Predictors of the Clinical Outcome After Arthroscopic Partial Meniscectomy for Acute Trauma-Related Symptomatic Medial Meniscal Tear in Patients More Than 60 Years of Age Hakan Sofu, M.D., Ali Oner, M.D., Yalkin Camurcu, M.D., Sarper Gursu, M.D., Hanifi Ucpunar, M.D., and Vedat Sahin, Ph.D.
Purpose: To determine predictors of the clinical outcome after arthroscopic partial meniscectomy performed for acute trauma-related medial meniscal tear leading to mechanical symptoms in patients more than 60 years of age. Methods: In this retrospective study with 4.1 years’ follow-up, the clinical data of 154 arthroscopic partial medial meniscectomies were evaluated. The body mass index (BMI), duration of symptoms, the hip-knee-ankle angle, type of the meniscal tear, presence of any chondral lesions, degenerative changes in the patellofemoral joint, the status of the cruciate ligaments and lateral meniscus, and the presence of any plica or synovitis were the independent variables. Visual Analog Scale (VAS) and Lysholm Knee Scoring Scale were the instruments used as outcome measures. Multivariate analysis was performed to determine the major predictors. Results: The mean VAS score for 154 knees evaluated in this study improved from 5.6 points preoperatively to 2.3 points at the latest follow-up. The mean Lysholm score improved from 43 points to 72.7 points. VAS and Lysholm scores at the latest follow-up were significantly worse in patients with a preoperative BMI 26 kg/m2, hip-knee-ankle angle > 5 , grade III or IV chondral lesion of the medial compartment according to Outerbridge classification, degenerative changes in patellofemoral joint surfaces, and an anterior cruciate ligament that was either partially ruptured or degenerative with increased laxity. Conclusions: A preoperative BMI 26 kg/m2, Outerbridge grade III or IV chondral lesion of the medial compartment of the operated knee joint diagnosed during arthroscopic intervention, degenerative changes in patellofemoral joint surfaces, and the presence of an anterior cruciate ligament either partially ruptured or degenerative with increased laxity should be considered as the major predictors of the clinical outcome after arthroscopic partial meniscectomy performed for acute trauma-related symptomatic medial meniscal tear in patients more than 60 years of age. Level of Evidence: Level IV, prognostic case series.
A
cute meniscal tears may interfere with the normal biomechanics and functions of the knee joint during motion and, thus, may lead to severe pain
From the Department of Orthopedics and Traumatology, Erzincan University Faculty of Medicine (H.S., V.S.), Erzincan; Department of Orthopedics and Traumatology, Erzincan Mengucekgazi Education and Research Hospital (A.O.), Erzincan; Department of Orthopedics and Traumatology, Devrek State Hospital (Y.C.), Zonguldak; and Department of Orthopedics and Traumatology, Baltalimani Bone and Joint Diseases Education and Research Hospital (S.G., H.U.), Istanbul, Turkey. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received June 10, 2015; accepted November 20, 2015. Address correspondence to Hakan Sofu, M.D., Department of Orthopedics and Traumatology, Erzincan University Faculty of Medicine, Bas¸baglar mahallesi 24030, Erzincan, Turkey. E-mail: [email protected] Ó 2016 by the Arthroscopy Association of North America 0749-8063/15509/$36.00 http://dx.doi.org/10.1016/j.arthro.2015.11.040
accompanied by mechanical symptoms throughout daily living activities as well as impairment of the quality of life.1 Although the number of arthroscopic surgeries as a treatment modality in late middle-aged or elderly patients with established osteoarthritis have been reported as having decreased dramatically during the past decade, the number of arthroscopic partial meniscectomies regarding the same age groups have maintained an increasing trend during the same time period.2-4 Failed nonoperative treatment and the physical examination findings such as positive McMurray test, joint line tenderness, and effusion have been shown among the clinical factors that most influenced a surgeon’s decision to recommend partial meniscectomy for those patients.5 Today, the clinical results and benefits as well as the necessity of the arthroscopic surgery performed for meniscal lesions in late middle-aged or elderly patients are still
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol
-,
No
-
(Month), 2016: pp 1-8
1
2
H. SOFU ET AL.
controversial.2,6,7 Determining which patients will be less likely to improve as well as the specific factors influencing the improvements in function and pain is crucially important in clinical evaluation of such cases.8 The purpose of this study was to determine predictors of the clinical outcome after arthroscopic partial meniscectomy performed for acute trauma-related medial meniscal tear leading to mechanical symptoms in patients more than 60 years of age. We hypothesized that age more than 65 years, body mass index (BMI) 26 kg/m2, Outerbridge grade III or IV chondral lesion, and advanced joint space narrowing would be associated with lower clinical outcomes after arthroscopic partial meniscectomy in patients more than 60 years of age.
Methods This study retrospectively evaluated the clinical data of the patients more than 60 years of age who underwent arthroscopic partial medial meniscectomy. Between January 2006 and January 2010, 608 patients were operated on. The ones with degenerative meniscal lesions leading to long-standing chronic symptoms and treated surgically were excluded. One hundred and sixty-one patients arthroscopically treated for acute
trauma-related meniscal lesions were identified (Fig 1). Six patients lost to follow-up were excluded. Patients with a medical history of knee surgery, coexisting lateral meniscal tear, and/or total rupture of the anterior cruciate ligament (ACL) diagnosed on the preoperative magnetic resonance imaging (MRI), a history of any fracture of the same extremity, rheumatologic or inflammatory diseases, and the ones with end stage osteoarthritis of the ipsilateral hip or ankle joint were also excluded. The clinical data of 154 arthroscopic partial medial meniscectomies performed in 128 patients more than 60 years of age with a diagnosis of acute trauma-related symptomatic tear were evaluated after having approval from the local ethical research committee. Twenty-six patients with separate traumatic events that led to acute locking symptoms were operated on both knees at different time intervals. Preoperative MRI was obtained for all knees to establish differential diagnoses and prove meniscal tear suspected on physical examination. Main indications for surgical treatment were acute onset of the complaints clearly caused by a trauma and locking of the affected knee that was impossible to relieve without operative measures. Therefore, none of our patients had a cortisone injection or physical therapy as conservative
Fig 1. Flow chart demonstrating the excluded patients. (ACL, anterior cruciate ligament.)
3
PARTIAL MENISCECTOMY FOR ELDERLY PATIENTS
treatment before surgery. A standard arthroscopic partial medial meniscectomy procedure was performed for all knees. An acute traumatic event is defined as a trauma occurred unexpectedly and leads to physical disturbance of the human body that requires medical treatment. All meniscal tears were acute trauma-related symptomatic lesions of the medial meniscus, leading to locking and/or catching symptoms. A fall is defined as an event that results in a person coming to rest inadvertently on the ground or floor or other lower level. Preoperatively, age, BMI, duration of symptoms up to decision of the surgical treatment, and radiographic measurement of the alignment of the lower extremity that was evaluated by measuring the hip-knee-ankle angle (HKA) and defined as varus in case of a positive angular value were recorded. Medial joint space narrowing evaluated radiographically and classified according to Kellgren-Lawrence classification was noted preoperatively and at the latest followup for each operated knee. All surgical procedures were performed by 2 of the authors (H.S. and A.O.) who also determined the Outerbridge classification of chondral lesions together intraoperatively. During surgery, arthroscopic examinations were first performed to confirm the preoperative diagnosis as well as concomitant intra-articular pathologies. The type of the medial meniscal tear, presence of any chondral lesions on the medial femoral condyle and medial tibial plateau according to the Outerbridge classification, degenerative changes on the chondral surfaces of the patellofemoral joint, the status of the cruciate ligaments and lateral meniscus, and the presence of any plica or synovitis were noted. Active and passive motion exercises were started at the first postoperative day and full weight bearing was also allowed. At the time of hospital discharge, all patients were advised to continue active range of motion and quadriceps strengthening exercises for at least 3 months postoperatively. Routine clinical follow-up visits were conducted at 2 weeks, 3 months, and 1 year postoperatively, then annually thereafter. Visual Analog Scale (VAS) and Lysholm Knee Scoring Scale were the instruments used as outcome measures to evaluate the changes in the patients’ clinical status regarding the meniscal surgery from preoperative to the latest postoperative follow-up visit. All complications were recorded. Statistical analysis was achieved by using the Wilcoxon signed-rank test to compare related data of preoperative and postoperative periods, and the Mann-Whitney U test to compare independent variables influencing the clinical outcomes according to the VAS and Lysholm score. Multivariate analysis was performed to determine major predictors of the clinical outcome. A post hoc analysis was performed for each of the variables to determine the power of the study. The level of significance was set at P .05.
Results The study group consisted of 109 females and 19 males with a median age of 63 (range, 60 to 75) years at the time of surgery. The mean postoperative follow-up time was 4.1 0.7 (range, 3 to 5) years. The mechanism of injury was a fall in 62 (40.2%) of the knees, sports injury in 49 (31.8%), and traffic accident in 43 (27.9%) (Table 1). Age at the time of surgery was 65 years or less in 112 knees and was more than 65 years in 42 knees. The mean BMI of the study group was 25.5 3.2 kg/m2 preoperatively. Fifty-two of the patients had a BMI 26 kg/m2, whereas the other 76 had a BMI < 26 kg/m2. The mean duration of symptoms until decision of the surgical treatment was 3.7 1.9 weeks. It was 3 weeks or less in 80 knees, whereas more than 3 weeks in 74 knees. The mean HKA was measured as 3.9 3.4 in favor of varus alignment, and HKA > 5 was detected in 54 of the knees. Preoperatively, grade II medial joint space narrowing according to KellgrenLawrence classification was noted in 97 (63%) knees, whereas it was grade III in 57 knees (37%). The type of the meniscal tear validated during arthroscopic examination was complex tear in 68 knees (44.2%), bucket handle in 47 knees (30.5%), and radial flap tear in 39 knees (25.3%). Hemarthrosis was detected in 91 (59%) of the knees, whereas hemorrhage around the tear site was observed in 38 (24.6%). None of the tears was suitable for repair. Grade III or IV chondral lesion of the medial compartment according to Outerbridge classification was noted in 71 knees (46.1%), whereas grade II chondral lesion was detected in 83 (53.9%) of the knees. None of the knees was Outerbridge grade I. Patellofemoral degeneration was present in 66 knees (42.9%). Anterior cruciate ligament was either partially ruptured or degenerative with increased laxity in 39 knees (25.3%). Degenerative changes in lateral meniscus were detected in 47 of the knees (30.5%). Synovial hypertrophy and arthroscopic findings of synovitis were noted in 29 knees (18.8%), whereas
Table 1. Mechanisms of Injury Leading to Acute TraumaRelated Medial Meniscal Tear Mechanisms of Injury Fall During walking Fall from stairs Fall from height Due to seizure Sports injury Running Trekking Football Tennis Traffic accident Vehicle-pedestrian accident Bicycle accident
n 28 17 11 6 19 12 10 8 27 16
4
H. SOFU ET AL.
medial supra- or infrapatellar plica was identified in 21 knees (13.6%). The mean VAS score for 154 knees evaluated in this study improved from 5.6 1.4 (range, 2 to 9) points preoperatively to 2.3 1.5 (range, 0 to 5) points at the latest follow-up (P < .05). The mean Lysholm score improved from 43 9.8 (range, 24 to 45) points to 72.7 11.2 (range, 51 to 90) points (P < .05). The progression of the clinical outcomes according to VAS and Lysholm scores remained relatively stable over the entire postoperative follow-up period (Fig 2). VAS and Lysholm scores at the latest follow-up were significantly worse in patients with a preoperative BMI 26 kg/m2, HKA > 5 , grade III or IV chondral lesion of the medial compartment according to Outerbridge classification, degenerative changes in patellofemoral joint surfaces, and an ACL that was either partially ruptured or degenerative with increased laxity (Tables 2 and 3) (P < .05). Therefore, these variables were identified as potential predictors of the clinical outcomes after arthroscopic partial meniscectomy performed for acute isolated medial meniscal tear leading to mechanical symptoms in patients more than 60 years of age. These factors were included in multivariate analysis. A preoperative BMI 26 kg/m2, grade III or IV chondral lesion of the medial compartment according to Outerbridge classification, degenerative changes in patellofemoral joint surfaces, and an ACL that was either partially ruptured or degenerative with increased laxity were identified as the major predictors according to multivariate analysis (Table 4). Age at the time of surgery, preoperative grade of medial joint space narrowing determined according to Kellgren-Lawrence classification, duration of symptoms until decision of the surgery, degenerative changes in the lateral meniscus, presence of a medial supra- or infrapatellar plica, and synovial hypertrophy and/or arthroscopic findings of synovitis had no effects on the clinical results. The overall complication rate of this study was 1.9% (3 of 154 knees), which consisted of deep venous thrombosis in 2 knees and superficial wound infection in the form of cellulitis in 1 knee. We did not observe any septic arthritis, pulmonary embolism, neurovascular complication, and complex regional pain syndrome. During the whole postoperative follow-up period, 16 knees required another surgical intervention. High tibial osteotomy was the secondary surgical intervention in those 16 knees. None of the knees underwent joint replacement surgery. At the latest follow-up, 81 knees had still grade II medial joint space narrowing according to Kellgren-Lawrence classification, 70 had grade III, and 3 had grade IV.
Discussion
The most important finding of this study was that the clinical outcome after arthroscopic partial medial meniscectomy performed for trauma-related tears in
patients more than 60 years of age could be predicted according to BMI, the level of any chondral lesion of the medial compartment diagnosed during arthroscopy, presence of degenerative changes in patellofemoral joint surfaces, and an ACL either partially ruptured or degenerative with increased laxity. Unexpectedly, age more than 65 years at the time of surgery and grade III medial joint space narrowing determined according to preoperative radiographic evaluation were not found to be statistically significant predictors of the outcome. This finding was probably due to the relief of acute locking symptoms resulted in similar postoperative improvements during patients’ daily living activities independent of the preoperative age or baseline radiographic changes. Although increasing number of isolated meniscus repairs without a concomitant increase in meniscectomies in younger patients has been reported, the incidence of arthroscopic partial meniscectomies in late middle-aged or elderly patients has maintained an increasing trend during the last decade with the largest relative increase reported in patients older than 55 years of age.4,9 On the other hand, the controversies about the necessity as well as the clinical benefits of the arthroscopic procedures performed for meniscal lesions in such patients still continue.2,6,7 According to a recent prospective randomized single-blinded study, patients’ age or symptom history did not affect the outcome, and thus, the authors concluded that middle-aged patients with meniscal symptoms may benefit from arthroscopic surgery.2 Lyman et al.5 reported that significant variation existed among practicing orthopaedic surgeons with regard to decision making for arthroscopic partial meniscectomy in patients more than 40 years of age. However, acute trauma-related symptomatic meniscal tears generally do not respond to nonoperative treatment and require surgical intervention independent of the patient’s age due to a persistence of severe pain, accompanied by locking of the knee that restricts knee motion and in turn can restrict the patient’s activities of daily living. Therefore, the main purpose of this study was to identify the predictors of the clinical outcome after arthroscopic partial meniscectomy performed for acute trauma-related symptomatic medial meniscal tear in patients more than 60 years of age. According to Haviv et al.,8 female gender was correlated to worse postoperative function and longer rehabilitation time, whereas age showed no significant association. Similarly in this study, no statistically significant change in the outcomes according to age at the time of surgery was detected. On the other hand, we could not test the effect or predictive value of gender because the distribution was not suitable (female/male ratio was 109/19) to achieve a comparative analysis. In general, one would think that males would have more traumatic injuries, but it
PARTIAL MENISCECTOMY FOR ELDERLY PATIENTS
5
Fig 2. (A) Progression of Visual Analog Scale scores according to the variables over the entire postoperative follow-up. (B) Progression of Lysholm scores according to the variables over the entire postoperative follow-up. A plus (þ) sign indicates the presence of the variable. (ACL, anterior cruciate ligament; BMI, body mass index; HKA, hip-knee-ankle angle; Lat, lateral; PF, patellofemoral; w, week.)
was not so in our study group. No specific reason was observed to explain this disproportionate distribution in gender. In their study, included 98 patients with a
mean age of 52 years and a mean follow-up of 5 years, Akkaya et al.10 did not detect any significant influences of BMI and preoperative symptom
6
H. SOFU ET AL.
Table 2. Visual Analog Scale Scores According to Independent Variables Visual Analog Scale Score Age at the time of surgery 65 yr Age at the time of surgery > 65 yr BMI < 26 kg/m2 BMI 26 kg/m2 HKA 5 HKA > 5 Joint space narrowingdgrade II Joint space narrowingdgrade III Duration of symptoms 3 wk Duration of symptoms > 3 wk Chondral lesiondgrade II Chondral lesiondgrade III-IV Patellofemoral degeneration () Patellofemoral degeneration (þ) ACLdintact ACLdlax or partially ruptured Lateral meniscusdintact Lateral meniscusddegenerated Supra- or infrapatellar plica () Supra- or infrapatellar plica (þ) Synovitis () Synovitis (þ)
n 112 42 89 65 100 54 97 57 74 80 83 71 88 66 115 39 107 47 133 21 125 29
Preoperative 5.6 1.2 5.7 1.5 5.4 1.3 5.9 1.5 5.6 1.5 5.5 1.2 5.4 1.3 5.9 1.4 5.8 1.3 5.4 1.4 5.2 1.3 6 1.4 5.2 1.2 6.1 1.4 5.6 1.4 5.5 1.4 5.5 1.2 5.6 1.4 5.7 1.3 5.5 1.4 5.5 1.3 5.8 1.3
Latest Follow-up 2.3 1.4 2.5 1.2 1.8 1.1 3.1 1.5 1.7 1.2 3.5 1.3 2.2 1.2 2.5 1.1 2.1 1.2 2.5 1.3 1.9 1.7 2.8 1.2 1.7 1.1 3.1 1.3 2.1 1.1 2.9 1.2 2.2 1.2 2.5 1.3 2.4 1.1 2.3 1.2 2.2 1.2 2.7 1.4
P Value .381
Purpose: To determine predictors of the clinical outcome after arthroscopic partial meniscectomy performed for acute trauma-related medial meniscal tear leading to mechanical symptoms in patients more than 60 years of age. Methods: In this retrospective study with 4.1 years’ follow-up, the clinical data of 154 arthroscopic partial medial meniscectomies were evaluated. The body mass index (BMI), duration of symptoms, the hip-knee-ankle angle, type of the meniscal tear, presence of any chondral lesions, degenerative changes in the patellofemoral joint, the status of the cruciate ligaments and lateral meniscus, and the presence of any plica or synovitis were the independent variables. Visual Analog Scale (VAS) and Lysholm Knee Scoring Scale were the instruments used as outcome measures. Multivariate analysis was performed to determine the major predictors. Results: The mean VAS score for 154 knees evaluated in this study improved from 5.6 points preoperatively to 2.3 points at the latest follow-up. The mean Lysholm score improved from 43 points to 72.7 points. VAS and Lysholm scores at the latest follow-up were significantly worse in patients with a preoperative BMI 26 kg/m2, hip-knee-ankle angle > 5 , grade III or IV chondral lesion of the medial compartment according to Outerbridge classification, degenerative changes in patellofemoral joint surfaces, and an anterior cruciate ligament that was either partially ruptured or degenerative with increased laxity. Conclusions: A preoperative BMI 26 kg/m2, Outerbridge grade III or IV chondral lesion of the medial compartment of the operated knee joint diagnosed during arthroscopic intervention, degenerative changes in patellofemoral joint surfaces, and the presence of an anterior cruciate ligament either partially ruptured or degenerative with increased laxity should be considered as the major predictors of the clinical outcome after arthroscopic partial meniscectomy performed for acute trauma-related symptomatic medial meniscal tear in patients more than 60 years of age. Level of Evidence: Level IV, prognostic case series.
A
cute meniscal tears may interfere with the normal biomechanics and functions of the knee joint during motion and, thus, may lead to severe pain
From the Department of Orthopedics and Traumatology, Erzincan University Faculty of Medicine (H.S., V.S.), Erzincan; Department of Orthopedics and Traumatology, Erzincan Mengucekgazi Education and Research Hospital (A.O.), Erzincan; Department of Orthopedics and Traumatology, Devrek State Hospital (Y.C.), Zonguldak; and Department of Orthopedics and Traumatology, Baltalimani Bone and Joint Diseases Education and Research Hospital (S.G., H.U.), Istanbul, Turkey. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received June 10, 2015; accepted November 20, 2015. Address correspondence to Hakan Sofu, M.D., Department of Orthopedics and Traumatology, Erzincan University Faculty of Medicine, Bas¸baglar mahallesi 24030, Erzincan, Turkey. E-mail: [email protected] Ó 2016 by the Arthroscopy Association of North America 0749-8063/15509/$36.00 http://dx.doi.org/10.1016/j.arthro.2015.11.040
accompanied by mechanical symptoms throughout daily living activities as well as impairment of the quality of life.1 Although the number of arthroscopic surgeries as a treatment modality in late middle-aged or elderly patients with established osteoarthritis have been reported as having decreased dramatically during the past decade, the number of arthroscopic partial meniscectomies regarding the same age groups have maintained an increasing trend during the same time period.2-4 Failed nonoperative treatment and the physical examination findings such as positive McMurray test, joint line tenderness, and effusion have been shown among the clinical factors that most influenced a surgeon’s decision to recommend partial meniscectomy for those patients.5 Today, the clinical results and benefits as well as the necessity of the arthroscopic surgery performed for meniscal lesions in late middle-aged or elderly patients are still
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol
-,
No
-
(Month), 2016: pp 1-8
1
2
H. SOFU ET AL.
controversial.2,6,7 Determining which patients will be less likely to improve as well as the specific factors influencing the improvements in function and pain is crucially important in clinical evaluation of such cases.8 The purpose of this study was to determine predictors of the clinical outcome after arthroscopic partial meniscectomy performed for acute trauma-related medial meniscal tear leading to mechanical symptoms in patients more than 60 years of age. We hypothesized that age more than 65 years, body mass index (BMI) 26 kg/m2, Outerbridge grade III or IV chondral lesion, and advanced joint space narrowing would be associated with lower clinical outcomes after arthroscopic partial meniscectomy in patients more than 60 years of age.
Methods This study retrospectively evaluated the clinical data of the patients more than 60 years of age who underwent arthroscopic partial medial meniscectomy. Between January 2006 and January 2010, 608 patients were operated on. The ones with degenerative meniscal lesions leading to long-standing chronic symptoms and treated surgically were excluded. One hundred and sixty-one patients arthroscopically treated for acute
trauma-related meniscal lesions were identified (Fig 1). Six patients lost to follow-up were excluded. Patients with a medical history of knee surgery, coexisting lateral meniscal tear, and/or total rupture of the anterior cruciate ligament (ACL) diagnosed on the preoperative magnetic resonance imaging (MRI), a history of any fracture of the same extremity, rheumatologic or inflammatory diseases, and the ones with end stage osteoarthritis of the ipsilateral hip or ankle joint were also excluded. The clinical data of 154 arthroscopic partial medial meniscectomies performed in 128 patients more than 60 years of age with a diagnosis of acute trauma-related symptomatic tear were evaluated after having approval from the local ethical research committee. Twenty-six patients with separate traumatic events that led to acute locking symptoms were operated on both knees at different time intervals. Preoperative MRI was obtained for all knees to establish differential diagnoses and prove meniscal tear suspected on physical examination. Main indications for surgical treatment were acute onset of the complaints clearly caused by a trauma and locking of the affected knee that was impossible to relieve without operative measures. Therefore, none of our patients had a cortisone injection or physical therapy as conservative
Fig 1. Flow chart demonstrating the excluded patients. (ACL, anterior cruciate ligament.)
3
PARTIAL MENISCECTOMY FOR ELDERLY PATIENTS
treatment before surgery. A standard arthroscopic partial medial meniscectomy procedure was performed for all knees. An acute traumatic event is defined as a trauma occurred unexpectedly and leads to physical disturbance of the human body that requires medical treatment. All meniscal tears were acute trauma-related symptomatic lesions of the medial meniscus, leading to locking and/or catching symptoms. A fall is defined as an event that results in a person coming to rest inadvertently on the ground or floor or other lower level. Preoperatively, age, BMI, duration of symptoms up to decision of the surgical treatment, and radiographic measurement of the alignment of the lower extremity that was evaluated by measuring the hip-knee-ankle angle (HKA) and defined as varus in case of a positive angular value were recorded. Medial joint space narrowing evaluated radiographically and classified according to Kellgren-Lawrence classification was noted preoperatively and at the latest followup for each operated knee. All surgical procedures were performed by 2 of the authors (H.S. and A.O.) who also determined the Outerbridge classification of chondral lesions together intraoperatively. During surgery, arthroscopic examinations were first performed to confirm the preoperative diagnosis as well as concomitant intra-articular pathologies. The type of the medial meniscal tear, presence of any chondral lesions on the medial femoral condyle and medial tibial plateau according to the Outerbridge classification, degenerative changes on the chondral surfaces of the patellofemoral joint, the status of the cruciate ligaments and lateral meniscus, and the presence of any plica or synovitis were noted. Active and passive motion exercises were started at the first postoperative day and full weight bearing was also allowed. At the time of hospital discharge, all patients were advised to continue active range of motion and quadriceps strengthening exercises for at least 3 months postoperatively. Routine clinical follow-up visits were conducted at 2 weeks, 3 months, and 1 year postoperatively, then annually thereafter. Visual Analog Scale (VAS) and Lysholm Knee Scoring Scale were the instruments used as outcome measures to evaluate the changes in the patients’ clinical status regarding the meniscal surgery from preoperative to the latest postoperative follow-up visit. All complications were recorded. Statistical analysis was achieved by using the Wilcoxon signed-rank test to compare related data of preoperative and postoperative periods, and the Mann-Whitney U test to compare independent variables influencing the clinical outcomes according to the VAS and Lysholm score. Multivariate analysis was performed to determine major predictors of the clinical outcome. A post hoc analysis was performed for each of the variables to determine the power of the study. The level of significance was set at P .05.
Results The study group consisted of 109 females and 19 males with a median age of 63 (range, 60 to 75) years at the time of surgery. The mean postoperative follow-up time was 4.1 0.7 (range, 3 to 5) years. The mechanism of injury was a fall in 62 (40.2%) of the knees, sports injury in 49 (31.8%), and traffic accident in 43 (27.9%) (Table 1). Age at the time of surgery was 65 years or less in 112 knees and was more than 65 years in 42 knees. The mean BMI of the study group was 25.5 3.2 kg/m2 preoperatively. Fifty-two of the patients had a BMI 26 kg/m2, whereas the other 76 had a BMI < 26 kg/m2. The mean duration of symptoms until decision of the surgical treatment was 3.7 1.9 weeks. It was 3 weeks or less in 80 knees, whereas more than 3 weeks in 74 knees. The mean HKA was measured as 3.9 3.4 in favor of varus alignment, and HKA > 5 was detected in 54 of the knees. Preoperatively, grade II medial joint space narrowing according to KellgrenLawrence classification was noted in 97 (63%) knees, whereas it was grade III in 57 knees (37%). The type of the meniscal tear validated during arthroscopic examination was complex tear in 68 knees (44.2%), bucket handle in 47 knees (30.5%), and radial flap tear in 39 knees (25.3%). Hemarthrosis was detected in 91 (59%) of the knees, whereas hemorrhage around the tear site was observed in 38 (24.6%). None of the tears was suitable for repair. Grade III or IV chondral lesion of the medial compartment according to Outerbridge classification was noted in 71 knees (46.1%), whereas grade II chondral lesion was detected in 83 (53.9%) of the knees. None of the knees was Outerbridge grade I. Patellofemoral degeneration was present in 66 knees (42.9%). Anterior cruciate ligament was either partially ruptured or degenerative with increased laxity in 39 knees (25.3%). Degenerative changes in lateral meniscus were detected in 47 of the knees (30.5%). Synovial hypertrophy and arthroscopic findings of synovitis were noted in 29 knees (18.8%), whereas
Table 1. Mechanisms of Injury Leading to Acute TraumaRelated Medial Meniscal Tear Mechanisms of Injury Fall During walking Fall from stairs Fall from height Due to seizure Sports injury Running Trekking Football Tennis Traffic accident Vehicle-pedestrian accident Bicycle accident
n 28 17 11 6 19 12 10 8 27 16
4
H. SOFU ET AL.
medial supra- or infrapatellar plica was identified in 21 knees (13.6%). The mean VAS score for 154 knees evaluated in this study improved from 5.6 1.4 (range, 2 to 9) points preoperatively to 2.3 1.5 (range, 0 to 5) points at the latest follow-up (P < .05). The mean Lysholm score improved from 43 9.8 (range, 24 to 45) points to 72.7 11.2 (range, 51 to 90) points (P < .05). The progression of the clinical outcomes according to VAS and Lysholm scores remained relatively stable over the entire postoperative follow-up period (Fig 2). VAS and Lysholm scores at the latest follow-up were significantly worse in patients with a preoperative BMI 26 kg/m2, HKA > 5 , grade III or IV chondral lesion of the medial compartment according to Outerbridge classification, degenerative changes in patellofemoral joint surfaces, and an ACL that was either partially ruptured or degenerative with increased laxity (Tables 2 and 3) (P < .05). Therefore, these variables were identified as potential predictors of the clinical outcomes after arthroscopic partial meniscectomy performed for acute isolated medial meniscal tear leading to mechanical symptoms in patients more than 60 years of age. These factors were included in multivariate analysis. A preoperative BMI 26 kg/m2, grade III or IV chondral lesion of the medial compartment according to Outerbridge classification, degenerative changes in patellofemoral joint surfaces, and an ACL that was either partially ruptured or degenerative with increased laxity were identified as the major predictors according to multivariate analysis (Table 4). Age at the time of surgery, preoperative grade of medial joint space narrowing determined according to Kellgren-Lawrence classification, duration of symptoms until decision of the surgery, degenerative changes in the lateral meniscus, presence of a medial supra- or infrapatellar plica, and synovial hypertrophy and/or arthroscopic findings of synovitis had no effects on the clinical results. The overall complication rate of this study was 1.9% (3 of 154 knees), which consisted of deep venous thrombosis in 2 knees and superficial wound infection in the form of cellulitis in 1 knee. We did not observe any septic arthritis, pulmonary embolism, neurovascular complication, and complex regional pain syndrome. During the whole postoperative follow-up period, 16 knees required another surgical intervention. High tibial osteotomy was the secondary surgical intervention in those 16 knees. None of the knees underwent joint replacement surgery. At the latest follow-up, 81 knees had still grade II medial joint space narrowing according to Kellgren-Lawrence classification, 70 had grade III, and 3 had grade IV.
Discussion
The most important finding of this study was that the clinical outcome after arthroscopic partial medial meniscectomy performed for trauma-related tears in
patients more than 60 years of age could be predicted according to BMI, the level of any chondral lesion of the medial compartment diagnosed during arthroscopy, presence of degenerative changes in patellofemoral joint surfaces, and an ACL either partially ruptured or degenerative with increased laxity. Unexpectedly, age more than 65 years at the time of surgery and grade III medial joint space narrowing determined according to preoperative radiographic evaluation were not found to be statistically significant predictors of the outcome. This finding was probably due to the relief of acute locking symptoms resulted in similar postoperative improvements during patients’ daily living activities independent of the preoperative age or baseline radiographic changes. Although increasing number of isolated meniscus repairs without a concomitant increase in meniscectomies in younger patients has been reported, the incidence of arthroscopic partial meniscectomies in late middle-aged or elderly patients has maintained an increasing trend during the last decade with the largest relative increase reported in patients older than 55 years of age.4,9 On the other hand, the controversies about the necessity as well as the clinical benefits of the arthroscopic procedures performed for meniscal lesions in such patients still continue.2,6,7 According to a recent prospective randomized single-blinded study, patients’ age or symptom history did not affect the outcome, and thus, the authors concluded that middle-aged patients with meniscal symptoms may benefit from arthroscopic surgery.2 Lyman et al.5 reported that significant variation existed among practicing orthopaedic surgeons with regard to decision making for arthroscopic partial meniscectomy in patients more than 40 years of age. However, acute trauma-related symptomatic meniscal tears generally do not respond to nonoperative treatment and require surgical intervention independent of the patient’s age due to a persistence of severe pain, accompanied by locking of the knee that restricts knee motion and in turn can restrict the patient’s activities of daily living. Therefore, the main purpose of this study was to identify the predictors of the clinical outcome after arthroscopic partial meniscectomy performed for acute trauma-related symptomatic medial meniscal tear in patients more than 60 years of age. According to Haviv et al.,8 female gender was correlated to worse postoperative function and longer rehabilitation time, whereas age showed no significant association. Similarly in this study, no statistically significant change in the outcomes according to age at the time of surgery was detected. On the other hand, we could not test the effect or predictive value of gender because the distribution was not suitable (female/male ratio was 109/19) to achieve a comparative analysis. In general, one would think that males would have more traumatic injuries, but it
PARTIAL MENISCECTOMY FOR ELDERLY PATIENTS
5
Fig 2. (A) Progression of Visual Analog Scale scores according to the variables over the entire postoperative follow-up. (B) Progression of Lysholm scores according to the variables over the entire postoperative follow-up. A plus (þ) sign indicates the presence of the variable. (ACL, anterior cruciate ligament; BMI, body mass index; HKA, hip-knee-ankle angle; Lat, lateral; PF, patellofemoral; w, week.)
was not so in our study group. No specific reason was observed to explain this disproportionate distribution in gender. In their study, included 98 patients with a
mean age of 52 years and a mean follow-up of 5 years, Akkaya et al.10 did not detect any significant influences of BMI and preoperative symptom
6
H. SOFU ET AL.
Table 2. Visual Analog Scale Scores According to Independent Variables Visual Analog Scale Score Age at the time of surgery 65 yr Age at the time of surgery > 65 yr BMI < 26 kg/m2 BMI 26 kg/m2 HKA 5 HKA > 5 Joint space narrowingdgrade II Joint space narrowingdgrade III Duration of symptoms 3 wk Duration of symptoms > 3 wk Chondral lesiondgrade II Chondral lesiondgrade III-IV Patellofemoral degeneration () Patellofemoral degeneration (þ) ACLdintact ACLdlax or partially ruptured Lateral meniscusdintact Lateral meniscusddegenerated Supra- or infrapatellar plica () Supra- or infrapatellar plica (þ) Synovitis () Synovitis (þ)
n 112 42 89 65 100 54 97 57 74 80 83 71 88 66 115 39 107 47 133 21 125 29
Preoperative 5.6 1.2 5.7 1.5 5.4 1.3 5.9 1.5 5.6 1.5 5.5 1.2 5.4 1.3 5.9 1.4 5.8 1.3 5.4 1.4 5.2 1.3 6 1.4 5.2 1.2 6.1 1.4 5.6 1.4 5.5 1.4 5.5 1.2 5.6 1.4 5.7 1.3 5.5 1.4 5.5 1.3 5.8 1.3
Latest Follow-up 2.3 1.4 2.5 1.2 1.8 1.1 3.1 1.5 1.7 1.2 3.5 1.3 2.2 1.2 2.5 1.1 2.1 1.2 2.5 1.3 1.9 1.7 2.8 1.2 1.7 1.1 3.1 1.3 2.1 1.1 2.9 1.2 2.2 1.2 2.5 1.3 2.4 1.1 2.3 1.2 2.2 1.2 2.7 1.4
P Value .381
