Improving the management of patients with meniscal lesions of the knee

Meniscal lesions in the knee are common and keyhole surgery to excise a meniscal tear, arthroscopic partial meniscectomy (APM), is one of the most commonly performed orthopaedic surgical procedures worldwide. Despite the frequency with which the procedure is performed, the effectiveness of the procedure has been challenged by the publication of a series of clinical trials reporting similar outcomes following physiotherapy or placebo surgery. The broad aims of this thesis were (1) to determine trends and variation in the use of APM and consider if there is evidence for potential overuse of the procedure, (2) to systematically appraise the effectiveness of APM in different patient groups, (3) to determine the potential risks associated with undergoing APM, and (4) to deliver standardised descriptive terminology and treatment guidance informed by this new research.
APM was found to be performed increasingly frequently in England over a twenty-year period to 31 March 2017 and there was variation both in the intervention rate and the rate of patients subsequently undergoing a knee arthroplasty within one-year. This variation implied potential overuse of the procedure in some populations, especially those with advanced osteoarthritis, and suggested the need for new clinical treatment guidance to improve and standardise the care pathway for these patients.
The clinical effectiveness of APM was found to be limited in patients with osteoarthritis, improved in patients without osteoarthritis, but the interpretation of the evidence is limited by poor quality validation of outcome measures for use in patients with meniscal tears. No trial evidence was identified for patients meeting the strictest selection criteria, specifically a clinically and radiologically unstable meniscal tear, without osteoarthritis, for symptoms failing to resolve after physiotherapy.
The short-term risk (90-days) from undergoing APM was found to be low, with serious medical complications (myocardial infarction, stroke, death) occurring less frequently than in the general population. The risk of pulmonary embolism and septic arthritis was, however, elevated and for every 1500 fewer APMs performed, one pulmonary embolism and two knee infections could be prevented. In the long-term, patients with a history of APM were ten-times more likely to undergo arthroplasty annually in comparison to the general population without a history of APM. Women were at greater risk, with 22% undergoing arthroplasty within 15-years, in comparison to 10% of men.
A standardised terminology for the description and classification of the clinical and radiological features found in patients with meniscal lesions was developed through an expert consensus process. Using these definitions, a treatment appropriateness exercise was undertaken, informed by the new analysis of the latest clinical and epidemiological evidence, ultimately supporting the development of a new treatment guideline endorsed by the national knee society.
In conclusion, the findings reported in this thesis suggest there has been variation within the care pathway for patients with meniscal lesions which may be associated with undesirable outcomes and uncommon but serious adverse events. This thesis reports new standardised treatment guidance, with supporting evidence, and a corresponding change in clinical practice to improve the management of patients with meniscal lesions of the knee is recommended.

Keywords: effectiveness
risks
meniscus
meniscal lesions
arthroscopy
surgery
complications
arthroscopic surgery
knee
meniscal tears
outcomes
clinical
meniscal
meniscectomy
Advisor: Beard, D
Hopewell, S
Judge, A
Price, A