Okay, now we're going to move ahead with don't bother with repair. Partial meniscectomy is the best. I'm Laith Jhazraoui, chief of sports medicine at NYU, and I'm going to present an argument why partial meniscectomy should be used more often than we are actually using it. I have no pertinent disclosures for this talk. In terms of the epidemiology, over 450,000 meniscus surgeries were performed in 2009. It's the most common CBT code reported in the board's collection period during this time. And the typical average is about 60 meniscus cases per orthopedic surgeon per year, which is a pretty significant amount. The one thing that has been picked up is that there has been an increase in meniscus repairs and allografts during this time period also in patients under 25. So the big thing about this, we know that the meniscus plays an important role. It's not a vestigial structure, and it plays a critical role in shock absorption and the prevention of progression of arthritis in patients. And certainly once people who don't have a meniscus, they're going to be prone to developing arthritis. This has been published numerous times. We know the meniscectomized knee and a lot of these cases, most of them were done open. And we know that when you take out the entire meniscus, you're probably going to develop arthritis. And this has been well published in the literature. And it's also been shown in cases, even with arthroscopy, when you take a significant amount out that you're going to develop premature arthritis. So uniform poor clinical results. And we know it's been hammered into us that we don't want to take out the meniscus because you're going to end up with something like this, a post-meniscectomy arthritic knee. But I think some of the important things to understand in discussing failure rates and time to failure with your patients, what are some good guidelines? And I think the key to understand is that at about two years, there's as high as a 30% failure rate for all types of meniscus repairs that we do in these patients. And so it begs the discussion, if you brought up these numbers to patients, would they actually go for it despite knowing some of the numbers of arthritis in the future? And I think it warrants a discussion. Maybe we're doing too many repairs. It's clear that after about 10 years post-scope, that you're getting arthritis. And we see this in repairs as well. Having a repair and even a successfully healed repair doesn't mean that you're not going to get arthritis. And it's been reported in the literature in about 22% of cases that you start to see arthritis after about 10 years, even in a successfully healed meniscus repair. After resection, we know it's going to be higher. And in that case, 36% of the cases have arthritis after 10 years post-meniscectomy. Is that really a significant difference compared to 22%? But I think when you factor in that there's a higher re-operate for patients who have repairs, this all starts to make us question whether we are over-indicating or over-pushing meniscus repairs in patients. I think when you look at some of these systematic reviews, it becomes quite alarming at the high rate of failure when you look at these pooled failure rates. And in this study, looking at five separate studies, and it was as high as 25%, whether it was clinical or re-operation rate. And then also the understanding that a failed meniscus repair also increases the risk of arthritis at nine-year follow-up. And in this study, 26.7% had developed OA in the index-operated compartment, essentially the same compartment as the meniscus repair, and this was at nine-year follow-up. So the fact that, one, if the meniscus repair fails and then you still clean it up, you're developing arthritis as well in those knees. And I think, look, there are different patient populations. This young patient represents about 35% of the cases we see. This may be a little different in terms of proceeding with a repair, as opposed to this guy, who, again, tore his meniscus, maybe being a little overactive. But these are two different patients, and the idea of even considering any type of repair on this patient would, I think, be silly in a case like that. Degenerative tears, these come up as well. And I think when you look at the literature, it's all over the place, but I think a degenerative tear in patients, particularly older, at least warrant a period of non-operative treatment. So when you look at the partial meniscectomy literature, when they're performed on symptomatic tears, typically we perform them on symptomatic tears not responsive to conservative treatment. And I think that's where not responsive to conservative treatment and not amenable to repair. And those are the ones that we do partial resection on. I think there are others that I'm going to present that maybe we reconsider whether we're going to do a repair, maybe we push forward to a partial meniscectomy. We know that the clinical outcomes are generally very favorable in these patients who have partial meniscectomy, and sometimes we have seen them in our patients that maybe we're pushing the indication for repair on these patients. They don't quite do as well as some of our partial meniscectomy patients. And while it's radiographic findings, they start to develop some arthritis. I'm sure most of you've had patients who have two knees that they come in, they've had one scope many years ago, and it has arthritis in it. They're doing well on that knee and the other knee where they're seeing you for a meniscus tear, they're not doing so well. And that specific knee doesn't have arthritis. I think the key to understand is, again, with arthroscopic meniscectomy, the less you remove, the less the progression of the arthritis. And I think it's important when you look at these cases that you're not going to take all the abnormal tissue out. You're just going to take the tissue out that's unstable. And I think looking at the vascularity and what could actually heal is critical. And when you really look at this, you can see a significant portion of the meniscus, even if you repair it, will not heal. And I've certainly been guilty of trying to extend this indication in younger patients. But I think you're looking at a very small percentage of menisci that can actually heal. And a majority of our meniscus cases are going to be partial meniscectomy cases. So what really matters, I think, you know, the ones that I'm going to say, all right, these are ones where you probably should repair it. Simple vertical red-red tears. Almost all red-red tear types, because those have the highest chance of healing. Acute tears, depending on the location, even extending to the red-white zone. Tears with ACL reconstructions, I extend the indications a little bit. And just understand that less than one centimeter length tears typically do not need to be repaired. And then I'm a little more aggressive in repairing the lateral meniscus tears, as these play a critical role. And often can sometimes, when you resect a lot of it, lead to poor outcomes. I think the importance of looking at a patient like this, when you get that initial look, that you could see that meniscus. And as much as I'm stressing the knee, I can't get back there. I think the importance is, you know, considering the MCL release, when we're doing a partial meniscectomy, it really makes this case a lot easier. And I just throw this in as an aside to really improve our outcomes with partial meniscectomy cases. And you can see here, there's at least about 30 to 40% of this person's meniscus left. I think there are other cases that we say, 26-year-old MMA athlete, okay, we're going ahead and repairing this. And, you know, how you repair it and how you proceed with it, I think there are many ways to do it that are correct. But the idea is, okay, young athlete, red, red tear, we're probably going to fix it. And as I go through with these all inside devices, I think the key is saying, okay, I think that looks like we did a pretty good job and we saved this individual's knee. And you can go, again, I think technique's important on these things, going above and below the meniscus to kind of make it look like this, almost an essentially normal meniscus. And then here's, here he is over here at three months post-op, maybe a little early doing this type of stuff, but very difficult holding this individual back. And so, what happened to him? He returns to fighting at eight months. So, he did no deep knee squats to stress that, you know, meniscus early on. He wins a fight, but starts to have locking in that specific knee that we repaired. And this is what we see when we go back. So, it retore. So, the concern is, okay, well, should we have repaired this in the first place? I think a lot of us would say yes, give it a shot. But this is important for this guy. I mean, he stayed out a significant amount of time for his, you know, from getting paid for what he does, which is MMA fighting, that maybe we should have just taken it out on him. And this is what we ended up with, you know, a more significant portion of his meniscus out. But you know what? He went back, you know, pretty quickly and was fighting again. And now, you know, he had no pain in that left knee, but now his right knee started hurting. And you see this, you know, tear. And then when you go in, same thing as the other side. So, I guess the question is, would someone, you know, repair this side similar to what we did on his left, but in this case, I just took it out again. And he's been fighting successfully now on both knees with no symptoms. And this is what we left him with. Now, what about pushing the limits of meniscus repair? This often comes up, and this gets me a little concerned, you know, especially in athletes who want to get back. Because we do hold these patients back for a significant period of time, at least four months before they can go back, and even more with some more of these complicated tears. And in a tear like this that is being fixed, I don't know if you can tell the athlete that he's going to have greater than a 70% success rate in terms of getting this to heal. So, my concern is doing things that are sort of, you know, pushing the limits, so to say. And really, it's, we got to be sensitive to the patient's time, and really realistic about whether we can get him back. So, I just throw that out there to caution you in terms of over-indicating these repairs. I think in summary, we know with meniscus repair, there's good long-term functional outcome in healed repairs, and I think the key is understanding the word healed. That progression of OA is less than in meniscectomy patients. I think the key to understand is that the progression of OA is less, especially in those patients who have a healed repair, and probably in those patients when they're comparing it to significantly meniscectomized patients. The ones that we do less of a repair, less of a resection on, they're obviously going to have much slower progression of OA. And I think the key to understand is that the failure rate is as high as 30% in these patients, and can occur as early as, can occur even after two years or more. So, I think in counseling patients, you got to explain this. Thank you for your time, and I appreciate the course directors, Dr. Critch and Dr. Gomal, for allowing me to participate. Thank you.

Dr. Laith Jhazraoui

partial meniscectomy

knee surgeries

meniscus

arthritis