Complex Tears, Extrusion, and Larger Excision Are Prognostic Factors for Worse Outcomes 1 and 2 Years After Arthroscopic Partial Meniscectomy for Degenerative Meniscal Tears: A Secondary Explorative Study of the Surgically Treated Group From the Odense-Oslo Meniscectomy Versus Exercise (OMEX) Trial

Preoperative Predictors of Arthroscopic Partial Meniscectomy Outcomes: The APM Index Score

BACKGROUND

Preoperative risk factors contributing to poor outcomes after arthroscopic partial meniscectomy (APM) have not yet been consolidated and codified into an index scoring system used to predict APM success.

PURPOSE

To create an index score using available preoperative factors to predict the likelihood of favorable postoperative outcomes after APM.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

A consecutive cohort of patients undergoing primary APM were enrolled in this study. Patients completed pre- and postoperative patient-reported outcome measure (PROM) questionnaires that included the Knee injury and Osteoarthritis Outcome Score (KOOS), visual analog scale (VAS) for pain, Veterans RAND 12-Item Health Survey (VR-12 Physical and Mental), and Marx Activity Rating Scale (MARS). Multivariable logistic regression models were performed to evaluate independent predictors of KOOS Pain, Symptoms, and Activities of Daily Living scores and achievement of the minimal clinically important difference (MCID) and substantial clinical benefit (SCB). The authors assigned points to each variable proportional to its odds ratio, rounded to the nearest integer, to generate the index score.

RESULTS

In total, 468 patients (mean age, 49 years [SD, 10.4 years; range, 19-81 years]) were included in this study. In the univariate analysis, shorter symptom duration, lower Kellgren-Lawrence (KL) grade, lower preoperative KOOS Pain value, and lower VR-12 Physical score were associated with a higher likelihood of clinical improvement at 1 year. In the multivariable model for clinical improvement with MCID, symptom duration (<3 months: OR, 3.00 [95% CI, 1.45-6.19]; 3-6 months: OR, 2.03 [95% CI, 1.10-3.72], compared with >6 months), KL grade (grade 0: OR, 3.54 [95% CI, 1.66-7.54]; grade 1: OR, 3.04 [95% CI, 1.48-6.26]; grade 2: OR, 2.31 [95% CI, 1.02-5.27], compared with grade 3), and preoperative KOOS Pain value (score <45: OR, 3.00 [95% CI, 1.57-5.76]; score of 45-60: OR, 2.80 [95% CI, 1.47-5.35], compared with score >60) were independent significant predictors for clinical improvement. The scoring algorithm demonstrated that a higher total score predicted a higher likelihood of achieving the MCID: 0 = 40%, 1 = 68%, 2 = 80%, 3 = 89%, and 4 = 96%.

CONCLUSION

Using this model, the authors developed an index score that, using preoperative factors, can help identify which patients will achieve clinical improvement after APM. Longer symptom duration and higher KL grade were associated with a decreased likelihood of clinical improvement as measured by KOOS Pain at 1 year postoperatively.

Outcomes of Meniscal Repair in Patients Aged 40 and Above: A Systematic Review

PURPOSE

Meniscal injuries are increasingly common in older age groups. Age is often cited as a contraindication to undergoing meniscal repair due to concerns regarding failure rates. There has recently, however, been an increasing shift towards repair in older populations. The purpose of this study was to review outcomes of meniscal repair in patients over the age of 40.

METHODS

A systematic search of the following databases was conducted of PubMed, SCOPUS, Web of Science, and Cochrane Library to identify studies reporting failure rates of patients over 40 with meniscal injuries undergoing repair. The definition of meniscus failure was noted for each study evaluated in this systematic review. Further data surrounding clinical and radiological outcomes were recorded and evaluated, when available.

RESULTS

Thirteen studies were included in this review, encompassing a total of 316 meniscal repairs in patients over the age of 40 years. The overall failure rate was found to be 15.5% (49/316) (range 0-33.3%). There was no difference in the failure rate in those over 40 vs. under 40, and the two groups had equivalent functional outcomes.

CONCLUSIONS

Age should not be considered a contra-indication for meniscal repair. Appropriately selected older patients can have acceptably low failure rates with meniscal repair and similar functional outcomes to those under the age of forty. Meniscal repairs in those over 40 achieved better functional outcomes than patients of the same age group who underwent meniscectomy.

"You're stuck in the middle here": a qualitative study of GPs' experiences of managing knee pain attributed to a degenerative meniscal tear

BACKGROUND

Exercise is the recommended first-line therapy for a degenerative meniscal tear (DMT). Despite this, knee pain attributed to DMTs are a common presentation to specialist orthopaedic clinics. In the primary care setting, the general practitioner (GP) plays a central role in managing patients with knee pain, but to date their perspective has not been explored in relation to DMTs. This study explored GPs' experiences of managing people with knee pain attributed to a DMT.

METHODS

A qualitative research design was adopted and practices in the South and Mid-West of Ireland were contacted via recruitment emails circulated through professional and research networks. Interested GPs contacted the researchers via email, and purposive and snowball sampling was used for recruitment. Semi-structured interviews were conducted online or over the telephone. Interviews were digitally recorded and transcribed. Data was analysed using an inductive approach to thematic analysis. Ethical approval was granted by the Irish College of General Practitioners (ICGP_REC_21_0031).

RESULTS

Seventeen semi-structured one-on-one interviews were conducted. Three main themes were identified with related subthemes: (1) GPs' experiences of relational aspects of care, (2) GP beliefs about what constitutes best care for patients with a DMT, and (3) how GP practice is enacted within the current healthcare setting. GPs described the challenge of maintaining a strong clinical alliance, while managing perceived patient expectations of a 'quick fix' and advanced imaging. They reported slowing down clinical decisions and feeling 'stuck' with limited options when conservative treatment had failed. GPs believed that exercise should be the core treatment for DMTs and emphasised engaging patients in an active approach to recovery. Some GPs believed arthroscopy had a role in circumstances where patients didn't improve with physiotherapy. Limited access to public physiotherapy and orthopaedic services hampered GPs' management plans and negatively impacted patient outcomes.

CONCLUSIONS

GP beliefs around what constitutes best care for a DMT generally aligned with the evidence base. Nonetheless, there was sometimes tension between these beliefs and the patient's own treatment expectations. The ability to enact their beliefs was hampered by limited access to conservative management options, sometimes leading to early escalation of care.

Age alone does not affect the joint survivorship after arthroscopic partial meniscectomy for degenerative medial meniscus tears: a propensity-score matched survival analysis

PURPOSE

To evaluate the effect of age itself on the joint survivorship after arthroscopic partial meniscectomy (APM) for degenerative medial meniscus tears (DMTs).

METHODS

Patients undergoing APM for DMTs during 1999-2010 were retrospectively reviewed. The inclusion criteria were as follows: (1) DMTs identified on preoperative MRI scans, (2) no definite history of trauma, and (3) follow-up duration more than 5 years. In evaluation of the joint survivorship, the endpoint was defined as conversion to arthroplasty (or realignment osteotomy) or progression to Kellgren-Lawrence grade 4. The study population was divided into older and younger groups by a cutoff age at which the difference in the joint survival rates was maximized, using a time-dependent receiver operating characteristic (ROC) curve. The two groups were then matched based on propensity scores. The joint survival rates were compared between the groups using Kaplan-Meier analysis, before and after propensity score matching (PSM).

RESULTS

A total of 633 knees were included. The cutoff age was calculated as 60 years. Before PSM, 239 knees were allocated to the older group (≥ 60 years) and 394 knees to the younger group (< 60 years). A significant difference in the joint survival rates was noted between the groups (log-rank test, p < 0.001). After PSM, 183 knees remained in each group. The difference in the survival rates was no more statistically significant (n.s.). The latest Lysholm scores of the older and the younger groups before PSM were 72.2 ± 20.8 and 79.9 ± 19.6, respectively (p < 0.001); however, the scores after PSM were 73.2 ± 20.3 and 77.4 ± 20.5, respectively (n.s.).

CONCLUSIONS

Joint survivorship after APM was affected by other factors associated with the aging process, such as cartilage status and meniscal tear pattern, rather than age itself. Advanced age should not be the only reason for precluding APM in treatment of DMTs. APM is a viable option when treating DMTs in elderly patients if adopted with caution. According to this study, a surgeon should assess the age-related factors when he considers APM in elderly patients.

LEVEL OF EVIDENCE

III.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

IV.

An individualized decision between physical therapy or surgery for patients with degenerative meniscal tears cannot be based on continuous treatment selection markers: a marker-by-treatment analysis of the ESCAPE study

PURPOSE

Marker-by-treatment analyses are promising new methods in internal medicine, but have not yet been implemented in orthopaedics. With this analysis, specific cut-off points may be obtained, that can potentially identify whether meniscal surgery or physical therapy is the superior intervention for an individual patient. This study aimed to introduce a novel approach in orthopaedic research to identify relevant treatment selection markers that affect treatment outcome following meniscal surgery or physical therapy in patients with degenerative meniscal tears.

METHODS

Data were analysed from the ESCAPE trial, which assessed the treatment of patients over 45 years old with a degenerative meniscal tear. The treatment outcome of interest was a clinically relevant improvement on the International Knee Documentation Committee Subjective Knee Form at 3, 12, and 24 months follow-up. Logistic regression models were developed to predict the outcome using baseline characteristics (markers), the treatment (meniscal surgery or physical therapy), and a marker-by-treatment interaction term. Interactions with p < 0.10 were considered as potential treatment selection markers and used these to develop predictiveness curves which provide thresholds to identify marker-based differences in clinical outcomes between the two treatments.

RESULTS

Potential treatment selection markers included general physical health, pain during activities, knee function, BMI, and age. While some marker-based thresholds could be identified at 3, 12, and 24 months follow-up, none of the baseline characteristics were consistent markers at all three follow-up times.

CONCLUSION

This novel in-depth analysis did not result in clear clinical subgroups of patients who are substantially more likely to benefit from either surgery or physical therapy. However, this study may serve as an exemplar for other orthopaedic trials to investigate the heterogeneity in treatment effect. It will help clinicians to quantify the additional benefit of one treatment over another at an individual level, based on the patient's baseline characteristics.

LEVEL OF EVIDENCE

II.

Maximum subjective outcome improvement is reported by 3 Months following arthroscopic partial meniscectomy: A systematic review

Purpose

To review patient outcomes in the literature following arthroscopic partial meniscectomy (APM) in order to identify when patients report reaching subjective maximal improvement postoperatively.

Methods

A systematic review of the literature from January 2004 to August 2019 was conducted using PRISMA guidelines to identify articles evaluating patient-reported outcome measures (PROMs) up to a minimum of 6 months after APM in patients >18 years old. Studies were excluded if additional interventions were performed such as repairs, ligamentous reconstruction or repair, cartilaginous manipulation, or revision surgery. PROMs were pooled between studies at preoperative, 3 months, 6 months, 1 year, and 2 year time points. Weighted averages were used within a mixed model method in order to account for the differences in sample size and variance among studies. Significant improvements in PROMs at various time intervals were statistically analyzed using minimal clinically important difference.

Results

A total of 12 studies including 1663 patients who underwent APM were selected for the review. The pooled cohort consisted of 1033 (62%) males and 630 (38%) females. Significant improvements were demonstrated from preoperative scores to 3 months postoperatively in Knee Injury and Osteoarthritis Outcome Score subcategories, Lysholm, and visual analog scale scores while no differences were found for Tegner and International Knee Documentation Committee scores. Although statistically significant improvement in PROMs remained at all postoperative time points compared to preoperative scores, no significant differences were observed after 3 months postoperatively.

Conclusions

Patients undergoing APM had significant mean changes in legacy PROMs by 3 months postoperatively that exceeded given minimal clinically important difference values, without further clinically important improvement reported up to 2 years postoperatively.

Study design

Level III, systematic review.

Arthroscopic partial meniscectomy: did it ever work?

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

On a Trajectory for Success-9 in Every 10 People With a Degenerative Meniscus Tear Have Improved Knee Function Within 2 Years After Treatment: A Secondary Exploratory Analysis of a Randomized Controlled Trial

OBJECTIVE

To identify trajectories of patient-reported knee function over 5 years in patients with degenerative meniscal tears, and to explore whether baseline characteristics were associated with trajectories of sport and recreational function.

DESIGN

Prospective cohort study.

METHODS

We conducted a secondary exploratory analysis of the Odense-Oslo Meniscectomy Versus Exercise randomized controlled trial. Patient-reported knee function was assessed with the Knee injury and Osteoarthritis Outcome Score (KOOS) at baseline, 3 months, 1 year, 2 years, and 5 years. We used group-based trajectory modeling to identify subgroups of patients who followed distinctive patterns of change. Multinomial logistic regression was used to examine the associations of patient demographics, knee function, and disease-related factors with KOOS sport and recreational function subscale trajectories.

RESULTS

The analysis of data from a sample of 140 participants identified 3 trajectories for all KOOS subscales: (1) low, minimal improvement (10%-12% of the participants), (2) moderate, gradual improvement (20%-36%), and (3) high, early improvement (53%-70%). Baseline prognostic factors for deteriorating function in sport and recreational activities were higher body mass index, poorer mental health, greater knee pain, lower perceived knee function, poorer quadriceps and hamstrings muscle strength, poorer functional performance, more meniscal extrusion, and radiographic signs of knee osteoarthritis.

CONCLUSION

We found 3 distinct trajectories of patient-reported knee function over 5 years: (1) low, minimal improvement, (2) moderate, gradual improvement, and (3) high, early improvement. Nine in every 10 participants improved at least gradually over 2 years after diagnosis of a degenerative meniscal tear. J Orthop Sports Phys Ther 2021;51(6):289-297. Epub 10 May 2021. doi:10.2519/jospt.2021.10025.

Sonographic evaluation of lateral meniscal extrusion: implementation and validation

INTRODUCTION

Meniscal extrusion (ME) is an important indicator of and prognostic factor for various knee pathologies. To date, no standardized protocol for the ultrasound-based examination of lateral ME exists. The purpose of the present study was to test the reliability and validity of lateral ME measurements using a standardized ultrasound-based examination protocol.

MATERIALS AND METHODS

A group consisting of 11 healthy volunteers (Group I, male and female, 18-45 years) as well as a group of 10 consecutive patients who had undergone all-inside lateral meniscal radial tear repair were included (Group II, male and female, 23-43 years). Lateral ME, the main outcome parameter, was measured by ultrasound (US; both groups) and magnetic resonance imaging (MRI; Group II only). Both knees of all subjects were examined in an unloaded state and under axial compression of the knee (50% of body weight). Repeated measurements obtained in Group I by 2 observers were used for reliability testing, and the validity of US was assessed through comparison with MRI data (Group II).

RESULTS

A total of 66 US images of Group I, obtained by each observer, were analyzed for reliability testing. Forty US and MR images of Group II were assessed for validation. Results showed good interrater (ICC = 0.904) and excellent intrarater (ICC = 0.942) reliability of US-based measurements of lateral ME. Agreement with MRI results was poor (ICC = 0.439), with US systematically overestimating results by 1.1 mm on average.

CONCLUSIONS

Ultrasound is a reliable, quick and cost-effective technique for lateral ME measurement, but results are not readily comparable with MRI.

TRIAL REGISTRATION

The study was registered in the European Union Clinical Trials Register (EudraCT-Number: 2017-005037-24).

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

IV.