Meniscectomy is one of the oldest and most commonly performed orthopaedic procedures. First described in 1866 and popularized by Smillie in the 1970s, meniscectomy has remained one of the most commonly performed orthopaedic procedures in the world. In a recent review of cases presented during Part II of the ABOS (American Board of Orthopaedic Surgery) certification examination, CPT (Current Procedural Terminology) code 29881 (arthroscopic partial medial meniscectomy) was the most common procedure performed in all years surveyed and outnumbered the next most common procedure by a ratio of 2:11. That is a lot of menisci being removed!
In 1948, T.J. Fairbank published his landmark paper, “Knee Joint Changes After Meniscectomy.”2 Building on observations of others before him, he concluded that “meniscectomy is not wholly innocuous” and “it seems likely that narrowing of the joint space will predispose to early degenerative changes.” Several other authors, years later, reliably duplicated his astute observations, and the predictable changes that the knee undergoes after meniscectomy bear his name.
Following Fairbank’s observations, the orthopaedic community came to realize that the meniscus is not the “appendix of the knee,” and poor outcomes in young patients and cruciate ligament-deficient patients became readily apparent. With the advent of arthroscopy, partial meniscectomy took the place of total meniscectomy, but the problems observed by Fairbank were not completely avoided.
A natural progression toward meniscal preservation and salvage followed, and this led to an explosion in the basic science involving meniscal healing, vascularity, and function. It is hard to imagine that, prior to thirty years ago, the premise that is the foundation of the paper by Nepple et al. did not exist. There was no discussion of meniscal repair. Henning, DeHaven, Arnoczky, and others, building on the work of Fairbank and the giants who preceded them, put forth the concept that meniscal salvage was worthwhile and gave us the techniques and the knowledge necessary to make meniscal salvage possible3,4.
This paper is a great, comprehensive collection of the next generation of meniscal pioneers. Just as Fairbank questioned in 1948 whether the changes he was observing were connected to later osteoarthritis, we are left to question what the true outcomes of meniscal repair are and whether we prevent the changes that he observed.
This paper is helpful in that quest. The authors concisely summarized and reviewed thirteen papers with more than five years of follow-up after meniscal repair. With a pooled rate of meniscal failure of 23.1% at greater than five years, we are left with the observation that >75% of meniscal repairs were clinically successful over that time period. Although no orthopaedic surgeon likes reoperation, this failure rate may be worth the risk, given the predictable course of articular cartilage degeneration that ensues after the alternative of meniscal resection. This paper is also quick to point out that the failure rates for newer, all-inside suture-based devices are not included in this paper and that the longer-term outcomes of such techniques remain unknown.
The future of meniscal repair remains bright. As newer, easier-to-use, and less traumatic surgical techniques are developed and biologic agents are introduced to enhance healing and repair success, there is likely to be improvement on these outcomes.
It remains to be seen if meniscal preservation can prevent arthritis. As the authors point out, this question is difficult to answer with the current data. However, the few studies that have compared the radiographic prevalence of arthritis between successful and unsuccessful repairs seem to indicate that the ultimate goal of meniscal preservation—prevention of articular cartilage degeneration—may be possible.
When I was a sports medicine fellow at the University of Pittsburgh, Chris Harner often jokingly told me that he was in the “Save the Meniscus” society. Although no such society exists, I think the value of that sentiment is key. There is no “appendix” in the knee, and our default as surgeons should always be to repair first and resect only when repair is not feasible.