WHAT IS ALREADY KNOWN ON THIS TOPIC

Meniscus tears are common orthopaedic injuries, particularly among younger populations with a majority occurring in the setting of acute injury, often of sports-related origin.

While large database studies have shown that patient demographic and socioeconomic factors impact the management of meniscus tears, these studies have included older patients with degenerative meniscus tears, where treatment protocols and ideologies differ significantly from younger populations.

WHAT THIS STUDY ADDS

This study revealed significant associations between patient demographics, socioeconomic factors and surgical choices for isolated meniscus tears in younger patients.

Older age and higher Area Deprivation Index were more likely to result in meniscectomy versus meniscus repair. While higher-volume knee surgeons favoured meniscus repair, a growing trend of meniscus repair rates was observed among lower-volume knee surgeons in recent years.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

With the increasing push towards meniscus preservation for the longevity of the knee joint, surgeons should be aware of the patient-related and surgeon-related characteristics that may impact the care of isolated meniscus tears in younger patients.

Introduction

Meniscus tears, classified broadly as traumatic or degenerative in nature, are common yet impactful orthopaedic injuries due to their potential adverse effect on the long-term health of the knee joint.1 2 Particularly among younger populations, traumatic meniscus tears predominate,3 with a majority occurring in the setting of acute injury, often of sports-related origin.4 While non-operative management may be considered for asymptomatic tears, the increasing body of literature and guidelines recommend surgical management, specifically meniscus repair, for younger patients experiencing sustained symptoms.5 This approach is favoured due to the improved patient-reported, clinical and radiological outcomes achieved through meniscus repair compared with meniscectomy.6 However, meniscectomies still comprise the majority of meniscus surgeries in younger, often sports-participating, populations, possibly due to the shorter time and higher rates of return to sport compared with meniscus repair.7 8

While large database studies have shown that patient demographic and socioeconomic factors impact the management of meniscus tears,4 9 these studies have included older patients with degenerative meniscus tears, where treatment protocols and ideologies favouring non-operative management differ significantly from those in younger populations favouring operative management.5 10 11 However, the impact of patient- and surgeon-related factors on the management of isolated meniscus tears in younger populations remains sparse. Available data suggest that younger patients of non-white race and with non-private insurance experience increased delays in time to surgery12 and increased rates of meniscectomy in the setting of concomitant anterior cruciate ligament reconstruction (ACL-R).13 In addition, while neighbourhood disadvantage has been associated with inferior orthopaedic outcomes following hip and knee arthroplasty and ACL-R,14 15 limited data exist examining the role of neighbourhood disadvantage on outcomes following meniscus tears. Finally, while it has been shown that surgeons with higher ACL-R volume perform meniscus repair more frequently than meniscectomy in the setting of ACL-R,16 it remains unknown how surgeon volume impacts rates of meniscus repair and meniscectomy in the setting of isolated meniscus tears.

The primary aim of this study was to investigate the impact of demographic and socioeconomic factors on the management of isolated meniscus tears in young patients. The secondary aim of this study was to identify trends in the surgical management of isolated meniscus tears, both overall and based on surgeon volume, in a single large healthcare system composed of academic and community hospitals. The hypothesis was that non-white race, non-private insurance status, and increased neighbourhood disadvantage would be associated with higher rates of meniscectomies that persist even after controlling for surgeon volume. The secondary hypothesis was that overall rates of meniscus repair would increase over time compared with meniscectomy, with higher-volume knee surgeons performing higher rates of meniscus repair than lower-volume surgeons.

Methods

All patients aged 14–44 years who underwent surgery for an isolated meniscus tear from January 2016 to August 2022 were identified in a database and analysed for inclusion. All surgeries were performed at a single large healthcare system, which compromises 23 hospitals and involves 84 orthopaedic surgeons. Among these hospitals, eight are considered academic, providing training for students, residents and fellows while 15 hospitals are classified as non-academic or community hospitals. Exclusion criteria included a prior history of ipsilateral knee surgery, meniscus allograft transplantation, and concomitant ligamentous, osseous, or chondral procedures. Inclusion and exclusion criteria were applied using current procedural terminology (CPT) codes relevant for meniscectomy, meniscus repair and all concomitant procedures. All CPT codes used for inclusion and exclusion criteria may be found in online supplemental appendix table 1.

Data regarding patient age, sex (male or female), race (white or non-white), insurance status (private or non-private) and Area Deprivation Index (ADI) were recorded. The ADI is a novel-validated metric representing social disadvantage of communities by Census Block Group17 18 and is scored from 1 to 100, with a higher ADI indicating increased deprivation and neighbourhood disadvantage. The ADI was collected by cross-referencing the patient’s zip code with the ADI for their Census Block Group as published by the Centers for Disease Control and Prevalence.19 Surgeon volume was determined based on a combination of meniscectomies and meniscus repairs performed per year over the study period, as higher-volume knee surgeons have been demonstrated to perform meniscus repair more often than lower-volume surgeons.20 Higher-volume knee surgeons were defined as performing at least 35 meniscus procedures, including at least 15 meniscus repairs, per year, whereas lower-volume knee surgeons were defined by <35 meniscus procedures or <15 meniscus repairs per year, based on previous groupings reported in the literature.21

Equity, diversity and inclusion

This study includes a large cohort composed of both female and male patients from a single healthcare network who underwent surgery for isolated meniscus tears. Important demographic and socioeconomic factors, including age, sex, race, insurance status and neighbourhood disadvantage, were analysed to determine their impact on the management of isolated meniscus tears. In doing so, this study sought to examine the potential influence of accessibility to healthcare and disadvantages associated with geographical location and socioeconomic status. Race was dichotomised as white vs non-white race to account for the relatively small numbers of persons in the non-white categories. In doing so, this minimised the differences in the number of subjects in the non-white vs white participant groups, which improves statistical power. Further, prior evidence has shown that those who are non-white often are a greater disadvantage than those that are white.13 22 Having said this, we recognise that each race is different from others, and we do not mean to unfairly homogenise them. Finally, our research team includes both female and male researchers across a variety of educational backgrounds, professional disciplines, and levels.

Statistical analysis

Statistical analysis was performed by using Microsoft Excel (Microsoft V.16.69) and SPSS Statistics (IBM V.28.0). Normality of distributions was determined using the Kolmogorov-Smirnov test. Patient demographic and socioeconomic variables were assessed between meniscus treatment groups (meniscectomy versus meniscus repair), using independent-samples t-tests for normally distributed continuous variables, Mann-Whitney U test for ordinal or non-normally distributed data and χ2 tests for dichotomous and categorical variables. For the analysis, patient age was grouped as 14–29 years vs 30–44 years based on the mean age of the cohort. Patient ADI was subdivided into quartiles and grouped as <25th percentile, 25th–75th percentile and >75th percentile, to identify the impact of ADI in patients with the lowest and highest neighbourhood disadvantage. A multivariable binary logistic regression model was then performed between procedure types to calculate OR and 95% CI for all significant factors. Surgeon volume was added to the logistic regression model due to previous literature demonstrating an association between surgeon volume and meniscus treatment type.16 23 Rates of meniscus repair and meniscectomy were assessed between surgeon volume groups for each year of the study period using χ2 analysis. Finally, patient demographic and socioeconomic variables were assessed between surgeon volume groups using univariate analyses as previously discussed. Statistical significance was set to p<0.05 (two sided) for all tests.

A post hoc two-tailed power analysis was performed using the final sample size and alpha set to 0.05. Post hoc power analysis demonstrated a power of 0.99 achieved to assess differences in rates of meniscus repair versus meniscectomy between surgeon volume groups. Post hoc power analysis additionally demonstrated a power of 0.99 and 0.93 achieved to assess differences in mean ADI between surgeon volume groups and meniscectomy versus meniscus repair groups, respectively.

ResultsDescriptive characteristics of cohort

Following all exclusion criteria, a total of 1552 patients (mean age: 31.2 years, SD: 9.7 years; 29.6% female) treated by 84 orthopaedic surgeons were included for analysis (figure 1). The mean ADI of the cohort was 63.7 (SD: 18.7), 13.6% of patients were of non-white race, and 25.4% of patients had non-private insurance. Seven higher-volume surgeons were identified, all of whom were sports-fellowship trained, with an average of 66 (SD: 19.1) meniscus procedures per year, including 26 (SD: 7.1) meniscus repairs per year. The lower-volume surgeon cohort was composed of 77 surgeons across a variety of orthopaedic subspecialties, who performed an average of 15 (SD: 18.5) meniscus procedures per year, including 1 (SD: 2.2) meniscus repair per year. Higher-volume knee surgeons performed 549 (35.4%) of included cases, whereas lower-volume knee surgeons performed 1003 (64.6%) of included cases.

Figure 1

Flow chart of inclusion and exclusion criteria. MAT, meniscus allograft transplantation; n, number of patients; y.o., years old.

Impact of patient demographic and socioeconomic factors on meniscus treatment

Meniscectomy was performed more often than meniscus repair in patients of older age (32.7 vs 26.0 years, p<0.001), female sex (31.0% vs 24.4%, p=0.018), and ADI >25th percentile (table 1). Multivariable binary logistic regression indicated that age 30–44 years (OR 3.82, 95% CI 2.94 to 4.96; p<0.001), ADI 25th–75th percentile (OR 1.57, 95% CI 1.16 to 2.11; p=0.003) and ADI >75th percentile (OR 1.48, 95% CI 1.04 to 2.10; p=0.028) were associated with increased odds of receiving a meniscectomy versus meniscus repair. When adding surgeon volume to the logistic regression model, age 30–44 years old (OR 3.57, 95% CI 2.74 to 4.65), ADI 25th–75th percentile (OR 1.55, 95% CI 1.15 to 2.10; p=0.004) and ADI >75th percentile (OR 1.46, 95% CI 1.02 to 2.07; p=0.037) remained significant predictors of undergoing meniscectomy versus meniscus repair (table 2).

Table 1

Comparison of patient demographics and socioeconomic factors based on meniscus treatment type

Table 2

Multivariable binary logistic regression for meniscectomy

Trends in meniscus repair rates based on surgeon volume

During the study period, a total of 1208 (77.8%) meniscectomies and 344 (22.2%) meniscus repairs were performed. Higher-volume knee surgeons performed significantly higher rates of meniscus repair compared with lower-volume surgeons each year from 2016 to 2021, but not in 2022, where the difference was not significant (table 3). Additionally, higher-volume knee surgeons experienced an increase in rates of meniscus repair compared with meniscectomy from 2017 to 2019 (31.5%–47.1%, respectively), followed by a reduction in 2020 and 2021 (39.5% and 28.6%, respectively), and increase again in 2022 (32.6%). Conversely, lower-volume knee surgeons performed increasingly higher rates of meniscus repair compared with meniscectomy each year throughout the study period (3.4% in 2016 to 27.2% in 2022).

Table 3

Number and per cent of operative patients receiving meniscus repair versus meniscectomy over time between lower-volume and higher-volume knee surgeons

Association between patient demographic and socioeconomic factors and surgeon volume

Patients of older age (32.7 vs 28.5 years, p<0.001) and non-private insurance (28.3% vs 20.0%, p<0.001) were more likely to undergo operative treatment by a lower-volume knee surgeon, whereas patients of non-white race (16.4% vs 12.1%, p=0.017) were more likely to undergo operative treatment by a higher-volume knee surgeon (table 4).

Table 4

Comparison of patient demographics and socioeconomic factors based on operating surgeon volume

Discussion

The findings of this study suggest that demographic and socioeconomic factors in younger patients with isolated meniscus tears are significantly associated with the treatment they receive. Most importantly, older patient age and increased neighbourhood disadvantage resulted in increased odds of receiving a meniscectomy versus meniscus repair. In addition, higher-volume knee surgeons were found to perform higher rates of meniscus repair than lower-volume knee surgeons up to the year 2022. A trend towards increasing rates of meniscus repair among lower-volume knee surgeons was also observed during that time. The results of the present study support the existing literature suggesting that both patient and surgeon characteristics play pivotal roles in the management of orthopaedic injuries.4 9

While the role of certain socioeconomic factors, such as race and insurance status, has been studied extensively within orthopaedics,4 12 less evidence exists examining the impact of neighbourhood disadvantage on surgical decision-making. The ADI is a novel metric that considers neighbourhood location, housing quality and access to care; it has been demonstrated to impact healthcare outcomes, utilisation of healthcare and hospital readmission rates,24 all of which are important considerations in the management of meniscus tears. Current data examining the impact of neighbourhood disadvantage in orthopaedics have largely focused on management and outcomes following ACL injury and suggest that lower neighbourhood socioeconomic status is associated with delays in time to ACL-R, increased prevalence of meniscus tears at time of ACL-R, and inferior patient-reported outcomes following ACL-R.15 25 These trends in access to care and inferior patient-reported outcomes among patients with increased neighbourhood disadvantage are highlighted in the total hip and knee arthroplasty literature.14 26

In the present study, higher ADI resulted in increased odds of receiving a meniscectomy independent of the influence of surgeon volume, demonstrating its crucial role as a socioeconomic consideration that can impact the management of meniscal pathology. While the mechanism of undergoing meniscectomy versus meniscus repair was not examined in this large database study, previous literature demonstrates disadvantaged or marginalised patients attend fewer physical therapy sessions postoperatively.27 This may have prompted surgical decision-making towards meniscectomy, given the longer and more demanding rehabilitation process following meniscus repair.28 Altogether, patients in the included study population with higher ADI may be geographically predisposed to suboptimal care following isolated meniscus tears, which may have detrimental effects on the long-term health of the knee.29

As with ADI, previous literature indicates the primary concern regarding the impact of insurance status on the management of meniscus injuries is access to care. A recent large database study of over 32 000 patients found that non-private insurance was associated with lower rates of receiving meniscus surgery than patients with private insurance.4 Further studies have demonstrated that non-private insurance status is associated with increased delays in time to initial evaluation and surgery following isolated meniscus injury, however, no difference in the ultimate rate of surgical intervention.12 30 In the present study, while an association was found between patients with non-private insurance and operative management by lower-volume knee surgeons, insurance status was not found to impact rates of treatment type for meniscus injury. Along with the findings of this study, the prior literature supports the notion that insurance status may significantly impact surgical timing and surgeon characteristics in younger patients with meniscus tears but may have less impact on the treatment ultimately received. Nevertheless, insurance status remains an important socioeconomic consideration in the treatment of such patients, as delays to surgical intervention may predispose patients to chronic meniscus tears that are irreparable or result in a poorer prognosis following repair.5 31

The impact of surgeon volume on the management and outcomes of orthopaedic injuries has started to gain focus across multiple subspecialties.32 33 With regard to the management of meniscus and ACL tears, higher-volume knee surgeons have been shown to perform increased rates of meniscus repair during ACL-R and experience decreased rates of meniscectomy following meniscus repair procedures.16 20 34 Similar trends favouring meniscus repair have also been observed among surgeons operating at higher-volume hospitals.35 In the present study, higher-volume knee surgeons performed higher rates of meniscus repair across the study period relative to lower-volume knee surgeons, however, lower-volume knee surgeons demonstrated a nearly 24% increase in rates of meniscus repair from 2016 to 2022, nearing rates of higher-volume knee surgeons in later years. Interestingly, higher-volume knee surgeons experienced a decrease in rates of meniscus repair in 2020 and 2021, which may have been secondary to the impact of the COVID-19 pandemic on elective sports medicine surgery and/or delays in surgical intervention for meniscus tears.36 37 However, a similar trend was not observed among lower-volume knee surgeons, possibly due to the already fewer meniscus repairs performed compared with higher-volume knee surgeons. A previous study analysing trends in the management of meniscus tears from 2004 to 2012 using the American Board of Orthopaedic Surgery database found sports fellowship-trained surgeons performed significantly higher rates of meniscus repair compared with non-sports fellowship-trained surgeons across the full study period.6 Given the trends observed in this prior study, the findings of the present study indicate the high rates of meniscus repair among higher-volume knee surgeons, and the increasing rates of meniscus repair among lower-volume knee surgeons, may be explained by a recent shift in surgical strategy towards ‘saving the meniscus’ and various guidelines recommending meniscus repair as a first-line surgical treatment option in younger patients.5 11

Limitations

There are several limitations to the present study. First, as a retrospective, large database study, the specific location, size and type of meniscus tears included in this study were unable to be determined. Second, the specific indications and contraindications for each treatment type, such as time from injury to surgery, were not analysed in this study. Individuals from disadvantaged areas may have more limited access to care, which could increase the time from onset of symptoms to surgery rendering some meniscus tears less repairable than others. However, given the nature of a registry study that primarily uses CPT codes, the time from onset of symptoms to surgery was not available in the dataset. Third, in some cases, neighbourhood socioeconomic status may not be associated with individual socioeconomic status, leading to some possible bias. Finally, while the inclusion of patients 14–44 years to exclude patients with degenerative meniscus tears was based on previous definitions reported in the literature,38 39 the present study was unable to identify the degree of osteoarthritis in the knee, which may have guided surgical decision-making in patients where significant osteoarthritis was found.

Conclusion

Demographic and socioeconomic factors are significantly associated with the surgical management of isolated meniscus tears in younger patients, with older age and increasing neighbourhood disadvantage favouring treatment with meniscectomy over repair. While higher-volume knee surgeons performed higher rates of meniscus repair for isolated meniscus tears in younger patients, lower-volume surgeons have performed increasing rates of meniscus repair over recent years. With the increasing push towards meniscus preservation for the long-term health of the knee joint, surgeons should be aware of the patient-related and surgeon-related characteristics that may impact the care of isolated meniscus tears in younger patients.

Data availability statement

No data are available.

Ethics statementsPatient consent for publication

Not applicable.

Ethics approval

Ethical approval for this retrospective study was obtained from the associated university’s Institutional Review Board (No: STUDY19030196).

Acknowledgments

We would like to acknowledge Nathaniel Setar and Stephen Koscumb from the University of Pittsburgh Medical Center Department of Clinical Analytics for their involvement in the development and modifications of the data model utilised in the present study.