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Update on meniscal repair highlights need for re-evaluation of outcomes
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SEATTLE — In defining the success of meniscal repair, a noted surgeon said physicians should consider patient reported outcomes and structural changes to the meniscus, and evaluate results based on the location of the tear.
“In the future, clinically, you should understand that there [are] unique roles between the medial meniscus and the lateral meniscus,” Kurt P. Spindler, MD, said during a presentation at the American Orthopedic Society for Sports Medicine Annual Meeting. “I think that as a new standard, meniscal repairs should be evaluated by their patient reported outcomes done in multivariable analysis, and also should look at structure measurements.” He noted that specialized X-rays can be utilized within a clinic to validate structural changes.
Spindler suggested that surgeons and researchers rethink the current standard for success after meniscus repair, which is the absence of revision surgery. “Traditionally, we looked at no reoperation for symptomatic failure as success,” he said. However, he questioned whether this standard provides an accurate view of outcome for the patient. “That is no longer sufficient and does not answer the question of the function of the meniscus,” Spindler said.
Kurt P. Spindler
Subjective outcomes
Instead, he suggested physicians use patient-reported outcome measures, such as pain scales, activities of daily living, function and return to sports. “We need to think about how we define success of meniscus repair,” he continued. “We should evaluate meniscal repair for the future by patient reported outcomes, and we should also evaluate structural changes because, in reality, the meniscus provides chondral protection.”
Previous published studies reported failure rates between 14% and 27% for meniscal repair, he said, noting recent studies on concomitant meniscus and ACL repair were linked to poor outcomes. Specifically, lateral meniscus repair, said Spindler, was reported in a Multicenter Orthopaedic Outcomes Network study to have outcomes similar to a normal meniscus. However, medial meniscus repair was tied to poorer outcome.
Structure and function
Changes in structure can also be measured and monitored, including joint space width. A study recently presented at the Osteoarthritis Research Society meeting in France of more than 200 patients determined that the joint space width was similar between the medial meniscus and untreated tear. “We had definitely some joint space width changes, and meniscal repair was between meniscectomy,” said Spindler. “The meniscectomy groups have the largest amount of cartilage change, the meniscal repair is in between. So, meniscal repair on the medial side is either half bad or half good. It depends on your viewpoint.” He also pointed out during ACL reconstruction the specific treatment between no treatment for a tear vs. excision vs. repair is not necessarily interchangeable, but is based on the type of tear especially with reference to blood supply as well as the condition of the meniscus.
In addition, he commented that the patient’s age was an important variable in determining joint space. “Age was a powerful factor in looking at joint space after ACL reconstruction,” said Spindler. Two thirds of patients within the study were between 15 years and 20 years, with the oldest patient being 30 years and youngest patient being 15 years. “There is a 1-mm change here between that group of young people and old people in their response to the articular cartilage,” said Spindler.
Additional study is needed to create “more longitudinal cohorts to improve medial meniscus healing” as well as creative solutions to the problems of medial meniscus loss, he said. The latter would be something Spindler hoped engineers and researchers would devote effort toward. – by Katie Pfaff
Reference:
Spindler KP. Presented at: American Orthopaedic Society for Sports Medicine Annual Meeting; July 10-13, 2014; Seattle.
For more information:
Kurt P. Spindler, MD, can be reached at Cleveland Clinic Sports Health Center, 5555 Transportation Blvd., Garfield Heights, OH 44125; email: spindlk@ccf.org.
Disclosure: Spindler has no relevant financial disclosures.