Abstract
Purpose
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To provide a comprehensive, systematic review on the relationship and effects of smoking on clinical outcomes after meniscus surgery.
Methods
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The following combination of keywords was entered into the electronic search engines: meniscus, meniscus repairs, meniscectomy, meniscal tear, meniscus excision AND (smoke OR smoking OR nicotine OR tobacco). The year of the study, country, type of study, number of subjects, medial/lateral/both menisci, body mass index, smoking status, mean age, gender, follow-up, type/pattern of injury, surgical implications and clinical outcomes were recorded.
Results
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A total of 23 studies published in 2013–2024 were included in the analysis. In ten studies, the meniscus injury was associated with an anterior cruciate ligament (ACL) tear. In four studies, the effect of smoking on meniscal allograft transplantation (MAT) was investigated. The neutral effect of smoking on meniscus surgery was revealed in nine studies, and only one of them focused on isolated meniscus pathology and surgery. The negative effect of smoking on meniscus surgery was shown in ten papers, with four papers focused on isolated meniscus tears and six papers presenting data with concurrent ACL reconstructions.
Conclusions
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This systematic review found that the results regarding the impact of smoking on meniscus repair outcomes were conflicting. Nevertheless, MAT and meniscus repair performed in the presence of concurrent ligamentous injury, both being demanding surgical procedures, require reduction of factors that may contribute to failure. Therefore, cessation of smoking in patients undergoing these procedures is highly advised.
Introduction
Historically, it was believed that menisci play no important role in knee joint function, and that is why open total meniscectomy was routinely performed (1). As it turned out, either lack of meniscal tissue or meniscal tears irreversibly lead to cartilage lesions and osteoarthritis (OA), which raised their importance and crucial role in the congruence and kinematics of the knee joint as a vital contributor (2). The main aim of joint preservation surgery should be meniscal integrity as an essential step in meniscus surgery. Menisci play an important role in knee joint biomechanics, and in addition to being passive joint stabilizers, they are also involved in facilitating load transmission, shock absorption and proprioception, as well as cartilage nutrition, lubrication and protection. The main goal in joint preservation surgery is to re-establish meniscal tissue integrity in order to fulfill their role in the knee joint: being shock absorber, facilitate load transmission, participating in proprioception, as well as articular cartilage nutrition, lubrication and protection (1, 3, 4, 5, 6).
‘Save the meniscus’ became a slogan of the new era of meniscus surgery. Untreated meniscal tears and meniscectomy were overshadowed by minimally invasive surgery and joint preservation techniques such as meniscal repairs, meniscal allografts and scaffolds. The main purpose was to slow down cartilage degeneration and OA progression (1, 4, 5, 7, 8).
Meniscal tears are the second most common knee joint injury, which is thought to be underestimated (9). The menisci are subjected to various stresses during knee joint motion: tensile, compressive and shear (10). Snoeker et al. recognized squatting, kneeling, crawling, chair sitting, stair climbing, lifting and walking as risk factors for meniscal tears (11). Furthermore, the association between increased cartilage loss in the involved compartment and meniscal tears has been reported (12).
The negative impact of smoking on conditions such as neoplasms, endocrine disorders, cardiovascular disease and bone healing has been reported (13). In orthopedic surgery, tobacco use has become a crucial negative healing factor (14). However, the literature regarding the impact of smoking on meniscal surgery is ambiguous. Some authors claim that tobacco use adversely affects results of meniscal surgery, while others did not find such a correlation (15, 16). Thus, the purpose of this study was to provide a comprehensive, systematic review on the relationship and effects of smoking on clinical outcomes after meniscus repair surgery. The investigation hypothesized that the known negative effects of nicotine, such as vasoconstriction and hypoperfusion, may affect meniscal tissue healing (14, 17).
Materials and methods
Search strategy
To identify all of the essential studies that reported relevant information and data concerning the association of meniscus surgery and smoking, an extensive search of the major and significant electronic databases (PubMed, Cochrane Central, ScienceDirect) was performed by two independent authors (JZ, JP). A systematic investigation was conducted from August 2022 to 2024, using combinations of the following key terms:(meniscus OR meniscus repairs OR meniscectomy OR meniscal tear OR meniscus excision) AND (smoke OR smoking OR nicotine OR tobacco)with no limits regarding the year of publication. Moreover, an additional intensive search through the references of all identified studies was conducted. A systematic review of the collected literature was carried out according to the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) (Supplementary material (see section on Supplementary materials given at the end of the article)). The PRISMA checklist of our project was presented in Fig. 1. The study was submitted to PROSPERO (International prospective register of systematic reviews).
PRISMA 2020 flow diagram for new systematic reviews, which included searches of databases and registers only. *Consider, if feasible to do so, reporting the number of records identified from each database or register searched (rather than the total number across all databases/registers). **If automation tools were used, indicate how many records were excluded by a human and how many were excluded by automation tools.
Citation: EFORT Open Reviews 10, 4; 10.1530/EOR-24-0097
Eligibility assessment
Screening of databases was carried out independently by two authors (JZ, PP). After the database search, three independent reviewers (JZ, JP, MZ) screened all the papers and identified a title, abstract and full text concerning smoking and clinical outcomes after meniscus surgery, also with the presence of concurrent ligament and cartilage lesions in the knee. Clinical human studies, levels of evidence I–IV, in the English language, were evaluated and analyzed in this systematic review. Non-English language studies, case studies, reviews, letters to editors, conference abstracts or studies containing incomplete or irrelevant data were not eligible for inclusion (level of evidence V). Meniscal surgery was defined as meniscal repair, allograft transplantation and partial meniscectomy/debridement. Exclusion criteria were as follows: any clinical outcomes and basic science studies analyzing outcomes after surgery in any joint other than the knee. Papers without clearly described outcomes after surgical treatment of the meniscus were excluded. The senior author and expert in evidence-based medicine (RL) made the final decision in case of disagreement among the authors.
Data extraction
Three independent reviewers (JZ, JP, MZ) extracted the initially screened and relevant data, including the year of the study, country, type of the study, number of subjects, medial/lateral/both menisci, body mass index (BMI), smoking status, mean age, gender, follow-up, type/pattern of injury, surgical implications and clinical outcomes.
Risk of bias assessment
The risk of bias assessment was performed using the Cochrane collaboration’s risk of bias tool. Risk of bias was assigned to the following domains as ‘low’, ‘high’ or ‘unclear’: sequence generation/allocation concealment (selection bias), blinding of participants and personnel (performance bias), blinding of outcome assessment (detection bias), incomplete outcome data (attrition bias), selective outcome reporting (reporting bias) and other sources of bias. The quality of papers was assessed independently by two reviewers, with agreement.
Results
A total of 22 studies published in between 2013 and 2024 were included in the analysis. The general characteristics and demographic data were presented in Table 1. Most of the studies were level IV evidence (n = 15) and level III evidence (n = 5). There was one study with level I evidence and one with level II evidence. In 20 papers the authors investigated the medial meniscus, in 15 papers both the medial and lateral meniscus and for two studies specific data about meniscus laterality were not presented. The total number of included subjects was n = 120,646 from which n = 19,648(16.3%) were smokers. However, in the study by Laurendo et al. the exact number of smokers was not mentioned. There were n = 66,405 males and n = 54,225 females, although Basques et al. did not report the exact number of the male/female population, having presented the percentage instead. Recalculation of absolute numbers was required in that case. The mean age of the subjects was 36.6 years. Only five studies specifically explored the effects of smoking on isolated meniscal tears (Supplementary Table 1). In 10 studies the meniscus injury was associated with an ACL tear and chondral pathology (2) and OA (1). The follow-up duration was presented in 19 studies, and the mean follow-up was 4.9 months (range, 1.0–81.6) (Supplementary Table 1 and Table 2). The surgical method of treatment was defined in six studies and mainly it was an all-inside repair or a meniscectomy. BMI was indicated in 14 studies with a mean value of 30.4. In four studies the effect of smoking on meniscal allograft transplantation (MAT) was investigated (Table 2). Moreover, there were two multicenter cohort studies on ACL injuries with concomitant meniscal repair surgeries (Supplementary Table 1).
The general characteristics and demographic data of the included studies on meniscus surgery and smoking.
| Reference | Study type | LOE | Country | Publication year | Meniscus | Subjects, n | Smokers | Male/female | Mean age (years) |
|---|---|---|---|---|---|---|---|---|---|
| Blackwell et al. (18) | III | USA | 2016 | Medial meniscus 65%; lateral meniscus 27%; both menisci 8% | 104 | 52 | 32/20 | 27.9 | |
| Johnsen et al. (19) | CSS | IV | Denmark | 2019 | n/a | 620 | 138 | 80/54 | 45 |
| Moses et al. (15) | RCS | IV | USA | 2017 | Medial and lateral meniscus | 51 | 10 | 34/17 | 25 |
| Cox et al. (20) | PCS | I | USA | 2014 | Medial and lateral meniscus | 1411 | 135 | 785/626 | 23 |
| Buyukkuscu et al. (21) | RCS | IV | Turkey | 2019 | Medial meniscus | 33 | 15 | 23/10 | 46.1 |
| MOON knee group et al. (22) | COS | II | USA | 2020 | Medial and lateral meniscus | 3276 | 302 | 1433/1843 | 23 |
| Uzun et al. (23) | IV | Turkey | 2019 | Lateral meniscus | 43 | 12 | 37/6 | 29.5 | |
| Laurendon et al. (24) | RCS | IV | France | 2017 | Medial meniscus 58.6%; lateral meniscus 36.8%; both menisci 4.6% | 87 | n/a | 61/26 | 28.5 |
| Astur et al. (25) | PCS | III | Brazil | 2018 | 107 isolated ACL tears; 72 ACL tears + medial meniscus injury; 60 isolated medial meniscus tears | 239 | 51 | 196/43 | 33 |
| Uzun et al. (26) | CS | IV | Turkey | 2017 | Medial meniscus | 80 | 30 | 76/4 | 29.1 |
| Basques et al. (27) | CCS | III | USA | 2015 | n/a | 17774 | 15.7% | 53.1%/46.9% | 53 |
| Haviv et al. (28) | IV | Israel | 2015 | Medial and lateral meniscus | 201 | 59 | 133/68 | 44.4 | |
| Haklar et al. (29) | CS | IV | Turkey | 2013 | Medial meniscus | 112 | 46 | 94/18 | 34.57 |
| Antosh et al. (30) | TS | IV | USA | 2019 | Medial and lateral meniscus | 104 | 40 | 95/9 | 28 |
| Waterman et al. (31) | CS | IV | USA | 2016 | Medial and lateral meniscus | 230 | 84 | 203/24 | 27.2 |
| Beletsky et al. (32) | TCS | IV | USA | 2020 | Medial and lateral meniscus | 126 | 17 | 72 | 48.9 |
| Franovic et al. (33) | CS | IV | USA | 2020 | Medial and lateral meniscus | 166 | 20 | 85/81 | 55.2 |
| Domżalski et al. (16) | RCS | IV | Poland | 2021 | Medial and lateral meniscus | 92 | 47 | 36/56 | 31.5 |
| Zaffagnini et al. (34) | CS | IV | Italy | 2016 | Medial and lateral meniscus | 147 | 18 | 117/30 | 44.8 |
| Heyer et al. (35) | CS | IV | USA | 2019 | Medial and lateral meniscus | 95,191 | 15,781 | 53,138/42,053 | 47.1 |
| Zabrzyński et al. (36) | CS | III | Poland | 2022 | Medial meniscus | 50 | 17 | 32/18 | 41.68 |
| Kraus et al. (37) | RCPS | III | USA | 2021 | Medial and lateral meniscus | 509 | 39 | 206/301 | n/a |
CS, case series; CCS, case-control study; COS, cohort study; CSS, cross-sectional study; LOE, level of evidence; PCS, prospective cohort study; RCS, retrospective cohort study; RCPS, retrospective comparative study; TS, therapeutic study; TCS, therapeutic case series.
Smoking as a risk factor in meniscal allograft transplantation surgery.
| Reference | Mean follow-up | BMI | Type of injury | Surgical implications | Outcomes | Overall effect |
|---|---|---|---|---|---|---|
| Antosh et al. (30) | n/a | n/a | n/a | Meniscal allograft transplantation | Return to duty at more than 2 years (OR = 0.48 (95% CI: 0.13–1.74; P = 0.267); there was no difference in return-to-duty rates between tobacco smokers and non-tobacco users | Neutral |
| Zaffagnini et al. (34) | 4 years | 25.2 | n/a | Meniscal allograft transplantation | There was no difference reported between tobacco smokers and non-tobacco users | Neutral |
| Waterman et al. (31) | n/a | n/a | n/a | Meniscal allograft transplantation | Tobacco use was associated with significantly increased risk of failure (OR = 2.22; 95% CI: 1.19–4.17; P = 0.028) | Negative |
BMI, body mass index.
Neutral effect of smoking on meniscus surgery
This section included nine studies. Only Zabrzyński et al. focused on isolated meniscus pathology and surgery (18). The follow-up time ranged from 3 to 72 months. The mean BMI was 25.88. In three studies meniscal lesions were associated with OA; Johnsen et al. reported the prevalence of OA in 37.7% of smokers, Buykkuscu et al. in >90%, while Beletsky et al. in 70.6% (36, 37, 38). No significant relationship between smoking and OA was found. Furthermore, in the study by Buyukkuscu et al. no difference between smoker and non-smoker groups (P > 0.05) was shown regarding preoperative and postoperative Lysholm and IKDC scores. Zabrzyński et al. also noted no association between smoking indices and functional outcomes after all-inside repair of chronic medial meniscus tear (18). In four studies with concurrent cruciate ligament tears: Moses et al. revealed concomitant anterior cruciate ligament (ACL) tears in 54.9% study population, Laurendon et al. in 70%, Astur et al. in 179/239 and Haviv et al. in 11% (15, 19, 20, 21). In the mentioned studies, no association between smoking and impaired clinical results after surgery was found. Laurendon et al. and Moses et al. reported no link between meniscus postsurgical failure and smoking habit (15, 21). The degenerative character of the injuries predominated; Johnsen et al. revealed 50% degenerative injuries in smokers and 59.3% in non-smokers, Buyukkuscu et al. presented chronic tears (>8 weeks) in more than 90% of patients, Haviv et al. in 55% of their study population and Beletsky et al. in 41.27% (20, 22, 23, 24). Buyukkuscu et al. reported on the zones of meniscal lesions and 42.4% injuries were in the red-red zone and 57.6% in the red-white zone (23). The medial meniscus was more frequently torn, as shown by Moses et al. 74.5%, Buyukkuscu et al.>90% and Laurendon et al. 58.6% (15, 21, 23). On the other hand, the MOON Knee Group investigated the influence of smoking on clinical outcomes after ACL reconstruction (25). They identified failure risk factors in patients undergoing ACL surgery with concomitant meniscus repair. They concluded that patients who had quit smoking (compared with non-smokers) had a greater risk of subsequent meniscal surgery (25).
Negative effect of smoking on meniscus surgery
Ten papers were included in this section, although only four papers focused on isolated meniscus tears and six papers presented data with concurrent ACL tears. The follow-up duration ranged from 1 to 72 months. The mean BMI was 25.4. The period between trauma and surgery was defined in three studies and ranged from 29.6 to 122.62 days. In two studies, the surgical technique was defined as an all-inside repair. The failure risk of meniscus repairs in smokers was 27% (P = 0.0076) in Blackwell et al., 25% (P < 0.05) in Uzun et al. and 37.5% (P = 0.008) also in Uzun et al. study (26, 27, 28). Blackwell et al. summarized that the failure risk after meniscus repair was 3.8 times higher for smokers compared to non-smokers (26). In the studies by Uzun et al. failures of meniscal repairs occurred mainly in the red-white zones, and failure rates were higher for smokers than for nonsmokers (P = 0.008) (27, 28). At the 3-month follow-up after meniscus surgery, Franovic et al. reported that ‘never smokers’ experienced significantly greater improvements than ‘former smokers’ or ‘current smokers’ (P < 0.048, P < 0.035) (29). Some authors suggested that smoking history may prove useful in postoperative outcome prediction. In the study by Haklar et al. no association between impaired meniscus healing and smoking, suture type and the length of tear in isolated meniscal injuries (P = 0.005) was observed. However, in the group of meniscus tears with a concurrent ACL tear, smoking significantly affected meniscal healing (P = 0.05) (30). Moreover, Cox et al. performed meniscus surgery along with ACL reconstruction (31). The study population consisted of patients with primary ACL tears and concomitant articular cartilage lesions and meniscal tears (medial-38%, lateral-46%). The authors found that significant predictors of lower outcome scores were lower baseline scores, higher BMI, lower education level, smoking and ACL revisions. Specifically, current smokers and previous smokers had lower IKDC and KOOS scores (31).
Negative effect of smoking on meniscectomy
Basques et al. reported that in 17,774 patients who underwent meniscectomy, smokers had higher odds of readmission (OR: 1.67; P = 0.033) (32). Such a correlation was also observed in patients with diabetes and pulmonary diseases. Interestingly, in contrary to smoking, age >65 years did not increase the odds of any studied adverse events. Moreover, Kraus et al. observed that patients who failed nonoperative treatments, including injections and physical therapy and also were active smokers at the time of partial meniscectomy had significantly worse baseline and postoperative patient-reported outcome measures (PROMs) compared with nonsmokers (33).
Smoking and meniscal allograft transplantation
The influence of smoking on clinical outcomes after MAT was investigated by authors of four studies included in this review. Antosh et al. reported a high rate of tobacco use in a population that underwent MAT (39%), yet no differences in a military population between tobacco smokers and non-smokers were observed (OR: 0.48 (0.13–1.74); P = 0.267). Moreover, no correlation between return to full duty and variables such as age, gender, tobacco use or BMI was reported (34). In addition, Zaffagnini et al. did not report any significant differences between both groups (35). On the contrary, Waterman et al. with a similarly high rate of smoking among participants (37%), reported a link between tobacco use and increased risk of failure (OR: 2.22; 95% CI: 1.19–4.17; P = 0.028) (36).
Discussion
The most important finding of this systematic review was that smoking may have a major negative impact on meniscus surgery. However, results regarding the impact of smoking on meniscus repair outcomes were conflicting (14, 26, 37, 38, 39, 40, 41, 42, 43, 44).
The most important determinants of successful meniscus surgery are vascularization pattern, nutritional status and morphological pattern of the tear (5). Meniscus blood supply determines the healing potential of a torn meniscus. Medial and lateral genicular arteries constitute a major source of blood supply, but in the mature skeleton, vascularization patterns differ. The red-red zone, which is 10–25% of the meniscus, is supplied by the vessels. Quite the opposite, the white zone, which is nourished by diffusion form the synovial fluid, which forms the inner 1/3 of the meniscus. Between them occurs the red-white zone, with combined features of both. Although newer studies reported that the degree of vascular penetration into the periphery of the lateral and medial meniscus ranges from 0 to 48% and 0 to 42%, respectively (45).
It was believed that meniscal tears can be repaired only in the peripheral zone, but Barber-Westin et al. presented meniscus healing potential in the red-white zone with decreased vascularity, with an 86% rate of healed meniscal tears (46). Moreover, it was shown that meniscal repair significantly improved patients’ symptoms at 2 years follow-up regardless of the tear zone (47). In addition, animal studies have revealed that this fibrocartilaginous tissue is able to heal without significant vascular contribution (47).
Seven of the studies included in this review showed no correlation between smoking and postoperative failure. Moses et al. suggested that this fact may be associated with the meniscus vascularization pattern and possible vascular effects of smoking (15). Systemic effects of smoking through the circulatory system have been widely studied (48).
Although it is well known that smoking has adverse effects on fracture union, tendon and wound healing, bone mineral density and clinical outcomes of knee ligament surgery, the deleterious effects of smoking on meniscus surgery have not been well defined. In their systematic review, Kanneganti et al. in 2014 clearly showed that the current literature highlights the negative effects of smoking on knee ligament and articular cartilage surgery; however, the scarcity of data on meniscus surgery was underlined (14).
We believe that the adverse effects of tobacco use, such as vasoconstriction, hypoperfusion and free radical formation, may have a significant negative impact on meniscus healing (38). Nicotine stimulates the neovascularization process, which is described as ‘pathological’, attributing to newly formed capillaries with abnormal permeability (49). Having adverse effects on microcirculation and promoting pathological angiogenesis, smoking may contribute to the high failure rates following meniscal repairs, which were reported in some of the studies included in this review.
The tissue-specific effects of smoking on the musculoskeletal system are an ongoing subject. Zabrzynski et al. in their study, observed a negative correlation between smoking history and the extent of neovascularization and reported that smoking impairs the vascularization of tendons (17). Novikov et al. observed that smoking cigarettes is associated with worse objective and subjective outcome measures, as well as increased rates of complications following primary anterior cruciate ligament reconstruction (50). Michaud et al. demonstrated the negative effect of smoking on neovascularization and its association with a significant reduction of capillary density in ischemic muscles (51). Smoking has a significant impact on cartilage, resulting in tissue damage and the development of inflammatory processes, which result in an enhanced risk of OA (52).
Kraus et al. noted that patients who were active smokers at the time of partial meniscectomy had significantly worse baseline and postoperative PROMs compared with nonsmokers (33). It seems to be clear that tobacco smoking impairs the regeneration of musculoskeletal tissues and subsequently the functional outcomes, although data from our study do not entirely support this statement (11, 18, 23).
The success of meniscus repair surgery relies on several variables. As we presented, the majority of the studies focus on complex injuries of the knee joint, predominantly with associated chondropathy and ACL tears. Interestingly, it was reported that meniscal repairs performed at the time of ACL reconstruction had better outcomes than isolated repairs. However, it was shown that with the use of biological augmentation, such as marrow venting, similar results may be achieved even in the treatment of isolated meniscal lesions (53).
In addition, the morphology of tears may be described as simple or complex, localized in various zones of vascularization. Furthermore, they may be acute or chronic, with the development of degenerative tears. Those so-called ‘degenerative’ tears could be resistant to the influence of smoking, maybe due to already impaired vascularization (18, 54). The issue of higher BMI is also important in meniscus surgery because these patients usually require intervention more frequently. Patients with moderate or severe obesity (BMI >25) have inferior short-term outcomes compared with non-obese patients after partial meniscectomy (54). The association between smoking and worse postoperative functional results in ACL reconstructions, as well as delayed bone healing and wound healing capacity after this surgery, is well known (48, 49). The negative impact of smoking was predominantly observed in complex knee injuries with concurrent ACL tears. Interestingly, no significant impact of tobacco use on clinical outcomes has been proven in the population with OA (24). Moreover, in several studies with a concurrent ACL tear, a neutral association between clinical outcomes and smoking was presented (15, 19, 20, 21, 28). Two high-level evidence, multicenter, cohort studies reporting results regarding risk factors for unsuccessful ACL reconstruction with concomitant meniscus tears were included in this review. Cox et al. concluded that smokers and ex-smokers had lower postoperative functional scores (31). Although the MOON Knee Group results showed an overall neutral effect of smoking on meniscus surgery, they stated that ex-smokers had a greater likelihood of having subsequent meniscus surgery (25). In light of this review, in patients undergoing knee ligament surgery with concomitant meniscus repair, cessation of smoking is a rational recommendation. This might reduce the risk of postoperative meniscus failure, especially in full-thickness tears with vertical, longitudinal and bucket-handle patterns in the red-white zone with limited vascularization (28).
Subsequent meniscal surgery can have psychological, economic and social effects on patients and also on the national health system (55, 56). Cancienne et al. observed higher rates of reoperation, infection and venous thromboembolism (VTE) in smokers undergoing ACL reconstruction (57). Considering the high percentage of meniscal tears in patients undergoing revision ACL reconstruction, eliminating modifiable risk factors such as smoking for these types of surgeries should lower the failure rates, which ultimately reduces the economic burden on the national health system (58).
Irreparable meniscal tears treated with subtotal or total meniscectomy ultimately lead to a predictable pattern of progressive joint degeneration, particularly within the lateral compartment (36). MAT is a treatment modality for patients with persistent or recurrent symptoms after partial meniscectomy and a remnant meniscus (34). Numerous authors recommend MAT for physically active patients with meniscus insufficiency to diminish pain and, potentially, prevent or slow down the development of OA (59, 60).
Lee et al. noted that additional procedures (such as realignment osteotomy, ligament reconstruction and articular cartilage repair) are performed simultaneously or in a staged manner along with MAT in more than 50% of total MATs (61).
However, the failure rate after MAT may be discouraging, ranging from 0% up to 87.5% (62, 63, 64, 65). There has been discussion on the exact risk factors of MAT surgery failure. We presented two studies that focused on tobacco use in patients who underwent MAT. These papers presented contradictory results. Nevertheless, MAT is a very demanding surgical procedure dedicated for high-volume surgeons and potential candidates should minimize their potential risk factors, including cessation of smoking.
The recent literature contains reviews about meniscal repair and failure risks. In a systematic review, Hamilton et al. did not find a significant difference between male and female patients (66). Rothermel et al. revealed no significant difference in the meniscus repair failure rate between patients older than 40 and younger than 40 (67). In the review by Everhart et al. factors such as the chronicity of the tear, surrounding cartilage health and age showed no significant difference in failure rates in patients over 40 years of age who underwent meniscal repair (68). A 5-year follow-up meta-analysis of meniscus repair was published in 2012 by Nepple et al. (69). They found an increased rate of failure over time, especially after 2 years of repair.
There were some limitations of this systematic review. First, the methodology of the included studies, the concurrent lesions of the knee joint (mostly ACL tears and chondral injuries), operative methods (meniscus suturing, partial meniscectomies), follow-up period and study designs varied significantly. Second, the literature on this topic mostly includes retrospective level III and IV evidence studies. Third, a source of selection bias was also inherent, as only English-language studies were included. In addition, the included clinical studies only examined tobacco smoking and not smokeless tobacco or other forms of nicotine uptake. We supported a well-established tool to minimize the risk of bias; however, we realize that there are various scales used for the assessment of paper quality. In the majority of included studies, we observed an overall low risk of bias; however, some studies presented limitations with an unclear risk of bias, such as: random sequence generation in four papers (domain 1), allocation concealment in two papers (domain 1), blinding of participants and personnel in five papers (domain 2), incomplete outcome data in two papers (domain 4), selective reporting in five papers (domain 5) and various bias problems in four papers (domain 6).
Conclusions
Overall, smoking may have a negative impact on meniscus surgery. However, data regarding the impact of smoking on meniscus repair outcomes were conflicting. Nevertheless, MAT and meniscus repair performed in the presence of concurrent ligamentous injury, both being demanding surgical procedures, require the reduction of factors that may contribute to failure. Therefore, cessation of smoking in patients undergoing these procedures is highly advised.
Supplementary materials
This is linked to the online version of the paper at https://doi.org/10.1530/EOR-24-0097.
ICMJE Statement of Interest
The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the work.
Funding Statement
This work did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.
Author contribution statement
JZ and JP contributed to the conceptualization of the study. The methodology was developed by JZ, JP, MZ and PP. JZ and ŁŁ handled the software. JZ was responsible for validation. Formal analysis was performed by JZ, JP and MZ. The investigation was conducted by JZ, JP and MZ. Resources were provided by PP and ŁŁ. JZ, JP and PP curated the data. JZ and JP prepared the original draft. MZ, PP and ŁŁ contributed to writing, review and editing. Visualization was carried out by JZ and JP. ŁŁ and RL supervised the project. Project administration was managed by JZ. All authors have read and agreed to the published version of the manuscript.
References
- 1↑
Mordecai SC . Treatment of meniscal tears: an evidence based approach. World J Orthop 2014 5 233. (https://doi.org/10.5312/wjo.v5.i3.233)
- 2↑
Lamplot JD , Tompkins WP , Friedman MV , et al. Radiographic and clinical evidence for osteoarthritis at medium-term follow-up after arthroscopic partial medial meniscectomy. Cartilage 2019 13 588S–594S. (https://doi.org/10.1177/1947603519892315)
- 3↑
Bryceland JK , Powell AJ & Nunn T . Knee menisci: structure, function, and management of pathology. Cartilage 2017 8 99–104. (https://doi.org/10.1177/1947603516654945)
- 4↑
Doral MN , Bilge O , Huri G , et al. Modern treatment of meniscal tears. EFORT Open Rev 2018 3 260–268. (https://doi.org/10.1302/2058-5241.3.170067)
- 5↑
Weber J , Koch M , Angele P , et al. The role of meniscal repair for prevention of early onset of osteoarthritis. J Exp Orthop 2018 5 10. (https://doi.org/10.1186/s40634-018-0122-z)
- 6↑
Logerstedt DS , Scalzitti DA , Bennell KL , et al. Knee pain and mobility impairments: meniscal and articular cartilage lesions revision 2018: clinical practice guidelines linked to the international classification of functioning, disability and health from the orthopaedic section of the American physical therapy association. J Orthop Sports Phys Ther 2018 48 A1–A50. (https://doi.org/10.2519/jospt.2018.0301)
- 7↑
Saltzman BM , Cotter EJ , Wang KC , et al. Arthroscopically repaired bucket-handle meniscus tears: patient demographics, postoperative outcomes, and a comparison of success and failure cases. Cartilage 2020 11 77–87. (https://doi.org/10.1177/1947603518783473)
- 8↑
Xu C & Zhao J . A meta-analysis comparing meniscal repair with meniscectomy in the treatment of meniscal tears: the more meniscus, the better outcome? Knee Surg Sports Traumatol Arthrosc 2015 23 164–170. (https://doi.org/10.1007/s00167-013-2528-6)
- 9↑
Chahla J , Dean CS , Moatshe G , et al. Meniscal ramp lesions: anatomy, incidence, diagnosis, and treatment. Orthop J Sports Med 2016 4 232596711665781. (https://doi.org/10.1177/2325967116657815)
- 10↑
McDermott ID & Amis AA . The consequences of meniscectomy. J Bone Joint Surg Br 2006 88-B 1549–1556. (https://doi.org/10.1302/0301-620X.88B12.18140)
- 11↑
Snoeker BAM , Bakker EWP , Kegel CAT , et al. Risk factors for meniscal tears: a systematic review including meta-analysis. J Orthop Sports Phys Ther 2013 43 352–367. (https://doi.org/10.2519/jospt.2013.4295)
- 12↑
Crema MD , Guermazi A , Li L , et al. The association of prevalent medial meniscal pathology with cartilage loss in the medial tibiofemoral compartment over a 2-year period. Osteoarthritis Cartilage 2010 18 336–343. (https://doi.org/10.1016/j.joca.2009.11.003)
- 13↑
Xu B , Anderson DB , Park E-S , et al. The influence of smoking and alcohol on bone healing: Systematic review and meta-analysis of non-pathological fractures. EClinicalMedicine 2021 42 101179. (https://doi.org/10.1016/j.eclinm.2021.101179)
- 14↑
Kanneganti P , Harris JD , Brophy RH , et al. The effect of smoking on ligament and cartilage surgery in the knee: a systematic review. Am J Sports Med 2012 40 2872–2878. (https://doi.org/10.1177/0363546512458223)
- 15↑
Moses MJ , Wang DE , Weinberg M , et al. Clinical outcomes following surgically repaired bucket-handle meniscus tears. Phys Sportsmed 2017 45 329–336. (https://doi.org/10.1080/00913847.2017.1331688)
- 16↑
Domzalski M , Muszynski K , Mostowy M , et al. Smoking is associated with prolonged time of the return to daily and sport activities and decreased knee function after meniscus repair with outside-in technique: Retrospective cohort study. J Orthop Surg 2021 29 230949902110122. (https://doi.org/10.1177/23094990211012287)
- 17↑
Zabrzynski J , Gagat M , Paczesny L , et al. Correlation between smoking and neovascularization in biceps tendinopathy – a functional preoperative and immunohistochemical study. Ther Adv Chronic Dis 2020 11 2040622320956418. (https://doi.org/10.1177/2040622320956418)
- 18↑
Zabrzyński J , Paczesny Ł , Zabrzyńska A , et al. Smoking has No influence on outcomes after repair of the medial meniscus in the hypo and avascular zones – a pilot study. Int J Environ Res Public Health 2022 19 16127. (https://doi.org/10.3390/ijerph192316127)
- 19↑
Astur DC , Sbampato IN , Arliani GG , et al. Association of tobacco dependence, alcoholism and anabolic steroids with meniscoligamentous injuries. Acta Ortop Bras 2018 26 236–239. (https://doi.org/10.1590/1413-785220182604172699)
- 20↑
Haviv B , Rutenberg TF , Yaari L , et al. Which patients are less likely to improve after arthroscopic rotator cuff repair? Acta Orthop Traumatol Turc 2019 53 356–359. (https://doi.org/10.1016/j.aott.2019.02.003)
- 21↑
Laurendon L , Neri T , Farizon F , et al. Prognostic factors for all-inside meniscal repair. A 87-case series. Orthop Traumatol Surg Res 2017 103 1017–1020. (https://doi.org/10.1016/j.otsr.2017.05.025)
- 22↑
Beletsky A , Gowd AK , Liu JN , et al. Time to achievement of clinically significant outcomes after isolated arthroscopic partial meniscectomy: a multivariate analysis. Arthrosc Sports Med Rehabil 2020 2 e723–e733. (https://doi.org/10.1016/j.asmr.2020.06.002)
- 23↑
Buyukkuscu MO , Misir A , Hamrayev AJ , et al. Clinical and radiological outcomes following isolated vertical medial meniscal tear repair in patients over 40 years old. J Orthop Surg 2019 27 230949901983630. (https://doi.org/10.1177/2309499019836300)
- 24↑
Johnsen MB , Pihl K , Nissen N , et al. The association between smoking and knee osteoarthritis in a cohort of Danish patients undergoing knee arthroscopy. BMC Musculoskelet Disord 2019 20 141. (https://doi.org/10.1186/s12891-019-2518-z)
- 25↑
MOON Knee Group, Sullivan JP , Huston LJ , et al. Incidence and predictors of subsequent surgery after anterior cruciate ligament reconstruction: a 6-year follow-up study. Am J Sports Med 2020 48 2418–2428. (https://doi.org/10.1177/0363546520935867)
- 26↑
Blackwell R , Schmitt L , Flanigan DC , et al. Smoking increases the risk of early meniscus repair failure. Orthopaedic J Sports Med 2014 2 2325967114S0011. (https://doi.org/10.1177/2325967114S00115)
- 27↑
Uzun E , Misir A , Kizkapan TB , et al. Evaluation of midterm clinical and radiographic outcomes of arthroscopically repaired vertical longitudinal and bucket-handle lateral meniscal tears. Orthopaedic J Sports Med 2019 7 232596711984320. (https://doi.org/10.1177/2325967119843203)
- 28↑
Uzun E , Misir A , Kizkapan TB , et al. Factors affecting the outcomes of arthroscopically repaired traumatic vertical longitudinal medial meniscal tears. Orthopaedic J Sports Med 2017 5 232596711771244. (https://doi.org/10.1177/2325967117712448)
- 29↑
Franovic S , Kuhlmann NA , Pietroski A , et al. Preoperative patient-centric predictors of postoperative outcomes in patients undergoing arthroscopic meniscectomy. Arthroscopy 2020 37 964–971. (https://doi.org/10.1016/j.arthro.2020.10.042)
- 30↑
Haklar U , Donmez F , Basaran SH , et al. Results of arthroscopic repair of partial- or full-thickness longitudinal medial meniscal tears by single or double vertical sutures using the inside-out technique. Am J Sports Med 2013 41 596–602. (https://doi.org/10.1177/0363546512472046)
- 31↑
Cox CL , Huston LJ , Dunn WR , et al. Are articular cartilage lesions and meniscus tears predictive of IKDC, KOOS, and Marx activity level outcomes after anterior cruciate ligament reconstruction? A 6-year multicenter cohort study. Am J Sports Med 2014 42 1058–1067. (https://doi.org/10.1177/0363546514525910)
- 32↑
Basques BA , Gardner EC , Varthi AG , et al. Risk factors for short-term adverse events and readmission after arthroscopic meniscectomy: does age matter? Am J Sports Med 2015 43 169–175. (https://doi.org/10.1177/0363546514551923)
- 33↑
Kraus NR , Lowenstein NA , Garvey KD , et al. Smoking negatively effects patient-reported outcomes following arthroscopic partial meniscectomy. Arthrosc Sports Med Rehabil 2021 3 e323–e328. (https://doi.org/10.1016/j.asmr.2020.09.021)
- 34↑
Antosh IJ , Cameron KL , Marsh NA , et al. Likelihood of return to duty is low after meniscal allograft transplantation in an active-duty military population. Clin Orthop Relat Res 2020 478 722–730. (https://doi.org/10.1097/CORR.0000000000000915)
- 35↑
Zaffagnini S , Grassi A , Marcheggiani Muccioli GM , et al. Survivorship and clinical outcomes of 147 consecutive isolated or combined arthroscopic bone plug free meniscal allograft transplantation. Knee Surg Sports Traumatol Arthrosc 2016 24 1432–1439. (https://doi.org/10.1007/s00167-016-4035-z)
- 36↑
Waterman BR , Rensing N , Cameron KL , et al. Survivorship of meniscal allograft transplantation in an athletic patient population. Am J Sports Med 2016 44 1237–1242. (https://doi.org/10.1177/0363546515626184)
- 37↑
Abate M , Vanni D , Pantalone A , et al. Cigarette smoking and musculoskeletal disorders. Muscles Ligaments Tendons J 2013 03 63–69. (https://doi.org/10.11138/mltj/2013.3.2.063)
- 38↑
AL-Bashaireh AM , Haddad LG , Weaver M , et al. The effect of tobacco smoking on musculoskeletal health: a systematic review. J Environ Public Health 2018 2018 4184190. (https://doi.org/10.1155/2018/4184190)
- 39↑
Baumgarten KM , Gerlach D , Galatz LM , et al. Cigarette smoking increases the risk for rotator cuff tears. Clin Orthop Relat Res 2010 468 1534–1541. (https://doi.org/10.1007/s11999-009-0781-2)
- 40↑
Bishop JY , Santiago-Torres JE , Rimmke N , et al. Smoking predisposes to rotator cuff pathology and shoulder dysfunction: a systematic review. Arthroscopy 2015 31 1598–1605. (https://doi.org/10.1016/j.arthro.2015.01.026)
- 41↑
Sheung-tung H . Adverse effects of smoking on outcomes of orthopaedic surgery. J Orthopaedics Trauma Rehabil 2017 23 54–58. (https://doi.org/10.1016/j.jotr.2017.04.001)
- 42↑
Santiago-Torres J , Flanigan DC , Butler RB , et al. The effect of smoking on rotator cuff and glenoid labrum surgery: a systematic review. Am J Sports Med 2015 43 745–751. (https://doi.org/10.1177/0363546514533776)
- 43↑
Zabrzyński J , Gagat M , Łapaj Ł , et al. Relationship between long head of the biceps tendon histopathology and long-term functional results in smokers. A time to reevaluate the Bonar score? Ther Adv Chronic Dis 2021 12 204062232199026. (https://doi.org/10.1177/2040622321990262)
- 44↑
Zabrzyński J , Huri G , Gagat M , et al. The impact of smoking on clinical results following the rotator cuff and biceps tendon complex arthroscopic surgery. J Clin Med 2021 10 599. (https://doi.org/10.3390/jcm10040599)
- 45↑
Crawford MD , Hellwinkel JE , Aman Z , et al. Microvascular anatomy and intrinsic gene expression of menisci from young adults. Am J Sports Med 2020 48 3147–3153. (https://doi.org/10.1177/0363546520961555)
- 46↑
Barber-Westin SD & Noyes FR . Clinical healing rates of meniscus repairs of tears in the central-third (red-white) zone. Arthroscopy 2014 30 134–146. (https://doi.org/10.1016/j.arthro.2013.10.003)
- 47↑
Cinque ME , DePhillipo NN , Moatshe G , et al. Clinical outcomes of inside-out meniscal repair according to anatomic zone of the meniscal tear. Orthop J Sports Med 2019 7 232596711986080. (https://doi.org/10.1177/2325967119860806)
- 48↑
Yanbaeva DG , Dentener MA , Creutzberg EC , et al. Systemic effects of smoking. Chest 2007 131 1557–1566. (https://doi.org/10.1378/chest.06-2179)
- 49↑
Lee J & Cooke JP . Nicotine and pathological angiogenesis. Life Sci 2012 91 1058–1064. (https://doi.org/10.1016/j.lfs.2012.06.032)
- 50↑
Novikov DA , Swensen SJ , Buza JA , et al. The effect of smoking on ACL reconstruction: a systematic review. Phys Sportsmed 2016 44 335–341. (https://doi.org/10.1080/00913847.2016.1216239)
- 51↑
Michaud S-É , Ménard C , Guy L-G , et al. Inhibition of hypoxia-induced angiogenesis by cigarette smoke exposure: impairment of the HIF-1α/VEGF pathway. FASEB J 2003 17 1150–1152. (https://doi.org/10.1096/fj.02-0172fje)
- 52↑
Haugen IK , Magnusson K , Turkiewicz A , et al. The prevalence, incidence, and progression of hand osteoarthritis in relation to body mass index, smoking, and alcohol consumption. J Rheumatol 2017 44 1402–1409. (https://doi.org/10.3899/jrheum.170026)
- 53↑
Dean CS , Chahla J , Matheny LM , et al. Outcomes after biologically augmented isolated meniscal repair with marrow venting are comparable with those after meniscal repair with concomitant anterior cruciate ligament reconstruction. Am J Sports Med 2017 45 1341–1348. (https://doi.org/10.1177/0363546516686968)
- 54↑
Erdil M , Bilsel K , Sungur M , et al. Does obesity negatively affect the functional results of arthroscopic partial meniscectomy? A retrospective cohort study. Arthroscopy 2013 29 232–237. (https://doi.org/10.1016/j.arthro.2012.08.017)
- 55↑
Kim S , Bosque J , Meehan JP , et al. Increase in outpatient knee arthroscopy in the United States: a comparison of national surveys of ambulatory surgery, 1996 and 2006. J Bone Joint Surg Am 2011 93 994–1000. (https://doi.org/10.2106/JBJS.I.01618)
- 56↑
Sochacki KR , Varshneya K , Calcei JG , et al. Comparing meniscectomy and meniscal repair: a matched cohort analysis utilizing a national insurance database. Am J Sports Med 2020 48 2353–2359. (https://doi.org/10.1177/0363546520935453)
- 57↑
Cancienne JM , Gwathmey FW , Miller MD , et al. Tobacco use is associated with increased complications after anterior cruciate ligament reconstruction. Am J Sports Med 2016 44 99–104. (https://doi.org/10.1177/0363546515610505)
- 58↑
Widener DB , Wilson DJ , Galvin JW , et al. The prevalence of meniscal tears in young athletes undergoing revision anterior cruciate ligament reconstruction. Arthroscopy 2015 31 680–683. (https://doi.org/10.1016/j.arthro.2014.10.006)
- 59↑
Hutchinson ID , Moran CJ , Potter HG , et al. Restoration of the meniscus: form and function. Am J Sports Med 2014 42 987–998. (https://doi.org/10.1177/0363546513498503)
- 60↑
Verdonk PCM , Demurie A , Almqvist KF , et al. Transplantation of viable meniscal allograft: Survivorship analysis and clinical outcome of one hundred cases. J Bone Joint Surg Am 2005 87 715–724. (https://doi.org/10.2106/JBJS.C.01344)
- 61↑
Lee B-S , Kim H-J , Lee C-R , et al. Clinical outcomes of meniscal allograft transplantation with or without other procedures: a systematic review and meta-analysis. Am J Sports Med 2018 46 3047–3056. (https://doi.org/10.1177/0363546517726963)
- 62↑
ElAttar M , Dhollander A , Verdonk R , et al. Twenty-six years of meniscal allograft transplantation: is it still experimental? A meta-analysis of 44 trials. Knee Surg Sports Traumatol Arthrosc 2011 19 147–157. (https://doi.org/10.1007/s00167-010-1351-6)
- 63↑
Hergan D , Thut D , Sherman O , et al. Meniscal allograft transplantation. Arthroscopy 2011 27 101–112. (https://doi.org/10.1016/j.arthro.2010.05.019)
- 64↑
Matava MJ . Meniscal allograft transplantation: a systematic review. Clin Orthop Relat Res 2007 455 142–157. (https://doi.org/10.1097/BLO.0b013e318030c24e)
- 65↑
Rosso F , Bisicchia S , Bonasia DE , et al. Meniscal allograft transplantation: a systematic review. Am J Sports Med 2015 43 998–1007. (https://doi.org/10.1177/0363546514536021)
- 66↑
Hamilton C , Flanigan DC , Patel KH , et al. Meniscus repair failure risk does not differ by sex: a systematic review. J ISAKOS 2020 5 98–102. (https://doi.org/10.1136/jisakos-2019-000379)
- 67↑
Rothermel SD , Smuin D & Dhawan A . Are outcomes after meniscal repair age dependent? A systematic review. Arthroscopy 2018 34 979–987. (https://doi.org/10.1016/j.arthro.2017.08.287)
- 68↑
Everhart JS , Magnussen RA , Poland S , et al. Meniscus repair five-year results are influenced by patient pre-injury activity level but not age group. Knee 2020 27 157–164. (https://doi.org/10.1016/j.knee.2019.11.005)
- 69↑
Nepple JJ , Dunn WR & Wright RW . Meniscal repair outcomes at greater than five years: a systematic literature review and meta-analysis. J Bone Joint Surg Am 2012 94 2222–2227. (https://doi.org/10.2106/JBJS.K.01584)
