Applied Evidence

Managing atraumatic meniscal tears in middle-aged patients

J Fam Pract. 2017 November;66(11):E1-E6

From The Journal of Family Practice | 2017;66(11):E1-E6.

References

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3. Englund M, Guermazi A, Gale D, et al. Incidental meniscal findings on knee MRI in middle-aged and elderly persons. N Engl J Med. 2008;359:1108-1115.

4. Sihvonen R, Paavola M, Malmivaara A, et al. Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. N Engl J Med. 2013;369:2515-2524.

5. Moseley JB, O’Malley KO, Petersen NJ, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2002;347:81-88.

6. Bhattacharyya T, Gale D, Dewire P, et al. The clinical importance of meniscal tears demonstrated by magnetic resonance imaging in osteoarthritis of the knee. J Bone Joint Surg. 2003;85:4-9.

7. Paxton ES, Stock MV, Brophy RH. Meniscal repair versus partial meniscectomy: a systematic review comparing reoperation rates and clinical outcomes. Arthroscopy. 2011;27:1275-1288.

8. Fairbank TJ. Knee joint changes after meniscectomy. J Bone Joint Surg Br. 1948;30B:664-670.

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12. Herrlin SV, Wange PO, Lapidus G, et al. Is arthroscopic surgery beneficial in treating non-traumatic, degenerative medial meniscal tears? A five-year follow-up. Knee Surg Sports Traumatol Arthrosc. 2013;21:358-364.

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14. Kise NJ, Risberg MA, Stensrud S, et al. Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: randomised controlled trial with two year follow-up. BMJ. 2016;354:i3740.

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16. Katz JN, Brophy RH, Chaisson CE, et al. Surgery versus physical therapy for a meniscal tear and osteoarthritis. N Engl J Med. 2013;368:1675-1684.

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The findings: Mild to moderate OA and meniscal tears

The authors of a 2002 double-blind, placebo-controlled trial randomly assigned 180 patients with degenerative meniscus tears and knee OA to either arthroscopic debridement, arthroscopic lavage, or placebo surgery consisting of superficial skin incisions without insertion of an arthroscope.⁵ Patients were eligible if they were ≤75 years of age and had not undergone arthroscopy of the knee within the previous 2 years. Arthritis was graded utilizing the Kellgren-Lawrence scale (0-4) and by calculating a severity score (0-12) by adding the individual scores for each of the 3 compartments of the knee; patients were excluded if they had a severity grade ≥9. One-quarter of the participants had severe arthritis, with scores of 7 or 8. Outcomes were measured over a 24-month period. At no point did either of the intervention groups report less pain or better function than the sham-surgery group.⁵

Additionally, in a single-center RCT involving 178 patients with mild to severe OA, subjects were randomly assigned to surgical lavage and arthroscopic debridement together with optimized physical and medical therapy or to treatment with physical and medical therapy alone.¹⁵ Patients were excluded if they had “bucket handle” meniscal tears detected by physical exam or by MRI, previous arthroscopic surgery, previous major knee trauma, or steroid injections in the last 3 months. All participants were required to have Kellgren-Lawrence grade 2, 3, or 4 arthritis.

The researchers used 2 validated outcome measures to evaluate pain, symptoms, and functional ability and followed the patients for 2 years after the initiation of treatment. This study failed to show that arthroscopic surgery provided any additional benefit to optimized physical and medical therapy.¹⁵

A 2013 multicenter, RCT randomly assigned 351 patients ≥45 years with a meniscal tear and radiographic evidence of mild to moderate OA to either surgery and postoperative physical therapy or to a standardized physical therapy regimen.¹⁶ Patients were required to have at least one symptom that was consistent with a meniscal tear for approximately one month. About 30% of the patients who were assigned to physical therapy alone underwent surgery within 6 months. There were no significant differences between the 2 groups in the magnitude of improvement in functional status or pain at 6 or 12 months.

Finally, a prospective Scottish study consisting of 270 patients with everything from no signs of OA to advanced OA who underwent APM were sent preoperative and 6-month postop questionnaires evaluating ADLs, pain, symptoms, quality of life, and body mass index (BMI).¹⁷ Their OA was graded via preop MRI or radiographs and confirmed by the operating surgeon. The investigators were unable to demonstrate any significant benefit associated with arthroscopic meniscectomy, and, therefore, could not recommend the procedure for patients with moderate to advanced OA.

However, in their analysis, 3 subgroup populations were found to benefit from APM: those with greater body habitus (BMI >30 kg/m²), those without signs of OA, and those with early OA. Limitations of this study included the lack of randomization, blinding, a control, and long-term follow up, and that the authors didn’t use established OA grading criteria.¹⁷

The bottom line: Nonoperative treatment benefits most patients

Physical therapy is an appropriate first-line treatment for degenerative meniscus tears in middle-aged patients. In fact, a trial of nonoperative treatment is likely to benefit the majority of patients. In addition, avoiding surgery eliminates surgical complications and decreases overall health care costs.

Reserve APM for those patients without significant OA who fail to improve after physical therapy, who have mechanical symptoms, or who have intra-articular loose bodies.

Consider a trial of nonoperative treatment, as it is likely to benefit the majority of patients with degenerative meniscal tears.

In addition, exercise therapy is an effective treatment for patients with knee OA. It improves function and limits joint pain in both acute arthritic flares and more long-term, chronic situations. There is strong evidence that strengthening plays a critical role in reducing symptoms and improving muscle strength, physical ability, and quality of life.¹⁹ It has been suggested that physical exercise 3 times a week for 4 months could lead to >35% improvement of knee function.²⁰ In contrast, other studies reported that while 91% of patients 11.5 years after APM considered their knees “normal or almost normal,” patients actually experienced a reduction in postoperative physical activity and quality of life.²¹

The most recent American Academy of Orthopaedic Surgeons (AAOS) guidelines²²do not recommend for or against arthroscopic partial meniscectomy in patients with knee OA and a torn meniscus. In middle-aged patients, MRI abnormalities of the meniscus do not consistently correlate with symptoms. Many meniscus lesions are asymptomatic or not the primary source of pain in the setting of OA.³

Potential harms and considerations. Deep venous thrombosis is the most frequently reported adverse event of arthroscopic surgery, with an approximate incidence of 4.13 per 1000 procedures, followed by less frequent complications such as infection, pulmonary embolism, and death.¹⁸

It is important to note that the degenerative meniscus tears that occur in middle age and that are associated with OA are not the same as acute, traumatic meniscus tears. All of the studies discussed here included patients with chronic knee pain and excluded patients with sudden onset pain from a single physical event. Many of the studies excluded patients with bucket-handle tears or severe mechanical symptoms (ie, locking). APM may be indicated for these meniscus tears regardless of age or OA status.

Making a sensible choice. Ultimately, physicians and their patients must use the best evidence available to make sensible clinical decisions. The ability to retain native meniscal tissue is of utmost importance to maintaining the longevity of their knee. According to previous studies, OA progression is more likely to occur after meniscectomy than after nonoperative treatment.²³

CORRESPONDENCE
William Bassett, MD, Department of Orthopedics, Rutgers-Robert Wood Johnson Medical School, 51 French St., PO Box 19, New Brunswick, NJ 08903; wpb31@rwjms.rutgers.edu.