Abstract
Purpose
To investigate the rates of knee reoperation and medical complications after meniscal repair versus partial meniscectomy (APM) up to 10 years after surgery.
Methods
All patients ≥ 15 years old operated for a meniscal tear with meniscus repair or partial meniscectomy at Scania University Hospital were included, between year 2010 and 2014. Information was retrieved from patient records until the year 2020. Rates of any reoperation, reoperation in same meniscus and medical complications were estimated. Differences were also estimated in the three outcomes in a subgroup aged 15–40 years using flexible parametric survival models adjusted for age, sex, knee laterality, tear type, medial/lateral, anterior cruciate ligament (ACL) status, osteoarthritis, body mass, height and smoking.
Results
Records identified 2098 patients (395 undergoing meniscal repair and 1703 partial meniscectomy) with 540 reoperations in 430 patients. The incidence rate of reoperation was 32/1000 person‐years (95% confidence interval [CI] 29–35) and of reoperation in the same meniscus 19/1000 person‐years (95% CI 17–21). There were 2.1% postoperative complications. In the age group 15‐40 years, with only bucket‐handle, longitudinal and horizontal tears, 341 patients had meniscal repair and 361 partial meniscectomy. The incidence rate of any reoperation was 105 (95% CI 90–122) per 1000 person‐years in the meniscal repair group and 24 (95% CI 18–31) in the partial meniscectomy group. The adjusted hazard ratio of any reoperation comparing meniscal repair with partial meniscectomy was 4.3 (95% CI 3.1–6.0) and of reoperations in the same meniscus 17 (95% CI 9–31). 3.3% patients had postoperative complications (15 after meniscal repair and 14 after partial meniscectomy).
Conclusions
The risk of any knee reoperation after meniscal repair had a four‐fold increase compared with partial meniscectomy, and for same meniscus reoperations about 17‐fold. The rate of medical postoperative complications was low.
Level of Evidence
Level III.
Keywords: arthroscopy, meniscus repair, meniscectomy, knee surgery, reoperation
Abbreviations
- ACL
anterior cruciate ligament
- ACLR
anterior cruciate ligament reconstruction
- APM
arthroscopic partial meniscectomy
- ASA
American Society of Anaesthesiologists
- BMI
body mass index
- CI
confidence interval
- HR
hazard ratio
- ICD10
International Classification of Diseases, version 10
- ICRS
International Cartilage Repair Society
- KOOS
Knee injury and Osteoarthritis Outcome Score
- NCSP
Nordic Medico‐Statistical Committee
- OA
osteoarthritis
- SD
standard deviation
- VTE
venous thrombus embolism
INTRODUCTION
Arthroscopic partial meniscectomy (APM) is the most common type of knee surgery with an estimated numbers of procedures close to a million per year in the United States [12]. In recent years, the trend has been to treat meniscus injuries with repair, instead of partial meniscectomy when possible [1, 11, 23, 24]. In Sweden (population 10.4 million, 2021), there were more than 8000 meniscus surgeries in 2012, with an incidence rate of arthroscopic knee surgery for acute traumatic meniscus tears of 13.7 per 100,000 person years [18]. Meniscal repair for acute tears could lead to a lower risk of knee osteoarthritis (OA) as compared to partial meniscectomy [20]. However, repair of the meniscus requires more time in the operating room than partial meniscectomy and longer rehabilitation period with activity restrictions, longer absence from work and slower return to sports [3, 15, 39]. Still, meniscal repair is reported to be cost‐effective compared to partial meniscectomy in the treatment of traumatic meniscal injuries, but not in the presence of knee OA [8].
The risk of meniscus repair failure is reported to be around 15% (ranging from 0% to 44%) [4, 22, 26, 27, 29, 32, 33, 38], whereas studies on partial meniscectomy often reports lower frequencies of complications and number of reoperations [10, 28, 31]. Since the studies of Stein et al. in 2010 and Paxton et al. in 2011, reports of a large cohort comparing partial meniscectomy versus meniscus repair are limited [21, 25, 31, 37]. There is a lack of recent studies comparing partial meniscectomy and meniscus repair in a large patient material without patient selection, with clear definitions of reoperations and treatment failure outcomes.
Thus, the aim of this study was to investigate the risk of reoperation of the ipsilateral knee for all causes and reoperation of the same meniscus (true failure) after meniscal repair and partial meniscectomy, as well as other medical complications in a well‐defined large clinical cohort with a follow‐up of 5–10 years. The second aim was to compare meniscal repair and partial meniscectomy regarding risk of reoperation of the ipsilateral knee for all causes, reoperation of the same meniscus and other medical complications in a subgroup of patients aged 15–40 years with tears potentially suitable for meniscal repair. The hypothesis was that meniscus repair is associated with increased rates of reoperations and complications compared to partial meniscectomy.
MATERIALS AND METHODS
The study was approved by the Regional Lund University Ethics Committee (IRB 2016‐873/2017‐02‐07 and IRB 2019‐02850/20191121) and it adheres to the rules of the Helsinki Declaration of 1975, as revised in 2000.
A cohort study was performed using prospectively ascertained healthcare data from the most southern region in Sweden, Scania (population 1.3 million). The OrtReg database was used and it has been developed by orthopaedic surgeons in Scania. All orthopaedic operations performed by the public healthcare in the region are registered in it and linkable by the patient's unique personal identification number providing information of birthdate, sex, current residential address and death of the patients. It contains diagnostic codes according to the International Classification of Diseases, version 10 (ICD‐10) and surgical procedure codes according to the Nordic Medico‐Statistical Committee (NCSP) as well as a wide range of data about the procedures performed and tissue observations, which is filled in by the surgeon after each surgery.
To record postoperative complications and to supplement patient characteristics the Orbit system and the Melior patient medical records were reviewed. Orbit is the regional surgical planning system containing all intraoperative medical data from all surgeries in the region. Melior is a digital medical record and contain diagnostic codes from any visit to a public hospital in the region. From Melior and Orbit we retrieved preoperative data comprising age, gender, smoking status, weight, height, medications administered intraoperatively and presence of other diseases in the knee joint. Journal text and registered diagnosis were screened for adverse events by the junior author (FBP). In cases where there was any doubt whether to include it as a knee surgery related complication or not, it was also reviewed by the senior author (PN).
Definition of reoperations and complications
The primary outcomes of interest were reoperation for all causes and reoperation in the same meniscus. The second outcome of interest was complications. Any new surgery done in the ipsilateral knee during the follow‐up was considered a reoperation. A reoperation in the same meniscus (i.e., meniscus surgery failure) was defined as new meniscal surgery in the same meniscus (medial vs. lateral) during follow‐up. Total knee replacement was considered a reoperation in the same meniscus for both medial and lateral menisci. A complication was any serious adverse medical event found in the medical records up to 2 years postoperatively that maybe could be directly linked to the knee surgery. This longer period was chosen to also capture slowly evolving complications like arthrofibrosis [6, 35]. Local pain, swelling, hemarthrosis not in need of treatment, and local loss of skin sensation, were anticipated and not regarded as serious medical complications.
Cohort inclusion and exclusion criteria
All patients matching the following inclusion criteria were identified: (a) NCSP‐code of NGD11 (partial meniscectomy) and/or NGD21 (meniscus suture) stated in the surgical report; (b) hospital of surgery: Malmoe, Lund or Trelleborg; (c) year of surgery: 2010–2014; (d) age 15 years or older at time of surgery; and (e) resident in Scania. Each person could only be included once, if bilateral knee surgery, the first surgery in the records was selected.
Patients were excluded according to the schedule presented in Figure 1. Baseline group characteristics are displayed in Table 1.
Figure 1.
Flowchart of the study.
Table 1.
Baseline characteristics of the cohort.
| All patientsa | Subgroup 15–40 yearsb | |||
|---|---|---|---|---|
| All | APM | Meniscus repair | ||
| N | 2098 | 702 | 361 | 341 |
| Age, years, mean (SD) | 39.0 (14.7) | 26.2 (7.3) | 27.9 (7.1) | 24.4 (7.1) |
| Female, N (%) | 701 (33.4) | 223 (31.8) | 90 (24.9) | 133 (39.0) |
| Length, cm, mean (SD)* | 176.3 (9.0) | 177.1 (9.1) | 178.2 (9.1) | 176.0 (8.9) |
| Weight, kg, mean (SD)* | 82.2 (15.7) | 78.7 (14.1) | 80.6 (14.0) | 76.7 (14.0) |
| BMI, mean (SD)* | 26.4 (4.2) | 25.0 (3.5) | 25.3 (3.5) | 24.7 (3.6) |
| Smoker, N (%)* | 290 (14.3) | 103 (14.9) | 63 (17.8) | 40 (11.9) |
| Right knee, N (%) | 1080 (51.5) | 377 (53.7) | 196 (54.3) | 181 (53.1) |
| Knee OA, N (%) | 754 (35.9) | 76 (10.8) | 44 (12.2) | 32 (9.3) |
| ASA grade* | ||||
| 1, N (%) | 1390 (73.0) | 556 (85.0) | 279 (84.0) | 277 (86.0) |
| 2, N (%) | 495 (26.0) | 97 (14.8) | 53 (16.0) | 44 (13.7) |
| 3, N (%) | 20 (1.0) | 1 (0.2) | 0 (0) | 1 (0.3) |
Abbreviations: APM, arthroscopic partial meniscectomy; ASA, American Society of Anaesthesiologists; BMI, body mass index; OA, osteoarthritis; SD, standard deviation.
Missing data: length n = 66 (3.1%), BMI n = 66 (3.1%), weight n = 62 (3.0%), smoker n = 77 (3.7%) and ASA grade n = 193 (9.2%).
Missing data group 15–40: length: APM n = 10 (2.8%) meniscus repair n = 6(1.8%), weight APM n = 8 (2.2%) meniscus repair n = 6(1.8%), BMI, APM n = 10 (2.8%) meniscus repair n = 6 (1.8%), smoker APM n = 8 (2.2%) meniscus repair n = 4(1.2%), ASA grade: APM n = 29 (8.0%) meniscus repair n = 19 (5.6%).
Subgroup of patients 15–40 years old
For the second aim, to compare reoperations rates between meniscal repair and partial meniscectomy, a more homogenous cohort of patients between 15 and 40 years of age was created, depicted in Figure 2, to exclude most degenerative meniscal injuries, accounting for that the meniscus quality and rate of meniscal repair tend to decrease with age. It also included only types of meniscal tears typically amendable for repair, namely tears classified as bucket‐handle, longitudinal or horizontal tears, as these could theoretically be eligible for either partial meniscectomy or meniscal repair [30].
Figure 2.
Flowchart for subgroup 15–40 years old.
Knee stability was classified into three groups: (1) Stable knees at preoperative examination, (2) unstable knees, ACL‐tears or previous ACLR with unstable knee at preoperative examination and (3) ACLR at index surgery.
Data collection
Intra‐operative data were collected regarding type and locations of meniscus tear, type and location of surgery, all specified as medial or lateral, status of cartilage and ligaments and other surgery performed in the index knee. In cases of concurrent meniscal repair and partial meniscectomy, the surgery was considered as meniscal repair. Knee OA was recorded from the patients' preoperative medical records or intra‐operative diagnosis by the surgeon. Knee OA was considered present if having ICRS Grade III on one surface or Grade II on a minimum of two opposing cartilage surfaces in the compartment. Clearly localised traumatic cartilage damage was not considered as OA, irrespective of depth. The knee was defined as ACL‐stable if all ACL stability tests were negative = 0 (Lachman, Forward Drawer and Pivot‐shift tests).
Surgical technique
The arthroscopies were performed by a wide variety of surgeons, from residents and trauma‐specialists to specialists in knee arthroscopy, where the latter performed 87% of all surgeries and 96% of repairs. In most cases of meniscal repair, the surfaces of the meniscal tears were abraded with a diamond‐coated rasp whereafter the meniscus was sutured. Typically, tears in the posterior horn and body were sutured with all‐inside Fast‐Fix anchors or in a few rare cases during 2010, meniscal arrows. Tears in the anterior part were sutured with an inside‐out or an outside‐in technique. Sometimes small holes were made in the femoral notch with a Steadman pick, to induce bleeding with bone marrow into the joint. All ACLR were given pre‐op antibiotics. Hamstrings grafts were used in almost all cases of ACLR.
Statistical analysis
The following analyses were performed: (a) estimating of incidence rates of reoperations and complications in the whole cohort; (b) comparison of reoperations rates between males and females in the whole cohort; and (c) comparison of reoperations rates between partial meniscectomy and meniscal repair in the subgroup 15–40 years. Further, reoperations rates between partial meniscectomy and meniscal repair were compared stratified by ACL status and, lastly, stratified by compartment (medial, lateral or both menisci). Patients were followed until end of study period 2019‐12‐31 or death. Time to the first reoperation during follow‐up is presented using Kaplan‐Meier survival curves. Rates of reoperations in the total cohort and the subgroup were estimated in two ways. In the analysis of first reoperations (any reoperation or reoperations in the same meniscus), each patient was followed‐up from index surgery to first reoperation, death or 2019‐12‐31. In analysis of all reoperations, an Andersen‐Gill model was assumed, where each person contributes with all reoperations observed and the time until end of study or death. Incidence rates are reported per 1000 person‐years with 95% jackknife confidence intervals derived with function stptime in Stata.
Rates of reoperations were compared between groups, males and females in the whole cohort, or patients undergoing partial meniscectomy versus meniscal repair in the subgroup, using flexible parametric survival models (with 2 degrees of freedom) with first reoperation as outcome. The models were adjusted for pre‐specified confounders: age, sex (in analysis of meniscal repair vs. partial meniscectomy), surgery type (meniscal repair vs. partial meniscectomy, in the analysis of sex), tear type, knee laterality, body mass, inverse of height squared, smoking, operated menisci (medial, lateral, both) and ACL status. To estimate if ACL status at the index surgery modifies the association between meniscal repair/partial meniscectomy and reoperations, an interaction was included between surgery type (meniscal repair vs partial meniscectomy) and ACL status at index surgery. Relative risks (hazard ratio [HR]) as well as difference in absolute risk are reported. The number of missing values in relevant variables are presented in table footnotes and was low. Persons with missing data in relevant variables were excluded from the regression models. Due to the epidemiological nature of the study, no corrections for multiple testing were used. All estimates are reported with 95% confidence intervals (CI). Data were entered in a secure Excel spreadsheet (Microsoft® Corp., Redmond, WA). IBM© SPSS© Statistics, version (29.0.0.0) and Stata 18 were used for the statistical analyses.
RESULTS
Preoperative patient characteristics are presented in Table 1 and operative findings in Table 2.
Table 2.
Surgical characteristics of the whole study cohort.
| All patients | |
|---|---|
| N = 2098 | |
| Type of surgery | |
| Partial meniscectomy | 1703 (81.2) |
| Meniscus repair | 395 (18.8) |
| ACL visual status | |
| Bleeding | 6 (0.3) |
| Normal | 1217 (58.0) |
| Partial tear | 153 (7.3) |
| Previous ACLR | 88 (4.2) |
| Acute rupture | 42 (2.0) |
| Old rupture | 590 (28.1) |
| ACL stability | |
| Intraoperatively stable knee | 1314 (62.6) |
| Intraoperatively unstable knee | 362 (17.3) |
| ACLR at Index surgery | 422 (20.1) |
| Antibiotics a | 455 (24.4) |
| Tear type | |
| Bucket‐handle | 650 (31.0) |
| Degenerative | 608 (29.0) |
| Flap | 469 (22.4) |
| Horizontal | 54 (2.6) |
| Complex | 7 (0.3) |
| Longitudinal | 194 (9.2) |
| Radial | 116 (5.5) |
| Discoid meniscus | 35 (1.7) |
| Medial tear | 1623 (77.4) |
| Lateral tear | 767 (36.6) |
| Medial suture | 280 (13.3) |
| Lateral suture | 135 (6.4) |
Note: Numbers are n (%).
Abbreviations: ACL, anterior cruciate ligament; ACLR, ACL reconstruction; APM, arthroscopic partial meniscectomy.
Missing data: antibiotics n = 233 (11.1%).
Reoperations
Study participants had a total follow‐up time of 13,624 person‐years. The incidence rate of the first reoperation was 32 per 1000 person‐years (95% CI 29–35). Figure 3 shows time to first reoperation. Considering all reoperations (i.e. allowing for multiple reoperations), the study had 16,081 person‐years of observation time with 540 reoperations in total, which leads to a reoperation rate of 34 (95% CI 31–37) per 1000 person‐years. Reoperations details in Table 3.
Figure 3.
Kaplan–Meier graph showing time to first knee reoperation for all causes in the whole cohort. The blue area shows 95% confidence interval.
Table 3.
Reoperations and complications in the whole study cohort.
| All patients | |
|---|---|
| Number of patients with reoperations, N (%) | |
| 1 Reoperation | 337 (16.1) |
| 2 Reoperations | 80 (3.8) |
| 3 Reoperations | 9 (0.4) |
| 4 Reoperations | 4 (0.2) |
| Total number of reoperations, N | 540 |
| Total number of reoperated patients, N (%) | 430 (20.5) |
| Number of complications, N (%) | 47 (2.1) |
| Number of complications in patients without concomitant ACLR, N (%) | 25 (1.5) |
Abbreviation: ACLR, anterior cruciate ligament reconstruction.
The reoperation rate (including TKA) of the same meniscus was 19 (17–21) per 1000 person‐years.
In both the whole cohort and in the subgroup, the most commonly performed surgery at the first reoperation was a new meniscus surgery. Complete list of reoperations in Supporting Information: Appendix Table 11.
Number of later ACLRs performed within 4 months of index surgery in the whole cohort was 26 patients (27.4%) out of 95 ACLR performed as first reoperation.
Postoperative complications
Proportion (95% CI) of postoperative complications was 2.1% (1.6–2.9) within 2 years from index surgery (29 patients in partial meniscectomy group and 16 in meniscal repair group, described in Table 4). They occurred with a median of 26 days (range: 6–135) from index surgery.
Table 4.
List of surgery complications in all 2098 patients (47 complications in 45 patients).
| N = 47 | Complications (45 patients) | Mean age | Mean BMI | Women, N | Meniscus repair, N | APM, N |
|---|---|---|---|---|---|---|
| 1 | Acute compartment syndrome | 34 | 41.3 | 0 | 0 | 1 |
| 13 | Arthrofibrosis | 36.2 | 26.5 | 4 | 7 | 6 |
| 2 | Inflammatory arthritis | 36.5 | 27.8 | 2 | 0 | 2 |
| 5 | Major knee bleeding | 33.8 | 23.3 | 0 | 1 | 4 |
| 4 | Nerve injury/pain | 29.3 | 23.8 | 1 | 3 | 1 |
| 4 | Other | 53.8 | 21.9 | 2 | 0 | 4 |
| 6 | Septic arthritis | 33.3 | 24.6 | 1 | 2 | 4 |
| 6 | Superficial wound infection | 28.8 | 23.8 | 1 | 3 | 3 |
| 6 | VTE/pulmonary embolism (1) | 47.5 | 26.4 | 3 | 0 | 6 |
Note: Complete list in Supporting Information: Appendix Table 9.
Abbreviations: APM, arthroscopic partial meniscectomy; BMI, body mass index; VTE, venous thrombus embolism.
Sex differences
Males had lower rates of reoperation than females, crude HR 0.65 (95% CI 0.56–0.82) and fully adjusted HR of 0.61 (95% CI 0.47–0.80). This corresponded to 8.5% less reoperations in males 5 years after index surgery (95% CI −13.4 to −3.6). (Details in Supporting Information: Appendix S1).
Comparison of meniscal repair versus partial meniscectomy in subgroup 15–40 years old
Table 1 presents subgroup patient characteristics and operative findings are presented in Table 5.
Table 5.
Surgical data for the subgroup 15–40 years, only bucket‐handle, longitudinal and horizontal meniscus tears.
| All | APM | Meniscus repair | |
|---|---|---|---|
| N | 702 | 361 | 341 |
| Torniquet | 701 (99.9) | 360 (99.7) | 341 (100) |
| Antibiotics a | 307 (46.9) | 132 (39.9) | 175 (54.2) |
| ACL visual status | |||
| Bleeding | 3 (0.4) | 0 (0) | 3 (0.9) |
| Normal | 214 (30.4) | 124 (34.3) | 90 (26.4) |
| Partial tear | 49 (7.0) | 27 (7.5) | 22 (6.5) |
| Previous ACLR | 41 (5.8) | 22 (6.1) | 19 (5.6) |
| Acute rupture | 28 (4.0) | 7 (1.9) | 21 (6.2) |
| Old rupture | 367 (52.3) | 181 (50.1) | 186 (54.5) |
| ACL stability | |||
| Intraoperatively stable knee | 253 (36.0) | 143 (39.6) | 110 (32.3) |
| Intraoperatively unstable knee | 157 (22.4) | 99 (27.4) | 58 (17.0) |
| ACLR at Index surgery | 292 (41.6) | 119 (33.0) | 173 (50.7) |
| Tear type | |||
| Bucket‐handle | 509 (72.5) | 300 (83.1) | 209 (61.3) |
| Displaced bucket‐handle | 253 (36.0) | 151 (41.8) | 102 (29.9) |
| Horizontal | 33 (4.7) | 25 (6.9) | 8 (2.3) |
| Longitudinal | 160 (22.8) | 36 (10.0) | 124 (36.4) |
| Medial tear | 536 (76.4) | 265 (73.4) | 271 (79.5) |
| Lateral tear | 289 (41.2) | 140 (38.8) | 149 (43.7) |
| Medial suture | 255 (36.3) | n/a | 255 (74.8) |
| Lateral suture | 106 (15.1) | n/a | 106 (31.1) |
Note: Numbers are n (%).
Abbreviations: ACL, anterior cruciate ligament; ACLR, anterior cruciate ligament reconstruction; APM, arthroscopic partial meniscectomy.
Missing data: antibiotics: APM n = 30 (8.3%) meniscus repair n = 18 (5.3%).
Reoperation for all causes was more than four times more common in the meniscus repair group versus partial meniscectomy, the unadjusted HR was 3.8 (95%CI 2.8–5.1) and when adjusting for confounders it was 4.3 (95%CI 3.1–6.0). Number of reoperations described in Table 6. Five years after index surgery, 46% (95%CI 42–52) of the repairs were reoperated, while only 15% (95%CI 11–18) in the partial meniscectomy group (Figure 4). The meniscus repair reoperation incidence rate was 105 (95%CI 90–122) per 1000 person‐years, compared to in the partial meniscectomy group with an incidence rate of 24 (95%CI 18–31) per 1000 person‐years.
Table 6.
Reoperations and complications in subgroup 15–40 years old.
| All | APM | Meniscus repair | |
|---|---|---|---|
| Number of patients with reoperation | |||
| 1 Reoperation | 167 (23.8) | 48 (13.3) | 119 (34.9) |
| 2 Reoperations | 52 (7.4) | 9 (2.5) | 43 (12.6) |
| 3 Reoperations | 2 (0.3) | 1 (0.3) | 1 (0.3) |
| 4 Reoperations | 1 (0.1) | 0 | 1 (0.3) |
| Total number of reoperations, N | 281 | 69 | 212 |
| Number of reoperated patients | 222 (31.6) | 58 (16.1) | 164 (48.1) |
| Number of other complications | 23 (3.3) | 8 (2.2) | 15 (4.4) |
| Number of complications in patients without concomitant ACLR | 7 (1.0) | 2 (0.6) | 5 (1.5) |
Note: Numbers are n (%).
Abbreviations: ACLR, anterior cruciate ligament reconstruction; APM, arthroscopic partial meniscectomy.
Figure 4.
The (adjusted) proportion (95% confidence interval [CI]) reoperated for all causes in subgroup 15–40 years old. Coloured areas show 95% CIs.
Among meniscal repairs the rate of reoperations in the same meniscus was increased 17‐fold (95%CI 9–31) compared to partial meniscectomy when adjusted for confounders (crude HR for reoperation was 15 [95% CI 8–28]). At 5 years after index surgery, 34.7% (95%CI 29.8–40.4) had been reoperated on in the meniscal repair group while only 2.6% (95%CI 1.5–4.8) in the partial meniscectomy group (Figure 5). In the meniscal repair group, the rate of reoperation in the same meniscus was 68.3 (95% CI 56.6–82.8) per 1000 person‐years (126 reoperations in 341 persons) and in the partial meniscectomy group 4.0 (95% CI 2.2–7.8) per 1000 person‐years (11 reoperations in 361 persons).
Figure 5.
The (adjusted) proportion reoperated in the same meniscus, group 15–40 years. Coloured areas show 95% confidence intervals.
Postoperative complications in the subgroup 15–40 years old
There were 3.3% (95% CI 2.1–4.8) postoperative complications within 2 years from index surgery (15 patients with meniscal repair and 8 partial meniscectomy), listed in Table 7. They occurred with a mean 57 days (SD 14.9) and median of 30.0 days (SD 71.2, range 1–286) from index surgery.
Table 7.
List of surgical complications, subgroup 15–40 years old, with bucket‐handle, longitudinal or horizontal meniscal tear.
| N = 24 | Complications (23 patients) | Mean age | Mean BMI | Women, N | Meniscus repair, N | APM, N |
|---|---|---|---|---|---|---|
| 9 | Arthrofibrosis | 31.3 | 26.3 | 3 | 6 | 3 |
| 4 | Major knee bleeding | 29.3 | 22.5 | 0 | 1 | 3 |
| 3 | Nerve injury/pain | 23.3 | 22.9 | 1 | 3 | 0 |
| 2 | Septic arthritis | 21.5 | 21.9 | 0 | 2 | 0 |
| 5 | Superficial wound infection | 25.2 | 23.44 | 1 | 3 | 2 |
| 1 | Venous thrombus embolism | 33 | 26.1 | 0 | 0 | 1 |
Note: 24 complications in 23 patients. Complete list in Supporting Information: Appendix Table 10.
Abbreviations: APM, arthroscopic partial meniscectomy; BMI, body mass index.
ACL‐status and risk of reoperations in subgroup 15–40 years old
Reoperation was more common among patients with isolated meniscus repair, 89 out of 168 (53%) than in meniscus repair patients with concomitant ACLR, 75 out of 173 (43%), Table 8.
Table 8.
Risk of reoperation dependant on ACL stability, subgroup 15–40 years old, with bucket‐handle, longitudinal and horizontal tears.
| Incidence rate per 1000 person‐years (95% CI) meniscus repair APM | Adjusted HR meniscus repair vs. APM (95% CI) | Meniscus repair, N | APM, N | ||
|---|---|---|---|---|---|
| Reoperation, all causes | |||||
| Stable | 88 (67–117) | 8 (4–16) | 8 (4–17) | 110 | 143 |
| Unstable | 246 (181–336) | 35 (23–54) | 5 (3–9) | 58 | 99 |
| ACLR at index | 88 (71–111) | 36 (25–52) | 2 (1–4) | 173 | 119 |
| Reoperation in the same meniscus | |||||
| Stable | 82 (62–109) | 110 | |||
| Unstable | 82 (54–123) | 58 | |||
| ACLR at index | 57 (44–74) | 173 | |||
Abbreviations: ACL, anterior cruciate ligament; ACLR, anterior cruciate ligament reconstruction; APM, arthroscopic meniscus repair.
The reoperations rates for all causes after partial meniscectomy versus repair differed depending on the ACL status, Figure 6.
Figure 6.
The (adjusted) proportion reoperated for all causes in group: stable, unstable and anterior cruciate ligament reconstruction (ACLR). Coloured areas show 95% confidence intervals.
The effect of knee stability on reoperation rate in the same meniscus was only analysed in meniscus repair group, due to small numbers in the partial meniscectomy group. There was no evidence of differences in reoperations in the same meniscus based on ACL status but the uncertainty around the estimates was considerable. Reoperation in the same meniscus could be more common in stable knees compared to knees with ACLR at index, adjusted HR (95% CI) 1.24 (0.81–1.90). Comparing unstable knees versus ACLR at index, reoperation in the same meniscus could be more common in unstable knees, HR 1.44 (0.87–2.38), Figure 7.
Figure 7.
Knee stability groups, adjusted cumulative incidence curves, same meniscus reoperations. Coloured areas show 95% confidence intervals.
In meniscus repair patients with a complete ACL tear that did not have concomitant ACL surgery, the number of ACLRs performed within 4 months of index surgery in the subgroup 15–40 was 15 patients (50%) out of 30 ACLR after index.
Medial versus lateral
Comparing reoperation for any cause of the medial and lateral meniscus, the difference in proportion reoperated at 5 years, between repair and partial meniscectomy was 37% (95%CI 29%–45%) in medial meniscus, 23% (95%CI 11%–36%) in lateral meniscus and 26% (95%CI 10%–41%) when both menisci were operated on.
Medial meniscus repairs had a 53% higher risk than lateral repairs of a reoperation in the same meniscus, HR 1.53 (95%CI 0.97–2.43). Incidence rate of reoperation in the same meniscus was 80/1000 person years (95%CI 63–101) in the medial meniscus, 57/1000 person years (95%CI 38–88) in the lateral meniscus and 46/1000 person years (95%CI 28–81) if both menisci were repaired.
Suture material
The study was not intended to compare suture materials or techniques. Of the 395 meniscal repair surgeries, Fast‐Fix suture anchors were used in 359, whereof a combination of Fast‐Fix and inside‐out or outside‐in sutures were used in 21 cases. The study also included 15 patients with meniscal arrows, with 10 patients reoperated, eight because of suture failure.
DISCUSSION
The main findings of the study were that one in five patients with meniscus surgery had any ipsilateral knee reoperation, with more than half of these being within 2 years of the index surgery. Among patients below 40 years of age, there was a four‐fold increase in reoperation of all causes and a 17‐fold increase in same meniscus reoperations after meniscal repair compared with partial meniscectomy.
In counselling patients about meniscus injury treatment, it is important to have knowledge of potential differences in terms of risk of complications and reoperations, as well as expected suture survival rate. Highly cited studies on partial meniscectomy versus meniscal repair by Paxton et al. and Stein et al. are now more than 13 years old and since arthroscopic surgery continues to evolve, new updated data is important [25, 37]. In a register study of meniscal repair by Lyman et al. on 9605 American patients, the rate of failure, measured as reoperation with partial meniscectomy after meniscal repair was 8.9% for 3 years mean follow‐up, with a markedly better performance for high volume surgeons [16]. The authors did not report risk for other reoperations than partial meniscectomy. The present study differs both in length of follow‐up as well as a more comprehensive description and inclusion of all reoperations performed. High volume surgeons have been suggested to have lower reoperation rates after meniscus repair, and though most repairs in our study were performed by experienced surgeons, a number of the less complicated surgeries were delegated to surgeons with few meniscus surgeries per year. There are huge differences both worldwide and even within the same country, according to how, why and how frequently partial meniscectomies and meniscal repairs are performed. When comparing studies from different countries, one important factor is that different systems for delivering healthcare influence the frequency of arthroscopic procedures [9].
In this study, the whole cohort and especially the subgroup aged 15–40 years displayed high proportions of potential seriously injured knees with 72% bucket‐handle meniscus tears and 64% ACL injuries. The somewhat higher numbers of reoperations in this study cohort compared with other studies could be explained by the presence of a high proportion of severely injured knees with worse prognosis. Also, the finding that more bucket‐handle meniscal tears had partial meniscectomy than a meniscal repair, even in the subgroup aged 15–40 years suggests a potential underutilization of attempts at meniscal repair. It has been reported that ACL‐injured patients have more meniscal damage with longer time between injury and surgery [5, 19].
Previous research has suggested that meniscus repairs concomitant with ACLR results in better meniscus healing rates, medial meniscus repairs have higher reoperation‐rates than lateral repairs, and intrameniscal arrow implants are inferior to all‐inside sutures [7, 13, 27, 29, 32]. This study also confirmed all these findings. The patients with concomitant ACLR did have both fewer all cause reoperations and same meniscus reoperations than meniscal repair alone in unstable knees.
The finding that more men receive meniscus surgery, but women have almost 30% higher both all causes reoperation rates and same meniscus reoperations is somewhat difficult to explain. Studies report that women tend to have a longer recovery time and lower KOOS scores after a meniscus injury, which may influence the risk of reoperation [17]. One explanation could be that men are more willing to choose primary surgery while women included for meniscus surgery have more severe knee injuries or that women more often report post‐operative symptoms leading to a reoperation [2].
The low number of complications, despite including also minor complications not coded in registries, ranging between 1.5% for partial meniscectomy alone to 4.4% for meniscal repair with concomitant ACLR, is in line with the literature [14, 36]. This supports the notion that arthroscopic meniscus surgery is a safe procedure in a routine healthcare setting. Moreover, the most frequent complication was arthrofibrosis which might as well be a consequence of the initial knee trauma and not necessarily due to surgery. The number of postoperative infections was very small, and though not the aim to study this, the study supports not routinely giving preoperative antibiotics in meniscus surgery without ACLR.
A strength of the study is the large numbers of included patients undergoing meniscus surgery and studied in detail in a routine healthcare setting with a long‐time follow‐up. The use of prospectively ascertained data from included patients and surgical charts from the included hospitals contributes to high external validity. The study depicts patients operated on 'in real life', without the limiting patient selections commonly present in trials when study results usually are not generalisable for the whole population and a variable level of experience among surgeons. Further, the study incorporates data on BMI, smoking, OA, ACL status and any concomitant knee injuries, reoperations and complications from our medical records which is more accurate than studies relying on patient self‐report [34].
This study had some limitations. With the numerous surgeons involved, there are potential variability in surgeon‐reported knee OA and meniscal injury data. A major limitation is the lack of information on activity level and subjective knee symptoms for all patients both before and after surgery, as this could differ between groups. Another study on 421 patients from the same cohort has suggested that KOOS‐scores at mean 4 years postoperatively is almost the same for both partial meniscectomy and meniscal repair [2]. Interestingly, the KOOS for patients with concurrent ACLR are higher than after meniscus surgery alone, irrespective of patients age [2].
Importantly, the observational nature of the data, as arthroscopic surgeries were not randomly assigned to subjects, creates confounding by indication (i.e., there is a patient selection by the surgeon which may influence risk of reoperation and complications). Further, the data lack date of meniscus injury, therefore time from injury to surgery can't be measured. In a study from Ronnblad et al., this was however suggested not to essentially influence the healing rate [29]. There may also be missing some reoperations done outside the Scania region, or by private care, but this ought to be minimal within the follow‐up period.
CONCLUSIONS
In conclusion, the present study found a four‐fold increased rate of reoperation after meniscal repair vs partial meniscectomy, higher risk after medial vs lateral meniscus repairs, but a low rate of other medical complications in a routine healthcare setting. The information should be considered together with all other considerations by the surgeon and the patient when counselling before meniscus surgery.
AUTHOR CONTRIBUTIONS
Fredrik Boric‐Persson (responsible) was involved in study conception and design, data collection, the data analysis, interpretation of results, and drafted the manuscript. Aleksandra Turkiewicz (statistician) was involved in study design, data analysis and manuscript draft editing. Martin Englund (supervisor) was involved in manuscript draft editing. Paul Neuman (lead investigator) was involved in study conception and design, interpretation of results, and manuscript drafting and editing. All authors read and approved the final manuscript.
CONFLICT OF INTEREST STATEMENT
Martin Englund reports consultancy for Grünenthal Sweden and Key2Compliance. Paul Neuman: Consultant fees has been received infrequently from Arthrex and Smith & Nephew during medical education events and instructional courses. The other authors declare no conflicts of interest.
ETHICS STATEMENT
The study was approved by the Regional Lund University Ethics Committee (IRB 2016‐873/2017‐02‐07 and IRB 2019‐02850/20191121) and it adheres to the rules of the Helsinki Declaration of 1975, as revised in 2000. Patients were publicly informed about the study and the option of opting out of the study publication in concordance with the ethical approval.
Supporting information
KSSTA_ReopCompl_10y_MR_APM_APPENDIX_revMINOR_prod.
ACKNOWLEDGEMENTS
This work was supported by the Swedish Research Council, Österlund Foundation, Greta and Johan Kock Foundation, Gustaf V 80‐Year Birthday Foundation, Governmental Funding of Clinical Research within National Health Service (ALF), the Swedish Rheumatism Association, the Foundation for People with Movement Disability in Skåne, and the Faculty of Medicine, Lund University. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
DATA AVAILABILITY STATEMENT
Author elects to not share dataResearch data are not shared. The individual data are neither publicly available nor available for data sharing due to ethical restrictions and national legislation of use of Swedish healthcare data.
REFERENCES
- 1. Abram SGF, Price AJ, Judge A, Beard DJ. Anterior cruciate ligament (ACL) reconstruction and meniscal repair rates have both increased in the past 20 years in England: hospital statistics from 1997 to 2017. Br J Sports Med. 2020;54(5):286–291. [DOI] [PubMed] [Google Scholar]
- 2. Alerskans S, Kostogiannis I, Neuman P. Patient's subjective knee function 3‐5 years following partial meniscectomy or meniscus repair compared to a normal population: a retrospective cohort study. BMJ Open Sport Exerc Med. 2022;8(3):e001278. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3. Boric‐Persson F, Turkiewicz A, Neuman P, Englund M. Sick leave after arthroscopic meniscus repair vs. arthroscopic partial meniscectomy. Osteoarthritis Cartilage Open. 2023;5(1):100340. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4. Chand SB, Santhosh G, Saseendran A, Gopinath AV, Chand GB, Viswambharan V, et al. Efficacy and long‐term outcomes of arthroscopic meniscus repair: a systematic review and meta‐analysis. Cureus. 2024;16(10):e70828. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5. Cristiani R, Janarv P‐M, Engström B, Edman G, Forssblad M, Stålman A. Delayed anterior cruciate ligament reconstruction increases the risk of abnormal prereconstruction laxity, cartilage, and medial meniscus injuries. Arthroscopy. 2021;37(4):1214–1220. [DOI] [PubMed] [Google Scholar]
- 6. Ekhtiari S, Horner NS, de Sa D, Simunovic N, Hirschmann MT, Ogilvie R, et al. Arthrofibrosis after ACL reconstruction is best treated in a step‐wise approach with early recognition and intervention: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2017;25(12):3929–3937. [DOI] [PubMed] [Google Scholar]
- 7. Farinelli L, Meena A, Montini D, Patralekh MK, Piritore G, Grassi M, et al. Failure rate of isolated medial meniscus repair in the stable knee: systematic review and meta‐analysis. Knee Surg Sports Traumatol Arthrosc. 2024;33:1333–1344. [DOI] [PubMed] [Google Scholar]
- 8. Feeley BT, Liu S, Garner AM, Zhang AL, Pietzsch JB. The cost‐effectiveness of meniscal repair versus partial meniscectomy: a model‐based projection for the United States. Knee. 2016;23(4):674–680. [DOI] [PubMed] [Google Scholar]
- 9. Hamilton DF, Howie CR. Knee arthroscopy: influence of systems for delivering healthcare on procedure rates. BMJ. 2015;351(September):1–4. [DOI] [PubMed] [Google Scholar]
- 10. Hong SY, Han W, Jang J, Lee J, Ro DH, Lee MC, et al. Prognostic factors of mid‐to long‐term clinical outcomes after arthroscopic partial meniscectomy for medial meniscal tears. Clin Orthop Surg. 2022;14(2):227–235. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11. Jacquet C, Pujol N, Pauly V, Beaufils P, Ollivier M. Analysis of the trends in arthroscopic meniscectomy and meniscus repair procedures in France from 2005 to 2017. Orthop Traumatol Surg Res. 2019;105(4):677–682. [DOI] [PubMed] [Google Scholar]
- 12. Kim S, Bosque J, Meehan JP, Jamali A, Marder R. Increase in outpatient knee arthroscopy in the United States: a comparison of National Surveys of Ambulatory Surgery, 1996 and 2006. J Bone Jt Surg. 2011;93(11):994–1000. [DOI] [PubMed] [Google Scholar]
- 13. Kise NJ, Drogset JO, Ekeland A, Sivertsen EA, Heir S. All‐inside suture device is superior to meniscal arrows in meniscal repair: a prospective randomized multicenter clinical trial with 2‐year follow‐up. Knee Surg Sports Traumatol Arthrosc. 2014;23(1):211–218. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14. Lai WC, Mange TR, Karasavvidis T, Lee Y‐P, Wang D. Low early complication rates after arthroscopic meniscus repair and meniscectomy. Knee Surg Sports Traumatol Arthrosc. 2023;31(10):4117–4123. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15. Lee YS, Lee OS, Lee SH. Return to sports after athletes undergo meniscal surgery: a systematic review. Clin J Sport Med. 2019;29(1):29–36. [DOI] [PubMed] [Google Scholar]
- 16. Lyman S, Hidaka C, Valdez AS, Hetsroni I, Pan TJ, Do H, et al. Risk factors for meniscectomy after meniscal repair. Am J Sports Med. 2013;41(12):2772–2778. [DOI] [PubMed] [Google Scholar]
- 17. Mai C, Mai P, Hinz M, Saenger R, Seil R, Tischer T, et al. Females show worse functional outcome and quality of life compared to males 2 years after meniscus surgery: data analysis from the German Arthroscopy Registry. Knee Surg Sports Traumatol Arthrosc. 2024;32(10):2644–2654. [DOI] [PubMed] [Google Scholar]
- 18. Mattila VM, Sihvonen R, Paloneva J, Felländer‐Tsai L. Changes in rates of arthroscopy due to degenerative knee disease and traumatic meniscal tears in Finland and Sweden. Acta Orthop. 2016;87(1):5–11. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19. Mehl J, Otto A, Baldino JB, Achtnich A, Akoto R, Imhoff AB, et al. The ACL‐deficient knee and the prevalence of meniscus and cartilage lesions: a systematic review and meta‐analysis (CRD42017076897). Arch Orthop Trauma Surg. 2019;139(6):819–841. [DOI] [PubMed] [Google Scholar]
- 20. Migliorini F, Schäfer L, Bell A, Weber CD, Vecchio G, Maffulli N. Meniscectomy is associated with a higher rate of osteoarthritis compared to meniscal repair following acute tears: a meta‐analysis. Knee Surg Sports Traumatol Arthrosc. 2023;31(12):5485–5495. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21. Mutsaerts ELAR, van Eck CF, van de Graaf VA, Doornberg JN, van den Bekerom MPJ. Surgical interventions for meniscal tears: a closer look at the evidence. Arch Orthop Trauma Surg. 2016;136(3):361–370. [DOI] [PubMed] [Google Scholar]
- 22. Nepple JJ, Block AM, Eisenberg MT, Palumbo NE, Wright RW. Meniscal repair outcomes at greater than 5 years: a systematic review and meta‐analysis. J Bone Jt Surg. 2022;104(14):1311–1320. [DOI] [PubMed] [Google Scholar]
- 23. Nilsen KN, Øhrn F‐D, Årøen A, Myklebust TÅ, Aae TF. Arthroscopic meniscal surgery in Norway from 2010 to 2020: a paradigmatic shift. J Exp Orthop. 2024;11(4):e70113. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24. Parker BR, Hurwitz S, Spang J, Creighton R, Kamath G. Surgical trends in the treatment of meniscal tears. Am J Sports Med. 2016;44(7):1717–1723. [DOI] [PubMed] [Google Scholar]
- 25. Paxton ES, Stock MV, Brophy RH. Meniscal repair versus partial meniscectomy: a systematic review comparing reoperation rates and clinical outcomes. Arthroscopy. 2011;27(9):1275–1288. [DOI] [PubMed] [Google Scholar]
- 26. Pelletier S, Djebara A, Freychet B, Carnessechi O, Graveleau N, Louis M‐L, et al. Francophone Arthroscopy Society (SFA) . Medial meniscal repair in stable knees: survival rate and risk factors for failure at a minimum of 5 years. Orthop Traumatol: Surg Res. 2023;109(8S):103681. [DOI] [PubMed] [Google Scholar]
- 27. 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(5):835–844. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28. Reigstad O, Grimsgaard C. Complications in knee arthroscopy. Knee Surg Sports Traumatol Arthrosc. 2006;14(5):473–477. [DOI] [PubMed] [Google Scholar]
- 29. Ronnblad E, Barenius B, Engstrom B, Eriksson K. Predictive factors for failure of meniscal repair: a retrospective dual‐center analysis of 918 consecutive cases. Orthop J Sports Med. 2020;8(3):2325967120905529. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30. Sallé de Chou E, Pujol N, Rochcongar G, Cucurulo T, Potel J‐F, Dalmay F, et al. Analysis of short and long‐term results of horizontal meniscal tears in young adults. Orthop Traumatol: Surg Res. 2015;101(8):S317–S322. [DOI] [PubMed] [Google Scholar]
- 31. Salzler MJ, Lin A, Miller CD, Herold S, Irrgang JJ, Harner CD. Complications after arthroscopic knee surgery. Am J Sports Med. 2014;42(2):292–296. [DOI] [PubMed] [Google Scholar]
- 32. Schweizer C, Hanreich C, Tscholl PM, Blatter S, Windhager R, Waldstein W. Meniscal repair outcome in 3829 patients with a minimum follow‐up from 2 years up to 5 years: a meta‐analysis on the overall failure rate and factors influencing failure. Am J Sports Med. 2024;52(3):822–831. [DOI] [PubMed] [Google Scholar]
- 33. Schweizer C, Hanreich C, Tscholl PM, Ristl R, Apprich S, Windhager R, et al. Nineteen percent of meniscus repairs are being revised and failures frequently occur after the second postoperative year: a systematic review and meta‐analysis with a minimum follow‐up of 5 years. Knee Surg Sports Traumatol Arthrosc. 2022;30(7):2267–2276. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34. Selçuk H, Roos EM, Grønne DT, Ernst MT, Skou ST. Agreement between self‐reported information and administrative data on comorbidities, imaging and treatment in Denmark – A validation study of 38,745 patients with knee or hip osteoarthritis. Clin Epidemiol. 2021;13(March):779–790. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35. Shelbourne KD, Patel DV. Treatment of limited motion after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 1999;7(2):85–92. [DOI] [PubMed] [Google Scholar]
- 36. Sochacki KR, Varshneya K, Calcei JG, Safran MR, Abrams GD, Donahue J, et al. Comparing meniscectomy and meniscal repair: a matched cohort analysis utilizing a National Insurance Database. Am J Sports Med. 2020;48(10):2353–2359. [DOI] [PubMed] [Google Scholar]
- 37. Stein T, Mehling AP, Welsch F, von Eisenhart‐Rothe R, Jäger A. Long‐term outcome after arthroscopic meniscal repair versus arthroscopic partial meniscectomy for traumatic meniscal tears. Am J Sports Med. 2010;38(8):1542–1548. [DOI] [PubMed] [Google Scholar]
- 38. Villarreal‐Espinosa JB, Berreta RS, Pallone L, Rubin J, Allende F, Gómez‐Verdejo F, et al. Failure and complication rates following meniscal all‐inside and inside‐out repairs: a systematic review and meta‐analysis. Knee Surg Sports Traumatol Arthrosc. 2024;33(6):1992–2009. [DOI] [PubMed] [Google Scholar]
- 39. Willinger L, Herbst E, Diermeier T, Forkel P, Woertler K, Imhoff AB, et al. High short‐term return to sports rate despite an ongoing healing process after acute meniscus repair in young athletes. Knee Surg Sports Traumatol Arthrosc. 2019;27(1):215–222. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
KSSTA_ReopCompl_10y_MR_APM_APPENDIX_revMINOR_prod.
Data Availability Statement
Author elects to not share dataResearch data are not shared. The individual data are neither publicly available nor available for data sharing due to ethical restrictions and national legislation of use of Swedish healthcare data.