Management of Nonarthritic Meniscal Tears

A Qualitative, Patient-Centered Assessment of Decision Making

Patrick Nelson, MD; Surabhi Bhatt, MS; Michael Terry, MD; Vehniah Tjong, MD

Disclosures

Curr Orthop Pract. 2020;31(4):373-378. 

In This Article

Abstract and Introduction

Abstract

Background: Meniscal lesions are the most common intraarticular knee injury. Treatment involves a decision for conservative management or surgery. Recent literature has demonstrated similar outcomes between these two methods in patients with meniscal tears and minimal arthritis. This study explores factors influencing a patient's decision to choose operative versus nonoperative management in the treatment of nonarthritic meniscal lesions.

Methods: Semistructured interviews were conducted with patients ages 18 to 50 yr old, with MRI confirmed diagnosis of meniscal tear and minimum of 2-year follow-up. Patients with Kellen-Lawrence Grade 2 or greater, with prior knee injuries, or knee surgeries were excluded. Qualitative analysis was performed to derive codes, categories, and themes. An assessment of patient-reported outcomes including the Knee Injury and Osteoarthritis Outcome Score (KOOS) and Marx activity score was also conducted.

Results: Twenty-four patients with meniscal tears were interviewed. Those who chose surgical management with arthroscopic partial meniscectomy (n=12) cited significant pain, desire for definitive treatment, and aggressive personality traits. The nonoperative group (n=12) frequently had social constraints precluding surgery, more conservative personalities, and symptoms that did not affect their daily lives. The nonoperative group had significantly lower KOOS scores in symptoms (90.2 vs. 76.5, P=0.05), sports and recreation (84.2 vs. 64.2, P=0.05), and quality of life (QOL) (85.4 vs. 62.0, P=0.01).

Conclusions: Psychological and social factors such as pain perception, personality, and time commitments affected patients' decisions to undergo surgical or conservative management for meniscal tears. This study may help surgeons and other health care professionals better understand and educate patients contemplating surgery.

Level of Evidence: Level IV.

Introduction

Meniscal injuries are the most common intraarticular knee lesions with a mean annual prevalence of 66 per 100,000.[1] Treatment of these injuries involves either nonoperative management with activity modification, physical therapy (PT), and antiinflammatory medication or surgical treatment with arthroscopic meniscal partial debridement or repair. Recent published literature has suggested that patient outcomes for those treated with nonoperative management are comparable to arthroscopic partial meniscectomy for degenerative meniscal tears.[2,3] However, at least one-third of the nonoperative patients went on to have partial meniscectomies in the 5-year follow-up study with improved results.[4] These studies primarily focused on nonacute, degenerative tears in patients with some degree of arthritis. In addition, there is evidence that partial meniscectomy leads to a higher rate of arthritis, especially when comparing lateral to medial debridement after long-term follow-up.[5,6] When operating on patients over 40 yr old, response to partial meniscectomy is strongly related to the degree of articular degeneration.[7] Therefore, proper patient selection for surgery is essential.

Numerous studies have focused on decision making from a physician's perspective (i.e. type of lesion, lesion location, extent of lesion).[8,9] Having a strong understanding of a patient's clinical presentation and pathology is essential for proper management, but other factors must be considered when recommending elective surgery. Many studies have looked at how psychological and lifestyle factors such as fear, priorities, and personality can affect a patient's return to preinjury activity.[10,11] However, limited patient-centered studies focusing on treatment decisions exist. Given the challenges and complexity of proper management of these patients, the objective of this study was to better understand the psychological and lifestyle factors involved in patients' decisions for management of acute, nonarthritic meniscal tears.

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