What is the best treatment approach for a patient with a moderate bilobed meniscus?

From the Guidelines

The best treatment approach for a patient with a moderate bilobed meniscus is to initially try conservative management, including physical therapy and intra-articular injections, before considering arthroscopic partial meniscectomy if symptoms persist.

Treatment Approach

When considering treatment for a moderate bilobed meniscus, it's essential to weigh the benefits and risks of each approach. Conservative management is typically the first line of treatment, as it can help alleviate symptoms and improve function. This may include physical therapy, focusing on quadriceps and hamstring strengthening exercises, as well as intra-articular injections, such as corticosteroids, which have been shown to be effective in reducing pain and improving function in patients with knee osteoarthritis 1.

Surgical Intervention

If conservative measures fail to provide relief after 6-12 weeks, arthroscopic partial meniscectomy may be considered to remove the unstable portion of the meniscus while preserving as much functional tissue as possible. However, it's crucial to note that meniscus tears in patients with knee osteoarthritis are often a result of the degenerative process, and surgical treatment may not always lead to significant improvement 1.

Key Considerations

• The bilobed configuration of the meniscus may predispose to tears at the junction between lobes, making it essential to carefully evaluate the tear and develop a treatment plan accordingly.
• Meniscal repair is preferred over resection when the tear is in the vascular "red zone" of the meniscus, as this preserves the load-bearing function of the meniscus and reduces the risk of future osteoarthritis.
• Post-surgical rehabilitation typically involves progressive weight-bearing as tolerated, with return to full activities within 4-6 weeks for meniscectomy or 3-6 months for meniscal repair.

Evidence-Based Recommendations

The American Academy of Orthopaedic Surgeons recommends against the routine use of hyaluronic acid in patients with knee osteoarthritis, due to inconsistent evidence supporting its effectiveness 1. Additionally, oral narcotics, including tramadol, should not be used in the treatment of knee osteoarthritis due to the notable increase in medication-related adverse effects with no consistent improvement in pain and function 1.

• Conservative management, including physical therapy and intra-articular injections, should be the initial treatment approach for patients with a moderate bilobed meniscus.
• Arthroscopic partial meniscectomy may be considered if symptoms persist after 6-12 weeks of conservative management.
• Meniscal repair is preferred over resection when the tear is in the vascular "red zone" of the meniscus.

From the Research

Treatment Approaches for Moderate Bilobed Meniscus

• The treatment approach for a patient with a moderate bilobed meniscus depends on various factors, including the type and extent of the injury, as well as the patient's age and functional status 2.
• Arthroscopic surgery is a common treatment approach for meniscal injuries, with arthroscopic partial meniscectomy (APM) being the most frequently performed procedure 3, 4.
• However, recent studies have shown that outcomes after APM are no better than those after sham/placebo surgery, leading to a shift towards meniscal repair as a viable and effective alternative 4.
• Meniscal repair aims to achieve meniscal healing while avoiding the adverse effects of partial meniscectomy, and is now increasingly recommended for repairable tears, especially in young and physically active patients 4.
• Conservative management, including osteopathic techniques and exercise rehabilitation, may also be an effective approach for managing meniscal injuries, as demonstrated in a case report of a 20-year-old male with a traumatic meniscal injury 5.
• The choice of treatment approach should be individualized based on the patient's specific needs and circumstances, taking into account factors such as the severity of the injury, the patient's age and functional status, and the presence of any associated conditions 3, 2, 6.

Considerations for Treatment

• The anatomy and biomechanical functions of the menisci are important considerations in the treatment of meniscal injuries, as highlighted in a review of the human meniscus 6.
• The incidence of meniscal injuries is on the rise, attributed to increased participation in sporting activities, and MRI remains the imaging modality of choice for diagnosis 2, 4.
• Research on meniscal regeneration and regenerative medicine appears promising, and may offer new treatment options for meniscal injuries in the future 4.