Updated Clinical Practice Guideline Released for Managing Acute Isolated Meniscal Pathology

The American Academy of Orthopaedic Surgeons (AAOS) has issued a new Clinical Practice Guideline (CPG) for the Management of Acute Isolated Meniscal Pathology. The guideline was initially created to help clinicians treat patients suspected of or diagnosed with an acute isolated meniscal tear, which often occur from a traumatic injury with knee rotation and flexion or a direct impact.

While meniscal tears can befall people of all ages, these injuries typically occur in a young active population, specifically high school and college athletes. Meniscal injuries can have a significant physical and emotional impact as patients need to take time off from work or school. For athletes, return to sport could take up to four to seven months after surgery.
 
“Treating acute meniscal tears is still an evolving area and compared to other guidelines that detail recommendations for the treatment of various musculoskeletal issues, the body of evidence surrounding this injury is relatively lacking,” said Robert Brophy, M.D., co-chair of the guideline development group. “While acute meniscal tears are common, there is more heterogeneity in terms of the injury, the pattern associated with the injury, and treatments, making it a more difficult area to study. This new CPG is a first step towards establishing guidelines and laying the foundation for developing a higher level of evidence to inform future recommendations.”
 
New Diagnosis and Treatment Recommendations
The new guideline resulted in one strong and two moderate recommendations for diagnosing and managing patients with acute meniscal injury. The CPG is not intended for patients with concurrent ligament issues like anterior cruciate ligament tears, nor is it appropriate for those suspected of chronic or degenerative meniscal tears. The CPG includes:

• A strong recommendation stating that magnetic resonance imaging (MRI) is the preferred imaging modality to diagnose acute meniscal tears because of its high accuracy, while computerized tomography (CT) arthrography or ultrasound can be used, particularly when MRI is not available or is contraindicated.
• A moderate recommendation that a physical examination, including joint line tenderness, the McMurray test and the Thessaly test, can effectively diagnose acute meniscal tears and may yield more accurate results when combined.
• A moderate recommendation that when indicated in treating an acute meniscal tear, surgery should preserve as much functional meniscal tissue as possible to mitigate patient risk for osteoarthritis, underscoring the importance of trying to preserve the meniscus to delay or prevent advancement of joint degeneration. 

The CPG workgroup formulated six options for physicians and patients to consider. Options are used when there is little, conflicting or no evidence. Highlights of the options include:

• A limited strength option states that patients with an acute meniscal tear who have failed conservative nonoperative treatment such as physical therapy may have better outcomes from surgical intervention within six months of injury.
• The workgroup concluded that patients with a displaced or displacing acute meniscal tear—particularly those restricting knee range of motion—can benefit from acute surgical intervention. The workgroup also advises that patients with a symptomatic acute meniscal tear who could benefit from a repair should be considered for early surgical intervention because it could optimize the likelihood for success.
• A limited strength option states that meniscus repair can improve patient outcomes compared to partial meniscectomy in acute isolated meniscal tears with healing potential.
• Biological enhancements, specifically bone marrow venting or platelet-rich plasma, received a limited strength option as a consideration to improve outcomes in patients undergoing surgical repair of acute isolated meniscal tears.
• Based on the workgroup’s clinical opinion, physical therapy/rehabilitation may be beneficial to patients who present with an acute non-displaced isolated meniscal tear not amenable to repair when implemented as a non-operative treatment option as well as for those recovering from meniscal surgery. 

“There’s no doubt physical therapy is an integral part of the treatment algorithm for people with acute meniscal tears,” Brophy commented. “Whether you’re trying to avoid surgery, planning on not doing surgery, or decide to do surgery, there will likely be a role for physical therapy as part of the treatment or recovery process.”
 
While the study of acute meniscal tears is complex, physicians and patients now have a starting point to weigh the pros and cons to make informed decisions. “It is important to understand this CPG is a guide, not a prescription,” Brophy noted. “However, this can help patients make an informed decision with their surgeon regarding optimal treatment for their injury.”
 
CPGs are not meant to be stand-alone documents but rather serve as a point of reference and educational tool for orthopedic surgeons and healthcare professionals managing patients presenting with complaints that may be attributable to acute isolated meniscal tears. CPGs recommend accepted approaches to treatment and/or diagnosis and are not intended to be a fixed protocol for treatment or diagnosis. The full Clinical Practice Guideline for the Management of Acute Isolated Meniscal Pathology is used for reference by orthopedic surgeons and other physicians, and is available through AAOS’ OrthoGuidelines website and free mobile app. 
 
Development of this CPG was a collaborative effort between representatives from the American Academy of the Physical Medicine and Rehabilitation; the National Athletic Trainers’ Association; the American Orthopaedic Society for Sports Medicine, the American Physical Therapy Association; the Pediatric Orthopaedic Society of North America; and the American Medical Society for Sports Medicine.
 
With more than 39,000 members, AAOS is the world’s largest medical association of musculoskeletal specialists. The organization advances musculoskeletal health and provides comprehensive education to help orthopedic surgeons and allied health professionals best treat patients. AAOS is the source for information on bone and joint conditions, treatments and related musculoskeletal healthcare issues; and it leads the healthcare discussion on advancing quality.