Outcomes of Arthroscopic Repair versus Observation in Older Patients

Abstract

Objectives: Meniscal root tears occur in a bimodal distribution, affecting both young healthy athletes and older patients with early degenerative knees. Root tears lead to de-tensioning of the meniscus and have been associated with increased contact forces and cartilage damage. Management of older patients with root tears is controversial and the efficacy of different treatment options is unclear. The primary aim of this study is to compare the clinical outcomes of patients undergoing an all-inside arthroscopic repair technique versus non-operative management for posterior meniscal root tears. Methods: 48 patients diagnosed with a posterior meniscal root tear between 2006 and 2015 were identified and divided into 2 groups, the arthroscopic repair group (AR, 30 knees), and the observation group (O: 18 knees). The AR group underwent a meniscal root repair technique where two all-inside sutures were used to reduce the root back to its remnant (reduction sutures) thereby re-tensioning the meniscus. One mattress suture was then added to strengthen the repair and repair the construct to the posterior capsule. KOOS subscores (Symptoms, Pain, Activities of Daily Living (ADL), Sports and Rec, Quality of Life), Lysholm, Tegner, and VR12 PCS questionnaires were used as the primary outcome measures at a minimum 2 years follow-up. Differences in baseline patient characteristics between the surgical and non-surgical group were examined using Fisher’s exact tests for categorical variables and Mann-Whitney U tests for continuous variables. For changes from baseline to follow up between the surgical and non-surgical group, independent sample t-tests or Mann-Whitney U tests were conducted depending on normality. A Fisher’s exact test was also utilized to analyze the rates of conversation to total knee arthroplasty (TKA) between the surgical and non-surgical group. Results: There were significant changes in all baseline to follow up mean KOOS subscores (all subscores: p < 0.001), Lysholm (p < 0.001), Tegner (p = 0.0002), and VR12 PCS (p < 0.001) scores for the AR group, while the O group had a significant difference in only mean KOOS pain (p = 0.003), KOOS ADL (p = 0.006), and VR12 PCS (p = 0.038) scores from baseline to follow-up. The AR group had a significantly larger increase from baseline to follow up in mean KOOS pain scores (32.0) compared to the O group (15.7) (p = 0.009), KOOS symptom scores (AR: 24.2, O: 9.3, p = 0.029) as well as in Lysholm scores (AR: 27.3 and O: 7.1; p = 0.016). During the follow-up period, 3.3% of patients in the AR group underwent a TKA, which was significantly lower than the 33.3% of patients in the O group (p = 0.008). The hazard of TKA conversion is estimated to be 93.2% lower for patients in the AR group compared to the O group (p = 0.013). Conclusion: Our study found a significant improvement in all clinical outcome scores in the AR group at 2-year follow-up. There was a significantly larger increase in KOOS pain, KOOS symptom, and Lysholm scores in the AR group compared to the O group. The AR group also had a significantly lower conversion to TKA and significantly lower hazard of TKA conversion as compared to the O group. Surgical management showed higher functional outcomes and decreased TKA conversion rates as compared to observation and should be considered as a treatment option for the treatment of meniscal root tears in the older population.