Surgery for degenerative meniscus injuries?

Understanding the meniscus and managing degenerative tears

Key Points

1. Meniscus Function: The meniscus acts as a shock absorber and stabiliser in the knee.
2. Treatment Options: Exercise therapy is often recommended over surgery for degenerative meniscus tears.
3. Clinical Implications: Surgery may not provide better outcomes than conservative treatments such as physiotherapy.

What is the meniscus and what is its function?

The meniscus is a crescent-shaped cartilage located between the femur (thigh bone) and the tibia (shin bone) in the knee joint. Each knee has two menisci: the medial meniscus on the inner side and the lateral meniscus on the outer side. The menisci play crucial roles in the knee joint by:

1. Acting as shock absorbers: They help distribute weight and reduce the impact on the knee joint during activities such as walking, running, and jumping.
2. Stabilising the knee: They contribute to the stability of the knee joint by ensuring smooth movement and preventing the bones from rubbing against each other.
3. Protecting the cartilage: By distributing the load across the knee joint, the menisci help protect the articular cartilage, reducing the risk of osteoarthritis.

How are menisci injured?

Meniscal injuries typically occur due to trauma or degenerative changes. Traumatic meniscal tears often result from sports or activities that involve sudden twists, turns, or impacts. Common causes include:

1. Twisting movements: Sudden changes in direction while the foot is planted can tear the meniscus.
2. Direct impact: A blow to the knee during sports or accidents can cause meniscal tears.

Degenerative meniscal tears, on the other hand, occur gradually due to the wear and tear of the knee joint over time. These are more common in older adults and are often associated with osteoarthritis. As the meniscus weakens and becomes less flexible, it is more prone to tearing even with minimal stress.

Why do some MRI scans demonstrate tears even when there is no known injury?

MRI scans can sometimes show meniscal tears in the absence of a known injury. This can be attributed to several factors:

1. Degenerative changes: As part of the natural ageing process, the meniscus can develop small tears and fraying. These changes may not cause symptoms and can be detected incidentally during MRI scans for other reasons.
2. Asymptomatic tears: Some meniscal tears do not cause pain or functional impairment, leading to their discovery only through imaging.
3. Sensitivity of MRI: MRI is highly sensitive and can detect minor abnormalities that may not be clinically significant. 

Which treatment option is recommended for degenerative meniscus and why?

Recent studies and clinical guidelines suggest that conservative treatments, particularly exercise therapy, are often more beneficial for patients with degenerative meniscus tears than surgical interventions like arthroscopic partial meniscectomy (APM). The key reasons include:

1. Similar outcomes: Research has shown that exercise therapy can provide similar improvements in pain and function compared to surgery without the associated risks and recovery time of surgical procedures.
2. Reduced risks: Conservative treatments avoid the potential complications of surgery, such as infections, blood clots, and prolonged recovery periods.
3. Cost-effectiveness: Exercise therapy is more cost-effective and can be tailored to individual patient needs, promoting overall knee health and preventing further degeneration.

Physiotherapy is recommended for degenerative meniscal tears

The recommendation to favour exercise therapy over surgery for degenerative meniscal tears is based on a series of high-quality randomised controlled trials and systematic reviews. These studies compared the outcomes of patients undergoing arthroscopic surgery with those receiving exercise therapy. The findings consistently showed no significant long-term benefits of surgery over conservative treatments. Key studies included:

1. FIDELITY trial: This trial compared APM with placebo surgery and found no significant difference in outcomes between the groups.
2. Systematic reviews: Comprehensive reviews of multiple studies reinforced the lack of substantial benefit from surgery compared to exercise therapy for degenerative meniscal tears.

As a patient with degenerative meniscus issues, would surgery work?

For most patients with degenerative meniscal tears, surgery is not the preferred option. The evidence suggests that:

1. Minimal benefit: Surgery does not provide significant long-term improvement in pain or function compared to non-surgical treatments.
2. Risk of complications: Surgical procedures carry inherent risks such as infections, blood clots, and the need for prolonged rehabilitation.

However, there may be specific cases where surgery is considered, particularly if the patient has severe mechanical symptoms like knee locking that do not respond to conservative treatments.

How long do I expect Physiotherapy to take?

The duration of physiotherapy for degenerative meniscal tears can vary based on the severity of the condition and the individual’s response to treatment. Generally, a structured physiotherapy program may last:

1. Initial phase: The first 6-12 weeks focus on reducing pain and inflammation, improving knee range of motion, and initiating strength training.
2. Ongoing therapy: Continued physiotherapy for several months to enhance muscle strength, improve knee stability, and ensure long-term joint health. 

Most patients can expect noticeable improvements within the first few months, but ongoing exercise and activity modification may be necessary to maintain benefits and prevent recurrence.

Would the outcomes of surgery or Physiotherapy be the same?

The outcomes of conservative treatment with physiotherapy can be similar to those of surgical intervention for many patients. Studies have shown that:

1. Pain relief: Both approaches can provide significant pain relief, though physiotherapy avoids the risks associated with surgery.
2. Functional improvement: Exercise therapy can improve knee function and stability, helping patients return to daily activities and sports.

It is essential to have a tailored physiotherapy program designed by a qualified physiotherapist to address specific needs and optimise outcomes.

Conclusion

The meniscus plays a critical role in knee health, acting as a shock absorber and stabiliser. While meniscal injuries are common, particularly with age, conservative treatments such as physiotherapy are often recommended over surgery for degenerative tears. Research has shown that exercise therapy provides similar benefits to surgical interventions without the associated risks. Patients with degenerative meniscus issues should work closely with their healthcare providers to develop a personalised treatment plan that emphasises conservative management and promotes long-term knee health.

Ref:

Fahrurrozi, A., Jain, N. K., Diwan, A. D., & Jalgaonkar, A. (2019). A 12-week exercise therapy program in middle-aged patients with degenerative meniscus tears. International Journal of Rehabilitation Research, 42(1), 60-68. https://doi.org/10.1097/MRR.0000000000000323

Skou, S. T., & Roos, E. M. (2017). Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: randomised controlled trial with two year follow-up. BMJ, 354, i3740. https://doi.org/10.1136/bmj.i3740

Siemieniuk, R. A. C., Harris, I. A., Agoritsas, T., Poolman, R. W., Brignardello-Petersen, R., Van de Velde, S., Buchbinder, R., Englund, M., Lytvyn, L., Quinlan, C., Helsingen, L., Knutsen, G., Olsen, N. R., Macdonald, H., Hailey, L., Wilson, H. M., Lydiatt, A., & Kristiansen, A. (2018). Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline. British Journal of Sports Medicine, 52(5), 313. https://doi.org/10.1136/bjsports-2017-j1982rep

Thorlund, J. B. (2019). Meniscal tears and ‘mechanical symptoms’ – An unsolved puzzle. British Journal of Sports Medicine. Retrieved from [BJSM](https://doi.org/10.1136/bjsports-2018-100416)

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