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Editorial Commentary: Meniscal Repair, When Possible, Is Better for Patients Than Meniscectomy

      Abstract

      Patients do not do as well after meniscectomy as after repair. Although saving the meniscus is not always easy and the success rate of repair is not 100%, repair—when possible—remains the best option for patients in the long run. Meniscal repair rates are on the rise, especially in younger patients, but are not high enough. Recent research has shown that more than 95% of meniscal procedures are partial meniscectomies. Improved surgical techniques and instrumentation, as well as a continued increase in understanding the importance of repair, are leading to an increase in meniscal repair rates. Preserve as much meniscus as possible and as often as possible.
      I read with great interest the work by Bradley, Cevallos, Jansson, Lansdown, Pandya, Feeley, Ma, and Zhang
      • Bradley K.
      • Cevallos N.
      • Jansson H.
      • et al.
      Younger patients are more likely to undergo arthroscopic meniscal repair and revision meniscal surgery in a large cross-sectional cohort.
      entitled “Younger Patients Are More Likely to Undergo Arthroscopic Meniscal Repair and Revision Meniscal Surgery in a Large Cross-Sectional Cohort.” The authors used PearlDiver, a large publicly available healthcare records database, to add to the discussion on one of the hottest topics in sports medicine: treatment of meniscal tears. Specifically, they sought to determine trends in meniscal repair from 2010 to 2017, as well as the subsequent risk of revision surgery within 2 years postoperatively. The results were what I would expect but only to a degree. Meniscal repair rates are on the rise; however, they may still not be high enough based on this study. I was somewhat surprised to find that meniscal debridement was the procedure of choice 96.6% of the time in this study. There was a significant but slight rise in the rate of repair from 2.7% to 4.4% over the study period. I was, however, somewhat relieved to read that in the youngest patients, aged 10 to 19 years, repair was performed 23% of the time. Repair, however, was no free lunch, and the database showed a 10.6% rate of revision surgery in the 2-year period after repair.
      Meniscal repair seems to be one of the hottest and most spoken about topics in sports medicine these days. It is hard to attend a webinar or go to a course and avoid discussions about meniscal repair—and for good reason. Improved surgical techniques and instrumentation, as well as an increase in the literature, are leading to an increase in meniscal repair across the board. A very similar study to the one at hand was performed by Abrams et al.
      • Abrams G.D.
      • Frank R.M.
      • Gupta A.K.
      • Harris J.D.
      • McCormick F.M.
      • Cole B.J.
      Trends in meniscus repair and meniscectomy in the United States, 2005-2011.
      Using the same PearlDiver database, this study also found an increase in the total number of meniscal repairs from 2007 to 2011.
      • Bradley K.
      • Cevallos N.
      • Jansson H.
      • et al.
      Younger patients are more likely to undergo arthroscopic meniscal repair and revision meniscal surgery in a large cross-sectional cohort.
      Moreover, DeFroda et al.
      • DeFroda S.F.
      • Yang D.S.
      • Donnelly J.C.
      • Bokshan S.L.
      • Owens B.D.
      • Daniels A.H.
      Trends in the surgical treatment of meniscal tears in patients with and without concurrent anterior cruciate ligament tears.
      used the PearlDiver database to look at meniscal repair trends in the setting of isolated injury and concomitant anterior cruciate ligament reconstruction (ACLR). The findings were similar to those of Bradley et al.
      • Bradley K.
      • Cevallos N.
      • Jansson H.
      • et al.
      Younger patients are more likely to undergo arthroscopic meniscal repair and revision meniscal surgery in a large cross-sectional cohort.
      From 2010 to 2015, there was a decrease in the rate of isolated meniscectomy.
      • DeFroda S.F.
      • Yang D.S.
      • Donnelly J.C.
      • Bokshan S.L.
      • Owens B.D.
      • Daniels A.H.
      Trends in the surgical treatment of meniscal tears in patients with and without concurrent anterior cruciate ligament tears.
      Similarly, the largest proportion of isolated meniscal repair was observed in the younger patient cohort, with 15- to 19-year-old patients representing 37.4% of all repairs. A similar failure rate was identified in this study as well; 12.4% of isolated meniscal repairs underwent subsequent meniscectomy. This rate decreased to 10.8% when repair was performed in the setting of ACLR.
      • DeFroda S.F.
      • Yang D.S.
      • Donnelly J.C.
      • Bokshan S.L.
      • Owens B.D.
      • Daniels A.H.
      Trends in the surgical treatment of meniscal tears in patients with and without concurrent anterior cruciate ligament tears.
      But is a failure rate of 10% really representative of the patient population we will treat, and what about our high-level patients? Logan et al.
      • Logan M.
      • Watts M.
      • Owen J.
      • Myers P.
      Meniscal repair in the elite athlete: Results of 45 repairs with a minimum 5-year follow-up.
      reported the 5-year outcomes of 42 elite-level athletes who underwent meniscal repair, and although they found an 81% return-to-play rate, they observed a 24% rate of repair failure, with 11% being atraumatic in nature, that is, not related to a new injury. A recent meta-analysis by Schweizer et al.
      • Schweizer C.
      • Hanreich C.
      • Tscholl P.M.
      • et al.
      Nineteen percent of meniscus repairs are being revised and failures frequently occur after the second postoperative year: A systematic review and meta-analysis with a minimum follow-up of 5 years.
      examined studies performed in the past 20 years with at least 5 years’ follow-up. Twelve studies consisting of 864 patients were included, and the authors found an overall failure rate of 19.1%, with no statistically significant difference in repair with versus without ACLR (18.7% failure rate for repair with ACLR vs 28% for isolated repair). In addition, there was no difference in the failure rate for medial (24.4%) versus lateral (19.5%) repair.
      • Schweizer C.
      • Hanreich C.
      • Tscholl P.M.
      • et al.
      Nineteen percent of meniscus repairs are being revised and failures frequently occur after the second postoperative year: A systematic review and meta-analysis with a minimum follow-up of 5 years.
      This was also a rare study that looked at tear type; no significant difference in the failure rate was found between longitudinal and bucket-handle tears. This review did, however, find a significantly higher failure rate for all-inside repair versus inside-out repair (22.3% vs 5.6%). So, while we continue to add to the literature and we continue to push the envelope regarding indicating patients for repair (rightfully so), repair is no free lunch and the failure rate can be as high as 10% to 30%.
      • Abrams G.D.
      • Frank R.M.
      • Gupta A.K.
      • Harris J.D.
      • McCormick F.M.
      • Cole B.J.
      Trends in meniscus repair and meniscectomy in the United States, 2005-2011.
      • DeFroda S.F.
      • Yang D.S.
      • Donnelly J.C.
      • Bokshan S.L.
      • Owens B.D.
      • Daniels A.H.
      Trends in the surgical treatment of meniscal tears in patients with and without concurrent anterior cruciate ligament tears.
      • Logan M.
      • Watts M.
      • Owen J.
      • Myers P.
      Meniscal repair in the elite athlete: Results of 45 repairs with a minimum 5-year follow-up.
      • Schweizer C.
      • Hanreich C.
      • Tscholl P.M.
      • et al.
      Nineteen percent of meniscus repairs are being revised and failures frequently occur after the second postoperative year: A systematic review and meta-analysis with a minimum follow-up of 5 years.
      So why not just cut out the meniscal tear as in 96% of the cases in the present study? Ever since the seminal 1982 publication by Arnoczky and Warren
      • Arnoczky S.P.
      • Warren R.F.
      Microvasculature of the human meniscus.
      with the iconic image of the perimeniscal capillary plexus, we have all been taught one basic, almost dogmatic, tenet: “The meniscus doesn’t heal.” This landmark study using 20 cadavers identified that this plexus supplies blood supply to the meniscus but that only the peripheral 10% to 25% of the meniscus receives this blood supply.
      • Arnoczky S.P.
      • Warren R.F.
      Microvasculature of the human meniscus.
      So if the meniscus “won’t” heal, let’s just remove the tear. It may not be that simple. If a patient has a fracture, we do not just throw out the comminuted “non-reconstructible” pieces, so why do we treat the meniscus in this manner? The jury is no longer out, plain and simple: Patients do not do as well after meniscectomy when compared with repair. Englund et al.
      • Englund M.
      • Roos E.M.
      • Roos H.P.
      • Lohmander L.S.
      Patient-relevant outcomes fourteen years after meniscectomy: Influence of type of meniscal tear and size of resection.
      reported 14-year follow-up for 205 patients who underwent meniscectomy from 1983 to 1985. Although this study no longer reflects some of our current treatment modalities (143 patients underwent an open procedure), this article does give some early clues to the importance of the meniscus in the functional health of the knee. The authors reported that traumatic tears fare better than degenerative tears and observed that patients who underwent partial meniscectomy compared with a subtotal procedure did better long term.
      • Englund M.
      • Roos E.M.
      • Roos H.P.
      • Lohmander L.S.
      Patient-relevant outcomes fourteen years after meniscectomy: Influence of type of meniscal tear and size of resection.
      The moral of the story: preserve as much meniscus as possible. Fabricant and Jokl
      • Fabricant P.D.
      • Jokl P.
      Surgical outcomes after arthroscopic partial meniscectomy.
      published a review on surgical outcomes after arthroscopic partial meniscectomy, and as can be expected, a variety of factors affect outcomes. Patients with peripheral flap tears, that is, tears with a worse blood supply, took longer to return to sport and required more revision surgical procedures than those with bucket-handle tears.
      • Fabricant P.D.
      • Jokl P.
      Surgical outcomes after arthroscopic partial meniscectomy.
      Regarding osteoarthritis, progression was greater in patients who underwent medial meniscectomy among those aged older than 40 years. Radiographic progression was worse after medial meniscectomy for patients with varus knees compared with valgus knees. Finally, the Outerbridge score at the time of surgery correlated with worse patient-reported outcomes at 12 years after surgery.
      • Fabricant P.D.
      • Jokl P.
      Surgical outcomes after arthroscopic partial meniscectomy.
      Head-to-head studies favor repair also. Stein et al.
      • Stein T.
      • Mehling A.P.
      • Welsch F.
      • von Eisenhart-Rothe R.
      • Jäger A.
      Long-term outcome after arthroscopic meniscal repair versus arthroscopic partial meniscectomy for traumatic meniscal tears.
      reported outcomes for 81 patients with traumatic medial meniscal tears (42 who underwent meniscectomy and 39 who underwent repair). The authors had a long-term outcome period of 8.8 years and found that repair slowed arthritis progression; 80% of repair patients had no detectable arthritis compared with 40% after meniscectomy. The preinjury level was reached by 96% of repair patients versus only 50% of meniscectomy patients.
      • Stein T.
      • Mehling A.P.
      • Welsch F.
      • von Eisenhart-Rothe R.
      • Jäger A.
      Long-term outcome after arthroscopic meniscal repair versus arthroscopic partial meniscectomy for traumatic meniscal tears.
      Clearly, the treatment of meniscal tears is complex, with many variables in play. The challenge remains identifying proper patients in whom to attempt repair, and which patients will do well with this treatment.
      The current study by Bradley et al.
      • Bradley K.
      • Cevallos N.
      • Jansson H.
      • et al.
      Younger patients are more likely to undergo arthroscopic meniscal repair and revision meniscal surgery in a large cross-sectional cohort.
      is timely because it not only reinforces a positive trend in favor of repairing tears, especially in the younger patient, but also lends some insight as to the 2-year reoperation rate. For me, as someone who has recently completed fellowship training, it is easy to be excited about meniscal repair and pushing the limits of repair, especially after working with leaders in the field and having the honor and privilege to attend countless courses in person and via video conferencing demonstrating the latest techniques for even the most severe tear patterns. One thing some of my more experienced mentors, though, would remind me in the operating room and the clinic is that repair is not a guarantee of healing. The study by Bradley et al. confirms this with a large data set, finding a 10% reoperation rate within 2 years. This should be included in the conversation regarding repair versus debridement. My current treatment algorithm is modeled somewhat after the findings of the aforementioned studies. The younger the patient, the more aggressive I will be with the repair, even in cases with the most complex tear patterns. Similarly, I tend to be aggressive with root tears in functional patients, as the long-term consequences of these tears have been well documented.
      • LaPrade R.F.
      • Floyd E.R.
      • Carlson G.B.
      • et al.
      Meniscal root tears: Solving the silent epidemic.
      ,
      • Stein J.M.
      • Yayac M.
      • Conte E.J.
      • Hornstein J.
      Treatment outcomes of meniscal root tears: A systematic review.
      At the same time, I believe in the importance of explaining to a patient the difference between a meniscal repair and a simple cleanup that the patient’s favorite athlete may have undergone, allowing the athlete to return in a few weeks for the playoffs. It is also important to disclose that failure is possible, which could result in subsequent surgery. In the worst-case scenario, we can always perform debridement later, but more of these tears may heal with repair than originally thought.
      • Dai W.
      • Leng X.
      • Wang J.
      • Hu X.
      • Ao Y.
      Second-look arthroscopic evaluation of healing rates after arthroscopic repair of meniscal tears: A systematic review and meta-analysis.
      ,
      • Barber-Westin S.D.
      • Noyes F.R.
      Clinical healing rates of meniscus repairs of tears in the central-third (red-white) zone.
      The decision for repair versus meniscectomy will always be a challenging one, but clearly, the paradigm is shifting, albeit slowly.
      Despite the current literature, including this great addition to our armamentarium advising to save the meniscus by Bradley et al.,
      • Bradley K.
      • Cevallos N.
      • Jansson H.
      • et al.
      Younger patients are more likely to undergo arthroscopic meniscal repair and revision meniscal surgery in a large cross-sectional cohort.
      their study does have inherent limitations often found with most big data publications. First, these data do not allow for the capture of patient-reported outcomes. Revision surgery was used as a surrogate, but we also do not know how well patients who did not require additional surgery fared. Moreover, as the authors point out, these types of studies can be limited by coding accuracy and coding errors. Additionally, tear type, chronicity, repair type, and rehabilitation protocol cannot be specified, making it difficult to apply these findings on a more granular level. I commend the authors, however, for identifying an important trend—and one that I hope will continue regarding an increase in meniscal repair. When additional studies are performed in the not-so-distant future, we hope to see not only a continuation of this trend but also a significant shift in the proportion of repair to debridement as we continue to improve surgically and with our indications for repair. Although saving the meniscus is not always easy, when possible, it is the best options for our patients in the long run.

      Supplementary Data

      References

        • Bradley K.
        • Cevallos N.
        • Jansson H.
        • et al.
        Younger patients are more likely to undergo arthroscopic meniscal repair and revision meniscal surgery in a large cross-sectional cohort.
        Arthroscopy. 2022; 38: 2875-2883
        • Abrams G.D.
        • Frank R.M.
        • Gupta A.K.
        • Harris J.D.
        • McCormick F.M.
        • Cole B.J.
        Trends in meniscus repair and meniscectomy in the United States, 2005-2011.
        Am J Sports Med. 2013; 41: 2333-2339
        • DeFroda S.F.
        • Yang D.S.
        • Donnelly J.C.
        • Bokshan S.L.
        • Owens B.D.
        • Daniels A.H.
        Trends in the surgical treatment of meniscal tears in patients with and without concurrent anterior cruciate ligament tears.
        Phys Sportsmed. 2020; 48: 229-235
        • Logan M.
        • Watts M.
        • Owen J.
        • Myers P.
        Meniscal repair in the elite athlete: Results of 45 repairs with a minimum 5-year follow-up.
        Am J Sports Med. 2009; 37: 1131-1134
        • Schweizer C.
        • Hanreich C.
        • Tscholl P.M.
        • et al.
        Nineteen percent of meniscus repairs are being revised and failures frequently occur after the second postoperative year: A systematic review and meta-analysis with a minimum follow-up of 5 years.
        Knee Surg Sports Traumatol Arthrosc. 2021; 30: 2267-2276
        • Arnoczky S.P.
        • Warren R.F.
        Microvasculature of the human meniscus.
        Am J Sports Med. 1982; 10: 90-95
        • Englund M.
        • Roos E.M.
        • Roos H.P.
        • Lohmander L.S.
        Patient-relevant outcomes fourteen years after meniscectomy: Influence of type of meniscal tear and size of resection.
        Rheumatology. 2001; 40: 631-639
        • Fabricant P.D.
        • Jokl P.
        Surgical outcomes after arthroscopic partial meniscectomy.
        J Am Acad Orthop Surg. 2007; 15: 647-653
        • Stein T.
        • Mehling A.P.
        • Welsch F.
        • von Eisenhart-Rothe R.
        • Jäger A.
        Long-term outcome after arthroscopic meniscal repair versus arthroscopic partial meniscectomy for traumatic meniscal tears.
        Am J Sports Med. 2010; 38: 1542-1548
        • LaPrade R.F.
        • Floyd E.R.
        • Carlson G.B.
        • et al.
        Meniscal root tears: Solving the silent epidemic.
        J Arthrosc Surg Sports Med. 2021; 2: 47-57
        • Stein J.M.
        • Yayac M.
        • Conte E.J.
        • Hornstein J.
        Treatment outcomes of meniscal root tears: A systematic review.
        Arthrosc Sports Med Rehabil. 2020; 2: e251
        • Dai W.
        • Leng X.
        • Wang J.
        • Hu X.
        • Ao Y.
        Second-look arthroscopic evaluation of healing rates after arthroscopic repair of meniscal tears: A systematic review and meta-analysis.
        Orthop J Sports Med. 2021; 923259671211038289
        • Barber-Westin S.D.
        • Noyes F.R.
        Clinical healing rates of meniscus repairs of tears in the central-third (red-white) zone.
        Arthroscopy. 2014; 30: 134-146