Meniscal Symptoms Research Articles

Knee Arthroscopic Surgery in Middle-Aged Patients With Meniscal Symptoms: A 10-Year Follow-up of a Prospective, Randomized Controlled Trial

Background: Short- and midterm evaluations of arthroscopic meniscal surgery have shown little or no effect in favor of surgery, although long-term effects, including radiographic changes, are unknown. Purpose: To compare the 10-year outcomes in middle-aged patients with meniscal symptoms between a group that received an exercise program alone and a group that received knee arthroscopy in addition to the exercise program with respect to the prevalence of radiographic and symptomatic osteoarthritis (OA), patient-reported outcomes, and clinical status. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: Of 179 eligible patients aged 45 to 64 years, 150 were randomized to undergo either 3 months of exercise therapy (nonsurgery group) or knee arthroscopy in addition to the exercise therapy (surgery group). Surgery usually consisted of partial meniscectomy (n = 56) or diagnostic arthroscopy (n = 8). Radiographs were assessed according to the Kellgren-Lawrence score at the baseline and 5- and 10-year follow-ups. Patient-reported outcome measures were reported at the baseline and 1-, 3-, 5-, and 10-year follow-ups. Clinical status was assessed at a 10-year follow-up. The primary outcomes were radiographic OA and changes in the Knee injury and Osteoarthritis Outcome Score Pain subscale (KOOSPAIN) from the baseline to the 10-year follow-up. The primary analysis was performed using the intention-to-treat approach. Results: At the time of the 10-year follow-up, eight patients had died, leaving 142 eligible patients. Radiographic OA was assessed for 95 patients (67%), questionnaires were answered by 110 (77%), and the clinical status was evaluated for 95 (67%). Radiographic OA was present in 67% of the patients in each group (P≥ .999); symptomatic OA was present in 47% of the nonsurgery group and 57% of the surgery group (P = .301). There were no differences between groups regarding changes from baseline to 10 years in any of the KOOS subscales. Conclusion: Knee arthroscopic surgery, in most cases consisting of partial meniscectomy or diagnostic arthroscopy, in addition to exercise therapy in middle-aged patients with meniscal symptoms, did not increase the rates of radiographic or symptomatic OA and resulted in similar patient-reported outcomes at the 10-year follow-up compared with exercise therapy alone. Considering the short-term benefit and no long-term harm from knee arthroscopic surgery, the treatment may be recommended when first-line treatment—including exercise therapy for ≥3 months—does not relieve patient’s symptoms. Registration: Clinical Trials NCT01288768 (ClinicalTrials.gov identifier).

The Role of Ultrasound in the Diagnosis and Treatment of Meniscal Injuries.

This review evaluates the current understanding of the role of ultrasound in the diagnosis and treatment of meniscal disorders. Ultrasound (US) demonstrates similar sensitivity and specificity when compared to magnetic resonance imaging in the evaluation of meniscal injuries when compared to arthroscopy. Meniscal extrusion (ME) under US can be a reliable metric to evaluate for meniscal root tears in knees with and without osteoarthritis (OA). Sonographic ME is associated with development of OA in knees without OA. US following allograft meniscal transplant may be useful in predicting graft failure. US findings can be used to screen for discoid menisci and may demonstrate snapping of a type 3 discoid lateral meniscus. Shear wave elastography for meniscal injuries is in its infancy; however, increased meniscal stiffness may be seen with meniscal degeneration. Perimeniscal corticosteroid injections may provide short term relief from meniscal symptoms, and intrameniscal platelet-rich plasma injections appear to be safe and effective up to three years. Ultrasound-assisted meniscal surgery may increase the safety of all inside repairs near the lateral root and may assist in assessing meniscal reduction following root repair. Diagnostic US can demonstrate with high accuracy a variety of meniscal pathologies and can be considered a screening tool. Newer technologies such as shear wave elastography may allow us to evaluate characteristics of meniscal tissue that is not possible on conventional imaging. US-guided (USG) treatment of meniscal injuries is possible and may be preferable to surgery for the initial treatment of degenerative meniscal lesions. USG or US-assisted meniscal surgery is in its infancy.

Item-Specific Knee Injury and Osteoarthritis Outcome Score Characterization of Patients With Medial Meniscus Root Tear.

Most studies regarding medial meniscus posterior root tear (MMPRT) report total Knee injury and Osteoarthritis Outcome Score (KOOS) subscale values as important patient-reported outcomes, but there are few symptom-specific characterizations of patients with MMPRT. The purpose of this study was to characterize the prevalence and severity of symptoms and functional limitations among patients with MMPRT based on item-level KOOS responses. It was hypothesized that patients with MMPRT would show similar symptoms to those of other meniscal tear types, with items from the KOOS pain subscale forming a majority of the most severe and prevalent symptoms. Cross-sectional study; Level of evidence, 3. The records of 1466 patients with medial meniscus root tear between January 2017 and December 2021 at a single institution were reviewed. KOOS subscale scores and item-specific responses from initial evaluation were collected for each patient. Each KOOS item was scored on a scale from 1 (none/least severe) to 5 (extreme/most severe). Median and mean item-level responses were calculated and ranked in order of most to least severe. For statistical analysis, item-level prevalence rates were calculated as the proportion of patients reporting at least mild symptoms and ranked from most to least prevalent. Included were 61 patients with MMPRT verified on magnetic resonance imaging (MRI). The most severe items according to item-level KOOS response were as follows: awareness of knee problem (mean, 4.62 [95% CI, 4.47-4.78]), difficulty jumping (mean, 4.06 [95% CI, 3.73-4.39]), difficulty twisting or pivoting (mean, 4.04 [95% CI, 3.76-4.32]), difficulty kneeling (mean, 3.98 [95% CI, 3.65-4.31]), and modification of lifestyle (mean, 3.94 [95% CI, 3.69-4.20]). The most prevalent items were knee stiffness later in the day, pain going up- or downstairs, difficulty ascending stairs, difficulty getting in and out of the car, difficulty twisting or pivoting, awareness of knee problem, and modification of lifestyle, with all patients reporting at least mild symptoms for each. Of the 11 most severe and prevalent symptoms, 8 came from the KOOS-Pain item-specific responses. Pain-related items made up a majority of the most severe and most prevalent symptoms as identified by the item-specific KOOS responses. However, meniscal symptoms commonly seen in other tear types, such as clicking and knee stiffness, were still quite prevalent in patients with MMPRT.

High failure rate after medial meniscus bucket handle tears repair in the stable knee

BackgroundIt is nowadays recommended to “Save the meniscus“. This paradigm is based on the affirmation that an extended meniscectomy exposes to the risk of long-term secondary osteoarthritis and the global failure rate of a longitudinal tear repair remains low, whether it is the medial or lateral meniscus, with or without anterior cruciate ligament (ACL) reconstruction. However, each kind of lesion has to be studied separate. PurposeThe study aimed to focus on a homogeneous population of isolated repair of the bucket handle tear (BHT) of the medial meniscus (MM) in patients with stable knees to evaluate failure rate at a minimum of three years of follow-up. The secondary objectives were to evaluate any risk factors or protective factors of failure, clinical outcomes, and secondary amount of meniscectomy in failure cases compared to the amount of meniscus fixed in the first surgery. MethodsAll patients who underwent arthroscopic repair of a BHT of the MM situated in the red-on-red or red-on white (RW) zone on a stable knee between January 2010 and December 2018 were evaluated retrospectively. Failure was defined as a need for reoperation for recurrence of meniscal symptoms (pain, locking) on the medial side with per-operative confirmation of the absence of healing. The following parameters were studied: demographics (age, gender, BMI), time from injury to surgery, clinical scores (Tegner, Lysholm, International Knee Documentation Committee [IKDC]), surgical findings (extent and zone of the tear), surgical management (number and type of suture). ResultsThirty-nine patients were included. The mean follow-up was 77.2±24.4 [36–141] months. Twenty-seven (69%) failures were recorded. In 56% (15/27) of the reoperations, the meniscectomy amount was smaller than what it would have been done in the first surgery. All clinical scores improved significantly from pre- to post-operatively; all patients met minimal clinically important differences for all the scores. No risk factors were found significant in the multivariate analysis. ConclusionRepairing an isolated BHT of the MM is associated with a high failure rate. Despite the failure, we observed that the meniscectomy area was smaller than documented in the primary surgery in most of the cases and repair must still be considered as the first option. Level of evidenceIV; retrospective cohort series.

Knee arthroscopic surgery in middle-aged patients with meniscal symptoms. a 10-year follow-up of a prospective, randomized study

Knee arthroscopic surgery in middle-aged patients with meniscal symptoms. a 10-year follow-up of a prospective, randomized study

Good clinical scores, no evidence of excessive anterior tibial translation, a high return to sport rate and a low re-injury rate is observed following anterior cruciate ligament reconstruction using autologous hamstrings augmented with suture tape.

Augmented anterior cruciate ligament reconstruction (ACLR) techniques have been proposed to reduce the high reported re-injury rates and low rates of return to sport (RTS). This study reports clinical outcomes, RTS and re-injury rates in patients undergoing ACLR using autologous hamstrings augmented with suture tape. A total of 53 patients were prospectively recruited, undergoing ACLR using hamstrings with suture tape augmentation, combined with a structured rehabilitation programme. Outcomes were collected to 24months, including patient-reported outcome measures (PROMs), KT-1000 measurements, peak isokinetic knee strength and a four hop test battery. Limb Symmetry Indices (LSIs) were calculated for performance measures, whilst RTS rates, re-tears and re-operations were presented. There were no significant side-to-side differences in anterior tibial translation between the operated and non-operated knees at 6months (p = 0.433), with no increase (p = 0.841) in side-to-side anterior tibial translation from 6 to 24months. At 24months, 98.0% of patients demonstrated normal (< 3mm) or near normal (3-5mm) side-to-side differences. LSIs for peak knee extensor torque (p < 0.0001) and the single (p = 0.001), triple (p = 0.001) and triple crossover (p < 0.0001) hop tests for distance significantly improved. All PROMs significantly improved (p < 0.0001), with 70.2% and 85.7% of patients actively participating in pivoting sports at 12 and 24months, respectively. Three patients underwent secondary procedures for meniscal symptoms. One patient suffered an ACL re-tear (17months), with no further ipsilateral or contralateral injuries. ACLR with suture tape augmentation demonstrated no evidence of excessive anterior tibial translation, high-scoring PROMs, sound performance scores, a high rate of RTS and low re-injury rate.

Risk factors for the long-term incidence and progression of knee osteoarthritis in older adults: role of nonsurgical injury.

For one of the most chronic medical conditions, osteoarthritis, uncertainties remain on the impact of injury chronology, the role of repeat injury on the incidence/progression of this disease and the need for knee arthroplasty. To explore, in an older adult population, how nonsurgical knee injuries relate to osteoarthritis incidence/progression and the weight of independent risk factors for arthroplasty. A cohort study design evaluates the long-term impact of injuries on knee osteoarthritis outcomes. Knees with no prior injury (n = 6358) and with at least one injury (n = 819) ⩽20 years before study inclusion were from the Osteoarthritis Initiative cohort. Sociodemographic, clinical and structural [X-ray, magnetic resonance imaging (MRI)] data at study inclusion and changes within 96 months were analysed. Statistics included a mixed model for repeated measurements, generalized estimating equations and multivariable Cox regression with covariates. At inclusion, knees with prior injury demonstrated greater incidence and severity of osteoarthritis (p ⩽ 0.001). At 96 months, there was a greater increase in symptoms [Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain, p = 0.002], joint space width (JSW, p = 0.039) loss, medial cartilage volume loss (CVL, p ⩽ 0.001) and bone marrow lesion size (BML, p ⩽ 0.049). Knees with/without injury at inclusion but with new ones over time had a pronounced increase in symptoms (all WOMAC scores, p ⩽ 0.001), JSW loss, lateral (without) and medial CVL, lateral (without) and medial meniscal extrusion and medial BML (without; all p ⩽ 0.030). Levels of lateral and medial meniscal extrusion (without) and symptoms (with/without; all WOMAC scores, p ⩽ 0.001) were all accentuated with a repeated new injury. Risk factors associated with the highest knee arthroplasty occurrence are new meniscal extrusion and new injury (p ⩽ 0.001). This study highlights the importance of nonsurgical knee injury in older adults as an independent risk factor for knee osteoarthritis and arthroplasty. These data will be beneficial in clinical practice as they will help identify individuals at greater risk of significant disease progression and worst disease outcomes for a customized therapeutic approach.

Association Between Baseline Meniscal Symptoms and Outcomes of Operative and Nonoperative Treatment of Meniscal Tear in Patients With Osteoarthritis.

Patients with meniscal tears reporting meniscal symptoms such as catching or locking have traditionally undergone arthroscopy. The present study was undertaken to investigate whether patients with meniscal tears who report meniscal symptoms have greater improvement with arthroscopic partial meniscectomy (APM) than physical therapy (PT). We used data from the Meniscal Tear in Osteoarthritis Research (MeTeOR) trial, which randomized participants with knee osteoarthritis (OA) and meniscal tear to APM or PT. The frequency of each meniscal symptom (clicking, catching, popping, intermittent locking, giving way, swelling) was measured at baseline and 6 months. We used linear regression models to determine whether the difference in improvement in Knee Injury and Osteoarthritis Outcome Score (KOOS) pain score at 6 months between patients treated with APM versus PT was modified by the presence of each meniscal symptom. We also determined the percentage of participants with resolution of meniscal symptoms by treatment group. We included 287 participants. The presence (versus absence) of any of the meniscal symptoms did not modify the improvement in KOOS pain score between APM versus PT by >0.5 SD (all P interaction >0.05). APM led to greater resolution of intermittent locking and clicking than PT (locking 70% versus 46%, clicking 41% versus 25%). No difference in resolution of the other meniscal symptoms was observed. Meniscal symptoms were not associated with improved pain relief. Although symptoms of clicking and intermittent locking had a greater reduction in the APM group, the presence of meniscal symptoms in isolation should not inform clinical decisions surrounding APM versus PT in patients with meniscal tear and knee OA.

Editor's Spotlight/Take 5: Persistent Tennis Elbow Symptoms Have Little Prognostic Value: A Systematic Review and Meta-analysis.

Editor's Spotlight/Take 5: Persistent Tennis Elbow Symptoms Have Little Prognostic Value: A Systematic Review and Meta-analysis.

Isolated Arthroscopic Partial Meniscectomy Is More Effective at Improving Meniscal Symptoms in Comparison With Mechanical Symptoms in Patients With Concomitant Untreated Chondral Lesions

To rank Knee Injury and Osteoarthritis Outcome Score (KOOS) questions from most to least improvement after arthroscopic partial meniscectomy (APM) and compare improvement of meniscal versus mechanical symptoms. A secondary analysis of the Chondral Lesions and Meniscus Procedures (ChAMP) Trial was performed. Inclusion criteria were age 30 years or older with degenerative meniscal tear failing nonoperative management, with or without associated unstable chondral lesions. No chondral debridement was performed. Responses to the 42 KOOS questions ranged from 0 (extreme problems) to 4 (no problems), and were answered preoperatively and at 1 year after isolated APM. The 1-year mean change, or delta (Δ), was calculated for each KOOS question and the Δ for meniscal and mechanical symptoms were statistically compared. Greatest improvement in 135 eligible patients was observed for questions about (1) awareness of knee problems (Δ= 1.93, standard deviation [SD]= 1.38), (2) frequency of knee pain (Δ= 1.93, SD= 1.29), (3) degree of difficulty while twisting/pivoting on the injured knee (Δ= 1.88, SD= 1.13), (4) degree of difficulty while running (Δ= 1.67, SD= 1.30), and (5) being troubled by lack of confidence in the knee (Δ=21.67, SD= 1.11). Least improvement was observed for questions about: (1) degree of difficulty while getting on/off the toilet (Δ= 0.94, SD= 0.96), (2) feel grinding or hear clicking when the knee moves (Δ= 0.90, SD= 1.25), 3) degree of difficulty while getting in/out of the bath (Δ= 0.88, SD= 1.00), (4) knee catches/hangs up during movement (Δ= 0.80, SD= 1.09), and (5) the ability to straighten the knee fully (Δ= 0.54, 1.44). There was greater improvement for the KOOS questions pertaining to meniscal versus mechanical symptoms (P < .00001). KOOS symptoms as reported by subjects' responses to the questions pertaining to the frequency of knee pain, twisting/pivoting, running, squatting, and jumping showed the most improvement 1 year after isolated APM, whereas those relating to mechanical symptoms improved the least. Focusing on meniscal rather than mechanical symptoms may help surgeons better identify patients expected to benefit from APM. IV, retrospective analysis of prospectively collected data.

The Importance of a Thorough History and Exam: Commentary on an article by Evan M. Farina, MD, et al.: "Meniscal and Mechanical Symptoms Are Associated with Cartilage Damage, Not Meniscal Pathology".

The Importance of a Thorough History and Exam: Commentary on an article by Evan M. Farina, MD, et al.: "Meniscal and Mechanical Symptoms Are Associated with Cartilage Damage, Not Meniscal Pathology".

Intra-substance meniscal changes and their clinical significance: a meta-analysis

The degeneration of radial tie fibres of the central meniscal layer, and thinning of its lamellar layer results in increased intensity signals on magnetic resonance imaging, making it difficult to differentiate from true meniscal tear. This study aimed to assess the rate of encountered MRI grades 1 and 2 intrasubstance meniscal changes, and to set guidelines to report these changes based on predicted clinical outcome. A systematic review approach was employed using search engines, libraries, and databases (Google Scholar, ERIC, PubMed, and Medline) to search for scholarly sources on meniscal lesions and their significance in MRI published between 1 January 2000 and 30 June 2019. It retrieved 2750 abstracts, out of which 2738 were excluded and 13 studies meeting inclusion criteria were meta-analysed. It found an association between intrasubstances meniscal changes and outcomes. It resulted that intrasubstance meniscal changes were preservable through the protective functioning of the meniscus. Other than weight gain, no other significant risk factor of developing true meniscal tears later in life was found. It is important to examine intrasubstance meniscal change when patients suffer from mechanical meniscal symptoms especially in old age.

Knee Arthroscopic Surgery in Middle-Aged Patients With Meniscal Symptoms: A 5-Year Follow-up of a Prospective, Randomized Study

Background:Arthroscopic meniscal surgery is a common orthopaedic procedure in middle-aged patients, but the efficacy of this procedure has been questioned. In this study, we followed up the only randomized controlled trial that has shown a 1-year benefit from knee arthroscopic surgery with an exercise program compared with an exercise program alone.Purpose:To (1) evaluate whether knee arthroscopic surgery combined with an exercise program provided an additional 5-year benefit compared with an exercise program alone in middle-aged patients with meniscal symptoms, (2) determine whether baseline mechanical symptoms affected the outcome, and (3) compare radiographic changes between treatment groups.Study Design:Randomized controlled trial; Level of evidence, 1.Methods:Of 179 eligible patients aged 45 to 64 years, 150 were randomized to either a 3-month exercise program (nonsurgery group) or to the same exercise program plus knee arthroscopic surgery (surgery group) within 4 weeks. Radiographs were assessed, according to the Kellgren-Lawrence grade, at baseline and at the 5-year follow-up. The primary outcome was the change in Knee injury and Osteoarthritis Outcome Score (KOOS)–Pain (KOOSPAIN) subscore from baseline to the 5-year follow-up. We performed an as-treated analysis.Results:A total of 102 patients completed the 5-year questionnaire. At the 5-year follow-up, both groups had significant improvement in KOOSPAIN subscores, although there was no significant change from the 3-year scores. There was no between-group difference in the change in the KOOSPAIN subscore from baseline to 5 years (3.2 points [95% CI, –6.1 to 12.4]; adjusted P = .403). In the surgery group, improvement was greater in patients without mechanical symptoms than in those with mechanical symptoms (mean difference, 18.4 points [95% CI, 8.7 to 28.1]; P < .001). Radiographic deterioration occurred in 60% of patients in the surgery group and 37% of those in the nonsurgery group (P = .060).Conclusion:Knee arthroscopic surgery combined with an exercise program provided no additional long-term benefit after 5 years compared with the exercise program alone in middle-aged patients with meniscal symptoms. Surgical outcomes were better in patients without mechanical symptoms than in patients with mechanical symptoms during the preoperative period. Radiographic changes did not differ between treatment groups.Registration:NCT01288768 (ClinicalTrials.gov identifier).

Knee arthroscopic surgery in middle-aged patients with meniscal symptoms: a 5-year follow-up of a prospective, randomized study

Knee arthroscopic surgery in middle-aged patients with meniscal symptoms: a 5-year follow-up of a prospective, randomized study

Association of baseline meniscal symptoms on outcomes of operative and non-operative treatment of meniscal tear in patients with osteoarthritis

Purpose: Arthroscopic partial meniscectomy (APM) is performed frequently for the treatment of meniscal tear in patients with knee osteoarthritis (OA). While trials have shown that APM and physical therapy (PT) have similar outcomes in this population, many clinicians are taught that in the setting of ‘meniscal symptoms’-- such as clicking, catching, popping, swelling, and giving way-- APM may be preferred over PT. However, there has been little study of whether patients with ‘meniscal symptoms’ have better outcomes following APM than PT. Methods: We used data from the Meniscal Tear in Osteoarthritis Research (MeTeOR) Trial of APM vs. PT. Subjects were at least 45 years or older, had meniscal damage on MRI, and evidence of OA changes on imaging. Those with a chronically locked knee were excluded. Participants who crossed-over between treatment groups within 6 months were excluded, while those crossing over after 6 months were included in the group to which they were randomized. At baseline patients graded the frequency of meniscal symptoms – including clicking, catching, popping, locking, giving way, and swelling – as 1) none; 2) once/week; 3) 2–6 times/week; 4) 1–2 times/day; and 5) several times/day. We regarded each meniscal symptom as binary – 0) none and 1) any. The outcome was change from baseline to 6 months in the Knee Injury and Osteoarthritis Outcome Pain Score (KOOS, scored 0–100, 100 worst). We investigated the difference in change in KOOS pain score at 6 months between APM and PT in participants with and without each meniscal symptom. We analyzed the interaction between each dichotomized meniscal symptom variable, treatment type (APM, PT) and change in KOOS Pain. All analyses were adjusted for age, sex, baseline KOOS pain score, and body mass index (BMI). Results: The sample consisted of 244 knees (one per person). Sixty-four percent of participants reported any clicking, 51% any catching, 49% any popping, 28% any locking, 49% any giving way, and 72% any swelling. At baseline patients undergoing APM and PT had similar KOOS Pain scores (∼45 points). On average, subjects receiving APM had reduction in pain scores from baseline to six months of 24 points (95% CI 21, 27), and those receiving PT had reduction of 20 points (95% CI 17, 24). We did not find evidence that individual meniscal symptoms modified the relationship between the treatment type and outcome. Sample-based statistics for each meniscal symptom are presented in Figure 1. Giving way was the only meniscal symptom where the difference in treatment outcome between APM and PT (8 points), approached commonly used thresholds for clinically important difference in KOOS Pain (8–10 points; Figure 1), but that difference did not reach statistical significance. Conclusions: Contrary to the clinical teaching recommending that patients with meniscal symptoms are more likely to respond to APM, these data do not provide evidence that the presence of each meniscal symptom is associated with statistically significantly greater reduction in pain with APM compared to PT.

Middle-aged patients with an MRI-verified medial meniscal tear report symptoms commonly associated with knee osteoarthritis

Background and purpose — No consensus exists on when to perform arthroscopic partial meniscectomy in patients with a degenerative meniscal tear. Since MRI and clinical tests are not accurate in detecting a symptomatic meniscal lesion, the patient’s symptoms often play a large role when deciding when to perform surgery. We determined the prevalence and severity of self-reported knee symptoms in patients eligible for arthroscopic partial meniscectomy due to a degenerative meniscal tear. We investigated whether symptoms commonly considered to be related to meniscus injury were associated with early radiographic signs of knee osteoarthritis.Patients and methods — We included individual baseline items from the Knee injury and Osteoarthritis Outcome Score collected in 2 randomized controlled trials evaluating treatment for an MRI-verified degenerative medial meniscal tears in 199 patients aged 35–65 years. Each item was scored as no, mild, moderate, severe, extreme, and at least “mild” considering the symptoms present. Early radiographic signs of osteoarthritis, defined as a Kellgren and Lawrence grade of at least 1, were seen in 70 patients.Results — At least monthly knee pain, pain during stair walking and when twisting on the knee, and lack of confidence in knee was present in at least 80% of the patients. Median severity was at least moderate for knee pain, pain when twisting on the knee, pain walking on stairs, lack of confidence in knee, and clicking. Mechanical symptoms such as catching were rare. Early radiographic signs of osteoarthritis were associated with an increased risk of self-reported swelling, catching, and stiffness later in the day; the odds ratio was 2.4 (95% CI 1.2–4.9), 2.3 (1.2–4.3), and 2.3 (1.1–5.0), respectively.Interpretation — Middle-aged patients with a degenerative medial meniscus tear reported symptoms commonly associated with knee osteoarthritis. Frequent knee pain, presence of lack of confidence in the knee, and clicking did not distinguish those with a meniscal tear alone from those with early radiographic knee OA. Our findings support the notion that symptoms reported by those with a degenerative meniscal tear represent early signs of knee osteoarthritis.

Arthroscopic partial meniscectomy versus placebo surgery for a degenerative meniscus tear: a 2-year follow-up of the randomised controlled trial

ObjectiveTo assess if arthroscopic partial meniscectomy (APM) is superior to placebo surgery in the treatment of patients with degenerative tear of the medial meniscus.MethodsIn this multicentre, randomised, participant-blinded and outcome...

Knee Arthroscopic Surgery in Middle-Aged Patients With Meniscal Symptoms: A 3-Year Follow-up of a Prospective, Randomized Study

Background: The optimal treatment for middle-aged patients with knee pain and meniscal lesions has been extensively debated. Most previous studies have revealed only short-term beneficial results of knee arthroscopic surgery. The authors have previously shown a positive benefit of knee arthroscopic surgery and an exercise program after 1 year when compared with an exercise program alone. Purpose: To evaluate if knee arthroscopic surgery combined with an exercise program provided an additional long-term benefit after 3 years compared with an exercise program alone in middle-aged patients with meniscal symptoms. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: Of 179 eligible patients, aged 45 to 64 years, 150 were randomized to (1) a 3-month exercise program (nonsurgery group) or (2) the same as group 1 plus knee arthroscopic surgery within 4 weeks (surgery group). The primary outcome was the change in the Knee Injury and Osteoarthritis Outcome Score (KOOS) subscore of pain between baseline and the 3-year follow-up. Results from the 1-year follow-up have been published previously. Results: Both treatment groups improved significantly in the KOOS pain subscore at 3 years’ follow-up in the intention-to-treat and as-treated analyses (P < .001). The between-group difference for the change in the KOOS pain subscore between baseline and the 3-year follow-up was no longer statistically significant, neither in the intention-to-treat analysis (7.6 points; 95% CI, –0.6 to 15.9; P = .068) nor in the as-treated analysis (5.3 points; 95% CI, –3.1 to 13.8; P = .216). The factorial analysis of the effect of the intervention and age, onset of pain, and mechanical symptoms indicated that older patients improved more, regardless of treatment, and surgery may be more beneficial for patients without mechanical symptoms (as-treated analysis). The effect of the predictive factors on the KOOS pain subscore was uncertain because of the small sample size in the subgroup analyses. Conclusion: The benefit of knee arthroscopic surgery, seen at 1 year in middle-aged patients with meniscal symptoms, was diminished at 3 years and was no longer statistically significant. Clinical Relevance: Knee arthroscopic surgery may be beneficial for middle-aged patients with meniscal symptoms in addition to an exercise program. Older age and absence of mechanical symptoms should not be contraindications to surgery. Registration: NCT01288768 (ClinicalTrials.gov identifier)

Associations among meniscal damage, meniscal symptoms and knee pain severity.

Meniscal tears occur frequently in patients with knee osteoarthritis (OA). The aim of our study was to determine whether meniscal damage identified on magnetic resonance imaging (MRI) is associated with the severity of knee pain or the frequency of meniscal symptoms in patients with knee OA. We performed a cross-sectional study using data from the Meniscal Tear in Osteoarthritis Research (MeTeOR) trial. We characterized meniscal damage hierarchically as: root tear; maceration; long and short complex or horizontal tears; and simple tears. Subjects completed the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Pain Scale and a survey of frequency of meniscal symptoms. We used multivariable general linear models to assess the relationships between meniscal damage and 1) pain severity; and 2) meniscal symptoms, after adjusting for demographic and radiographic features. In further analysis root tear was considered as a binary variable. Analysis included 227 knees. Root tears were present in 19%, maceration in 14%, long complex or horizontal tears in 22%, short complex or horizontal tears in 30%, and simple tears in 14%. Root tears were associated with higher WOMAC pain scores. The adjusted mean WOMAC pain score was 45.2 (standard error (SE) 2.7) for those with root tear and 38.7 (SE 1.2) for subjects without root tear (P=0.03). We did not find statistically significant associations between meniscal morphology and frequency of meniscal symptoms. Root tears were associated with greater pain than meniscal tears or maceration. We did not find a relationship between meniscal damage and meniscal symptoms.

Early Operative Versus Delayed or Nonoperative Treatment of Anterior Cruciate Ligament Injuries in Pediatric Patients.

Reference: Ramski DE, Kanj WW, Franklin CC, Baldwin KD, Ganley TJ. Anterior cruciate ligament tears in children and adolescents: a meta-analysis of nonoperative versus operative treatment. Am J Sports Med. 2014;42(11):2769-2776. Clinical Questions: In pediatric patients, does early operative treatment of an anterior cruciate ligament (ACL) injury result in decreased knee instability compared with delayed or nonoperative treatment? This review focused on the PubMed/MEDLINE and EMBASE databases. The following query searches were used: ACL or anterior cruciate ligament and young or child or children or pediatric or immature. Dates searched were not specified. A separate search was also conducted of abstracts published between 2009 and 2011 from the American Academy of Orthopaedic Surgeons; American Orthopaedic Society for Sports Medicine; International Society of Arthroscopy, Knee Surgery, and Orthopaedic Sports Medicine; European Society of Sports Traumatology, Knee Surgery, and Arthroscopy; American Orthopaedic Association; Arthroscopy Association of North America; Pediatric Orthopaedic Society of North America; and American Academy of Pediatrics conferences. Available studies were included only if they were written in English; were of level 1, 2, or 3 evidence (grading taxonomy not stated); were cohort designs that compared nonoperative and operative treatments; involved an early versus delayed ACL reconstruction that could be prospective or retrospective; and reported primary outcome interest measures. Animal studies, basic science studies, case series, reviews, commentaries, and editorials were excluded from the review. A systematic assessment tool, Guide to Community Preventive Services: Systematic Reviews and Evidence-Based Recommendations, was used by 2 of the authors to independently grade the quality of each study that met the inclusion criteria. The tool focused on 6 areas: intervention and study description, sampling, measurement, analysis, interpretation of results, and other execution factors. This tool helped to ensure consistency, reduce bias, and improve the validity and reliability of preventive health care studies. Eleven studies met the inclusion criteria. Six studies compared nonoperative with operative treatment, and 5 studies compared early reconstruction (open physes) with delayed reconstruction (closed physes). Studies in this meta-analysis consisted of the following: four level-3 prospective studies, four level-3 retrospective studies, one level-2 retrospective study, one level-3 case-control study, and one level-3 study with both prospective and retrospective data collection. All of the studies included data related to patient demographics, treatment interventions, follow-up duration, presence of any meniscal symptoms, time to return to sport participation, patient-reported outcomes (International Knee Documentation Committee [IKDC], Lysholm, or Tegner scores), the need for a second surgical procedure, and any posttreatment problems. Of those who chose the nonoperative route, 75% reported instability, whereas only 13.6% of those who had surgery reported instability. These data also showed that nonoperative or delayed-operative patients were 33.7 times more likely to report instability than the early operative group. Those who chose the nonoperative route had a 12 times greater risk (odds ratio = 12.2, 95% confidence interval = 1.55, 96.3) of developing a meniscal tear after the initial injury. Three studies included in the meta-analysis reported return to sport status, but only 2 studies provided adequate data for both operative and nonoperative patients. In 1 study, 92% of operative patients were able to return to sport, but only 43.75% of nonoperative patients were able to do so. The second study reported that all operative and nonoperative patients were able to return to the same level of sport after injury. Of those in the early operative group, 6% required a repeat surgical intervention for either an ACL rerupture or a meniscal tear, and 19% of those who initially chose nonoperative treatment eventually needed surgery to repair the ACL or meniscus. Findings favor the early operative group over the delayed operative and nonoperative groups based on IKDC scores. One study reported a significant difference in operative patients, with an IKDC mean score of 95 compared with 87 in the nonoperative group. Similarly, a different study reported a mean score of 94.6 in the early operative group compared with 82.4 in the delayed operative group and was stated to have met the minimal clinically important difference (MCID). The MCID was not met for the Lysholm and Tegner scores between operative and nonoperative patients. The results of this meta-analysis favor early operative treatment for pediatric patients with ACL tears over delayed or nonoperative treatment. Early operative treatment is initiated shortly after the injury, while the patient is still skeletally immature and the growth plates are open. Current evidence suggests that early ACL reconstruction will result in less knee instability and a more likely return to the preinjury activity level without affecting the growth plates or causing growth disturbances.