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.
Highlights
The menisci are fibrocartilaginous structures located between the medial and lateral tibiofemoral joints that function to reduce knee joint loads by shock absorption
No significant between-group differences from baseline to 12 months in any primary outcome (LKS, Western Ontario Meniscal Evaluation Tool (WOMET) and knee pain after exercise). Both groups reported an improvement in knee pain, function and a high level of treatment satisfaction using Visual analogue scale (VAS), Lysholm knee scoring (LKS), Tegner activity scale, patient subjective knee pain and satisfaction
Surgical approaches to the treatment of meniscal pathology can be broadly categorised as menisectomy or repair
Summary
The menisci are fibrocartilaginous structures located between the medial and lateral tibiofemoral joints that function to reduce knee joint loads by shock absorption. In vitro studies have demonstrated that joint stresses are related to the amount of meniscus removed [7]. When patients undergoing partial or total menisectomy have been compared, the amount of tissue resected was demonstrated to be inversely related to knee function [8]. Arthroscopic partial menisectomy (APM) remains the most common surgical intervention for meniscal pathology and the most common orthopaedic surgical procedure in the United States, with more than 465,000 people undergoing the procedure annually [9]. There is no study that has compared whether APM is superior to nonoperative therapy in the treatment of traumatic meniscal tears. There are, some commonalities emerging from both randomised controlled trials (RCTs) and observational studies that have examined therapeutic interventions for meniscal pathology
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