Horizontal Meniscus Tears: Surgery or Conservative Care?While wisdom, self-confidence, and the ability to go easy oneself often increases with age, the physical body is not always so kind. As Dolly Parton once said, Time marches on and sooner or later you realize it is marching across your face. But time also has a way of creating degenerative changes in other places as well, such as the knee.
For example, tears of the meniscus (cartilage in the knee) are more common in late middle age. The posterior horn of the medial meniscus is especially likely to develop tears as we get older. The medial meniscus is the portion of the cartilage along the inside of the knee joint (closest to the other knee). The posterior horn is located on the back half of the meniscus.
Horizontal meniscal tears (from side to side dividing the posterior horn in two parts) are the topic of this study from the Center for Joint Disease in Korea. The goal was to see how patients with degenerative horizontal tears of the posterior horn of the medial meniscus responded to surgical treatment versus conservative care (strengthening program).
Treatment choice for this type of meniscal tear is not always easy. These are difficult tears because they can go deep into the joint capsule. Removing part or the entire meniscus can result in ongoing painful symptoms. A partial meniscectomy eventually leads to a second surgery to remove the entire meniscus (total meniscectomy). Studies also show that partial or total meniscectomy can lead to early arthritis.
All patients included (total of 102) in this study were between the ages of 43 and 62 and experiencing intense knee pain. Mechanical symptoms such as clicking and/or popping were also reported by most of the patients. Two groups were followed for two years after treatment: the surgical (meniscectomy) group and the strengthening (nonoperative) group. Patients were assigned to their group using random selection. There was a four-to-one ratio of women to men (81 women and 21 men).
The exercise group was supervised by a physical therapist as they worked on muscle strength, flexibility, and endurance. Details of the eight-week exercise program (including a home exercise portion) were provided. For the surgical group, arthroscopy was used to remove frayed tissue and smooth the joint surface (partial meniscectomy). One orthopedic surgeon performed all of the procedures. No one had a complete meniscectomy. Everyone participated in the same exercise program as the nonoperative group but without the benefit of a physical therapist's supervision.
A variety of measurements were used to compare results including pain, knee motion, activity, and patient satisfaction. The statistical analysis showed no difference in outcomes between the two groups. Pain relief, improved function, and very satisfied patients were the final results for both groups. Only a small number of patients in both groups continued to report painful symptoms at the final check-up.
In summary, this study provides evidence that horizontal meniscal tears can be treated successfully with a nonoperative approach. The tear tends to remain stable and no further treatment is required. Previous routine management with arthroscopic partial meniscectomy may not be needed after all. The authors comment that the symptoms associated with this type of degenerative change in the meniscus may get better in time no matter how it is treated. Further study is required to compare treatment groups with non-treatment groups to know for sure.
Ji-Hyeon Yim, MD, et al. A Comparative Study of Meniscectomy and Nonoperative Treatment for Degenerative Horizontal Tears of the Medial Meniscus. In The American Journal of Sports Medicine. July 2013. Vol. 41. No. 7. Pp. 1565-1570.
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