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Why menisectomy?
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Why menisectomy? - June 29, 2003 1:17:00 PM
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nrl
Posts: 121
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From: israel
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Lately I had quite a few patients who had a meniscus tear and did not want an operation. The orthopedic surgeon told them that it was their only good option. Since I don’t agree, I decided to search the literature again (I have done this a few times before). I still can’t find any good evidence that shows surgery is better than conservative treatment. A Cochrane review concludes there is no such evidence.
What’s the routine treatment for meniscus tear where you’re working?
Nirit
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Re: Why menisectomy? - June 30, 2003 5:31:00 AM
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PTupdate.com
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I have treated many patients with an apparent meniscal tear, and the success rate via conservative therapy is around 50:50. Sometimes I have good streaks, other times not.
A lot will depend on the tear itself. Lateral tears are harder to treat, as the forces involved with the injury are often higher. Remember, the lateral meniscus is able to move up to 11mm during full flexion from extension. Being this mobile means that more force is often required to injure it. The medial meniscus is not very mobile, and thus more vulnerable. Plus, it has many soft tissue attachments, making it more vulnerable to outside forces/strain.
The size and location of the tear matter. A small tear in the vascular zone, or red zone, may actually scar down and "heal". One in the avascular zone that is large will have a harder time. A bucket handle type tear is always subjected to constant agitation, and can enlarge and begin to block motion.
Conservative treatment is an option in many of these patients, unless there is a severe ROM blockage and loss of gait function. I have had luck on a few occasions of manually reducing a bucket handle tear, but around 50% end up flipping back sometime later in the day.
PT treatment as performed by me includes various anti-inflammatory modalities. Stretch the hamstrings, as they have direct attachment and can pull the meniscus. Tight ITB may cause lateral patellar tilt and tracking, and thus pull on the meniscopatellar ligament. Tight GSC can lead to delayed and/or excessive pronation, and this twisting (in those with a higher angled subtalar axis) can agitate the meniscus. Tight quads can cause compressive forces to the PF joint.
Use a stationary cycle with high seat and low resistance to flush synovial fluid around the cartilage for nourishment. Strengthen carefully, especially hamstrings to avoid pulling. If doing adduction, make sure the knee is locked out to avoid a valgus stress and pull on the medial meniscus.
A couple of recent studies come to mind. One indicates that even with meniscectomy, rehab is not really that necessary and persons did quite well without it. I concur with this.
Another indicates that a high percentage of persons in their 40's and 50's (up to 76%) have meniscal tears on MRI but are asymptomatic! Also, in cases of more severe knee OA, there is a 100% liklihood of a meniscus tear. Thus, just because their MRI says they have a tear does not mean that is where their pain is coming from! Remember the lesson we all learned years ago with HNP in the lumbar spine when MRI's became commonly used?
In a nutshell, a meniscus tear does not mean surgery is required at that time. The tear will not really heal, but the inflammation may be reduced, pain reduced, and scarring may occur. It may get them by until a later date. For those who fail conservative care, surgery is a good option with very very good results.
John Duffy, PT OCS [URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
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Re: Why menisectomy? - June 30, 2003 6:25:00 AM
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mcap56
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From: New York, NY
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NRL:
If surgery is being considered why are they choosing menisectomy over repair. In my area they are pretty much trying to repair all tears, regardless of location first. There is some research that even tears in the avascular zone can be repaired. Menisectomy is performed after if it doesn't take.
As for research, you will only get cohort studies without controls. How would you do a study on this? You could randomly allocate people and then subject them to sham menisectomy and compare the results over the long term. But we know this will never happen. Many surgeries, unfortunately are a matter of faith.
I think that for patients with meniscal tears, it becomes a matter of function and how many "episodes" they have. IF their knee frequently swells and locks, then they might be better off with surgery. Here they are experimenting with transplant for those who previously had total menisectomy but the jury is still out.
Mcap
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Re: Why menisectomy? - June 30, 2003 9:15:00 AM
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tucker
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From: Texas
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"You could randomly allocate people and then subject them to sham menisectomy and compare the results over the long term. But we know this will never happen."
I'm not sure, did you see the study last year where they did a placebo arthroscopy? Interesting study.
A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2002 Jul 11;347(2):81-8.
Conclusion:In this controlled trial involving patients with osteoarthritis of the knee, the outcomes after arthroscopic lavage or arthroscopic debridement were no better than those after a placebo procedure.
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Re: Why menisectomy? - June 30, 2003 3:33:00 PM
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mcap56
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Yes....I did see the study and I have reviewed it with my students on occaision. It was a great study. However, the sample was very small. Furthermore, they were using a procedure that has long been thought to be questionable. If I remember correctly they were talking about debridement in cases of OA. This is a different story. Of course, if they could get IRB and enough subjects, I would be all for looking into it. A lot of surgeries that are currently performed would probably not stand up to RCTs. Perhaps IDET is next on the list? A study using a similar procedure with a sham control demonstrated no benefit.
mcap
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Re: Why menisectomy? - July 1, 2003 4:25:00 AM
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nrl
Posts: 121
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From: israel
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Mcap, “A lot of surgeries that are currently performed would probably not stand up to RCTs” .Totally agree with you. This is what my post is about really. Do you think arthroscopy, menisectomy and meniscal repair would?
How about comparing conservative to operative treatment. As far as I know this has not been done. Especially long term results. I think the incisions might have adverse influence on PF joint , especially long term.
After more then 10 years of treating those patients my feeling is conservative treatment is good enough for most patients . Still waiting for someone to prove it.
Anyway available evidence is inconclusive according to a Cochrane review.
Surgical treatment for meniscal injuries of the knee in adults.
Cochrane Database Syst Rev. 2000;(2):.
REVIEWER'S CONCLUSIONS: The lack of randomised trials means that no conclusions can be drawn on the issue of surgical versus non-surgical treatment of meniscal injuries, nor meniscal tear repair versus excision. In randomised trials so far reported, there is no evidence of difference in radiological or long term clinical outcomes between arthroscopic and open meniscal surgery, or between total and partial meniscectomy.
Would you agree that based on that review, all patients with meniscal tears should first try conservative treatment and then, if not successful, be referred to surgery?
Nirit
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Re: Why menisectomy? - July 1, 2003 4:38:00 AM
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mcap56
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Absolutely....
mcap
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Re: Why menisectomy? - July 1, 2003 12:27:00 PM
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nrl
Posts: 121
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From: israel
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Thanks.
Another article I remember which is interesting :
Negative knee arthroscopy: Is it really negative? Arthroscopy 2001 Jul;17(6):620-3
Purpose: To evaluate the outcome of patients in whom knee arthroscopy proved to be normal.
Type of Study: Retrospective study.
Methods: Knee arthroscopy is probably the most common procedure performed in orthopaedic practice. A number of patients who undergo this procedure do not have any abnormality detected. Is negative arthroscopy really such an unnecessary procedure? Hospital records of patients who had undergone knee arthroscopy were retrospectively studied and all patients with a normal knee arthroscopy were selected. Fifty-three patients (55 knees) with a normal arthroscopy were included into the study. Patients were then interviewed either by telephone or questionnaire to ascertain current symptoms, job changes, and patient perception of the procedure.
Results: The mean follow-up was 43 months. Fifty percent of the patients had a history of injury, and the preoperative diagnosis was thought to be a meniscal lesion or a rupture of the anterior cruciate ligament in 38% of patients. Sixty-eight percent of the patients felt that they were better and there were no complications. The incidence of all symptoms were significantly reduced after arthroscopy.
Conclusions: A significant number of patients felt that they were better after the knee arthroscopy. The reason for this is not entirely clear. It may well be attributable to a placebo effect, the fact that patients now know that there is no abnormality and learn to live with the symptoms, or there may be an additional benefit of the procedure itself.
Mcap-can you please send me an e- mail .I’d like some info about your EBP lectures.
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Re: Why menisectomy? - August 1, 2003 7:12:00 PM
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fconijn
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From: The Netherlands
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Mcap,
"Absolutely"? I can't agree with that. It all depends on how much pain the patient has, how much pain the (modified) McMurray elicites, what the other tests show, and what the patient wants to do with the knee in the near future. I'd think that in a number of cases a physiotherapist would not act in the best interest of his/her patient if s/he would advise conservative therapy. It all depends...
One should also realise that menisectomy is rarely performed anymore. Usually, only the torn part is being cut away, leaving the biggest part to stay.
R.,
Frank Conijn, PT
Editor, Physical Therapist's Literature Update
The Internet Journal of Literature Updates for Clinicians in Primary Care Orthopaedic Medicine
[URL=http://www.ptlitup.com]www.ptlitup.com[/URL]
[QUOTE]Originally posted by mcap56:
Absolutely....
mcap[/QUOTE]
[This message has been edited by fconijn (edited August 01, 2003).]
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Re: Why menisectomy? - August 1, 2003 7:48:00 PM
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mcap56
Posts: 619
Joined: October 26, 2002
From: New York, NY
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We may call it menisectomy but I believe that we are all referring to partials. Furthermore, at my last practice, repair as opposed to menisectomy was first tried on almost every patient unless the tear was really small.
You are correct.....there are some cases where surgery isn't advised. However, these were usually those with extreme functional limitations and knees that were locked or would easily become stuck. Otherwise, there is very little reason to go ahead quickly. Even if you are going to operate, you want to maximize the strength, rom and proprioception first.
mcap
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Re: Why menisectomy? - August 2, 2003 3:48:00 PM
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nrl
Posts: 121
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From: israel
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When I write “menisectomy” I mean partial menisectomy. I agree that patients with a locked knee should be operated as quickly as possible
A few questions (for information, not for the argument) :
“It all depends on how much pain the patient has” – why? What’s the evidence on pain as an indicator for meniscus surgery?
Tests – in regards to ACL tears the lit. shows the different tests are not indicative of functional stability. What’s the evidence on meniscus tests in regards to function?
What about the Cochrane review cited? What weight should we give the review versus common practice?
Lately I’ve been speaking with a surgeon I work with, about something I’ve been thinking for a while. I think that since this is an intra-articular injury full weight bearing should not be incouraged for 3-6 weeks. What do you think?
Nirit
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Re: Why menisectomy? - August 2, 2003 6:36:00 PM
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mcap56
Posts: 619
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From: New York, NY
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My mistake. It should say there are some cases where early surgery is warranted.....locked knee, extreme functional deficits, etc. Most cases however, would be advised to rehab first.
Nirit:
I agree. Pain probably shouldn't be the primary consideration. We all have seen how poorly it can correlate to function. I would sooner use one of the knee scales as a guide. If the function is good, then control the pain and rehab the injury.
As for your question, I am not sure. We usually left our meniscal tears WBAT as they recovered. However, I don't know of much research in the area.
best,
mcap
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Re: Why menisectomy? - August 3, 2003 2:38:00 AM
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nrl
Posts: 121
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From: israel
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A few hospitals here are now limiting weight bearing after ACL tears for as long as 6 weeks. The reason is the high prevalence of chondral lesions. I don’t know of research looking at chondral lesions after meniscus tear. I suspect it will not be as high as after ACL injury .
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Re: Why menisectomy? - August 4, 2003 6:33:00 PM
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PTupdate.com
Posts: 1478
Joined: October 8, 2001
From: Pittsburgh, PA USA
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I was once told by a surgeon that some tears are "pushed apart" with weightbearing, while others are compressed together, thus his rationale for when to permit weightbearing and when to limit it.
Often pain is the ONLY reason someone undergoes a partial menisectomy, and by the time they reach that stage, I cannot blame them. Others, once the pain and exacerbation stages are eliminated, ROM and strength are restored, they function fairly well. They may have trouble squatting, or be stiff after periods of full flexion. They may have progression of their tear, but if no pain, most prefer to hold off on the surgery.
John Duffy, PT OCS [URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
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Re: Why menisectomy? - August 7, 2003 11:01:00 PM
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fconijn
Posts: 20
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From: The Netherlands
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Nirit,
EBP does not mean Every Bit must be Proved. Even if there would be no evidence that partial menisectomy is better than conservative treatment, there still is such a thing a clinical insight and sound-mind decisions. As there is no evidence that conservative is better than surgery, you cannot just go ahead with conservative without considering the risks. The risk obviously is that the tear is going to get larger, beyond repair, while it may now be within repair limits. (No, I do not refer to a surgeon when I know s/he does not do repairs.)
You're saying: "Tests – in regards to ACL tears the lit. shows the different tests are not indicative of functional stability". Please explain then why Malanga et al (1) in April published a literature review in which they concluded that the drawer tests are sufficiently valid, and the McMurray is sufficiently specific (which is probably all you need, in this case). Functional stability may be something else than structural stability, but if there's pain, atrophy is around the corner. And gone is the functional stability then.
A sound way to go in (suspected) small meniscal tears is to adopt a wait-and-see attitude for eight weeks. Be sure the patient understands that s/he has to take it easy, and avoid all aggravating activities. If by that time complaints have resolved, you can start a gradual reloading program to the necessary level. But if by that time complaints have not resolved, or if the gradual reloading makes the complaints return, arthroscopy is the treatment of choice. Repair if possible, and partial menisectomy if not. That is the current opinion of most specialists (meniscal implants still have a way to go). If you wanna divert from that, I think you should have hard evidence, and better be well insured.
Ref:
1. Malanga GA et al, Physical examination of the knee: A review of the original test description and scientific validity of common orthopedic tests. Arch Phys Med Rehab 2003; 84(4):592-603.
R.,
Frank
F.J.J. Conijn, PT
Editor, Physical Therapist's Literature Update
The Internet Journal of Literature Updates for Clinicians in Primary Care Orthopaedic Medicine & Rehabilitation [URL=http://www.ptlitup.com]www.ptlitup.com[/URL]
[QUOTE]Originally posted by nrl:
When I write “menisectomy” I mean partial menisectomy. I agree that patients with a locked knee should be operated as quickly as possible
A few questions (for information, not for the argument) :
“It all depends on how much pain the patient has” – why? What’s the evidence on pain as an indicator for meniscus surgery?
Tests – in regards to ACL tears the lit. shows the different tests are not indicative of functional stability. What’s the evidence on meniscus tests in regards to function?
What about the Cochrane review cited? What weight should we give the review versus common practice?
Lately I’ve been speaking with a surgeon I work with, about something I’ve been thinking for a while. I think that since this is an intra-articular injury full weight bearing should not be incouraged for 3-6 weeks. What do you think?
Nirit [/QUOTE]
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Re: Why menisectomy? - August 8, 2003 8:09:00 AM
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mcap56
Posts: 619
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From: New York, NY
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Fconijn:
I agree with a wait and see approach although I probably wouldn't limit it to just small tears. Why can't larger tears attempt conservative treatment first?
You really can't have it both ways. It's true, with conservative management you may risk progression of the tear. However, surgery is not without risk either. If the repair doesn't take or isn't performed and there is a menisectomy, then you have profound biomechanical changes within the knee and increased risk for all kinds of future problems. More or less than just leaving the tear there???? Who knows. But unless the patient is locked and simply can't function, I see know harm in waiting. That's the way the "experts" who I worked with handled it.
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Re: Why menisectomy? - August 8, 2003 8:28:00 AM
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coloradojulie
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Just went to an inservice/conference at the Steadman Hawkins Clinic...interesting talk of chondral lesions during the initial injury itself. Meaning that when you tear the ACL or meniscus, there is impact to the joint surfaces (including the thin tissue layer over the articular cartilage...name escapes me). An inflammatory reaction insues locally in this tissue and the result is progressive deterioration (to a degree) of the articular surface. This may be the chondral dammage aforementioned. Dr. Steadman is apparently quite adament that this structure (the outer tissue layer) not be touched during surgery to prevent the inflammatory reaction.
Chemial mediators can be dammaging to the tissue. They are looking at early management of this "healing" response (going from inflammation, cartilage thickening (cellular proliferation) to subseqent breakdown...) to stop it's progression in the articular surface. It makes sense...and maybe something to consider post op as well as during conservative management. I don't think they have developed a protocol for prevention to date.
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Re: Why menisectomy? - August 8, 2003 11:13:00 AM
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mcap56
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From: New York, NY
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Although not specifically for articular cartilege, there is evidence that some types of cartilege (tendons and ligaments) heal better in the presence of NSAIDs (indomethicin I think was the drug studied in this case). I wonder what the effect is on hyaline cartilege. Of course, it's always a fine line between controlling inflammation and prevention of healing. Did they discuss initial conservative management and inflammation control???
mcap
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Re: Why menisectomy? - August 9, 2003 5:11:00 AM
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nrl
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From: israel
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EBP- is definitely not just reviews or meta-analysis. However it does mean, in my view looking at common practices and rethinking about them. This is what I’m trying to do when looking at the issue of arthroscopy at the knee.
Surgery and pain – I’m sorry I do not see how surgery reduces pain. It is not my clinical experience. Logically, and from experience, the incisions of arthroscopy are a potential source of pain. Especially because they go through the fat pads.
Tests- clinical test you stated are sufficient for clinical diagnosis. As for function this is another question. The ACL is a good example. “Measurements of anterior laxity in anterior cruciate ligament-deficient patients were not correlated with measures of functional outcome used in this study. Functional outcome measurements that are partially based on joint laxity measures, such as the International Knee Documentation Committee form, may artificially overestimate the disability after anterior cruciate ligament rupture.” (Snyder-Mackler L, Fitzgerald GK, Bartolozzi AR 3rd, Ciccotti MG. The relationship between passive joint laxity and functional outcome after anterior cruciate ligament injury.
Am J Sports Med. 1997 Mar-Apr;25(2):191-5. )
“If you wanna divert from that, I think you should have hard evidence …” or I can use Harris’s criteria for evaluating scientific merit (Harris SR. How should treatments be critiqued for scientific merit? Phys Ther. 1996;76:175-181.]). I think in regards to meniscal injuries we can present a good case for conservative treatment. As for insurance – I don’t really think this is a problem since there is no evidence, to my knowledge, that shows the option offered by PT is not as good as any other option. Cochrane reviews can be used to our advantage.
One last point/story – last June I presented a lecture about conservative treatment of ACL in the WCPT conference in Barcelona. After the lecture some in the audience told us about common practice in different countries. One said, “Where I work, none of the patients go to surgery:” he then made a dramatic pause and added that “the nearest surgeon is 400 miles away “. They do well. This is country with excellent health system. What do you think about that? .
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Re: Why menisectomy? - August 9, 2003 4:20:00 PM
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mcap56
Posts: 619
Joined: October 26, 2002
From: New York, NY
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Certainly one can't deny that there is a tremendous socio/economic phenomenon associated with many kinds of orthopedic surgery. In some cases the surgeons are far too quick to operate. There is not only money at stake, but prestige, ego and a host of other factors.
We all know the evidence or lack thereof for many kinds of spinal surgery. However, take a quick tour of the back pain web sites out there and you will see surgery advertised as a reasonable option for many conditions including DDD. One supposedly reputable site claimed that only one in ten cases of DDD will require surgery. Well....since everyone over 50 has some form of DDD......you can do the math. This is a particular problem with comp cases who always seem to end up with EMGs that always seem to end up positive. Surgery occurs a few steps down the line. A recent New York Times Magazine article highlighted the massive industry associated with Spine surgery.
Again....I must agree with NRL. We don't have to oppose surgery in every case and there certainly is a place for it. But I think we need to step back and realize that RCTs have never been done and that a decent amount of improvement may be placebo or otherwise.....
mcap
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