Clinical practice guidelines for the management of meniscal lesions and isolated lesions of the anterior cruciate ligament of the knee in adults

Abstract

Context: Meniscal lesions and isolated anterior cruciate ligament (ACL) knee injuries are common. In 2006, about 130,000 patients were admitted to hospital for meniscal surgery and 35,000 for ACL surgery in France. Surgical techniques and indications have evolved over recent years, and interest in meniscus preservation has increased due to the higher risk of femorotibial osteoarthritis following meniscectomy.

Objectives: To encourage good practices in meniscal lesions surgery (particularly meniscus preservation) and to clarify indications and techniques in ACL reconstruction surgery.

Methods: A systematic review of the literature (1996-2007) was performed. It was submitted to a multidisciplinary working group of experts in the field (n=10) who drafted an evidence report and clinical practice guidelines which were subsequently amended in the light of comments from 50 peer reviewers.

Main recommendations: (i) Meniscal repair should only be used to heal peripheral meniscal lesions affecting healthy meniscal tissue (injury) in vascularised areas (red-red zone or red-white zone). The current trend is towards use of hybrid implants (fixation material combined with suture wire) and an exclusively arthroscopic technique. (ii) Traumatic meniscal lesions do not always require a meniscectomy; no surgery or meniscal repair should systematically be considered. (iii) The assessment and management of non-traumatic degenerative meniscal lesions depend on the extent of cartilage damage. (iv) All ACL ruptures do not require reconstructive surgery. The indication for reconstruction is based on symptoms, in particular functional instability. As far as acute ACL injuries are considered, reconstruction by arthroscopy should preferably be delayed to reduce the thromboembolic events or joint stiffness. (v) Bone-tendon-bone graft and hamstring tendon reconstruction give similar results. (vi) Lateral tenodesis should be limited to specific cases.