Outcomes and Patient Satisfaction

With Arthroscopic Partial Meniscectomy

for Degenerative and Traumatic Tears
in Middle-Aged Patients With No or Mild
Osteoarthritis
Alejandro Lizaur-Utrilla,*yz PhD, MD, Francisco A. Miralles-Muñoz,y PhD, MD,
Santiago Gonzalez-Parreño,y PhD, MD, and Fernando A. Lopez-Prats,z PhD, MD
Investigation performed at Elda University Hospital, Elda, Spain

Background: There is controversy about the benefit of arthroscopic partial meniscectomy (APM) for degenerative lesions in
middle-aged patients.
Purpose: To compare satisfaction with APM between middle-aged patients with no or mild knee osteoarthritis (OA) and a degen-
erative meniscal tear and those with a traumatic tear.
Study Design: Cohort study; Level of evidence, 2.
Methods: A comparative prospective study at 5 years of middle-aged patients (45-60 years old) with no or mild OA undergoing
APM for degenerative (n = 115) or traumatic (n = 143) tears was conducted. Patient satisfaction was measured by a 5-point Likert
scale and functional outcomes by the Knee injury and Osteoarthritis Outcome Score (KOOS) and Western Ontario and McMaster
Universities Osteoarthritis Index (WOMAC). Univariate and multivariate regression analyses were used to identify factors correlat-
ing with patient-reported satisfaction at 5 years postoperatively.
Results: Baseline patient characteristics were not different between groups. At the 5-year evaluation, the satisfaction rate in the
traumatic and degenerative groups was 68.5% versus 71.3%, respectively (P = .365). Patient satisfaction was significantly asso-
ciated with functional outcomes (r = 0.69; P = .024). In the degenerative group, 43 patients (37.4%) had OA progression to
Kellgren-Lawrence (K-L) grade 2 or 3, but only 24 patients (20.8%) had a symptomatic knee at final follow-up. Multivariate regres-
sion analysis for patient dissatisfaction at 5-year follow-up showed the following significant independent factors: female sex (odds
ratio [OR], 1.6 [95% CI, 1.1-2.3]; P = .018), body mass index .30 kg/m2 (OR, 2.6 [95% CI, 1.7-4.9]; P = .035), lateral meniscal
tears (OR, 0.6 [95% CI, 0.1-0.9]; P = .039), and OA progression to K-L grade 2 at final follow-up (OR, 1.4 [95% CI, 1.2-2.6];
P = .014). At the final evaluation, there were no significant differences between groups in pain scores (P = .648), WOMAC scores
(P = .083), or KOOS-4 scores (P = .187). Likewise, there were no significant differences in the KOOS subscores for Pain (P = .144),
Symptoms (P = .097), or Sports/Recreation (P = .150). Although the degenerative group had significantly higher subscores for
Activities of Daily Living (P = .001) and Quality of Life (P = .004), the differences were considered not clinically meaningful.
Conclusion: There were no meaningful differences in patient satisfaction or clinical outcomes between patients with traumatic and
degenerative tears and no or mild OA. Predictors of dissatisfaction with APM were female sex, obesity, and lateral meniscal tears.
Our findings suggested that APM was an effective medium-term option to relieve pain and recover function in middle-aged patients
with degenerative meniscal tears, without obvious OA, and with failed prior physical therapy.
Keywords: degenerative meniscus; osteoarthritis; partial meniscectomy; middle aged; satisfaction

Among adults over 50 years old, the prevalence of traumatic as traumatic or degenerative lesions and either may exhibit
meniscal tears ranges from 23% to 32% and degenerative different tear patterns. Traumatic meniscal tears usually
tears from 60% to 63%.8 Meniscal tears are mainly classified occur in younger active patients and can be attributed to
a specific event such as sports-related trauma. Degenerative
meniscal tears usually occur in middle-aged or older
patients without any history of significant acute trauma.
The American Journal of Sports Medicine
Degenerative tears are usually classified as radial tears of
1–8
DOI: 10.1177/0363546519857589 the middle third, posterior root tears, horizontal tears of
Ó 2019 The Author(s) the posterior third, flap tears, or complex tears.15

1
2 Lizaur-Utrilla et al The American Journal of Sports Medicine

Currently accepted indications for surgery are trau- overall satisfaction after APM, but only 1 of them used
matic tears with a clear history of mechanical symptoms, a validated instrument,32 and the follow-up was 1 year.
such as locking and catching, with joint-line pain and/or We hypothesized that patient satisfaction and clinical ben-
acute onset of symptoms that have failed nonsurgical efits in the medium term after APM would be similar
treatment.2 However, the treatment of degenerative between middle-aged patients with traumatic lesions and
meniscal tears in middle-aged patients is currently contro- those with degenerative lesions, with no or mild OA, who
versial. Several authors have suggested that a degenera- did not respond to prior physical therapy.
tive meniscal lesion may be an early sign of knee The main objective of this study was to assess patient
osteoarthritis (OA) rather than a separate clinical problem satisfaction after APM for degenerative meniscal tears as
requiring a meniscal intervention.8 Previous studies have compared with traumatic tears in middle-aged patients
reported that partial meniscectomy had little benefit in with no or mild knee OA after a follow-up of 5 years. The
patients with advanced OA20 but some benefit in those secondary objective was to identify the factors that deter-
with mild to moderate OA.16 Comparing arthroscopic par- mine favorable or unfavorable satisfaction with APM for
tial meniscectomy (APM) and exercise therapy for degener- degenerative meniscal tears.
ative lesions in middle-aged patients, some high-quality
studies have reported substantial improvement with both
procedures but no clinically meaningful differences.12,21
However, those studies included patients with moderate METHODS
knee OA (Kellgren-Lawrence17 [K-L] grade 2-3), and the
follow-ups were between 6 and 24 months. For patients A comparative prospective cohort study was designed to
with no or mild OA (K-L grade 0-1), some randomized stud- assess the outcomes of APM in middle-aged patients oper-
ies also found no significant differences in APM compared ated on between 2011 and 2013. The study was approved
with physical therapy32 or arthroscopic lavage.29 Con- by our institutional ethics committee, and informed consent
versely, other studies have reported significantly greater was required. The inclusion criteria were (1) consecutive
improvement at 12 to 24 months in patients with degener- middle-aged patients (45-60 years old), undergoing APM
ative meniscal tears and without OA who underwent APM for a meniscal tear, (2) no evidence or mild OA (K-L grade
as compared with physical therapy.7,9 0-1) on preoperative knee radiographs and magnetic reso-
On the other hand, it is difficult to discriminate between nance imaging (MRI), and (3) failed physical therapy after
symptoms caused by a meniscal tear and symptoms of at least 3 months in those patients who did not have a locked
early-stage OA.16 In addition, physical therapy does not knee. The exclusion criteria were a meniscal tear that was
always provide a durable benefit for all patients with suitable for repair, a discoid meniscus, ligament deficiency,
degenerative meniscal tears. Some randomized trials prior knee surgery, inflammatory arthritis, and evidence of
reported that as high as 19% to 35% of patients allocated OA (K-L grade 2). Additional exclusions were patients
to physical therapy crossed over to APM during the first with a varus or valgus deformity .5° or a workers’ compen-
year of follow-up.24 Thus, recent systematic reviews13,23 sation claim related to their operated knee.
concluded that APM may be considered a reasonable For the purpose of this study, the patients were included
option for degenerative meniscal tears in selected middle- in 1 of 2 groups: patients with a degenerative meniscal tear
aged patients, particularly if they have mild OA. (degenerative group) and those with a traumatic tear (trau-
There is some consensus on the use of APM for middle- matic group). The difference between tear types was based
aged patients with traumatic or degenerative meniscal on several parameters: (1) previous meniscal symptoms,
tears and mechanical symptoms.2,7 However, it may be dif- (2) sudden onset of symptoms after a violent knee event
ficult not to operate on degenerative meniscal tears in such as sports-related trauma, (3) MRI information of the
patients who have persistent knee symptoms and a limita- tear pattern provided by an experienced musculoskeletal
tion of activities after failed physical therapy.2 Only a few radiologist, and (4) intraoperative findings related to the
studies have investigated the difference in outcomes tear and status of the meniscus. A degenerative tear was
between traumatic and degenerative meniscal tears,19,32 defined as a slowly developing lesion occurring without
although those studies included young patients and the any history of trauma27 and appearing as a horizontal cleav-
follow-ups were 1 to 2 years. On the other hand, the effec- age (intrameniscal linear signal often communicating with
tiveness of a therapeutic procedure should be evaluated by the articular surface), radial, or complex tear pattern on
both functional and patient-related outcomes. However, MRI,6 and this was confirmed intraoperatively. A traumatic
patient satisfaction after APM for degenerative meniscal tear was defined by the absence of previous symptoms, sud-
tears is not clearly defined. A few studies7,11 have reported den onset of symptoms as a result of a specific or violent

*Address correspondence to Alejandro Lizaur-Utrilla, PhD, MD, Department of Orthopaedic Surgery, Elda University Hospital, Ctra Elda-Sax s/n, 03600
Elda, Alicante, Spain (email: lizaur1@telefonica.net).
y
Department of Orthopaedic Surgery, Elda University Hospital, Elda, Spain.
z
Department of Traumatology and Orthopaedics, Miguel Hernandez University, Sant Joan d’Alacant, Spain.
The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures
against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or respon-
sibility relating thereto.
AJSM Vol. XX, No. X, XXXX Arthroscopic Partial Meniscectomy for Degenerative and Traumatic Tears 3

knee incident (usually sports-related trauma), MRI infor- The primary endpoint for this study was 5-year follow-
mation of the tear pattern, and intraoperative findings to up, and the primary outcome was patient satisfaction
rule out an acute on degenerative tear. The surgical indica- with the current function of their knee. At 2 and 5 years
tion in both groups was a locked knee and patients who after surgery, the patients underwent clinical and radio-
reported mechanical symptoms (sensation of knee catching logical evaluations, including answering the following 2
or locking) with a limitation of activities after physical ther- questions regarding their perception of the clinical out-
apy for at least 3 months. comes of APM. Satisfaction was elicited using a 5-point
Likert scale (1, very dissatisfied; 2, somewhat dissatisfied;
3, neither satisfied nor dissatisfied; 4, somewhat satisfied;
Treatment Protocol and 5, very satisfied). The results were then dichotomized,
with values of 1, 2, and 3 assigned to ‘‘dissatisfaction’’ and
The diagnosis of a meniscal tear was based on clinical values of 4 and 5 assigned to ‘‘satisfaction.’’ The second
symptoms including knee pain, joint effusion, a catching question was the following: ‘‘Would you undergo surgery
sensation, and a positive McMurray test finding, which again?’’ (yes/no).
was then confirmed by MRI.2 Patients with an acute locked Clinical questionnaires were administered at baseline
knee primarily underwent arthroscopic surgery. Patients and at 2 and 5 years after surgery. The knee was assessed
without a locked knee underwent arthroscopic surgery if by the Knee injury and Osteoarthritis Outcome Score
they had persistent symptoms or a limitation of activities (KOOS).28 Subscores were calculated separately and trans-
after physical therapy for at least 3 months. Arthroscopic formed to a scale from 0 (worst) to 100 (best). The KOOS-4
surgery was not indicated for the incidental finding on score was also calculated to simplify interpretation, which
MRI of a meniscal tear in a patient without clinical symp- was the mean score of 4 of the 5 KOOS subscales (exclud-
toms or in those patients with a meniscal tear associated ing the Activities of Daily Living subscale that was known
with radiological evidence of OA (K-L grade 2). APM to display ceiling effects in more active patients).32 The
was indicated for a meniscal tear that was not amenable mean change (improvement) in the KOOS-4 score from
to repair. preoperatively to last follow-up was calculated. The West-
The supervised physical therapy program consisted of ern Ontario and McMaster Universities Osteoarthritis
progressive neuromuscular and strength exercises over Index (WOMAC)3 (pain and function scores) was also
12 weeks, performed twice per week.30 Exercises were administered to assess quality of life, and a visual analog
focused on maintaining range of motion (ROM), improving scale (VAS; 0-10) was conducted for knee pain. ROM of
hip and hamstring flexibility, increasing quadriceps and the knee was measured with a goniometer. Adverse events
hip strength, and retaining knee proprioception. and revision surgery were recorded. The physical activity
All arthroscopic procedures were performed with a tour- level was assessed by the Tegner classification.31
niquet under spinal anesthesia. Standard anterolateral Preoperative standard weightbearing anteroposterior
and anteromedial portals and a 4-mm arthroscope were and lateral radiography and MRI were performed for all
used. We performed APM in all patients to re-establish patients. Postoperatively, only radiographs were obtained.
meniscal regularity. The damaged and loose parts of the Preoperative and last follow-up images were evaluated by
meniscus were removed with the use of a mechanical consensus between an orthopaedic surgeon and a musculo-
shaver and meniscal basket. The strategy was to preserve skeletal radiologist to identify degenerative changes of the
as much meniscal tissue as possible. No medication was knee according to the K-L classification.17 In case of dis-
injected into the knee during or after arthroscopic surgery. agreements, confirmation was obtained from a second
All patients were discharged on the day of surgery. Rel- radiologist.
ative rest and no severe physical activity were encouraged
postoperatively for 1 week, but full weightbearing without
any assistive device was allowed immediately. The rehabil- Statistical Analysis
itation protocol included quadriceps strength training and
ROM exercises beginning 1 week after surgery. Patients Data analyses were performed under the supervision of
were allowed to return to daily activities at 3 weeks postop- a statistician. We powered the study to detect a minimal
eratively and to return to sports or recreational activities clinically important improvement in the KOOS-4 score.
at 2 months postoperatively. Roos and Lohmander28 suggested that the minimally per-
ceptible clinical improvement for the KOOS was between
8 and 10. According to the controlled trial by Kise et al,21
Evaluations to detect a 10-point difference in the KOOS-4 score with
an SD of 15, level of significance of .05, power of 90%,
Patients were prospectively evaluated preoperatively and and estimated 15% dropout rate, a minimum of 56 patients
postoperatively at 2, 6, 12, and 24 months. All patients was needed in each group. However, the sample size was
met that protocol. For the purpose of the present study, enlarged to minimize bias because of the high prevalence
the patients were invited to return for clinical and radio- of meniscal tears.
logical re-evaluations at 5 years after surgery. Patients Baseline characteristics were analyzed with the use of
who did not return to that last evaluation were excluded descriptive statistics. The distribution was assessed using
from the results analysis. the Kolmogorov-Smirnov test. The chi-square test, Fisher
4 Lizaur-Utrilla et al The American Journal of Sports Medicine

TABLE 1
Baseline Patient Characteristicsa

Traumatic Group (n = 143) Degenerative Group (n = 115) P Value

Age, y 54.6 6 8.2 56.3 6 7.7 .088

Sex, male/female, n 101/42 84/31 .387
BMI, kg/m2 27.6 6 5.1 28.5 6 6.7 .221
Tegner activity level, median (range) 3.3 (0-5) 3.0 (0-5) .085
Duration of symptoms, mo 6.0 6 4.1 8.0 6 4.2 .536
Affected meniscus, medial/lateral, n 120/23 90/25 .158
K-L grade, 0/1, n 75/68 54/61 .452
Tear pattern, n
Longitudinal 35 21 .287
Radial 14 5 .148
Horizontal 5 8 .256
Horizontal flap 12 6 .461
Vertical flap 27 30 .177
Complex 32 38 .067
Bucket-handle 18 7 .059

a
Data are reported as mean 6 SD unless otherwise indicated. BMI, body mass index; K-L, Kellgren-Lawrence.

exact test, or nonparametric Mantel-Haenszel test was the groups. Mechanical symptoms, such as locking, painful
used to compare categorical variables. For continuous var- clicking, or catching, were reported by 37 patients in the
iables, the Student t test or nonparametric Mann-Whitney degenerative group and 45 in the traumatic group (P =
U test was used, and the paired t test or Wilcoxon signed- .504). In both groups, the main reasons for physical therapy
rank test was applied for a comparison between preopera- failure were no pain relief, persistent effusion, and impair-
tive and postoperative data. One-way analysis of variance ment in daily activities.
was used to compare the means of 2 samples. The corre-
lation between continuous variables was carried out by the
Spearman test. Multivariate stepwise logistic regression Main Outcome
analyses were used to identify independent factors associ-
At 2-year follow-up (Table 2), 94 patients (81.7%) in the
ated with patient satisfaction and with the progression of
degenerative group were satisfied with their outcomes,
knee OA after surgery. Results were presented as the
with a median score of 4.1 (interquartile range, 3-5). In
odds ratio (OR) with 95% CI. The coefficient of multiple
the traumatic group, there were 112 patients (78.3%)
determination (adjusted R2) was used to indicate how
who were satisfied, with a median score of 3.7 (interquar-
much of the variability in patient dissatisfaction was
tile range, 3-5). The mean satisfaction score at 2 years
accounted for by the determinants in the final multiple lin-
was significantly higher in the degenerative group (P =
ear regression model (ranging from 0 as poor goodness of
.014), but the satisfaction rate was not significantly differ-
fit to 1 as excellent). Interobserver agreement for the radio-
ent (P = .301). At 2-year follow-up, there were 98 patients
graphic evaluation was assessed by the kappa coefficient.
(85.2%) in the degenerative group and 116 patients (81.1%)
Statistical analysis was performed with the use of SPSS
in the traumatic group who would undergo the treatment
(v 19; IBM). All reported P values were 2-tailed, and signif-
again under the same circumstances (P = .471).
icance was set at P \ .05.
At the 5-year evaluation (Table 2), the mean satisfaction
score was also higher in the degenerative group (P = .022),
but the satisfaction rate in the degenerative and traumatic
RESULTS groups was 71.3% versus 68.5%, respectively (P = .365).
There were 85 patients (73.9%) in the degenerative group
Patient Characteristics and 101 patients (70.6%) in the traumatic group who would
undergo the treatment again (P = .329).
There were 286 patients who met the inclusion criteria, and Overall, patient satisfaction was significantly associated
all of them were followed until 2 years postoperatively. How- with the KOOS-4 score (r = 0.69; P = .024). Univariate anal-
ever, 19 patients declined a re-evaluation at 5-year follow-up, yses demonstrated significantly worse patient satisfaction
and 9 others could not be contacted. Thus, those 28 patients at 5-year follow-up with respect to female sex (P = .036),
were excluded. Baseline characteristics of the remaining 258 obesity (body mass index [BMI] .30 kg/m2) (P = .028),
patients are shown in Table 1. There were 115 patients in the and lateral meniscal tears (P = .043) in either group. How-
degenerative group and 143 patients in the traumatic group. ever, age (P = .754) and duration of symptoms from onset
Overall, 185 (71.7%) were male and 73 (28.3%) female, with to surgery (P = .197) were not significantly associated
a mean age of 55.7 years (range, 45-60 years). There were with outcomes in either group. Likewise, satisfaction was
no significant differences in baseline characteristics between significantly decreased for the patients who had progression
AJSM Vol. XX, No. X, XXXX Arthroscopic Partial Meniscectomy for Degenerative and Traumatic Tears 5

TABLE 2 TABLE 3
Patient Satisfaction Over Time KOOS Scores Over Timea

Traumatic Group Degenerative Group P Value Traumatic Group Degenerative Group P Value

Satisfaction score, mean 6 SD KOOS Pain

2y 3.7 6 1.2 4.1 6 1.4 .014 Preoperative 57.8 6 14.1 56.7 6 15.8 .560
5y 3.2 6 1.6 3.6 6 1.2 .022 2y 78.3 6 15.6 84.4 6 16.4 .002b
Satisfied patients, n (%) 5y 74.8 6 12.4 77.2 6 13.6 .144
2y 112 (78.3) 94 (81.7) .301 KOOS Symptoms
5y 98 (68.5) 82 (71.3) .365 Preoperative 45.4 6 15.6 48.3 6 13.9 .116
Would undergo surgery again, n (%) 2y 71.4 6 14.2 74.6 6 13.9 .070
2y 116 (81.1) 98 (85.2) .471 5y 67.3 6 14.0 70.1 6 12.7 .097
5y 101 (70.6) 85 (73.9) .329 KOOS Activities of Daily Living
Preoperative 64.9 6 16.3 65.6 6 14.8 .721
2y 82.9 6 12.5 87.5 6 11.4 .002b
of their OA to K-L grade 2 or 3 at 5-year follow-up as com- 5y 76.2 6 13.0 82.0 6 10.7 .001b
pared with those who had grade 0 or 1 at 5-year follow-up (P KOOS Sports/Recreation
= .003). Preoperative 35.0 6 16.5 33.7 6 15.6 .517
Multivariate regression analysis for patient dissatisfac- 2y 54.6 6 12.5 57.6 6 13.7 .071
tion at 5-year follow-up showed female sex (OR, 1.6 [95% 5y 49.3 6 10.9 51.5 6 13.1 .150
CI, 1.1-2.3]; P = .018), BMI .30 kg/m2 (OR, 2.6 [95% CI, KOOS Quality of Life
Preoperative 41.9 6 15.7 44.2 6 14.6 .228
1.7-4.9]; P = .035), lateral meniscal tears (OR, 0.6 [95% CI,
2y 73.3 6 14.3 76.2 6 13.9 .102
0.1-0.9]; P = .039), and OA progression to K-L grade 2 at 5y 61.5 6 13.7 66.6 6 14.4 .004b
final follow-up (OR, 1.4 [95% CI, 1.2-2.6]; P = .014) as signif- KOOS-4
icant independent factors. These 4 variables together Preoperative 46.8 6 15.1 45.2 6 13.7 .373
accounted for 59% of the overall variability in patient satis- 2y 67.1 6 12.8 71.4 6 13.1 .008b
faction (adjusted R2 = 0.593). A degenerative meniscal tear 5y 64.6 6 13.2 66.9 6 14.4 .187
was not a significant factor for patient dissatisfaction at 5-
a
year follow-up (OR, 1.5 [95% CI, 0.6-3.9]; P = .262). Data are reported as mean 6 SD. KOOS, Knee injury and
Osteoarthritis Outcome Score.
b
Significant (P \ .05) but not clinically meaningful (difference
\10).
Secondary Outcomes
There were no significant baseline differences between the
groups in mean KOOS scores (Table 3). Both groups With respect to outcomes as measured by the WOMAC
improved significantly (P \ .001) in mean KOOS scores (Table 4), the degenerative group had a significantly better
from baseline at 2-year and 5-year follow-up (Table 3). WOMAC pain score at 2-year follow-up (P = .005), although
At 2-year follow-up, the degenerative group had signifi- the difference was not clinically meaningful, and there was
cantly higher scores on the KOOS subscales for Pain (P = no significant difference at 5-year follow-up (P = .083). The dif-
.002) and Activities of Daily Living (P = .002), although ference in the WOMAC function score was not significant at 2-
the differences between the groups for both subscales year (P = .481) and 5-year (P = .327) follow-up.
were considered not clinically meaningful (difference Likewise, the mean VAS pain score (Table 4) was signif-
\10). Likewise, at 5-year follow-up, the degenerative icantly better in the degenerative group at 2-year follow-up
group had significantly higher scores on the KOOS sub- (P = .006) but not at 5-year follow-up (P = .648). All
scales for Activities of Daily Living (P = .001) and Quality patients had improvement in ROM from preoperatively
of Life (P = .004), and these differences were also consid- to 2-year and 5-year follow-up, with no significant differen-
ered not clinically meaningful. ces between groups (Table 4).
At 2-year follow-up, the mean KOOS-4 score was signif- Return to previous activity levels (Table 4) at 2-year
icantly higher in the degenerative group compared with follow-up was achieved in 73.4% of patients in the trau-
the traumatic group (P = .008), although the difference matic group and 80.8% in the degenerative group (P =
was considered not clinically meaningful. However, there .159) and at 5-year follow-up in 60.1% and 61.7%, respec-
was no significant difference at 5-year follow-up (P = tively (P = .447). The most common reasons for not return-
.187). The degenerative group had significantly greater ing to prior activities were fear of knee reinjuries and
improvement in the mean KOOS-4 score from baseline to concerns about the physical ability of the knee.
2-year follow-up compared with the traumatic group There were no severe complications, such as deep infec-
(26.2 vs 20.3, respectively; P = .032), with a mean differ- tions, thromboembolic episodes, or nerve injuries, in either
ence between the groups of 5.9 (95% CI, 4.1-7.2; P = group. Other complications included a superficial infection
.026). However, the mean difference in KOOS-4 improve- needing antibiotics (1 patient in the degenerative group),
ment between the groups from baseline to 5-year follow- transient knee swelling (4 patients in the degenerative
up was 3.9 (95% CI, 0.9-11.4; P = .197), which was consid- group vs 3 in the traumatic group), and mild vastus medi-
ered not clinically meaningful. alis weakness (2 vs 3 patients, respectively). There was no
6 Lizaur-Utrilla et al The American Journal of Sports Medicine

TABLE 4 in the degenerative group and none in the traumatic group

Functional and Radiological Outcomes Over Timea had undergone total knee arthroplasty.
In univariate analysis, BMI .30 kg/m2 (P = .031),
Traumatic Degenerative female sex (P = .027), and lateral meniscal tears (P =
Group (n = 143) Group (n = 115) P Value
.041) were significant factors associated with increased
WOMAC pain odds of OA progression. Logistic regression analysis
Preoperative 57.4 6 16.1 58.5 6 14.7 .567 showed that female sex (OR, 2.6 [95% CI, 1.5-4.4]), BMI
2y 72.6 6 13.5 77.4 6 14.1 .005b .30 kg/m2 (OR, 2.5 [95% CI, 1.4-4.6]), and lateral meniscal
5y 70.1 6 12.6 72.6 6 9.9 .083 tears (OR, 1.9 [95% CI, 1.2-2.8]) were significant risk
WOMAC function factors.
Preoperative 59.6 6 12.3 57.4 6 11.7 .143
2y 78.2 6 12.6 79.3 6 12.3 .481
5y 71.7 6 13.2 73.4 6 14.3 .327
VAS pain
Preoperative 6.9 6 1.6 7.2 6 2.1 .207 DISCUSSION
2y 2.4 6 1.7 1.9 6 1.1 .006
5y 2.8 6 1.8 2.7 6 1.7 .648 The main finding of the present study was that APM provided
ROM, deg similar satisfaction at 5 years postoperatively to middle-aged
Preoperative 110.0 6 8.7 109.0 6 10.1 .401 patients with no or mild knee OA with degenerative meniscal
2y 121.0 6 7.9 119.0 6 11.3 .096 tears as compared with those with traumatic tears. Likewise,
5y 119.0 6 10.4 118.0 6 12.6 .485 the functional and radiological outcomes were similar between
Return to activities, n (%) the groups. Much study has been dedicated to determining
2y 105 (73.4) 93 (80.8) .159
the outcomes of APM. However, patient satisfaction after
5y 86 (60.1) 71 (61.7) .447
APM has not been clearly defined. To our knowledge, this is
K-L grade, 0/1/2/3, n
Preoperative 75/68/0/0 54/61/0/0 .452 the first study that compares patient satisfaction in the
5y 27/67/46/3 18/54/38/5 .347 medium term after APM for degenerative and traumatic
meniscal tears.
a
Data are reported as mean 6 SD unless otherwise indicated. In the literature, only a few studies have reported some
K-L, Kellgren-Lawrence; ROM, range of motion; VAS, visual ana- data of patient satisfaction after APM for degenerative
log scale; WOMAC, Western Ontario and McMaster Universities meniscal tears. In a prospective study32 comparing
Osteoarthritis Index. patients undergoing APM for traumatic meniscal tears
b
Significant (P \ .05) but not clinically meaningful (difference and those for degenerative meniscal tears, a significantly
\10).
larger improvement in the KOOS-4 score was found in
patients with degenerative tears, although functional out-
significant difference between the groups in the rate of comes were similar between the groups. In that study,
complications (P = .572). During the whole postoperative a larger proportion of patients with traumatic tears were
follow-up period, 7 knees (6.1%) in the degenerative group not satisfied with their knee function at 1-year follow-up,
and none in the traumatic group required another surgical compared with patients who had degenerative tears,
intervention because of OA progression. although the mean age was higher in the degenerative
group. El Ghazaly et al7 reported that patient satisfaction
at 1-year follow-up after APM was 85% regarding pain,
Radiological Outcomes 88% regarding swelling, and 90% regarding function, and
overall satisfaction afterward was 87%. However, a vali-
For the radiographic evaluation, the statistical analysis for dated measure for satisfaction was not used. In another
interobserver agreement revealed a kappa coefficient of study11 of APM for symptomatic degenerative meniscal
0.86 (P = .025), which was successful. At 5-year follow-up tears in patients with no preoperative radiographic OA,
(Table 4) in the degenerative group, 60 patients (52.2%) 79% of patients declared that they were satisfied with hav-
had some radiological knee change from preoperatively, ing undergone surgery at 1 year. Nevertheless, the authors
and 43 patients (37.4%) had a progression to K-L grade 2 also did not use a validated measure.
or 3. In the traumatic group, 76 patients (53.1%) had The use of APM for middle-aged patients with knee pain
some radiological knee change at 5-year follow-up, and is one of the most common surgical procedures.4 APM is
49 patients (34.2%) had a progression to K-L grade 2 or a successful procedure at relieving pain and improving
3. The difference between the groups in the rate of patients function in middle-aged patients with isolated meniscal
who developed a progression of OA to K-L grade 2 or 3 was tears and no degenerative knee changes.18 However, the
not significant (P = .347). Compared with the traumatic success rate of APM in elderly patients is less predictable
group, the OR for patients to develop OA progression in because of the higher prevalence of concomitant joint
the degenerative group was 0.8 (95% CI, 0.5-1.4). degeneration. APM has been shown to be of no benefit to
Among the patients with radiological OA progression, 24 patients with concomitant knee OA.25 However, the opti-
patients (20.8%) in the degenerative group and 18 patients mal treatment of a degenerative meniscal tear in patients
(23.6%) in the traumatic group had a symptomatic knee as with no or mild OA is controversial. A recent systematic
assessed by the KOOS. At final follow-up, 7 patients (6.1%) review23 concluded that patients with symptomatic
AJSM Vol. XX, No. X, XXXX Arthroscopic Partial Meniscectomy for Degenerative and Traumatic Tears 7

meniscal tears and degenerative changes in the knee can radiographic findings, failed nonoperative treatment, and
benefit from arthroscopic meniscectomy, particularly if positive physical examination findings (ie, positive McMur-
OA is mild. Another study,1 on a national audit into arthro- ray test result, joint-line tenderness, and effusion).
scopic knee practices, concluded that arthroscopic menis- A systematic review and meta-analysis of randomized
cectomy was beneficial regardless of patient BMI, controlled trials33 on APM versus nonoperative treatment
duration of symptoms, history of injuries, or presence of for degenerative meniscal tears in adults showed small,
early OA. On the contrary, several randomized studies although statistically significant, favorable results of
and meta-analyses reported that knee arthroscopic sur- APM up to 6 months for physical function and pain, but
gery was associated with harm and was not recommended no differences were found after 12-month to 24-month
for middle-aged or older patients with or without signs of follow-up. Another recent critical systematic review13 on
OA.22,34 APM versus physical therapy for degenerative meniscal
Sihvonen et al29 compared APM with arthroscopic lavage lesions found that the quality of the available published lit-
in patients with a degenerative medial meniscus without erature was not robust enough at this time to support
OA, obtaining similar outcomes at 1 year in both groups. claims of superiority for either alternative, and both
The authors concluded that the results argue against the APM and physical therapy could be considered reasonable
current practice of performing APM in patients with degen- treatment options for this condition. Another recent criti-
erative meniscal tears without OA. However, the act of per- cal review of the published literature reported that valid
forming surgery itself could have a placebo effect. Likewise, conclusions cannot be drawn with regard to the optimal
high levels of evidence have suggested that exercise had treatment for meniscal tears.10
similar benefits to APM at least in the short term. Kise In the present study, patients with lateral meniscal tears
et al21 compared exercise therapy against APM for degener- had worse outcomes than those with medial meniscal tears.
ative medial meniscal tears in middle-aged patients without We cannot provide a clear explanation for this. Other
radiological signs of OA. The authors found no differences authors5 have also reported worse results after APM for lat-
between groups in patient-reported knee function at 2- eral meniscal tears. A study14 with long-term follow-up sug-
year follow-up but greater muscle strength in the exercise gested that patients undergoing APM for lateral meniscal
group at 3 months. On the other hand, there was a crossover tears were at a higher risk of developing symptomatic OA
rate of 19% in patients going from the nonsurgical group to if they were over 40 years old, had a high BMI, and had val-
the surgical group. Herrlin et al,12 in a trial of 90 patients gus malalignment at the time of surgery.
aged 45 to 64 years with degenerative meniscal injuries ran- The strength of the present study was its prospective
domized to APM versus physical therapy, showed no advan- design and standardized indications for APM. In addition,
tage for APM with regard to improved pain or function. the outcome tool used for patient satisfaction was well
However, that study had some limitations. The APM group established and validated. To our knowledge, this study
had significantly poorer baseline characteristics, leading to is one of the longest studying the outcomes of APM in
possible selection bias. Moreover, there was a high crossover the management of degenerative meniscal tears. We
rate (28%) of patients going from exercise therapy to APM. believe that this study has significant clinical relevance
In a multicenter study, Katz et al16 also compared APM and will hopefully guide orthopaedic surgeons in their deci-
with physical therapy in patients who had evidence of OA. sion making on future selected patients with a degenera-
Outcomes were similar between groups at 1 year. However, tive meniscal tear.
30% of patients assigned initially to the physical therapy However, this study has several limitations. First, a lim-
group crossed over to surgery in the first 6 months. itation lies in the very nature of attempting to quantify the
Conversely, other randomized studies found more bene- subjectivity of patient satisfaction. The present study was
fit of APM over nonsurgical therapies in patients with powered to detect a 10-point difference in the KOOS-4 score
symptomatic degenerative meniscal tears.7,9,26 Gauffin instead of patient satisfaction because the latter is a subjec-
et al,9 comparing APM with exercise therapy, reported tive measure too difficult to quantify. While we attempted to
that both treatment groups improved significantly in the measure demographic, surgical, objective, and subjective
pain score at 1-year follow-up, but the change in the pain variables to correlate with satisfaction, certainly other var-
score was significantly larger in the surgical group than iables may have been omitted. Also, we did not measure the
the nonsurgical group. patient’s preoperative expectation regarding surgery, which
Although the nonoperative treatment of meniscal tears can influence postoperative satisfaction. The study was also
can improve symptoms especially in patients with degener- limited by the absence of a comparative nonsurgical group
ative tears,12 many patients with degenerative meniscal of middle-aged patients with degenerative meniscal tears.
tears have persistent pain after nonoperative therapy and Thus, our study could not directly compare clinical out-
elect to undergo APM. Moreover, exercise therapy usually comes after the surgical and nonsurgical treatment of
has a low adherence to treatment.9 However, APM is typi- meniscal tears in this patient population. However, the
cally advocated for patients with knee pain and an impair- main objective of the present study was to assess the opin-
ment in activities of daily living in whom a tear is ion of the patient after APM. The scarcity of studies report-
confirmed by MRI, particularly those without concomitant ing on patient satisfaction suggests a relative inattention to
knee OA, and after failure of nonoperative treatment.24 patient satisfaction among surgeons. Given the importance
According to a study,24 the 3 clinical factors that most influ- of patient satisfaction, future prospective studies are needed
enced a surgeon’s decision to recommend APM were normal to better define patient satisfaction after APM.
8 Lizaur-Utrilla et al The American Journal of Sports Medicine

CONCLUSION 15. Kamimura M, Umehara J, Takahashi A, Aizawa T, Itoi E. Medial

meniscus tear morphology and related clinical symptoms in patients
In conclusion, there were no meaningful differences in with medial knee osteoarthritis. Knee Surg Sports Traumatol
Arthrosc. 2015;23:158-163.
patient satisfaction or clinical outcomes between traumatic
16. Katz JN, Brophy RH, Chaisson CE, et al. Surgery versus physical
and degenerative tears in patients with no or mild OA. Pre- therapy for a meniscal tear and osteoarthritis. N Engl J Med.
dictors of dissatisfaction with APM were female sex, obe- 2013;368:1675-1684.
sity, and lateral meniscal tears. Our findings suggested 17. Kellgren JH, Lawrence JS. Radiological assessment of osteoarthro-
that APM was an effective option in the medium term to sis. Ann Rheum Dis. 1957;16:494-502.
relieve pain and recover function in middle-aged patients 18. Kijowski R, Woods MA, McGuine TA, Wilson JJ, Graf BK, De Smet
with degenerative meniscal tears, without obvious OA, AA. Arthroscopic partial meniscectomy: MR imaging for prediction
of outcome in middle-aged and elderly patients. Radiology.
and with failed prior physical therapy. 2011;259:203-212.
19. Kim JR, Kim BG, Kim JW, Lee JH, Kim JH. Traumatic and non-
traumatic isolated horizontal meniscal tears of the knee in patients less
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