Title: The MEniscal TeaR Outcome (METRO) Study: Understanding the disease process of young patients with a meniscal tear of the knee and response to treatment.
Funder: Department of Health and Social Care

Abstract: Background The meniscus is a c-shaped structure critical to load distribution across the knee joint. The meniscus can become damaged following trauma or repetitive loading. Meniscal tears often occur in patients with coexisting degeneration or arthritis within the knee. Although there is extensive high quality research examining the clinical effectiveness of treatments for meniscal tears, this is almost exclusively focused on older patients in whom widespread knee degeneration is common. There is however, a paucity of high quality research on treatment outcomes for younger patients (The aims of this study are to document the symptoms, imaging findings (MRI) of people who present with a meniscal tear under the age of 55, and to determine whether symptoms or MRI findings relate to treatment outcome. I also aim to explore the lived experiences of young patients with a meniscal tear.I will meet these aims through three integrated research studies: 1. Systematic review of the management of meniscal tears. I will review randomised controlled trials (RCT) and observational studies comparing operative versus non-operative management. This review will summarise the short and long term outcomes for each management option. 2. METRO cohort study. A prospective two-centre cohort study in separate NHS trusts will be performed. Patients with a new diagnosis of meniscal tear will be recruited from intermediate or secondary care (acute knee clinics) and followed up for 12 months. The presence of baseline factors, for example meniscal specific symptoms and the presence of arthritis diagnosed on magnetic resonance imaging will be identified. I will also investigate whether these features affects patient reported outcome measures. 3. METRO qualitative study. A purposive sample of 20 participants will be invited to take part in semi-structured interviews. This work will explore views on current treatment options and identify key symptoms that exacerbate presentation to healthcare services. I will also explore patient views on a future trial investigating the effectiveness of surgery in this population. Thematic analysis will be used to generate codes and overarching themes.Anticipated impact and dissemination Patient and public involvement work with younger people with meniscal tears has highlighted the anxieties patients feel the long-term impact their injuries may have on long-term function. My research will directly help these patients and I aim to not only communicate my research findings through conferences and publications but also via patient leaflets and social media. There is a need for a high quality RCT to assess the effectiveness of surgery in this population, however, prior to this, research is needed to understand the patient population. This includes identifying the proportion of patients with signs of arthritis and identifying the factors that affect patient outcome. The research will help refine the indications for surgery and help prevent unnecessary surgery. Each surgery costs 1300 and therefore refined use will have a significant economic impact.

Lay abstract: The meniscus is an important cartilage in the knee involved in distributing weight between the joint surfaces. Meniscal tears or injuries are common. The rates of surgery for meniscal injury have doubled between 2002-2012 with 150,000 procedures performed annually. However, for many older people (aged 55 and over) with meniscal injuries, physiotherapy is as effective as surgery. There is no high-quality research examining the management of meniscal injuries in younger people. Before comparing treatment options in younger people, we need to understand how many young patients with a meniscal tear have existing arthritis within the knee, what treatment they normally receive in the NHS, how the presence of arthritis on a magnetic resonance imaging (MRI) scan affects their treatment outcome, and whether there are certain symptoms that help in the decision to do surgery (as many surgeons believe) or not.Aim I aim to document the symptoms, imaging findings and current NHS treatment of people who present with a meniscal tear under the age of 55, and to determine which factors most closely relate to the success of treatment. I also aim to explore the experiences of young patients with a meniscal tear treated both with and without surgery.Method 1. Systematic review of the evidence: I will review the existing published evidence examining the short and long term effects of physiotherapy and surgery in young patients with a meniscal tear. 2. MEniscal TeaR Outcome (METRO) Study: I will invite patients who have been newly diagnosed with a meniscal tear from two hospitals to take part. The majority of these patients will undergo a period of physiotherapy, however, some may be put on a waiting list for surgery. I will collect information on patient specific features e.g. symptoms, age and gender and see how these features affect the treatment result. I will also use measures of arthritis in the knee based on MRI to investigate the proportion of young patients with signs of arthritis with a meniscal tear and whether this arthritis affects outcome. 3. METRO Interview study: I will invite 20 participants with a meniscal tear at various points of the treatment pathway for an interview. During this interview I will explore their views on the current treatment pathways and the management of meniscal injuries.Patient and Public involvement (PPI) Identifying features which affect outcomes in patients with early arthritis is a top 10 research priority by the James Lind Alliance Priority Setting Partnership. Patients were consulted in the planning of this application and will be actively involved of the design and communication of all three studies.Dissemination My work will be communicated at scientific conferences, orthopaedic journals, patient meetings and I will produce a freely available summary. I will also produce posters and leaflets which I will make available online using social media and patient websites.Intended benefits This work will allow patients and clinicians to understand what happens to the symptoms of people with meniscal injuries, which will help ensure that more people get the best treatment. Additionally by identifying the features that affect what happens we can identify which patients do well with physiotherapy and which require surgery. It will also allow a large randomised study to be planned to determine the best treatment for young people who are diagnosed with meniscal tears. For the health service, there is a potential economic benefit as each procedure costs around 1300. This work will ensure that patients are directed towards the right service at the right time, preventing unnecessary surgery with is associated complications but also reducing delays in treatment for those who could benefit from surgical intervention.

Research activity codes: 6.4 SURGERY;6.7 PHYSICAL
Health categories: MUSCULOSKELETAL