Structural pathology is not related to patient-reported pain and function in patients undergoing meniscal surgery

Tornbjerg, Simon Maretti; Nissen, Nis; Englund, Martin; Jørgensen, U. G.; Schjerning, Jeppe; Lohmander, L. Stefan; Thorlund, Jonas Bloch

doi:10.1136/bjsports-2016-096456

Cited by 42 publications

(28 citation statements)

References 28 publications

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“…The facts that only one-fourth of the patients showed a positive McMurray test, and conversely 49% of the patients reported mechanical symptoms, suggest that there is a need for further definition of the mechanical symptoms and description of the size, type and location of the meniscus tear. 29 In the same way, the timing to consider arthroscopic surgery can be a source of controversy. Three months from the onset of symptoms was agreed on as a general rule as it is the time generally adopted in the RCTs.…”

Section: Discussionmentioning

confidence: 99%

Surgical Management of Degenerative Meniscus Lesions: The 2016 ESSKA Meniscus Consensus

Beaufils

Becker²,

Kopf

et al. 2017

Joints

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Purpose A degenerative meniscus lesion is a slowly developing process typically involving a horizontal cleavage in a middle-aged or older person. When the knee is symptomatic, arthroscopic partial meniscectomy has been practised for a long time with many case series reporting improved patient outcomes. Since 2002, several randomised clinical trials demonstrated no additional benefit of arthroscopic partial meniscectomy compared to non-operative treatment, sham surgery or sham arthroscopic partial meniscectomy. These results introduced controversy in the medical community and made clinical decision-making challenging in the daily clinical practice. To facilitate the clinical decision-making process, a consensus was developed. This initiative was endorsed by ESSKA. Methods A degenerative meniscus lesion was defined as a lesion occurring without any history of significant acute trauma in a patient older than 35 years. Congenital lesions, traumatic meniscus tears and degenerative lesions occurring in young patients, especially in athletes, were excluded. The project followed the so-called formal consensus process, involving a steering group, a rating group and a peer-review group. A total of 84 surgeons and scientists from 22 European countries were included in the process. Twenty questions, their associated answers and an algorithm based on extensive literature review and clinical expertise, were proposed. Each question and answer set was graded according to the scientific level of the corresponding literature. Results The main finding was that arthroscopic partial meniscectomy should not be proposed as a first line of treatment for degenerative meniscus lesions. Arthroscopic partial meniscectomy should only be considered after a proper standardised clinical and radiological evaluation and when the response to non-operative management has not been satisfactory. Magnetic resonance imaging of the knee is typically not indicated in the first-line work-up, but knee radiography should be used as an imaging tool to support a diagnosis of osteoarthritis or to detect certain rare pathologies, such as tumours or fractures of the knee. Discussion The present work offers a clear framework for the management of degenerative meniscus lesions, with the aim to balance information extracted from the scientific evidence and clinical expertise. Because of biases and weaknesses of the current literature and lack of definition of important criteria such as mechanical symptoms, it cannot be considered as an exact treatment algorithm. It summarises the results of the “ESSKA Meniscus Consensus Project” ( ) and is the first official European consensus on this topic. The consensus may be updated and refined as more high-quality evidence emerges. Level of Evidence I.

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Section: Discussionmentioning

confidence: 99%

Surgical Management of Degenerative Meniscus Lesions: The 2016 ESSKA Meniscus Consensus

Beaufils

Becker²,

Kopf

et al. 2017

Joints

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“… 2016 , Tornbjerg et al. 2017 ). Of 8 major randomized controlled trials (RCTs) assessing surgical treatment of degenerative meniscal disease in patients with or without osteoarthritis (Moseley et al.…”

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confidence: 99%

Inappropriate use of arthroscopic meniscal surgery in degenerative knee disease

et al. 2017

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Background and purposeCurrent evidence suggests that arthroscopic knee surgery has no added benefit compared with non-surgical management in degenerative meniscal disease. Yet in many countries, arthroscopic partial meniscectomy (APM) remains among the most frequently performed surgeries. This study quantifies and characterizes the dynamics of the current use of knee arthroscopies in Switzerland in a distinctively non-traumatic patient group.MethodsWe assessed a non-accident insurance plan of a major Swiss health insurance company for surgery rates of APM, arthroscopic debridement and lavage in patients over the age of 40, comparing the years 2012 and 2015. Claims were analyzed for prevalence of osteoarthritis, related interventions and the association of surgery with insurance status.Results648,708 and 647,808 people were examined in 2012 and 2015, respectively. The incidence of APM, debridement, and lavage was 388 per 105 person-years in 2012 and 352 per 105 person-years in 2015 in non-traumatic patients over the age of 40, consisting mostly of APM (96%). Between years, APM surgery rates changed in patients over the age of 65 (p < 0.001) but was similar in patients aged 40–64. Overall prevalence of osteoarthritis was 25%. Insurance status was independently associated with arthroscopic knee surgery.InterpretationAPM is widely used in non-traumatic patients in Switzerland, which contrasts with current evidence. Many procedures take place in patients with degenerative knee disease. Surgery rates were similar in non-traumatic middle-aged patients between 2012 and 2015. Accordingly, the potential of inappropriate use of APM in non-traumatic patients in Switzerland is high.

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“…In a randomised, placebo-controlled study of patients with knee pain that was degenerative in origin, the prevalence of mechanical symptoms was 49 % after arthroscopic meniscus resection and 43 % in the placebo group (32). In another study, it turned out that pre-operatively self-reported pain and functional impairment were not associated with structural knee pathology, including degenerative meniscus injury, detected by subsequent arthroscopy (33).…”

Section: Symptoms and Findings For Meniscus Injuriesmentioning

confidence: 97%