Meniscal pathology - the evidence for treatment

Abstract

Whilst arthroscopic surgery for the treatment of meniscal tears is the most commonly performed orthopaedic surgery, meniscal tears at the knee are frequently identified on magnetic resonance imaging in adults with and without knee pain. The evidence for arthroscopic treatment of meniscal tears is controversial and lacks a supporting evidence base; it may be no more efficacious than conservative therapies. Surgical approaches to the treatment of meniscal pathology can be broadly categorised into those in which partial menisectomy or repair are performed. This review highlights that the major factor determining the choice of operative approach is age: meniscal repair is performed exclusively on younger populations, while older populations are subject to partial menisectomy procedures. This is probably because the meniscus is less amenable to repair in the older population where other degenerative changes co-exist. In middle-aged to older adults, arthroscopic partial menisectomy (APM) may treat the meniscus tear, but does not address the degenerative whole organ disease of knee osteoarthritis. Thus far, there is no convincing evidence that operative approaches are superior to conservative measures as the first-line treatment of older people with knee pain and meniscal tears. However, in two randomised controlled trials (RCTs) approximately one-third of subjects in the exercise groups had persisting knee pain with some evidence of improvement following APM, although the characteristics of this subgroup are unclear. From the available data, a first-line trial of conservative therapy, which includes weight loss, is recommended for the treatment of degenerative meniscal tears in older adults. The exception to this may be when mechanical symptoms, such as knee locking, predominate. Although requiring corroboration by RCTs, there is accumulating evidence from cohort studies and case series that meniscal repair rather than APM may improve function and reduce the long-term risk of knee osteoarthritis in young adults. There is no clear evidence from RCTs that one surgical method of meniscal repair is superior to another.

Augmentation Techniques for Meniscus Repair

“…24 Arthroscopic partial meniscectomy (APM) is still the most frequent orthopaedic procedure in orthopaedic surgery, although there is evidence that more conservative treatments should be preferred as the first-line treatment when not associated with an acute tear, such as with an ACL tear. [30][31][32][33] Indications for meniscus repair include symptoms directly attributable to the tear, reducibility of the tear, good tissue integrity, and favorable tear characteristics (e.g., single vertical) in one plane in the red-red (R-R) or red-white (R-W) zones of the meniscus or when an ACL is reconstructed. 15,29,34 The following tears are generally considered less amenable for repair: chronic tears with plastic deformity, complete tears with oblique, horizontal cleavage, or complex degenerative pattern in the W-W zone of the meniscus.…”

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

“…However, it is still debated whether the associated symptoms occur as a consequence of the osteoarthritis, the meniscal tear, or the combination of these factors. [5][6][7] Treatment of these lesions, if they are or become symptomatic, is currently a matter of considerable controversy. [8][9][10][11] The 2013 guidelines from the American Academy of Orthopedic Surgeons do not recommend arthroscopy with lavage and/or debridement in patients with primary symptomatic osteoarthritis of the knee.…”

A 12-week supervised exercise therapy program for young adults with a meniscal tear: Program development and feasibility study

“…Presence of mechanical symptoms (i.e. the sensation of catching an locking) is typically considered an important indication for meniscal surgery (Mezhov et al, 2014). However, a recent secondary analysis from a RCT comparing APM to sham surgery in patients aged 35e65 years with degenerative meniscal tears did not find a larger effect of APM for improving mechanical symptoms than sham surgery (Sihvonen et al, 2016).…”