TITLE: Portland Pivot Kick Study: Can a novel physical exam maneuver for medial meniscus tears predict improvement after partial medial meniscectomy?
AUTHORS: Samuel Moulton, Sean Sterrenberg, Kenneth Gundle, Mark Berkson

[DESCRIPTION]
<div class = "text-blocks"><div class = "text-block"><span style = "font-weight:bold;:UNDERLINE;">Specific Aims/Purpose</span></div><div class = "text-block">This study aims to evaluate patients with symptomatic medial meniscus tear verified by MRI using a novel physical exam maneuver, the Portland Pivot Kick (PPK). The goal is to assess whether patients with symptomatic medical meniscus tears have a change in the PPK before and after arthroscopic partial medial meniscectomy. This physical exam maneuver may help predict the potential benefit of arthroscopic partial medial meniscectomy in treating mechanical symptoms, even in the setting of degenerative joint disease.</div><div class = "text-block"><span style = "font-weight:bold;">Hypothesis:</span><span> Patients with a positive preoperative PPK will have improvement of mechanical symptoms and significantly improved subjective outcomes scores following arthroscopic partial medial meniscectomy.</span></div><div class = "text-block"><span style = "font-weight:bold;:UNDERLINE;">Scientific Rationale and Significance </span></div><div class = "text-block">Medial meniscal tears are common and they are often associated with osteoarthritis in elderly patients presenting with knee pain. One study reported a prevalence of 86% of medial meniscal tears in patients with symptomatic osteoarthritis. Management of medial meniscal tears include structured physical therapy and arthroscopic partial meniscectomy, with 700,000 partial meniscectomies performed annually in the United States.</div><div class = "text-block">Multiple randomized control trials have evaluated the efficacy of partial meniscectomies in patients with osteoarthritis by comparing surgery to physical therapy. Three of the 4 studies found no benefit to partial meniscectomy, while one study found a significant benefit to surgical treatment.  However, up to one third of patients in the randomized control trials crossed over from physical therapy to arthroscopic partial meniscectomy. A follow up analysis found that patients who crossed over to surgery after starting a course of physical therapy had a higher acute level of pain and similar outcome scores to patients who initially underwent surgery. These findings suggest that a subset of patients with meniscal tears and osteoarthritis elect for surgery even after physical therapy, leading to an improvement in symptoms.</div><div class = "text-block">Mechanical symptoms of catching or locking are often attributed to meniscal tears and used as evidence to recommend partial meniscectomy. However, there is no consensus on what exactly are mechanical symptoms specific to meniscal tears. Prior studies have evaluated mechanical symptoms solely based on subjective patient reports of knee catching and/or locking. There is a paucity of objective measures of mechanical symptoms of meniscal tears.  This study will investigate the efficacy of the PPK in identifying medial meniscal tears that may improve with surgical intervention. Medial meniscal tears are a common finding amongst the veteran population with knee pain, with a prevalence approaching 50% in older patients. This study will help provide a more objective measurement of symptomatic medial meniscal tears for both veterans and the general population.</div></div>

[STEPS]
?. The study timeline is as follows:
?. Initial visit : The patient will be evaluated by physical examination including the PPK maneuver. Arthroscopic partial meniscectomy will be offered as a surgical option to the patient. The patient will fill out the WOMAC and KOOS questionnaire.
?. Surgery: : Partial medial meniscectomy
?. 6 week post operative follow up: The patient will be reevaluated by physical examination including the PPK maneuver. The patient will fill out the WOMAC and KOOS questionnaire.
?. 6 month post operative follow up: The patient will be reevaluated by physical examination including the PPK maneuver. The patient will fill out the WOMAC and KOOS questionnaire.
?. 1 year post operative follow up: The patient will be reevaluated by physical examination including the PPK maneuver. The patient will fill out the WOMAC and KOOS questionnaire.
?. The patient will perform the following home exercises during the postoperative period:
?. Preoperative visit: The patient will be evaluated by physical examination including the PPK maneuver. Arthroscopic partial meniscectomy will be offered as a surgical option to the patient. The patient will fill out the WOMAC and KOOS questionnaire.