Abstract
Purpose
To compare knee osteoarthritis (OA) incidence within 5 years of surgery between 5 common sports medicine procedures: isolated anterior cruciate ligament (ACL) reconstruction, isolated meniscus repair (MR), isolated arthroscopic partial meniscectomy (APM), ACL reconstruction with MR (ACL + MR), and ACL reconstruction with APM (ACL + APM).
Methods
The PearlDiver Mariner M157Ortho database was searched. Five cohorts were identified using Current Procedural Terminology (CPT) codes and included those 16 to 60 years old who underwent isolated ACL reconstruction, isolated MR, ACL + MR, isolated APM, or ACL + APM repair. Groups were matched by age, sex, and presence of diagnosis codes for obesity. The incidence of knee OA diagnosis within 5 years of the index procedure was determined for each group, and odds ratios (ORs) were calculated and compared against isolated ACL reconstruction.
Results
Each group consisted of 7,672 patients (3,450 females, 4,222 males). A significantly greater proportion of the APM group was diagnosed with knee OA within 5 years of surgery compared to isolated ACL reconstruction (APM = 1,032/7,672 [13.5%] vs ACL = 745/7,672 [9.7%]; P ≤ .001; OR, 1.45; 95% confidence interval [CI], 1.31-1.60). Similarly, a greater proportion of the MR group was diagnosed with OA compared to isolated ACL reconstruction (MR = 826/7,672 [10.7%]; P = .030; OR, 1.12; 95% CI, 1.01-1.25). No differences in OA incidence were noted between the ACL + APM group when compared to isolated ACL reconstruction (P = .81). Patients undergoing ACL + MR demonstrated the lowest OA incidence with reduced odds when compared to isolated ACL reconstruction (ACL + MR = 575/7,672 [7.5%]; P < .001; OR, 0.75; 95% CI, 0.67-0.84).
Conclusions
In this analysis using CPT codes, APM was associated with the highest knee OA incidence, and ACL + MR was associated with the lowest OA incidence within 5 years of surgery.
Level of Evidence
Level III, retrospective cohort study.
It is well documented that traumatic knee injuries, including anterior cruciate ligament (ACL) and meniscus injuries, are a substantial risk factor for the development of post-traumatic osteoarthritis (PTOA).1, 2, 3, 4 The pathophysiology of PTOA development and progression is likely multifactorial and may include the effects of mechanical and neuromuscular alterations, a prolonged intra-articular inflammatory response, and concomitant cartilage damage at the time of injury.3,5 Traumatic knee injuries often occur in young, active patients, and thus, the onset of PTOA is often earlier than idiopathic osteoarthritis (OA).6 Because PTOA often affects patients earlier in life and can lead to substantial disability, it is important to identify the risk factors for its development.
ACL and meniscus injuries alone or in combination and the surgical techniques employed to treat them may alter the risk of PTOA. Studies have shown that the risk of PTOA development following ACL reconstruction is higher in patients with concomitant meniscus and/or chondral injuries versus ACL injuries alone.3,7 Furthermore, 1 study examining risk factors of PTOA development following ACL reconstruction found that patients who underwent concomitant meniscal repair or partial meniscectomy versus isolated ACL reconstruction had significantly higher grades of radiographic OA at 2 to 3 years following surgery.6,8 Some recent studies have shown that partial meniscectomy, whether performed at the time of ACL reconstruction or alone, may be a significant risk factor for PTOA development.9,10 Taken together, these results highlight that combined ACL and meniscal injuries, as well as partial meniscectomy as a treatment for these injuries, may be substantial risk factors for the development of PTOA. However, these risk factors are still not fully understood, and it is unknown whether ACL or meniscus injuries are the more important factor in early PTOA diagnosis. The purpose of this study was to compare knee OA incidence within 5 years of surgery between 5 common sports medicine procedures: isolated ACL reconstruction, isolated meniscus repair (MR), isolated arthroscopic partial meniscectomy (APM), ACL reconstruction with MR (ACL + MR), and ACL reconstruction with APM (ACL + APM). We hypothesized that APM and ACL + APM would have increased OA incidence relative to isolated ACL reconstruction.
Methods
The PearlDiver Mariner M157Ortho database, which contains insurance claims information on more than 157 million orthopaedic patients, was used in this retrospective cohort study. Current Procedural Terminology (CPT) codes were used to identify 5 patient cohorts: those with an isolated ACL reconstruction (CPT 29888), isolated MR (CPT 29882), ACL + MR (CPT 29888 and 29882), isolated APM (CPT 29880), or ACL + APM (CPT 29888 and 29880). Patients were excluded if they were outside of the ages of 16 to 60 years, underwent multiligament knee reconstruction, had a concomitant articular cartilage procedure, or had an OA diagnosis prior to their index procedure. All patients were required to have insurance coverage for a minimum of 6 months prior to and 5 years after the index procedure. Subsequent diagnosis of knee OA at any point within 5 years of the index surgical procedure was assessed. Patients with surgery dates between January 1, 2010, and October 31, 2016, were included.
Primary Outcome
The following codes were used to identify knee OA diagnosis: ICD-9-D-715.16 (osteoarthritis localized primary involving lower leg), ICD-9-D-715.26 (osteoarthritis localized secondary involving lower leg), ICD-9-D-715.36 (osteoarthritis localized, not specified whether primary or secondary involving lower leg), ICD-9-D-715.96 (osteoarthritis unspecified whether generalized or localized involving lower leg), and ICD-10-D-M17.
Statistical Analyses
Groups were matched by patient age, sex, and the presence of diagnosis codes for obesity (ICD-9 278.0 [obesity], ICD-10 E66.0 [obesity due to excess calories]). OA incidence for each surgical cohort was determined and odds ratios (ORs) were calculated in comparison to isolated ACL reconstruction. Kaplan-Meier survivorship curves were created to assess subsequent OA diagnosis in each patient cohort.
Results
Each of the 5 cohorts consisted of 7,672 patients (3,450 females and 4,222 males). These cohorts were matched by patient age, sex, and presence of diagnosis CPT codes for obesity and morbid obesity (Table 1). A significantly greater proportion of the APM group was diagnosed with knee OA within 5 years of surgery when compared to isolated ACL reconstruction (APM = 1,032/7,672 [13.5%] vs ACL = 745/7,672 [9.7%]; P ≤ .001; OR, 1.45; 95% confidence interval [CI], 1.31-1.60). Similarly, a greater proportion of the MR group was diagnosed with OA when compared to isolated ACL reconstruction (MR = 826/7,672 [10.7%] vs ACL = 745/7,672 [9.7%]; P = .030; OR, 1.12; 95% CI, 1.01-1.25). No differences in OA incidence were noted between the ACL + APM group when compared to isolated ACL reconstruction (P = .81). Patients undergoing ACL + MR demonstrated the lowest OA incidence with reduced odds when compared to isolated ACL reconstruction (ACL + MR = 575/7,672 [7.5%]; P < .001; OR, 0.75; 95% CI, 0.67-0.84) (Fig 1).
Table 1.
Patient Demographics and Osteoarthritis Incidence for the 5 Surgical Cohorts
| Cohort | N | Age, Mean ± SD, y | Female Sex, n (%) | Obese, n (%) | OA Incidence, n (%) | P Value∗ |
|---|---|---|---|---|---|---|
| ACL | 7,672 | 28.5 ± 11.3 | 3,450 (45.0) | 1,725 (22.5) | 745 (9.7) | — |
| APM | 7,672 | 28.6 ± 11.4 | 3,450 (45.0) | 1,725 (22.5) | 1,032 (13.5) | <.001 |
| MR | 7,672 | 28.5 ± 11.3 | 3,450 (45.0) | 1,725 (22.5) | 826 (10.7) | .030 |
| ACL + APM | 7,672 | 28.5 ± 11.3 | 3,450 (45.0) | 1,725 (22.5) | 736 (9.6) | .810 |
| ACL + MR | 7,672 | 28.5 ± 11.3 | 3,450 (45.0) | 1,725 (22.5) | 575 (7.5) | <.001 |
ACL, anterior cruciate ligament; APM, arthroscopic partial meniscectomy; MR, meniscus repair; OA, osteoarthritis.
P values represent the comparison in OA incidence between the isolated ACL group and the other groups.
Fig 1.
Kaplan-Meier survivorship curves showing the progression to subsequent osteoarthritis diagnosis after anterior cruciate ligament (ACL), arthroscopic partial meniscectomy (APM), meniscus repair (MR), ACL + MR, or ACL + APM.
Discussion
The most important finding of this study was that APM was associated with the highest incidence of OA within 5 years of surgery (13.5%). Surprisingly, the lowest OA incidence was observed in patients undergoing ACL reconstruction with concomitant MR (7.5%). These “big data” results confirm previous reports from prospective ACL cohorts and further support efforts to repair the meniscus whenever possible. These results partially support our hypothesis.
In the current study, a significantly greater proportion of patients who underwent APM were diagnosed with OA within 5 years of surgery compared to patients who underwent isolated ACL reconstruction. These results support the findings of previous studies that report the detrimental effects of APM on OA risk.1, 2, 3, 4, 5, 6 A recent review of previous studies demonstrated that patients had better Lysholm scores (OR, 2.20), lower rates of progression to knee OA (22.2% vs 48.3%), and lower odds of reoperation (OR, 0.05) when opting for MR as a treatment for medial meniscus root tears as opposed to APM.5 Similarly, in patients with lateral meniscus tears, Duethman et al.11 reported that meniscus repair was associated with decreased arthritis symptoms and greater improvement in International Knee Documentation Committee scores when compared to meniscectomy.
It has also been shown that patients with specific characteristics may be exposed to higher risk of knee OA following APM. Lamplot et al.10 found that females were more likely than males to have clinical OA within 6 years following APM (73% vs 21%, P = .009). The presence of a horizontal tear in a discoid lateral meniscus injury has also been reported to be one of the strongest predictors of knee OA within 5 years following APM.12 The decision to undergo APM should be made with careful consideration of these and other associated risk factors when patients discuss treatment options with their physician. Arthroscopy as treatment for meniscal tears has also been shown to increase the likelihood for total knee arthroplasty in the future and should therefore be yet another factor to be considered by the patient.13
An interesting finding from our study showed only 7.5% of patients undergoing ACL + MR were diagnosed with OA, which was significantly lower than the OA incidence of the matched group of patients who underwent isolated ACL reconstruction. This is a notable finding and one that should be explored more in the future. There has been some level of analysis and review of the positive outcomes of ACL + MR,14, 15, 16 but follow-up time was not extensive and long-term findings are unclear. One review by Petersen et al.17 examining case series with follow-up of more than 7 years found that MR combined with ACL reconstruction resulted in lower rerupture rates and contributed to positive effects on the results of ACL reconstruction. The review also noted lower rates of OA in these patients, which supports our findings.
Some studies have demonstrated findings that differ from those in this study. In particular, 1 meta-analysis18 and another systematic review14 reported a higher incidence of OA after ACL reconstruction with APM when compared to isolated ACL reconstruction. This stands in opposition to our findings, which showed ACL reconstruction + APM incidence (9.6%) to be similar to the OA incidence after isolated ACL reconstruction (9.7%, P = .81). First, the clinical studies included in the meta-analysis and systematic review have the advantage of combining both clinical and radiographic data when determining the incidence of OA. However, the current study has neither clinical nor radiographic data but instead was limited to only diagnosis codes. These methodological differences may contribute to the differences between studies. Second, while the current results did not identify a difference in OA incidence between ACL and ACL + APM groups, the results do not suggest that ACL + APM is somehow protective against OA compared to ACL alone.
Both postoperative biomechanical and biologic differences may be involved with the lower rates of knee OA following combined ACL + MR. Capin et al.19 demonstrated that patients undergoing ACL + APM showed meaningfully smaller peak knee flexion angle when compared to groups with either no medial meniscus involvement or with medial meniscus repair. Similar results were reported in another study that exhibited clear differences in the gait mechanics and tibiofemoral joint loading patterns of ACL + APM patients when compared to ACL + MR patients.20 Additionally, the biologic environment for healing may be better for meniscus tears that are repaired in conjunction with ACL reconstruction. Healing rates for meniscus tears repaired concurrently with ACL reconstruction are greater than those repaired in isolation.21, 22, 23, 24 It has been theorized that improved healing may be due to the release of bone marrow elements into the joint space when drilling bone tunnels and/or microfracture of the femoral notch during ACL reconstruction.25 More intensive long-term studies are highly indicated by these conclusions in order to explore the potential protective effect of combined ACL + MR.
Limitations
This study is not without limitations. Like all insurance claims database studies, the results can be impacted by coding variability. ICD-9 codes do not indicate laterality (right vs left), so we cannot definitively determine if the subsequent OA diagnosis is associated with the operative or contralateral knee but believe in the short time frame of this study that the diagnosis is more likely to be associated with the operative knee. Second, we are limited by only being able to use diagnosis codes to identify the prevalence of OA. Radiographic data are not available, and with countless providers involved with the more than 30,000 patients in this study, there is undoubtedly variability in the clinical criteria used for diagnosing OA between providers.
Our inclusion criteria for surgical cohorts did not differentiate between specific subcategories of surgical procedures or disease types. For example, we did not specify whether patients received a patellar tendon graft versus hamstring graft. Nor did we specify specific classifications of meniscus tears when including patients in cohorts. Patients were grouped based on surgical procedure codes. This is important to note given that different subdifferentiating factors could play an important role in the future development of osteoarthritis, including whether the osteoarthritis was caused by traumatic injury or was degenerative in nature.
It is important to recognize that our study used ICD-9 278.0 (obesity) and ICD-10 E66.0 (obesity due to excess calories) when matching our groups. A potential limitation of this is that each degree of obesity may vary between patients and could affect the risk for osteoarthritis development. Ideally, body mass index (BMI) would have been used for matching purposes, but again, we were limited in this insurance claims database study to only include diagnoses related to obesity and not BMI itself.
Conclusions
In this analysis using CPT codes, APM was associated with the highest knee OA incidence, and ACL + MR was associated with the lowest OA incidence within 5 years of surgery.
Disclosure
The authors report the following potential conflicts of interest or sources of funding: D.J. reports board membership with the American Orthopedic Society for Sports Medicine, Journal of Surgical Orthopedic Advances, Orthopedics Today, SLACK Incorporated, Southern Orthopedic Association, and Sports Medicine and Arthroscopy Review and has received research support from DJ Orthopaedics and Smith & Nephew Endoscopy. M.L.I. reports receiving a consulting fee/honorarium or payment for lectures from an UpToDate publication, the James E. Ireland Foundation, and Smith & Nephew speakers bureau. D.L. reports board membership with the American Journal of Sports Medicine and received payment for lectures from Smith & Nephew. A.S. reports board membership with the American Orthopedic Society for Sports Medicine and Arthroscopy Association of North American; is a consultant for Bioventus, Smith & Nephew, and Allosource; has provided expert testimony for Terumo; and has received research support from Flexion Therapeutics and Surgical Care Affiliates. C.J. reports board membership with the Video Journal of Sports Medicine and has received research support from Flexion Therapeutics and Smith & Nephew. All other authors (M.S., B.S., C.C.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
Supplementary Data
References
- 1.Ozeki N., Seil R., Krych A.J., Koga H. Surgical treatment of complex meniscus tear and disease: State of the art. J ISAKOS. 2021;6:35–45. doi: 10.1136/jisakos-2019-000380. [DOI] [PubMed] [Google Scholar]
- 2.Beaufils P., Pujol N. Management of traumatic meniscal tear and degenerative meniscal lesions. Save the meniscus. Orthop Traumatol Surg Res. 2017;103:S237–S244. doi: 10.1016/j.otsr.2017.08.003. (suppl) [DOI] [PubMed] [Google Scholar]
- 3.Ma J., Chen H., Liu A., Cui Y., Ma X. Medical exercise therapy alone versus arthroscopic partial meniscectomy followed by medical exercise therapy for degenerative meniscal tear: A systematic review and meta-analysis of randomized controlled trials. J Orthop Surg Res. 2020;15:219. doi: 10.1186/s13018-020-01741-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Li J., Zhu W., Gao X., Li X. Comparison of arthroscopic partial meniscectomy to physical therapy following degenerative meniscus tears: A systematic review and meta-analysis. Biomed Res Int. 2020;2020 doi: 10.1155/2020/1709415. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Ro K.H., Kim J.H., Heo J.W., Lee D.H. Clinical and radiological outcomes of meniscal repair versus partial meniscectomy for medial meniscus root tears: A systematic review and meta-analysis. Orthop J Sports Med. 2020;8 doi: 10.1177/2325967120962078. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Ruano J.S., Sitler M.R., Driban J.B. Prevalence of radiographic knee osteoarthritis after anterior cruciate ligament reconstruction, with or without meniscectomy: An evidence-based practice article. J Athl Train. 2017;52:606–609. doi: 10.4085/1062-6050-51.2.14. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.van de Graaf V.A., Noorduyn J.C.A., Willigenburg N.W., et al. ESCAPE Research Group Effect of early surgery vs physical therapy on knee function among patients with nonobstructive meniscal tears: The ESCAPE randomized clinical trial. JAMA. 2018;320:1328–1337. doi: 10.1001/jama.2018.13308. [published correction appears in JAMA 2018;320:2272-2273 and JAMA 2020;323:1001] [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Kise NJ, Risberg MA, Stensrud S, Ranstam J, Engebretsen L, Roos EM. Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: Randomised controlled trial with two year follow-up [published correction appears in BMJ 2017;356:j266 and BMJ 2018;363:k4893]. [DOI] [PMC free article] [PubMed]
- 9.Hall M., Juhl C.B., Lund H., Thorlund J.B. Knee extensor muscle strength in middle-aged and older individuals undergoing arthroscopic partial meniscectomy: A systematic review and meta-analysis. Arthritis Care Res (Hoboken) 2015;67:1289–1296. doi: 10.1002/acr.22581. [DOI] [PubMed] [Google Scholar]
- 10.Lamplot J.D., Tompkins W.P., Friedman M.V., Nguyen J.T., Rai M.F., Brophy R.H. Radiographic and clinical evidence for osteoarthritis at medium-term follow-up after arthroscopic partial medial meniscectomy. Cartilage. 2021;13:588S–594S. doi: 10.1177/1947603519892315. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Duethman N.C., Wilbur R.R., Song B.M., et al. Lateral meniscus tears in young patients: A comparison of meniscectomy and surgical repair. Orthop J Sports Med. 2021;9 doi: 10.1177/23259671211046057. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Ahn J.H., Kang D.M., Choi K.J. Risk factors for radiographic progression of osteoarthritis after partial meniscectomy of discoid lateral meniscus tear. Orthop Traumatol Surg Res. 2017;103:1183–1188. doi: 10.1016/j.otsr.2017.09.013. [DOI] [PubMed] [Google Scholar]
- 13.Winter A.R., Collins J.E., Katz J.N. The likelihood of total knee arthroplasty following arthroscopic surgery for osteoarthritis: A systematic review. BMC Musculoskelet Disord. 2017;18:408. doi: 10.1186/s12891-017-1765-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Zheng T., Song G., Li Y., et al. Clinical, radiographic, and arthroscopic outcomes of surgical repair for radial and avulsed lesions on the lateral meniscus posterior root during ACL reconstruction: A systematic review. Orthop J Sports Med. 2021;9 doi: 10.1177/2325967121989678. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Korpershoek J.V., de Windt T.S., Vonk L.A., Krych A.J., Saris D.B.F. Does anterior cruciate ligament reconstruction protect the meniscus and its repair? A systematic review. Orthop J Sports Med. 2020;8 doi: 10.1177/2325967120933895. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Milliron E.M., Magnussen R.A., Cavendish P., Quinn J., DiBartola A.C., Flanigan D.C. Repair of radial meniscus tears results in improved patient-reported outcome scores: A systematic review. Arthrosc Sports Med Rehabil. 2021;3:e967–e980. doi: 10.1016/j.asmr.2021.03.002. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Petersen W., Karpinski K., Bierke S., Müller Rath R., Häner M. A systematic review about long-term results after meniscus repair. Arch Orthop Trauma Surg. 2022;142:835–844. doi: 10.1007/s00402-021-03906-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Claes S., Hermie L., Verdonk R., Bellemans J., Verdonk P. Is osteoarthritis an inevitable consequence of anterior cruciate ligament reconstruction? A meta-analysis. Knee Surg Sports Traumatol Arthrosc. 2013;21:1967–1976. doi: 10.1007/s00167-012-2251-8. [DOI] [PubMed] [Google Scholar]
- 19.Capin J.J., Khandha A., Buchanan T.S., Snyder-Mackler L. Partial medial meniscectomy leads to altered walking mechanics two years after anterior cruciate ligament reconstruction: Meniscal repair does not. Gait Posture. 2019;74:87–93. doi: 10.1016/j.gaitpost.2019.08.017. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Capin J.J., Khandha A., Zarzycki R., Manal K., Buchanan T.S., Snyder-Mackler L. Gait mechanics after ACL reconstruction differ according to medial meniscal treatment. J Bone Joint Surg Am. 2018;100:1209–1216. doi: 10.2106/JBJS.17.01014. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Wasserstein D., Dwyer T., Gandhi R., Austin P.C., Mahomed N., Ogilvie-Harris D. A matched-cohort population study of reoperation after meniscal repair with and without concomitant anterior cruciate ligament reconstruction. Am J Sports Med. 2013;41:349–355. doi: 10.1177/0363546512471134. [DOI] [PubMed] [Google Scholar]
- 22.Westermann R.W., Wright R.W., Spindler K.P., Huston L.J., Group M.K., Wolf B.R. Meniscal repair with concurrent anterior cruciate ligament reconstruction: Operative success and patient outcomes at 6-year follow-up. Am J Sports Med. 2014;42:2184–2192. doi: 10.1177/0363546514536022. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Majeed H., Karuppiah S., Sigamoney K.V., Geutjens G., Straw R.G. All-inside meniscal repair surgery: Factors affecting the outcome. J Orthop Traumatol. 2015;16(3):245–249. doi: 10.1007/s10195-015-0342-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Kanto R., Yamaguchi M., Sasaki K., Matsumoto A., Nakayama H., Yoshiya S. Second-look arthroscopic evaluations of meniscal repairs associated with anterior cruciate ligament reconstruction. Arthroscopy. 2019;35:2868–2877. doi: 10.1016/j.arthro.2019.04.009. [DOI] [PubMed] [Google Scholar]
- 25.Freedman K.B., Nho S.J., Cole B.J. Marrow stimulating technique to augment meniscus repair. Arthroscopy. 2003;19:794–798. doi: 10.1016/s0749-8063(03)00695-9. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.