Degenerative Tears Research Articles

The Role of Arthroscopic Partial Meniscectomy in the Management of Degenerative Meniscus Tears: A Review of the Recent Literature.

Background:The use of arthroscopic partial meniscectomy for middle aged to older adults with knee pain is one of the most common surgical procedures with approximately 150,000 knee arthroscopies being carried out in the United Kingdom each year, and about five times that number in the United States. Despite this, the procedure remains controversial. The aim of this paper is to provide a comprehensive review of the role of arthroscopic meniscectomy in patients with degenerative meniscus tears and suggest recommendations for clinical practice.Methods:A thorough literature search was performed using available databases, including Pubmed, Medline, EMBASE and the Cochrane Library to cover important randomised control trials surrounding the use of arthroscopic partial meniscectomy.Results:The majority of randomised control trials suggest that arthroscopic partial meniscectomy is not superior to conservative measures such as exercise programmes. Furthermore, one randomised control trial found that arthroscopic partial meniscectomy was not even superior to sham surgery.Conclusion:There is significant overtreatment of knee pain with arthroscopic partial meniscectomy when alternative, less invasive and less expensive treatment options are equally effective. First-line treatment of degenerative meniscus tears should be non-operative therapy focused on analgesia and physical therapy to provide pain relief as well as improve mechanical function of the knee joint. Arthroscopic partial meniscectomy should be considered as a last resort when extensive exercise programmes and physiotherapy have been tried and failed.

Masso-kinésithérapie pour tendinopathie dégénérative de la coiffe des rotateurs de l’épaule

Physiotherapy for degenerative rotator cuff disease includes mobilization, muscle strengthening and prevention of sub-acromial impingement. It is a supervised treatment, organized in programs of 12 to 15 sessions, which are distributed to 2 to 3 per week. Randomized trials for chronic shoulder pain due to degenerative rotator cuff disease are numerous. They indicate therapeutic effect of physiotherapy. They also show particular value of muscle strengthening, dynamic humeral centering, technical combinations, and supervision by a physiotherapist. In the specific indication of degenerative rotator cuff tears, cohort studies show a clinically relevant and persistent improvement at 2 years in 75% of patients which were considered for surgery at baseline. Physiotherapy appears therefore as essential to consider first-line treatment for persistent shoulder pain due to degenerative rotator cuff disease without or with a tendinous tear.

Platelet-rich plasma supplementation in arthroscopic repair of full-thickness rotator cuff tears: a randomized clinical trial.

Results on the effectiveness of PRP supplementation in arthroscopic rotator cuff repair are conflicting, making it difficult to draw definitive conclusions. This was a prospective, randomized, and double-blind study with two groups of 20 patients each (PRP group and control group). Degenerative supraspinatus full-thickness tears grade C2-C3 were subjected to arthroscopic repair; PRP supplementation was given to patients in the PRP group. The outcomes were assessed by DASH, Constant scales, and ultrasound before and 6months after surgery. Pain measured by VAS was evaluated preoperatively and 7 and 30days after surgery. The two groups did not differ significantly by age, sex, and dominance of the affected side. In all surgical procedures, a long head of the biceps tenotomy and single-row repair were performed. The preoperative VAS was 5.6±2.4 in PRP group and 6.4±1.5 in the control group (p>0.05). The group supplemented with PRP reported a VAS significantly better in the first week (2.5±1.9 vs 5.3±2.1, p<0.05) and during the first month after surgery (1.5±1.0 vs 3.2±1.7, p<0.05) compared to the control group. The preoperative Constant and DASH scores were 39.95±12 and 51±15.2, respectively, in the PRP group and 41±11 (p>0.05) and 45±12.6 (p>0.05) in the control group. The average Constant score improved significantly after 6months to 81±11.2 (p<0.05) in the PRP group and 78.5±9 (p<0.05) in the control group. No differences were noted between the two groups (p>0.05). The DASH score after 6months was 17.4±8 (p<0.05) for the treatment group (the PRP group) and 21±8.4 (p<0.05) for the control group. No statistically significant differences were found as regards the DASH score in the two groups after 6months (p>0.05). The two groups showed no differences in the ultrasound evaluation after 6months either. No re-ruptures occurred in either group. PRP leads to a reduction in pain during a short-term follow-up. Pain reduction allows for a more rapid recovery of mobilization and improvement in functionality. Randomized controlled trial, Level of evidence, 1.

Repair of isolated horizontal meniscal tears with all-inside suture materials using the overlock method: outcome study with a minimum 2-year follow-up.

BackgroundThis study aimed to consider the use of a meniscal repair in patients in order to close the horizontal cleavage extending up to the avascular zone. The hypothesis was to examine the clinical and arthroscopic outcomes following meniscal repair of degenerative horizontal cleavage tears with new-generation all-inside suture materials using the overlock method.MethodsWe retrospectively reviewed a consecutive series of 55 patients which had a horizontal pattern, and finally, 27 patients with a horizontal tear only which required no additional intra-articular surgical intervention were included in the study. Arthroscopic meniscal repair was performed using the overlock method. Functional outcomes were evaluated using Lysholm knee scoring scale, Cincinnati scores, subjective International Knee Documentation Committee (IKDC) criteria and Tegner activity scale. Assessment of meniscal healing was evaluated clinically by the presence of meniscal signs. The preoperative and postoperative MRIs were examined.ResultsThe mean follow-up period was 29 months (range, 24–38). The mean Lysholm score improved significantly from 59.5 ± 12.4 points preoperatively to 90.0 ± 4.7 points postoperatively (P < 0.0001). The Cincinnati score increased from 14.8 ± 5.3 to 26.9 ± 1.6 (P < 0.0001). The Tegner activity score increased from 3.7 ± 1.4 to 6.4 ± 1.6 (P < 0.0001). The mean IKDC subjective score also improved significantly from 48.5 ± 9.8 preoperatively to 90.4 ± 5.0 postoperatively (P < 0.0001).ConclusionMeniscal repair of degenerative horizontal tears using the overlock method resulted in improved Lysholm and IKDC subjective scores. With careful selection of the patients and the horizontal meniscus tears, the success of the meniscus repairs increases. Repair can be recommended for all horizontal meniscus tears which can be repaired arthroscopically.

Traumatic and Degenerative Meniscus Tears Have Different Gene Expression Signatures

Background: Meniscus tears are classified as traumatic or degenerative based on the tear pattern. There is little evidence demonstrating biological differences between the 2 tear types. Hypothesis: Gene expression signatures in the injured meniscus are different between traumatic (vertical) and degenerative (complex, horizontal, or flap) tears. Study Design: Controlled laboratory study. Methods: Samples of the torn meniscus from the white-white zone were removed at the time of clinically indicated partial meniscectomy from 48 patients (37 with degenerative tears and 11 with traumatic tears). mRNA expression in the injured menisci was measured by quantitative real-time polymerase chain reaction for selected molecular markers of osteoarthritis, inflammation, and cartilage homeostasis (eg, cytokines/chemokines, aggrecanases/metalloproteinases, transcription factors, cartilage matrix genes, and adipokines). The tear pattern (traumatic or degenerative) and location (medial or lateral) were recorded for each patient. Gene expression differences between degenerative and traumatic tears were computed after adjusting for patients’ age, sex, and body mass index and for location of the resected meniscus (medial/lateral). Results: Gene expression in meniscus tears varied by pattern. Chemokines (IL8 [P < .001] and CXCL6 [P < .001]) and matrix metalloproteinases (MMP1 [P = .011] and MMP3 [P = .016]) were expressed at a significantly higher level in traumatic tears compared with degenerative tears. In contrast, COL1A1 was expressed at a lower level in traumatic tears compared with degenerative tears (P = .058). None of the genes tested demonstrated significant differences between medial and lateral meniscus tears. Conclusion: Traumatic meniscus tears overall exhibited a higher inflammatory/catabolic response as evidenced by higher levels of chemokine and matrix metalloproteinase expression than degenerative tears. These findings suggest that there is a (molecular) biological distinction between traumatic and degenerative tears. Clinical Relevance: The catabolic/inflammatory differences between traumatic and degenerative tears may be relevant to treatment decisions regarding the meniscus as well as advance our understanding of how meniscus tears relate to the development of knee osteoarthritis.

Quantifying Quadriceps Muscle Strength in Patients With ACL Injury, Focal Cartilage Lesions, and Degenerative Meniscus Tears: Differences and Clinical Implications.

Background:Reduced quadriceps strength influences knee function and increases the risk of knee osteoarthritis. Thus, it is of significant clinical relevance to precisely quantify strength deficits in patients with knee injuries.Purpose:To evaluate isokinetic concentric quadriceps muscle strength torque values, assessed both from peak torque and at specific knee flexion joint angles, in patients with anterior cruciate ligament (ACL) injury, focal cartilage lesions, and degenerative meniscus tears.Study Design:Cohort study; Level of evidence, 3.Methods:Data were synthesized from patients included in 3 previously conducted research projects: 2 prospective cohort studies and 1 randomized controlled trial. At the time of inclusion, all patients were candidates for surgery. Isokinetic concentric quadriceps muscle strength measurements (60 deg/s) were performed at baseline (preoperative status) and after a period of progressive supervised exercise therapy (length of rehabilitation period: 5 weeks for ACL injury, 12 weeks for cartilage lesions and degenerative meniscus). Outcome measures were peak torque and torque at specific knee flexion joint angles from 20° to 70°. All patients had unilateral injuries, and side-to-side deficits were calculated. For comparisons between and within groups, we utilized 1-way analysis of variance and paired t tests, respectively.Results:In total, 250 patients were included. At baseline, cartilage patients had the most severe deficit (39.7% ± 24.3%; P < .001). Corresponding numbers for ACL and degenerative meniscus subjects were 21.7% (±13.2%) and 20.7% (±16.3%), respectively. At retest, there was significant improvement in all groups (P < .001), with remaining deficits of 24.7% (±18.5%) for cartilage, 16.8% (±13.9%) for ACL, and 3.3% (±17.8%) for degenerative meniscus. Peak torque was consistently measured at 60° of knee flexion, whereas the largest mean deficits were measured at 30° at baseline and 70° at retest for the ACL group, at 70° at baseline and retest for the degenerative meniscus group, and at 60° at baseline and at 50° at retest for the cartilage group.Conclusion:This study underlines the importance of including torque at specific knee flexion joint angles from isokinetic assessments to identify the most severe quadriceps muscle strength deficits. Furthermore, it confirms the importance of progressive exercise therapy interventions before potential surgery in patients with knee injuries.

Radiographic progression of arthritic changes in shoulders with degenerative rotator cuff tears

Very little longitudinal information has been available regarding the relationship of cuff tears and arthritis. The purpose of this study was to determine the midterm risk of and risk factors for rotator cuff tear arthropathy progression in a cohort of subjects with an asymptomatic rotator cuff tear. Baseline (visit 1), 5-year (visit 2), and most recent follow-up (visit 3) radiographs were reviewed in a cohort of 105 subjects enrolled for longitudinal surveillance of asymptomatic degenerative rotator cuff tears and 33 controls. The radiographs were assessed in a blinded, randomized fashion by 3 observers who graded glenohumeral arthritic changes using the Hamada scores, Samilson-Prieto (SPO) scores, and acromiohumeral interval (AHI). Osteoarthritis (SPO classification), cuff tear arthropathy (Hamada classification), and AHI progressed between visits 1 and 3 (median, 8 years; P < .001 in all cases). SPO progression was not significantly different for partial- vs. full-thickness vs. control baseline tear types (P = .19). Both full-thickness and partial-thickness tears had greater progression in Hamada scores than controls did in the first 5 years of follow-up (P = .02 and P = .03, respectively), but scores did not differ between partial- and full-thickness tears. Tears with and without enlargement did not differ in progression in SPO grade, Hamada grade, or AHI. Glenohumeral arthritic changes progress significantly but remain minimal within an 8-year period in early to moderate degenerative cuff disease. Whereas the presence of a rotator cuff tear influences progression in Hamada grade, the magnitude of radiographic progression is not influenced by tear severity or enlargement at midterm time points.

Arthroscopic Distal Triceps Repair

In this note, we describe an arthroscopic repair of a degenerative tear of the triceps using a suture weave and an anatomic footprint anchor. We are able to assess, debride, and anatomically repair the distal triceps to its insertion. Compared with open procedures, this arthroscopic repair offers lower morbidity, faster recovery, and improved cosmesis. Our goal was to improve the function and strength of the elbow through this arthroscopic surgical fixation.

Arthroscopic meniscectomy of traumatic versus atraumatic tears in middle aged patients: is there a difference?

Meniscal tears can be classified in various ways, one of which is into traumatic or degenerative. It is not known whether partial meniscectomy of clinically defined traumatic compared to degenerative tears in middle age patients has favorable results. The purpose of this study was to compare the outcome after arthroscopic partial meniscectomy of clinically defined traumatic to degenerative meniscal tears in middle age patients. Eighty-six middle aged patients with stable knees and no radiographic signs of osteoarthritis who had arthroscopic partial meniscectomy were divided into a study group of 43 patients with a preceding knee injury related to their knee symptoms (traumatic group) and a control group of 43 uninjured patients (atraumatic group), matched by age, sex, body mass index and comorbidities. The surgical findings and postoperative clinical scores were compared between the two groups. There were no statistical differences in surgical findings of tear types and degree of chondral lesions. At the end of the follow-up 33 (77%) patients in each group were satisfied to have had the operation. The median Lysholm score improved from 65.9±17.4 to 77.4±21.2 points (P=0.001) in the traumatic group and from 65.3±17 to 82.4±17.7 in the atraumatic group (P<0.0001). Arthroscopic partial meniscectomy in middle aged patients with stable knees and no signs of radiographic osteoarthritis improve pain and function. There were no differences in surgical findings and short term clinical outcome between patients with and without preceding knee injury.

Candidate gene approach identifies six SNPs in tenascin-C (TNC) associated with degenerative rotator cuff tears.

Evidence for a heritable predisposition to rotator cuff tears (RCTs) is growing. Unrelated Caucasian individuals with surgically diagnosed full thickness RCTs (cases) and elderly Caucasian controls with intact rotator cuffs were screened for differences at the candidate genes: TNC, Col5A1, TIMP-1, MMP-1, MMP-2, MMP-3, MMP-9, and MMP-13. A first cohort (59 cases; 32 controls) was genotyped with the Sequenom MassARRAY iPLEX system. Of 142 SNPs within about 67-kbp of the TNC gene, 30 were tested for differences in proportions between cases and controls. A second, matched cohort (96 patients; 44 controls) was also genotyped for the same 30 SNPs, but with the KASP™ genotyping technology. Combining the two cohorts and after Bonferroni correction, six SNPs were significantly associated with RCT. Compared to controls, RCT patients showed a significantly higher rate of homozygosity at rs72758637, rs7021589, and rs1138545; a significantly higher rate of heterozygosity at rs10759753, rs3789870, and rs7035322 and a higher minor allele frequency at rs3789870. Rs1138545, a missense SNP in exon10 might be of biological significance because it varies the amino acid sequence close to the TNC-FNIII5 domain. The FNIII5 domain binds multiple growth factors and co-ligates with integrins during tendon healing. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:894-901, 2017.

Mechanical Symptoms and Arthroscopic Partial Meniscectomy in Patients with Degenerative Meniscus Tear: A Secondary Analysis of a Randomized, Placebo-controlled Trial

Mechanical Symptoms and Arthroscopic Partial Meniscectomy in Patients with Degenerative Meniscus Tear: A Secondary Analysis of a Randomized, Placebo-controlled Trial

Does application of moderately concentrated platelet-rich plasma improve clinical and structural outcome after arthroscopic repair of medium-sized to large rotator cuff tear? A randomized controlled trial

Platelet-rich plasma (PRP) has the potential to improve tendon-bone healing. The evidence is still controversial as to whether PRP application after repair of medium-sized to large cuff tears leads to superior structural and clinical outcome, especially after single-row repair. In a randomized study, 102 patients (PRP group, 52 patients; control group, 50 patients) with medium-sized and large degenerative posterosuperior tears were included for arthroscopic repair with a minimum follow-up of 2 years. Patients were evaluated with clinical scores (visual analog scale score, Constant-Murley score, University of California-Los Angeles score, and American Shoulder and Elbow Surgeons score) and ultrasound to assess retear and vascularity pattern of the cuff. Visual analog scale scores were significantly lower in the PRP group than in controls at 1 month, 3 months, and 6 months but not later. Constant-Murley scores were significantly better in the PRP group compared with controls at 12 and 24 months, whereas University of California-Los Angeles scores were significantly higher in the PRP group at 6 and 12 months (P < .05). The American Shoulder and Elbow Surgeons score in both groups was comparable at all the times. At 24 months, retear in the PRP group (n = 2; 3.8%) was significantly lower than in the control group (n = 10; 20%; P = .01). The retear difference was significant only for large tears (PRP:control group, 1:6; P = .03). Doppler ultrasound examination showed significant vascularity in the PRP group repair site at 3 months postoperatively (P < .05) and in peribursal tissue until 12 months. Application of moderately concentrated PRP improves clinical and structural outcome in large cuff tears. PRP also enhances vascularity around the repair site in the early phase.

Regeneration of knee joint menisci – methods review

Abstract At present, there is no need to convince anyone that menisci are crucial structures dealing with a huge number of responsibilities, and its absence in a knee joint results in irretrievable chondral damage. A lot of methods have been recently developed to treat meniscal tears: physical therapy as a first and, for some cases, a last step, bonding by biodegradable sutures, screws, or arrows, collagen and polyurethane scaffolds designed for partial meniscus replacement, and finally allograft transplantation. However, all of them have numerous limitations and can be used in specific conditions only. That is the reason why partial and total meniscectomy is up to this time a common operation in the case of degenerative or complex meniscus tears despite its well-known degenerative consequences. Trials to overcome those limitations are ongoing, and the challenge to invent a long-term successful regeneration method or to design a substitute that well mimics an anatomical meniscus is still in front of us.

What's New in Sports Medicine.

This update is based on the scientific and investigational activities in the specialty of sports medicine from September 2014 to August 2015. It includes a review of pertinent research and articles published in the three premier journals of our specialty, namely, The Journal of Bone & Joint Surgery, The American Journal of Sports Medicine , and Arthroscopy: The Journal of Arthroscopic and Related Surgery. ### Rotator Cuff #### Degenerative Rotator Cuff Tear History The natural history of degenerative rotator cuff tear progression is still being elucidated. There are many studies that show the prevalence of asymptomatic rotator cuff tears, but few exist that evaluate the long-term prospective patient history. Keener et al. attempted to characterize the amount of rotator cuff tear enlargement and progression of symptoms with initial asymptomatic tears. They studied asymptomatic rotator cuff tears in patients who had a symptomatic contralateral rotator cuff tear. In their study, they showed that tears enlarged in almost one-half of the patients over a median of 3 years and those patients who experienced tear enlargement tended to have an onset of new pain. Progressive degenerative changes within the supraspinatus and infraspinatus muscles were associated with tear enlargement compared with the control group. These findings show that many of these tears may progress and may become symptomatic1. #### Therapy After Rotator Cuff Repair Although therapy after rotator cuff repair is universal, the optimal timing of rehabilitation initiation is still unknown. Studies have suggested that outcome scores are better with early passive motion (<6 weeks after the surgical procedure) than with delayed motion (≥6 weeks), but the association of rehabilitation schedule and retear rate is not fully understood. In a systematic review and meta-analysis, Kluczynski et al. found that, in randomized controlled studies, there was not a significant difference between the 2 rehabilitation schedules with respect to retear rates. With analysis of those studies that did not …

Mechanical symptoms as an indication for knee arthroscopy in patients with degenerative meniscus tear: a prospective cohort study

According to prevailing consensus, patients with mechanical symptoms are those considered to most likely benefit from arthroscopic surgery. The aim of this study was to determine the value of using patients' pre-operative self-reports of mechanical symptoms as a justification surgery in patients with degenerative meniscus tear/knee disease. Pragmatic prospective cohort of 900 consecutive patients with symptomatic degenerative knee disease and meniscus tear undergoing arthroscopic partial meniscectomy (APM) was collected from one public orthopedic referral center specialized in arthroscopic surgery during 2007-2011. The patients' subjective satisfaction, self-rated improvement, change in Western Ontario Meniscal Evaluation Tool (WOMET) score, and patients' ratings of the knee using a numerical rating scale (NRS) was assessed at 1year postoperatively. Multivariable regression models, adjusted for possible confounders and intermediates, were used to compare the outcomes in those with and without preoperative mechanical symptoms. The proportion of patients satisfied with their knee 12 months after arthroscopy was significantly lower among those with preoperative mechanical symptoms than among those without (61% vs 75%, multivariable adjusted risk ratio [RR] 0.84; 95% confidence interval [CI] 0.76, 0.92). Similarly, the proportion reporting improvement was lower (RR 0.91; 95% CI 0.85, 0.97). No statistically significant difference was found in change in WOMET or NRS between the two groups. Of those with preoperative mechanical symptoms, 47% reported persistent symptoms at 12 months postoperatively. Our observational data contradicts the current tenet of using patients' self-report of mechanical symptoms as a justification for performing arthroscopic surgery on patients with degenerative meniscus tear.

Acute TFCC Injury

Wrist injuries are common in athletic competition and tears of the triangular fibrocartilage complex (TFCC) are the main source of athletes presenting with acute onset ulnar-sided wrist pain. Treatment for TFCC injuries varies based on the acuity and location of the tear. Degenerative tears are often associated with ulnar positive variance and are best treated with debridement and joint leveling. The focus on athletes encompasses primarily acute injuries, which are often traumatic in nature from twisting such as a torque to the wrist or from a fall on an outstretched hand. Acute tears on the periphery of the TFCC have been shown to have adequate blood supply and potential to heal, and both open and arthroscopic repair techniques have been described. Arthroscopic procedures have shown improved outcomes to open. Athletes and their families should be made aware of the various surgical options available to them and treatment should be tailored to each individual situation.

Arthroscopic lateral acromion resection (ALAR) optimizes rotator cuff tear relevant scapula parameters

The acromion index (AI), critical shoulder angle (CSA) and lateral acromion angle (LAA) are predictive for degenerative rotatory cuff tears. Their unfavorable values are associated with a suboptimal deltoid force vector. The aim of this study was to evaluate whether an optimization of the radiological parameters could be achieved through a specific arthroscopic lateral acromion resection (ALAR). The procedure was performed in eight fresh frozen cadaver shoulders. True a.p. and axial radiographs were taken before and after the intervention for radiological evaluation. The anterior and posterior acromion edges were marked with a spinal needle. Then 1cm of the lateral acromion was resected with a 5.0 acromionizer (Arthrex Inc., Naples, FL, USA) beginning from the anterior aspect. The resection was completed over the total width of 1cm from anterior to posterior. Finally the deltoid insertion was dissected via an open approach to ensure its integrity. The fluoroscopy images were evaluated regarding the pre- and postinterventional parameters AI, CSA and LAA. After the intervention, the mean AI could be significantly reduced from 0.62±0.11 to 0.40±0.15 (p=0.012). Also the mean CSA was significantly reduced from 35.0°±7.65° to 25.12°±8.29° (p=0.018). The LAA could not be significantly changed (76.5°±14.02° vs. 82.13±8.93; p=0.107). There was no injury to the deltoid insertion. The radiographic parameters AI und CSA can be optimized significantly by ALAR without macroscopic discontinuity of the deltoid insertion. Level IV, case series without comparison group.

Surgical Repair Did Not Improve Functional Outcomes More Than Conservative Treatment for Degenerative Rotator Cuff Tears.

Lambers Heerspink FO, van Raay JJ, Koorevaar RC, van Eerden PJ, Westerbeek RE, van’t Riet E, van den Akker-Scheek I, Diercks RL. Comparing surgical repair with conservative treatment for degenerative rotator cuff tears: a randomized controlled trial. J Shoulder Elbow Surg. 2015 Aug;24(8):1274-81. ### Question: In patients with degenerative rotator cuff tears, how does surgical repair compare with conservative treatment with respect to functional outcomes? ### Design: Randomized (unclear allocation concealment), unblinded, controlled trial with 12 months of follow-up. ### Setting: A university hospital and 2 regional hospitals in the Netherlands. ### Patients: 56 patients (mean age, 61 years; 63% men) with degenerative, nontraumatic full-thickness rotator cuff tears were enrolled. Exclusion criteria included trauma associated with the onset of complaints, previous shoulder surgery, frozen shoulder, osteoarthritis of the glenohumeral or acromioclavicular joint, diabetes, cognitive disorders, and neurologic diseases affecting the upper extremities. 45 patients (80%) were included in the analysis. ### Intervention: Patients were allocated to surgery (n = 25) or conservative treatment (n = …

Mechanical Symptoms and Arthroscopic Partial Meniscectomy in Patients With Degenerative Meniscus Tear: A Secondary Analysis of a Randomized Trial.

Recent evidence shows that arthroscopic partial meniscectomy (APM) offers no benefit over conservative treatment of patients with a degenerative meniscus tear. However, patients who report mechanical symptoms (sensations of knee catching or locking) may benefit from APM. To assess whether APM improves mechanical symptoms better than sham surgery. Randomized, patient- and outcome assessor-blinded, sham surgery-controlled, multicenter trial. (ClinicalTrials.gov: NCT00549172). 5 orthopedic clinics in Finland. Adults (aged 35 to 65 years) with a degenerative medial meniscus tear and no knee osteoarthritis. APM or sham surgery. Patients' self-report of mechanical symptoms before surgery and at 2, 6, and 12 months after surgery. 70 patients were randomly assigned to APM, and 76 were assigned to sham surgery. Thirty-two patients (46%) in the APM group and 37 (49%) in the sham surgery group reported catching or locking before surgery; the corresponding numbers at any follow-up were 34 (49%) and 33 (43%), with a risk difference of 0.03 (95% CI, -0.06 to 0.12). In the subgroup of 69 patients with preoperative catching or locking, the risk difference was 0.07 (CI, -0.08 to 0.22). Analyses were post hoc, and the results are only generalizable to knee catching and occasional locking because few patients reported other types of mechanical symptoms. Resection of a torn meniscus has no added benefit over sham surgery to relieve knee catching or occasional locking. These findings question whether mechanical symptoms are caused by a degenerative meniscus tear and prompt caution in using patients' self-report of these symptoms as an indication for APM. Academy of Finland.

Biomechanical Effects of a Horizontal Medial Meniscal Tear and Subsequent Leaflet Resection

Background: Horizontal, degenerative tears of the medial meniscus and subsequent meniscectomy can compromise the biomechanical function of the meniscus in load transmission and weightbearing, leading to the development of radiographic and symptomatic tibiofemoral arthritis. Hypothesis: Resection of both leaflets of a horizontal medial meniscal tear will increase peak contact pressures and decrease contact areas in comparison with resection of only the inferior leaflet. Study Design: Controlled laboratory study. Methods: Twelve fresh-frozen human cadaveric knees had tibiofemoral peak contact pressures and contact areas under an 1800-N axial load measured by Tekscan in the control state. A horizontal tear was created in the posterior horn of the medial meniscus, and the knees were retested. The knees were tested a third time after resection of the inferior leaflet (single leaflet) and a final time after resection of the superior leaflet (both leaflets). The Friedman test was used to test for group differences in peak pressure (psi) and contact area (mm2) between test conditions (native, tear, inferior leaflet resection, and resection of both leaflets). Results: For the medial compartment, there was a statistically significant difference in peak pressure (P = .03) but not in contact area (P = .70) between testing conditions. Median peak pressure in the medial compartment was significantly greater for resection of both leaflets compared with the tear (406.5 vs 294.7 psi, respectively; P = .002). Median contact area in the medial compartment was greatest for resection of both leaflets (602.7 mm2), but there were no statistically significant differences between test conditions (P = .70). For the lateral compartment, there were no statistically significant differences in peak pressure (P = .99) or contact area (P = .77) between test conditions. Conclusion: Resection of a single inferior leaflet after a horizontal medial meniscal tear preserves much of the original biomechanical function of the meniscus. Resection of both leaflets leads to a significant increase in contact pressure dispersed over the same contact area, which results in an undesirable biomechanical environment. Clinical Relevance: Arthroscopic inferior leaflet resection is a viable option for providing symptomatic relief of horizontal medial meniscal tears and preserves the ability of the meniscus to absorb axial loading on the knee joint, theoretically decreasing the risk of subsequent osteoarthritis.