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DOI 10.1007/s00402-015-2351-2
Abstract
Introduction The aim of the present study was to compare the outcomes of various surgical treatments for
meniscal injuries including (1) total and partial meniscectomy; (2) meniscectomy and meniscal repair; (3) meniscectomy and meniscal transplantation; (4) open and
arthroscopic meniscectomy and (5) various different repair
techniques.
Materials and methods The Bone, Joint and Muscle
Trauma Group Register, Cochrane Database, MEDLINE,
EMBASE and CINAHL were searched for all (quasi)
randomized controlled clinical trials comparing various
surgical techniques for meniscal injuries. Primary outcomes of interest included patient-reported outcomes
scores, return to pre-injury activity level, level of sports
participation and persistence of pain using the visual analogue score. Where possible, data were pooled and a metaanalysis was performed.
Results A total of nine studies were included, involving a
combined 904 subjects, 330 patients underwent a meniscal
repair, 402 meniscectomy and 160 a collagen meniscal
implant. The only surgical treatments that were compared
in homogeneous fashion across more than one study were
the arrow and inside-out technique, which showed no
difference for re-tear or complication rate. Strong evidence-based recommendations regarding the other surgical
treatments that were compared could not be made.
Conclusions This meta-analysis illustrates the lack of
level I evidence to guide the surgical management of
meniscal tears.
Level of evidence Level I meta-analysis.
Keywords Meniscus Meniscectomy Meniscal repair
Meniscal transplant Meta-analysis Clinical outcomes
Introduction
Meniscal tears are one of the most common injuries in
orthopaedic sports medicine with an incidence of 24 per
100,00 per year [1]. They show a bimodal distribution with
a first peak in the young, athletic population and the second
peak in middle-aged patients with degenerative joint disease [1]. Surgical procedures involving the meniscus are
performed in close to one million patients are year in the
United States alone [2, 3].
Surgical treatment of meniscal injuries has undergone
several developments over the past two decades [4, 5],
moving from open to arthroscopic surgery, from total to
partial meniscectomy and adding novel treatments such as
repair using a variety of devices/techniques, transplant,
collagen implants and xenografts [69]. The indications for
some is these treatment options overlap and consensus
about the best treatment option is lacking. For example, the
efficacy of arthroscopic meniscectomy for the treatment of
degenerative meniscal tears has recently come under
scrutiny [10, 11].
The aim of the present meta-analysis was to compare the
outcomes of (1) total and partial meniscectomy; (2)
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Eligibility criteria
Types of outcomes
Methods
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Statistical Analysis
All dichotomous outcomes were expressed as risk ratios
with 95 % confidence intervals (95 % CI) and all continuous outcomes as mean differences with 95 % CI. The
outcomes of similar treatments were pooled where possible. This was done using a random effects model.
Heterogeneity of these data was determined using the I2.
An I2 greater than 50 % was considered moderate heterogeneity and above 75 % as severe heterogeneity [18]. If the
I2 was greater than 50 %, data were deemed to
Results
A total of nine studies were included in this meta-analysis,
involving a combined 904 subjects (Fig. 1) [1927]. Study
size ranged from 40 to 311 participants. Three hundred
thirty patients underwent a meniscal repair, 402 meniscectomy and 160 a collagen meniscal implant.
Characteristics of the included studies
The characteristics of the included studies are shown in
Table 1. The majority of the included studies focused on
longitudinal tears only [1921, 23, 25, 26]. In three studies,
the tear had to be in the redred or red-white zone for
patients to be included [19, 21, 25]. Two studies only
included patients with a meniscal tear greater than 10 mm
[19, 23].
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Study design
RCT
Quasi
randomized
RCT
RCT
RCT
Authors
AlbrechtOlsen
et al. [19]
123
Biedert [20]
Bryant et al.
[21]
Hamberg
et al. [22]
Hanteset al.
[23]
O: 28.5I:
28A: 25
AP: 46.9AT:
46.0OP:
46.3OT:
52.2
A: 25.1I: 25.7
30.4
A: 26.5I: 25.5
Mean age
(year)
57
40
100
40
68
No
44:13
36:4
62:38
21:19
55:13
Gender
(M:F)
23 months (1737)
At least 8 weeks
26.5 months
(1238)
34 months
Mean follow-up
Allinside technique
(n = 20)
Inside-out technique
(n = 20)
Outside-in technique
(n = 17)
Arthroscopic total
meniscectomy (n = 10)
Arthroscopic partial
meniscectomy (n = 10)
Conservative (n = 12)
Interventions
Complication rate
Full-thickness
rupture [10 mm in
length, \6 mm from the
capsule
Complication rate
KT-1000
arthrometer laxity
Meniscus healing
rate
IKDC knee
evaluation
Number of visits
Muscle strength
LKSS
Return to sport
Operation time
Knee range of
motion
Measure
ACL QOL
Re-tear rate
Complication rate
WOMET
Complication rate
Control MRI
Radiography
Pain
IKDC
Meniscal healing
Outcome measures
Type of tear
No differences
between
techniques in
complication rate
Inside-out is
superior to outsidein or all-inside
technique
Arthroscopic partial
meniscectomy is
superior to other
techniques
No statistically
significant
differences
between sutures
and arrows
Partial
meniscectomy
should be
performed for
intra-substance
meniscal lesions
Better healing in
arrow repair group
Main findings
RCT
RCT
RCT
RCT
Hedeet al.
[24]
Jarvela et al.
[25]
Kise et al.
[26]
Rodkey
et al. [27]
39.3
B: 26.9F:
25.5
S: 30A: 32
34.5
Mean age
(year)
311
46
42
200
No
243:68
26:20
29:13
154:38
Gender
(M:F)
59 months (1692)
24 months
27 months 9
12 months
Mean follow-up
Bioabsorbable meniscus
arrow (n = 21)
Bioabsorbable Trinion
meniscal screw (n = 21)
Interventions
Vertical longitudinal
meniscal tears eligible for
arthroscopic all-inside
meniscal repair
Traumatic longitudinal
unstable meniscal tear in
a redred zone or in the
redwhite zone of the
meniscus
Type of tear
Complication rate
Osteoarthritis (outer
bridge)
Re-operation rate
LKSS
Persistent pain
(VAS)
TAS
KOOS
Re-operation rate
MRA evaluation
IKDC score
KLSS
Clinical examination
Radiological
changesBone
mineral changes
Complication
rateKnee
instability
LKSS
Outcome measures
The collagen
implant had no
positive effects in
patients with acute
injuries
The collagen
implant was
superior in the
recurrent group
No difference
between groups for
functional
outcome
Lower reoperation
rate with FasT-Fix
sutures compared
to Biofix arrows
More chondral
damage with arrow
fixation
Preservation of the
peripheral rim of
the meniscus
improved
functional
outcome
Partial
meniscectomy is
superior to open
meniscectomy
Main findings
A arrow suturing, ACL anterior cruciate ligament, APM arthroscopic partial meniscectomy, B biofix, F female, FF fast-fix; I inside-out suture repair, IKDC International Knee Documentation
Committee, KOOS Knee Injury and Osteoarthritis Outcome Score, LKSS Lysholm Knee Scoring Scale, M male, Mo months, MRA/MRI magnetic resonance angiography/imaging, QOL quality
of life, RCT randomized controlled trial, TAS Tegner Activity Scale, VAS Visual Analogue Scale, WOMET Western Ontario Meniscal Evaluation Tool
Study design
Authors
Table 1 continued
123
123
There are no level I studies reporting on meniscal transplant, but one study describes a collagen meniscal implant
[27]. Rodkey et al. reported on 311 patients with either an
irreparable meniscal tear or prior partial meniscectomy and
randomized these patients to either a collagen meniscal
implant or arthroscopic meniscectomy. At 2-year follow-up
they found no significant difference for patient-reported
physical function, LKSS, patient satisfaction, pain scores
and complications [27]. However, they did find that there
were fewer unplanned re-operations as a results of disabling or persistent pain or mechanical symptoms in the
collagen implant group when compared to the meniscectomy group (89 versus 74 % survival rate, p = 0.04) [27].
Open versus arthroscopic approach
There were no studies that specifically focused on this
comparison. However, as reported earlier, Hamberg et al.
studied both an open and arthroscopic approach to partial
and total meniscectomy, the results of which can be read in
the Partial versus total meniscectomy paragraph [22].
Discussion
The most important finding of this systematic review and
meta-analysis is that there is a lack of level I evidence on
the surgical treatment options for meniscal injuries. Only
the outcome of the arrow technique versus inside-out
sutures was evaluated in more than one level I study with
good homogeneity. Pooling of these data showed that
there was no difference in outcome for recurrent tears,
minor complications and major complications. The other
comparisons between treatment strategies were either only
found in one level I study, or the studies were too
heterogeneous to allow for pooling of the results. Therefore the aim of the present meta-analysis to compare the
Fig. 3 Forest plot of the comparison arrow versus suture repair, outcome: recurrent tear
Fig. 4 Forest plot of the comparison arrow versus suture repair, outcome: complications
123
123
Limitations
Strong points of this systematic review/meta-analysis are
that every attempt was made to minimize error and bias
during the review process by performing each step by at
least two authors independently. In addition, none of the
authors were involved in any of the included studies. There
was no restriction in language for the search or inclusion of
studies. The references list of all included studies was
carefully reviewed, meeting abstracts were searched and
experts in the field were contacted for potentially missed
studies. However, this study does have limitations. There is
a chance that publication bias has resulted in unpublished
trials with negative results. Some of the included studies
had a low sample size. In addition, various studies showed
heterogeneity which impaired pooling of the results. Some
of the predefined primary and secondary outcomes of
interest were not reported in literature such as swelling,
stiffness, range of motion, muscle atrophy, muscle weakness and length of hospital stay. All these aforementioned
factors affect the quality of evidence presented in the metaanalysis.
Clinical implications and recommendations
for the future
With the recent scrutiny of the efficacy of arthroscopic
partial meniscectomy for degenerative meniscal tears [10,
11], it is more important than ever to critically assess
current orthopaedic practice. This meta-analysis illustrates
the lack of level I evidence to guide the surgical management of meniscal tears. Large, possibly multi-center, double-blinded, randomized clinical trials comparing the
various treatment options are necessary to ensure strong
treatment recommendations founded on evidence-based
medicine.
Conclusion
The aim of the present meta-analysis was to compare the
outcomes of (1) total and partial meniscectomy; (2) meniscectomy and meniscal repair; (3) meniscectomy and
meniscal transplantation; (4) open and arthroscopic meniscectomy and (5) various different repair techniques for the
treatment of meniscal injuries. The only surgical treatments
that were compared in homogeneous fashion across more
than one study were the arrow and inside-out technique,
which showed no difference for re-tear or complication rate.
This meta-analysis illustrates the lack of level I evidence to
guide the surgical management of meniscal tears.
Conflict of interest The authors did not receive any outside funding
or grants directly related to the research presented in this manuscript.
The authors state that this manuscript is an original work only submitted to this book. The authors hold the rights to all the material
presented in this manuscript. All authors contributed to the preparation of this work. Author Job Doornberg has received a research grant
from the Marti-Keuning-Eckhardt Foundation for his post-doctoral
research. The remaining authors declare that they have no conflict of
interest.
Type of bias
Description
Relevant domains
in the risk of bias
tool
Selection
bias
Sequence
generation
Blinding of
participants and
personnel
Detection
bias
Blinding of
outcome
assessment
Other potential
threats to validity
Attrition bias
Incomplete
outcome data
Performance
bias
Appendix
See Tables 2 and 3.
Menisci, tibial/
2.
3.
4.
Athletic Injuries/
5.
6.
Knee.tw.
7.
Or/26
8.
Menisci*.tw.
9.
And/78
10.
1 or 9
11.
12.
13.
Randomized.tiab.
14.
Placebo.tiab.
15.
16.
Randomly.tiab.
Trial.tiab.
17.
Groups.tiab.
18.
11 or 12 or 13 or 14 or 15 or 16 or 17
19.
20.
18 not 19
21.
10 and 20
Reporting
bias
Allocation
concealment
Other potential
threats to validity
Selective outcome
reporting
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