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Evidence Based Management of Meniscal Tears
KennethG.Swan,Jr.,MD
• NODISCLOSURES
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Meniscus
• Oncethoughttobeaves@gialmuscleremnantwithnoknownpurpose,nowknowntobe:– Importantstructureforkneeforcedistribu@on– Secondarystabilizeroftheknee– Lossofen@remensicus(openmeniscectomy)leadstoprogressivedegenera@vechangesdecadeslater• Fairbanks,JBJS,1948
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Meniscus Tear
• Common– 35%ofpeopleovertheageof50haveameniscustear
– 2/3ofthesepeopleareASYMPTOMATIC– Inthepresenceofosteoarthri@s,prevalenceincreasesto100%ifGradeIVarthri@cchanges
• Canbetrauma@cordegenera@ve….
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“….its all about the blood supply…”
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Arnonczky,AJSM,1982
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Meniscus Repair
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Meniscus Injury
• Trauma@cvsatrauma@c/denera@ve– Trauma@c:Younger,acutelypainfulswollenknee– Degenera@ve:Middleage-older,chronicvsacute-on-chronicvsacutelypainfulknee
• Catching,clicking,lockingofthekneemayoccur• Exammayincludepainfulrangeofmo@on,affectedjointlinetenderness,andposi@veprovaca@vemaneuvers(McMurray’s,Appley’s)
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Meniscus Injury: Diagnosis
• History,Physical• PlainRadiographs!• MRI
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Meniscal Injury Treatment: Young patient
• Nonopera@vetreatmentNOTtypicallyrecommended
• SurgerytoPRESERVEthemeniscus(i.e.,repairordebride,preventtearprogression)
• Defini@onofyoung?– <25yearsold?– <35yearsold?– <50yearsold?
• Why?
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MENISCECTOMY • REMOVALOFMENISCALTISSUEDECREASESCONTACTSTRESSAREA,INCREASINGSTRESSONTHEARTICULARCARTILAGE
• INCREASEDSTRESSISINPROPORTIONTOTHEAMOUNTOFMENISCUSREMOVED
• INCREASEDSTRESSINEVITABLYLEADSTODEGENERATIONOFTHEJOINT
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Meniscectomy and Osteoarthritis
• Fairbanks,JBJS,1948– Describedprogressiveradiographicchangesajeropenmeniscectomy,withupto14yrsf/u
– *Nocorrela@onwithclinicalfindings• Jorgensen,JBJS,1987– 4.5and14.5yrclinicalandradiographicf/uofathletesajeropenmeniscectomy
– c/lkneeradiographsforcontrol• 89%radiographicchanges• 67%symptoma@c• 34%nosports(duetokneepain)
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OA after arthroscopic meniscus repair vs partial meniscectomy
• Stein,AJSM,2010• Level3Cohort• 4.5and9yrblindedradiographicf/u• Young(ish)pa@ents:avgage~31• Isolated,“trauma@ctears”;bothgroups,ver@caltears/bucket
handle• Resultsat9years:
– Meniscectomy:60%OAchanges(GradeIFairbanks)– Meniscusrepair:20%OAchanges(GradeIFairbanks)
– NoGrade2or3changesseen• Repairmuchhigherreturntopriorsport(96%vs50%)
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“SAVE THE MENISCUS….”
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Meniscus Tear, Young Pt.: REPAIR WHEN POSSIBLE
• Young,healthypa@ent– Nonsmoker
• RedZone,Red-WhiteZone• Favorabletearpasern(Ver@cal,Buckethandle)• Acute?• Inconjunc@onwithACLreconstruc@on*• Stableknee
• Morgan,AJSM1991
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Meniscus Repair Healing Rate
• ~82%• Ifanisolatedrepair:~50%healingrate• **Ifinconjunc@onwithACLR:~90%healingrate
– Tenuta,AJSM,1994(WestPoint,A/Aeval)– Cannon,AJSM,1992(arthrogramorA/A)– Westerman,AJSM,2014(MOONGROUP)
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CLINICAL QUESTION
WHATISTHEOPTIMALTREATMENTOFAMIDDLEAGEDPATIENTWITHASYMPTOMATICMENISCUSTEAR?
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• PubMedSearch– Relevantar@cles– Searchterms“meniscus”,“meniscusrepair”,“meniscectomy”,“meniscalhealing”
– Alllevelsofstudiesconsideredforhistoricalpurposes– LevelIandIIstudiesincludedinoutcomesreview
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Levels of Evidence
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Knee Arthroscopy
• ~700,000arthroscopicpar@almedialmeniscectomies/yearintheU.S.in2006
• Butshouldwebedoingthis?
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Meniscus Tear
• Common– 35%ofpeopleovertheageof50haveameniscustear
– 2/3ofthesepeopleareASYMPTOMATIC– Inthepresenceofosteoarthri@s,prevalenceincreasesto100%ifGradeIVarthri@cchanges
• Canbetrauma@cordegenera@ve….
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Arthroscopy for Osteoarthritis?
• Mosely,NEngJMed,2002• RCT,LevelI• Arthroscopywithdebridementandmensicectomyvs.lavagesurgeryvs.shamsurgery
• Conclusions:NODIFFERENCEAMONGGROUPS!
– Kirkley,NEngJMed,2008,similarfindings
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Should we ‘scope this patient’s knee for their meniscus tear?
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Arthroscopy and Osteoarthritis
• InGeneral:DoinganarthroscopyforapaIentwithadvancedarthriIsnolongerappropriate!
• WhataboutkneearthroscopyformeniscustearinapaIentwithmildarthriIcchanges?
• NoarthriIs?
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Arthroscopy vs Sham Surgery for Degenerative Meniscus Tears
• Sihvonen,NEngJMed,2013• Mul@centerRCT,Level2Evidence• [email protected]@entswithoutOA
• Findings:NODIFFERENCEb/tGROUPS@12mos• Importantly,sta@s@caldifferenceinseverityofnon-radiographicappearanceofarthri@sseeninsurgicalvs.shamgroup.
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Knee arthroscopy vs PT for meniscus tears
• Herrlin,KSSTA,2013• RCT,Level1• NoorminimalOA(<grade1)• Middleagedpa@ents• Findings:– PTgroupdidaswellasArthroscopy/PTgroupat5years
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• Arthritis Surgery In Ailing Knees Is Cited as Sham• ByGINAKOLATA• Published:July11,2002
• Common Knee Surgery Does Very Little for Some, Study Suggests
• ByPamBelluck• Published:December25,2013
• The Placebo Effect Doesn’t Apply Just to Pills• OCT.6,2014
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Knee arthroscopy vs PT for meniscus tears
• Herrlin,KSSTA,2013• RCT,Level1• NoorminimalOA(<grade1)• Middleagedpa@ents• Findings:– PTgroupdidaswellasArthroscopy/PTgroupat5years– HOWEVER:33%ofpa/entshadcrossedoverintothesurgicalgroup,andimproveda?erarthroscopy!!
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Knee arthroscopy vs PT for meniscus tears
• Herrlin,KSSTA,2013• RCT,Level1• NoorminimalOA(<grade1)• Middleagedpa@ents• Findings:– PTgroupdidaswellasArthroscopy/PTgroupat5years– HOWEVER:33%ofpa/entshadcrossedoverintothesurgicalgroup,andimproveda?erarthroscopy!!
– NoprogressionofOAinsurgicalgroup
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Arthrosocopy vs PT for Meniscus Tear and [mild-moderate] Osteoarthritis
• Katz,NEngJMed,2013• RCT,mul@centered,LevelIEvidence• ArthroscopyandPTvsPTalone• 12mosf/u,pt.age>45yrs• Results:NODIFFERENCE!
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Arthrosocopy vs PT for Meniscus Tear and [mild-moderate] Osteoarthritis
• Katz,NEngJMed,2013• RCT,mul@centered,LevelIEvidence• ArthroscopyandPTvsPTalone• 12mosf/u,pt.age>45yrs• Results:NODIFFERENCE!– But:• 35%crossover,withimprovedresults• Treatmentfailure:PTalone(49%),Arthroscopy(25%)
– (WOMAC)
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Arthroscopy vs Conservative Tx for Meniscus Tears
• “Notallmeniscustearsneedsurgery..”
• “Thisdoesnotmeanallmeniscustearsdonotneedsurgery”
• RobertBrophy,MD• WashingtonUniversity,St.Louis,MO• JBJS,2014
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Non-Op Treatment, Meniscus
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Does knee arthroscopy and meniscectomy lead to osteoarthritis?
• Paxton,Arthroscopy,2011• Systema@cReview,LevelIV
• 10yearss/pmeniscectomy,36%ofpa@entshadFairbanksI/IIchanges(nonehadIII/IV)
• Meniscusrepair,21%hadI/IIchanges
• Reopera@onrate:Meniscectomy(3.9%),Repair(21%)
• But:DIFFERENTPTPOPULATIONS/AVGAGE….
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Knee arthroscopy vs PT for meniscus tears
• Herrlin,KSSTA,2013• RCT,Level1• NoorminimalOA(<grade1)• Middleagedpa@ents• Findings:– PTgroupdidaswellasArthroscopy/PTgroupat5years– HOWEVER:33%ofpa/entshadcrossedoverintothesurgicalgroup,andimproveda?erarthroscopy!!
– NoprogressionofOAinsurgicalgroup
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CLINICAL QUESTION WHATISTHEOPTIMALTREATMENTOFAMIDDLEAGED
PATIENTWITHASYMPTOMATICMENISCUSTEAR?
• Non-operaIvemanagementisanappropriatefirststep,withphysicaltherapy,acIvitymodificaIons,+/-medicaIons,+/-bracing
• ArthroscopyandparIalmeniscectomymaybeconsideredin
thosewhofailnon-operaIvemeasures• Arthroscopyunpredictableinthosewithmoreadvanced
arthriIs,andshouldnotbethefirstlineoftreatmentinthesepaIents
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SUMMARY
• Non-operaIvemanagementisanappropriatefirststep,withphysicaltherapy,acIvitymodificaIons,+/-medicaIons,+/-bracing
• ManypaIentswilldowellwithoutsurgery• ArthroscopyandparIalmeniscectomymaybeconsideredinthose
whofailnon-operaIvemeasures
• LiteraturenotconclusiveonparIalmeniscectomyandosteoarthriIs:causeoreffect?
• ArthroscopyunpredictableinthosewithmoreadvancedarthriIs,
andshouldnotbethefirstlineoftreatmentinthesepaIents
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Meniscus References 1) FairbankTJ.Kneejointchangesajermeniscectomy.JBoneJointSurg1948;30B(4):6702) JorgensenU,Sonne-HolmS,LauridsenF,etal.Long-termfollow-upofmeniscectomyinathletes:aprospec@velongitudinal
study.JBoneJointSurg1987;69B(1):80-833) ArnoczkySP,WarrenRF.Microvasculatureofthehumanmeniscus.AmJSportsMed1982;10(2):90-954) SteinT,MehlingAP,WelschF,etal.Long-termoutcomeajerarthroscopicmeniscalrepairversusarthroscopicpar@al
[email protected];38(8):1542-15485) BhasacharyyaT,GaleD,DewireP,etal.Theclinicalimportanceofmeniscaltearsdemonstratedbymagne@cresonanceimaging
[email protected];85A(1):4-96) EnglundM,GuermaziA,GaleD,etal.IncidentalmeniscalfindingsonkneeMRIinmiddle-agedandelderlypersons.NEnglJMed
2008;359:1108-11157) MorganCD,WojtysEM,CasscellsCDetal.Arthroscopicmeniscalrepairevaluatedbysecond-lookarthroscopy.AmJSportsMed
1991;19(6):632-6388) TenutaJJ,ArcieroRA.Arthroscopicevalua@onofmeniscalrepairs.AmJSportsMed1994;22(6):797-8029) CannonWD,VisoriJM.Theincidenceofhealinginarthroscopicmeniscalrepairsinanteriorcruciateligament-reconstructed
kneesversusstableknees.AmJSportsMed1992;20(2):176-18110) WestermannRW,WrightRW,SpindlerKP.Meniscalrepairwithconcurrentanteriorcruciateligamentreconstruc@on.AmJ
SportsMed2014;42(9):2184-219211) MoseleyJB,O’MalleyK,PetersenNJ,etal.Acontrolledtrialofarthroscopicsurgeryforosteoarthri@softheknee.NEnglJMed
2002;347(2):81-8712) KirkleyA,BirminghamTB,LitchfieldRB,etal.Arandomizedtrialofarthroscopicsurgeryforosteoarthri@softheknee.NEnglJ
Med2008;359(11):1097-110713) SihvonenR,PaavolaM,MalmivaaraA,etal.Arthroscopicpar@almeniscectomyversusshamsurgeryforadegenera@vemeniscal
tear.NEnglJMed2013;369:2515-252414) HerrlinSV,WangePO,LapidusG,etal.Isarthroscopicsurgerybeneficialintrea@ngnon-trauma@c,degenera@vemedial
meniscaltears?Afiveyearfollow-up.KneeSurgSportsTraumatolArthros2013;21:358-36415) KatzJN,BrophyRH,ChaissonCE,etal.Surgeryversusphysicaltherapyforameniscaltearandosteoarthri@s.NEngJMed2013;
368:1675-168416) PaxtonSE,StockMV,BrophyRH.Meniscalrepairversuspar@almeniscectomy:Asystema@creviewcomparingreopera@on
ratesandclinicaloutcomes.Arthroscopy2011;27(9):1275-1288
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THANK YOU!
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Evidence Based Management of Meniscal Tears
KennethG.Swan,Jr.,MD
