnels in the receptor tibial plateau to hold the bone plugs (bone tunnel implements). The present study demonstrated that an all-arthroscopic approach to MAT was feasible. Furthermore, the specifically designed surgical instruments allowed for consistent preparation of grafts and recipient tissues, contributing to a standardized approach to MAT. The present findings indicate that an all-arthroscopic approach to MAT may be achievable. They also provide the incentive for future clinical studies to directly compare the outcomes and to initiate the standardization of the procedure to optimize MAT and maximize patient outcomes and quality of life.

Arthroscopic partial meniscectomy versus placebo surgery for a degenerative meniscus tear: a 2-year follow-up of the randomised controlled trial

OBJECTIVE

To assess if arthroscopic partial meniscectomy (APM) is superior to placebo surgery in the treatment of patients with degenerative tear of the medial meniscus.

METHODS

In this multicentre, randomised, participant-blinded and outcome assessor-blinded, placebo-surgery controlled trial, 146 adults, aged 35-65 years, with knee symptoms consistent with degenerative medial meniscus tear and no knee osteoarthritis were randomised to APM or placebo surgery. The primary outcome was the between-group difference in the change from baseline in the Western Ontario Meniscal Evaluation Tool (WOMET) and Lysholm knee scores and knee pain after exercise at 24 months after surgery. Secondary outcomes included the frequency of unblinding of the treatment-group allocation, participants' satisfaction, impression of change, return to normal activities, the incidence of serious adverse events and the presence of meniscal symptoms in clinical examination. Two subgroup analyses, assessing the outcome on those with mechanical symptoms and those with unstable meniscus tears, were also carried out.

RESULTS

In the intention-to-treat analysis, there were no significant between-group differences in the mean changes from baseline to 24 months in WOMET score: 27.3 in the APM group as compared with 31.6 in the placebo-surgery group (between-group difference, -4.3; 95% CI, -11.3 to 2.6); Lysholm knee score: 23.1 and 26.3, respectively (-3.2; -8.9 to 2.4) or knee pain after exercise, 3.5 and 3.9, respectively (-0.4; -1.3 to 0.5). There were no statistically significant differences between the two groups in any of the secondary outcomes or within the analysed subgroups.

CONCLUSIONS

In this 2-year follow-up of patients without knee osteoarthritis but with symptoms of a degenerative medial meniscus tear, the outcomes after APM were no better than those after placebo surgery. No evidence could be found to support the prevailing ideas that patients with presence of mechanical symptoms or certain meniscus tear characteristics or those who have failed initial conservative treatment are more likely to benefit from APM.

Arthroscopic meniscectomy for degenerative meniscal tears reduces knee pain but is not cost-effective in a routine health care setting: a multi-center longitudinal observational study using data from the osteoarthritis initiative

OBJECTIVES

It is disputed whether arthroscopic meniscectomy is an (cost-) effective treatment for degenerative meniscus tears in day-to-day clinical practice. The objective of this study was to assess the cost-effectiveness of arthroscopic meniscectomy in subjects with knee osteoarthritis, in routine clinical practice, while taking into account the increased risk for future knee replacement surgery. We compared cost-effectiveness of arthroscopic meniscectomy compared to no surgery.

DESIGN

We used a state transition (Markov) simulation model to evaluate the cost-effectiveness of arthroscopic meniscectomy compared to no surgery in subjects with knee osteoarthritis (age range 45-79 years). Data used in the preparation of the current study were obtained from the Osteoarthritis Initiative (AOI) database. We applied a 9 years' time horizon (which is equal to the current OAI study follow up period), and evaluated cost-effectiveness from a societal perspective. The main outcome measure was the incremental cost-effectiveness ratio (Euros per quality adjusted life-year (QALY) gained).

RESULTS

Arthroscopic meniscectomy was associated with 8.09 (SD ± 0.07) QALYs at a cost of € 21,345 (SD ± 841), whereas the no surgery was associated with 8.05 (SD ± 0.07) QALYs at a cost of € 16,284 (SD ± 855). For arthroscopic meniscectomy, the incremental cost per QALY gained was € 150,754.

CONCLUSIONS

In day-to-day clinical practice, arthroscopic meniscectomy in subjects with knee osteoarthritis is associated with € 150,754 per QALY gained, which exceeds the generally accepted willingness to pay (WTP) (range € 20,000-€ 80,000).

Middle-aged patients with an MRI-verified medial meniscal tear report symptoms commonly associated with knee osteoarthritis

Background and purpose - No consensus exists on when to perform arthroscopic partial meniscectomy in patients with a degenerative meniscal tear. Since MRI and clinical tests are not accurate in detecting a symptomatic meniscal lesion, the patient's symptoms often play a large role when deciding when to perform surgery. We determined the prevalence and severity of self-reported knee symptoms in patients eligible for arthroscopic partial meniscectomy due to a degenerative meniscal tear. We investigated whether symptoms commonly considered to be related to meniscus injury were associated with early radiographic signs of knee osteoarthritis. Patients and methods - We included individual baseline items from the Knee injury and Osteoarthritis Outcome Score collected in 2 randomized controlled trials evaluating treatment for an MRI-verified degenerative medial meniscal tears in 199 patients aged 35-65 years. Each item was scored as no, mild, moderate, severe, extreme, and at least "mild" considering the symptoms present. Early radiographic signs of osteoarthritis, defined as a Kellgren and Lawrence grade of at least 1, were seen in 70 patients. Results - At least monthly knee pain, pain during stair walking and when twisting on the knee, and lack of confidence in knee was present in at least 80% of the patients. Median severity was at least moderate for knee pain, pain when twisting on the knee, pain walking on stairs, lack of confidence in knee, and clicking. Mechanical symptoms such as catching were rare. Early radiographic signs of osteoarthritis were associated with an increased risk of self-reported swelling, catching, and stiffness later in the day; the odds ratio was 2.4 (95% CI 1.2-4.9), 2.3 (1.2-4.3), and 2.3 (1.1-5.0), respectively. Interpretation - Middle-aged patients with a degenerative medial meniscus tear reported symptoms commonly associated with knee osteoarthritis. Frequent knee pain, presence of lack of confidence in the knee, and clicking did not distinguish those with a meniscal tear alone from those with early radiographic knee OA. Our findings support the notion that symptoms reported by those with a degenerative meniscal tear represent early signs of knee osteoarthritis.

Can we predict the clinical outcome of arthroscopic partial meniscectomy? A systematic review

NHS-Prospero registration number

42016048592

Objective

In order to make a more evidence-based selection of patients who would benefit the most from arthroscopic partial meniscectomy (APM), knowledge of prognostic factors is essential. We conducted a systematic review of predictors for the clinical outcome following APM.

Design

Systematic review

Data sources

Medline, Embase, Cochrane Central Register, Web of Science, SPORTDiscus, PubMed Publisher, Google Scholar

Inclusion criteria

Report an association between factor(s) and clinical outcome; validated questionnaire; follow-up >1 year.

Exclusion criteria

<20 subjects; anterior cruciate ligament-deficient patients; discoid menisci; meniscus repair, transplantation or implants; total or open meniscectomy.

Methods

One reviewer extracted the data, two reviewers assessed the risk of bias and performed a best-evidence synthesis.

Results

Finally, 32 studies met the inclusion criteria. Moderate evidence was found, that the presence of radiological knee osteoarthritis at baseline and longer duration of symptoms (>1 year) are associated with worse clinical outcome following APM. In addition, resecting >50% of meniscal tissue and leaving a non-intact meniscal rim after meniscectomy are intra-articular predictive factors for worse clinical outcome. Moderate evidence was found that sex, onset of symptoms (acute or chronic), tear type or preoperative sport level are not predictors for clinical outcome. Conflicting evidence was found for the prognostic value of age, perioperative chondral damage, body mass index and leg alignment.

Summary/conclusion

Long duration of symptoms (>1 year), radiological knee osteoarthritis and resecting >50% of meniscus are associated with a worse clinical outcome following APM. These prognostic factors should be considered in clinical decision making for patients with meniscal tears.

Inappropriate use of arthroscopic meniscal surgery in degenerative knee disease

Background and purpose - Current evidence suggests that arthroscopic knee surgery has no added benefit compared with non-surgical management in degenerative meniscal disease. Yet in many countries, arthroscopic partial meniscectomy (APM) remains among the most frequently performed surgeries. This study quantifies and characterizes the dynamics of the current use of knee arthroscopies in Switzerland in a distinctively non-traumatic patient group. Methods - We assessed a non-accident insurance plan of a major Swiss health insurance company for surgery rates of APM, arthroscopic debridement and lavage in patients over the age of 40, comparing the years 2012 and 2015. Claims were analyzed for prevalence of osteoarthritis, related interventions and the association of surgery with insurance status. Results - 648,708 and 647,808 people were examined in 2012 and 2015, respectively. The incidence of APM, debridement, and lavage was 388 per 10⁵ person-years in 2012 and 352 per 10⁵ person-years in 2015 in non-traumatic patients over the age of 40, consisting mostly of APM (96%). Between years, APM surgery rates changed in patients over the age of 65 (p < 0.001) but was similar in patients aged 40-64. Overall prevalence of osteoarthritis was 25%. Insurance status was independently associated with arthroscopic knee surgery. Interpretation - APM is widely used in non-traumatic patients in Switzerland, which contrasts with current evidence. Many procedures take place in patients with degenerative knee disease. Surgery rates were similar in non-traumatic middle-aged patients between 2012 and 2015. Accordingly, the potential of inappropriate use of APM in non-traumatic patients in Switzerland is high.

Patients Older Than 40 Years With Unilateral Occupational Claims for New Shoulder and Knee Symptoms Have Bilateral MRI Changes

BACKGROUND

Minor events that occur in the workplace sometimes are evaluated with MRI, which may reveal age-related changes in the symptomatic body part. These age-related changes are often ascribed to the event. However, evidence of similar or worse pathophysiology in the contralateral joint would suggest that the symptoms might be new, but the pathophysiology is not.

QUESTIONS/PURPOSES

Using a convenience sample of occupational injury claimants with bilateral MRI to evaluate unilateral knee or shoulder symptoms ascribed to a single event at work, we sought to determine whether MRI findings of the shoulder and knee are more often congruent or incongruent with new unilateral symptoms.

METHODS

Two hundred ninety-four occupational injury claimants employed at companies throughout Texas that do not subscribe to workers' compensation insurance, who were older than 40 years, and with unilateral shoulder or knee symptoms, were studied. Starting in 2012, all patients seen by OccMD Group PA who present with unilateral symptoms ascribed to work undergo bilateral MRI, based on several previous occasions where bilateral MRI proved to be a compelling demonstration that perceived injuries are more likely age-related, previously well-adapted pathophysiology. MRI findings (anything described as abnormal by the radiologist; eg, defect size or signal change) was considered congruent if the abnormality of one or more structures on the symptomatic side was greater than that of the corresponding structures in the asymptomatic joint. Bivariate analysis was used to compare the frequency of MRI findings congruent and incongruent with symptoms. Logistic regression was used to evaluate factors associated with MRI findings of the shoulder or knee.

RESULTS

Less than half of the patients with shoulder (90 of 189; 48%; p = 0.36) or knee (45 of 105; 43%; p = 0.038) symptoms had worse pathologic features on the symptomatic side. Older age was associated with disorders in the infraspinatus tendon (59 ± 8 versus 56 ± 8 years; p = 0.012), glenoid labrum (60 ± 9 versus 57 ± 8 years; p = 0.025), and biceps tendon (60 ± 8 versus 57 ± 8 years; p = 0.0038). Eighty-seven percent of patients (91 of 105) had structural changes in the medial meniscus described by the radiologist.

CONCLUSIONS

Occupational injury claimants 40 years of age and older with unilateral knee and shoulder symptoms ascribed to a work event tend to have bilateral age-related MRI changes. Age-related disorders should be distinguished from acute injury.

LEVEL OF EVIDENCE

Level IV, diagnostic study.

Knee Arthroscopic Surgery in Middle-Aged Patients With Meniscal Symptoms: A 3-Year Follow-up of a Prospective, Randomized Study

BACKGROUND

The optimal treatment for middle-aged patients with knee pain and meniscal lesions has been extensively debated. Most previous studies have revealed only short-term beneficial results of knee arthroscopic surgery. The authors have previously shown a positive benefit of knee arthroscopic surgery and an exercise program after 1 year when compared with an exercise program alone.

PURPOSE

To evaluate if knee arthroscopic surgery combined with an exercise program provided an additional long-term benefit after 3 years compared with an exercise program alone in middle-aged patients with meniscal symptoms.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

Of 179 eligible patients, aged 45 to 64 years, 150 were randomized to (1) a 3-month exercise program (nonsurgery group) or (2) the same as group 1 plus knee arthroscopic surgery within 4 weeks (surgery group). The primary outcome was the change in the Knee Injury and Osteoarthritis Outcome Score (KOOS) subscore of pain between baseline and the 3-year follow-up. Results from the 1-year follow-up have been published previously.

RESULTS

Both treatment groups improved significantly in the KOOS pain subscore at 3 years' follow-up in the intention-to-treat and as-treated analyses ( P < .001). The between-group difference for the change in the KOOS pain subscore between baseline and the 3-year follow-up was no longer statistically significant, neither in the intention-to-treat analysis (7.6 points; 95% CI, -0.6 to 15.9; P = .068) nor in the as-treated analysis (5.3 points; 95% CI, -3.1 to 13.8; P = .216). The factorial analysis of the effect of the intervention and age, onset of pain, and mechanical symptoms indicated that older patients improved more, regardless of treatment, and surgery may be more beneficial for patients without mechanical symptoms (as-treated analysis). The effect of the predictive factors on the KOOS pain subscore was uncertain because of the small sample size in the subgroup analyses.

CONCLUSION

The benefit of knee arthroscopic surgery, seen at 1 year in middle-aged patients with meniscal symptoms, was diminished at 3 years and was no longer statistically significant.

CLINICAL RELEVANCE

Knee arthroscopic surgery may be beneficial for middle-aged patients with meniscal symptoms in addition to an exercise program. Older age and absence of mechanical symptoms should not be contraindications to surgery. Registration: NCT01288768 ( ClinicalTrials.gov identifier).

Signs of knee osteoarthritis common in 620 patients undergoing arthroscopic surgery for meniscal tear

Background and purpose - Recent evidence has questioned the effect of arthroscopic knee surgery for middle-aged and older patients with degenerative meniscal tears with or without concomitant radiographic knee osteoarthritis (OA). We investigated the prevalence of early or more established knee OA and patients' characteristics in a cohort of patients undergoing arthroscopic surgery for a meniscal tear. Patients and methods - 641 patients assigned for arthroscopy on suspicion of meniscus tear were consecutively recruited from February 2013 through January 2015. Of these, 620 patients (mean age 49 (18-77) years, 57% men) with full datasets available were included in the present study. Prior to surgery, patients completed questionnaires regarding onset of symptoms, duration of symptoms, and mechanical symptoms along with the knee injury and osteoarthritis outcome score (KOOS). At arthroscopy, the operating surgeon recorded information about meniscal pathology and cartilage damage. Early or more established knee OA was defined as the combination of self-reported frequent knee pain, cartilage damage, and the presence of degenerative meniscal tissue. Results - 43% of patients (269 of 620) had early or more established knee OA. Of these, a large proportion had severe cartilage lesions with almost half having a severe cartilage lesion in at least 1 knee compartment. Interpretation - Based on a definition including frequent knee pain, cartilage damage, and degenerative meniscal tissue, early or more established knee OA was present in 43% of patients undergoing knee arthroscopy for meniscal tear.

A Special Tear Pattern of Anterior Horn of the Lateral Meniscus: Macerated Tear

BACKGROUND

We describe a special, interesting phenomenon found in the anterior horn of the lateral meniscus (AHLM): most tear patterns in the AHLM are distinctive, with loose fibers in injured region and circumferential fiber bundles were separated. We name it as macerated tear. The goal of this study was to bring forward a new type of meniscal tear in the AHLM and investigate its clinical value.

MATERIALS AND METHODS

AHLM tears underwent arthroscopic surgery from January 2012 to December 2014 were included. Data regarding the integrity of AHLM were prospectively recorded in a data registry. Tear morphology and treatment received were subsequently extracted by 2 independent reviewers from operative notes and arthroscopic surgical photos.

RESULTS

A total of 60 AHLM tears in 60 patients (mean age 27.1 years) were grouped into horizontal tears (n = 15, 25%), vertical tears (n = 14, 23%), complex tears (n = 6, 10%), and macerated tears (n = 25, 42%). There were 6 patients with AHLM cysts in macerated tear group and one patient in vertical tear group. 60 patients were performed arthroscopic meniscus repairs and were followed-up with averaged 18.7 months. Each group had significant postoperative improvement in Lysholm and IKDC scores (p < 0.05). However, the macerated tear group showed least functional recovery of Lysholm and IKDC scores compared to other groups (p < 0.05). In addition, there were no differences in postoperative range of motion, return to work, or return to sport/other baseline activities between the four groups (p > 0.05).

CONCLUSIONS

This study demonstrated that the macerated tear is common in the tear pattern of AHLM. However, feasibility of the treatment of this type of meniscal tear, especially the meniscus repairs still requires further study.

Development of a Chinese version of the Western Ontario Meniscal Evaluation Tool: cross-cultural adaptation and psychometric evaluation

Background

The Western Ontario Meniscal Evaluation Tool (WOMET) is a questionnaire designed to evaluate the health-related quality of life (HRQOL) of patients with meniscal pathology. Our study aims to culturally adapt and validate the WOMET into a Chinese version.

Methods

We translated the WOMET into Chinese. Then, a total of 121 patients with meniscal pathology were invited to participate in this study. To assess the test-retest reliability, the Chinese version WOMET was completed twice at 7-day intervals by the participants. The construct validity was assessed using Pearson’s correlation coefficient or Spearman’s correlation to test for correlations among the Chinese version WOMET and the eight domains of Short Form-36 (SF-36), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and the International Knee Documentation Committee (IKDC) score. Responsiveness was tested by comparison of the preoperative and postoperative scores of the Chinese version WOMET.

Results

The test-retest reliability of the overall scale and different domains were all found to be excellent. The Cronbach’s α was 0.90. The Chinese version WOMET correlated well with other questionnaires which suggested good construct validity. We observed no ceiling and floor effects of the Chinese version WOMET. We also found good responsiveness for the effect size, and the standardized response mean values were 0.86 and 1.11.

Conclusions

The Chinese version of the WOMET appears to be reliable and valid in evaluating patients with meniscal pathology.

Determinants of knee replacement in subjects with a history of arthroscopy: data from the osteoarthritis initiative

OBJECTIVE

To investigate the risk and determinants of knee replacement (KR) in subjects with or at risk of osteoarthritis (OA) and a history of arthroscopy.

METHODS

Data from the osteoarthritis initiative cohort were analyzed (n = 4796, up to the seventh year of follow-up). Cox proportional hazard analysis was used to determine the risk of KR according to the history of arthroscopy. A multivariable model was used to determine the risk factors for KR among subjects with a history of arthroscopy (n = 842), including age, gender, body mass index, history of knee injury, and baseline physical activity scale for the elderly, Western Ontario and McMaster (WOMAC) total score, and radiographic Kellgren and Lawrence (KL) score.

RESULTS

History of arthroscopy was associated with risk of KR after adjustments for the mentioned determinants of OA (HR: 1.90 (1.49-2.44); P value <0.001). Female gender (HR: 1.86 (1.30-2.68); P value <0.001), higher WOMAC (HR: 1.02 (1.01-1.03); P value <0.001), and KL score (HR: 2.64 (2.08-3.35); P value <0.001) increased the risk of KR among subjects with a history of arthroscopy. Subjects with a history of knee injury had 50 % lower risk of KR (HR: 0.50 (0.35-0.72); P value <0.001) after arthroscopy.

CONCLUSION

Female gender, more clinical symptoms and radiographic signs of OA, was associated with higher risk of future KR in subjects with a history of arthroscopy. Subjects with arthroscopy in the setting of concomitant knee injury were 50 % less likely to undergo KR compared to subjects who underwent arthroscopy without a history of concomitant knee injury.

A Web-Based Platform for Patients With Osteoarthritis of the Hip and Knee: A Pilot Study

Background

Chronic conditions are the leading cause of disability throughout the world and the most expensive problem facing the health care systems. One such chronic condition is osteoarthritis (OA), a frequent cause of major disability.

Objective

To describe the effect on joint pain for the first users of a newly developed Web-based osteoarthritis self-managing program, Joint Academy, and to examine whether these patients would recommend other OA patients to use the program.

Methods

Patients with clinically established knee or hip OA according to national and international guidelines were recruited from an online advertisement. A trained physiotherapist screened the eligible patients by scrutinizing their answers to a standardized questionnaire. The 6-week program consisted of eight 2- to 5-minute videos with lectures about OA, effects of physical activity, self-management, and coping strategies. In addition, exercises to improve lower extremity physical function were introduced in daily video activities. During the course of the program, communication between physiotherapist and patients was based on an asynchronous chat. After 6 weeks, patients were able to continue without support from the physiotherapist. Patients reported their current pain weekly by using a numeric rating scale (range 0-10; 0=no pain, 10=worst possible pain) as long as they were in the program. In addition, after 6 weeks patients answered the question “What is the probability that you would recommend Joint Academy to a friend?”

Results

The eligible cohort consisted of 53 individuals (39 women; body mass index: mean 27, SD 5; age: mean 57, SD 14 years). With the continued use of the program, patients reported a constant change in pain score from mean 5.1 (SD 2.1) at baseline to mean 3.6 (SD 2.0) at week 12. Six patients participated for 30 weeks (mean 3.2, SD 2.1). Overall, the patients would highly recommend Joint Academy to other OA patients, suggesting that the platform may be useful for at least some in the vast OA population.

Conclusions

Joint Academy, a Web-based platform for OA therapy, has the potential to successfully deliver individualized online treatment to many patients with OA that presently lack access to treatment.