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Most elite athletes return to competition following operative management of meniscal tears: a systematic review
  1. Seper Ekhtiari1,
  2. Moin Khan1,2,
  3. Jacob M Kirsch2,
  4. Patrick Thornley3,
  5. Christopher M Larson4,
  6. Asheesh Bedi2
  1. 1 Michael G DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
  2. 2 Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan, USA
  3. 3 Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
  4. 4 Twin Cities Orthopedics, Minnesota Orthopedic Sports Medicine Institute, Edina, Minnesota, USA
  1. Correspondence to Dr Asheesh Bedi, University of Michigan, Sports Medicine and Shoulder Service, Ann Arbor, MI 48106, USA; abedi{at}med.umich.edu

Abstract

Importance Meniscal injuries are common among athletes. When operative management is indicated, the decision between meniscal repair and meniscectomy is not always clear, particularly in elite athletes.

Objective The aim of this systematic review was to (1) compare outcomes for partial meniscectomy and repair for the management of meniscus tears in elite athletes and (2) describe return-to-play (RTP) rates and complications for each operation.

Evidence review MEDLINE, Embase and PubMed were searched from inception through to 5 March 2017. All studies were screened in duplicate for eligibility. Data extracted included demographics, surgical technique and RTP rate and timeline.

Findings Ten studies (725 athletes) were included involving 355 elite athletes undergoing meniscal repair (111 patients) or partial/total meniscectomy (244). The majority of athletes were men (82.8%) and had a mean age of 25.0 years (14–38). Athletes were followed for a mean of 5.3 years (range=3 months to 18.4 years). American football was the most common sport (153 athletes), followed by soccer (69) and basketball (67). Athletes undergoing meniscal repair demonstrated a pooled mean RTP time of 7.6 months in comparison to 4.3 months for those undergoing partial meniscectomy (P<0.0001). Of athletes undergoing meniscal repair, 86.5% RTP at their preoperative level, compared with 80.4% of athletes undergoing partial meniscectomy (P=0.24). Following meniscectomy, athletes who were taller, drafted in higher rounds and had played or started more games preoperatively were less likely to suffer negative career impacts postoperatively. Satisfaction rates (92% vs 76%) and clinical scores (8.8 vs 6.9, P=0.05) were higher among recreational than elite athletes.

Conclusion Athletes undergoing partial meniscectomy RTP sooner than those undergoing meniscal repair. Both operations are safe and the majority of athletes RTP at their preoperative level of competition following either operation. Further research is required to identify when each option is preferable in this population.

Relevance Based on the currently available evidence, meniscectomy and meniscal repair are both viable options for elite athletes with meniscal injuries. Each method has small advantages and disadvantages compared with the other, and thus a shared decision should be made with the athlete.

Level of evidence Level IV, systematic review of level III and IV studies.

  • meniscus
  • elite athlete
  • debridement
  • repair

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What is already known

  • Meniscal injuries are common in athletes, particularly in cutting and pivoting sports.

  • Meniscal repair in the general population provides significantly better results than meniscectomy.

What are the new findings

  • Meniscectomy and meniscal repairs are both viable options in elite athletes, allowing the majority to return-to-play at their preoperative level.

  • For patients undergoing meniscectomy, certain preoperative factors related to physical stature and previous performance predict more successful return-to-play.

Introduction

The meniscus is a critical structure in the knee joint, and is involved in the distribution of stress,1 shock absorption,2 joint stability3 and functions as a medium for nutrient transfer.4 Previously, the meniscus was viewed largely as a vestigial structure and most lesions were treated with total meniscectomy.5 With an improved understanding of meniscal function and contact mechanics of the knee, meniscus repair has been strongly favoured when possible in an attempt to preserve the meniscus and thus reduce the risk of early onset osteoarthritis associated with total meniscectomy.5

Meniscal injuries are very common, accounting for two-thirds of all knee injuries.6 In addition, they are more common in males, with male:female ratios of between 2.5 and 4 reported.6 Traumatic meniscal tears are very common among athletes.7 In a 10-year study of over 6000 athletes, Majewski et al found that meniscal injuries represent the second-most common knee injury among athletes and are most common in sports such as soccer and skiing.7 The most common mechanism for traumatic meniscal tear is a twisting of the femur relative to the tibia with a knee that is flexed to about 45 degrees.8 Both knees are equally affected, although the lateral meniscus is more often injured than the medial meniscus in cases of isolated meniscal injury.8

In the general population, meniscal repair provides significantly improved long-term results in comparison to meniscectomy.9 For elite and professional athletes, however, the decision-making may be more complicated due to conflicting goals for return to competitive play versus longevity and preservation of the knee joint. Furthermore, the high-demand activities of elite competitive cutting and pivoting sports may place meniscus repairs at uniquely greater risk for failure and revision partial meniscectomy in comparison to the general population.10 However, these outcomes have not been reported to date.

Thus, the purpose of this systematic review was to: (1) present the reported outcomes for both partial meniscectomy and meniscal repair for the management of meniscus tear in elite athletes; (2) describe return-to-play (RTP) rates and timelines; and (3) identify complications and revision rates for each procedure. It was hypothesised that meniscal repair would result in more time missed from play and an increased failure rate in an elite athletic population.

Methods

This study was conducted according to the methodology described in the Cochrane Handbook for Systematic Reviews of Intervention 11 and is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.12

Eligibility criteria

We included all studies that provided clinical, functional or radiographic outcomes for meniscal repair or debridement in the elite athlete. Athletes with concomitant injuries and procedures were included. Elite athletes were defined as those competing in the highest level professional league in a given sport, or amateur athletes competing on an international level. Collegiate athletes were not included. Exclusion criteria consisted of case reports, non-English language publications, editorials, reviews, expert opinion and basic science papers as well as studies with fewer than five patients.

Identification of studies

Multiple search strategies were used to identify potentially eligible studies. A comprehensive search of Embase, MEDLINE and PubMed was performed from database inception through to 5 March 2017. Investigators with methodological and content expertise developed and performed the search. Medical Subject Headings and Emtree headings were used to increase search sensitivity (online supplementary appendix 1). The search strategy was adapted in PubMed to search for articles published online ahead of print. A hand search of related references and cited articles was performed to identify any additional relevant studies for inclusion.

Supplementary file 1

Study screening and assessment of eligibility

All titles and abstracts were screened independently by two reviewers for eligibility using piloted screening forms. Duplicates were manually excluded. Reviewers evaluated the full text of all potentially eligible studies from title and abstract screening to determine final eligibility. Once a final list of articles was selected for inclusion, the reference list of each article was screened for any additional articles that may have been omitted.

Data extraction and assessment of methodological quality

Data were abstracted independently and in duplicate by two reviewers, using a piloted electronic data extraction form (Microsoft Excel). Extracted data included but was not limited to the following : study design, year of publication, country of origin, patient demographics, surgical technique, RTP timelines and levels, concomitant procedures and complications and revisions. A priori, we planned on analysis of studies reporting concomitant procedures (eg, anterior  cruciate   ligament (ACL) reconstruction) and degree of associated chondral injury.

We graded the level of evidence for all studies according to the criteria of Wright  et al.13 All included studies were assessed for methodological quality using the Methodological Index for Non-Randomised Studies (MINORS).14 MINORS assessed the quality of non-randomised studies, with a set of 12 items, each scored 0, 1 or 2. For non-comparative studies, only eight criteria apply, thus giving a maximum possible score of 16, while the maximum score for comparative studies is 24.

Statistical analysis

For each stage of the screening process, a kappa (κ) value was calculated to assess inter-reviewer agreement. Based on previous literature, κ values were categorised a priori  as follows: κ>0.60 to indicate substantial agreement; 0.21≤κ≤0.60 to indicate moderate agreement and κ<0.21 to indicate slight agreement.15 Regarding the methodological quality assessment (MINORS), agreement was assessed using an intraclass correlation coefficient (ICC). No evidence exists which specifies how best to classify MINORS score; thus, it was determined a priori that MINORS score would be categorised as such: 0–5 to indicate very low quality; 6–9 to indicate low quality, 10–14 to indicate fair quality and >14 to indicate good quality evidence. Data were reported primarily using descriptive statistics, with measures of variance (eg, SD, 95% CI) used as appropriate. When mean values were unavailable median values were used. Statistical analysis was performed using SPSS Version 23.

Results

Study characteristics

Our initial search yielded 1246 studies, of which 10 met the inclusion and exclusion criteria for this review (figure 1). Agreement among the reviewers was substantial at the title/abstract (κ=0.67; 95% CI 0.54 to 0.81) and full text (κ=0.84; 95% CI 0.66 to 1.00) stages. The included studies comprised seven case series, two cohort studies and one case-control study (table 1).

Table 1

Characteristics of included studies

Figure 1

Outline of systematic search strategy used.

Study quality

All studies were non-randomised and thus eligible for MINORS criteria assessment. Seven of the 10 studies (70%) were of level IV evidence, while the remaining three studies were of level III evidence. The included studies had a mean MINORS score of 9.5/16±1.4 for non-comparative studies and 13/24±2.7 for comparative studies, indicating a low to fair quality of evidence. There was substantial inter-reviewer agreement on MINORS scoring (ICC=0.76; 95% CI 0.29 to 0.93).

Patient demographics

The 10 studies included a total of 725 patients, of whom 355 patients (367 knees) were elite athletes who underwent meniscal repair or partial meniscectomy. Treatment choice was directed by tear pattern and surgeon discretion. Mean follow-up was 5.3 years (range=3 months to 18.4 years). The studies were conducted around the world, with three studies from the USA,16–18 five studies from Europe19–23 and one study each from Australia10 and Japan.24 There were 294 male athletes (82.8%) and 36 female athletes (12.0%), with gender not reported for 54 patients (15.2%). The mean age of included athletes was 25.0 years (range=14–38 years). The mean age of athletes undergoing meniscectomy was 26.3 years, compared with the mean age of athletes undergoing meniscal repair at 23.0 years (P=0.18). The most common sport was American football (153 athletes, 43.1%), followed by soccer (69 athletes, 19.4%) and basketball (67 athletes, 18.9%). Table 2 contains a complete list of sports reported in included studies.

Table 2

Sports played by elite athletes included in the study

Surgical procedures

Seven studies (244 patients, 68.7%) reported on patients undergoing partial or total meniscectomy,16–18 20 21 24 25 whereas three studies (111 patients, 31.3%) reported on meniscal repair patients.19 22 23 The amount of meniscus resected (as a percentage of total) was not reported and thus could not be analysed separately. For athletes undergoing meniscal repair, an all-inside technique was used in 69 (60.5%) cases,19 23 while an inside-out technique was used in 45 cases (39.5%).10 Laterality was only reported for 100 patients, of which 55 were performed on the right knee. Overall, 119 patients underwent concomitant ACL reconstruction (33.5%). Where reported, the lateral meniscus was the more commonly operated on (120/190, 63.2%) compared with the medial meniscus (62/190, 32.6%). Both menisci required an operation in eight cases (4.2%).

RTP rates and timelines

Across nine studies (290 athletes) reporting on RTP including both partial meniscectomy and repair, 82.8% (n=240) of all athletes returned to play at the same competitive level after the operation.16 18–25 Among patients undergoing meniscal repair (including concomitant procedures), 86.5% returned to play (96/111 athletes), while among those undergoing meniscectomy (including concomitant procedures), the RTP rate was 80.4% (144/179), P=0.24. Pooled results across studies identified 81.3% of athletes returning to play (130/160) following isolated meniscal surgery (repair or meniscectomy) in comparison to 75.5% (40/53) for those undergoing concomitant ACL reconstruction, P=0.47.

Considering only available data for isolated meniscal surgeries, 92.9% of athletes (13/14) undergoing isolated meniscal repair returned to play at the same level activity, while 83.8% of athletes (109/130) undergoing isolated meniscectomy returned to play at the same level, χ2=0.37, P=0.79. A mean RTP time of 6.3 months was reported for 50 athletes undergoing isolated meniscal surgery (repair or meniscectomy). Logan et al separately reported mean RTP time for athletes undergoing concomitant ACL reconstruction and found RTP times to be increased for patients undergoing concomitant ACL reconstruction (11.8 vs 5.6 months).10 Available data from 60 athletes undergoing meniscal repair demonstrated a pooled mean RTP time of 7.55 months, while 68 athletes undergoing uncomplicated meniscectomy had a pooled mean RTP time of 4.3 months, P<0.0001 (table 3).

Table 3

Return-to-play rate and timeline

Factors affecting RTP

Alvarez-Diaz et al found that while RTP rates were not affected, all patients who had persistent pain at RTP had grade II or greater cartilage damage.22 Aune et al, in their study of National Football League (NFL) players, identified athletes who were taller (P=0.047), had started more games prior to surgery (P=0.004) and played ‘non-speed positions’ (tight end, offensive line and defensive line) (P=0.021) were more likely to RTP following meniscal surgery. As well, players drafted in fourth round or earlier had an OR of 3.7 for RTP (P=0.014).16 Similarly, Minhas et al found that National Basketball Association (NBA) players undergoing meniscectomy had significantly fewer games played compared with NBA players undergoing other orthopaedic surgeries (P=0.027).18 Brophy et al, also analysing NFL players, found that career length (5.6 vs 7.0 years, P=0.026) and number of games played (62 vs 85, P=0.018) were significantly reduced in athletes undergoing isolated meniscectomy compared with controls. Interestingly, patients undergoing isolated ACL reconstruction or ACL reconstruction concomitant with meniscectomy did not experience a reduction in career length or games played postoperatively.17

Subjective outcomes

Three studies reported on subjective patient-reported outcomes.19 20 24 Hoshikawa et al found that the ‘clinical score’ among recreational athletes was significantly higher compared with elite athletes (8.8 vs 6.9, P=0.05). As well, the sport-specific satisfaction rate was 92% among recreational athletes and 76% among elite athletes (no direct comparison reported).23 Tucciarone et al identified athletes undergoing concomitant ACL reconstruction had significantly higher International Knee Documentation Committee scores in comparison to those with isolated meniscus injury (93.8 vs 81.2, P<0.001).19 Sonnery-Cottet et al reported outcomes on 10 patients who experienced rapid chondrolysis following meniscectomy and found athletes were able to resume preinjury level of activity at a mean 8 (±2.45) months following the index procedure.20

Complications and revisions

From two studies, a total of 15 patients (all undergoing meniscectomy) were reported to have experienced rapid chondrolysis postoperatively.20 21 One patient experienced an infective process postoperatively and required arthroscopic lavage.21 Overall, 16 patients had postoperative complications (4.5%) and 17 (4.8%) required revision arthroscopy. Given that all cases of chondrolysis were reported in studies specifically looking at this topic, the complication rate from the remaining studies was only 0.3% (1/340). Where reported, time to revision ranged from 6 months to over 3 years. For 114 cases of meniscal repair (111 athletes), a total of 17 failures (14.9%) were reported, although only 10 cases (8.8%) were atraumatic failures.

Discussion

Key findings

The results of this review suggest elite athletes undergoing partial meniscectomy return to play sooner than those undergoing meniscal repair. We found the vast majority of elite athletes undergoing both meniscal repair and partial or total meniscectomy are able to return to the same level of competition following surgical intervention, with most returning to play in less than 1 year. Finally, although a greater percentage of players may return to play after undergoing meniscal repair compared with meniscectomy, data are limited and may be confounded by a less severe tear pattern, reduced degenerative changes prompting meniscal repair and concomitant ACL reconstruction. Although rapid chondrolysis was the most commonly reported complication in this review, this is likely due to the inclusion of one study looking specifically at this complication. It is generally reported to be a rather rare complication of meniscectomy.20 The overall complication rate excluding rapid chondrolysis was extremely low.

We found players with concomitant ACL reconstruction had a slightly lower RTP; however, this was not statistically significant. It is interesting to note Tucciarone et al found elite athletes with concomitant ACL injury reported improved patient-reported outcomes in comparison to those with isolated meniscus injuries. This may be related to patients with concomitant ACL injury being prescribed a more formal, closed-chain rehabilitation programme postoperatively as observed by Logan et al. 10 In addition, ACL reconstruction decreases the risk of future knee injury, including meniscal tears and future operations and has been shown to improve the healing of meniscal injuries repaired concomitantly compared with in isolation.25 A combination of these factors may explain the finding in the current review, although further research is required to elucidate this finding.

Certain characteristics in elite athletes may be associated with improved recovery from meniscus surgery and thus are important to consider when making management decisions in this population. Consistent with previous literature, those elite athletes who are in more established positions preoperatively (eg, higher draft round, more games played and started, etc) are more likely to RTP postoperatively.26 As well, as discussed in previous literature, position-specific advice is crucial to the management of athletic injuries and the RTP process.27 This is further supported by this review in that American football players in certain positions may be less negatively impacted by meniscal injury.

This review had a number of strengths, including a broad search strategy and inclusive eligibility criteria. In addition, duplicate screening at all stages was performed to minimise the likelihood of reviewer bias. Finally, a manual search was performed and the reference list of all included studies screened, in an attempt to ensure no articles were omitted.

Future studies that prospectively compare clinical and radiographic outcomes for equivalent tear patterns in elite athletes will be invaluable to further understand the findings in this systematic review. Such studies would offer insight on RTP, and patient satisfaction and the progression of osteoarthritis with each treatment approach. Admittedly, such trials may be difficult to perform in this population, given the small population size from which to draw upon. In addition, future studies with long-term follow-up can help to fully inform elite athletes and surgeons of both the short-term and long-term effects of meniscal management strategies.

Limitations

The primary limitation of this review is the low volume and quality of evidence available specifically focused on meniscal management in elite athletes. Due to the small amount of heterogeneous data, no meta-analysis was possible. In addition, it was not possible to stratify by results by type of tear (eg, root tears, complete radial tears, longitudinal tears, etc) due to limited reported data. Confounding variables such as degenerative changes in the knee joint, tear pattern, amount of resection and the judgement of the treating surgeon were not available and it is, therefore, important to interpret the results of this systematic review with some caution. Furthermore, two studies included in this review were published in 1983, at which time surgical techniques and rehabilitation protocols were quite different than they are today. Finally, there were no studies that directly compared meniscectomy and meniscal repair in elite athletes; this comparison would be difficult to make in any case given that the lesions appropriate for each type of treatment can be quite different.

Conclusion

Athletes undergoing partial meniscectomy return to play sooner than those undergoing meniscal repair. The majority of elite athletes return to play at their preoperative level of competition following meniscal repair or meniscectomy. Both operations are safe, with low complication and revision rates. Further research is required to identify when each option is preferable in this population.

References

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Footnotes

  • Contributors SE and JMK carried out the search, screening process and assessment of study quality. SE and PT extracted the data. SE drafted the manuscript. PT and JMK edited the manuscript. MK and AB conceived the study, and provided key expert input and editing throughout the process. CML edited the manuscript and provided key expert input. All authors read and approved the final manuscript.

  • Competing interests CML reports consultancy fees from Smith & Nephew and A3 Surgical, and stock options in Smith & Nephew. AB reports consultancy fees from Arthrex.

  • Provenance and peer review Commissioned; externally peer reviewed.

  • Data sharing statement No unpublished data. All extracted data reported.

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