Save the meniscus Mais pourquoi? #$%&' ()"*+!," Philippe Neyret E Servien S Lustig P Verdonk
One or more of the authors of the next presentation have identified no potential conflicts of interest 2
Consequences Yong Bae 2012 Med biol eng comput 3D finite model Partial meniscectomy can be considered as a better treatment than subtotal/total meniscectomy, and a high possibility of degenerative osteoarthritis is anticipated after total meniscectomy Moreover medial meniscectomy has the potential to bring about degenerative OA in both the Medial and the Lateral compartment of a knee joint. Partial M SubT M Total T M
Clinical results Pengas JBJS(br) 2012 Meniscectomy leads to symptomatic osteoarthritis of the knee later in life, with a resultant 132-fold increase in the rate of total knee replacement in comparison to their geographical and age-matched peers
Clinical results Petty Sports Med Arthros. 2012 The long-term outcome after arthroscopic partial meniscectomy in this systematic review of the literature including studies with 8 to 16 years follow-up showed that radiographic signs of OA are significant but clinical symptoms of knee OA are not significant Future research of higher level of evidence with longer term FU is required to determine whether the radiographs signs ultimately overshadow clinical symptoms after partial arthroscopic meniscectomy
Abrams AJSM July 2013 No change in population under 65y in the US population for the years 2005 to 2011 387,833 Meniscectomies 23,640 M Repairs 84,927 ACL R Significant increased number of isolated meniscal repairs performed and a doubling of the incidence of the repairs from 2005 to 2011 No significant increase of meniscectomies
Is Meniscectomy necessary? Herrlin KSSTA 2013 At 24 and 60 months this prospective (96 patients) randomized intervention study indicates that arthroscopic surgery followed by exercise therapy did not result in better patient-reported outcomes than exercise therapy alone in the treatment of non traumatic, degenerative medial meniscus tears in most middle-aged patients with no or slight osteoarthritis in the knee.
Is Meniscectomy necessary? KATZ NEJM 2013 IN THE INTENTION-TO-TREAT ANALYSIS, WE DID NOT FIND SIGNIFICANT DIFFERENCES BETWEEN THE STUDY GROUPS IN FUNCTIONAL IMPROVEMENT 6 MONTHS AFTER RANDOMIZATION; HOWEVER, 30% OF THE PATIENTS WHO WHERE ASSIGNED TO PHYSICAL THERAPY ALONE UNDERWENT SURGERY WITHIN 6 MONTHS. The US Department of Health and Human Service s physical activity guidelines http://www.health.gov/paguidelines/guidelines/default.aspx.
Meniscal repair Stein, T., Mehling, A. P., Welsch, F., Eisenhart-Rothe, von, R., & Jäger, A. (2010). Long-term outcome after arthroscopic meniscal repair versus arthroscopic partial meniscectomy for traumatic meniscal tears. The American Journal of Sports Medicine, 38(8), 1542 1548 Arthroscopic meniscal repair offers significantly improved results for isolated traumatic meniscal tears regarding the long-term follow-up in osteoarthritis prophylaxis and sports activity recovery compared with partial meniscectomy.
Meniscal roots Review article Vyas D., Harner CD, Meniscus root repair Sports Med Arthrosc 2012: 86-94 Han, S. B.. (2010). Arthroscopy Medial Meniscal posterior root tear can result in early OA Kim and al 2011 Arthroscopy There is less joint space narrowing and decreassing of the Kellgreen-Lawrence grade in the repair group of medial meiniscus root versus partial meniscectomy (about 4y FU) Shelbourne 2011 AJSM At a mean of 10 years follow-up of posterior lateral meniscus root tears left in situ, mild lateral joint-space narrowing was measured without significant differences in subjective or objective scores compared with controls
OUTCOME EVALUATION Clinical results can be evaluated according to Self-satisfaction index Functional scores :IKDC or Lysholm Rate of secondary surgery Radiological evaluation includes Standard AP monopodal support view Profile views and particularly Bipodal AP view at 45 of flexion MRI, arthro-mri and arthro-ct scan are not regularly part of standard postoperative evaluation Numerous studies have reported the results of meniscectomy. However, direct comparison between these studies remains difficult because of the diversity of the procedures performed.
Stable Knee
Studies Subjective results Follow-up Functional results Degenerative changes Neyret et al. [ 78 ] 20 years 35 % after medial meniscectomy, 12% after lateral Ramadier et al. [ 88 ] 3 to 6 months 90% good and very good results after MM, 85% after LM Rangger et al. [ 89 ] 53 months 38% after MM, 25% after LM Northmore-Ball et al. [ 82 ] 4.3 years 88% satisfied after MM, 95% after LM Bonneux et al. [ 15 ] 48% good and very good after LM 8.2 years 39% after LM Hoser et al. [ 42 ] 10.3 years 58% good and very good results after LM 39% of arthritis after LM SFA [ 21 ] 90 % feel normal after MM, 86% after LM 11 years 86% free of symptom after MM, 80% after LM 22% after MM, 38% after LM Higuchi et al. [ 41 ] 12 years 84% satisfied after MM, 73% after LM 60% after MM, 33% after LM Grana et al. [ 38 ] 90% very satisfied after MM, 85% after 7 months STABLE KNEES LM Allen et al. [ 5 ] 17 years Higher rate after LM
Subjective Results VS* S D Dissati. MM 75% 21% 4% 1% LM 58% 36% 6% 4% Chatain F,, Neyret P, Société Française Arthroscopie (2003) A comparative study of medial versus lateral arthroscopic partial meniscectomy on stable knees: 10-year minimum follow-up. Arthroscopy
Medial vs Lateral Moreover, higher reoperation rates (about twice as much) have been reported after lateral meniscectomy comparing to medial (further arthroscopies, osteotomies or arthroplasties). Bonneux I (2002) Acta Orthop Belg. Chatain F (2003) Arthroscopy Rockborn P (1995) Acta Orthop Scand.
Radiological Results The difference of prevalence of radiological degenerative changes in comparison with the opposite knee was: 31-9 = 22% 42-4 = 38% MM LM
Prognostic Factors Age at operation Chondral lesions at operation Width of Meniscectomy Chondral lesions at operation MM LM
Radiological Results @ 20Y 2008 A B C D C+D LM 25% 19% 30% 26% 56% Opp. K 72% 16% 9% 3% 12% 56% OA prevalence 56-12 = 44% n = 89
Radiological Results A B C D C+D LM 32% 15% 30% 23% 53% Healthy Opp K 100% OA incidence 30 +23 =53% n = 47
Results 22 y after a lateral meniscectomy, what should we expect? 40 % no pain no OA 27 % no pain but OA 3 % with pain no OA 67% no Pain 43% no OA 30 % pain OA n = 89
Prognostic Factors The influence of lower limb axial alignment is still matter of debate. More directed studies should be done before further considerations regarding this matter. Chatain F SFA (2003) Arthroscopy Neyret Ph (1993) Am J Sports Med.
Traumatic vs Degenerative According to the literature analysis, resection of traumatic longitudinal tears is supposed to provide better results than complex degenerative tears. Englund M (2004) Arthritis Rheum. Osti L (1994) Arthroscopy Matsusue Y (1996) Arthroscopy Saragaglia D (1992) Rev Chir Orthop
Traumatic vs Degenerative Cartilage damage is the strongest predictor of worse functional results. The presence of cartilage lesions particularly those affecting the patella influenced negatively the final outcome. Meredith DS (2005) Arthroscopy Ramadier JO, Beaufils P (1983) Rev Chir Orthop Bonamo JJ (1992) Am J Sports Med
Ciccotti. Arthroscopy 2012 This study shows a high prevalence of articular damage as defined by the Outerbridge classification in patients undergoing arthroscopic surgery for meniscal pathology. Risk factors that correlate with articular cartilage include increasing age, elevated BMI, medial compartment pathology, and knee contractures (evidence Level 4). 1010 patients 2005-2009 Med. FT 48% Lat. FT 25% PF 45% > 60y 86% 50-59y 85% 20-29 32% < 20Y 13%
Conclusions The long term outcome doesn t seem to be influenced by the arthroscopic technique. Clinical and radiological outcomes were better after MM than after LM Meniscal Accident vs Meniscal Desease
Unstable Knee
Meniscectomy in ACL deficient Knee Meniscectomy in ACL reconstructed knee
Isolated Meniscectomy Radiological results At radiological evaluation, meniscectomy over an unstable knee predisposes to arthritic evolution. This osteoarthritis has some characteristics such as hooked tibial spines, osteophytes of the intercondylar notch and the tibia remains fixed in anterior translation with a postero-medial cupula. Ait Si Selmi T (2006). Knee Bolano LE (1993) Am J Sports Med Dejour H, (1999). Rev Chir Orthop
Meniscectomy in ACL deficient knee Neyret P., Donell S. and al J.B.J.S. (Br), 1993 Follow-up Degenerative changes 20-24 years 61% pre OA - OA 25-29 years 71% pre OA - OA 30-34 years 86% pre OA - OA Neyret P. Rev. Chir. Orthop., 1988
Meniscectomy in ACL deficient Knee Meniscectomy in ACL reconstructed knee
Radiological results at 24y The series 1978-1983 : 423 ACL Reconstructions Follow-up : 251 in 1986 (mean FU : 4y) 148 in 1992 (mean FU : 11.5y) 103 in 1999 (mean FU : 17y) 125 in 2006 (mean FU :24.5y) 100 radiological FU AJSM 2010
Radiological outcome TF joint
Known medial OA risk factors Cartilage lesions (x5) Medial meniscectomy (x3) Shelbourne KD, Gray T. Results of ACL reconstruction based on meniscus and articular cartilage status at the time of surgery. Am J Sports Med 2000. Factors affecting results : 1- Articular cartilage damage 2- partial/total medial meniscectomy
Meniscus & ACL status. Subtotal MM / unstable knee : 90 % OA and 10 % pre-oa 26.5 y Neyret P, Walch G, Dejour H. La meniscectomie interne intra murale selon la technique de A. Trillat. Resultats a long terme de 258 interventions. Rev Chir Orthop 1988. Subtotal MM / stabilized knee : 42 % OA and 27 % pre-oa 24.5 y Normal meniscus / stabilized knee : 12 % OA and 24 % pre-oa 24.5 y
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