INTRODUCTION
Preservation of meniscal function is the most important goal of meniscal surgery. The overall incidence of meniscal tears that require surgery is 60 to 70 per 100 000 person years, and approximately one-third of these tears are sports related.1 They are particularly common in athletes involved in contact level I sports that involve frequent pivoting, such as soccer and American football.2 Treating meniscal tears in athletes poses a significant challenge for orthopedic surgeons. Because absence from sports can have cost implications and can hinder the athlete's career, athletes, pressured by coaches and teammates, feel significant pressure to return to sports (RTS) as soon as possible.1 Although multiple factors influence treatment outcomes, the ultimate goal of meniscal surgery should be to only remove torn and nonfunctional tissue through limited meniscectomy or meniscal repair strategies for the tear pattern.3
Athletes with injuries almost always want to RTS as soon as possible and would like to know how long it will be before they can resume sports activities. However, the time to RTS after meniscectomy is still unknown.4 Furthermore, there are various types of meniscus surgeries such as partial meniscectomy, meniscus repair, and meniscal allograft transplantation (MAT). Therefore, the time to RTS could vary depending on the type of surgery. However, to date, few studies have specifically addressed RTS after meniscal repair in athletes.
Meniscal allograft transplantation is often performed as a salvage procedure in patients with minimal viable meniscal tissue in the knee and who are at a high risk of arthritis progression.1 Unfortunately, this patient profile is observed more commonly in the athletic population as many athletes are willing to incur the risks of in-season meniscectomy for faster recovery and RTS.5 There are reports of this procedure being used for nonprofessional athletes, and studies have also reported improvement in the quality of life and activities of daily living in a slightly older, less active patient population.6–11 However, it is still unknown whether this procedure is an effective treatment for “postmeniscectomy syndrome” in professional athletes.
The most important expectation of athletes is to RTS at the preinjury sports activity level, irrespective of age or level of sports activity. However, it is not well established in the meniscal surgery compared with the anterior cruciate ligament reconstruction (ACLR) that the optimal timing to RTS is more predictable and short partly due to accelerated rehabilitation.12 The main aim of this systematic review of the literature was to determine the time to and rate of the RTS after meniscal surgery and to compare these values among the different types of meniscal surgeries, such as meniscectomy, meniscal repair, and MAT. The hypotheses of this study were that the time to and rate of the RTS after partial meniscectomy would be shortest and highest and these would be longest and lowest after MAT.
MATERIALS AND METHODS
Search Strategy
To verify the research question, a rigorous and systematic approach conforming to the preferred reporting items for systematic review and meta-analysis (PRISMA) guidelines was used.13 In phase 1 of the PRISMA search, the MEDLINE, EMBASE, and Cochrane databases (October 2016) were searched. Using a Boolean strategy, the following field search terms were used: Search ((((((meniscectomy) OR partial meniscectomy)) OR ((repair) OR meniscal repair)) OR ((transplantation) OR meniscal transplantation))) AND ((return to sports) OR return to preinjury activity). The citations in the included studies were screened, and we also reviewed unpublished articles by conducting physical searches. The bibliographies of the relevant articles were subsequently crosschecked for articles that were not identified in the search. In phase 2, the abstracts and titles were screened for their relevance. In phase 3, the full text of the selected studies was reviewed to assess the inclusion criteria and methodological appropriateness with a predetermined question. In phase 4, a systematic review was conducted, if appropriate.
Eligible Criteria
Studies that met the following criteria were included: (1) English article, (2) full-text available, (3) study on athletes, and (4) primary outcome is RTS after meniscal surgery, such as meniscectomy, meniscal repair, and MAT. Exclusion criteria were as follows: (1) non-English article, (2) full text not available, (3) articles on nonathletes, and (4) no information on the percentage and exact time of RTS after meniscal surgery (Figure 1). Articles that reported on RTS after meniscal surgery as the primary outcome, although combined ligament reconstruction or concomitant surgeries were performed, were also included.
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Figure 1.: PRISMA flow chart.
Data Extraction
Data were extracted using the following standardized protocol: first author, publication year, publication journal, level of evidence, study design, number of athletes, type of sports and number of participants, level of athletes, age at the time of surgery, sex, follow-up period, surgical procedure, concomitant procedures, subsequent procedures, percentage of RTS, activity level at the time of RTS, time to RTS, and other relevant findings.
Quality Assessment
To assess the methodological quality of the case series, the risk of bias (ROB) for interrupted time series studies as suggested by the Effective Practice and Organization of Care (EPOC) was used. Risk of bias consists of 7 standard criteria: independency, prespecification of the intervention effect, effect of the intervention to data collection, knowledge of the allocated intervention, address of the incomplete outcome data, selective outcome reporting, and other ROB. Risk of bias was also scored as “Yes (low ROB),” “No (high ROB),” or “Unclear.”
RESULTS
Search
Eleven articles were included in the final analysis.4,6,7,14–21 The detailed characteristics of the included studies are summarized in Table 1. Nine retrospective case series, 1 prospective case series, and 1 retrospective cohort study were included. A total of 514 cases were included in the final analysis: 264 cases of partial meniscectomy, 120 of meniscal repair, and 130 of MAT. The mean patient age at the time of the surgery was 25.1 ± 6.2 years, and soccer or football injuries were the most common. Most athletes were participating at a competitive level. Concomitant procedures, including ACLR, chondral debridement, microfracture, high tibial osteotomy, and others, were performed in 7 studies.7,14–17,20,21 Subsequent procedures were addressed in 8 studies.4,7,14,16–18,20,21 The percentage of RTS was reported in 10 studies,6,7,14–21 and the level of sport activity after RTS was reported in all studies. The time to RTS was reported in 10 studies.4,6,7,15–21
TABLE 1.: Demographics of Included Studies
TABLE 1-A.: Demographics of Included Studies
Quality
The findings of a detailed quality assessment are provided in Table 2. Among the 7 criteria, 5 criteria (prespecification of the intervention effect, effect of the intervention to data collection, address of the incomplete outcome data, selective outcome reporting, and other ROB) showed little ROB. However, independency (criteria 1) was scored as “Yes” for 5 (45.5%) and “No” for 6 (54.5%) studies. Knowledge of the allocated intervention (criteria 4) was scored as “Unclear” for 9 (81.8%) studies.
TABLE 2.: Quality Assessment of Included Studies (EPOC Assessment for Case Series)
Return to Sports
All detailed data are summarized in Table 3.
TABLE 3.: Return to Sports of Included Studies
TABLE 3-A.: Return to Sports of Included Studies
Return to Sports After Partial Meniscectomy
Four studies4,15,18,19 reported on evaluations performed after partial meniscectomy. In 2 studies,15,19 only partial lateral meniscectomy was performed, and the other 2 studies4,18 reported on a mixed group of partial lateral meniscectomy and partial medial meniscectomy. Only 1 study included concomitant procedures.15 Most players returned to the preinjury level of sports activity between 7 and 9 weeks except athletes in the series of Aune et al15 (61% RTS at a professional level at 8.5 months). Nawabi et al18 reported that time to RTS after a partial lateral meniscectomy [7 (5-18) weeks] was significantly longer than that after a partial medial meniscectomy [5 (3-6) weeks; P < 0.01]. They reported that cumulative probability of RTS was 6.31 times greater for players with a medial meniscus (MM) injury versus a lateral meniscus (LM) injury (hazard ratio = 6.31; 95% confidence interval [CI], 3.15-12.64). By contrast, Kim et al4 reported that time to RTS was significantly longer after a partial medial meniscectomy [79 (63-95) days] than after a partial lateral meniscectomy [61 (50-73) days; P = 0.017]. However, the adverse events and subsequent procedures reported by both studies were similar. In the study of Nawabi et al,18 29 players (69%) in the LM group experienced adverse events during the early recovery phase, that is, all had persistent effusions and 4 had lateral joint line pain. By contrast, only 4 players (8%) in the MM group had adverse events. Finally, 3 (7%) in the LM and none in the MM group required subsequent arthroscopic surgery. Kim et al4 also reported that pain and/or effusion after RTS was found in 22% of patients in the MM group and 53% in the LM group, and 3 (7.5%) in the LM group required subsequent arthroscopic surgery.
Regarding concomitant procedures, Aune et al15 reported that undergoing concomitant procedures did not have a significant effect on an athlete's likelihood of RTS, nor did any specific procedure affect the odds of RTS. Different results were obtained depending on the cartilage surface that was not performed with any procedure. Aune et al15 reported no significant difference between groups regarding the cartilage surface, but Osti et al19 reported a significantly longer time to RTS in athletes with meniscal tears associated with articular cartilaginous lesions (78 vs 45 days). The time to RTS differed according to the tear type, and the average RTS for isolated longitudinal, radial, horizontal, and complex type tears was 38, 42, 55, and 49 days, respectively [P < 0.001; between isolated longitudinal (38 days) and complex lesions (49 days)].19 The RTS also differed according to the amount of resection [small: n = 17, 79 (65-93) days; large: n = 17, 54 (39-69) days, P = 0.0155].4 The time to RTS was shorter among elite and competitive-level athletes than recreational athletes [elite: 54 (37-70) days; competitive-level: 53 (43-60) days; recreational: 88 (69-107); P < 0.0001 between recreation, elite, and competitive-level], and nonspeed positon players were found to be 4 times more likely to RTS (95% CI, 1.3-15.4; P = 0.014).4,15
Return to Sports After Meniscal Repair
Three studies14,16,20 performed evaluation after meniscal repair. Of the athletes, 81% to 88.9% returned to sports. One study14 reported that repair of the posterior horn was performed by an all-inside arthroscopic technique using the FasT-Fix system (Smith & Nephew, Andover, Massachusetts). In other 2 studies,16,20 repair of the LM and/or MM was performed using an arthroscopically assisted inside-out technique. One study reported a higher failure rate with MM repair than with LM repair [MM (35.5%) vs LM (7.1%); P = 0.047]. All 3 studies reported performing concurrent ACLR in 51.7%, 63.3%, and 83.3% of athletes. Two studies reported on the time to RTS.16,20 Two studies reported a similar time to RTS after isolate meniscal repair, with the average being 5.6 months, and the time to RTS was longer for athletes who required concurrent ACLR (8.23 and 11.8 months). The Tegner activity score was found to be significantly greater (P = 0.02) for athletes who did not undergo ACLR (8.0) than that for athletes who required ligament reconstruction (6.8).20 However, combined ACLR did not affect the percentage of RTS immediately after recovering from the surgery [meniscal repair alone: 13 (92%); meniscal repair + ACLR: 13 (86.6%); n.s.] and a mean follow-up 6 years playing competitive soccer [meniscal repair alone: 3 (21.4%); meniscal repair + ACLR: 5 (33.3%); n.s.], level of RTS (P = 0.075), and failure rate [isolated meniscal repair (14.3%) vs combined ACLR (28.9%); P = 0.42].14,16,20
Return to Sports After Meniscal Allograft Transplantation
Four studies6,7,17,21 evaluated the outcomes after MAT. In 3 studies,6,17,21 MAT of the LM and/or MM was performed, and the site of MAT was not indicated in 1 study. Three studies7,17,21 reported performing concurrent procedures in 45%, 58%, and 53.8% of athletes. The RTS percentage was 67% to 85.7%. Most athletes returned to the preinjury sports level, except for 33% of athletes who returned with a decreased activity level in the series of Zaffagnini et al.21 The time to RTS ranged from 7.6 to 16.5 months. In all 4 studies, the parameters that affect the ability to RTS or RTS at the preinjury activity level were not found. No significant differences in the time to return to official competition was found between patients who underwent medial or lateral MAT; patient with none, mild, or severe chondral damage; and those who underwent isolated or combined MAT. Three studies reported that subsequent procedures were performed in 12%, 25%, and 30% of athletes.
DISCUSSION
The main goal of this systematic review of the literature was to determine the time and rate of the RTS and to compare these values according to the type of meniscal surgery performed, such as meniscectomy, meniscal repair, and MAT. The principal findings of this systematic review were as follows: Most players returned to the preinjury activity level from 7 to 9 weeks after partial meniscectomy. Patients experienced more adverse effects after partial lateral meniscectomy than after partial medial meniscectomy. The time to RTS differed slightly according to the tear type. After meniscal repair, 81% to 88.9% of athletes returned to sports. The time to RTS after isolated meniscal repair was on average 5.6 months, and the time to RTS was longer for athletes who required concurrent ACLR (8.23 and 11.8 months, respectively). However, concomitant ACLR did not affect the rate of RTS and level of sports activity at the time of RTS; however, the Tegner activity score was higher in patients who did not undergo ACLR. After MAT, 67% to 85.7% of athletes returned to sports, and the time to RTS ranged from 7.6 to 16.5 months. No significant differences in the time to return to official competition were found between patients who underwent medial or lateral MAT, patient with none/mild or severe chondral damage, and those who underwent isolated or combined MAT.
The definition of the term RTS is fundamental as the term can be interpreted in several ways. The period before which an athlete can RTS activity without restrictions after surgery remains controversial. Return to sports should be defined as the period after surgery before which an athlete is fit enough to compete with other athletes at the same level in official sporting events. An athlete may not be able to RTS owing to his/her psychological state, despite meeting all objective criteria. This suggests that there may be differences in the psychological states of athletes that RTS and those who do not RTS.12 Indeed, it has been observed in some studies that although athletes have good outcomes regarding pain relief, stability, and range of motion, most athletes do not RTS at the same level.22 Most of the articles included in our analysis did not address this aspect, and they did not propose any criteria or indicators that enable assessment of RTS at the preinjury activity level. This implies that the time to RTS differs among different studies. Furthermore, athletes may RTS although they have not regained full function and muscle weakness and imbalance persist.
The time at which athletes return to their preinjury activity levels after meniscal surgery is not well established. The time to RTS after ACLR is relatively well known as compared to that after meniscal surgery, although meniscal surgeries are more commonly performed as compared to ACLR. Return to sports is based on the outcomes of functional movement tests that assess agility, balance, strength, and proprioception.23–27 In an updated systematic review and meta-analysis,28 81% of subjects returned to sports activity, 65% returned to their preinjury level of sport activity, and 55% returned to competitive-level sport after ACLR; however, the study had limitations. The meta-analysis model regarding RTS after ACLR did not allow for the investigation of interaction effects between physical and contextual factors. Hence, it is not possible to conclude whether a particular combination of factors contributes to improving or reducing the chances of RTS after ACLR. The high I2 values that indicate a high heterogeneity make it impossible to derive a strong conclusion. Furthermore, the quality of the articles included in the review may also have a bearing. These drawbacks were adjusted for in our analysis. The included studies were mostly case series, and it was impossible to derive a logical conclusion.
However, this article has some strong points. To the best of our knowledge, this is the first systematic review to evaluate the time to RTS, rate of RTS, and level of sports activity at the time of RTS after meniscal surgery. These values were separately evaluated according to the type of the meniscal surgery performed. The findings of this study provide information on the likelihood of RTS and the time to RTS according to the type of meniscal surgery. In addition, RTS outcomes can vary if concurrent procedures are performed, and adverse events can be predicted. Finally, the findings of the current study can guide future studies aimed at deriving a strong conclusion. This systematic review had limitations. First, we only included studies that primary outcome was an RTS. However, bias could be increased if we include articles that have RTS as a secondary outcome because secondary outcome could also be affected by the primary outcome. Therefore, we only included articles that have RTS as the primary outcome for the quality control. Second, despite the importance of the subject, there were no randomized clinical trials or case–control studies, and this analysis only included case series or cohort study. Therefore, a pooled analysis was impossible and a strong conclusion could not be drawn. Third, there were differences in concomitant surgery, and it can affect the timing of the RTS. Fourth, RTS was not accurately defined and the level of the RTS was also different in the included studies, making direct comparison among studies difficult.
CONCLUSIONS
Despite the limited evidence in this study, the time to and rate of RTS varied according to the type of meniscal surgery performed. The shortest time to RTS and the highest RTS rate were observed after partial meniscectomy. The time to RTS was slightly shorter, and the RTS rate was higher after meniscal repair than after MAT. Concurrent procedures such as ACLR prolonged the time to RTS, but it had no effect on the RTS rate and the level of sports activity at the time of RTS.
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