Okay, so it is 832, we will go ahead and get started. Thanks everyone for tuning in for this installment in the National Fellow Online Lecture Series. I'm Robbie Bowers from Emory Sports Medicine in Atlanta, Georgia. I'll serve as the moderator tonight. Before we get started with the talk, let's just go through a little bit of housekeeping. So the next lecture will be next Wednesday night, usual time, 8.30 p.m. Eastern Time. The topic will be apophysitis with Aaron Provence as a speaker and Matthew Wise serving as moderator. So tonight's lecture will be on meniscus injuries and management. Our speaker will be Dr. William or Bill Berrigan from the University of California, San Francisco. And again, I'll serve as a moderator. For a formal introduction, just a couple housekeeping topics. Again, this is to serve as an adjunct to your individual programs, educational topics that you go over the course of the year, is to provide fellows with direct access to a wide variety of AMS SM members and even some invited guest speakers at times. And really our focus is to help you to prepare with CAQ exam preparation, as well as to present high-yield clinical topics to you. So if you'll keep your device on mute, turn off your video. If you have any questions, please submit those through the chat function. I will then ask Dr. Berrigan and we'll have a discussion at the end of his talk regarding those questions. And there will be a link to an evaluation form that will be in the chat function if whoever's attending now live, if you wouldn't mind going through and filling out that evaluation, that'd be very helpful. So again, tonight's topic is meniscus injuries and management. Before introduction, I would say that while this may not be the most highlighted topic on the CAQ, it's an extremely relevant topic, I think from a clinical standpoint, as far as pathology and an injury that you're going to see as a sports medicine doc over and over and over. And I think as sports medicine physicians on the non-operative side, we need to know which of these injuries we can manage non-surgically and which ones need to be referred for surgical intervention sooner rather than later. So I think it's a very high-yield clinical topic. So with that said, our speaker tonight is going to be Dr. William Berrigan from the University of California, San Francisco. He completed his residency in PM&R at MedStar Georgetown at Washington, D.C. and then served with us as a sports medicine fellow here at Emory in Atlanta and was our first two-year fellow serving as a chief fellow in a second year. So with that said, I will let Dr. Berrigan take it away. Thanks, Robbie. I appreciate that. Let me see. I'll just go ahead and share my screen here. Can you see that? Okay. Okay. So my goal here tonight is just as Robbie said, is to cover as much for the CAQ and then more importantly is the clinical aspect and see which one is surgical and which ones are not. And so we'll kind of dive deep into that today. So these are just my disclosures, nothing really relevant to this talk today. I would like to acknowledge two people. So Dr. Nick Kolivos, who's our meniscus guru here at UCSF. He's helped me with some of the surgical side and some of the images will come from his patients in addition to one of our fantastic surgeons, Dr. Ellie LaRocque, who has helped out with this as well. So we'll first start out with the anatomy of the meniscus. So the meniscus is a piece of fibrocartilaginous structure. So it's primarily made up of type one collagen. So this is about 90% of the meniscus. The rest is some other types of collagen between types two and six. So what it does is it provides this nice cushion-like structure. And the medial meniscus is more of a C shape that encompasses about 60% of the tibia, whereas the lateral meniscus is more of an oval shape where it encompasses more of the tibia. What I'm highlighting here in this image is the roots because that'll be important when we talk about it later. But there's the anterior root and the posterior root of the medial and lateral meniscus. And you can see how close they are to our collateral ligaments. The meniscus is also held to the tibia by these small little ligaments as well. And then there's also meniscocapsular ligaments that hold that meniscus in place. So there is a variant in anatomy that I should talk about, and this is called the discoid meniscus. So this is basically where the meniscus has a different shape. And so you don't get that normal C-type shape, you get a more disc-like appearance. And so there's three different types of this, and that's classified by the Watanabe classification. So type one is a discoid shape, and it doesn't have a posterior attachment. Type B is more of an incomplete discoid meniscus, but the difference is it does have a posterior attachment. And then C kind of looks like a normal meniscus, but it doesn't have that posterior attachment. So when you don't have a posterior attachment, that leads to more instability and more likelihood of injury. So these discoid meniscus are more likely to be injured, or at least unstable. When we go through the basic science of it and look at the vasculature, it's different parts of the meniscus have different blood supplies. And what do I mean by that is just the peripheral portion of the meniscus has a higher amount of blood supply to the area, and then it goes down as you get more to the inner portion. So we refer to these as different types of zones. So the peripheral third is called the red zone, and then the middle third is the red white zone, and then the inner third is that white zone. And this has kind of been a classic description of how we look at the vasculature. And this is very important because it has importance and relevance to what can respond to a meniscal repair and surgical treatments. When we look at the function of the meniscus, it really acts as the shock absorber. So it increases the congruence of the articulating surfaces of the knee joint. And this leads to the ability to transmit load. So it's kind of like a pebble when you drop it in water, where you get this ripple effect. So the axial load that's coming down on the meniscus, the meniscus is able to translate that outwards and absorb that force. It also provides stability in this way, provides some appropriate exception. And then if we think about it, it also limits some of the motion at extreme angles. So when you go into extension or hyperextension, that meniscus is actually pushed anterior to posterior. So if you could think about this where patients are having pain with that hyperextension motion or if we're doing a bounce home, that meniscus is being pushed posteriorly. And then when we go into flexion, the meniscus is being shifted kind of from medial outwards to lateral with the compression. When we classify meniscus tears, we look at where they're located. So the meniscus can be divided into the anterior horn, the mid body, and the posterior horn. And then we look at these different zones. And we talked about the red, red, white, and white zone, but we are kind of getting more into a different type of classification system. And the reason this is, is because there's a lot of variability with that. And as you age, that vasculature can change. So now it's looked at zone one, two, and three, and these are more measured in different millimeters rather than looking at where the blood flow is. And then we have our posterolateral roots, posterior medial roots. So that could be the classification as well. So there's different types of meniscus tears. So you have horizontal tears. These are more of your degenerative tears. You have vertical tears, which is usually in an acute injury. Those vertical tears can turn into a bucket handle tear where that part of that meniscus flips and goes into the tibial notch. The radial tears are tears that are extending from inwards to outwards. And these could be in more of an oblique fashion, which is a parrot beak tear, which is a type of a radial tear. And then when we see degenerative tears, these are more of a mix of everything. So they could be longitudinal, vertical, or kind of a complexity of types of tears. So the mechanism of a meniscal injury for the medial meniscus in a traumatic injury is usually tibial rotation with a knee flex during weight bearing. So this happens often in soccer and football. When we see the lateral meniscus, this is usually an injury after squatting and full flexion with rotation, i.e. in wrestling. Any time you see a lateral meniscus tear, think about a discoid meniscus. Most of the time, the discoid meniscus is present on the lateral side. So especially in our young athletes where they have meniscal type symptoms, think discoid meniscus on your differential. Common between both the lateral and medial meniscus in these traumatic tears are painful clicking, popping, and catching. In our degenerative tears, this is different. So these are older patients, usually greater than age 50. They have some chronic pain localized either lateral or the medial portion of the joint. They can have intermittent swelling, mechanical symptoms, locking, catching, clicking. They could have pain at night from the condyles kind of rubbing against each other or the meniscus getting tweaked. These are all things to look out for in a degenerative tear. So physical exam for the meniscus is actually pretty good, and it's not any one single test that does it, but it's a combination of the tests. So the combination of the McMurray joint line tenderness and the Thessaly test has been shown to be just as accurate, or at least just as sensitive in picking up a meniscus tear as an MRI. So we like to see the combination of those tests. And so when we look at the McMurray test, this is where you internally rotate the tibia and then you extend outwards. And this is testing the lateral meniscus. If you externally rotate the tibia and then extend the other way, then you're testing the medial meniscus. Sensitivity on this isn't great, so it's one of the lower tests for the meniscus. But again, we're looking for a combination of tests. And the positive test is a pain or snap concerning for a tear. The Thessaly test is the best test that you can do for the meniscus with the highest sensitivity and specificity. And you can see here, basically you just have the patient do a quarter leg squat, they come down and then you hold on to them, or they could hold on to something else, and then they twist from side to side. And this is applying an axial load to the meniscus while also providing friction in that twisting motion. So beyond physical exam, we'd like to go to imaging. So first step is usually to get some radiographs. Radiographs aren't going to show you much, but they can rule out other causes of knee pain. So in an acute injury, you could be looking for loose bodies. And anyone over the age of 50 should get some radiographs to look for degenerative changes along with it. So that's where that's providing. Also with insurance issues, we always know that you need the radiographs to get the MRI. So ultrasound can be used, but it's really a poor visualization of the meniscus. And so it can be suitable for screening with a decent sensitivity and specificity, but know that it's never able to tell what type of tear it is, which is important as we move forward. If you look at ultrasound, you might see these anechoic-type cleft areas within the triangular substance of the meniscus. So the meniscus is usually a triangle, it's hypoechoic. So if you see any anechoic areas within the meniscus, that can be significant for a tear. We also look for it coming out of the joint, so meniscal extrusion. And you could see cysts in the area as well. So these are all indirect signs of a meniscal injury. But MRI is going to be your gold standard for imaging. This could be used for planning for surgery, informing the patient. It's not necessary to get in suspected degenerative meniscus tears. So when we look at ultrasound, this is a paper that came out of Journal of Ultrasound and Medicine, and they looked at how else could we evaluate the meniscus. So they had the patient supine, they had the patient do an active leg lift, and then they had them upright and weight-bearing. And they looked at the degree of meniscal extrusion with a normal meniscus, with mucoid degeneration, and with a torn meniscus. And they found that there was a significantly more extrusion with the weight-bearing, and a mucoid degeneration, and a torn meniscus, and both were similar. So this, again, can be used as a similar screening tool. And this is what it looks like. So the transducer here is long axis to the joint. The MRI in A and B is what it correlates with. So C is when the patient is supine, D is when they do a leg lift, and E is when they're actually weight-bearing on that joint. And so you can see the progressive degree of extrusion of the meniscus as evidenced by the arrowheads moving forward. MRI, a normal meniscus, is going to look like a triangular shape, so it's going to look like a bow tie. And that's this low-intensity signal on the T1 and T2 images. The meniscus tear is going to have some sort of abnormal signal that we see within the meniscus. Now, there's something called the two-slice touch rule. And so if you see abnormal signal within the meniscus on one slice, there's a very low positive predictive value that there's a meniscus tear. But if you see it on two slices in a row, this has a much higher positive predictive value for identifying a meniscus tear. And you should always look to see if that signal comes in contact with an articular surface. They can then be classified into two different planes, vertical and horizontal. And then it can also be a description of the type or shape of the tear, longitudinal, radial, or horizontal. And we'll go into this in a little bit more detail. So this is a vertical tear. So a vertical tear divides the meniscus into two sides. So it goes straight up here, the signal intensity that goes from the inferior portion into the superior portion here. And we see that in both the sagittal and the coronal planes. These types of tears, again, are in acute injuries, and they have the potential to become unstable and flip up into something like a bucket handle. A radial tear is a tear that originates from the inner portion and then spreads outwards. So this is a pretty significant radial tear. So here's the coronal image showing the absence of a meniscus in that area. And this correlates to the sagittal images, which is in the midbody where you see this signal. So radial tears are usually in that midbody of the meniscus. Horizontal tears, or they're also called cleavage tears or fish mouth tears, these are more of your degenerative tears, and it can separate the meniscus into a superior and inferior portion. And what you're looking for here is signal intensity within the meniscus that is linear pattern. So we can see that both on the coronal on the left, and then on the right, we see that in the sagittal image. Bucket handle tear has a couple classic signs that you can see on MRI. So this is that vertical tear that's flipped up into the notch. And so you can see something called a double PCL sign. So that's that arrow that we're looking at, so when you're scrolling through the sagittal images, you might see the PCL, and then you're wondering, why does it look like there's two PCLs? Well, actually, that meniscus is being flipped up to the notch, and that's what you're seeing as that second image there. You can also see something called a double anterior meniscus sign, where you see the anterior meniscus is divided, and then you could also see an absence of that meniscus, which we're seeing here in the posterior aspect of the joint on the sagittal aspect. Further on, we're going to be distinguishing acute traumatic tears versus degenerative tears, and we're also going to be distinguishing stable versus unstable, because both of them have different types of management. Stable traumatic knees, so this means there's no ligamentous damage within the knee itself. About 6% of acutely injured knees will sustain some sort of meniscus tear, 15% with acute knee trauma and hemarthrosis sustained will have an isolated meniscus tear, so often it's not just isolated meniscus tear, there's other ligamentous damage, and then when this occurs, about 75% involve the medial meniscus, but we look at unstable knees, meaning there's other ligamentous damage associated with it. It's a different type of picture, so an acute ACL plus an MCL, you're more likely to see a lateral meniscus tear than a medial meniscus tear, and interestingly enough, if there's an MCL tear present, a grade 3 MCL is more protective compared to a grade 2, so more successful outcomes there. Acute ACL, you're often more likely to see a lateral meniscus tear than a medial meniscus tear, and then 25% to 33% do not have a meniscus tear in an acute ACL, so the majority of ACLs will have some sort of meniscus pathology, and a chronic ACL, this is associated with a meniscus tear in up to 96% of patients, and more often you're going to see a medial meniscus than a lateral meniscus. An unstable meniscus is a central portion of the tore meniscus that can actually be dislocated towards the joint space, towards that center of the femoral condyle. This can lead to locking and pain and these mechanical symptoms. It also engage, or is able to engage, we're seeing a tibial plateau and MCL into the notch, or if it's displaced at least 5 millimeters, this is also considered an unstable meniscus. Examples of this are longitudinal tears that turn into bucket handles, you're going to have flat tears that engage between the femoral condyle and the tibial plateau, and all radial tears are also considered to be unstable. So the treatment for an acute meniscus injury is to alleviate pain and swelling. So you're going to start with your PRICE technique, or your Peace and Love, so you're going to protect it, rest it, ice, compression, elevation, and maybe some anti-inflammatories to help the swelling get down. You can use a knee brace, it's not really required, but it can provide some potential stability, or if the patient would like that, they can provide some more awareness of the knee. Activity modifications is important, obviously withholding from sport, avoiding different activities that provoke pain, such as deep knee flexion. And then early physical therapy can be great because you might have a lack of flexion or extension and this can affect surgical outcomes in terms of having a stiff knee post-surgery. So it's important to try to get that pain-free range of motion as tolerated with either early physical therapy or teaching them how to do it on their own. If they decide that they do not want to do surgery for these acute tears, then injections are options like we do, corticosteroid HA and the biologics. So an acute tear that occurred less than six weeks is a great indication for surgery. If they have a concurrent ACL, if it's in the red zone or that peripheral zone one, with good vasculature for healing, if it's complex and extensive meniscal rips, tears greater than one centimeter, these respondents should be surgical. And then all young healthy candidates at less than the age of 40 should really be considered for surgical management of these acute meniscus injuries. So how do they do surgical management? Well, there is partial meniscectomy or arthroscopic partial meniscectomy. They don't do total meniscectomy that was done several years ago because we know we need that meniscus. But even then, we should try to preserve the meniscus as much as possible, and partial meniscectomy should be a last resort. So this may be the case in complex tears or if there's a high degree of degeneration or flap tears or non-reducible bucket handle tear, but the majority of surgeons are leaning towards trying to repair the meniscus because of its specific function. So this is a study that came out last year. It was a multi-center randomized study of 100 patients aged 18 to 45. They looked at a traumatic isolated meniscal tear without any knee arthritis, and they compared a partial meniscectomy versus PT. So the patients also had the option to cross over at three months. So keep in mind, this is not a repair, this is a partial meniscectomy. And what they found is that the physical therapy group and the arthroscopic partial meniscectomy group did pretty similar at multiple different time points throughout the two years in terms of functional and pain score. So their conclusions from this study was that young patients with an isolated traumatic meniscal tear and early arthroscopic partial meniscectomy was not superior to a strategy of physical therapy with an optional delayed partial meniscectomy. So interestingly about this, 41% crossed over to receive the APM. So that's a pretty high crossover rate. So you'd think that the 41% weren't responding to physical therapy. And then they never designated the type of meniscus tear, which can be important because certain ones are not as easy to repair and others can be easily repaired. And so, again, this is partial meniscectomy, not meniscal repair. It'd be more interesting to see the difference between those two. So as we go from resection to preservation, we're seeing more and more surgeries being done this way. And the rates have doubled in the last five years. So you can see this example is the radial tear. And this was done with an all-inside technique and we're able to suture it up. And it looks pretty good, similar to the normal meniscus. Now factors that affect the meniscus repair. One is location. So Cooper zones one and two, so those peripheral areas, do have a higher success rate with zone one having the best healing rate. Zone three still is successful, but it is harder to repair in those areas. So some surgeons will go in, they'll repair as much as they can in the other zones. And if it extends to zone three, they might do some partial meniscectomy, but still repair as much as they can. Location in terms of anterior horn versus mid-body versus posterior horn. This does not actually have any effect on outcomes. The length of the tear is controversial. Some say that one centimeter, this kind of a cutoff for positive versus negative outcomes, but realistically this is controversial within the literature and should not be considered any contraindication to a meniscal injury and repair. Modifiable and non-modifiable risk factors. So age does not affect the failure rate. BMI, although this does increase the likelihood of having a degenerative meniscus tear, it doesn't change the effect on the outcomes for repair. Level activity is also controversial, meaning we still have our higher level athletes, professional athletes that are able to return to their previous level of play after a meniscal repair if the proper time and rehabilitation is allowed. It hasn't really been studied in terms of lower limb alignment. There was a small case series, about 58 patients that came out and it was a poster presentation in July of last year, but they did show that preoperative alignment did not really influence outcomes, but this should be further studied. So there's a few different techniques to repair the meniscus, and this is the caveat, I'm not a surgeon, but I'll do my best to explain this. So the inside-out technique was previously, or still is kind of considered the gold standard, but we're seeing more surgeons move towards an all-inside technique. But the inside-out technique is you take the device and you suture the meniscal tear, and then you attach that to the capsule, and you tie the knots outside of the capsule. So this can be used in longer tears, so you need to do this inside-out technique for ones that need more extensive suturing in that area. But the all-inside technique is where you're able to go into the device and go to the meniscal tear itself, and provide the sutures with the device, and be able to sew that up with the suture, and successfully repair the meniscus. And this could be directed posterior, so this is a way to repair some of these meniscal root tears. Circumferential repairs, there's even more devices that are coming out, so if you see this vertical tear here, basically the device is able to come in and you could get this mid-portion of the meniscus, and the mid-body of the meniscus, which is nice the way it's able to be directed. And then you just circumferentially suture them together, so it ends up looking something like this. And this is very widely used now, and with successful outcomes. So if we look at long-term outcomes of these meniscal repairs at greater than five years, the overall failure rate is about 22%. But what we really need to start doing is looking at early generation versus what we're doing now, because the devices have changed. So early generation all-inside techniques, where all the suturing is done inside, the failure rate is about 30.2%, versus the modern all-inside techniques are about 15.8%. And then if we look at the inside-out versus modern all-inside, it's pretty similar as well, about 14.2% and 15.8%. And with the ACL reconstruction versus an ACL intact, they're also pretty similar, 21.2% and 23.3%. So the more everything develops, the higher the success rate as we move forward. What about if the meniscus tear was just left in situ? So with ACL reconstruction, there's a low rate of reoperation, so about 0% to 30%. Lateral meniscus tears, they have a lower rate of reoperation than medial meniscus tear. And length greater than 10 millimeters may affect outcomes, as I discussed before. So the European Society recommendation, which is kind of an international recommendation for the meniscus, recommend that lateral meniscus less than 10 millimeters can be left as is, versus a medial meniscus should always be repaired. Now, if we look at a radial tear, so that's extending from inside outward, and they could also extend obliquely, this is equivalent to a functionally deficient meniscus. And the reason being is because you're losing that effect of the shock absorption, being able to move outwards in a circumferential pattern. So even if this is in zone 3, it should be attempted to repair as much as possible. And as I said, there may be a portion of a partial meniscectomy in addition to the repair if it's in that zone 3. Root tears, so posterior laterally, are more associated with an acute injury, traumatic and ACL tears. These should always be repaired. So just like a tree, you're ripping out the roots. So this meniscus becomes unstable, and you also have a functionally deficient meniscus, which could lead to early arthritis or accelerated arthritis. These posterior medial tears are more degenerative. So that depends more on the degree of arthritis, the degree of cartilage changes, whether or not you repair those. And this study looked at the actual contact pressures of the meniscus and a root tear. So A is a normal meniscus, and then this is a cadaver study where they simulated a root tear, and they found that there was excessive contact pressure. It's increased with a root tear. And then they compared that to a total meniscectomy and found pretty similar outcomes in terms of the contact pressure. So essentially, that root tear is equivalent to a total meniscectomy. Now, these bucket handle tears are the vertical tears that can flip up into the notch. These should always be repaired, and they often can cause these mechanical symptoms where the knee is stuck and can't fully extend or flex in the area. And so this is going to be a video of a bucket handle repair that was repaired. But also, it shows different types of meniscus tears to show that not only does the knee show that it's not always isolated. So in this arthroscopic image, here's our meniscus here. You have a vertical tear, and then you can see there it's a bucket handle. So the vertical tear has turned into a bucket handle tear. If you go further into meniscus, you can see this horizontal cleavage tear. And then if we go underneath, you see a small flap tear as well. And so this was repaired with an all-inside technique. And you can see at the end of the repair, it's solid and looks like the previous normal meniscus. So in a discoid meniscus, and we talked about this a little bit earlier, this is a nice algorithm to look at. But what you want to identify is, are there symptoms? So are there mechanical symptoms? Is it painful? And so that's what you look for in these athletes. You're not prophylactically fixing these at any point. So if they have mechanical symptoms and pain, then they consider partial meniscectomy with or without a meniscal repair or a saucerization procedure, where you actually take the meniscus and get that discoid shape into more of a normal shape. This can often lead to a tear, a horizontal tear. So that tear is usually repaired. So this is an MRI image of a discoid meniscus. So you can see here the abnormal shape of that discoid meniscus. And it has a tear that's associated with it here. Other MRI criteria for a discoid meniscus is three cuts in a row, so 5 millimeters each, so about 15 millimeters. If you see the meniscus, then that is a diagnostic criteria for a discoid meniscus. And these can be repaired. So this is a, you see that the horizontal tear ended up being repaired with that all-inside technique. So can you use biologics to augment these surgical outcomes? Well, so far, we're seeing similar rates of failure and revision with biologics. Now, take this with a grain of salt because all these studies don't necessarily report platelet counts and dosage. So maybe we'll see this change in the future. But as of now, we don't have any evidence that adding PRP to these repairs is able to increase the outcomes or increase the favorable outcomes. The BMAC hasn't really been studied for this. This is a one case series of 150 patients that looked at BMAC and showed that it did better at six weeks and three months, but no difference at one year. So essentially, the BMAC didn't enhance anything for the repair. As we learn more about techniques for aspiration, maybe this will change as well. There's a lot of research that needs to be done for BMAC. But as of now, currently, we don't see a difference. Now, I'm going to transition from those acute traumatic tears to degenerative meniscus tears. So degenerative meniscus tear is a slow progression of this degeneration over time. There's no acute trauma. These are usually those horizontal cleavage tears. You can get an MRI on these patients that are requesting it. They're usually incidental findings. And if there's any sort of osteoarthritis in the knee, on your radiographs, they're pretty much associated with the degenerative meniscus tear. As over 90% of patients will have some sort of symptomatic knee OA, will have a meniscus tear associated with it. What you're going to see is a linear intrameniscus signal, as I showed earlier, it's often the posterior horn. These tears increase with age, and if there's any OA present, again, it's very likely that there's going to be a degenerative meniscus tear there. Conservative options for these are anti-inflammatories, injections, usually recommend at least three to six months of physiotherapy or home exercises before you consider anything else. And then the anything else is, well, you can do biologics, you could do arthroscopic partial meniscectomy, and you could do a repair. So let's talk about biologics, so this is a non-operative intervention. So this is a study published in 2019 by Kaminsky and colleagues, looked at 72 patients and compared trepanation of the meniscus, so back and forth needling the meniscus, plus PRP compared to just trepanation alone. And they found that the failure rate for this was 70% with trepanation alone versus 48% with PRP, and failure rate was just determined by meniscal non-union on arthroscopy or on the MRI. It wasn't talking about pain and function. But when we look at the pain and functional scales, and they specifically looked at the percentage that improved with the MCID, you see a significant number improving with the PRP compared to trepanation in both the visual analogue scale and these functional measures with COUS pain symptoms, ADLs, and also our WOMAC measures, with even up to 86% improving at least with the MCID. And then they also looked at arthroscopy-free survival, so did these interventions keep them from getting a scope? And what they found was that the procedure with PRP decreased the necessity for a scope in the future, so you're only at about an 8% rate, and you had 28% in the trepanation group alone. Very interesting. And this has also been looked at for other interventions that are beyond PRP, so microfragmented adipose tissue, the MFAT. This is a study that was done by Malenga and colleagues of 20 patients. Most of them were a complex tear, some were horizontal, and others as well, and the majority had mild to moderate osteoarthritis. And they found that all COUS measures at 3 months, 6 months, 12 months had improved with the MFAT treatment, and then the numerical pain scores had also decreased from about a 5 to a 2. And so this is some promising information, and also Walter Reed currently has an ongoing trial looking at MFAT comparing to trepanation with saline. So we're going to enroll 80 patients that have failed conservative management, injecting about 2 cc's of MFAT into the meniscus, about all you can get into the meniscus, and the rest into the joint, 4 to 5 ml's in the joint, and they'll be looking at different functional and pain measures. So it's exciting, and we'll see what this results lead to. Well, the question is, how do you do it? So this is a study, or this is a paper, a cadaver paper by Bari and colleagues from the All Star team, and it showed that when you look at the meniscus in that long axis, you're able to see that long axis of the joint, so you see that triangular shape of the meniscus, you go in out of plane and identify the needle tip. Once you see the needle tip out of plane, then you rotate that transducer, so you're able to visualize the needle and long axis, and then you're able to direct that towards the posterior horn of the meniscus to inject the biologic. So moving on towards surgery, the arthroscopic partial meniscectomy is still one of the most common procedures performed in the world, and even in the United States, although we are seeing some sort of trends that are that are going on, and some countries are starting to not approve the partial meniscectomy. Why is that? Well, since 2002, the majority of studies are favoring conservative management over any partial meniscectomy, but the question is, is there actually a partial, is there actually a place for the partial meniscectomy in these patients? And I'll present the evidence, and I will argue that there is. So in an unstable meniscus with mechanical symptoms, there's been a pooled analysis of RCTs that revealed there was actually no benefit with a partial meniscectomy than with conservative management, and this was also supported by other studies looking at mechanical symptoms, showing that there was really nothing, no evidence to support the prevailing idea that this is a requirement for a partial meniscectomy. And then other studies have shown that with partial meniscectomy, you have a higher rate of knee replacement, so this looks at a threefold increase in the risk for future knee replacement surgery. So let's look at the largest studies or largest trials that have been done looking at this. So this is the Fidelity trial, so it's a multi-center randomized participant outcome assessor-blinded placebo surgery controlled trial. It's a mouthful, 146 adults, and they had either received partial meniscectomy or a scope. They looked at changes in imaging, and they also looked at functional outcome measures, and what they found was that the functional measures using the WOMET had similar outcomes with placebo compared to the partial meniscectomy all the way out through 60 months. In the imaging, they found 72% of the partial meniscectomy group and 60% of the placebo group had at least one grade progression in the OA with a risk difference of 13%. 81% and 88% were able to return to normal activities, so that's pretty similar, and satisfaction rate was overall also pretty similar. Now this study also had a high rate of crossover, so 25% to 30%. So 25% to 30% had thought that what they had done with scope was not good enough, and they had received the partial meniscectomy, which is again a pretty high number. And so this study has been done. It's called the METEOR trial, a very large group in seven sites. It's NIH-funded, and they're looking at arthroscopic partial meniscectomy compared to physical therapy, and they looked at 351 patients seeing functional measures in the COOS and to total knee replacement as well, and what they found was that the partial meniscectomy and the PT groups did similar out through 60 months. You see some improvement with the arthroscopic partial meniscectomy group that is larger, especially within those first few months. It was not statistically significant, but there is the potential there. When they looked at how many of them went on to knee replacement, so here in the red, we see the physical therapy group. In the blue, we see the partial meniscectomy group, and in the green, we see those that had crossed over, so we do see a higher number that are crossing over to or that have led to a knee replacement in those that had surgery. So their conclusion was that the considerable pain relief was good in both groups. There was favorable results, and the overall knee replacement rate was pretty low. It was greater than the partial meniscectomy group, but it was pretty low, and when they did the numbers, it was a two-fold increase hazard ratio for the total knee replacement in the arthroscopic partial meniscectomy group. So what they wanted to see is who actually crossed over and why would they cross over, so they looked at independent predictors of crossover to partial meniscectomy among those randomized to PT. They looked at pain relief at six months in between all these groups. Now, it was a low sample size. They had 48 patients that had crossed over, but what they found was that predictors of crossover were these acute presentations, less than a year, and they had higher pain scores, so these patients were actually in more pain and had some sort of injury, so acute on crime that led to this, and they were more likely to choose this surgical approach. When we look at age, sex, BMI, symptoms, all other things, they didn't have any association with crossover, and they found that those who crossed over are as likely to experience improvement in pain as those originally randomized to partial meniscectomy, so it's good because you can think it doesn't matter if it's necessarily delayed, but if these patients are thinking or convinced that they need surgery, they want surgery, or they are in a higher level of pain, maybe it's not a bad option for them. So looking at this trial, again, they wanted to look at the structural changes within the knee, and they looked at MRI, OAD scores, they looked at 18 months and 60 months, and they did find that both groups had a progression in the osteophytes, also in the cartilage scores and changes, but they did see that was higher in the partial meniscectomy group compared to the PT group, so both groups had worsening. It was noticed most within that first 18 months and kind of plateaued from 18 to 60 months, and again, we did see it more in the orthostatopic partial meniscectomy group than the PT, and also there's a progression that osteophyte size in the partial meniscectomy group. Now the question is, is this clinically significant? So they looked to see if this is correlated with any of the knee outcome measures, and what they found is they didn't see any clinically important association between the changes in the bone marrow lesions or the osteophytes or synovitis and subsequent pain, so these changes within the cartilage itself might not be associated with pain, and maybe those that had an increased pain level and decided to get the partial meniscectomy for those that would cross over, maybe they were more predisposed to surgery, and potentially they were more likely to be accepting of having a total knee replacement in the future. There's just some things to consider when we're looking at it in terms of, not necessarily counting out a partial meniscectomy as an option for these degenerative tears, but all that being said, there's been multiple trials showing no benefit compared to conservative management. This has been all the way since 2002, and there's also been multiple studies showing that you do develop OA after partial meniscectomy, so the consensus for the European society looking at this and kind of the international type consensus is non-operative treatment for three months, MRI if not already done. If there's evidence of OA, treat the OA. If there's no evidence, then consider surgery, and if that's repairable, repair it, but then also you can consider the partial meniscectomy. Root tears, this is a different story, so these aren't our usual repair candidates. They're greater than age 50, maybe overweight, usually non-athletic, and so you have the functionally deficient meniscus with the root tear, so it all depends on what degree of osteoarthritis you have. If it's mild to maybe low grade, moderate, there might be repair candidates. If it's more on the moderate to severe side, you're not going to touch that to repair it, and this is what we're looking at here is with that root tear. So, meniscectomy and the repair are not the only options. There's also a meniscal transplant. This isn't a new procedure. We're just hearing about it more. This first one was done in the 80s, and now there's more long-term studies, although most are level three and four. Indication for this are continued pain, continued joint line pain that they had had until a subtotal or partial meniscectomy in that area, and there's very strict criteria of who can do this. Very strict criteria of who can get a meniscus transplant, so that knee must be stable, so it's a higher failure rate with any sort of ligament instability, so those ligaments usually need to be fixed up as well in the process. There must be healthy, good cartilage, so if you look at Fairbanks changes, which is changes in imaging based on the meniscus, and so there must be less than grade two degeneration. There also must be less than 50% cartilage change in that area. Have to be well aligned, and if they're not well aligned, you have to address that malalignment, and the reason these are all the specifics is because if you put that cadaver meniscus on there, then you can overload it if you don't miss this criteria, and then the transplant is going to fail. It's important to know that this is a long post-operative period, so it's almost similar to ACL, where it takes nine to twelve months to return to sport, and we're not looking at these high-level athletes to return to sports. These aren't who you're going to give this meniscal transplant to, but they must be compliant with the protocol, so they have to be braced and extension on crutches for about six weeks, and they don't return to their ADLs to like eight weeks, so it is a pretty extensive process the patients need to be educated on. However, the outcomes are good, so we're seeing more long-term outcomes, 141 months out, 168 in Lysholm and VAS scores, that the meniscus transplant can be successful in those selective patients. So, I talked about a long, prolonged time to return to play for the meniscus transplant. Well, let's look at everything else we talked about today in terms of how long it'll take to return to play. So, this is my protocol for the work of biologics. When we do that into the meniscus, it's based on some of the other literature out there, is usually within the first week or at least the first three days, they're non-weight-bearing on crutches. They don't, and they slowly progress. They're out of the brace in about four weeks, and then at six to eight weeks, they can start to return to sport, so it's about six to eight weeks before you're getting there. In terms of a partial meniscectomy, there's no standardized rehab protocol for this, but usually they're full weight-bearing in about a half a week, active range of motion in three to four weeks, and nonspecific training three weeks. Back to that sport at seven weeks, and our athletes that are rehabbing extensively, this can be a quicker time period, and a lot of athletes might consider they might want a partial meniscectomy because they'll be able to return to sport faster, but that's where education is important, because when we do see that, this is a study by Smith and colleagues looking at meniscus injuries in elite college American football athletes, and those that had undergone a partial meniscectomy, 27% had OA versus 11%, and those that had undergone a repair, and they've also looked at female athletes that had undergone a partial meniscectomy, and there was significant chondral loss when they had an isolated meniscus injury treated with that partial meniscectomy, and so why do I say that? Because a meniscus repair can take about four to six months if it's isolated in terms of the rehabilitation. Protocols are tailored by the different type of tear and how they decide to repair it, but the most important factor is time post-surgery in terms of return to sport and success there. Now, there's multiple different criteria for return to sport. Usually, it's full, painless range of motion, normal mechanics, appropriate proprioception, psychological readiness. These are all important, but then objectively, this is one test. It's called the flea test. Looking at single leg hops, you do a distance. You do time to triple hop and crossover. You compare it to the contralateral side, and ideally, you're looking to get 85-90, but greater than 90% compared to the contralateral side with strength in some of these times to be able to return to play and not be more at risk, and then the athlete needs to be ready to return to play as well. From the meniscus, it's an evolving field. There are many that don't need surgery. We're starting to trend away from that meniscectomy, working towards repairing the meniscus, save the meniscus. Selective or targeted approach is key as every patient is different, and I believe that as we move forward, we'll see biologics playing an increasingly important role within the future. These are my references, and I did have one CAQ questions for you all. That was one of the more high-yield topics. We'll put a poll out there, but this is an 11-year-old female that complains of a few months of right knee pain with episodes of swelling and popping. She plays soccer and participates in dance. She denies any injuries. However, on the examination, there's no effusion or laxity. There's lateral joint line tenderness, and that's appreciated with a positive McMurray test. She has knee radiographs that demonstrate a widened lateral joint space and which diagnosis should be considered at this time. We'll just give it a little more time for everyone to get their answers in. All right. And you guys are all on point. So it's a discoid meniscus. So remember these young athletes consider a discoid meniscus. It's most often that lateral meniscus. One thing I didn't talk about is you can see increased space on knee radiographs or widened lateral joint space. These are all things to consider with these lateral, with the discoid meniscus. Remember if they're unstable causing symptoms or pain, that's when they work to do surgery. If they're not causing any symptoms or if it's just like a click, then you just, then you do non-operative or you do conservative management. And that's it. And I'll take any questions y'all have. Great. Thanks, Bill. Appreciate it. Great talk and summary of that, of that topic. So let's take a look and see. I'll give people a little bit of time to put a question in the chat if you have any. I did, I'll throw a question in your way. So in, you know, going through and preparing this talk, I think a lot of us tend to think, and maybe others think differently, that if there are mechanical symptoms present, that that is a faster indication to send for surgery. And I kind of sense a little bit of, you know, maybe a different approach from your talk. So from a standpoint of mechanical symptoms, so they have pain and so they have intermittent catching and maybe some intermittent locking, is that not a reason to refer for surgery sooner rather than later? So if we look at acute meniscus injuries, so that's always, it will always be an indication to refer for surgery. When we're talking more about degenerative meniscus tears, so there was that study that showed that in the degenerative meniscus tear, there's actually multiple studies that showed if they have mechanical symptoms, a partial mastectomy hasn't really been shown to be beneficial. So that doesn't mean that there isn't a meniscus tear in that degenerative process or kind of a complex tear where something can be repaired. So I think it's still always worth a conversation with the surgeon to see exactly, you know, what can be done and if it's worth doing anything, surgically at that point. But I agree, you know, before reading some of these studies, I would always think mechanical symptoms, let's send it, but maybe there is a place for just doing conservative management for these patients. For mechanical symptoms more for the degenerative tears, right? Correct, correct. Yeah. And so based on the information from this talk, just in summary, which are the meniscus tears that present to you that you, without question, send directly to the surgeon? So any acute meniscus tear, especially in a young patient, you want to send to a surgeon. Usually if it's a acute meniscal injury, that's really more of an indication. If there's any sort of instability or ligamentous damage associated with it, that should be sent immediately to a surgeon as well. If it's an acute injury that is causing those mechanical symptoms, that's an indication. And in terms of the degenerative cases, so those that have been non-responsive to any conservative management over at least three months, that's when I would consider sending them to surgery to talk about if a meniscectomy, partial meniscectomy or a repair may be an option. Also, if we look at types of tears, so radial tears, the goal would be to repair those because that can lead to a functionally deficient meniscus, so you get accelerated arthritis with that. In addition to the root tears, that's also a functionally deficient meniscus, so equivalent to like a total meniscectomy. So those should be, especially if there's not that bad of arthritis, those should be repaired as well, from my understanding. Okay, so here's a situation as far as maybe patients that are a little bit in the gray area. So have someone say they're in their mid-40s and they have some mild arthritis and maybe more mild to moderate. They complain of an acute injury, so maybe something low, they're not playing a sport. So say they were getting out of their car and they twisted their ankle, so say they were getting out of their car and they twisted on it or getting up from the dinner table and kind of twisted on their knee and felt an acute pop, and then you get an MRI and it shows a meniscus tear, but it's not really clear because there was some arthritis that, is it acute or is that more of a degenerative tear, kind of an acute on chronic? And they're complaining of pain and mechanical symptoms. What do you do in that situation? Do you try to rehab them and talk about injection first or is that one that you would send to the surgeon? So I think it depends on the type of tear. It's like a horizontal tear. That's probably worth rehabbing and seeing what they could do, potentially doing an injection. If it looks more like a root or a radial tear, potentially a vertical tear, then that might be worth talking to the surgeon initially up front. It's never the wrong answer to put them into physical therapy, try that first and see where it goes. And then, I mean, they could always have a delayed repair, a delayed partial mastectomy. If you look at the delayed partial mastectomy, we're seeing similar outcomes to those that have it initially too. So that's important. It will say if they have some sort of acute root tear or a potential acute root tear, the time is more important. Usually within a year, you can get some changes on imaging for that. But I don't think it's a wrong answer or it's ever a wrong approach to try physical therapy, see where they're at, do that with conservative management, potentially discuss the MRI with some of your surgeons and see what they think as well. Yeah, I agree with that. I think anytime I see a root tear, I generally just reflex and send them just to be safe. And if the surgeon doesn't wanna fix it at that point, then we can always go back for non-operative treatment. Anytime I see a root tear, definitely will send them. And I think what you bring up is important to more of a little bit of nuance to this. It isn't just about degenerative versus acute. I think if you have that gray area, you need to look at the type of tear it is. So it's not necessarily, oh, they have a meniscus tear and they have some symptoms. Is it more of that horizontal degenerative type tear that you try to rehab versus a vertical or radial tear where you may be quicker to send to the surgeon? So I think there's more in-depth information to look at than just is there a tear, is there not a tear? And so I think it's just important for those of us on the non-surgical side to know those things, to make sure we're doing the best for the patients and sending them for surgery appropriately versus trying to rehab some of these that should likely do well. So there are no other questions in the chat. So thanks again, Bill, for a great talk tonight on certainly a high-yield clinical topic that we all should be familiar with how to treat on the musculoskeletal side. So thank you everyone for tuning in tonight. And thanks again, Dr. Berrigan, we really appreciate it. Thanks for having me, Robbie.

3rd Edition, CASE 48

3rd Edition

Rheumatology

meniscus injuries

anatomy

diagnosis

treatment options

surgical intervention

meniscal repair

degenerative tears

biologics

partial meniscectomy