Total meniscus replacement with a 3D printing of network hydrogel composite scaffold in a rabbit model

PURPOSE

The aim of this study was to evaluate the role of a novel total meniscal implant in promoting meniscal regeneration and protecting articular cartilage in a rabbit model for 3 and 6 months.

METHODS

Thirty-six New Zealand rabbits were selected and divided into poly(ɛ-caprolactone) (PG-Pg) scaffold group, meniscectomy group and sham group. In this study, it was investigated whether PG-Pg scaffold can prevent articular cartilage degeneration and promote tissue degeneration, and its mechanical properties at 3 and 6 months after surgery were also explored.

RESULT

The degree of articular cartilage degeneration was significantly lower in the PG-Pg scaffold group than in the meniscectomy group. The number of chondrocytes increased in the PG-Pg scaffold at 3 and 6 months, while a gradual increase in the mechanical properties of the PG-Pg stent was observed from 6 months.

CONCLUSION

The PG-Pg scaffold slows down the degeneration of articular cartilage, promotes tissue regeneration and improves biomechanical properties after meniscectomy. This novel meniscus scaffold holds promise for enhancing surgical strategies and delivering superior long-term results for individuals with severe meniscus tears.

LEVEL OF EVIDENCE

NA.

Arthroscopic Meniscal Repair and Meniscectomy for Adult Discoid Lateral Meniscus Results in Progression to Valgus Alignment and Lateral Compartment Degeneration Compared With Nonoperative Treatment and Nondiscoid Lateral Meniscus

PURPOSE

To analyze the effect of the arthroscopic meniscal procedure in adult discoid lateral meniscus (DLM) according to the age and meniscal-preserving by making comparisons with the nondiscoid lateral meniscus (N-DLM).

METHODS

From March 2014 to October 2020, a comparative analysis was performed in adults with DLM who underwent arthroscopic meniscal procedures (operative DLM: 134 knees), nonoperative treatment (nonoperative DLM: 56 knees), and adult N-DLM who underwent arthroscopic meniscal procedures (operative N-DLM: 64 knees). These patients were between 20 and 65 years old and completed a minimum follow-up of 2 years. Patients with DLM who underwent arthroscopic procedure were divided into subgroups according to age and extent of the meniscal-preserving. The following parameters were assessed and compared between the groups: (1) coronal limb alignment, (2) osteoarthritis grade, and (3) clinical outcomes and the minimal clinically important difference.

RESULTS

The coronal limb alignment was significantly changed to valgus in the order of operative DLM, N-DLM, and nonoperative DLM (Δ mechanical hip-knee-ankle angle: 3.23 ± 1.85 vs 1.35 ± 1.03° vs -0.57 ± 1.88°; P < .05). Operative DLM showed most prominent osteoarthritic change in the lateral compartment, followed by the N-DLM and nonoperative DLM groups (40.3% vs 17.2% vs 5.3%; P < .05). These changes in operative DLM were more prominent in older adults who underwent meniscal-sacrificing procedures and resulted in less-satisfactory clinical outcomes (all P < .05).

CONCLUSIONS

Arthroscopic surgery for adult DLM resulted in progression to valgus alignment and lateral compartment degeneration compared with nonoperative treatment and arthroscopic surgery of the adult N-DLM. Old ager and having a meniscal-sacrificing procedure showed more rapid radiographic changes and lower clinical outcomes.

LEVEL OF EVIDENCE

Level III, retrospective comparison study.

Osteoarthritis Development Following Meniscectomy vs. Meniscal Repair for Posterior Medial Meniscus Injuries: A Systematic Review

This systematic review aims to evaluate critically and synthesize the existing literature on the outcomes of meniscectomy versus meniscal repair for posterior medial meniscus injuries, with a focus on osteoarthritis (OA) development. We sought to assess the incidence of OA following both treatment modalities, compare functional outcomes post-treatment, and identify factors influencing treatment choice, providing evidence-based recommendations for clinical decision-making. A comprehensive search strategy was employed across PubMed, Scopus, and Embase up until December 2023, adhering to PRISMA guidelines. The primary outcomes included OA development, functional knee outcomes, and quality of life measures. Six studies met the inclusion criteria, encompassing 298 patients. The systematic review revealed a significant association between meniscal repair and decreased progression of OA compared to meniscectomy. Meniscectomy patients demonstrated a 51.42% progression rate towards OA, significantly higher than the 21.28% observed in meniscal repair patients. Functional outcomes, as measured by the International Knee Documentation Committee (IKDC) and Lysholm scores, were notably better in the repair group, with average scores of 74.68 (IKDC) and 83.78 (Lysholm) compared to 67.55 (IKDC) and 74.56 (Lysholm) in the meniscectomy group. Furthermore, the rate of complete healing in the repair group was reported at 71.4%, as one study reported, indicating a favorable prognosis for meniscal preservation. However, these pooled data should be interpreted with consideration to the heterogeneity of the analyzed studies. Meniscal repair for posterior medial meniscus injuries is superior to meniscectomy in preventing OA development and achieving better functional outcomes and quality of life post-treatment. These findings strongly suggest the adoption of meniscal repair as the preferred treatment modality for such injuries, emphasizing the need for a paradigm shift in clinical practice towards preserving meniscal integrity to optimize patient outcomes.

Arthroscopic partial meniscectomy for the degenerative meniscus tear: a comparison of patients included in RCTs and prospective cohort studies

BACKGROUND AND PURPOSE

Concerns exist regarding the generalizability of results from randomized controlled trials (RCTs) evaluating arthroscopic partial meniscectomy (APM) to treat degenerative meniscus tears. It has been suggested that study populations are not representative of subjects selected for surgery in daily clinical practice. Therefore, we aimed to compare patients included in trials and prospective cohort studies that received APM for a degenerative meniscus tear.

PATIENTS AND METHODS

Individual participant data from 4 RCTs and 2 cohort studies undergoing APM were collected. 1,970 patients were analyzed: 605 patients included in RCTs and 1,365 included in the cohorts. We compared patient and disease characteristics, knee pain, overall knee function, and health-related quality of life at baseline between the RCT and cohort groups using standardized differences, ratios comparing the variance of continuous covariates, and graphical methods such as quantile-quantile plots, side-by-side boxplots, and non-parametric density plots.

RESULTS

Differences between RCT and the cohort were observed primarily in age (younger patients in the cohort; standardized difference: 0.32) and disease severity, with the RCT group having more severe symptoms (standardized difference: 0.38). While knee pain, overall knee function, and quality of life generally showed minimal differences between the 2 groups, it is noteworthy that the largest observed difference was in knee pain, where the cohort group scored 7 points worse (95% confidence interval 5-9, standardized difference: 0.29).

CONCLUSION

Patients in RCTs were largely representative of those in cohort studies regarding baseline scores, though variations in age and disease severity were observed. Younger patients with less severe osteoarthritis were more common in the cohort; however, trial participants still appear to be broadly representative of the target population.

Health-economic evaluation of meniscus tear treatments: a systematic review

PURPOSE

To evaluate the overall evidence of published health-economic evaluation studies on meniscus tear treatment.

METHODS

Our systematic review focuses on health-economic evaluation studies of meniscus tear treatment interventions found in PubMed and Embase databases. A qualitative, descriptive approach was used to analyze the studies' results and systematically report them following PRISMA guidelines. The health-economic evaluation method for each included study was categorized following one of the four approaches: partial economic evaluation (PEE), cost-effectiveness analysis (CEA), cost-benefit analysis (CBA), or cost-utility analysis (CUA). The quality of each included study was assessed using the Consensus on Health Economic Criteria (CHEC) list. Comparisons of input variables and outcomes were made, if applicable.

RESULTS

Sixteen studies were included; of these, six studies performed PEE, seven studies CUA, two studies CEA, and one study combined CBA, CUA, and CEA. The following economic comparisons were analyzed and showed the respective comparative outcomes: (1) meniscus repair was more cost-effective than arthroscopic partial meniscectomy (meniscectomy) for reparable meniscus tear; (2) non-operative treatment or physical therapy was less costly than meniscectomy for degenerative meniscus tear; (3) physical therapy with delayed meniscectomy was more cost-effective than early meniscectomy for meniscus tear with knee osteoarthritis; (4) meniscectomy without physical therapy was less costly than meniscectomy with physical therapy; (5) meniscectomy was more cost-effective than either meniscus allograft transplantation or meniscus scaffold procedure; (6) the conventional arthroscopic instrument cost was lower than laser-assisted arthroscopy in meniscectomy procedures.

CONCLUSION

Results from this review suggest that meniscus repair is the most cost-effective intervention for reparable meniscus tears. Physical therapy followed by delayed meniscectomy is the most cost-effective intervention for degenerative meniscus tears. Meniscus scaffold should be avoided, especially when implemented on a large scale.

LEVEL OF EVIDENCE

Systematic review of level IV studies.

Strength-Based Rehabilitation on Clinical Outcomes in Patients Postpartial Meniscectomy: A Systematic Review and Meta-analysis

OBJECTIVE

The aim of the study is to determine the effect of strength-based rehabilitation programs on patients who underwent partial meniscectomy procedures.

DESIGN

Three databases MEDLINE, PubMed, and Embase were searched from inception to May 9, 2022. Data on functional outcomes such as quadriceps and hamstring strengths, as well as patient-reported outcomes such as Knee Osteoarthritis and Outcome Score and visual analog scale were recorded.

RESULTS

A total of nine studies comprising 417 patients were included in this review. There were no significant differences in quadriceps or hamstring strength measures between preinterventation and postintervention for both groups. Knee Osteoarthritis and Outcome Scores significantly increased from preintervention and postintervention in both control and exercise groups. Visual analog scale scores changed from 5.0 to 1.4 cm in the exercise arm and 3.1 to 1.9 cm in the control arm.

CONCLUSIONS

Strength-based exercise programs for patients postpartial meniscectomy did not result in significantly different improvements in quadriceps or hamstring strength compared with control programs. However, strength-based exercise programs resulted in significantly higher Knee Osteoarthritis and Outcome Scores and a greater decrease in visual analog scale scores. Further studies, specifically well-designed systematic randomized controlled trials, are necessary to elucidate the specifics behind what type of exercises to use in addition to load progression and frequency of training.

[Research progress of knee meniscal repair techniques]

Objective

To review the research progress of meniscus repair in recent years, in order to provide help for the clinical decision-making of meniscus injury treatment.

Methods

The domestic and foreign literature related to meniscal repair in recent years was extensively reviewed to summarize the reasons for the prevalence of meniscal repair, surgical indications, various repair methods and long-term effectiveness, the need to deal with mechanical structural abnormalities, biological enhancement repair technology, rehabilitation treatment, and so on.

Results

In order to delay the occurrence of osteoarthritis, the best treatment of meniscus has undergone an important change from partial meniscectomy to meniscal repair, and the indications for meniscal repair have been expanding. The mid- and long-term effectiveness of different meniscal repair methods are ideal. During meniscus repair, the abnormality of lower limb force line and meniscus protrusion should be corrected at the same time. There are controversies about the biological enhancement technology to promote meniscus healing and rehabilitation programs, which need further study.

Conclusion

Meniscal repair can restore the normal mechanical conduction of lower limbs and reduce the incidence of traumatic osteoarthritis, but the poor blood supply and healing ability of meniscal tissue bring difficulties to meniscal repair. Further development of new biological enhanced repair technology and individualized rehabilitation program and verification of its effectiveness will be an important research direction.

Has Arthroscopic Meniscectomy Use Changed in Response to the Evidence? A Large-database Study From Spain

BACKGROUND

Several randomized clinical trials on the treatment of meniscal tears have shown that surgery is not superior to nonoperative treatment in middle-aged and older adults. However, clinical practice has not changed consistently worldwide in response to this evidence, and arthroscopic meniscectomy remains one of the most frequently performed operations.

QUESTIONS/PURPOSES

(1) How has the use of arthroscopic meniscectomy changed in Spain between 2003 and 2018, particularly in middle-aged (35 to 59 years) and older patients (over 60 years) relative to younger patients? (2) How have surgical volumes changed across different healthcare areas in the same health system? (3) How has the proportion of outpatient versus inpatient arthroscopic procedures changed over time?

METHODS

Data on all 420,228 arthroscopic meniscectomies performed in Spain between 2003 and 2018 were obtained through the Atlas of Variations in Medical Practice project (these years were chosen because data in that atlas for 2002 and 2019 were incomplete). This database has been promoted by the Spanish Health Ministry since 2002, and it collects basic information on all admissions to public and public-private partnership hospitals. The Spanish population of 2003 was used to calculate age- and sex-standardized rates of interventions per 10,000 inhabitants and year. To assess the change in standardized rates among the age groups over the study period, a linear regression analysis was used. Standard small-area variation statistics were used to analyze variation among healthcare areas. Data on outpatient surgery and length of stay for inpatient procedures were also included.

RESULTS

The standardized rate of arthroscopic meniscectomy in Spain in 2003 was 4.8 procedures per 10,000 population (95% CI 3.9 to 5.6), while in 2018, there were 6.3 procedures per 10,000 population (95% CI 5.4 to 7.3), which represents an increase of 33%. Standardized rates increased slightly in the age group < 35 years (0.06 interventions per 10,000 inhabitants per year [95% CI 0.05 to 0.08]), whereas they increased more markedly in the age groups of 35 to 59 years (0.14 interventions per 10,000 inhabitants per year [95% CI 0.11 to 0.17]) and in those 60 years and older (0.13 interventions per 10,000 inhabitants per year [95% CI 0.09 to 0.17]). The variability among healthcare areas in the meniscectomy rate progressively decreased from 2003 to 2018. In 2003, 32% (6544 of 20,384) of knee arthroscopies were performed on an outpatient basis, while in 2018, these accounted for 67% (19,573 of 29,430).

CONCLUSION

We observed a progressive increase in arthroscopic meniscectomies in Spain; this procedure was more prevalent in older patients presumed to have degenerative pathologic findings. This increase occurred despite increasing high-level evidence of a lack of the additional benefit of meniscectomy over other less-invasive treatments in middle-aged and older people. Our study highlights the need for action in health systems with the use of financial, regulatory, or incentive strategies to reduce the use of low-value procedures, as well as interventions to disseminate the available evidence to clinicians and patients. Research is needed to identify the barriers that are preventing the reversal of interventions that high-quality evidence shows are ineffective.

LEVEL OF EVIDENCE

Level III, therapeutic study.

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

IMPORTANCE

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

OBJECTIVES

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

DESIGN, SETTING, AND PARTICIPANTS

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

INTERVENTIONS

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

MAIN OUTCOMES AND MEASURES

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

RESULTS

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

CONCLUSIONS AND RELEVANCE

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

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01850719.

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.

The effects of different repair methods for a posterior root tear of the lateral meniscus on the biomechanics of the knee: a finite element analysis

PURPOSE

To explore the impact of different repair methods for a lateral meniscus posterior root tear on the biomechanics of the knee joint using finite element analysis.

METHODS

Finite element models of a healthy knee were established on the basis of MRI data from a volunteer using Mimics software, and the validity of the models was tested. The changes in the contact mechanics and kinematics of these finite element models under different repair approaches were then analyzed and compared.

RESULTS

The normal meniscus had the maximum joint contact area, the minimum contact pressure, and the minimum contact stress. When total meniscectomy of the lateral meniscus was performed, the lateral compartment had the minimum joint contact area, the maximum contact pressure and the maximum contact stress. When complete avulsions of the posterior root of the lateral meniscus occurred, the maximum values of contact pressure and contact stress were between those of an intact meniscus and those of a meniscus treated with total meniscectomy. Lateral meniscal root attachment reconstruction by the single-stitch and double-stitch techniques resulted in a significant decrease in joint contact pressure and contact stress, leading to values comparable to those of a normal knee joint, and the double-stitch technique performed better than the single-stitch technique.

CONCLUSIONS

Repair surgery for lateral meniscal posterior root avulsions can effectively restore the contact mechanics and kinematics of the knee joint, and the double-stitch technique can result in better clinical outcomes than the single-stitch technique.

Reduced opioid prescribing following arthroscopic meniscectomy does not negatively impact patient satisfaction

BACKGROUND

Prior research has demonstrated that physician desire to optimize patient satisfaction is a cause of over-prescription of opioid medications in the healthcare setting. The purpose of this study was to investigate what effect, if any, decreased opioid prescribing following arthroscopic meniscectomy had on Press-Ganey (PG) satisfaction survey scores.

METHODS

A retrospective review of prospectively-collected data was conducted on patients who underwent arthroscopic meniscectomy between October2014-October2019. Inclusion criteria consisted of complete PG information, no history of trauma, connective tissue disease, or prior knee surgery. Groups were separated based on date of surgery relative to implementation of an institutional opioid reduction policy which occurred on October 1, 2018. Prescriptions were converted to milligram-morphine-equivalents (MME) for direct comparison between opioids. Minimal-Detectable-Change (MDC) was calculated to evaluate clinical significance of any statistically significant findings.

RESULTS

554 patients were included in this analysis (452pre-protocol, 102post-protocol). The groups did not differ statistically (p > 0.05) with respect to any patient demographics (age, BMI, sex, prior opioid use, opioid naivete) with the exception of smoking history; 54.4% in the pre-protocol group and 32.4%in the post-protocol group; p < 0.001. Mean discharge dose for the pre-protocol group was 229.3 ± 141MME, and 80.05 ± 82.7MME post-protocol; P < 0.0001. There were no statistically significant differences between pre-and-post-protocol satisfaction with pain control scores; P = 0.15. The differences between satisfaction with pain control did not meet clinical or statistical significance, based on a calculated MDC = 0.368. Among pre-protocol patients, 372(82.3%) gave a "top box" response to the question "degree-to-which-your-pain-was-controlled", compared to 91(89.2%) from the post-protocol group; P = 0.10.

CONCLUSION

A reduction in opioids prescribed after arthroscopic meniscectomy was not associated with any difference in patient satisfaction with pain management, as measured by the Press-Ganey survey. LOE: 3.

Clinical outcomes of meniscus repair and partial meniscectomy: Does tear configuration matter?

PURPOSE

We report our experience with the effect of location and configuration of meniscal tears on clinical outcomes.

METHODS

A retrospective review of patients who underwent partial meniscectomy or meniscal repair between 2008 and 2016 was conducted. One hundred fourteen knees in 106 patients were included, comprising 43 partial meniscectomies and 71 meniscal repairs. Patients were graded pre- and postoperatively with the International Knee Documentation Committee (IKDC) score and Tegner Activity Level Scale. Meniscal tears were classified according to location (anterior horn, body, posterior horn, and others) and type (radial, horizontal, longitudinal, and complex) and subgroups were analyzed for their effect on outcomes.

RESULTS

All tears, whether treated with partial meniscectomy or repair, showed significant improvement in postoperative scores (p < 0.05); 39.47% of tears involved the posterior horn alone, 10.53% involved the body alone, 3.51% involved the anterior horn alone, and 46.49% were complex tears that spanned more than one area. Complex tears treated with repair had significantly better scores (IKDC, p = 0.002; Tegner, p = 0.008) than complex tears treated with meniscectomy. Longitudinal tears showed results suggesting better short-term outcomes with meniscectomy than with repair (IKDC, p = 0.036; Tegner p = 0.018), a potential statistical anomaly. Horizontal and radial tears showed no significant difference in outcomes, regardless of treatment. Tears in different locations (anterior horn, body, posterior horn, and others) showed no significant difference in outcomes, regardless of treatment.

CONCLUSION

Meniscal surgery yields significant improvement in postoperative scores. Complex tears showed significantly better postoperative scores when treated with repair.

Medial and Lateral Meniscus Allograft Transplantation Showed No Difference With Respect to Graft Survivorship and Clinical Outcomes: A Comparative Analysis With a Minimum 2-Year Follow-Up

PURPOSE

To compare the differences with respect to clinical and graft survivorship and patient-reported outcomes (PROs) between lateral (LMAT) and medial (MMAT) meniscus allograft transplantation.

METHODS

Patients having a primary MAT between 1998 and 2016 were enrolled. The inclusion criteria were (1) patients who had a minimum 2-year follow-up and (2) patients who had magnetic resonance imaging (MRI) >2 years after surgery. Knees with localized grade 4 articular cartilage lesions >3 cm² at the time of MAT were excluded. Clinical failure was defined as follows: modified Lysholm score <65, meniscectomy >50% of the graft, meniscectomy to the meniscocapsular junction zone, conversion to revision MAT, or realignment osteotomy or arthroplasty. Graft failure was defined as follows: tears involving >50% of the graft or unhealed peripheral rim observed on MRI. Kaplan-Meier survival analysis with log-rank test was used to compare survivorship between LMAT and MMAT. Patient-reported outcomes were compared based on the Hospital for Special Surgery, modified Lysholm, and International Knee Documentation Committee subjective scores collected preoperatively and at the final follow-up.

RESULTS

A total of 299 knees (249 LMAT, 50 MMAT, mean age 33.0 ± 9.8 years) were included. Twenty clinical [2 MMAT (4.0%), 18 LMAT (7.2%)] and 24 graft [2 MMAT (4.0%), 22 LMAT (8.8%)] failures were identified. The mean clinical follow-up period was 63.1 ± 43.1 months (range 2 to 248), and MRI follow-up period was 62.6 ± 43.8 months (range 2 to 248). No significant differences in clinical and graft survivorship were found between the LMAT and MMAT groups (P = .481, P = .271, respectively). PROs preoperatively and at last follow-up also showed no significant difference between the groups.

CONCLUSION

No significant differences in clinical survivorship, graft survivorship, and PROs were found between the LMAT and MMAT groups.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Partial meniscectomy does not affect the biomechanics of anterior cruciate ligament reconstructed knee with a lateral posterior meniscal root tear

PURPOSE

The purpose of this study was to determine the effects of a lateral meniscus posterior root tear, partial meniscectomy, and total meniscectomy on knee biomechanics in the setting of anterior cruciate ligament (ACL) reconstruction.

METHODS

Thirteen fresh-frozen cadaver knees were tested with a robotic testing system under an 89.0-N anterior tibial load at full extension (FE), 15°, 30°, 60° and 90° of knee flexion and a simulated pivot-shift loading (7.0 Nm valgus and 5.0 Nm internal tibial rotation) at FE, 15° and 30° of knee flexion. Anterior tibial translation (ATT) and the in-situ force of ACL graft under the different loadings were measured in four knee states: (1) ACL reconstruction with intact lateral meniscus (Intact meniscus), (2) ACL reconstruction with lateral meniscal posterior root tear (Root tear), (3) ACL reconstruction with lateral posterior partial meniscectomy (Partial meniscectomy) and (4) ACL reconstruction with total lateral meniscectomy (Total meniscectomy).

RESULTS

Under anterior tibial loading, compared with an intact meniscus, root tear significantly increased ATT at 15° and 30° of knee flexion (p < 0.05) and partial meniscectomy had almost same increased ATT as with root tear at any knee flexion between FE and 90°. Under simulated pivot-shift loading, total meniscectomy increased ATT compared with intact meniscus, root tear, partial meniscectomy at FE (p < 0.05).

CONCLUSION

Under anterior tibial and simulated pivot-shift loading, partial meniscectomy has no significant effect on the stability of ACL-reconstructed knee with lateral meniscal posterior root tear, while total meniscectomy increased laxity at less than 30° of knee flexion. Clinically, in cases of irreparable meniscal root tears or persistent pain a partial meniscectomy can be considered in the setting of ACL reconstruction.

Predicting outcome of repair of medial meniscus posterior root tear with early osteoarthritis using bone single-photon emission computed tomography/computed tomography

Repair of medial meniscus posterior root tear (MMPRT) is considered as an effective early intervention strategy for osteoarthritis. We aimed at evaluating whether or not single-photon emission computed tomography/computed tomography (SPECT/CT) could predict the treatment outcome.Eleven patients with MMPRT who underwent preoperative SPECT/CT were retrospectively enrolled. Clinical symptoms were evaluated based on the knee injury and osteoarthritis outcome score (KOOS) and visual analogue scale (VAS) for pain. The uptake pattern of the medial tibial plateau (MTP) on SPECT/CT was visually assessed. Additionally, the maximum lesion-to-cortical counts ratio (LCRmax) for the anterior and posterior aspects of MTP and anterior-posterior MTP ratio (APR) were quantitatively assessed. Spearman correlation analyses were performed between the change in clinical symptom scores and preoperative SPECT/CT patterns.All patients showed increased radiotracer uptake in MTP. Among them, 8 (73%) showed dominant uptake in the anterior aspect of MTP. The rest 3 (27%) showed posterior-dominant uptake. Patients with anterior-dominant patterns tended to show better outcomes in terms of the postoperative KOOS score (P = .07). Anterior MTP LCRmax showed a negative correlation with the change in VAS (ρ = -0.664, P < .03). APR showed a correlation with the change in the KOOS score (ρ = 0.655, P < .03).Patients with MMPRT with relatively higher uptake in the anterior aspect of MTP could have better clinical outcomes after the repair. The preoperative SPECT/CT pattern may have a predictive value in selecting patients with good postoperative outcomes.

Lateral meniscal cysts: long-term clinical and radiological results of a partial meniscectomy and percutaneous decompressive needling

INTRODUCTION

The aim of this study was to describe clinical and radiological long-term results of an arthroscopic partial meniscectomy associated with an outside-in decompressive needling of the cyst for lateral parameniscal cyst.

METHODS

Eighteen patients with symptomatic parameniscal cysts treated between April 2002 and September 2009 were retrospectively included in the study. All patients underwent arthroscopic partial meniscectomy (preserving peripheral rim) and needling of the cyst using a 20-gauge needle. Pre- and post-operative IKDC, Tegner, and Lysholm scores were used to evaluate clinical results. Radiological results were obtained from pre- and post-operative radiographies and post-operative MRI scans. Both supine and weight bearing MRI examinations were performed. Kellgren-Lawrence and WORMS scales were used to evaluate osteoarthritis development of the knee.

RESULTS

The mean follow-up period was 11.6 ± 2.6 years (range 7-15). Horizontal lesions were found in 56% of patients. All patients fully recovered. Mean Lysholm scores passed from mean pre-operative value 52 ± 16.9 to post-operative 85 ± 11.9 (P < 0.01) and mean IKDC scale score changed from 49.5 ± 14.7 to 67 ± 23.5 (P < 0.01). Mean Tegner scores did not change significantly. Post-operative radiographies showed a Kellgren-Lawrence scale grade 0 in six patients (33%), a grade I in eight (44%), a grade II in three (17%), and a grade III in one patient (6%). No patients were found with a Kellgren-Lawrence scale grade IV. No significant differences with pre-operative radiographies were found (chi-square = 1.867; df = 3; P = 0.60) in osteoarthritis development of the knee. Reported WORMS scores had an average of 12.4 ± 5.1. No recurrence of any cysts was observed.

DISCUSSION

Different treatments for lateral meniscal cysts have been proposed, but proper management of the cyst is still controversial. The results of this study suggest that the outside-in needling of the cyst associated with partial meniscectomy is a highly effective, simple, and repeatable technique. Excellent clinical outcomes were reported at a mean follow-up of 11.6 ± 2.6 years (range 7-15). Imaging evaluation showed no significant evolution to osteoarthritis of the knee.

CONCLUSIONS

Partial arthroscopic meniscectomy associated with percutaneous decompressive needling of the cyst wall under arthroscopic visualization showed positive clinical and radiological long-term results. Neither traditional radiographies nor innovative standing MRIs showed findings of osteoarthritis.

Direct treatment cost outcomes among patients with medial meniscus deficiency: results from a 24-month surveillance study

Objective: Meniscus deficiency is highly prevalent in the United States and represents a substantial societal cost burden. The objective of this case series was to evaluate and compare direct costs associated with treatment for acute or degenerative medial meniscus deficiency.Methods: Case series patients (n = 50) received either non-surgical therapy or an operative partial meniscectomy based on clinical assessment by the principal study investigator which included physical examination and MRI. Cumulative 24-month direct treatment costs were compared between non-surgical and operative cohorts. Direct treatment costs were calculated using billing record reimbursements for all medical services administered by the treating institution, and imputed for medical services prescribed by the treating physician but provided external to the treating institution.Results: At study initiation, 33 patients (67%) were treated with non-surgical care, and 17 patients (33%) received a partial medial meniscectomy. By 24 months, average direct treatment costs were highest for patients who received a partial medial meniscectomy at study initiation ($4488 ± $1265) compared to patients who received non-surgical care at study initiation ($4092 ± $7466), although differences in average direct treatment costs were not statistically significant across treatment cohorts (p = .830). Average direct treatment costs were highest for the subgroup of patients who initiated non-surgical therapy but received a subsequent total knee arthroplasty during the study period (n = 2; $32,197 ± $169).Conclusion: Findings from this case series suggests that patients with acute or degenerative meniscus deficiency incur substantial direct treatment costs related to their knee pathology, particularly for patients receiving total knee arthroplasty.

Clinical and Radiologic Outcomes of Patients With Lax Healing After Medial Meniscal Root Repair: Comparison With Subtotal Meniscectomy

PURPOSE

To compare radiologic and clinical outcomes between patients who underwent medial meniscus posterior root tear (MMPRT) repair and were subsequently classified as having lax healing based on second-look arthroscopy and patients who underwent subtotal meniscectomy for an MMPRT.

METHODS

The patients who received pullout repair or subtotal meniscectomy due to MMPRT between January 2011 and December 2014 were retrospectively reviewed. Among the patients who underwent MMPRT repair, those whose lax healing of the repair site was confirmed by second-look arthroscopy (repair/lax healing group) and among the patients who received subtotal meniscectomy, those who have varus deformity of <5° and a Kellgren-Lawrence grade of ≤2 (meniscectomy group) were included in the study population. Medial joint space width, Kellgren-Lawrence grade, International Knee Documentation Committee Subjective Knee Evaluation Form score, and Lysholm Knee score were used for radiologic and clinical assessment.

RESULTS

The meniscectomy group included 24 patients (average follow-up, 37.2 months), and the repair/lax healing group included 21 patients (average follow-up, 39.2 months). The 2 groups showed improved patient-reported outcomes postoperatively (P < .001). However, medial joint space width (P < .001) became narrow and Kellgren-Lawrence grade (P = .002 and P = .005, respectively) worsened. Comparison of the radiologic outcomes between the 2 groups revealed that the repair/lax healing group had less Kellgren-Lawrence grade progression than the meniscectomy group (P = .014). The grade progressed by ≥2 grades in 4 patients (16.7%) and 0 patients in the meniscectomy and repair/lax healing groups, respectively (P < .001).

CONCLUSIONS

Although the repair/lax healing group showed improved functional outcomes on short-term follow-up, arthritic change progressed radiologically. Nevertheless, the repair/lax healing group showed better radiologic outcomes than the meniscectomy group, despite lax healing of the repair site. However, because of the small number of cases in this study, the results of this study could be associated with potential for type II or β errors.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Partial medial meniscectomy leads to altered walking mechanics two years after anterior cruciate ligament reconstruction: Meniscal repair does not

BACKGROUND

Partial meniscectomy dramatically increases the risk for post-traumatic, tibiofemoral osteoarthritis after anterior cruciate ligament reconstruction (ACLR). Concomitant medial meniscus surgery influences walking biomechanics (e.g., medial tibiofemoral joint loading) early after ACLR; whether medial meniscus surgery continues to influence walking biomechanics two years after ACLR is unknown.

RESEARCH QUESTION

Does medial meniscus treatment at the time of ACLR influence walking biomechanics two years after surgery?

METHODS

This is a secondary analysis of prospectively collected data from a clinical trial (NCT01773317). Fifty-six athletes (age 24 ± 8 years) with operative reports, two-year biomechanical analyses, and no second injury prior to two-year testing participated after primary ACLR. Participants were classified by concomitant medial meniscal status: no medial meniscus involvement (n = 36), partial medial meniscectomy (n = 9), and medial meniscus repair (n = 11). Participants underwent biomechanical analyses during over-ground walking including surface electromyography; a validated musculoskeletal model estimated medial compartment tibiofemoral contact forces. Gait variables were analyzed using 3 × 2 ANOVAs with group (medial meniscus treatment) and limb (involved versus uninvolved) comparisons.

RESULTS

There was a main effect of group (p = .039) for peak knee flexion angle (PKFA). Participants after partial medial meniscectomy walked with clinically meaningfully smaller PKFAs in both the involved and uninvolved limbs compared to the no medial meniscus involvement group (group mean difference [95%CI]; involved: -4.9°[-8.7°, -1.0°], p = .015; uninvolved: -3.9°[-7.6°, -0.3°], p = .035) and medial meniscus repair group (involved: -5.2°[-9.9°, -0.6°], p = .029; uninvolved: -4.7°[-9.0°, -0.3°], p = .038). The partial medial meniscectomy group walked with higher involved versus uninvolved limb medial tibiofemoral contact forces (0.45 body weights, 95% CI: -0.01, 0.91 BW, p = 0.053) and truncated sagittal plane knee excursions, which were not present in the other two groups.

SIGNIFICANCE

Aberrant gait biomechanics may concentrate high forces in the antero-medial tibiofemoral cartilage among patients two years after ACLR plus partial medial meniscectomy, perhaps explaining the higher osteoarthritis rates and offering an opportunity for targeted interventions.

LEVEL OF EVIDENCE

Level III.

Correlation Between Synovial Fluid Biomarkers and Leg-Fat Area Ratios in Patients Undergoing ACL Reconstruction With or Without an Associated Meniscectomy

PURPOSE

This study attempts to establish whether local adiposity of the knee at the level of the joint line is associated with alterations in synovial fluid biomarker concentrations in patients undergoing ACL reconstruction with or without an associated meniscectomy.

METHODS

Patients undergoing ACL reconstruction were prospectively enrolled at the time of surgery from July 2011 to January 2015. Synovial fluid samples were collected just prior to incision and the concentrations of 10 biomarkers of interest were determined using a multiplex magnetic bead immunoassay. Knee adiposity was assessed via measures of leg fat area using magnetic resonance axial T2 images at the level of the joint line. Measurement was determined by subtracting the sum of the joint area, consisting of bony and muscle areas, from the total leg area with six different ratios assessed. Groups were evaluated by injury type (isolated ACL, ACL + meniscal injury, and total cohort). The correlation between synovial fluid biomarker levels and leg fat area ratios was evaluated using Spearman's correlation.

RESULTS

There were 22 females and 26 males, with a mean age of 33.8 years (± 10.5) and a mean BMI of 25.3 (± 4.0). In the setting of isolated ACL injury, there was a statistically significant correlation between leg fat ratios and interleukin- 6, vascular endothelial growth factor, and interleukin-1 receptor antagonist. In patients with concomitant meniscal tears, there was an inverse correlation between leg fat ratios and monocyte chemoattractant protein-1.

CONCLUSION

The leg fat to total leg volume ratio and leg fat to joint space volume ratio were the most consistent measures for alterations in post-injury synovial fluid biomarker concentrations. Analysis of synovial fluid at the time of ACL reconstruction demonstrated significant correlations between specific leg-fat area ratios and synovial fluid biomarker concentrations. Local adiposity around the knee joint appears to modulate the biochemical environment of the joint and can clinically help guide prognostic discussions with the patient.

Analysis of the trends in arthroscopic meniscectomy and meniscus repair procedures in France from 2005 to 2017

INTRODUCTION

In 2008, the French National Authority for Health (HAS) recommended that "conservative" treatments be adopted for meniscal lesions. This recommendation and the lack of superiority of meniscectomy over non-operative treatment for meniscus degeneration have modified the treatment pathway. However, the impact of these findings on French clinical practice is not known. The objective of this study was to evaluate the change over time in the number of alternative surgical procedures (meniscectomy and meniscus repair) and regional variation in France using data from the French agency for information on hospital care (ATIH).

HYPOTHESIS

We hypothesized that the number of meniscectomy procedures will decrease, and the number of repair procedures will increase over time at various healthcare facilities.

PATIENTS AND METHODS

Between 2005 and 2017, the number of hospitalizations in the Medicine-Surgery-Obstetrics wards for meniscectomy (NFFC003 and NFCC004) or meniscus repair (NFEC001 and NFEC002) was evaluated overall and then based on whether the stay occurred in public or private sector hospitals in France. Data were extracted from the ATIH database and the findings were (1) related to French demographics during the period in question; (2) separated into public or private sector hospitals; (3) distributed into various regions in France and; (4) stratified by patient age.

RESULTS

Between 2005 and 2017, 1,564,461 meniscectomy and 63,142 meniscus repair procedures were done in France. Over this period in the entire country, the meniscectomy rate gradually decreased from 19.80/10,000 inhabitants in 2005 to 15.77/10,000 inhabitants in 2017 (21.4% reduction) (p<0.0001) while the meniscus repair rate increased from 0.42/10,000 inhabitants in 2005 to 1.36/10,000 inhabitants in 2017 (320% increase) (p<0.0001). The largest meniscectomy reduction effort occurred in private sector hospitals, going from 15.79 to 12.01/10,000 inhabitants in 12 years; the decrease was smaller in public hospitals (going from 4.01 to 3.77/10,000 inhabitants) (p<0.0001 in both cases). The change in the procedure ratio between private and public hospitals was asymmetric, with the meniscus repair/meniscectomy ratio clearly increasing more in public hospitals (4% to 12.6%) between 2005 and 2017 than in private hospitals (1.6% to 6.6%) (p<0.0001). We found large regional differences: regions in Eastern France had higher meniscectomy rates, while regions in Western France had higher meniscus repair rates. When the analysis of procedures between 2008 and 2017 was stratified by age, a similar increase in repair procedures was found in all age brackets. Conversely, the reduction in meniscectomy was most apparent before 40 years of age, and the number of meniscectomy procedures was stable after 60 years of age.

CONCLUSION

These findings suggest there has been a significant shift in the surgical management of meniscal injuries towards more conservative treatments. But the large variations between regions in France is evidence of a continued disparity in clinical practices.

LEVEL OF EVIDENCE

IV, retrospective study without control group.

Oral shea nut oil triterpene concentrate supplement ameliorates pain and histological assessment of articular cartilage deterioration in an ACLT injured rat knee osteoarthritis model

Osteoarthritis (OA) is a multifactorial joint disease and a common disabling condition in the elderly population. The associated pain and pathohistological changes in cartilage are common features of OA in both humans and animal models. Shea nut oil extract (SheaFlex75) contains a high triterpenoid concentration and has demonstrated anti-inflammatory and antiarthritic effects in both human and animal studies. In this study, we aim to investigate the potential of SheaFlex75 to prevent articular cartilage deterioration in a rat model of chronic OA progression. By employing anterior cruciate ligament transection (ACLT) with medial meniscectomy (MMx)-induced OA, we found attenuation of both early and chronic onset OA pain and cartilage degeneration in ACLT+MMx rats receiving SheaFlex75 dietary supplementation. Under long-term oral administration, the rats with induced OA presented sustained protection of both pain and OA cartilage integrity compared to the OA-control rats. Moreover, rats subjected to long-term SheaFlex75 ingestion showed normal biochemical profiles (AST, BUN and total cholesterol) and presented relatively lower triglycerides (TGs) and body weights than the OA-control rats, which suggested the safety of prolonged use of this oil extract. Based on the present evidence, preventive management is advised to delay/prevent onset and progression in OA patients. Therefore, we suggest that SheaFlex75 may be an effective management strategy for symptom relief and cartilage protection in patients with both acute and chronic OA.

Partial meniscectomy adversely affects return-to-sport outcome after anatomical double-bundle anterior cruciate ligament reconstruction

PURPOSE

The purposes of this study were to determine whether the partial meniscectomy combined with ACL reconstruction affect the postoperative return-to-sport and to identify if partial meniscectomy has an influence on the graft failure following an anatomical double-bundle ACL reconstruction case.

METHODS

A retrospective cohort study including 426 primary double bundle ACL reconstruction cases. There were 206 males and 220 females, median age of 28.4 years, median BMI of 23.0, median preinjury Tegner score of 7.0 and median follow-up period after surgery of 24.0 months. Patients with less than 12 months of follow-up, revision surgery, multi-ligaments injury, previous contralateral knee ligaments injury and postoperative infection cases were excluded. Furthermore, patients who had meniscal repair were excluded in order to compare the outcomes between patients who had intact menisci and those who underwent partial meniscectomy. There were 227 patients with intact menisci (group A) and 199 patients with partial meniscectomy (group B). The median age was younger and the preoperative Tegner score was higher in group A. The patients in group B were subcategorized as the site of partial meniscectomy, including medial (group C), lateral (group D) and bicompartmental (group E) meniscectomy. There were 74, 94, and 31 patients in group C, D, and E, respectively. Return-to-sport (running and sport phase) and graft failure were included in our primary outcomes, and functional outcome as Lysholm knee scores was included in secondary outcome.

RESULTS

The rate of return to running phase and sport phase were 91% (387/426) and 76% (303/399), the mean time taken to return to running and sport phase were 5.7 months and 11.1 months, respectively. There was significant difference in the returning to sport phase between group A and B (p = 0.01), and between group A and D/E subgroups (p = 0.007). There were fourteen graft failures (3.5%) in total. In addition, 9 and 5 graft failures in group A and B, respectively. Of the 5 graft failures in group B, 2 and 3 graft failures in group C and D, respectively. There was no significant difference of the graft failure ratio among the groups.

CONCLUSION

Our study demonstrates that partial meniscectomy has an adverse effect on the return to sport phase following the anatomical double-bundle ACL reconstruction. Therefore, greater postoperative care would be needed to return to sport with partial meniscectomy in ACL reconstruction cases. On the contrary, partial meniscectomy is not considered to be the risk factor for graft failure at short-term follow-up.

LEVEL OF EVIDENCE

Case-control study, Level III.

Introduction of an MR-based semi-quantitative score for assessing partial meniscectomy and relation to knee joint degenerative disease: data from the Osteoarthritis Initiative

OBJECTIVES

To develop an MR-based semi-quantitative meniscus scoring technique for postoperative assessment of the degree of meniscal resection, to test its reproducibility, and to study the relationship between the amount of resection and degenerative disease burden.

METHODS

We studied the right knee of 135 participants from the Osteoarthritis Initiative that underwent meniscal surgery an average of 14 years previously. The amount of meniscal resection was assessed on baseline 3.0-T MRIs and calculated as meniscus resection score (MenRS) with a range of 0 to 18. Knee abnormalities at baseline and 48 months were graded using a modified Whole-Organ Magnetic Resonance Imaging Score (WORMS). Subjects were also stratified according to meniscal resection performed after injury versus without preceding injury. Statistical analysis included intra-class correlation coefficient (ICC) to determine reproducibility as well as regression models and partial correlations to correlate MenRS with WORMS outcomes.

RESULTS

ICC values for intra- and inter-observer reproducibility of MenRS were 0.980 and 0.977, respectively. Overall, the amount of meniscal resection showed a significant correlation with baseline WORMS grades: higher MenRS was associated with higher total WORMS grades (p = 0.004) and cartilage (p = 0.004) and ligament (p < 0.001) subscores. However, no significant association between MenRS and change in WORMS grades over 48 months was found. The relationship between MenRS and baseline WORMS grades did not change after adjusting for a reported history of knee injury.

CONCLUSIONS

Postoperative assessment of the knee following partial meniscectomy using the newly developed MenRS showed excellent reproducibility and significant cross-sectional correlation with WORMS gradings.

KEY POINTS

• The newly developed semi-quantitative MR-based meniscal resection score demonstrated excellent reproducibility. • A significant correlation between the amount of meniscal resection measured using the newly developed score and the degree of overall knee joint degenerative disease and cartilage defects was found.

Effect of Early Surgery vs Physical Therapy on Knee Function Among Patients With Nonobstructive Meniscal Tears: The ESCAPE Randomized Clinical Trial

IMPORTANCE

Despite recent studies suggesting arthroscopic partial meniscectomy (APM) is not more effective than physical therapy (PT), the procedure is still frequently performed in patients with meniscal tears.

OBJECTIVE

To assess whether PT is noninferior to APM for improving patient-reported knee function in patients with meniscal tears.

DESIGN, SETTING, AND PARTICIPANTS

Noninferiority, multicenter, randomized clinical trial conducted in 9 hospitals in the Netherlands. Participants were aged 45 to 70 years with nonobstructive meniscal tears (ie, no locking of the knee joint). Patients with knee instability, severe osteoarthritis, and body mass index greater than 35 were excluded. Recruitment took place between July 17, 2013, and November 4, 2015. Participants were followed up for 24 months (final participant follow-up, October 11, 2017).

INTERVENTIONS

Three hundred twenty-one participants were randomly assigned to APM (n = 159) or a predefined PT protocol (n = 162). The PT protocol consisted of 16 sessions of exercise therapy over 8 weeks focused on coordination and closed kinetic chain strength exercises.

MAIN OUTCOMES AND MEASURES

The primary outcome was change in patient-reported knee function on the International Knee Documentation Committee Subjective Knee Form (range, 0 to 100; from worse to best) from baseline over a 24-month follow-up period. The noninferiority margin was defined as a difference between treatment groups of 8 points and was assessed with a 1-sided α of .025. The primary analysis followed the intention-to-treat principle.

RESULTS

Among 321 patients who were randomized (mean [SD] age, 58 [6.6] years; 161 women [50%]), 289 (90%) completed the trial (161 women and 158 men). In the PT group, 47 participants (29%) had APM during the 24-month follow-up period, and 8 participants randomized to APM (5%) did not have APM. Over a 24-month follow-up period, knee function improved in the APM group by 26.2 points (from 44.8 to 71.5) and in the PT group by 20.4 points (from 46.5 to 67.7). The overall between-group difference was 3.6 points (97.5% CI, -∞ to 6.5; P value for noninferiority = .001). Adverse events occurred in 18 participants in the APM group and 12 in the PT group. Repeat surgery (3 in the APM group and 1 in the PT group) and additional outpatient visits for knee pain (6 in the APM group and 2 in the PT group) were the most frequent adverse events.

CONCLUSIONS AND RELEVANCE

Among patients with nonobstructive meniscal tears, PT was noninferior to APM for improving patient-reported knee function over a 24-month follow-up period. Based on these results, PT may be considered an alternative to surgery for patients with nonobstructive meniscal tears.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01850719.

Trends in isolated meniscus repair and meniscectomy in Japan, 2011-2016

BACKGROUND

Meniscus surgery is the most commonly performed orthopedic surgery, and despite recent emphasis on saving the meniscus, the current status of meniscus surgeries is little known in many countries, including Japan. The National Database of Health Insurance Claims and Specific Health Checkups of Japan and the Statistics of Medical Care Activities in Public Health Insurance track meniscus surgeries through health insurance claims. The National Database provides the numbers for 2014 and 2015, and the Statistics of Medical Care Activities provides the numbers from June 2011 to June 2016. Our aim was to analyze isolated meniscus surgery numbers and meniscus repair ratios by age group based on the National Database and evaluate trends of meniscus repair ratios for the latest six years from the Statistics of Medical Care Activities.

METHODS

Meniscus surgeries by age group were counted from the National Database for 2014-2015, and meniscus repair ratios (meniscus repairs/meniscus surgeries) were calculated. The numbers were also counted from the Statistics of Medical Care Activities in 2011-2016. For statistical analysis of annual trends of meniscus repair ratios, the Cochran-Armitage trend test was used. Meniscus surgeries with concomitant knee ligament surgeries were excluded.

RESULTS

According to the National Database, isolated meniscus surgeries totaled 34,966 in 2015, with peak ages of patients in their late teens and 60s. The meniscus repair ratio was 19% in 2014 and 24% in 2015. According to the Statistics of Medical Care Activities, the meniscus repair ratio was 9% in 2011 and significantly increased to 25% in 2016 (p = 0.0008). The ratio also increased significantly in each age group between the early 20s and late 70s.

CONCLUSIONS

Approximately 35,000 meniscus surgeries are performed in Japan annually, with peak ages in the late teens and 60s. The number of meniscus repairs has increased over the past six years.

Annual trends in arthroscopic meniscus surgery: Analysis of a national database in Japan

Background

The importance of meniscus preservation is widely recognized. There have been a few studies describing trends in meniscectomy and meniscus repair in the United States; however, they presented differing results. We reported annual trends in meniscus surgery, using a national database in Japan.

Methods

We interrogated the Diagnosis Procedure Combination database, which represents approximately half of all hospital admissions in Japan. We included the patients who underwent meniscectomy and meniscus repair between July 2007 and March 2015. The diagnosis, age and sex of each patient were recorded.

Results

We identified 83,105 patients: 69,310 underwent meniscectomy; 13,416 underwent meniscus repair and 379 underwent both in a single admission. The proportion of patients undergoing meniscus repair rose from 7.0% in 2007 to 25.9% in 2014 (p < 0.001), while the proportion undergoing meniscectomy fell from 92.8% in 2007 to 73.3% in 2014 (p < 0.001). Among patients under 30 years old, the proportions undergoing meniscus repair or meniscectomy in 2014 were 50.3% versus 48.3%, respectively. A bimodal age distribution was observed for meniscectomy, with peaks at 10–19 years of age and 60–69 years of age, whereas most patients undergoing meniscus repair were 10–19 years of age.

Conclusions

We found characteristic trends where the popularity of meniscus repair increased rapidly at the expense of meniscectomy in Japan during the study period. In the last survey year, the proportion of meniscus repair exceeded that of meniscectomy in those younger than 30 years. Meniscectomy was undertaken most often in adolescents and early old age, while meniscus repair was undertaken most often in adolescents.

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.

Anatomical variant of the meniscus related to posterior junction: a case report

BACKGROUND

There are several reports on anatomical differences of the meniscus. However, there are only a few reports on abnormalities in both menisci and anatomical differences in anterior cruciate ligament insertions.

CASE PRESENTATION

This is a case report of a 36-year-old Hispanic man presenting symptoms, including knee pain, locking, and effusion, with an anatomical abnormality of the menisci corresponding to the fusion of the posterior horns of the menisci in tandem with the insertion of the posterior meniscus fibers in the anterior cruciate ligament.

CONCLUSIONS

This is the first study describing a meniscus anatomical variant with isolated posterior junction of the posterior horn with an anomalous insertion to the anterior cruciate ligament. The recognition of meniscus variants is important as they can be misinterpreted for more significant pathology on magnetic resonance images.

The effects of intra-articular levobupivacain versus levobupivacain plus magnesium sulfate on postoperative analgesia in patients undergoing arthroscopic meniscectomy: A prospective randomized controlled study

Objective

The aim of this study was to compared the effectiveness of intraarticular levobupivacain with levobupivacain and magnesium sulfate.

Methods

In this prospective randomized double blinded study, 96 patients (67 male, 29 female; age range: 18–65 years) with ASA (American Society of Anesthesiologist) score I and II, who had undergone arthroscopic meniscectomy operation, were divided to 3 groups that had postoperative analgesia with intra-articular saline injection (control group), levobupivacain injection (L group) or levobupivacain and magnesium sulfate injection (LM group). Patients were compared with postoperative VAS (Visual Analog Score) score during rest and activity, opioid analgesic need, non-opioid analgesic need and other medication needs.

Results

Postoperative VAS scores during rest and activation at early postoperative period were significantly lower at LM group when compared with L group and lower than control group at all time periods. Opioid analgesic need, non-opioid analgesic need and other medication needs for non-pain symptoms were lower at LM group when compared with L and control groups at all time periods.

Conclusion

Intraarticular magnesium sulfate plus Levobupivacain injection is a safe and effective method for post operative pain management after arthroscopic meniscectomy.

Keywords: Intra-articular injection, Magnesium sulfate, Levobupivacain, Postoperative analgesia, Chondrocyte apoptosis, Pain management, Arthroscopic menisectomy

Level of Evidence

Level I, Therapeutic study

[Current treatment strategy of meniscal lesions in athletes]

The primary goal of meniscal treatment in elite athletes is to guarantee knee function for sports performance and to prevent osteoarthritic changes. The meniscus acts not only as cushion in the femorotibial joint but also as a major secondary stabilizer with its posterior medial and lateral horns. Therefore, the integrity of the meniscal tissue is crucial for knee function and needs to be preserved, especially when the meniscal lesion is found in the periphery (vascularized zone). For ideal tissue healing, a stable knee is prerequisite.Partial meniscectomy as little as possible is only performed, if the lesion cannot be sutured, is highly degenerative or localized in the non-vascularized (white-white) area which has low to none healing potential.