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The Guide to Knee Meniscus Tears

Updated: Jun 20


The medical machine acts quickly. This is a good thing when situations are dire and life or limb are at stake. However, in less serious situations the expediency of the process may result in a failure to consider all the current evidence regarding diagnosis, treatment options, and their influence on prognosis. The urgency of the process may at first seem reassuring to the patient, instilling confidence that the clinician knows what they are doing. This process should be collaborative, but often it becomes authoritative. Patients are expected to make quick decisions as a layperson to the field. Thus, the process necessitates trust. Trust in the clinician, trust in the decision making, and trust that the information being delivered to them is the best we have (hopefully based on current research evidence).


This discussion could quickly become about informed consent; however, let's focus on prevalent issues in the musculoskeletal world that are often accompanied with imaging and a question of how we should manage this issue. This particular article will be about the knee meniscus. We will set out to answer the question: How significant is the meniscus, and when damaged, what should we do about it based on current best evidence?


So, what is the meniscus?

The meniscus is a fibrocartilaginous structure located in the tibiofemoral joint (i.e., the knee). Its anatomy and location are consistent with a function of shock absorption and force transmission. In each knee there is a meniscus on the medial (inner aspect) and lateral (outer aspect) side.


The meniscus may be altered from traumatic injuries or due to age-related changes over time. Meniscal injuries are considered the second most common knee injury, with an incidence of 12% – 14% (61 cases / 100,000 people in U.S.). It is estimated that 10-20% of all orthopedic surgeries involve the knee meniscus (850,000 patients / year). Logerstedt 2010


Classification of meniscal damage is typically based on location and orientation of a tear. Mordecai 2014

Tears can be vertical longitudinal, vertical radial, horizontal, oblique, and complex. Mordecai 2014 A complete vertical tear has the potential to fold over within the joint space, creating what is known as a “bucket-handle” tear. Mordecai 2014 Typically a bucket-handle tear is considered “unstable”, and classically is thought to provoke mechanical symptoms such as “locking” of the joint. Previously, such symptoms were thought to warrant surgical intervention. Silhvonen 2016 However, recent evidence has emerged contradicting this usual practice, more on this later.


The underlying problematic theme for addressing this issue is the premise of a structural finding being directly causative of patient symptoms.


If you’ve been following our work, it should be apparent that things are becoming harder to label as “pathologies” or even as abnormalities based on radiologic imaging alone. The knee is no different. For example, meniscal damage and osteoarthritis are readily identifiable in asymptomatic populations (no reported pain and/or disability). Recently an article investigated the prevalence of “abnormal” imaging findings in 115 asymptomatic individuals (230 knees) using MRI. Some background data on the included cohort:

  • 51 males, 64 females

  • Median age: 44 years (ranged between 25 - 73 years of age)

  • Based out of London

  • Median Body Mass Index (BMI): 25 (ranged from 19.6 - 38.1 kg/m2)

  • Physical activity (low intensity) was 2 hours / week (ranged from 0 - 4)

  • Purposefully included sedentary individuals (not meeting activity guidelines)

The authors’ primary findings:

Nearly all knees (227/230; [97%]) of asymptomatic individuals showed abnormalities in at least one of the knee structures on MRI, of varying grades of severity. These findings included meniscal tears, cartilage abnormalities, bone marrow oedema and tendon and ligament abnormalities." Horga 2020

To further demonstrate these individuals were indeed asymptomatic and functional, the mean Knee Injury and Osteoarthritis Outcome Score (KOOS) for each item was 90/100. Specific to our discussion, the authors identified 30% prevalence of meniscal tears and 18% of meniscal degeneration in participants’ knees. A variety of tear types were identified - horizontal (23% knees), complex (3%), vertical (2%), radial (2%), and bucket handle tears (1%). Finally, 3% of knees demonstrated meniscal extrusion, a situation where the meniscal margin is extending beyond the tibial margin. The authors conclude:

Our study questions clinical decision-making regarding arthroscopy and its efficacy in reducing symptoms and treatment. The high rate of asymptomatic adults with knee joint abnormalities on MRI may indicate why arthroscopy and other surgical interventions for these do not result in better outcomes than sham surgery. For example, there is no evidence to suggest that meniscectomy benefits patients presenting with meniscal tear symptoms more than sham surgery does. Moreover, meniscectomy and other surgical interventions could lead to further complications or deterioration of the articular cartilage and increase the risk of osteoarthritis. Horga 2020

(For more, Not Your Image, references for the knee see Culvenor et al, Beals et al, Pappas et al, van der Heijden et al, and Guermazi et al).


With this in mind we will now discuss the current evidence regarding the best management of people dealing with knee pain being attributed to meniscal tears given that imaging has likely already been done, regardless of necessity.


Management:


Based on the recent British Journal of Sports Medicine clinical practice guidelines, arthroscopic surgery for meniscal tears in the setting of degenerative knee osteoarthritis is NOT recommended. The guidelines state:


We make a strong recommendation against the use of arthroscopy in nearly all patients with degenerative knee disease, based on linked systematic reviews; further research is unlikely to alter this recommendation ... This recommendation applies to patients with or without imaging evidence of osteoarthritis, mechanical symptoms, or sudden symptom onset. Siemieniuk 2018

These guidelines include a discussion of a systematic review by Brignardello-Peterson. This is a review article that finds knee arthroscopy is no better than conservative management for patients with degenerative changes. Brignardello-Peterson 2017 The BJSM recommendation falls in line with what the research

has been demonstrating on the topic of chronic degenerative meniscal tears.


This paradigm shift will likely continue to take time. Immediately after the BJSM release, an open letter to the editor was written in the Arthroscopy Journal demonstrating a major appeal to authority, post-hoc fallacy, and confirmation bias.


Excerpts from the letter:

I question how the authors have the required knowledge base to critically analyze the articles they have chosen to review. Once again they seem to be predominantly epidemiologists, with the only orthopaedic input coming from an “orthopaedic resident” whose major interest seems to be research methodology. I personally would not have the confidence to cast judgment on a paper from a different specialty of orthopaedics, let alone a subject about which I do not have an intimate knowledge or extensive professional background. … I strongly believe that these (BMJ) conclusions cannot be justified based on the evidence presented and that they are wrong. I would be happy to discuss my detailed reasoning with you further and to introduce you to some of my patients. I appreciate that this is anecdotal but in the last two weeks I have seen a 50 year old joiner who was struggling to work because every time he knelt down his knee locked and in desperation had come to see me privately as he had been denied surgical referral after a “normal MRI.” After taking out his degenerate bucket handle tear he was back at work after a week.” Bollen 2018

Most recently, a 2019 review and meta-analysis by Abram et al sought to determine if patients do indeed benefit from APM over other interventions based on stratification of symptoms and radiological findings.


Three adult patient groups with meniscal tears and knee pain were assessed:

  • Group A: All patients with any meniscal tear type with or without radiological presence of osteoarthritis

  • Group B: Patients with any meniscal tear type without knee osteoarthritis

  • Group C: Patients with an “unstable” meniscal tear and without knee osteoarthritis

Arthroscopic Partial Meniscectomy was compared to:

  • other surgical interventions such as arthroscopic lavage, sham surgery (“...procedure requiring an anaesthetic and surgical skin incision but without any knee arthroscopy procedure (diagnostic, washout and other) being performed.”) Abram 2019 and placebo (diagnostic arthroscopy) surgery

  • Nonsurgical - physiotherapy and exercise therapy

  • Pharmacological -NSAIDS and Intra-articular Steroid Injection

  • No intervention - waiting list and active monitoring

Unfortunately, these data are not great. 20 total articles (10 RCTs and 1 cohort study) were included consisting of:

  • APM vs Surgical - 2 trials

  • APM vs Non-surgical - 7 trials and 1 cohort

  • APM vs Pharmacological - 1 trial

  • APM vs No intervention - 0 trials

The authors state -

Findings were limited by small sample size, small number of trials and cross-over of participants to APM from comparator interventions. Abram 2019

We can examine their forest plots for a better understanding of findings of APM vs non-surgical interventions (Physiotherapy).

Examining the overall standard mean difference (SMD) for each outcome, we can see how small the difference was between APM vs physiotherapy.

Group

Outcome

APM Total

Control Total

SDM

A

Pain

478

465

0.22 [0.03, 0.40]

A

Knee Function

532

518

0.18 [0.04, 0.33]

A

Quality of Life

183

167

0.43 [0.10, 0.75]

B

Pain

216

186

0.35 [0.04, 0.66]

B

Knee Function

269

238

0.30 [0.06, 0.53]

B

Quality of Life

129

115

0.59 [0.11, 1.07]

Notice, we do not have data on Group C, and this was a theme throughout the article. There was only a single article (cohort study) for group C who were intervened upon with APM after “failing” physical therapy. The authors state,

At 6-12 months, in trials with a non-surgical comparator, there was a small benefit in favour of APM for pain, knee-specific quality of life and function in studies including patients with osteoarthritis. Excluding patients with osteoarthritis, there was a small to moderate benefit in pain, knee-specific quality of life and function. The clinical importance of these differences is, however, uncertain. Abram 2019

Uncertain indeed, and after examining these forest plots, SMDs, and risk of bias, we need to seriously question the benefits being worth it in comparison to risk for surgery vs conservative management.


APM vs. other surgical interventions:


Two RCTs were included (Silhvonen et al and Roos et al), totaling 190 patients. Silhvonen’s study compared APM vs placebo surgery and Roos’s study APM vs sham surgery. Both of these studies excluded patients with OA, meaning their findings fit with groups 1 and 2 above. Overall, these two studies were rated low risk of bias on the Cochrane Collaboration Risk of Bias Tool. However, on one bias assessment, Roos was rated high for allowing 36% of patients to cross-over to APM before the final follow-up.


Overall, the authors found Silhvonen et al demonstrated no difference between APM and placebo surgery. Roos’s findings are a bit less straightforward. At six months there was “...no improvement in knee pain in comparison with sham surgery at under 6 months (SMD 0.26 [95% CI −0.41 to 0.93]; one trial; 35 patients; GRADE: low).”


But after 12 months - “...there was a moderate to large improvement in patients receiving APM in comparison with sham surgery (SMD 0.72 [95% CI 0.02 to 1.42]; one trial, 34 patients; GRADE: low) equivalent to a MD of 17.50 (95% CI 1.16 to 33.84) measured using the KOOS pain scale.”


Also knee function didn’t show improvement in APM vs sham surgery < 6 months nor at > 12 months. Finally, as it relates to knee-specific quality of life and generic quality of life, no difference occurred between APM and sham surgery <6 months nor at > 12 months.


APM vs. Pharmacologic treatment


A single trial was identified examining APM vs intra-articular corticosteroid injection that fit group 1 above. Related to knee pain and function, no improvement was found between APM and steroid injection at 6 - 12 months, however - “There was a moderate to large improvement at under 6 months (SMD 0.82 [95% CI 0.41 to 1.23]; MD 2.90 Oxford Knee Score [95% CI 1.50 to 4.30]; one trial; 98 patients; GRADE: low).”


The authors finally concluded -

Performing APM in all patients with knee pain and a meniscal tear is not appropriate, and surgical treatment should not be considered the first-line intervention. There may, however, be a small-to-moderate benefit from APM compared with physiotherapy for patients without osteoarthritis. No trial has been limited to patients failing non-operative treatment or patients with an unstable meniscal tear in a non-arthritic joint; research is needed to establish the value of APM in this population.” [emphasis ours] Abram 2019

We also can’t forget evidence demonstrating an increased risk of knee arthroplasty (joint replacement) after undergoing APM. Abram et al retrospectively examined a cohort of 834,393 patients with a history of APM and found:

Patients developing a meniscal tear undergoing APM are at greater risk of knee arthroplasty than the general population. This risk is three-times greater in the patient's affected knee than in the contralateral knee. Women in the cohort were at double the risk of progressing to knee arthroplasty compared with me. Abram 2019

Since this review, Noorduyn et al conducted a 5-year follow-up on their original trial in which participants received either APM or exercise therapy (see 2 year follow-up HERE). Briefly, the original trial randomized participants to APM, PT, or PT with delayed APM. Outcomes specific to pain and function were tracked at 3, 6, 12, and 24 months. The authors found PT was not inferior to APM at 3 and 6 months post-intervention, but that faded at 12 months and 24 months; albeit, all groups improved clinically. For the 5 year follow-up, the same patient questionnaires were completed as well as knee x-rays to assess osteoarthritis. The authors primary finding, PT remained non-inferior to APM and osteoarthritis progression was similar between groups (see Figure 3). Noorduyn 2022


Where does this leave us for clinical management?


Rehab clinicians (e.g., PMR, DC, AT, DPT) are uniquely poised to handle these cases. During an initial consultation, a discussion should involve patient beliefs about the issue and previous narratives supplied. Although this recent article by Oliveria et al focuses on people dealing with persistent hip pain, their line of questioning to explore patient’s beliefs is applicable in this context:

  1. Explain previous diagnoses given for symptoms and what do the labels mean to the individual (identity beliefs)

  2. What does the person think are the causes of their symptoms (cause belief)

  3. What consequences the person perceives the symptoms have (consequence beliefs)

  4. How long the person expected symptoms to last (timeline beliefs)

  5. How much control the person believed they had over their symptoms

  6. Actions the person took to address their symptoms

  7. How effective the person perceived these actions to be and what they believed it would take to get control over their symptoms (control beliefs)

During this discussion various beliefs such as those regarding imaging findings and/or avoidance of movements can be addressed in the context of the individual’s case while setting appropriate expectations and exploring management options.


Therapeutic exercises can then be implemented as needed that are specific to the patient’s goals to help return them to previous level of activity. Symptoms will likely improve with time and we simply need to guide the process back to desired activities while setting appropriate expectations and instilling behaviors to cope with any potential future symptoms.


With that said, many patients may be concerned about mechanical symptoms such as “locking”. Sihvonen has a study from 2016, Mechanical symptoms as an indication for knee arthroscopy in patients with degenerative meniscus tear: a prospective cohort study. 900 patients recruited, underwent arthroscopy, and followed-up with 1 year later.


The authors found 47% (243 out of 513 cases reporting mechanical symptoms) of participants reported persistent symptoms 12 months post-operatively. Additionally, the sample reporting no mechanical symptoms pre-operatively (282 participants), 11% (32) reported mechanical symptoms at 12-month follow-up. The authors’ findings continue to question the attempted validation for meniscal surgery based on mechanical symptoms, often attributed to bucket-handle tears.


In 2018, another Sihovnen publication was released. The authors compared arthroscopic partial meniscectomy APM) versus placebo surgery in participants with mechanical symptoms and those presenting with unstable meniscus tears. The authors found,

... no statistically significant difference between the APM and placebo surgery for symptomatic patients with a degenerative meniscus tear and no osteoarthritis (OA) in any of the used outcome measures over the course of 24-month follow-up. No evidence could be found to support the prevailing ideas that patients with presence of mechanical symptoms or certain meniscus tear characteristics or those who failed initial conservative treatment are more likely to benefit from APM. Sihvonen 2018

Their findings continue to question the validity of performing meniscal surgery based on mechanical symptoms. At this point, it appears the evidence is almost insurmountable regarding the appropriate plan of care for chronic degenerative meniscal tears.


This raises the question: what about traumatic tears? This is a difficult question to answer, because what designates a trauma? Sihovnen excluded patients who reported acute traumatic injuries in this latest study, but explains how convoluted this line of thinking is and current evidence still isn’t supportive:

“Obviously, the concepts ‘degenerative’ or ‘traumatic’ in the context of meniscal injuries are very vague by nature. In this trial, all patients with sudden injuries related to their own voluntary muscle activities (such as kneeling, bending or kicking) and patients with a minor twisting of the knee were included. In essence, our criteria for labelling a tear as ‘traumatic’ required a more substantial event, such as falling from a chair, stairs or bicycle, or slipping on ice.” Sihvonen 2018

This is typically where we can argue regarding unique considerations for young adults (18 - 40 years of age), pediatric patients (aged less than 18 years old), and athletes with a timeframe for their return to sport. Previously I'd discuss how we lack sufficient evidence to make informed decisions about these populations but that's changing.


Surgery vs Conservative Management in Young Patients


In 2018, Skou and Thorlund released a feasibility study titled, A 12-week supervised exercise therapy program for young adults with a meniscal tear: Program development and feasibility study. The authors examined the feasibility of exercise therapy in young adults aged 18 - 40 years of age. 6 patients were recruited with MRI confirmed meniscal alteration and deemed eligible for surgical intervention by orthopedist. Exclusion occurred if history of prior knee injury in same knee, clinical suspicion of displaced bucket-handle tear with MRI confirmation, or complete rupture of one or more knee ligaments. Exercise intervention was a 12-week group based program with supervision. Participants had 2 exercise sessions per week that lasted approximately 60 - 90 minutes. Sessions included the following:

  • 5 minute warm-up on stationary bike

  • 2 exercises used within first weeks with primary focus to reduce swelling and increase ROM

  • 8 neuro-muscular exercises for lower extremities

  • 4 strengthening exercises for lower extremities

The full protocol can be reviewed HERE. On one hand, I certainly think we can question the utility of some of these exercises and how individualized our prescriptions need to be on the other hand I think this perhaps is a good path to reframe from the idea that meniscus tear in this population must mean surgical correction.


The authors did find overall improvement in patient’s symptoms and function as demonstrated by subjective reporting and the KOOS, and no patient elected for surgery after the 12 week exercise therapy. There are obvious limitations here, small sample size, lack of control, and only males were included. However, as a feasibility study, this is a step towards achieving better quality studies to further reveal if exercise therapy should be the mainstay for this cohort over the often traditional surgical intervention.


Most recently, A van der Graaff et al published the first randomized controlled trial in a young population (18 to 45 years of age) diagnosed with traumatic meniscal tears comparing APM vs physical therapy (PT).


Importantly, patients were included based on the following:

  • Reported knee trauma in the previous 6 months associated with onset of knee symptoms

  • MRI identified grade 3 (full tear) of meniscus

  • No radiographic signs of osteoarthritis of the knee

Participants were then randomized to receive APM or PT. APM occurred within six weeks of inclusion. PT consisted of a 3 month regiment. Curious about PT? See here. The PT regiment had 3 phases:

  1. reduce knee swelling

  2. improve range of motion & restore muscle coordination and function

  3. increase activities of daily living and return to sport (e.g., jumping, skipping, running)

Overall, the program was likely suitable for folks not typically active and looking to return to usual daily activities such as going from sit to stand, walking, and climbing stairs. Participants in the PT group had the option to cross-over and receive delayed APM., of which 41% elected. Overall, the authors did not find a difference in outcomes (e.g., pain and function) at 2 years post intervention between groups (see figure below).

The authors conclude:

We did not find that arthroscopic partial meniscectomy was superior to physical therapy plus optional delayed arthroscopic partial meniscectomy at 24-month follow-up in young patients with isolated traumatic meniscal tears. Fifty-nine per cent of patients randomised to physical therapy did not undergo delayed arthroscopic partial meniscectomy during the follow-up period. A van der Graaff 2022

What about pediatric patients (<18 years of age) with meniscal tears?


Ferrari et al completed a systematic review on meniscal repair in children and adolescents, examining treatment approaches, healing, and outcomes. The authors state:

In conclusion, meniscal tears in patients 18 years old or younger are not uncommon, and they can be associated with a long period between the onset of symptoms and surgical treatment. Repairs of this injury produced good to excellent outcomes in most patients, regardless of the injury pattern, zone, or technique. Reported complications are minimal, increasing the potential application of this surgical treatment modality. Higher quality studies are needed to confirm the findings of this systematic review. [emphasis mine] Ferrari 2019

This review was completed on 8 case series studies and no randomized controlled trials. We already have good evidence that in other populations meniscal surgery is no better than sham or placebo surgery, which is why we need RCTs to make informed decisions. The authors stated that reported complications were minimal, but yet 44 participants out of 287 total participants went on to have meniscectomy after an initial meniscal repair. Oddly, Liechti et al also did a systematic review on the pediatric population with the same exact 8 case series studies. When re-reading the data from this systematic review three additional factors worth mentioning became apparent. First, although Ferrari et al is quoted above with 44 cases of meniscectomies after repair, Liechti et al reports - “A total of 52 failures in 301 total menisci were reported (17.3% failure rate) at a mean time of 16.6 months after initial surgery. Of these, 41 patients underwent partial meniscectomy at the time of revision surgery whereas 9 patients underwent re-repair.” Liechti 2019


Re-examining Ferrari et al’s table 2. the following post-repair interventions were identified:

  • 43 partial meniscectomies

  • 7 re-repairs

  • 1 meniscal debridement

Second, the outcome assessments are not well reported across studies, which makes it difficult to make bold claims in the conclusion such as -

  • Liechti et al - “The available data suggest that arthroscopic repair of a meniscal tear in the pediatric population is an effective treatment option that has a low failure rate, provides good clinical outcomes, and preserves meniscal tissue.” Liechti 2019

  • Ferrari et al - “In conclusion, meniscal tears in patients 18 years old or younger are not uncommon, and they can be associated with a long period between the onset of symptoms and surgical treatment. Repairs of this injury produced good to excellent outcomes in most patients, regardless of the injury pattern, zone, or technique.” Ferrari 2019

Examining the outcome data, we find a bit of a different story, mainly not well tracked or reported information from Liechti et al. The Tegner was developed to be administered in conjunction with the Lysholm specifically in ACL tear populations, but has also been used in meniscus tear situations. Collins 2011 Some of the studies show Tegner not changing, not reported, or improvement - a mixed bag. Lysholm is mostly not reported, not reported at baseline, or does show improvement pre-post operation. SF-36 wasn’t reported at all. IKDC is reported in the majority of studies as an overall score, Level 1, Level 2, A, or B format. Finally we see return to activity, with some not even tracking this information. I find the above listed conclusions a bit disproportionate in confidence comparatively to what Table 3 shows. Again, without well conducted randomized controlled trials, it’s difficult to know if the results we do see from these reviews are due to the surgical intervention itself, can’t be achieved with other interventional like education, time, and activity modification, or are merely masking natural history and regression to the mean.


Lastly and importantly - many of these meniscus tears co-occurred with ACL tears, from Liechtiet al, “This review of a total of 301 meniscal tears (134 medial, 127 lateral, 32 both medial and lateral, 8 location unspecified) demonstrated 172 concomitant anterior cruciate ligament (ACL) tears and 1 ACL-deficient knee in the included studies” [emphasis mine]


This should lead us to further question these reviews’ findings and their external validity to situations solely presenting with meniscal tears.


Chambers et al examined the available evidence on natural history in the pediatric population and states several limitations of current available data:

It is quite difficult to parse the natural history of meniscus tears from the current literature. There are patients who have meniscal injuries which are unrecognized, there are patients who have meniscal injuries with malalignment issues which may predispose to mechanical problems such as arthritis and most of the patients who have a symptomatic meniscus tear have surgical treatment of their injuries. Chambers 2019

What about subgrouping patients for APM?

Many argue there may exist a subgroup of patients who would benefit from surgical intervention for meniscus changes. Perhaps there are specific case variables we should use to classify a cohort as necessitating surgical intervention. That doesn’t appear to be the case at this time. Pihl et al published Wild goose chase – no predictable patient subgroups benefit from meniscal surgery: patient-reported outcomes of 641 patients 1 year after surgery. According to the authors, their primary aim was, “...identify those who might improve after APM [Arthroscopic Partial Meniscectomy], we combined the most logical prognostic factors to develop and validate a prognostic model to predict patients’ change in their self-reported outcome1 year following arthroscopic meniscal surgery.” Pihl 2020 The authors developed their prognostic model from the Knee Arthroscopy Cohort Southern Denmark (KACS), “...a prospective cohort following patients undergoing knee arthroscopy for a meniscal tear.” Pihl 2020 For this cohort, the KOOS (Knee Injury and Osteoarthritis Outcome Score) was the primary outcome measure of interest and was completed online by patients within 2 weeks pre-surgical intervention and at the 12 week and 52 week marks post-surgical intervention. Overall, the authors included 641 patients (600 with meniscal resection, 33 with repairs, and 8 with a combination of both surgical interventions). 12% of outcome data was missing at 52 week follow-up (76 patients). Their model findings:

Our results do not support the existence of specific subgroups of patients with certain preoperative characteristics having larger improvements in patient-reported outcomes after meniscal surgery. Pihl 2020

Variables often measured at baseline pre-surgical intervention on the meniscus were poor predictors for patient-reported outcomes post-surgery; these even included those mentioned above such as mechanical symptoms, onset (gradual onset -> traumatic), or knee catching/locking. The authors close by saying,

Despite considering a large number of clinically relevant factors collected preoperatively, change in patient-reported outcome 1 year following meniscal surgery was not possible to predict. Our results do not support the existence of subgroups with certain characteristics having a particularly favourable outcome after meniscal surgery. Pihl 2020

Van de Graaf et al take findings from Chambers et al a step further in their article, Can even experienced orthopaedic surgeons predict who will benefit from surgery when patients present with degenerative meniscal tears? A survey of 194 orthopaedic surgeons who made 3880 predictions. The authors surveyed orthopedic residents and surgeons in the Netherlands and Australia to assess:

  • Ability to predict outcomes in patients treated for meniscal tears

  • Identify differences between surgeons with vs without expertise in treating patients with knee pain

  • Assess differences in predictions between responders vs non responders to treatment

  • Identify patient characteristics leading surgeons to recommend APM vs non-surgical treatment. Graaf 2019

20 patient profiles were presented to participating orthopedists for review. These patient profiles were representative of participants in the ESCAPE randomized controlled trial comparing physical therapy vs APM, conducted by van der Graaf et al. Each profile included: demographics, symptoms, knee function, pain score, physical examination results, type of meniscus tear verified on MRI, and osteoarthritis level. The orthopedists were asked to designate which treatment, exercise or APM, for each profile. They were then asked to estimate their expected effect of treatment on knee function (5-point Likert scale ranging from strong deterioration to strong improvement) 2 years later for their preferred treatment as well as their non-preferred treatment. The participants were also asked about years of experience, field of expertise, and opinion about the quality of the research literature. Finally, the orthopedists were given a list of patient characteristics and asked how the variables influence their treatment recommendations (exercise therapy or APM), if at all. It has likely become obvious by now, but the primary outcome was the percentage of correct predictions for treatment outcome. The authors find overall, predictions are no better than coin flip -

Overall, 50.0% (95% CI 39.6% to 60.4%) of all predictions were correct. This percentage was similar between experienced knee surgeons and the other surgeons, 50.4% (95% CI 48.6% to 52.2%) vs 49.5% (95% CI 48.0% to 51.1%), respectively (p=0.58). Graaf 2019

Unsurprisingly, patient characteristics tipping the scales towards preferring APM included:

  • bucket handle tears (94% of surgeons)

  • knee locking (82%)

  • “Failed” non-operative treatment (82%),

  • traumatic etiology (76%), and

  • age <45 years (74%)

However, interestingly, exercise was preferred for patient characteristics including:

  • moderate to severe osteoarthritis (96%)

  • degenerative etiology (92%)

  • lack of obstructive complaints (88%)

  • age >45 years (87%), and

  • obesity (79%)

We’ve already discussed many of the characteristics being viewed as warranting APM and the lack of evidential support for these narratives. The authors end the piece with a final call to action: “We respectfully recommend that orthopaedic surgeons should rely more on the objective evidence from the literature when choosing treatment options.” Graaf 2019


Closing Remarks:


At this time, we are not seeing data supporting meniscal surgical intervention at the rate of current utilization. Specifically, we are struggling to find subgroups of patients warranting surgical intervention. Previously we thought perhaps younger and pediatric patients need surgical intervention, especially if context could be labeled as traumatic onset. The biggest update to this blog is the new data on these populations and calling into question the need for surgery for meniscus related issues.


One major barrier to updating clinical practice is our eagerness to peer beneath the surface with imaging in search of something to structurally fix, which may drive up perceived incidence rates of meniscal alterations despite also having evidence of asymptomatic presentations. Chambers et al’s conclusions aptly frame the road that lies ahead:

It will be very difficult, in a setting where there are physicians who are adept at diagnosing meniscus tears, have access to advanced imaging and have the means to treat meniscus tears that any natural history study will ever be performed. Perhaps a study could be performed in an underserved area of the world, with capture of all of the variables contributing to long-term problems, but none has been performed at this time. Chambers 2019

In other words, just because we can find and correct a structural change, we don’t know that we’ve actually had any meaningful effects beyond placebo-like contextual effects, natural history, and regression to the mean. It is unlikely our biomedical paradigm for approaching these symptoms will be greatly altered any time soon. For now, based on the current totality of evidence, our best bet is at minimal step-wise care involving conservative management via education and goal directed activity for knee symptoms being attributed to meniscal issues, regardless of population. Perhaps future evidence will emerge identifying subsets of populations warranting meniscal surgery, but as of now the evidence doesn’t appear supportive.


The premise that surgery is warranted requires identifying specific indications for surgery from a biological perspective, which is difficult given the current research suggesting the problems with identifying clear biological symptom “drivers” (see references in introduction). When and how much does “biology” matter? We are not entirely sure, and don’t have enough evidence to make informed decisions regarding the topic outside of extreme traumatic situations. Given what we’ve seen thus far with long-term outcomes after ACL reconstruction – our skepticism for the idea that surgery MUST be done is high.



References:

  1. Logerstedt DS, Snyder-Mackler L, Ritter RC, Axe MJ; Orthopedic Section of the American Physical Therapy Association. Knee pain and mobility impairments: meniscal and articular cartilage lesions [published correction appears in J Orthop Sports Phys Ther. 2010 Sep;40(9):597]. J Orthop Sports Phys Ther. 2010;40(6):A1-A35. doi:10.2519/jospt.2010.0304

  2. Mordecai SC, Al-Hadithy N, Ware HE, Gupte CM. Treatment of meniscal tears: An evidence based approach. World J Orthop. 2014;5(3):233-241. Published 2014 Jul 18. doi:10.5312/wjo.v5.i3.233

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  4. Horga LM, Hirschmann AC, Henckel J, Fotiadou A, Di Laura A, Torlasco C, D'Silva A, Sharma S, Moon JC, Hart AJ. Prevalence of abnormal findings in 230 knees of asymptomatic adults using 3.0 T MRI. Skeletal Radiol. 2020 Jul;49(7):1099-1107. doi: 10.1007/s00256-020-03394-z. Epub 2020 Feb 14. PMID: 32060622; PMCID: PMC7237395.

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