Return to Play After Lateral Meniscectomy Compared With Medial Meniscectomy in Elite Professional Soccer Players Danyal H. Nawabi,*y MD, FRCS(Orth), Suzie Cro,z BSc, MSc, Imran P. Hamid,§ MBBS, MRCS, and Andy Williams,§|| MBBS, FRCS(Orth), FFSEM(UK) Investigation performed at Fortius Clinic, London, UK Background: Meniscectomy is frequently performed in elite soccer athletes to allow return to a high level of performance as early as possible. Although lateral meniscectomy is known to have more serious long-term sequelae than medial meniscectomy, little is known about the effect of lateral meniscectomy on the time to return to play during the early recovery phase in professional soccer players. Hypothesis: Lateral meniscectomy results in longer times to return to preinjury level of competition and a higher incidence of adverse outcomes compared with medial meniscectomy in elite professional soccer players. Study Design: Cohort study; Level of evidence, 3. Methods: A single-surgeon database containing the injury history and operative details of elite soccer athletes from 2005 to 2009 was used to identify players who had undergone an isolated partial lateral or medial meniscectomy. The time to return to preinjury level of competition, the incidence of adverse events during early recovery, and the need for further arthroscopy were recorded. Time to return to play was analyzed by using the Kaplan-Meier method. A multivariate analysis was used to control for age, location of meniscectomy, percentage of meniscus excised, and type of tear. Results: Ninety soccer players were identified, of which 42 had a lateral meniscectomy and 48 had a medial meniscectomy. The median time to return to play, to the nearest week, was longer in the lateral group than the medial group (7 vs 5; P \ .001). At all time points after surgery, the cumulative probability of returning to play was 5.99 times greater (95% confidence interval, 3.3410.74; P \ .001) after medial meniscectomy. More lateral meniscectomy cases experienced adverse events related to pain/ swelling—29 (69%) vs 4 (8%) (P \ .001)—and required a second arthroscopy: 3 (7%) vs 0 (P = .098). Conclusion: The time to return to preinjury level of competition is significantly longer after lateral than medial meniscectomy in elite professional soccer athletes. Lateral meniscectomy has a higher incidence of adverse events in the early recovery period, including pain/swelling and the need for further arthroscopy. It is also associated with a significantly lower rate of return to play. These findings form the basis of an important discussion that must be had with player and club before a lateral meniscectomy is performed in elite soccer athletes. Keywords: lateral; meniscectomy; return to play; professional soccer
the knees and ankles.4,6 Due to the frequent actions of pivoting and cutting, the menisci are at particular risk of injury, with meniscal tears accounting for 8% of all injuries sustained over a season in professional soccer.4 Despite the geometric differences between the lateral and medial compartments of the knee and the kinematic differences between the menisci, it is the senior author’s (A.W.) opinion that surgeons often assume, in terms of early recovery after meniscectomy, that the implications are the same regardless of the compartment affected. Although historical studies have reported worse outcomes after lateral than medial meniscectomy,1,9 recent comparative studies have shown similar subjective and clinical results when comparing arthroscopic lateral to medial meniscectomy.5,7 These results, however, cannot be used to guide sports
Professional soccer is a competitive sport with a high frequency of lower extremity injuries predominantly affecting *Address correspondence to Danyal H. Nawabi, MD, FRCS(Orth), Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA (e-mail: [email protected]). y Hospital for Special Surgery, New York, New York, USA. z Medical Research Council Clinical Trials Unit, London, UK. § Chelsea and Westminster Hospital, London, UK. || Fortius Clinic, London, UK. One or more of the authors has declared the following potential conflict of interest or source of funding: A.W. is a consultant for Smith & Nephew Endoscopy. The American Journal of Sports Medicine, Vol. 42, No. 9 DOI: 10.1177/0363546514540271 Ó 2014 The Author(s)
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physicians involved in the treatment of professional soccer players, as the data have been derived from the general population. As soccer has now cemented its place as one of the most popular sports worldwide,6 the pressure on team physicians is immense in quickly restoring injured players to a high level of performance. There is currently a lack of data on the early consequences of meniscectomy in professional soccer players, with little known about the comparative effects of lateral and medial meniscectomy on the time to return to play. Furthermore, the incidence of adverse events during the early recovery phase—including pain, swelling, and the need for further arthroscopy—has not been studied. The purpose of this study was to compare the time to return to play and incidence of adverse events during the early recovery phase in elite professional soccer players after a lateral or medial meniscectomy. We hypothesized that athletes who underwent a lateral rather than medial meniscectomy would take longer to return to their preinjury level of competition and have a higher incidence of adverse outcomes during the early recovery phase.
MATERIALS AND METHODS A single-surgeon database containing the injury history and operative details of male elite professional soccer players in the 4 seasons between August 2005 and May 2009 was used to identify athletes who had undergone an isolated partial lateral or medial meniscectomy. All athletes were asked for permission for their data to be used in this study, and none refused. All athletes had been referred by their team physician or physical therapist and had clinical and radiologic (magnetic resonance imaging) evidence of a meniscal tear. Clinical follow-up data regarding persistent pain and effusions were recorded at biweekly intervals postoperatively until return to play was achieved. Athletes were excluded if they had a history of any of the following: concomitant ligament injury, prior meniscectomy of the ipsilateral or contralateral meniscus, prior meniscal repair, preexisting chondral damage, surgery to the contralateral knee, any nonmeniscal knee surgery, or bilateral knee injuries. For each player, the following was recorded: time to return to play, incidence of adverse events during the early recovery phase (joint-line pain, effusion, fat-pad inflammation), and need for further arthroscopy. Time to return to play was recorded as the time—to the nearest week—when the player returned to full training and was involved in his first competitive match for at least 45 minutes. For those players who required a second arthroscopy during the recovery period (ie, the period between the first arthroscopy and returning to play), the time to return to play included the time taken to recover from the second arthroscopy. A retrospective review of the operative records and intraoperative arthroscopic photographs was performed to determine the location of the meniscal tear, according to the classification used by Cooper et al,5 and the percentage of meniscal tissue excised. This classification system divides the meniscus into 3 radial segments and 4 circumferential
The American Journal of Sports Medicine
TABLE 1 Clinical Outcomes of 90 Arthroscopic Partial Meniscectomies Divided Into Lateral and Medial Meniscectomy Groups Meniscectomy Group
Time to return to play, wk, median (range) During recovery phase, n (%) Adverse events Second arthroscopy
Lateral (n = 42)
Medial (n = 48)
P Value
7 (5-18)
5 (3-6)
\.001a
4 (8) 0 (0)
\.001a .098
29 (69) 3 (7)
a
P \ .05.
zones. The radial segments are A, B, and C for the medial meniscus (A = posterior horn, C = anterior horn) and D, E, and F for the lateral meniscus (D = anterior horn, F = posterior horn). The 4 circumferential zones are as follows: 0 = meniscocapsular junction, 1 = outer third, 2 = middle third, and 3 = inner third. The type of tear was also documented as vertical, horizontal, radial, or complex.
Statistical Analysis The 2-tailed independent Student t test was used to compare normally distributed continuous variables between the lateral and medial meniscectomy groups. The Fisher 2-tailed exact test was used to compare categorical variables. A Kaplan-Meier analysis of the time to return to play was performed. An unadjusted statistical comparison of the time to return to play between lateral and medial meniscectomy was conducted by using the log-rank test and a univariable Cox proportional hazards regression analysis. An adjusted analysis, based on a multivariable Cox proportional hazards regression analysis, was also undertaken to describe the relationship between the time to return to play and lateral or medial meniscectomy, controlling for age, location of meniscectomy, percentage of meniscal tissue excised, and type of tear. Hazard ratios were calculated with 95% confidence intervals to quantify the relative probabilities of return to play. All statistical analysis was performed with Stata/IC (v 11.2; StataCorp); P \ .05 was considered statistically significant.
RESULTS Ninety soccer players were identified, of which 42 had a lateral meniscectomy and 48 had a medial meniscectomy. The mean age in the lateral and medial meniscectomy groups was 23.7 6 4.1 years and 22.4 6 3.6 years, respectively (P = .098). The results comparing the lateral and medial meniscectomy groups are summarized in Table 1. The median time to return to play after a lateral meniscectomy was significantly longer than after a medial meniscectomy (7 vs 5 weeks; P \ .001). Twenty-nine players (69%) in the lateral meniscectomy group had adverse
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TABLE 2 Comparison of Location, Quantity, and Type of Meniscal Tear Between Lateral and Medial Meniscectomy Groupsa Meniscectomy Groups Lateral (n = 42)
Medial (n = 48)
Segment A n/a 22 (46) AB n/a 23 (48) B n/a 3 (6) D 4 (9) n/a E 18 (43) n/a EF 7 (17) n/a F 13 (31) n/a Zone 0-1 16 (38) 31 (65) 2-3 26 (62) 17 (35) Percentage meniscus excisedb 19.2 (10-30) 27.6 (15-60) Type of tear Vertical 5 (12) 24 (50) Horizontal 4 (9) 0 (0) Radial 12 (29) 3 (6) Complex 21 (50) 21 (44)
P Value
.02
\.001 \.001
Figure 1. Kaplan-Meier analysis of the cumulative probability of returning to play against time for players with a lateral compared with a medial meniscectomy.
a Values are expressed as No. (%) unless otherwise indicated. n/a, not applicable. b Mean (range).
events during the early recovery phase, of which all had persistent effusions and 4 had lateral joint-line pain. In contrast, only 4 players (8%) in the medial meniscectomy group had adverse events, of which 2 had medial jointline pain and 2 had fat-pad inflammation. Three players (7%) in the lateral meniscectomy group required a further arthroscopy in the recovery phase, all of whom had persistent effusions. The repeat arthroscopy was performed at a median of 10 weeks (range, 8-11 weeks). No players in the medial meniscectomy group required a further arthroscopy in the recovery phase. Because of the small numbers of further arthroscopies observed (n = 3), it is unsurprising that the difference in further arthroscopies between the lateral and medial meniscectomy groups did not reach statistical significance, most likely due to a type II error. The majority of the lateral meniscal tears involved segment E (43%), zone 2 (62%) (Table 2). The majority of the medial meniscal tears involved the junction of segments A and B (48%), zone 1 (65%). On average, a larger proportion (P \ .001) of the medial meniscus was excised (27.6%) compared with the lateral meniscus (19.2%). The majority of the lateral meniscal tears were of a complex pattern (50%), whereas in the medial group, the majority were in a vertical orientation (50%) (P \ .001).
Time to Return to Play At all time points after meniscectomy, the cumulative probability of returning to play was higher after a medial meniscectomy versus a lateral (Figure 1). A univariable
Figure 2. Multivariable Cox regression analysis of the cumulative probability of returning to play against time after a lateral versus medial meniscectomy for a player of average age undergoing a primary arthroscopy with no preexisting chondral damage.
Cox proportional hazards model confirmed that the rate of returning to play was 5.99 times greater for players with a medial meniscectomy (hazard ratio = 5.99; 95% confidence interval, 3.34-10.74; P \ .001). Multivariable Cox proportional hazards regression analysis was performed to explore the effect of a lateral versus a medial meniscectomy on the time to return to play, adjusting for potential confounding variables such as age, location of meniscectomy, percentage of meniscal tissue excised, and type of tear (Figure 2 and Table 3). After adjustment for potential confounding variables at all time points after meniscectomy, the cumulative probability of returning to play was 6.31 times greater for
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TABLE 3 Multivariable Cox Regression Analyzing Hazard Ratios on Time to Return to Play Covariate Medial meniscectomy Age, y Zone of meniscal tear 0-1 (reference) 2-3 Percentage meniscus excised Type of tear Complex (reference) Vertical Horizontal Radial
Hazard Ratio (95% CI)
P Value
6.31 (3.15-12.64) 1.01 (0.95-1.08)
\.001 .793
1 1.26 (0.80-1.99) 0.99 (0.96-1.03)
.322 .674
1 1.08 (0.64-1.85) 0.47 (0.16-1.43) 0.96 (0.51-1.83)
.767 .186 .911
players with a medial versus lateral meniscectomy (hazard ratio = 6.31; 95% confidence interval, 3.15-12.64; P \ .001).
DISCUSSION Elite professional soccer players frequently suffer meniscal tears,4 and evidence-based guidance is difficult to provide to team physicians because of the absence of studies involving this group of athletes. This study investigated the time to return to play and adverse events encountered during the early recovery phase in professional soccer players undergoing an isolated lateral or medial meniscectomy, and it attempted to quantify the probability of return to elite competition. Although there is clearly a long-term issue of progressive chondral damage after meniscectomy,8 to the best of our knowledge, information is not available in the literature regarding return to preinjury levels of competition and early outcomes. Our study has shown that, on average, the time to return to play for an elite soccer player is 7 weeks after a lateral meniscectomy, compared with 5 weeks after a medial meniscectomy. The relative rate of return to preinjury level of competition at each time point during the recovery phase is 6 times greater after a medial meniscectomy. Our findings also show that those treating and coaching professional soccer players undergoing lateral meniscectomy should expect not only a slow recovery but also specific adverse events during recovery. We found that 69% of players in this study experienced persistent effusions and/or joint-line pain after lateral meniscectomy, with a small proportion needing further arthroscopy. Biomechanically, it is clear why the lateral compartment is more vulnerable than the medial. There are distinct anatomic differences between the medial and lateral articular contours.12 In the sagittal plane, the concavity of the medial tibial plateau and the convexity of medial femoral condyle give some congruity even in the absence of the medial meniscus. On the lateral side, however, the femoral and tibial sides are both convex, resulting in a smaller surface area of articular surface contact. Hence, the lateral meniscus is more vital than the medial meniscus to prevent high articular contact stresses. As a result,
the lateral meniscus carries 70% of the lateral compartment load, as compared with the medial meniscus, which only carries 50% of the medial compartment load.18 Kinematically, the lateral and medial menisci are also very different. In magnetic resonance imaging studies of in vivo meniscal movement, the lateral meniscus has a significantly larger excursion during knee motion.10,19 In hyperflexion, the posterior horn can be seen lying at the extreme posterior slope of the lateral tibial plateau. The current body of data regarding the outcome after meniscectomy has been derived from the general population. The findings therefore are not necessarily valid for elite soccer players. Furthermore, the few studies on this subject that differentiate lateral from medial meniscectomy are limited in their applicability to an athletic population. Historical papers have reported less favorable outcomes of meniscal loss in the lateral compared with the medial compartment.1,9,11,22 In a 30-year longitudinal study, McNicholas et al13 reported that 80% of patients had good or excellent results at long-term follow-up after medial meniscectomy, compared with only 47% of patients with a similar outcome after lateral meniscectomy. The limitation of these studies is that the majority of them have investigated the long-term outcomes of total meniscectomy as opposed to arthroscopic partial. Chatain et al3 were one of the first groups to perform a comparative clinical and radiologic study comparing the outcomes of arthroscopic lateral versus medial meniscectomy after more than 10 years of follow-up. Clinical assessment was performed subjectively with a patient satisfaction score and the IKDC (International Knee Documentation Committee) scoring form. After 10 years, more than 90% of patients were very satisfied or satisfied with the results of medial or lateral meniscectomy, with no significant difference in the IKDC scores. However, repeat surgery was required twice as often after lateral than medial meniscectomy on the same meniscus, and the long-term radiologic results were significantly worse in the lateral group. Note that the mean age of patients in this study was approximately 37 years, and none were professional athletes. Roos et al17 performed a study that addressed the issue of looking at a cohort of professional soccer players. They studied the prevalence of osteoarthritis in 3 groups of patients after meniscectomy: elite soccer players, nonelite soccer players, and matched controls. They found the highest prevalence of osteoarthritis in the group of elite soccer players. This study, however, did not differentiate between lateral and medial meniscectomy. The data from other professional sports that involve pivoting on the lower extremity and, as a result, have a high incidence of meniscal tears is more readily available in the literature. At the NFL (National Football League) invitational combine, more than 25% of athletes reported a history of previous meniscal surgery.15 Furthermore, after magnetic resonance imaging, full-thickness articular cartilage lesions of the knee were found present in 17.3% of elite NFL athletes, with the lateral compartment being at greater risk for cartilage loss. Previous meniscectomy was particularly associated with these lesions. In a casecontrol study of 5047 NFL athletes, patients with
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meniscectomy, with or without anterior cruciate ligament reconstruction, were compared with matched controls without previous surgeries.2 A history of meniscectomy— not anterior cruciate ligament reconstruction—was found to shorten the expected career of a professional football player. This study did not specify whether the meniscectomies were lateral or medial. Another study identified meniscal injuries occurring in the National Basketball Association21; over a 21-season span, 129 isolated meniscal tears were studied. Although the lateral meniscus was torn more frequently than the medial meniscus, there was no difference in the playing time lost between groups. This is in contrast to our findings and may perhaps be explained by a difference in lower extremity alignment between soccer and basketball players. In a study comparing 336 male soccer players to 458 male nonsoccer players aged 8 to 18 years, a significantly higher degree of genu varum was observed in the soccer players.20 The varus alignment would be expected to cause less lateral compartment loading and therefore reduce problems after lateral meniscectomy. However, we believe that because of the pivoting and turning that occur at great pace in soccer, the knee— even if statically aligned in varus—is subjected to heavy ‘‘dynamic’’ valgus loading, thus overriding the protective effect of genu varum. It should be stressed that while the findings of our study are worrying, they do not mean that a lateral meniscectomy is a bad operation. Chondral changes may occur after a meniscal tear, and meniscal resection may exacerbate these changes. Nevertheless, resection should always be as conservative as possible, and the potential for repair must always be considered. Even unfavorable tears that extend into the central avascular zone can result in a satisfactory clinical outcome if sutured.16 In our study, 65% of medial meniscal tears were peripheral (zones 0-1), compared with 38% of lateral meniscal tears. This finding may explain the significantly higher volume of medial meniscal tissue that was excised (27.6%) compared with lateral (19.2%). However, the multivariate analysis did not show zone of tear or amount of meniscal tissue excised to be significant predictors for return to play (P = .32). With regard to tear pattern, vertical tears were more prevalent in the medial (50%) versus lateral (12%) group, and radial tears occurred more frequently in the lateral (29%) versus medial (6%) group. These findings are similar to those reported by Metcalf and Barrett,14 who prospectively evaluated 1485 meniscal tears in stable knees and found that 77.5% of tears in the medial meniscus were vertical. They also found that 14% of tears in the lateral meniscus were radial, compared with only 2.1% in the medial group.14 We acknowledge that this study has limitations. First, we did not use the widely used sports knee outcome measures. Our assumption was that standard outcome measures would not be sensitive enough to evaluate an elite athlete and, as a result, would suffer from a ceiling effect. For this unique cohort, we preferred to assess relevant postsurgical outcomes, which are arguably more useful in managing the expectations of players and team management. Second, we did not record demographics, such as
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body mass index, foot dominance, and overall lower limb alignment. These factors can influence the occurrence of meniscal tears. Finally, we were unable to obtain data regarding the length of career after surgery. While the main focus was time to return to play, the durability of return to play is of great importance when treating a professional athlete, as the beneficial effects of surgery can be short-lived. Despite these limitations, this study analyzed a large number of elite professional soccer players after meniscectomy from a single-surgeon database into which clinical, intraoperative, and radiologic data were entered prospectively.
CONCLUSION The median time to return to play for elite soccer athletes is 2 weeks longer after lateral than medial meniscectomy. Lateral meniscectomy is associated with more adverse events in the early recovery phase and a higher likelihood of further arthroscopic surgery. With the increasing demands on players and team physicians, our findings provide a useful body of evidence to guide discussions among players, team management, agents and medical professionals before lateral meniscectomy is performed in a professional soccer player.
ACKNOWLEDGMENT Dr Danyal Nawabi thanks the British Orthopaedic Association and the Royal College of Surgeons of England for supporting his Fellowship Training in Sports Medicine.
REFERENCES 1. Abdon P, Turner MS, Pettersson P, Lindstrand A, Stenstro¨m A, Swanson AJ. A long-term follow-up study of total meniscectomy in children. Clin Orthop Relat Res. 1990;257:166-170. 2. Brophy RH, Gill CS, Lyman S, Barnes RP, Rodeo SA, Warren RF. Effect of anterior cruciate ligament reconstruction and meniscectomy on length of career in National Football League athletes: a case control study. Am J Sports Med. 2009;37:2102-2107. 3. Chatain PNF, Adeleine P, Chambat P, Neyret P. A comparative study of medial versus lateral arthroscopic partial meniscectomy on stable knees. Arthroscopy. 2003;19:842-849. 4. Chomiak J, Junge A, Peterson L, Dvorak J. Severe injuries in football players. Influencing factors. Am J Sports Med. 2000;28:58-68. 5. Cooper DE, Arnoczky SP, Warren RF. Meniscal repair. Clin Sports Med. 1991;10:529-548. 6. Dvorak J, Junge A. Football injuries and physical symptoms: a review of the literature. Am J Sports Med. 2000;28:3-9. 7. Fabricant PD, Jokl P. Surgical outcomes after arthroscopic partial meniscectomy. J Am Acad Orthop Surg. 2007;15:647-653. 8. Fairbank TJ. Knee joint changes after meniscectomy. J Bone Joint Surg Br. 1948;30:664-670. 9. Hede A, Larsen E, Sandberg H. Partial versus total meniscectomy: a prospective, randomised study with long-term follow-up. J Bone Joint Surg Br. 1992;74:118-121. 10. Johal P, Williams A, Wragg P, Hunt D, Gedroyc W. Tibio-femoral movement in the living knee: a study of weight bearing and nonweight bearing knee kinematics using ‘interventional’ MRI. J Biomech. 2005;38:269-276.
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11. Jorgensen U, Sonne H, Lauridsen F, Rosenklint A. Long-term followup of meniscectomy in athletes: a prospective longitudinal study. J Bone Joint Surg Br. 1987;69:80-83. 12. Martelli S, Pinskerova V. The shapes of the tibial and femoral articular surfaces in relation to tibiofemoral movement. J Bone Joint Surg Br. 2002;84:607-613. 13. McNicholas MJ, Rowley DI, McGurty D, et al. Total meniscectomy in adolescence: a thirty-year follow-up. J Bone Joint Surg Br. 2000;82:217-221. 14. Metcalf MH, Barrett GR. Prospective evaluation of 1485 meniscal tear patterns in patients with stable knee. Am J Sports Med. 2004;32:675-680. 15. Nepple JJ, Wright RW, Matava MJ, Brophy RH. Full-thickness knee articular cartilage defects in National Football League combine athletes undergoing magnetic resonance imaging: prevalence, location, and association with previous surgery. Arthroscopy. 2012;28:798-806. 16. Noyes FR, Barber-Westin SD. Arthroscopic repair of meniscal tears extending into the avascular zone in patients younger than twenty years of age. Am J Sports Med. 2002;30:589-600.
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17. Roos H, Lindberg H, Ga¨rdsell P, Lohmander LS, Wingstrand H. The prevalence of gonarthrosis and its relation to meniscectomy in former soccer players. Am J Sports Med. 1994;22:219-222. 18. Seedhom BB, Dowson D, Wright V. Proceedings: functions of the menisci. A preliminary study. Ann Rheumatic Dis. 1974;33:111. 19. Vedi V, Williams A, Tennant SJ, Spouse E, Hunt DM, Gedroyc WMW. Meniscal movement: an in-vivo study using dynamic MRI. J Bone Joint Surg Br. 1999;81:37-41. 20. Witvrouw E, Danneels L, Thijs Y, Cambier D, Bellemans J. Does soccer participation lead to genu varum? Knee Surg Sports Traumatol Arthrosc. 2009;17:422-427. 21. Yeh PC, Starkey C, Lombardo S, Vitti G, Kharrazi FD. Epidemiology of isolated meniscal injury and its effect on performance in athletes from the national basketball association. Am J Sports Med. 2012;40:589-594. 22. Yocum L, Kerlan R, Jobe F, Carter V. Isolated lateral meniscectomy: a study of twenty-six patients with isolated tears. J Bone Joint Surg Am. 1979;61:338-342.
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the knees and ankles.4,6 Due to the frequent actions of pivoting and cutting, the menisci are at particular risk of injury, with meniscal tears accounting for 8% of all injuries sustained over a season in professional soccer.4 Despite the geometric differences between the lateral and medial compartments of the knee and the kinematic differences between the menisci, it is the senior author’s (A.W.) opinion that surgeons often assume, in terms of early recovery after meniscectomy, that the implications are the same regardless of the compartment affected. Although historical studies have reported worse outcomes after lateral than medial meniscectomy,1,9 recent comparative studies have shown similar subjective and clinical results when comparing arthroscopic lateral to medial meniscectomy.5,7 These results, however, cannot be used to guide sports
Professional soccer is a competitive sport with a high frequency of lower extremity injuries predominantly affecting *Address correspondence to Danyal H. Nawabi, MD, FRCS(Orth), Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA (e-mail: [email protected]). y Hospital for Special Surgery, New York, New York, USA. z Medical Research Council Clinical Trials Unit, London, UK. § Chelsea and Westminster Hospital, London, UK. || Fortius Clinic, London, UK. One or more of the authors has declared the following potential conflict of interest or source of funding: A.W. is a consultant for Smith & Nephew Endoscopy. The American Journal of Sports Medicine, Vol. 42, No. 9 DOI: 10.1177/0363546514540271 Ó 2014 The Author(s)
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physicians involved in the treatment of professional soccer players, as the data have been derived from the general population. As soccer has now cemented its place as one of the most popular sports worldwide,6 the pressure on team physicians is immense in quickly restoring injured players to a high level of performance. There is currently a lack of data on the early consequences of meniscectomy in professional soccer players, with little known about the comparative effects of lateral and medial meniscectomy on the time to return to play. Furthermore, the incidence of adverse events during the early recovery phase—including pain, swelling, and the need for further arthroscopy—has not been studied. The purpose of this study was to compare the time to return to play and incidence of adverse events during the early recovery phase in elite professional soccer players after a lateral or medial meniscectomy. We hypothesized that athletes who underwent a lateral rather than medial meniscectomy would take longer to return to their preinjury level of competition and have a higher incidence of adverse outcomes during the early recovery phase.
MATERIALS AND METHODS A single-surgeon database containing the injury history and operative details of male elite professional soccer players in the 4 seasons between August 2005 and May 2009 was used to identify athletes who had undergone an isolated partial lateral or medial meniscectomy. All athletes were asked for permission for their data to be used in this study, and none refused. All athletes had been referred by their team physician or physical therapist and had clinical and radiologic (magnetic resonance imaging) evidence of a meniscal tear. Clinical follow-up data regarding persistent pain and effusions were recorded at biweekly intervals postoperatively until return to play was achieved. Athletes were excluded if they had a history of any of the following: concomitant ligament injury, prior meniscectomy of the ipsilateral or contralateral meniscus, prior meniscal repair, preexisting chondral damage, surgery to the contralateral knee, any nonmeniscal knee surgery, or bilateral knee injuries. For each player, the following was recorded: time to return to play, incidence of adverse events during the early recovery phase (joint-line pain, effusion, fat-pad inflammation), and need for further arthroscopy. Time to return to play was recorded as the time—to the nearest week—when the player returned to full training and was involved in his first competitive match for at least 45 minutes. For those players who required a second arthroscopy during the recovery period (ie, the period between the first arthroscopy and returning to play), the time to return to play included the time taken to recover from the second arthroscopy. A retrospective review of the operative records and intraoperative arthroscopic photographs was performed to determine the location of the meniscal tear, according to the classification used by Cooper et al,5 and the percentage of meniscal tissue excised. This classification system divides the meniscus into 3 radial segments and 4 circumferential
The American Journal of Sports Medicine
TABLE 1 Clinical Outcomes of 90 Arthroscopic Partial Meniscectomies Divided Into Lateral and Medial Meniscectomy Groups Meniscectomy Group
Time to return to play, wk, median (range) During recovery phase, n (%) Adverse events Second arthroscopy
Lateral (n = 42)
Medial (n = 48)
P Value
7 (5-18)
5 (3-6)
\.001a
4 (8) 0 (0)
\.001a .098
29 (69) 3 (7)
a
P \ .05.
zones. The radial segments are A, B, and C for the medial meniscus (A = posterior horn, C = anterior horn) and D, E, and F for the lateral meniscus (D = anterior horn, F = posterior horn). The 4 circumferential zones are as follows: 0 = meniscocapsular junction, 1 = outer third, 2 = middle third, and 3 = inner third. The type of tear was also documented as vertical, horizontal, radial, or complex.
Statistical Analysis The 2-tailed independent Student t test was used to compare normally distributed continuous variables between the lateral and medial meniscectomy groups. The Fisher 2-tailed exact test was used to compare categorical variables. A Kaplan-Meier analysis of the time to return to play was performed. An unadjusted statistical comparison of the time to return to play between lateral and medial meniscectomy was conducted by using the log-rank test and a univariable Cox proportional hazards regression analysis. An adjusted analysis, based on a multivariable Cox proportional hazards regression analysis, was also undertaken to describe the relationship between the time to return to play and lateral or medial meniscectomy, controlling for age, location of meniscectomy, percentage of meniscal tissue excised, and type of tear. Hazard ratios were calculated with 95% confidence intervals to quantify the relative probabilities of return to play. All statistical analysis was performed with Stata/IC (v 11.2; StataCorp); P \ .05 was considered statistically significant.
RESULTS Ninety soccer players were identified, of which 42 had a lateral meniscectomy and 48 had a medial meniscectomy. The mean age in the lateral and medial meniscectomy groups was 23.7 6 4.1 years and 22.4 6 3.6 years, respectively (P = .098). The results comparing the lateral and medial meniscectomy groups are summarized in Table 1. The median time to return to play after a lateral meniscectomy was significantly longer than after a medial meniscectomy (7 vs 5 weeks; P \ .001). Twenty-nine players (69%) in the lateral meniscectomy group had adverse
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TABLE 2 Comparison of Location, Quantity, and Type of Meniscal Tear Between Lateral and Medial Meniscectomy Groupsa Meniscectomy Groups Lateral (n = 42)
Medial (n = 48)
Segment A n/a 22 (46) AB n/a 23 (48) B n/a 3 (6) D 4 (9) n/a E 18 (43) n/a EF 7 (17) n/a F 13 (31) n/a Zone 0-1 16 (38) 31 (65) 2-3 26 (62) 17 (35) Percentage meniscus excisedb 19.2 (10-30) 27.6 (15-60) Type of tear Vertical 5 (12) 24 (50) Horizontal 4 (9) 0 (0) Radial 12 (29) 3 (6) Complex 21 (50) 21 (44)
P Value
.02
\.001 \.001
Figure 1. Kaplan-Meier analysis of the cumulative probability of returning to play against time for players with a lateral compared with a medial meniscectomy.
a Values are expressed as No. (%) unless otherwise indicated. n/a, not applicable. b Mean (range).
events during the early recovery phase, of which all had persistent effusions and 4 had lateral joint-line pain. In contrast, only 4 players (8%) in the medial meniscectomy group had adverse events, of which 2 had medial jointline pain and 2 had fat-pad inflammation. Three players (7%) in the lateral meniscectomy group required a further arthroscopy in the recovery phase, all of whom had persistent effusions. The repeat arthroscopy was performed at a median of 10 weeks (range, 8-11 weeks). No players in the medial meniscectomy group required a further arthroscopy in the recovery phase. Because of the small numbers of further arthroscopies observed (n = 3), it is unsurprising that the difference in further arthroscopies between the lateral and medial meniscectomy groups did not reach statistical significance, most likely due to a type II error. The majority of the lateral meniscal tears involved segment E (43%), zone 2 (62%) (Table 2). The majority of the medial meniscal tears involved the junction of segments A and B (48%), zone 1 (65%). On average, a larger proportion (P \ .001) of the medial meniscus was excised (27.6%) compared with the lateral meniscus (19.2%). The majority of the lateral meniscal tears were of a complex pattern (50%), whereas in the medial group, the majority were in a vertical orientation (50%) (P \ .001).
Time to Return to Play At all time points after meniscectomy, the cumulative probability of returning to play was higher after a medial meniscectomy versus a lateral (Figure 1). A univariable
Figure 2. Multivariable Cox regression analysis of the cumulative probability of returning to play against time after a lateral versus medial meniscectomy for a player of average age undergoing a primary arthroscopy with no preexisting chondral damage.
Cox proportional hazards model confirmed that the rate of returning to play was 5.99 times greater for players with a medial meniscectomy (hazard ratio = 5.99; 95% confidence interval, 3.34-10.74; P \ .001). Multivariable Cox proportional hazards regression analysis was performed to explore the effect of a lateral versus a medial meniscectomy on the time to return to play, adjusting for potential confounding variables such as age, location of meniscectomy, percentage of meniscal tissue excised, and type of tear (Figure 2 and Table 3). After adjustment for potential confounding variables at all time points after meniscectomy, the cumulative probability of returning to play was 6.31 times greater for
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TABLE 3 Multivariable Cox Regression Analyzing Hazard Ratios on Time to Return to Play Covariate Medial meniscectomy Age, y Zone of meniscal tear 0-1 (reference) 2-3 Percentage meniscus excised Type of tear Complex (reference) Vertical Horizontal Radial
Hazard Ratio (95% CI)
P Value
6.31 (3.15-12.64) 1.01 (0.95-1.08)
\.001 .793
1 1.26 (0.80-1.99) 0.99 (0.96-1.03)
.322 .674
1 1.08 (0.64-1.85) 0.47 (0.16-1.43) 0.96 (0.51-1.83)
.767 .186 .911
players with a medial versus lateral meniscectomy (hazard ratio = 6.31; 95% confidence interval, 3.15-12.64; P \ .001).
DISCUSSION Elite professional soccer players frequently suffer meniscal tears,4 and evidence-based guidance is difficult to provide to team physicians because of the absence of studies involving this group of athletes. This study investigated the time to return to play and adverse events encountered during the early recovery phase in professional soccer players undergoing an isolated lateral or medial meniscectomy, and it attempted to quantify the probability of return to elite competition. Although there is clearly a long-term issue of progressive chondral damage after meniscectomy,8 to the best of our knowledge, information is not available in the literature regarding return to preinjury levels of competition and early outcomes. Our study has shown that, on average, the time to return to play for an elite soccer player is 7 weeks after a lateral meniscectomy, compared with 5 weeks after a medial meniscectomy. The relative rate of return to preinjury level of competition at each time point during the recovery phase is 6 times greater after a medial meniscectomy. Our findings also show that those treating and coaching professional soccer players undergoing lateral meniscectomy should expect not only a slow recovery but also specific adverse events during recovery. We found that 69% of players in this study experienced persistent effusions and/or joint-line pain after lateral meniscectomy, with a small proportion needing further arthroscopy. Biomechanically, it is clear why the lateral compartment is more vulnerable than the medial. There are distinct anatomic differences between the medial and lateral articular contours.12 In the sagittal plane, the concavity of the medial tibial plateau and the convexity of medial femoral condyle give some congruity even in the absence of the medial meniscus. On the lateral side, however, the femoral and tibial sides are both convex, resulting in a smaller surface area of articular surface contact. Hence, the lateral meniscus is more vital than the medial meniscus to prevent high articular contact stresses. As a result,
the lateral meniscus carries 70% of the lateral compartment load, as compared with the medial meniscus, which only carries 50% of the medial compartment load.18 Kinematically, the lateral and medial menisci are also very different. In magnetic resonance imaging studies of in vivo meniscal movement, the lateral meniscus has a significantly larger excursion during knee motion.10,19 In hyperflexion, the posterior horn can be seen lying at the extreme posterior slope of the lateral tibial plateau. The current body of data regarding the outcome after meniscectomy has been derived from the general population. The findings therefore are not necessarily valid for elite soccer players. Furthermore, the few studies on this subject that differentiate lateral from medial meniscectomy are limited in their applicability to an athletic population. Historical papers have reported less favorable outcomes of meniscal loss in the lateral compared with the medial compartment.1,9,11,22 In a 30-year longitudinal study, McNicholas et al13 reported that 80% of patients had good or excellent results at long-term follow-up after medial meniscectomy, compared with only 47% of patients with a similar outcome after lateral meniscectomy. The limitation of these studies is that the majority of them have investigated the long-term outcomes of total meniscectomy as opposed to arthroscopic partial. Chatain et al3 were one of the first groups to perform a comparative clinical and radiologic study comparing the outcomes of arthroscopic lateral versus medial meniscectomy after more than 10 years of follow-up. Clinical assessment was performed subjectively with a patient satisfaction score and the IKDC (International Knee Documentation Committee) scoring form. After 10 years, more than 90% of patients were very satisfied or satisfied with the results of medial or lateral meniscectomy, with no significant difference in the IKDC scores. However, repeat surgery was required twice as often after lateral than medial meniscectomy on the same meniscus, and the long-term radiologic results were significantly worse in the lateral group. Note that the mean age of patients in this study was approximately 37 years, and none were professional athletes. Roos et al17 performed a study that addressed the issue of looking at a cohort of professional soccer players. They studied the prevalence of osteoarthritis in 3 groups of patients after meniscectomy: elite soccer players, nonelite soccer players, and matched controls. They found the highest prevalence of osteoarthritis in the group of elite soccer players. This study, however, did not differentiate between lateral and medial meniscectomy. The data from other professional sports that involve pivoting on the lower extremity and, as a result, have a high incidence of meniscal tears is more readily available in the literature. At the NFL (National Football League) invitational combine, more than 25% of athletes reported a history of previous meniscal surgery.15 Furthermore, after magnetic resonance imaging, full-thickness articular cartilage lesions of the knee were found present in 17.3% of elite NFL athletes, with the lateral compartment being at greater risk for cartilage loss. Previous meniscectomy was particularly associated with these lesions. In a casecontrol study of 5047 NFL athletes, patients with
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meniscectomy, with or without anterior cruciate ligament reconstruction, were compared with matched controls without previous surgeries.2 A history of meniscectomy— not anterior cruciate ligament reconstruction—was found to shorten the expected career of a professional football player. This study did not specify whether the meniscectomies were lateral or medial. Another study identified meniscal injuries occurring in the National Basketball Association21; over a 21-season span, 129 isolated meniscal tears were studied. Although the lateral meniscus was torn more frequently than the medial meniscus, there was no difference in the playing time lost between groups. This is in contrast to our findings and may perhaps be explained by a difference in lower extremity alignment between soccer and basketball players. In a study comparing 336 male soccer players to 458 male nonsoccer players aged 8 to 18 years, a significantly higher degree of genu varum was observed in the soccer players.20 The varus alignment would be expected to cause less lateral compartment loading and therefore reduce problems after lateral meniscectomy. However, we believe that because of the pivoting and turning that occur at great pace in soccer, the knee— even if statically aligned in varus—is subjected to heavy ‘‘dynamic’’ valgus loading, thus overriding the protective effect of genu varum. It should be stressed that while the findings of our study are worrying, they do not mean that a lateral meniscectomy is a bad operation. Chondral changes may occur after a meniscal tear, and meniscal resection may exacerbate these changes. Nevertheless, resection should always be as conservative as possible, and the potential for repair must always be considered. Even unfavorable tears that extend into the central avascular zone can result in a satisfactory clinical outcome if sutured.16 In our study, 65% of medial meniscal tears were peripheral (zones 0-1), compared with 38% of lateral meniscal tears. This finding may explain the significantly higher volume of medial meniscal tissue that was excised (27.6%) compared with lateral (19.2%). However, the multivariate analysis did not show zone of tear or amount of meniscal tissue excised to be significant predictors for return to play (P = .32). With regard to tear pattern, vertical tears were more prevalent in the medial (50%) versus lateral (12%) group, and radial tears occurred more frequently in the lateral (29%) versus medial (6%) group. These findings are similar to those reported by Metcalf and Barrett,14 who prospectively evaluated 1485 meniscal tears in stable knees and found that 77.5% of tears in the medial meniscus were vertical. They also found that 14% of tears in the lateral meniscus were radial, compared with only 2.1% in the medial group.14 We acknowledge that this study has limitations. First, we did not use the widely used sports knee outcome measures. Our assumption was that standard outcome measures would not be sensitive enough to evaluate an elite athlete and, as a result, would suffer from a ceiling effect. For this unique cohort, we preferred to assess relevant postsurgical outcomes, which are arguably more useful in managing the expectations of players and team management. Second, we did not record demographics, such as
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body mass index, foot dominance, and overall lower limb alignment. These factors can influence the occurrence of meniscal tears. Finally, we were unable to obtain data regarding the length of career after surgery. While the main focus was time to return to play, the durability of return to play is of great importance when treating a professional athlete, as the beneficial effects of surgery can be short-lived. Despite these limitations, this study analyzed a large number of elite professional soccer players after meniscectomy from a single-surgeon database into which clinical, intraoperative, and radiologic data were entered prospectively.
CONCLUSION The median time to return to play for elite soccer athletes is 2 weeks longer after lateral than medial meniscectomy. Lateral meniscectomy is associated with more adverse events in the early recovery phase and a higher likelihood of further arthroscopic surgery. With the increasing demands on players and team physicians, our findings provide a useful body of evidence to guide discussions among players, team management, agents and medical professionals before lateral meniscectomy is performed in a professional soccer player.
ACKNOWLEDGMENT Dr Danyal Nawabi thanks the British Orthopaedic Association and the Royal College of Surgeons of England for supporting his Fellowship Training in Sports Medicine.
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