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

Hohmann, Erik; Glatt, Vaida; Tetsworth, Kevin; Cote, Mark P.

doi:10.1016/j.arthro.2018.04.018

Cited by 20 publications

(20 citation statements)

References 47 publications

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“…We found 2 systematic reviews that evaluated study quality and risk of bias for RCTs and that examined the effectiveness of APM. 58,87 Hohmann et al 58 found insufficient evidence to conclude superiority of APM or physical therapy for treating degenerative meniscal tears, owing to high risk of bias and studies being moderate to low quality. Also, the study samples were small and there was heterogeneity in eligibility criteria, outcome measures, and physical therapy protocols.…”

Section: Resultsmentioning

confidence: 99%

“…43,68,73 Substantial evidence is available demonstrating no difference in clinical outcomes for APM versus conservative management for degenerative meniscal tears 1,70,77,78,106,132 ; however, the available evidence may be biased and of low quality. 58,87 Clinical outcomes tended to improve after APM and reoperation rates were low, although knee osteoarthritis is likely to develop after APM. 13,102,104 Meniscal repairs have been associated with good clinical outcomes overall, 45,81,143 and for isolated meniscal repairs there has been no difference in clinical outcomes between all-inside versus inside-out repairs.…”

Section: Discussionmentioning

confidence: 99%

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An Up-to-Date Review of the Meniscus Literature: A Systematic Summary of Systematic Reviews and Meta-analyses

Smoak

Matthews

Vinod

et al. 2020

Orthopaedic Journal of Sports Medicine

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Background: A large number of systematic reviews and meta-analyses regarding the meniscus have been published. Purpose: To provide a qualitative summary of the published systematic reviews and meta-analyses regarding the meniscus. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic search of all meta-analyses and systematic reviews regarding the meniscus and published between July 2009 and July 2019 was performed with PubMed, CINAHL, EMBASE, and the Cochrane database. Published abstracts, narrative reviews, articles not written in English, commentaries, study protocols, and topics that were not focused on the meniscus were excluded. The most pertinent results were extracted and summarized from each study. Results: A total of 332 articles were found, of which 142 were included. Included articles were summarized and divided into 16 topics: epidemiology, diagnosis, histology, biomechanics, comorbid pathology, animal models, arthroscopic partial meniscectomy (APM), meniscal repair, meniscal root repairs, meniscal allograft transplantation (MAT), meniscal implants and scaffolds, mesenchymal stem cells and growth factors, postoperative rehabilitation, postoperative imaging assessment, patient-reported outcome measures, and cost-effectiveness. The majority of articles focused on APM (20%), MAT (18%), and meniscal repair (17%). Conclusion: This summary of systematic reviews and meta-analyses delivers surgeons a single source of the current evidence regarding the meniscus.

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Section: Resultsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

An Up-to-Date Review of the Meniscus Literature: A Systematic Summary of Systematic Reviews and Meta-analyses

Smoak

Matthews

Vinod

et al. 2020

Orthopaedic Journal of Sports Medicine

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“…Although several randomised controlled trials failed to demonstrate a clinically important benefit of APM over non-operative alternatives4–10 or sham surgery11 in middle-aged and older patients with symptomatic meniscal tears, these results have not led to a consistent decline in the number of APMs performed in daily practice 2 12. Common arguments for performing APM include being a difficult habit to break, being influenced by personal experiences (observational evidence), criticism of the experimental evidence (eg, low external validity) and a surgeon’s belief in being capable to identify which patient may still benefit more from surgery 13–19. Therefore, it is suggested to be up to the judgement of the treating surgeon to decide what is best for the individual patient 18…”

Section: Introductionmentioning

confidence: 99%

Can even experienced orthopaedic surgeons predict who will benefit from surgery when patients present with degenerative meniscal tears? A survey of 194 orthopaedic surgeons who made 3880 predictions

Graaf¹,

Bloembergen

Willigenburg

et al. 2019

Br J Sports Med

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ObjectivesTo examine the ability of surgeons to predict the outcome of treatment for meniscal tears by arthroscopic partial meniscectomy (APM) and exercise therapy in middle-aged patients.Design and settingElectronic survey. Orthopaedic surgeon survey participants were presented 20 patient profiles. These profiles were derived from a randomised clinical trial comparing APM with exercise therapy in middle-aged patients with symptomatic non-obstructive meniscal tears. From each treatment group (APM and exercise therapy), we selected five patients with the best (responders) and five patients with the worst (non-responders) knee function after treatment. 1111 orthopaedic surgeons and residents in the Netherlands and Australia were invited to participate in the survey.InterventionsFor each of the 20 patient profiles, surgeons (unaware of treatment allocation) had to choose between APM and exercise therapy as preferred treatment and subsequently had to estimate the expected change in knee function for both treatments on a 5-point Likert Scale. Finally, surgeons were asked which patient characteristics affected their treatment choice.Main outcomesThe primary outcome was the surgeons’ percentage correct predictions. We also compared this percentage between experienced knee surgeons and other orthopaedic surgeons, and between treatment responders and non-responders.ResultsWe received 194 (17%) complete responses for all 20 patient profiles, resulting in 3880 predictions. Overall, 50.0% (95% CI 39.6% to 60.4%) of the predictions were correct, which equals the proportion expected by chance. Experienced knee surgeons were not better in predicting outcome than other orthopaedic surgeons (50.4% vs 49.5%, respectively; p=0.29). The percentage correct predictions was lower for patient profiles of non-responders (34%; 95% CI 21.3% to 46.6%) compared with responders (66.0%; 95% CI 57.0% to 75.0%; p=0.01).In general, bucket handle tears, knee locking and failed non-operative treatment directed the surgeons’ choice towards APM, while higher level of osteoarthritis, degenerative aetiology and the absence of locking complaints directed the surgeons’ choice towards exercise therapy.ConclusionsSurgeons’ criteria for deciding that surgery was indicated did not pass statistical examination. This was true regardless of a surgeon’s experience. These results suggest that non-surgical management is appropriate as first-line therapy in middle-aged patients with symptomatic non-obstructive meniscal tears.Clinical trial registrationClinicalTrials.gov Identifier: NCT03462134.

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“…A systematic review and meta-analysis of randomized controlled trials 33 on APM versus nonoperative treatment for degenerative meniscal tears in adults showed small, although statistically significant, favorable results of APM up to 6 months for physical function and pain, but no differences were found after 12-month to 24-month follow-up. Another recent critical systematic review 13 on APM versus physical therapy for degenerative meniscal lesions found that the quality of the available published literature was not robust enough at this time to support claims of superiority for either alternative, and both APM and physical therapy could be considered reasonable treatment options for this condition. Another recent critical review of the published literature reported that valid conclusions cannot be drawn with regard to the optimal treatment for meniscal tears.…”

Section: Discussionmentioning

confidence: 99%

“…Some randomized trials reported that as high as 19% to 35% of patients allocated to physical therapy crossed over to APM during the first year of follow-up. 24 Thus, recent systematic reviews 13,23 concluded that APM may be considered a reasonable option for degenerative meniscal tears in selected middleaged patients, particularly if they have mild OA.…”

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confidence: 99%

Outcomes and Patient Satisfaction With Arthroscopic Partial Meniscectomy for Degenerative and Traumatic Tears in Middle-Aged Patients With No or Mild Osteoarthritis

et al. 2019

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Background: There is controversy about the benefit of arthroscopic partial meniscectomy (APM) for degenerative lesions in middle-aged patients. Purpose: To compare satisfaction with APM between middle-aged patients with no or mild knee osteoarthritis (OA) and a degenerative meniscal tear and those with a traumatic tear. Study Design: Cohort study; Level of evidence, 2. Methods: A comparative prospective study at 5 years of middle-aged patients (45-60 years old) with no or mild OA undergoing APM for degenerative (n = 115) or traumatic (n = 143) tears was conducted. Patient satisfaction was measured by a 5-point Likert scale and functional outcomes by the Knee injury and Osteoarthritis Outcome Score (KOOS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Univariate and multivariate regression analyses were used to identify factors correlating with patient-reported satisfaction at 5 years postoperatively. Results: Baseline patient characteristics were not different between groups. At the 5-year evaluation, the satisfaction rate in the traumatic and degenerative groups was 68.5% versus 71.3%, respectively ( P = .365). Patient satisfaction was significantly associated with functional outcomes ( r = 0.69; P = .024). In the degenerative group, 43 patients (37.4%) had OA progression to Kellgren-Lawrence (K-L) grade 2 or 3, but only 24 patients (20.8%) had a symptomatic knee at final follow-up. Multivariate regression analysis for patient dissatisfaction at 5-year follow-up showed the following significant independent factors: female sex (odds ratio [OR], 1.6 [95% CI, 1.1-2.3]; P = .018), body mass index >30 kg/m2 (OR, 2.6 [95% CI, 1.7-4.9]; P = .035), lateral meniscal tears (OR, 0.6 [95% CI, 0.1-0.9]; P = .039), and OA progression to K-L grade ≥2 at final follow-up (OR, 1.4 [95% CI, 1.2-2.6]; P = .014). At the final evaluation, there were no significant differences between groups in pain scores ( P = .648), WOMAC scores ( P = .083), or KOOS-4 scores ( P = .187). Likewise, there were no significant differences in the KOOS subscores for Pain ( P = .144), Symptoms ( P = .097), or Sports/Recreation ( P = .150). Although the degenerative group had significantly higher subscores for Activities of Daily Living ( P = .001) and Quality of Life ( P = .004), the differences were considered not clinically meaningful. Conclusion: There were no meaningful differences in patient satisfaction or clinical outcomes between patients with traumatic and degenerative tears and no or mild OA. Predictors of dissatisfaction with APM were female sex, obesity, and lateral meniscal tears. Our findings suggested that APM was an effective medium-term option to relieve pain and recover function in middle-aged patients with degenerative meniscal tears, without obvious OA, and with failed prior physical therapy.

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

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

Cited by 20 publications

References 47 publications

An Up-to-Date Review of the Meniscus Literature: A Systematic Summary of Systematic Reviews and Meta-analyses

An Up-to-Date Review of the Meniscus Literature: A Systematic Summary of Systematic Reviews and Meta-analyses

Can even experienced orthopaedic surgeons predict who will benefit from surgery when patients present with degenerative meniscal tears? A survey of 194 orthopaedic surgeons who made 3880 predictions

Outcomes and Patient Satisfaction With Arthroscopic Partial Meniscectomy for Degenerative and Traumatic Tears in Middle-Aged Patients With No or Mild Osteoarthritis

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