Guest CommentaryFrom OT Europe

Controversy continues about the treatment of meniscus tears

One of the most interesting discussions in the last decade within orthopaedics is the controversy regarding conservative or surgical treatment of meniscal tears, which is also one of the most common procedures in orthopaedics. The conclusions that were made after level 1 studies about treatment of meniscal tears, especially among health authorities, sought to ban arthroscopic surgery for degenerative meniscus lesions. The pendulum in the management of degenerative meniscus lesions moved from eminence-based arthroscopy surgery to evidence-based conservative treatment. Have we made the correct move? The question more accurately is, “Can we solely rely on the results of level 1 studies when it comes to our clinical practice?”

Roland Becker, MD
Roland Becker

Take the excellent study by Jeffrey N. Katz, MD, MSc, and colleagues published in the New England Journal of Medicine in 2013. The authors selected 351 patients from among 14,430 patients on which to perform a highly scientific study. Such patient selection is impossible in our daily practice. Studies like this one show the complexity with which we are dealing when it comes to meniscal tears and the results from level 1 studies alone are not the key to the entire solution for managing this condition. The findings have to be seen in a wider context.

Consensus for acute and chronic tears

The European Society of Sports Traumatology and Arthroscopy developed consensus about the management of acute and chronic meniscus tears and finished this project at the end of 2019. Meniscus pathologies have to be treated in a more differentiated way. Acute meniscus tears, often in conjunction with ligament or cartilage injury, should be surgically treated. In contrast, a degenerative meniscus lesion, which is caused by repetitive small trauma, should be treated conservatively first. Especially when pain is the patient’s major symptom, the pain may be due to the osteoarthritic changes within the knee and not due to the meniscus lesion. The duration of conservative treatment will depend upon the duration and type of symptoms. In instances when the knee locks, arthroscopy should be considered, even in knees with stage 2 osteoarthritis according to Kellgren and Lawrence. There are still some indications for arthroscopy in knees with mild degeneration. General agreement was given by the ESSKA consensus about the management of meniscus lesions in knees presenting with grade 3 and 4 OA. For example, the consensus noted arthroscopy will not be of help in these patients and an immediate, diagnostic MRI is also unnecessary in these patients. Weight-bearing radiographs, such as those that use the Rosenberg or Schuss view, are the most sensitive radiographs for joint space assessment.

Repair traumatic tears

In contrast to what is done for the degenerative lesion, the acute and symptomatic meniscus tears caused by an adequate trauma should be repaired. An acute meniscus tear often occurs in conjunction with ligament and cartilage injuries. Early MRI is recommended in patients with these types of tears to assess the type, size and location of the meniscus tear and the concomitant pathologies, and it is necessary for proper surgical planning.

More recently, the management of root tears and ramp lesions have been the subject of focus. Lateral meniscal root tears at the posterior horn occur frequently in conjunction with ACL injuries. However, medial meniscus root tears occur more often in knees in association with some degree of degeneration. There is general consensus that lateral root tears should be fixed to the bone, but the best way to manage medial root tears remains controversial. Recent studies have shown that even repair of the medial root tear can produce successful clinical results. However, meniscus extrusion was not reduced and the prevention of OA remains questionable. There is still room for further research.

All of the controversies have caused interesting discussion about and more research into the management of meniscal tears. The two consensus papers — one about the chronic meniscus lesion and the other about the acute meniscus tears — are published and provide some recommendations regarding the treatment of patients with a torn meniscus based on the highest level of evidence combined with the clinical experience of about 80 experts throughout Europe. These papers currently provide the best recommendations for the management of meniscus tears in our daily practice.

Disclosure: Becker reports no relevant financial disclosures.

One of the most interesting discussions in the last decade within orthopaedics is the controversy regarding conservative or surgical treatment of meniscal tears, which is also one of the most common procedures in orthopaedics. The conclusions that were made after level 1 studies about treatment of meniscal tears, especially among health authorities, sought to ban arthroscopic surgery for degenerative meniscus lesions. The pendulum in the management of degenerative meniscus lesions moved from eminence-based arthroscopy surgery to evidence-based conservative treatment. Have we made the correct move? The question more accurately is, “Can we solely rely on the results of level 1 studies when it comes to our clinical practice?”

Roland Becker, MD
Roland Becker

Take the excellent study by Jeffrey N. Katz, MD, MSc, and colleagues published in the New England Journal of Medicine in 2013. The authors selected 351 patients from among 14,430 patients on which to perform a highly scientific study. Such patient selection is impossible in our daily practice. Studies like this one show the complexity with which we are dealing when it comes to meniscal tears and the results from level 1 studies alone are not the key to the entire solution for managing this condition. The findings have to be seen in a wider context.

Consensus for acute and chronic tears

The European Society of Sports Traumatology and Arthroscopy developed consensus about the management of acute and chronic meniscus tears and finished this project at the end of 2019. Meniscus pathologies have to be treated in a more differentiated way. Acute meniscus tears, often in conjunction with ligament or cartilage injury, should be surgically treated. In contrast, a degenerative meniscus lesion, which is caused by repetitive small trauma, should be treated conservatively first. Especially when pain is the patient’s major symptom, the pain may be due to the osteoarthritic changes within the knee and not due to the meniscus lesion. The duration of conservative treatment will depend upon the duration and type of symptoms. In instances when the knee locks, arthroscopy should be considered, even in knees with stage 2 osteoarthritis according to Kellgren and Lawrence. There are still some indications for arthroscopy in knees with mild degeneration. General agreement was given by the ESSKA consensus about the management of meniscus lesions in knees presenting with grade 3 and 4 OA. For example, the consensus noted arthroscopy will not be of help in these patients and an immediate, diagnostic MRI is also unnecessary in these patients. Weight-bearing radiographs, such as those that use the Rosenberg or Schuss view, are the most sensitive radiographs for joint space assessment.

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Repair traumatic tears

In contrast to what is done for the degenerative lesion, the acute and symptomatic meniscus tears caused by an adequate trauma should be repaired. An acute meniscus tear often occurs in conjunction with ligament and cartilage injuries. Early MRI is recommended in patients with these types of tears to assess the type, size and location of the meniscus tear and the concomitant pathologies, and it is necessary for proper surgical planning.

More recently, the management of root tears and ramp lesions have been the subject of focus. Lateral meniscal root tears at the posterior horn occur frequently in conjunction with ACL injuries. However, medial meniscus root tears occur more often in knees in association with some degree of degeneration. There is general consensus that lateral root tears should be fixed to the bone, but the best way to manage medial root tears remains controversial. Recent studies have shown that even repair of the medial root tear can produce successful clinical results. However, meniscus extrusion was not reduced and the prevention of OA remains questionable. There is still room for further research.

All of the controversies have caused interesting discussion about and more research into the management of meniscal tears. The two consensus papers — one about the chronic meniscus lesion and the other about the acute meniscus tears — are published and provide some recommendations regarding the treatment of patients with a torn meniscus based on the highest level of evidence combined with the clinical experience of about 80 experts throughout Europe. These papers currently provide the best recommendations for the management of meniscus tears in our daily practice.

Disclosure: Becker reports no relevant financial disclosures.