Surgical Management of Degenerative Meniscus Lesions: The 2016 ESSKA Meniscus Consensus

Abstract

Purpose A degenerative meniscus lesion is a slowly developing process typically involving a horizontal cleavage in a middle-aged or older person. When the knee is symptomatic, arthroscopic partial meniscectomy has been practised for a long time with many case series reporting improved patient outcomes. Since 2002, several randomised clinical trials demonstrated no additional benefit of arthroscopic partial meniscectomy compared to non-operative treatment, sham surgery or sham arthroscopic partial meniscectomy. These results introduced controversy in the medical community and made clinical decision-making challenging in the daily clinical practice. To facilitate the clinical decision-making process, a consensus was developed. This initiative was endorsed by ESSKA. Methods A degenerative meniscus lesion was defined as a lesion occurring without any history of significant acute trauma in a patient older than 35 years. Congenital lesions, traumatic meniscus tears and degenerative lesions occurring in young patients, especially in athletes, were excluded. The project followed the so-called formal consensus process, involving a steering group, a rating group and a peer-review group. A total of 84 surgeons and scientists from 22 European countries were included in the process. Twenty questions, their associated answers and an algorithm based on extensive literature review and clinical expertise, were proposed. Each question and answer set was graded according to the scientific level of the corresponding literature. Results The main finding was that arthroscopic partial meniscectomy should not be proposed as a first line of treatment for degenerative meniscus lesions. Arthroscopic partial meniscectomy should only be considered after a proper standardised clinical and radiological evaluation and when the response to non-operative management has not been satisfactory. Magnetic resonance imaging of the knee is typically not indicated in the first-line work-up, but knee radiography should be used as an imaging tool to support a diagnosis of osteoarthritis or to detect certain rare pathologies, such as tumours or fractures of the knee. Discussion The present work offers a clear framework for the management of degenerative meniscus lesions, with the aim to balance information extracted from the scientific evidence and clinical expertise. Because of biases and weaknesses of the current literature and lack of definition of important criteria such as mechanical symptoms, it cannot be considered as an exact treatment algorithm. It summarises the results of the "ESSKA Meniscus Consensus Project" ( http://www.esska.org/education/projects ) and is the first official European consensus on this topic. The consensus may be updated and refined as more high-quality evidence emerges. Level of Evidence I.

Keywords: arthroscopic partial meniscectomy; consensus; degenerative lesion; management; meniscus.

Fig. 1

Formal Consensus Project.

Fig. 2

Development of an intrameniscus signal into a horizontal cleavage lesion in the posterior horn of a medial meniscus over a period of four years captured on repeat 3-Tesla knee MRI (courtesy of M Englund).

Fig. 3

Prevalence of meniscus lesions and destruction in a randomly recruited population-based sample. ( a ) Meniscus tear and ( b ) meniscus destruction (not classified as a tear) in the right knee of men ( n  = 426) and women ( n  = 565) aged 50–90 from Framingham, MA, USA. The diagnosis was based on MRI. Participants were not selected on the basis of knee or other joint problems. Error bars show the 95% CI (reprinted with permission from New Engl J Med).

Fig. 4

Meniscus pathway to knee osteoarthritis.

Fig. 5

Medial meniscus flap subluxated in the tibial gutter with bony impingement. This kind of specific degenerative meniscus lesion may be associated with significant mechanical symptoms and pain.

Fig. 6

Medial meniscus extrusion (>3 mm) demonstrating an early osteoarthritic stage (MRI: coronal view; T2 FS).

Fig. 7

Algorithm for the management of Degenerative Meniscus Lesions.