Does the long-term risk of degenerative change differ following meniscal repair and partial meniscectomy?

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1 Evidence in focus Systematic literature review and meta-analysis *smith&nephew Authors: Rachel Barrow MSc, Chris Saunders PhD, Guy Dolman M.Phil, Sarah Britton BA Smith & Nephew, Hull, United Kingdom Does the long-term risk of degenerative change differ following meniscal repair and partial meniscectomy? The well-established link between total meniscectomy and degenerative joint changes 1 led to the widespread adoption of partial over complete resection. However, in spite of more favourable results, even partial removal of the meniscus increases the risk of long-term degenerative changes. 2,3 This has made the use of meniscal repair, where appropriate, the treatment of choice for symptomatic tears. 4,5 The purpose of this review was to evaluate and compare the current evidence on the long-term risk of degenerative changes following partial meniscectomy or meniscal repair. Methods Literature search A thorough search of the peer-reviewed literature was conducted. The search strategy was as follows: Inclusion criteria English-language paper Published between 1990 and January 2017 Reported clinical outcomes following partial meniscectomy or meniscal repair with minimum five years mean follow-up Exclusion criteria Fewer than 10 patients Non-clinical study Figure 1: Search strategy Studies identified Title/abstract review Full text review Articles included in review Partial meniscectomy 364 EMBASE: 358 PubMed: 0 additional Hand-sourced: 6 additional -314 Excluded studies -28 Excluded studies 22 Meniscal repair 22 EMBASE: 18 PubMed: 0 additional Hand-sourced: 4 additional -3 Excluded studies -13 Excluded studies 6

2 Results Twenty-two studies reported on osteoarthritic (OA) changes of the affected knee joint in patients treated with partial meniscectomy, and six in those undergoing meniscal repair. All studies had a minimum five-year follow-up period. Proportional meta-analyses were performed to allow the results of different studies to be combined. This was done using the random effects model to account for heterogeneity between studies. After pooling the results, the final figures were reported as proportions alongside 95% confidence intervals (95% CIs). Figure 2: Long-term prevalence of degenerative changes following partial meniscectomy and meniscal repair surgery Partial meniscectomy Meniscal repair 57% 32% Cases with OA changes/progression Cases with no OA changes/progression n = 1726 (95% CI: 47-67%); mean follow up, 10 years n = 205 (95% CI: 16-52%); mean follow up, 9.6 years A pooled mean proportion of 57% of patients with a partial meniscectomy had development or progression of OA, compared with 32% of meniscal repair patients. Therefore, partial meniscectomy patients had 1.78 times* the risk of degenerative changes compared with meniscal repair patients. Conclusion The results of this review demonstrate that the relative risk of long-term degenerative change is 78% higher in patients treated with partial meniscectomy compared with those treated with meniscal repair. Considerations The 95% CIs reported within this analysis partially overlap. This means that while the results are clinically relevant they may not yet be statistically significant. This is likely to be due to the limited number of studies reporting long-term OA changes following meniscal repair. OA changes were reported inconsistently in the included studies; for the purpose of the analysis the percentage of patients that have either OA progression or the presence of OA changes has been combined. However, this review s conclusions are supported by head-to-head comparison studies which reported that meniscal repair led to lower rates of degenerative changes compared with 8, 13 partial meniscectomy. Caution must be used when interpreting these findings. There are differences in the demographics of the patient populations who were treated with meniscal repair versus meniscectomy. Older patients are more likely to be treated with meniscectomy versus repair and to have degenerative changes within the joint, irrespective of meniscal injury. Location and complexity of the tear may also differ. * The absolute risk for the meniscectomy group (0.57), divided by the absolute risk for the repair group (0.32).

3 Figure 3: Study characteristics Study, year Level I: Randomised controlled trials Level II: Prospective, comparative Level III: Retrospective, comparative Level IV: Case studies Study objective Mean age, years Number of cases Tear details* Mean follow-up, years % OA change/ progression Partial meniscectomy Andersson- Molina, Chatain, Chatain, Chung, Lutz, Rockborn and Gillquist, Shelbourne and Dersam, To compare radiographic signs of arthrosis among patients having undergone partial meniscectomy, total meniscectomy or no previous knee injury (control) To compare long-term results of partial medial meniscectomy with partial lateral meniscectomy To compare long-term results of partial medial meniscectomy with partial lateral meniscectomy To compare the clinical and radiologic results of partial meniscectomy with those of refixation in patients with medial meniscus posterior root tears at a minimum five-year follow-up To compare clinical and radiological results at 10 years between meniscectomy and meniscal repair To compare functional and radiographic outcomes after meniscectomy between patients with and without degenerative changes at the index operations To compare partial meniscectomy versus meniscus repair for bucket-handle lateral meniscus tears who underwent anterior cruciate ligament reconstruction Sommerlath, To compare menisical repair to partial meniscectomy in knees without major ligamentous injury Stein, Bolano and Grana, Bonneux and Vandekerckhove, To evaluate the mid- and long-term outcome of meniscal repair compared with partial meniscectomy in stable knees To review functional and radiographic results of partial meniscectomy at five-year follow-up To evaluate the long-term results of partial meniscectomy of lateral tears in a young and active population Covall and To assess roentgenographic changes following partial Wasilewski, meniscectomy in patients over 45 years of age Englund and Lohmander, Faunø and Nielsen, Han, Higuchi, To evaluate risk factors on development of radiographic OA long-term and symptoms following meniscectomy To review the long term effects of partial meniscectomy on clinical and radiological outcomes compared with non-operated knees To evaluate clinical and radiographic outcomes of partial meniscectomy for complete posterior medial meniscus root tears in patients with evidence of early OA To determine functional and radiographic changes on long-term follow up of knees with isolated meniscal tears after arthroscopic partial meniscectomy (medial) 109 (lateral) 1 transverse, 1 horizontal cleavage, 3 longitudinal vertical, 8 bucket-handle, 5 flap 173 vertical, 114 parrot beak, 41 degenerate, 18 complex, 16 non specified 40 vertical, 30 parrot beak, 18 degenerate, 5 horizontal, 5 discoid, 11 not specified Not stated Not stated transverse, 2 longitudinal, 8 horizontal, 22 buckethandle, 20 flap bucket-handle longitudinal, 3 bucket-handle 33 longitudinal, 4 buckethandle, 2 flap 18 flap radial, 14 horizontal degenerative, 14 buckethandle, 4 complex 12 flap, 6 radial, 5 buckethandle, 3 degenerative (discoid), 2 horizontal, 2 parrot beak, 1 vertical 23 complex, 13 flap, 8 degenerative, 6 horizontal, 5 longitudinal, 1 radial 84 flap, 10 horizontal, 27 degenerated/complex, 138 longitudinal, 23 radial, 9 healthy, 26 not classified 82 flap tear, 54 bucket-handle Not stated flap, 13 horizontal and degenerative, 20 buckethandle, 9 complex * Tear detail may not reflect total number of cases due to multiple tears in a single meniscus, or insufficient data stratification.

4 Figure 3: Study characteristics cont. Study, year Level I: Randomised controlled trials Level II: Prospective, comparative Level III: Retrospective, comparative Level IV: Case studies Study objective Mean age, years Number of cases Tear details* Mean follow-up, years % OA change/ progression Partial meniscectomy cont. Hoser, Hulet, Hulet, Jaureguito, To evaluate the long-term results of arthroscopic partial lateral meniscectomy in knees without associated damage To assess long-term functional and radiological outcomes of partial medial meniscectomies To evaluate the long-term effects of lateral meniscectomy and to identify those patients at the most risk of developing OA To review the long-term functional, clinical, and radiographic results of patients who underwent arthroscopic partial lateral meniscectomy Krüger-Franke, To assess long-term radiological and clinical outcomes following partial meniscectomy Rockborn and Gillquist, Scheller, To assess functional and radiographic outcome of arthroscopic meniscectomy (partial and subtotal) To assess clinical, functional, and radiographic long-term results of patients who underwent arthroscopic partial lateral meniscectomy in an otherwise normal knee longitudinal, 7 radial, 7 horizontal, 6 bucket-handle, 7 complex vertical, 4 complex Not stated bucket-handle, 8 horizontal, 7 flap, 1 radial 40 flap, 31 bucket-handle, 12 longitudinal, 11 horizontal, 9 radial 4 transverse, 5 longitudinalvertical, 5 horizontal cleavage, 19 bucket-handle, 11 flap 26 bucket-handle, 18 horizontal, 19 radial, 12 flap Meniscal repair Chung, Majewski, Stein, Johnson, To compare the clinical and radiologic results of partial meniscectomy with those of refixation in patients with medial meniscus posterior root tears at a minimum five-year follow-up To compare the midterm and long-term functional and radiographic outcome of meniscal suture repairs with the natural history of the uninjured knees of each of a cohort of patients To evaluate the mid- and long-term outcome of meniscal repair compared with partial meniscectomy in stable knees To assess long-term outcomes (>10 years) following isolated arthroscopic meniscal repair Not stated longitudinal longitudinal, 2 bucket-handle 33 longitudinal, 3 flap, 2 double longitudinal Pujol, To assess the long-term outcomes of meniscal repairs vertical To evaluate meniscal suturing using an inside-out Steenbrugge, technique and compare the findings with those of their previous follow-up examination Not stated * Tear detail may not reflect total number of cases due to multiple tears in a single meniscus, or insufficient data stratification.

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