Save the meniscus Mais pourquoi?

Philippe Neyret

E Servien

S Lustig

P Verdonk#$%&' ( )"*+! , "

2

One or more of the authors of the next presentation have identified no potential conflicts of interest

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

Consequences

PengasJBJS(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

PettySports 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

Clinical results

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

HerrlinKSSTA 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?

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.

• 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 repair

Review articleVyas D., Harner CD,

Meniscus root repair Sports Med Arthrosc 2012: 86-94

• Han, S. B.. (2010). ArthroscopyMedial Meniscal posterior root tear can result in early OA

• Kim and al 2011 ArthroscopyThere 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 AJSMAt 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 ”

Meniscal roots

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 years35 % after medial meniscectomy, 12%

after lateral

Ramadier et al. [88] 3 to 6 months90% 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 LM8.2 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 years86% free of symptom after MM, 80%

after LM22% 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

LM

7 months

Allen et al. [5] 17 years Higher rate after LM

STABLE KNEES

VS* S D Dissati.

MM 75% 21% 4% 1%

LM 58% 36% 6% 4%

Subjective Results

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

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

.

Medial vs Lateral

31 - 9 = 22% 42 - 4 = 38%

Radiological Results

• The difference of prevalence of radiological degenerative changes in comparison with the opposite knee was:

MM LM

• Age at operation

• Chondral lesions at operation

• Width of Meniscectomy

MM

• Chondral lesions at operation

Prognostic Factors

LM

n = 89

OA prevalence

56 -12 = 44%

A B C D C+D

LM 25% 19% 30% 26% 56%

Opp. K 72% 16% 9% 3% 12%

56%

Radiological Results@ 20Y 2008

n = 47

A B C D C+D

LM 32% 15% 30% 23% 53%HealthyOpp K 100%

30 +23 =53%

Radiological Results

OA incidence

n = 89

22 y after a lateral meniscectomy, what shouldwe expect ?

67% no Pain• 40 % no pain no OA

• 27 % no pain but OA

• 3 % with pain no OA

• 30 % pain § OA

Results

43% no OA

• 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.

Prognostic Factors

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%

• 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 “MeniscalDesease”

Conclusions

Unstable Knee

Meniscectomy in ACL deficient Knee

Meniscectomy in ACL reconstructed knee

Isolated Meniscectomy

• 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

Radiological results

Neyret P., Donell S. and al J.B.J.S. (Br), 1993

Neyret P. Rev. Chir. Orthop., 1988

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

Meniscectomy in ACL deficient knee

Meniscectomy in ACL deficient Knee

Meniscectomy in ACL reconstructed knee

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

Radiological results at 24y

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 damage2- partial/total medial meniscectomy

Subtotal MM / unstable knee :– 90 % OA and 10 % pre-OA

24.5 y

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.

Meniscus ＆ ACL status.

Subtotal MM / stabilized knee :– 42 % OA and 27 % pre-OA

Normal meniscus / stabilized knee :– 12 % OA and 24 % pre-OA

24.5 y

Thank You