Mentoring Minutes: Meniscal Tears of the Knee

REFERENCES AND NOTES

EFORT Open Rev. 2017 May 11;2(5):195-203. doi: 10.1302/2058-5241.2.160056. eCollection 2017 May. The knee meniscus: management of traumatic tears and degenerative lesions.
Beaufils P1, Becker R2, Kopf S3, Matthieu O4, Pujol N1.

- Robust scientific publications indicate the value of meniscal repair or non-removal in traumatic tears and non-operative treatment rather than meniscectomy in degenerative meniscal lesions

- In traumatic tears, the first-line choice is repair or non-removal. Longitudinal vertical tears are a proper indication for repair, especially in the red-white or red-red zones. Success rate is high and cartilage preservation has been proven.

- Degenerative meniscal lesions are very common findings which can be considered as an early stage of osteoarthritis in middle-aged patients. Recent randomized studies found that arthroscopic partial meniscectomy (APM) has no superiority over non-operative treatment.

- So non-operative treatment should be first line of choice, 3 months is considered acceptable threshold (meniscus consensus project).

Arthroscopy. 2016 Sep;32(9):1855-1865.e4. doi: 10.1016/j.arthro.2016.05.036. Epub 2016 Jul 27. Arthroscopic Partial Meniscectomy or Conservative Treatment for Nonobstructive Meniscal Tears: A Systematic Review and Meta-analysis of Randomized Controlled Trials.
van de Graaf VA1, Wolterbeek N2, Mutsaerts EL3, Scholtes VA3, Saris DB4, de Gast A5, Poolman RW3.

- To conduct a meta-analysis of randomized controlled trials comparing the outcome of arthroscopic partial meniscectomy (APM) with conservative treatment in adults with nonobstructive meniscal tears and to recommend a treatment of choice.

- We included 6 randomized controlled trials, with a total of 773 patients, of whom 378 were randomized to APM and 395 were randomized to the control treatment. After pooling the data of 5 studies, we found small significant differences in favor of the APM group for physical function at 2 to 3 months and at 6 months  We found no significant differences after 12 and 24 months.

Knee Surg Sports Traumatol Arthrosc. 2017 Feb;25(2):335-346. doi: 10.1007/s00167-016-4407-4. Epub 2017 Feb 16. Surgical management of degenerative meniscus lesions: the 2016 ESSKA meniscus consensus.
Beaufils P1, Becker R2, Kopf S3, Englund M4, Verdonk R5, Ollivier M1, Seil R6,7.

- A degenerative meniscus lesion is a slowly developing process typically involving a horizontal cleavage in a middle-aged or older person. When the knee is symptomatic, arthroscopic partial meniscectomy has been practiced for a long time with many case series reporting improved patient outcomes. Since 2002, several randomized clinical trials demonstrated no additional benefit of arthroscopic partial meniscectomy compared to non-operative treatment, sham surgery or sham arthroscopic partial meniscectomy.

- used patients > 35 without acute significant trauma… 84 surgeons,22 countries.

- main finding was that arthroscopic partial meniscectomy should not be proposed as a first line of treatment for degenerative meniscus lesions. Arthroscopic partial meniscectomy should only be considered after a proper standardized clinical and radiological evaluation and when the response to non-operative management has not been satisfactory. Magnetic resonance imaging of the knee is typically not indicated in the first-line work-up, but knee radiography should be used as an imaging tool to support a diagnosis of osteoarthritis or to detect certain rare pathologies, such as tumors or fractures of the knee.

BMJ. 2016 Jul 20;354:i3740. doi: 10.1136/bmj.i3740. Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: randomised controlled trial with two year follow-up.
Kise NJ1, Risberg MA2, Stensrud S3, Ranstam J4, Engebretsen L5, Roos EM6.

- No clinically relevant difference was found between the two groups in change in KOOS4 at two years (0.9 points, 95% confidence interval -4.3 to 6.1; P=0.72). At three months, muscle strength had improved in the exercise group (P≤0.004). No serious adverse events occurred in either group during the two year follow-up. 19% of the participants allocated to exercise therapy crossed over to surgery during the two year follow-up, with no additional benefit.

Open Orthop J. 2016 Dec 30;10:797-804. doi: 10.2174/1874325001610010797. eCollection 2016. The Role of Arthroscopic Partial Meniscectomy in the Management of Degenerative MeniscusTears: A Review of the Recent Literature.
Azam M1, Shenoy R2.

- majority of randomized control trials suggest that arthroscopic partial meniscectomy is not superior to conservative measures such as exercise programs. Furthermore, one randomized control trial found that arthroscopic partial meniscectomy was not even superior to sham surgery.

Int Orthop. 2015 Apr;39(4):769-75. doi: 10.1007/s00264-014-2539-z. Epub 2014 Oct 10. Arthroscopic partial meniscectomy is superior to physical rehabilitation in the management of symptomatic unstable meniscal tears.
El Ghazaly SA1, Rahman AAYusry AHFathalla MM.

- Stable peripheral tears may heal, while degenerative tears do well with physical therapy. However, the exact role of physical therapy in treating symptomatic unstable meniscal tears is not known

- Seventy patients with unstable meniscal tear met the inclusion criteria. Clinical examination, McMurray test and magnetic resonance imaging were done. Age ranged from 18-67 years (average 39.87). Mild osteoarthritis was seen in 20 cases. Physical therapy thrice a week for eight weeks was offered (quadriceps stimulation and neuromuscular strengthening exercises). After physical therapy, patients still complaining or unsatisfied were offered arthroscopic partial menisectomy (APM). Outcomes were evaluated using the VAS pain score and the Lysholm knee score.

- Mean VAS before interventions was 7.4, significantly improved to 5.16 after rehabilitation and to 1.9 after APM (p = 0.001). Mean Lysholm score before rehabilitation was 65.1 and improved to 69.6 after rehabilitation, the difference was non-significant. However, Lysholm score difference before and after APM showed a highly significant difference

- Pain and swelling improved after physical therapy. However, patients were not satisfied as limited range of knee motion persisted. APM was superior to physical therapy in treating symptomatic unstable meniscal tears, with high patient satisfaction and restored knee function.

Int J Sports Phys Ther. 2016 Aug;11(4):564-74. AN ALTERNATIVE APPROACH TO THE TREATMENT OF MENISCAL PATHOLOGIES: A CASE SERIES ANALYSIS OF THE MULLIGAN CONCEPT "SQUEEZE" TECHNIQUE.
Hudson R1, Richmond A1, Sanchez B1, Stevenson V1, Baker RT1, May J1, Nasypany A1, Reordan D2.

- purpose of this case series was to examine the effect of the Mulligan Concept (MC) "Squeeze" technique in physically active participants who presented with clinical symptoms of meniscal tears

- The MC "Squeeze" technique was applied in five cases of clinically diagnosed meniscal tears in a physically active population. The Numeric Pain Rating Scale (NRS), the Patient Specific Functional Scale (PSFS), the Disability in the Physically Active (DPA) Scale, and the Knee injury and Osteoarthritis Outcomes Score (KOOS) were administered to assess participant pain level and function.

- Signifcant improvements on pain, functional and disability scale.

- The MC "Squeeze" technique produced statistically and clinically significant changes across all outcome measures in all five participants.

J Orthop Sports Phys Ther. 2015 Jan;45(1):18-24, B1. doi: 10.2519/jospt.2015.5215. Validity of the Thessaly test in evaluating meniscal tears compared with arthroscopy: a diagnostic accuracy study.
Goossens P1, Keijsers Evan Geenen RJZijta Avan den Broek MVerhagen APScholten-Peeters GG.

- To evaluate the diagnostic accuracy of the Thessaly test compared with an arthroscopic examination in patients with suspected meniscal tears.

- The Thessaly test alone and the combination of the Thessaly and McMurray tests were considered as index tests, and arthroscopy was used as the reference test. - -

- Experienced physical therapists performed the Thessaly test at 20° of flexion and the McMurray test for both knees. The physical therapist was blinded to patient information, the affected knee, and the results from possible earlier diagnostic imaging. An orthopaedic surgeon blinded to the clinical test results from the physical therapist performed the arthroscopic examination.

- A total of 593 patients were included, of whom 493 (83%) had a meniscal tear, as determined by the arthroscopic examination.

- The Thessaly test had a sensitivity of 64% specificity of 53%, positive predictive value of 87%, negative predictive value of 23%, and positive and negative likelihood ratios of 1.37, and 0.68

- The combination of positive Thessaly and McMurray tests showed a sensitivity of 53% and specificity of 62%.

- The results of the Thessaly test alone or combined with the McMurray test do not seem useful to determine the presence or absence of meniscal tears.

Health Technol Assess. 2015 Aug;19(62):1-62. doi: 10.3310/hta19620. Diagnostic accuracy of the Thessaly test, standardised clinical history and other clinical examination tests (Apley's, McMurray's and joint line tenderness) for meniscal tears in comparison with magnetic resonance imaging diagnosis.
Blyth M1, Anthony I1, Francq B2, Brooksbank K1, Downie P3, Powell A1, Jones B1, MacLean A1, McConnachie A2, Norrie J4.

- To determine the diagnostic accuracy of the Thessaly test and to determine if the Thessaly test (alone or in combination with other physical tests) can obviate the need for further investigation by MRI or arthroscopy for patients with a suspected meniscal tear.

- Two cohorts of patients were recruited: patients with knee pathology (n = 292) and a control cohort with no knee pathology (n = 75).

- Participants were assessed by both a primary care clinician and a musculoskeletal clinician. Both clinicians performed the Thessaly test, McMurray's test, Apley's test, joint line tenderness test and took a standardised clinical history from the patient.

- The Thessaly test had a sensitivity of 0.66, a specificity of 0.39 and a diagnostic accuracy of 54% when utilised by primary care clinicians. This compared with a sensitivity of 0.62, a specificity of 0.55 and diagnostic accuracy of 59% when used by musculoskeletal clinicians. The diagnostics accuracy of the other tests when used by primary care clinicians was 54% for McMurray's test, 53% for Apley's test, 54% for the joint line tenderness test and 55% for clinical history. For primary care clinicians, age and past history of osteoarthritis were both significant predictors of MRI diagnosis of meniscal tears. For musculoskeletal clinicians age and a positive diagnosis of meniscal tears on clinical history taking were significant predictors of MRI diagnosis. No physical tests were significant predictors of MRI diagnosis in our multivariate models. The specificity of MRI diagnosis was tested in subgroup of patients who went on to have a knee arthroscopy and was found to be low 0.53 (95% confidence interval 0.28 to 0.77)], although the sensitivity was 1.0.