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Surgical intervention best as second line of treatment for most meniscal tears
Meniscal surgery should primarily be performed for traumatic tears or ones that lock the knee.
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“Meniscal tears, which lead to loss of meniscal function, are strong risk factors for development of knee osteoarthritis (OA),” Martin Englund, MD, an epidemiologist at Lund University, in Lund, Sweden, who performs clinical research into meniscal tears, told Orthopaedics Today Europe. “However, having OA puts you also at increased risk of developing degenerative meniscal tears. It is a complex relationship.”
Two key types of tears
Research has shown how common meniscal tears are. There are two main types of meniscal tears, according to Englund; those that occur after acute knee trauma, such as when a young athlete’s knee twists, and the more common, degenerative lesions, which often occur with no trauma.
He and his colleagues studied knee MRIs in the general population and found one-third of the middle-aged and elderly persons had a degenerative meniscal tear, based on results of their 2008 study published in the New England Journal of Medicine. Most of these tears were found in persons without knee symptoms.
With non-acute tears, patients may not remember a particular injury and the surgeon often discovers a degenerative tear via MRI examination after the patient reports knee pain, Englund said. While these are the kinds of tears that occur in the general population — most often the middle-aged and elderly — knee pain alone does not always mean surgery is indicated, Englund said.
“It is not necessarily the meniscal tear itself causing symptoms,” he said. “It might often be other features of the knee causing pain. But there is a pressure on the surgeon to do something to help the patient,” Englund said. “And, it is challenging for health professionals to differentiate meniscal pain from other sources of knee pain, such as early stage knee OA.”
In fact, Englund recommended orthopaedists not consider surgery as the first treatment of choice. In his presentation at the Congress, he advocated using surgical management primarily if the tear is traumatic or if there are large torn fragments of a degenerative tear lodged between the condyles. This may lock the knee so the patient is unable to move it, he said.
“In certain few selected patients, surgery may be necessary if there are large tears that cause obvious mechanical interference in the joint, but that is a rare occasion,” Englund said.
Englund advocated conservative care as the treatment of choice for degenerative meniscal tears, an approach that might include guided exercises and physical therapy and losing weight.
“We need to be much more conservative with surgical therapy with meniscal tears than previously thought,” Englund said, citing a large randomized study by Katz and colleagues recently published in the New England Journal of Medicine. Those researchers found no differences in outcomes for degenerative meniscal tears when results of surgical and non-surgical groups were compared, he said.
Surgical technique
A downside of surgery is that too much resection of meniscal tissue may predispose patients to knee OA since reduced meniscal function increases the risk of knee OA, Englund said.
Therefore, in the treatment of a meniscal tear, the surgeon should first consider if the tear is the cause of the knee pain and whether it is repairable. “The tears that are repairable are typically the ones occurring in young healthy persons, which are close to the joint capsule where the meniscus has blood supply so it can heal again,” Englund said. If they are in this zone, “then a suture should be made to preserve/restore meniscal function.”
If repair is not possible, the surgeon should next carefully remove meniscal torn tissue, which may cause joint interference.
“Leave as much functional meniscus tissue as possible with a partial meniscectomy,” he said.
“Unfortunately, this is a condition where we do not have many treatment options today because degenerative lesions cannot be repaired normally,” Englund said. “There are exciting studies soon to be published. I recommend [surgeons] keep following the literature because likely in the fall or summer we will see results from a trial comparing surgery with a placebo surgery procedure for degenerative meniscal tears.” – by Renee Blisard Buddle
- References:
- Englund M. N Eng J Med. 2008. doi:10.1056/NEJMoa0800777.
- Englund M. Paper #I-11. Presented at: Osteoarthritis Research Society International World Congress; April 18-21, 2013; Philadelphia.
- Katz J. N Eng J Med. 2013. doi:10.1056/NEJMoa1301408.
- For more information:
- Martin Englund, MD, can be reached at Department of Orthopedics, Klinikgatan 22, SE-221 85 Lund, Sweden; email: martin.englund@med.lu.se.
Disclosure: Englund has no relevant financial disclosures.
Perspective
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Philippe Beaufils, MD
I completely agree with Martin Englund. His studies are particularly important and relevant. His main conclusions are:
There is a relationship between degenerative meniscal lesions and osteoarthritis (OA) but we do not know exactly what is the cause and what is the consequence;
Knee pain and meniscus lesion on MRI are frequently associated due to the frequency of these two occurrences. It does not mean knee meniscus pathology is always the cause of knee pain;
According to these assertions, there are too many meniscectomies and meniscectomy should be indicated on careful examination, and
Meniscal preservation is the main message (meniscus repair or let the meniscus alone).
If we look, for example, at the French figures, about 130,000 meniscectomies are performed per year. It is the second most frequent orthopaedic procedure just behind carpal tunnel release. There are only 4% to 5% of meniscal repairs, while, theoretically speaking 15% to 20% of meniscal tears would be suitable for repair. The majority of these meniscectomies are indicated for degenerative meniscal lesions. One of our concerns is we are not able, in the same time, to measure the number of meniscal lesions which are left in place since these patients do not come to the surgeon, or if they come, they are not operated on. This is a real problem to assess in the daily practice. Since we do not know exactly what is the relationship between degenerative meniscal lesions and OA, indications for surgery can only be based on a clinical, pragmatic concept. I agree we have to be prudent in indicating meniscectomy, but an unstable, degenerative lesion has a low chance to spontaneously become asymptomatic. It is what we could call the painful unstable meniscal lesion. Arguments for this diagnosis are (one or several criteria) sudden onset, overuse, precise tenderness on the joint line, image of a flap on MRI and no macroscopic OA on standard X-rays. It is for us to decide the optimal indication of meniscectomy in degenerative meniscal lesions. We have to promote guidelines. Some countries have done so and a European consensus would probably be helpful.
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Rene Verdonk, MD, PhD
I share Professor Englunds thoughts completely on the meniscus issue. In the aging process of the knee, both the cartilage and meniscus lose their physiological bumper effect, overloading the subchondral bone and causing mechanical knee pain. Englund suggests two types of lesions to the meniscus, a traumatic one in the younger patient and a degenerative one, which is physiological in older aged patients. The young patients tear needs to be fixed to keep the meniscus intact (it needs to be sutured almost at all cost) and, if resected, then it needs to be considered for partial replacement. The older, aged degenerative tear needs to be left alone.
However, in these older patients, trauma does happen as well. These people are keeping more active and can fall, slip or tumble on top of the existing degenerative situation. Such an injury can add a traumatic tear. These need to be considered as tears that can require surgery.
As Englund clearly states, the history of the patient is of major importance. One should only consider arthroscopic meniscal surgery in the older-aged patient when a trauma is present in the history to save meniscal tissue and keep the normal knee physiology intact. You increase chances of quicker degeneration as the bumper effect of the meniscus is unduly removed. Additionally, save the meniscus should be todays slogan for meniscus pathology treatment. In younger patients, techniques should be used to partially replace the meniscus (after resection) to avoid cartilage degeneration due to weight-bearing and early osteoarthritis formation.
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