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Simple Medial Meniscus Posterior Horn Root Repair Using an All-Inside Meniscal Repair Device Combined with High Tibial Osteotomy to Maintain Joint-Space Width in a Patient with a Repairable Tear. Indian J Orthop 2020; 55:397-404. [PMID: 33927818 PMCID: PMC8046862 DOI: 10.1007/s43465-020-00234-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 08/13/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE To compare the radiological and clinical outcomes using simple medial meniscus posterior horn (MMPH) root repair using an all-inside meniscal repair device combined with high tibial osteotomy (HTO) and HTO alone. METHODS Between November 2013 and December 2016, patients treated for MMPH root tear along with HTO were enrolled. Based on the tear gap, the participants were divided into repairable (< 2 mm) and unrepairable (> 2 mm) categories. The participants in each group were divided into those amenable to simple MMPH root repair using an all-inside meniscal repair device and those that required no procedure for meniscus. Radiological parameters including mechanical femorotibial alignment (MA), posterior tibial slope (PTS) and medial joint-space width (JSW) were evaluated preoperatively and postoperatively at 2 years. For clinical evaluation, the WOMAC score was determined at the 2-year visit postoperatively. RESULTS A total of 81 knees including 48 repairable (group R) and 33 unrepairable (group I) knees were enrolled. A total of 43 knees underwent simple MMPH root repair using an all-inside meniscal repair device (subgroup r), whereas the other 38 knees did not (subgroup n). The MA, PTS, and their postoperative changes as well as the WOMAC scores showed no differences. However, the JSW in group Rr increased from 3.1 to 3.6 mm, but decreased from 3.7 to 3.4 in group Rn, which was a statistically significant difference. CONCLUSION Simple MMPH root repair using an all-inside meniscal repair device combined with HTO was more effective for the maintenance of JSW compared with HTO without a meniscal procedure in patients with repairable MMPH root tear and varus alignment. However, other options are needed for unrepairable MMPH root tear.
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102
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Helito CP, Melo LDP, Guimarães TM, Sobrado MF, Helito PVP, Pécora JR, Gobbi RG. Alternative Techniques for Lateral and Medial Posterior Root Meniscus Repair Without Special Instruments. Arthrosc Tech 2020; 9:e1017-e1025. [PMID: 32714813 PMCID: PMC7372599 DOI: 10.1016/j.eats.2020.03.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 03/29/2020] [Indexed: 02/03/2023] Open
Abstract
Improved understanding and treatment of posterior medial and lateral meniscus root tears have attracted increasing interest. These lesions significantly compromise meniscal function, which can result in an outcome resembling total meniscectomy, and are also a potential cause of knee instability. Despite facilitating repair procedures and reducing the operative time for these lesions, all-inside meniscal repair devices are not available in all circumstances or registered for use in all countries worldwide. Furthermore, all-inside arthroscopic devices can be expensive. Therefore, low-cost alternatives for the treatment of these lesions must be identified. We present 2 efficient and safe techniques: an outside-in technique for repairing medial meniscus root tears and a technique using a simple needle inserted through the transtibial tunnel for lateral meniscal root repairs, neither of which requires the use of specific instruments, thus enabling appropriate treatment of posterior medial and lateral meniscus root tears.
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Affiliation(s)
- Camilo Partezani Helito
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil,Hospital Sírio Libanês, SP, Brazil
| | - Lucas da Ponte Melo
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
| | - Tales Mollica Guimarães
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
| | - Marcel Faraco Sobrado
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil,Hospital Sírio Libanês, SP, Brazil,Address correspondence to Marcel Faraco Sobrado, M.D., Rua Dr. Ovídio Pires de Campos, 333, Cerqueira Cesar, São Paulo, SP, CEP: 05403-010, Brazil.
| | - Paulo Victor Partezani Helito
- Hospital Sírio Libanês, SP, Brazil,Grupo de radiologia musculoesqueléticas, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - José Ricardo Pécora
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
| | - Riccardo Gomes Gobbi
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
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103
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Abstract
Meniscal root tears are an increasingly recognized injury leading to notable functional limitations, potential rapid cartilage deterioration of the affected compartment, and subsequent risk of total knee arthroplasty if left untreated. Repair of these tears is advised when articular cartilage remains intact because both medial and lateral meniscus root repairs have demonstrated favorable results. Recent literature demonstrates decreased rates of osteoarthritis and arthroplasty after medial meniscus root repair compared with partial meniscectomy and nonsurgical management. The transtibial pull-out repair technique is most commonly used and provides a biomechanically strong suture construct with standard and familiar knee arthroscopy portals. Furthermore, repair has recently been shown to be economically effective by decreasing overall societal healthcare costs when compared with more conservative management strategies. This review outlines the evaluation, treatment, and documented outcomes of meniscal root repair, which is imperative to the preservation of knee function and maintaining quality of life.
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104
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Driban JB, Harkey MS, Barbe MF, Ward RJ, MacKay JW, Davis JE, Lu B, Price LL, Eaton CB, Lo GH, McAlindon TE. Risk factors and the natural history of accelerated knee osteoarthritis: a narrative review. BMC Musculoskelet Disord 2020; 21:332. [PMID: 32471412 PMCID: PMC7260785 DOI: 10.1186/s12891-020-03367-2] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 05/25/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Osteoarthritis is generally a slowly progressive disorder. However, at least 1 in 7 people with incident knee osteoarthritis develop an abrupt progression to advanced-stage radiographic disease, many within 12 months. We summarize what is known - primarily based on findings from the Osteoarthritis Initiative - about the risk factors and natural history of accelerated knee osteoarthritis (AKOA) - defined as a transition from no radiographic knee osteoarthritis to advanced-stage disease < 4 years - and put these findings in context with typical osteoarthritis (slowly progressing disease), aging, prior case reports/series, and relevant animal models. Risk factors in the 2 to 4 years before radiographic manifestation of AKOA (onset) include older age, higher body mass index, altered joint alignment, contralateral osteoarthritis, greater pre-radiographic disease burden (structural, symptoms, and function), or low fasting glucose. One to 2 years before AKOA onset people often exhibit rapid articular cartilage loss, larger bone marrow lesions and effusion-synovitis, more meniscal pathology, slower chair-stand or walking pace, and increased global impact of arthritis than adults with typical knee osteoarthritis. Increased joint symptoms predispose a person to new joint trauma, which for someone who develops AKOA is often characterized by a destabilizing meniscal tear (e.g., radial or root tear). One in 7 people with AKOA onset subsequently receive a knee replacement during a 9-year period. The median time from any increase in radiographic severity to knee replacement is only 2.3 years. Despite some similarities, AKOA is different than other rapidly progressive arthropathies and collapsing these phenomena together or extracting results from one type of osteoarthritis to another should be avoided until further research comparing these types of osteoarthritis is conducted. Animal models that induce meniscal damage in the presence of other risk factors or create an incongruent distribution of loading on joints create an accelerated form of osteoarthritis compared to other models and may offer insights into AKOA. CONCLUSION Accelerated knee osteoarthritis is unique from typical knee osteoarthritis. The incidence of AKOA in the Osteoarthritis Initiative and Chingford Study is substantial. AKOA needs to be taken into account and studied in epidemiologic studies and clinical trials.
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Affiliation(s)
- Jeffrey B Driban
- Division of Rheumatology, Allergy & Immunology, Tufts Medical Center, 800 Washington Street, Box #406, Boston, MA, 02111, USA.
| | - Matthew S Harkey
- Division of Rheumatology, Allergy & Immunology, Tufts Medical Center, 800 Washington Street, Box #406, Boston, MA, 02111, USA.,Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Mary F Barbe
- Department of Anatomy and Cell Biology, Temple University School of Medicine, 3500 North Broad Street, Philadelphia, PA, 19140, USA
| | - Robert J Ward
- Department of Radiology, Tufts Medical Center, 800 Washington Street, Boston, MA, 02111, USA
| | - James W MacKay
- Department of Radiology, University of Cambridge School of Clinical Medicine, Box 218, Level 5, Addenbrooke's Hospital, Cambridge, CB2 0QQ, UK.,Department of Radiology, Norwich Medical School, University of East Anglia, Research Park NR4 7U1, Norwich, UK
| | - Julie E Davis
- Milken Institute of Public Health, The George Washington University, 950 New Hampshire Ave NW, Washington, DC, 20052, USA
| | - Bing Lu
- Brigham and Women's Hospital and Harvard Medical School, 75 Francis Street PBB-B3, Boston, MA, 02115, USA
| | - Lori Lyn Price
- The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington Street, Box #63, Boston, MA, 02111, USA.,Tufts Clinical and Translational Science Institute, Tufts University, 800 Washington Street, Box #63, Boston, MA, 02111, USA
| | - Charles B Eaton
- Center for Primary Care and Prevention, Alpert Medical School of Brown University, 111 Brewster Street, Pawtucket, RI, 02860, USA
| | - Grace H Lo
- Medical Care Line and Research Care Line, Houston Health Services Research and Development (HSR&D) Center of Excellence Michael E. DeBakey VAMC, Houston, TX, USA.,Section of Immunology, Allergy, and Rheumatology, Baylor College of Medicine, Houston, TX. 1 Baylor Plaza, BCM-285, Houston, TX, 77030, USA
| | - Timothy E McAlindon
- Division of Rheumatology, Allergy & Immunology, Tufts Medical Center, 800 Washington Street, Box #406, Boston, MA, 02111, USA
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Pareek A, Parkes CW, Bernard C, Camp CL, Saris DBF, Stuart MJ, Krych AJ. Spontaneous Osteonecrosis/Subchondral Insufficiency Fractures of the Knee: High Rates of Conversion to Surgical Treatment and Arthroplasty. J Bone Joint Surg Am 2020; 102:821-829. [PMID: 32379123 DOI: 10.2106/jbjs.19.00381] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Spontaneous osteonecrosis of the knee has recently been termed subchondral insufficiency fracture of the knee (SIFK) to appropriately recognize the etiology of mechanical overloading of the subchondral bone. The purpose of this study was to assess clinical outcomes of SIFK based on progression to surgical treatment and arthroplasty, and to evaluate the risk factors that increase the progression to arthroplasty. METHODS A retrospective review was performed on patients with a diagnosis of SIFK, as confirmed with use of magnetic resonance images (MRIs). Baseline and final radiographs were reviewed. Baseline MRIs were also reviewed for injury characteristics. Failure was defined as progression to surgical treatment or conversion to arthroplasty. RESULTS Two hundred twenty-three patients (71% female) with a mean age of 65.1 years were included. SIFK affected 154 femora (69%) and 123 tibiae (55%), with medial compartment involvement in 198 knees (89%); 74% of medial menisci had root or radial tears, with a mean extrusion of 3.6 mm. Varus malalignment was identified in 54 (69%) of 78 knees. Seventy-six (34%) of all patients progressed to surgical intervention at 2.7 years, and 66 (30%) underwent arthroplasty at 3.0 years. The rates of conversion to surgical intervention and arthroplasty increased to 47% (37 of 79; p = 0.04) and 37% (29 of 79; p = 0.09), respectively, in patients with >5 years of follow-up. The 10-year survival rate free of arthroplasty for patients with SIFK on the medial femoral condyle (p < 0.01), SIFK on the medial tibial plateau (p < 0.01), medial meniscal extrusion (p = 0.01), varus alignment (p = 0.02), and older age (per year older; p = 0.003) was significantly higher than the survival rates of those without each respective condition. CONCLUSIONS Subchondral insufficiency fractures predominantly involve the medial compartment of the knee and commonly present with medial meniscal root and radial tears. Approximately one-third of patients progressed to total knee arthroplasty. Baseline arthritis, older age, location of the insufficiency fracture on both the medial femoral condyle and medial tibial plateau, meniscal extrusion, and varus malalignment were all associated with progression to arthroplasty. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Ayoosh Pareek
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota
| | - Chad W Parkes
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota
| | - Christopher Bernard
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota
| | - Christopher L Camp
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota
| | - Daniel B F Saris
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota
| | - Michael J Stuart
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota
| | - Aaron J Krych
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota
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106
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Stein JM, Yayac M, Conte EJ, Hornstein J. Treatment Outcomes of Meniscal Root Tears: A Systematic Review. Arthrosc Sports Med Rehabil 2020; 2:e251-e261. [PMID: 32548591 PMCID: PMC7283958 DOI: 10.1016/j.asmr.2020.02.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 02/11/2020] [Indexed: 12/01/2022] Open
Abstract
Purpose To report changes in outcomes for these 3 treatment options for meniscal root tears. Methods We systematically searched databases including PubMed, SCOPUS, and ScienceDirect for relevant articles. Criteria from the National Heart, Lung, and Blood Institute was used for a quality assessment of the included studies. A meta-analysis was performed to analyze changes in outcomes for meniscal repair. Results Nineteen studies, 12 level III and 7 level IV, were included in this systematic review, with a total of 1086 patients. Conversion to total knee arthroplasty (TKA) following partial meniscectomy ranged from 11% to 54%, 31% to 35% for nonoperative, conservative treatment, and 0% to 1% for meniscal repair. Studies comparing repair with either meniscectomy or conservative treatment found greater improvement and slower progression of Kellgren–Lawrence grade with meniscal repair. A meta-analysis of the studies included in the systematic review using forest plots showed repair to have the greatest mean difference for functional outcomes (International Knee Documentation Committee and Lysholm Activity Scale) and the lowest change in follow-up joint space. Conclusions In patients who experience meniscal root tears, meniscal repair may provide the greatest improvement in function and lowest risk of conversion to TKA when compared with partial meniscectomy or conservative methods. Partial meniscectomy appears to provide no benefit over conservative treatment, placing patients at a high risk of requiring TKA in the near future. However, future high-quality studies—both comparative studies and randomized trials—are needed to draw further conclusions and better impact treatment decision-making. Level of Evidence Level IV, systematic review of level III and level IV evidence
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Affiliation(s)
- Jonah M Stein
- Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A
| | - Michael Yayac
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A
| | - Evan J Conte
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A
| | - Joshua Hornstein
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A
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107
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Krych AJ, Bernard CD, Kennedy NI, Tagliero AJ, Camp CL, Levy BA, Stuart MJ. Medial Versus Lateral Meniscus Root Tears: Is There a Difference in Injury Presentation, Treatment Decisions, and Surgical Repair Outcomes? Arthroscopy 2020; 36:1135-1141. [PMID: 31973989 DOI: 10.1016/j.arthro.2019.11.098] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 10/30/2019] [Accepted: 11/04/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine (1) the demographic characteristics as well as radiographic findings of medial versus lateral meniscal root tears at time of presentation, (2) treatment decisions and clinical outcomes of patients undergoing medial versus lateral root repair, and (3) risk factors for worse clinical and radiographic outcomes. METHODS A retrospective review was performed to identify patients with symptomatic, medial, or lateral meniscus posterior root tears with a minimum 2-year follow-up. Radiographs were graded using Kellgren-Lawrence scores. Subanalysis was performed on 62 patients who underwent root repair. Tegner, Lysholm, International Knee Documentation Committee scores, and progression to arthroplasty were analyzed in the repair groups. Patient demographics, radiographic findings, and clinical outcomes were compared between medial meniscus posterior horn root tear (MMRT) and lateral meniscus root repair (LMRT). RESULTS Of the 141 root tears, 109 were MMRTs, 30 were LMRTs, and 2 patients had both. At the time of injury, patients with MMRTs had a significantly higher age (MMRT = 51.4 vs LMRT=24.6, P < .0001), body mass index (MMRT = 32.1 vs LMRT 25.8, P < .0001), Kellgren-Lawrence score (MMRT = 1.3 vs LMRT=0.6, P < .0001), and higher rate of major meniscal extrusion (MMRT = 72% vs LMRT = 20%, P < .0001). Of the 30 LMRT, 30/30 (100.0%) were treated with meniscal repair. With MMRT, 52/109 (48%) were treated nonoperatively, 27/109 (25%) with partial meniscectomy, and 30/109 (27%) with meniscal repair. Sixty-two patients underwent meniscus root repair with an average 41-month follow-up. LMRT had significantly increased International Knee Documentation Committee (LMRT = 89.5, MMRT = 80.4, P = .02) and Tegner scores (LMRT = 6.5, MMRT = 5.1, P < .05) compared with MMRT. CONCLUSIONS Compared with MMRTs, LMRTs occur in younger male patients with lower body mass index, less cartilage degeneration, less extrusion on magnetic resonance imaging, and more commonly with a ligament injury. Although good to excellent clinical outcomes were attained in select patients for both medial and lateral meniscus root repair, LMRTs may have better results after repair, suggesting that differences in injury and patient characteristics may contribute to differences in these outcomes. LEVEL OF EVIDENCE Retrospective comparative study, Level III.
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Affiliation(s)
- Aaron J Krych
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A..
| | - Christopher D Bernard
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Nicholas I Kennedy
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Adam J Tagliero
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Christopher L Camp
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Bruce A Levy
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Michael J Stuart
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
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108
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Dragoo JL, Konopka JA, Guzman RA, Segovia N, Kandil A, Pappas GP. Outcomes of Arthroscopic All-Inside Repair Versus Observation in Older Patients With Meniscus Root Tears. Am J Sports Med 2020; 48:1127-1133. [PMID: 32182103 DOI: 10.1177/0363546520909828] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Meniscus root tears lead to de-tensioning of the meniscus, increased contact forces, and cartilage damage. Management of older patients with root tears is controversial and the efficacy of different treatment options is unclear. PURPOSE To compare the clinical outcomes of patients with moderate knee osteoarthritis who underwent an all-inside meniscus root repair technique versus nonoperative management for either medial or lateral meniscus root tears. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS Patients with a diagnosed posterior meniscus root tear who underwent arthroscopic repair (AR: 30 knees) or nonoperative treatment with observation (O: 18 knees) were followed for a minimum of 2 years (mean follow-up, 4.4 years). The arthroscopic repair included all-inside sutures to reduce the root back to its remnant (reduction sutures), thereby re-tensioning the meniscus, and 1 mattress suture to strengthen the repair by reapproximating the construct to the posterior capsule. The data collected included the Knee injury and Osteoarthritis Outcome Score (KOOS), Lysholm, Tegner, and Veterans RAND 12-Item Health Survey (VR-12) Physical Component Summary (PCS) and Mental Component Summary (MCS) scores and conversion to total knee arthroplasty (TKA). RESULTS Medial meniscus root tears comprised 80.0% of the AR group and 77.8% of the O group. The average Kellgren-Lawrence grade was 2 in both groups. The baseline scores for the KOOS Symptoms subscale were lower for AR (50.2 ± 19.3) than for O (66.5 ± 16.1) (P = .003), as were the KOOS Knee-Related Quality of Life scores (AR, 26.7 ± 16.1; O, 39.6 ± 22.1) (P = .046). No differences were found between groups for the absolute values at follow-up except that follow-up Tegner scores were lower in the O group than in the AR group (P = .004). Significant improvements were seen in the AR group from baseline to ultimate follow-up in average KOOS subscale scores (P < .001), Lysholm scores (P < .001), Tegner scores (P = .0002), and VR-12 PCS scores (P < .001), whereas the O group had a significant improvement only in average KOOS Pain (P = .003), KOOS Function in Daily Living (P = .006), and VR-12 PCS (P = .038) scores. Compared with the O group, the AR group had a significantly larger improvement from baseline to follow-up in average KOOS Pain (P = .009), KOOS Symptoms (P = .029), and Lysholm scores (P = .016). During follow-up, 3.3% of the AR group underwent a TKA compared with 33.3% of the O group (P = .008). The hazard ratio of TKA conversion was 93.2% lower for the AR group compared with the O group (P = .013). CONCLUSION All-inside medial or lateral meniscus root repair showed improved functional outcomes and decreased TKA conversion rates compared with nonoperative treatment and may be considered as a treatment option for the management of meniscus root tears in older patients with moderate osteoarthritis.
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Affiliation(s)
- Jason L Dragoo
- Department of Orthopedic Surgery, University of Colorado, Englewood, Colorado, USA
| | - Jaclyn A Konopka
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
| | - Roberto A Guzman
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
| | - Nicole Segovia
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
| | - Abdurrahman Kandil
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
| | - George P Pappas
- South Carolina Sports Medicine & Orthopaedic Center, North Charleston, South Carolina, USA
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109
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Steineman BD, LaPrade RF, Haut Donahue TL. Nonanatomic Placement of Posteromedial Meniscal Root Repairs: A Finite Element Study. J Biomech Eng 2020; 142:1072350. [PMID: 31901167 DOI: 10.1115/1.4045893] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Indexed: 11/08/2022]
Abstract
Nonanatomic placement of posteromedial meniscal root repairs alters knee mechanics; however, little is known about how the position and magnitude of misplacement affect knee mechanics. Finite element knee models were developed to assess changes in cartilage and meniscus mechanics for anatomic and various nonanatomic repairs with respect to intact. In total, 25 different repair locations were assessed at loads of 500 N and 1000 N. The two-simple-suture method was represented within the models to simulate posteromedial meniscal root repairs. Anatomic repairs nearly restored total contact area; however, meniscal hoop stress decreased, meniscal extrusion increased, and cartilage-cartilage contact area increased. Repairs positioned further posterior altered knee mechanics the most and repairs positioned further anterior restored knee mechanics for posteromedial root repairs. Despite this, repair tension increased with further anterior placement. Anterior placement of repairs results in more restorative contact mechanics than posterior placement; however, anterior placement also increased the risk of suture cut-out or failure following repairs. Anatomic placement of repairs remains the best option because of the risks involved with anterior placement; however, suture methods need to be improved to better restore the strength of repairs to that of the native insertion. Proper placement of repairs is important to consider with meniscal root repairs because misplacement may negatively affect cartilage and meniscus mechanics in patients.
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Affiliation(s)
- Brett D Steineman
- Department of Biomechanics, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021
| | | | - Tammy L Haut Donahue
- Department of Biomedical Engineering, University of Massachusetts, Amherst, MA 01003
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Lee JK, Jung M, Yang JH, Song SY, Shin YS, Cha M, Jung D, Seo YJ. Repair versus nonrepair of medial meniscus posterior root tear: A systematic review of patients' selection criteria, including clinical and radiographic outcomes. Medicine (Baltimore) 2020; 99:e19499. [PMID: 32150112 PMCID: PMC7478593 DOI: 10.1097/md.0000000000019499] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The general consensus regarding a rational choice among various treatment strategies for medial meniscus posterior root tears (MMPRTs) has yet to be clearly established. The purpose of this systematic review was to analyze patient selection criteria based on index arthrosis, as well as clinical and radiological outcomes after repair or nonrepair treatment in patients with MMPRTs. METHODS A systematic electronic search was performed with established medical databases. Data from the selected studies which were assessed using the modified Coleman methodology score were analyzed in terms of index arthrosis and degree of lower limb alignment, functional and radiologic outcomes after meniscus repair, partial meniscectomy, and conservative treatment. RESULTS In total, 17 studies and 655 patients (665 cases) were enrolled in this study, of which 42% (279 cases) underwent MMPRT repair and 58% (386 cases) were treated using a nonrepair strategy. The mean age and the mean follow-up period were 54.7 years and 32.5 months in the repair group, respectively, and 57.0 years and 49.3 months in the nonrepair group, respectively. Based on the clinical data available in this study, most of the MMPRT repairs were performed in patients with mild arthrosis, mild varus alignment, and mild chondral injury. Although data were limited, the percentage of patients with mild chondral injury was only 40% in the nonrepair group, implying that the nonrepair group may have more advanced arthrosis at the baseline. Based on the available Lysholm score across the studies, good functional outcomes were obtained in the repair group, whereas the results of the nonrepair treatment exhibited fair functional outcomes that were somewhat heterogenous. The radiologic outcomes of the mean 5 years' follow-up study showed that arthritic change could not be prevented by either nonrepair or repair treatment. CONCLUSIONS In general, MMPRT repair led to significant improvement in clinical outcomes. On the contrary, the nonrepair group also showed symptomatic relief in some selected cases, despite the somewhat heterogenous results. Given the subgroup analysis for the functional results reported in this review, strict patient selection is important to obtain satisfactory clinical outcomes, regardless of the treatment option selected.
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Affiliation(s)
- Jin Kyu Lee
- Department of Orthopaedic Surgery, Hanyang University College of Medicine
| | - Min Jung
- Arthroscopy and Joint Research Institute, Department of Orthopaedic Surgery, Yonsei University College of Medicine, Seoul
| | - Jae Hyuk Yang
- Department of Orthopaedic Surgery, Hanyang University Guri Hospital
| | - Si Young Song
- Department of Orthopaedic Surgery, Hallym University Dongtan Sacred Heart Hospital, Gyeonggi-do
| | - Young-Soo Shin
- Department of Orthopaedic Surgery, Hallym University Chuncheon Sacred Heart Hospital, Gangwon-do, Republic of Korea
| | - Myoungsoo Cha
- Department of Orthopaedic Surgery, Hallym University Dongtan Sacred Heart Hospital, Gyeonggi-do
| | - Dawoon Jung
- Department of Orthopaedic Surgery, Hallym University Dongtan Sacred Heart Hospital, Gyeonggi-do
| | - Young-Jin Seo
- Department of Orthopaedic Surgery, Hallym University Dongtan Sacred Heart Hospital, Gyeonggi-do
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111
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Abstract
Meniscus root tears biomechanically disrupt normal joint loading and lead to joint overload with the possible development of spontaneous osteonecrosis of the knee and early-onset osteoarthritis. Proper identification and treatment of meniscal root tears has been proven to restore joint loading and improve patient outcomes.
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Affiliation(s)
| | - Marc Strauss
- Department of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Robert F LaPrade
- Twin Cities Orthopedics, 4060 West 65th Street, Edina, MN 55435, USA.
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112
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Lansdown DA, Feeley BT. Editorial Commentary: Are We Over-treating Meniscal Root Tears? Arthroscopy 2020; 36:533-534. [PMID: 32014182 DOI: 10.1016/j.arthro.2019.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 11/01/2019] [Indexed: 02/02/2023]
Abstract
Meniscal root tears function as a complete meniscectomy, with loss of hoop stress due to the detachment of the meniscus. Root tears have been increasingly recognized recently with improvements in diagnostic imaging and the understanding of meniscal biomechanics. Patients have a high rate of progression of osteoarthritis and subsequent knee replacement after a meniscal root tear. Recent advances in repair techniques, arthroscopic instrumentation, and biological augmentation strategies continue to offer surgeons ways to manage historically "irreparable" meniscal tears. Root repair clinical outcomes are generally favorable, although patients may still experience progressive degenerative changes.
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113
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Bernard CD, Kennedy NI, Tagliero AJ, Camp CL, Saris DBF, Levy BA, Stuart MJ, Krych AJ. Medial Meniscus Posterior Root Tear Treatment: A Matched Cohort Comparison of Nonoperative Management, Partial Meniscectomy, and Repair. Am J Sports Med 2020; 48:128-132. [PMID: 31765234 DOI: 10.1177/0363546519888212] [Citation(s) in RCA: 90] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND There are limited data comparing the outcomes of similarly matched patients with a medial meniscus posterior root tear (MMPRT) treated with nonoperative management, partial meniscectomy, or repair. PURPOSE/HYPOTHESIS The purpose was to compare treatment failure, clinical outcome scores, and radiographic findings for a matched cohort of patients who underwent either nonoperative management, partial meniscectomy, or transtibial pull-through repair for an MMPRT. We hypothesized that patients who underwent meniscus root repair will have lower rates of progression to arthroplasty than patients who were treated with nonoperative management or partial meniscectomy. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Patients who underwent transtibial medial meniscus posterior horn root repair were matched by meniscal laterality, age, sex, and Kellgren-Lawrence (K-L) grades to patients treated nonoperatively or with a partial meniscectomy. Progression to arthroplasty rates, International Knee Documentation Committee and Tegner scores, and radiographic outcomes were analyzed between groups. RESULTS Forty-five patients were included in this study (15 nonoperative, 15 partial meniscectomy, 15 root repair). Progression to arthroplasty demonstrated significant differences among treatment groups at a mean of 74 months (nonoperative, 4/15; partial meniscectomy, 9/15; meniscal repair, 0/15; P = .0003). The meniscus root repair group had significantly less arthritic progression, as measured by change in K-L grade from pre- to postoperatively (nonoperative, 1.0; partial meniscectomy, 1.1; meniscal repair, 0.1; P = .001). CONCLUSION Meniscus root repair leads to significantly less arthritis progression and subsequent knee arthroplasty compared with nonoperative management and partial meniscectomy in a matched cohort based on patient characteristics.
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Affiliation(s)
| | - Nicholas I Kennedy
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Adam J Tagliero
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Christopher L Camp
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Daniel B F Saris
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Bruce A Levy
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael J Stuart
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Aaron J Krych
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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114
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Everhart JS, Magnussen RA, Poland S, DiBartola AC, Blackwell R, Kim W, Kaeding CC, Flanigan DC. Meniscus repair five-year results are influenced by patient pre-injury activity level but not age group. Knee 2020; 27:157-164. [PMID: 31806508 DOI: 10.1016/j.knee.2019.11.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 10/09/2019] [Accepted: 11/10/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND The purpose of the study is to determine whether patient age group (≥40 years versus <40 years) and pre-injury activity level are independently predictive of symptomatic failure rates and patient-reported outcomes after meniscus repair with or without concomitant anterior cruciate ligament reconstruction (ACLR) at mean five years of follow-up. METHODS Two hundred and twenty-five patients (n = 61, age ≥40 years; n = 164, age <40; 11% sedentary, 63% recreational athletes, 26% competitive athletes; 72% cutting-pivoting sports, 28% non-cutting or non-pivoting sports) who underwent meniscal repair were assessed for symptomatic failure and subjective knee function at mean 5.4 years of follow-up. Symptoms were assessed with Knee Osteoarthritis Outcome Score (KOOS) and International Knee Documentation Committee Subjective (IKDC-S) scores. RESULTS Repair failure was 20% overall with no association with age group (<40 vs. ≥40 years) or level of activity. When compared with sedentary patients, IKDC-S scores were not associated with age group but were lower among sedentary patients (mean: 59.6, SE: 4.9) compared with recreational (mean: 78.9, SE: 2.5; p = 0.007) or competitive athletes (mean: 79.2, SE: 3.8; p = 0.02). KOOS-ADL scores were independently associated with age and were higher among patients <40 years. KOOS-pain, KOOS-sport, or KOOS-QOL were not associated with age group. Sedentary status was independently associated with lower KOOS scores for all sub-scores. CONCLUSIONS Meniscal repair failure rates and patient-reported outcomes do not differ substantially between older or younger patients of similar pre-injury activity level. Sedentary patients regardless of age have worse self-reported subjective outcomes compared with active patients.
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Affiliation(s)
- Joshua S Everhart
- The Ohio State University Wexner Medical Center, United States of America
| | - Robert A Magnussen
- The Ohio State University Wexner Medical Center, United States of America
| | - Sarah Poland
- The Ohio State University Wexner Medical Center, United States of America
| | - Alex C DiBartola
- The Ohio State University Wexner Medical Center, United States of America
| | - Ryan Blackwell
- The Ohio State University Wexner Medical Center, United States of America
| | - Walter Kim
- The Ohio State University Wexner Medical Center, United States of America
| | | | - David C Flanigan
- The Ohio State University Wexner Medical Center, United States of America.
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115
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Athiviraham A. Editorial Commentary: Failure With Continuity: Redefining Healing With Meniscal Root Repair. Arthroscopy 2019; 35:3087-3089. [PMID: 31699260 DOI: 10.1016/j.arthro.2019.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 07/06/2019] [Indexed: 02/02/2023]
Abstract
The importance of the medial meniscus posterior root for preserving knee joint kinematics, joint contact pressures, and articular cartilage integrity is well recognized. Medial meniscus root repair generally is associated with favorable clinical outcomes and radiographic changes compared with conservative treatment or subtotal meniscectomy; however, second-look arthroscopy often reveals some laxity at the repair site. Even in this latter situation of "failure with continuity" of the meniscus root repair, there may be benefit in delaying progression of radiographic degeneration changes. Given that the displacement of the repair often occurs with premature rehabilitative loading, it is important to delay the progression of weight-bearing until adequate healing has occurred.
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Cruz AI, Gao B, Ganley TJ, Pennock AT, Shea KG, Beck JJ, Ellis HB. Trends in Concomitant Meniscal Surgery Among Pediatric Patients Undergoing ACL Reconstruction: An Analysis of ABOS Part II Candidates From 2000 to 2016. Orthop J Sports Med 2019; 7:2325967119869848. [PMID: 31579682 PMCID: PMC6759752 DOI: 10.1177/2325967119869848] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Rates of anterior cruciate ligament (ACL) reconstruction among pediatric and adolescent patients are increasing. Limited knowledge exists about population-level rates of concomitant meniscal surgery in this age group. Purpose/Hypothesis This study sought to examine trends in concomitant meniscal procedures and describe short-term complications in pediatric and adolescent patients undergoing ACL reconstruction. We hypothesized that overall meniscal surgery rates are increasing and that the likelihood of performing meniscal repair or meniscectomy is associated with patient- and surgeon-specific factors. Study Design Cross-sectional study. Methods We queried ACL procedures in patients younger than 19 years reported by American Board of Orthopaedic Surgery (ABOS) part II examination candidates from 2000 to 2016. Regression models examined associations between patient and surgeon characteristics, year of surgery, follow-up time, meniscal procedure type, and number and type of complications. Results A total of 9766 cases were identified. Females represented 46% (n = 4468) of included cases. Mean patient age was 16.1 years (SD, 1.62 years; range, 0-18 years). The rate of concomitant ACL-meniscal procedures increased from the years 2000 to 2016 (49%-60%; P = .005). Surgeons with sports medicine (+7.0%) or pediatric orthopaedic fellowship (+6.6%) training had a higher likelihood of reporting a concomitant ACL-meniscal procedure (P = .003 and .006, respectively). Sports medicine-trained surgeons were more likely to perform meniscal repair compared with meniscectomy (+3.0%; P = .016). Younger patient age was associated with increased likelihood of undergoing meniscal repair compared with meniscectomy. Overall reported complication rate was 12.8%. Notable reported complications included infection (1.61%), arthrofibrosis (1.14%), and deep venous thrombosis or pulmonary embolism (0.11%). Sports medicine and pediatric orthopaedic fellowship training was associated with higher rates of reporting postoperative stiffness and/or arthrofibrosis. Conclusion Among ABOS part II candidates, concomitant ACL-meniscal surgery has become more common than isolated ACL procedures. Procedures involving sports medicine fellowship-trained surgeons and younger patients were associated with increased rates of meniscal repair compared with meniscectomy. Pediatric orthopaedic and sports medicine training was associated with a greater likelihood of being involved in a concomitant ACL-meniscal procedure of any kind, and surgeons with such training also reported a higher incidence of postoperative stiffness and/or arthrofibrosis in patients.
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Affiliation(s)
- Aristides I Cruz
- Department of Orthopaedic Surgery, Warren Alpert Medical School at Brown University, Hasbro Children's Hospital, Providence, Rhode Island, USA
| | - Burke Gao
- Warren Alpert Medical School at Brown University, Providence, Rhode Island, USA
| | - Theodore J Ganley
- Division of Orthopaedic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Andrew T Pennock
- Pediatric Orthopedics & Scoliosis Center, Rady Children's Hospital, San Diego, California, USA
| | - Kevin G Shea
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
| | - Jennifer J Beck
- Orthopaedic Institute for Children, University of California, Los Angeles, Los Angeles, California, USA
| | - Henry B Ellis
- Department of Orthopaedic Surgery, University of Texas Southwestern, Texas Scottish Rite Hospital for Children and Children's Medical Center, Dallas, Texas, USA
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117
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Ikuta F, Takahashi K, Hashimoto S, Mochizuki Y, Yuzawa Y, Inanami H, Takai S. Effect of physical therapy on early knee osteoarthritis with medial meniscal posterior tear assessed by MRI T2 mapping and 3D-to-2D registration technique: A prospective intervention study. Mod Rheumatol 2019; 30:738-747. [PMID: 31322024 DOI: 10.1080/14397595.2019.1646193] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Objectives: The purpose of this study was to verify that exercise aimed at improving knee kinematics in early-stage knee osteoarthritis (OA) patients with medial meniscus posterior root tears (MMPRTs) reduces knee adduction angle during gait and prevents rapid cartilage degeneration in the medial compartment of the knee.Methods: Subjects were randomly assigned to an adapting alignment exercise (AAE) group, with the goal of improving knee kinematics, and a muscle training and exercise (MTE) group. Before the start of the six-month intervention and following its completion, we performed an analysis of knee kinematics during gait using a 3D-to-2D registration technique and identified the area of cartilage degeneration using MRI T2 mapping.Results: The amount of change between pre- and post-intervention measurements of the maximum angle of adduction was 0.48° (95% CI: -0.14, 1.09) in the MTE group and -0.40° (-0.84, 0.04) in the AAE group (p = .039). The amount of change in the area of cartilage degeneration according to MRI T2 mapping expressed as MTE/AAE group was 7.7 mm2 (-0.4, 15.8)/-2.7 mm2 (-10.8, 5.3) at the posterior knee (p = .043).Conclusion: AAE could be a potential treatment method that improves the natural course of knee OA with MMRPTs.
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Affiliation(s)
- Futoshi Ikuta
- Department of Orthopedic Surgery, Nippon Medical School, Tokyo, Japan.,Inanami Spine and Joint Hospital, Tokyo, Japan
| | - Kenji Takahashi
- Department of Orthopaedic Surgery, International University of Health and Welfare Hospital, Tochigi, Japan
| | | | - Yusuke Mochizuki
- Department of Orthopedic Surgery, Nippon Medical School, Tokyo, Japan
| | | | | | - Shinro Takai
- Department of Orthopedic Surgery, Nippon Medical School, Tokyo, Japan
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118
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Lee BS, Bin SI, Kim JM, Park MH, Lee SM, Bae KH. Partial Meniscectomy for Degenerative Medial Meniscal Root Tears Shows Favorable Outcomes in Well-Aligned, Nonarthritic Knees: Response. Am J Sports Med 2019; 47:NP54-NP57. [PMID: 31365848 DOI: 10.1177/0363546519855356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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119
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Daney BT, Aman ZS, Krob JJ, Storaci HW, Brady AW, Nakama G, Dornan GJ, Provencher MT, LaPrade RF. Utilization of Transtibial Centralization Suture Best Minimizes Extrusion and Restores Tibiofemoral Contact Mechanics for Anatomic Medial Meniscal Root Repairs in a Cadaveric Model. Am J Sports Med 2019; 47:1591-1600. [PMID: 31091129 DOI: 10.1177/0363546519844250] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although posterior medial meniscal root (PMMR) repairs are often successful, postoperative meniscal extrusion after a root repair has been identified as a potential clinical problem. PURPOSE/HYPOTHESIS The purpose was to quantitatively evaluate the tibiofemoral contact mechanics and extent of meniscal extrusion after a PMMR repair. It was hypothesized that the addition of a centralization suture (into the posterior medial tibial plateau) would help restore normal joint load-bearing characteristics and restore the native amount of meniscal extrusion after a root tear. Furthermore, we hypothesized that the amount of meniscal extrusion would be greatest in loaded and flexed knees when measured at the posterior border of the medial collateral ligament (MCL). STUDY DESIGN Controlled laboratory study. METHODS Meniscal extrusion and tibiofemoral contact mechanics were measured using 3-dimensional digitization and pressure sensors in 10 nonpaired, human cadaveric knees. The PMMR of each knee was tested under 6 states: (1) intact; (2) type 2A PMMR tear; (3) anatomic transtibial pull-out root repair; (4) anatomic transtibial pull-out repair with centralization; (5) nonanatomic transtibial pull-out repair; and (6) nonanatomic transtibial pull-out repair with centralization, with randomization of the order of conditions 3 and 4, and 5 and 6. The testing protocol loaded knees with a 1000-N axial compressive force at 4 flexion angles (0°, 30°, 60°, 90°) in each state. Meniscal extrusion was measured with a 3-dimensional coordinate digitizer at 0° and 90° in both the loaded and unloaded states and calculated from the difference from the articular margin of the tibia to the periphery of the meniscus. Peak contact pressure, contact area, and total contact pressure were also recorded for all states at all flexion angles. Statistical analysis investigated the independent effects of flexion, state, and loading using 3 distinct 2-factor models. RESULTS Differences in the contact mechanics between repair techniques were most notable at higher flexion angles, demonstrating significantly higher average and peak contact pressures for nonanatomic repair states when compared with anatomic repairs with and without centralization (all P < .05). In unloaded knees at full extension, the magnitude of medial meniscal extrusion was significantly higher at the posterior border of the MCL compared with the posterior medial tibia ( P < .001) and adjacent to the root attachment on the tibia locations ( P < .001). Both anatomic repair states had no significant difference in the degree of extrusion when compared with the intact state. CONCLUSION The anatomic transtibial pull-out root repair and the anatomic transtibial pull-out root repair with centralization techniques best restored contact mechanics of the knee and meniscal extrusion when compared with root tear and nonanatomic repair states at time zero. There were no significant differences in contact pressure or magnitude of extrusion between the anatomic repair state and the anatomic repair with centralization state. We found that extrusion is best measured in the coronal plane at the posterior border of the MCL for unloaded knees. However, the degree of extrusion increased as the knee was loaded and flexed to 90°. CLINICAL RELEVANCE When there are concerns about meniscal extrusion with a medial meniscal root repair, the addition of a centralization suture may be beneficial for patients in reducing pathologic meniscal extrusion and restoring joint contact mechanics.
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Affiliation(s)
- Blake T Daney
- Steadman Philippon Research Institute, Vail, Colorado, USA.,The Steadman Clinic, Vail, Colorado, USA
| | - Zachary S Aman
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Joseph J Krob
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | | | - Alex W Brady
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | | | - Grant J Dornan
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Matthew T Provencher
- Steadman Philippon Research Institute, Vail, Colorado, USA.,The Steadman Clinic, Vail, Colorado, USA
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120
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Driban JB, Davis JE, Lu B, Price LL, Ward RJ, MacKay JW, Eaton CB, Lo GH, Barbe MF, Zhang M, Pang J, Stout AC, Harkey MS, McAlindon TE. Accelerated Knee Osteoarthritis Is Characterized by Destabilizing Meniscal Tears and Preradiographic Structural Disease Burden. Arthritis Rheumatol 2019; 71:1089-1100. [PMID: 30592385 DOI: 10.1002/art.40826] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 12/20/2018] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To determine whether accelerated knee osteoarthritis (KOA) is preceded by, and characterized over time by, destabilizing meniscal tears or other pathologic changes. METHODS We selected 3 sex-matched groups of subjects from the first 48 months of the Osteoarthritis Initiative, comprising adults who had a knee without KOA (Kellgren/Lawrence [K/L] radiographic grade <2) at baseline. Subjects in the accelerated KOA group developed KOA of K/L grade ≥3, those with typical KOA showed increased K/L radiographic scores, and those with no KOA had the same K/L grade over time. An index visit was the visit when the radiographic criteria for accelerated KOA and typical KOA were met (the no KOA group was matched to the accelerated KOA group). The observation period was up to 2 years before and after an index visit. Radiologists reviewed magnetic resonance (MR) images of the index knee and identified destabilizing meniscal tears (root tears, radial tears, complex tears), miscellaneous pathologic features (acute ligamentous or tendinous injuries, attrition, subchondral insufficiency fractures, other incidental findings), and meniscal damage in >2 of 6 regions (3 regions per meniscus: anterior horn, body, posterior horn). In addition, bone marrow lesions (BMLs) and cartilage damage on MR images were quantified. Linear mixed regression models were performed to analyze the results. RESULTS At 1 year before the index visit, >75% of adults with accelerated KOA had meniscal damage in ≥2 regions (odds ratio 3.19 [95% confidence interval 1.70-5.97] versus adults with typical KOA). By the index visit, meniscal damage in ≥2 regions was ubiquitous in adults with accelerated KOA, including 42% of subjects having evidence of a destabilizing meniscal tear (versus 14% of subjects with typical KOA). These changes corresponded to findings of larger BMLs and greater cartilage loss in the accelerated KOA group. CONCLUSION Accelerated KOA is characterized by destabilizing meniscal tears in a knee compromised by meniscal damage in >2 regions, and also characterized by the presence of large BMLs and greater cartilage loss.
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Affiliation(s)
| | | | - Bing Lu
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Lori Lyn Price
- Tufts Medical Center and Tufts University, Boston, Massachusetts
| | | | - James W MacKay
- University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, UK
| | - Charles B Eaton
- Alpert Medical School of Brown University, Pawtucket, Rhode Island
| | - Grace H Lo
- Baylor College of Medicine and Michael E. DeBakey VAMC, Houston, Texas
| | - Mary F Barbe
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Ming Zhang
- Tufts Medical Center, Boston, Massachusetts
| | | | | | - Matthew S Harkey
- Tufts Medical Center, Boston, Massachusetts, and University of Massachusetts Medical School, Worcester
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121
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Chahla J. Editorial Commentary: Meniscal Root Repairs: Let the Biology Help You! Arthroscopy 2019; 35:1240-1242. [PMID: 30954115 DOI: 10.1016/j.arthro.2018.12.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Accepted: 12/26/2018] [Indexed: 02/02/2023]
Abstract
Meniscal root tears are increasingly being recognized as important entities by the orthopaedic community. This is probably due to the catastrophic consequences of not identifying or addressing a root tear in a timely fashion, leading to the need for a total meniscectomy. The majority of the studies on root tears have been focused on natural history, diagnosis, biomechanical consequences, and fixation techniques. Conversely, rehabilitation concepts have been extrapolated from those applied after other meniscal tears/repairs, even though root tears probably constitute a completely different pathology from biological and biomechanical standpoints. Time zero studies are important to determine the effect of certain loads on the repaired structure without taking into consideration the healing process. This allows for examination of the effects that an accelerated protocol would have in the immediate postoperative phase after a root repair. As with any repaired structure, allowing time for the repaired tissue to heal is vital because failing to do so might lead to unrecoverable failure of the root fixation.
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122
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Kim JY, Bin SI, Kim JM, Lee BS, Oh SM, Cho WJ. A Novel Arthroscopic Classification of Degenerative Medial Meniscus Posterior Root Tears Based on the Tear Gap. Orthop J Sports Med 2019; 7:2325967119827945. [PMID: 30911565 PMCID: PMC6423685 DOI: 10.1177/2325967119827945] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background: Degenerative medial meniscus posterior root tears (MMPRTs) are reportedly
associated with medial compartment osteoarthritis and meniscal extrusion
with a displaced gap from the root insertion. However, degenerative MMPRTs
have not yet been clearly classified according to arthroscopic findings. Purpose: To classify degenerative MMPRTs according to the tear gap and to investigate
how the classification could reflect the joint condition properly. Study Design: Cohort study; Level of evidence, 3. Methods: Patients who underwent arthroscopic surgery, performed by a single
orthopaedic surgeon, for degenerative MMPRTs between August 2006 and
February 2017 were included. MMPRTs were classified according to tear
patterns observed during arthroscopic surgery (type 1, incomplete root tear;
types 2-5, complete root tears), with each type further divided by the size
of the tear gap, defined as the degree of tear displacement from the root
(type 2, no gap or overlapped; type 3, gap of 1-3 mm; type 4, gap of 4-6 mm;
type 5, gap of ≥7 mm). We compared preoperative factors, including the
Kellgren-Lawrence (K-L) grade, absolute extrusion, relative percentage of
extrusion (RPE), tear gap on magnetic resonance imaging (MRI), and
mechanical alignment, as well as intraoperative factors, including chondral
wear at surgery, between each MMPRT type. Results: A total of 116 root tears were categorized according to this classification:
type 1, 16.4% (19 knees); type 2, 9.5% (11 knees); type 3, 40.5% (47 knees);
type 4, 25.0% (29 knees); and type 5, 8.6% (10 knees). Chondral wear of the
medial femoral condyle (MFC) (P = .001), K-L grade
(P = .001), meniscal extrusion (P =
.001), and tear gap on MRI (P = .001) showed a tendency to
increase with a higher tear type. Chondral wear (ρ for MFC = 0.388; ρ for
MTP = 0.311), K-L grade (ρ = 0.390), and meniscal extrusion (ρ for absolute
extrusion = 0.500; ρ for RPE = 0.451) showed a moderate correlation with
tear type, whereas tear gap on MRI (ρ = 0.907) showed a strong correlation
with tear type. Conclusion: Our study introduces a new classification based on the tear gap that can
concisely describe a degenerative MMPRT. The classification system
demonstrated that a higher tear type (increasing displacement of the tear
gap in arthroscopic surgery) is associated with higher meniscal extrusion,
severe chondral wear, and greater severity of arthritis.
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Affiliation(s)
- Jae-Young Kim
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seong-Il Bin
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jong-Min Kim
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Bum-Sik Lee
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung-Mok Oh
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Won-Joon Cho
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Faucett SC, Geisler BP, Chahla J, Krych AJ, Kurzweil PR, Garner AM, Liu S, LaPrade RF, Pietzsch JB. Meniscus Root Repair vs Meniscectomy or Nonoperative Management to Prevent Knee Osteoarthritis After Medial Meniscus Root Tears: Clinical and Economic Effectiveness. Am J Sports Med 2019. [PMID: 29517925 DOI: 10.1177/0363546518755754] [Citation(s) in RCA: 133] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Medial meniscus root tears are a common knee injury and can lead to accelerated osteoarthritis, which might ultimately result in a total knee replacement. PURPOSE To compare meniscus repair, meniscectomy, and nonoperative treatment approaches among middle-aged patients in terms of osteoarthritis development, total knee replacement rates (clinical effectiveness), and cost-effectiveness. STUDY DESIGN Meta-analysis and cost-effectiveness analysis. METHODS A systematic literature search was conducted. Progression to osteoarthritis was pooled and meta-analyzed. A Markov model projected strategy-specific costs and disutilities in a cohort of 55-year-old patients presenting with a meniscus root tear without osteoarthritis at baseline. Failure rates of repair and meniscectomy procedures and disutilities associated with osteoarthritis, total knee replacement, and revision total knee replacement were accounted for. Utilities, costs, and event rates were based on literature and public databases. Analyses considered a time frame between 5 years and lifetime and explored the effects of parameter uncertainty. RESULTS Over 10 years, meniscus repair, meniscectomy, and nonoperative treatment led to 53.0%, 99.3%, and 95.1% rates of osteoarthritis and 33.5%, 51.5%, and 45.5% rates of total knee replacement, respectively. Meta-analysis confirmed lower osteoarthritis and total knee replacement rates for meniscus repair versus meniscectomy and nonoperative treatment. Discounted 10-year costs were $22,590 for meniscus repair, as opposed to $31,528 and $25,006 for meniscectomy and nonoperative treatment, respectively; projected quality-adjusted life years were 6.892, 6.533, and 6.693, respectively, yielding meniscus repair to be an economically dominant strategy. Repair was either cost-effective or dominant when compared with meniscectomy and nonoperative treatment across a broad range of assumptions starting from 5 years after surgery. CONCLUSION Repair of medial meniscus root tears, as compared with total meniscectomy and nonsurgical treatment, leads to less osteoarthritis and is a cost-saving intervention. While small confirmatory randomized clinical head-to-head trials are warranted, the presented evidence seems to point relatively clearly toward adopting meniscus repair as the preferred initial intervention for medial meniscus root tears.
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Affiliation(s)
| | | | - Jorge Chahla
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | | | - Peter R Kurzweil
- Southern California Center for Sports Medicine, Long Beach, California, USA
| | | | - Shan Liu
- Wing Tech Inc, Menlo Park, California, USA
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124
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Lee BS, Bin SI, Kim JM, Park MH, Lee SM, Bae KH. Partial Meniscectomy for Degenerative Medial Meniscal Root Tears Shows Favorable Outcomes in Well-Aligned, Nonarthritic Knees. Am J Sports Med 2019; 47:606-611. [PMID: 30673297 DOI: 10.1177/0363546518819225] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Arthroscopic meniscectomy has been commonly performed for persistent pain caused by degenerative medial meniscal posterior root tears (MMPRTs). However, risk factors that affect long-term outcomes and joint survivorship after meniscectomy are unclear. PURPOSE To identify the risk factors associated with end-stage osteoarthritis after arthroscopic meniscectomy for degenerative MMPRT for middle-aged or elderly patients and to determine the joint survivorship according to the identified risk factors. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS Data from 288 patients (24 male and 264 female), followed for at least 5 years after arthroscopic meniscectomy for degenerative MMPRTs performed between 1999 and 2010, were examined retrospectively. The modified Lysholm score was used for clinical evaluation. Cox proportional hazards regression analysis was used to assess factors that affect joint survivorship when conversion to total knee arthroplasty (TKA) was taken as the endpoint; these factors were age, sex, body mass index (BMI), preoperative tibiofemoral alignment (varus [<2° valgus] vs well-aligned [2°-10° valgus]), preoperative Kellgren-Lawrence grade (0 or 1 vs 2 or 3), and the modified Outerbridge grade of the medial compartment. Kaplan-Meier survival analysis and the log-rank test were used to compare overall survivorship with respect to each significant risk factor. RESULTS Mean age at the time of surgery was 58.9 years (range, 43-78 years). Sixty (20.8%) patients underwent TKA at 7.0 ± 3.6 years (range, 1.1-14.4 years) postoperatively. The mean follow-up time for those who did not undergo TKA was 8.9 ± 2.9 years (range, 4.5-16.5 years). The overall modified Lysholm score improved from 64.4 to 81.3 ( P < .001), but progression of radiographic arthritis was noted in 156 (61.9%) patients ( P < .001) at 2 years postoperatively. Age (hazard ratio [HR] = 1.049), BMI (HR = 1.092), varus alignment (HR = 2.283), and Kellgren-Lawrence grade 2 or higher (HR = 2.960) were significant risk factors for end-stage arthritis requiring TKA. Well-aligned nonarthritic knees (n = 131, 45.5%) survived significantly longer before requiring TKA than did knees with varus alignment or radiographic arthritis ( P < .05). The 5- and 10-year survival rates in these low-risk groups were 97.7% (95% CI, 95.2%-100.2%) and 89.1% (95% CI, 82.4%-95.8%), respectively. CONCLUSION Arthroscopic meniscectomy is an effective treatment for degenerative MMPRTs, with favorable long-term survival in well-aligned nonarthritic knees. However, meniscectomy should be undertaken cautiously in patients with varus alignment and preoperative radiographic osteoarthritis.
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Affiliation(s)
- Bum-Sik Lee
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Republic of Korea
| | - Seong-Il Bin
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Republic of Korea
| | - Jong-Min Kim
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Republic of Korea
| | - Min-Ho Park
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Republic of Korea.,Inbone Hospital, Bucheon, Gyeonggi-do, Republic of Korea
| | - Sang-Min Lee
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Republic of Korea
| | - Kun-Hyung Bae
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Republic of Korea
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125
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Okazaki Y, Furumatsu T, Kodama Y, Hino T, Kamatsuki Y, Okazaki Y, Masuda S, Miyazawa S, Endo H, Tetsunaga T, Yamada K, Ozaki T. Transtibial pullout repair of medial meniscus posterior root tear restores physiological rotation of the tibia in the knee-flexed position. Orthop Traumatol Surg Res 2019; 105:113-117. [PMID: 30482466 DOI: 10.1016/j.otsr.2018.10.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 10/10/2018] [Accepted: 10/23/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Medial meniscus posterior root tear (MMPRT) results in joint overloading and degenerative changes in the knee. Favorable clinical outcomes have been reported after transtibial pullout repair of MMPRT. To date, however, in vivo tibial rotational changes before and after root repair remain poorly understood. The purpose of this study was to investigate postoperative changes in tibial rotation following MMPRT pullout repair. HYPOTHESIS Pathological external rotation of the tibia in the knee-flexed position is caused by MMPRT and is reduced after transtibial pullout repair. PATIENTS AND METHODS Fifteen patients who underwent MMPRT pullout repair and 7 healthy volunteers were included. Magnetic resonance imaging examinations were performed in the 10° and 90° knee-flexed positions. The angles between the surgical epicondylar axis and a line between the medial border of the patellar tendon and the apex of the medial tibial spine were measured. Baseline was defined as a line lying at a right angle to the other, and a value was positive and negative when the tibia rotated internally and externally, respectively. RESULTS In the volunteer's normal knees, tibial internal rotation was +1.00°±3.27° at 10° flexion and +4.14°±3.46° at 90° flexion. In the MMPRT preoperative knees, tibial internal rotation was +1.07°±3.01° at 10° flexion and +1.27°±2.96° at 90° flexion. In the postoperative knees, tibial internal rotation was +1.60°±2.85° at 10° flexion and +4.33°±2.89° at 90° flexion. DISCUSSION This study demonstrates discontinuity of the MM posterior root may induce a pathological external rotation of the tibia during knee flexion and that MMPRT pullout repair reduces the pathological external rotation of the tibia in the knee-flexed position. LEVEL OF EVIDENCE III, comparative retrospective study.
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Affiliation(s)
- Yuki Okazaki
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikatacho, Kitaku, 700-8558 Okayama, Japan
| | - Takayuki Furumatsu
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikatacho, Kitaku, 700-8558 Okayama, Japan.
| | - Yuya Kodama
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikatacho, Kitaku, 700-8558 Okayama, Japan
| | - Tomohito Hino
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikatacho, Kitaku, 700-8558 Okayama, Japan
| | - Yusuke Kamatsuki
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikatacho, Kitaku, 700-8558 Okayama, Japan
| | - Yoshiki Okazaki
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikatacho, Kitaku, 700-8558 Okayama, Japan
| | - Shin Masuda
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikatacho, Kitaku, 700-8558 Okayama, Japan
| | - Shinichi Miyazawa
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikatacho, Kitaku, 700-8558 Okayama, Japan
| | - Hirosuke Endo
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikatacho, Kitaku, 700-8558 Okayama, Japan
| | - Tomonori Tetsunaga
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikatacho, Kitaku, 700-8558 Okayama, Japan
| | - Kazuki Yamada
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikatacho, Kitaku, 700-8558 Okayama, Japan
| | - Toshifumi Ozaki
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikatacho, Kitaku, 700-8558 Okayama, Japan
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Chung KS, Ha JK, Ra HJ, Lee HS, Lee DW, Park JH, Kim DH, Kim JG. Pullout fixation for medial meniscus posterior root tears: clinical results were not age-dependent, but osteoarthritis progressed. Knee Surg Sports Traumatol Arthrosc 2019; 27:189-196. [PMID: 30006654 DOI: 10.1007/s00167-018-5024-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 06/12/2018] [Indexed: 01/21/2023]
Abstract
PURPOSE This study investigated the outcomes of pullout fixation for medial meniscus posterior root tears (MMPRTs) in patients ≤ 60 years old versus patients > 60 years old. It was hypothesized that older patients would demonstrate results comparable with those of younger patients. METHODS Patients with pullout fixation who were followed-up for more than 5 years were included. Patients were categorized into two groups based on age (group A, ≤ 60 years; group B, > 60 years). The Lysholm score, Kellgren-Lawrence (K-L, 0/1/2/3/4) grade, and medial joint space width were evaluated retrospectively. Preoperative results were compared with the final results in each group, which were compared between groups. RESULTS Twenty-five patients in group A (mean age, 54.7 ± 3.8 years) and 22 patients in group B (mean age, 65.6 ± 4.4 years) were recruited. The mean follow-up duration was 70.9 months. The Lysholm score (group A, 53.0 ± 9.1 to 86.0 ± 12.1, P < 0.001; group B, 51.1 ± 7.1 to 82.9 ± 9.7, P < 0.001) improved significantly. However, the joint space width (group A, 4.7 ± 1.1 to 3.9 ± 1.1 mm, P < 0.001; group B, 4.7 ± 0.9 to 3.8 ± 0.9 mm, P < 0.001) and K-L grade (group A, 3/17/5/0/0 to 0/7/11/7/0, P < 0.001; group B, 2/14/6/0/0 to 0/3/14/5/0, P < 0.001) worsened significantly. No significant differences between groups were observed in final outcomes, including Lysholm score (n.s.), K-L grade (n.s.), and joint space narrowing (n.s.). No case with operation failure that require total knee arthroplasty was not observed. CONCLUSION MMPRT fixation did not prevent the progression of arthrosis completely. However, clinical outcomes were not age-dependent. Thus, age may not be a critical factor to consider when applying fixation. LEVEL OF EVIDENCE Retrospective case-control study; Level of evidence, IV.
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Affiliation(s)
- Kyu Sung Chung
- Department of Orthopedic Surgery and Sports Medical Center and Sports Medical Research Institute, Seoul Paik Hospital, College of Medicine, Inje University, Seoul, South Korea
| | - Jeong Ku Ha
- Department of Orthopedic Surgery and Sports Medical Center and Sports Medical Research Institute, Seoul Paik Hospital, College of Medicine, Inje University, Seoul, South Korea
| | - Ho Jong Ra
- Department of Orthopedic Surgery, Gangneung Asan Hospital, College of Medicine, Ulsan University, Gangneung, South Korea
| | - Han Sung Lee
- Department of Orthopedic Surgery, Hanil General Hospital, Seoul, South Korea
| | - Dhong Won Lee
- Department of Orthopedic Surgery and Sports Medical Center, KonKuk University Medical Center, 120-1 Neungdong-ro, Kwangjin-gu, Seoul, South Korea
| | - Jung Ho Park
- Department of Orthopedic Surgery and Sports Medical Center, KonKuk University Medical Center, 120-1 Neungdong-ro, Kwangjin-gu, Seoul, South Korea
| | - Du Han Kim
- Department of Orthopedic Surgery and Sports Medical Center, KonKuk University Medical Center, 120-1 Neungdong-ro, Kwangjin-gu, Seoul, South Korea
| | - Jin Goo Kim
- Department of Orthopedic Surgery and Sports Medical Center, KonKuk University Medical Center, 120-1 Neungdong-ro, Kwangjin-gu, Seoul, South Korea.
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127
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Meniscal root tears occur frequently in multi-ligament knee injury and can be predicted by associated MRI injury patterns. Knee Surg Sports Traumatol Arthrosc 2018; 26:3731-3737. [PMID: 29872868 DOI: 10.1007/s00167-018-5009-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 06/01/2018] [Indexed: 10/14/2022]
Abstract
PURPOSE The frequency of meniscal root tears in association with multi-ligament knee injury has not been established but adds to the complexity of surgical reconstruction and may have long-term consequences. Therefore, identifying root tears, on preoperative imaging, is important. The aim of this study was to identify the frequency of meniscal root tears, on preoperative magnetic resonance imaging, following multi-ligament injury and distinguish associated injury patterns that may aid detection. METHODS Cases were identified from a prospectively collected institutional database. The magnetic resonance imaging of 188 multi-ligament injuries [median age 31 years (range 16-64)] was retrospectively reviewed by three musculoskeletal radiologists with the presence of meniscal injuries recorded alongside the ligament injury pattern and intra-articular fractures. Assessment of injury pattern was solely made on this imaging. RESULTS 38 meniscal root injuries were identified in 37 knees (overall frequency = 20.2%; medial = 10.6%; lateral = 9.6%). The frequency of meniscal root tears was not increased in higher grade injuries (21.5% vs. 17.0%, n.s.). Valgus injury patterns were associated with lateral root tears (p < 0.05) and varus patterns were associated with medial root tears (p < 0.05). Further, fractures in the same compartment were associated with both medial and lateral root tears (p < 0.05). CONCLUSIONS Meniscal root tears occur more frequently in multi-ligament knee injury than previously reported with isolated anterior cruciate rupture. Root tears can be predicted by ligament injury patterns and fractures sustained (suggestive of a compressive force). In multi-ligament cases, the preoperative magnetic resonance imaging can be used to detect these tears and associated patterns of injury. LEVEL OF EVIDENCE IV.
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Navasartian DJ, DeBerardino TM. Meniscus Root Repair. OPER TECHN SPORT MED 2018. [DOI: 10.1053/j.otsm.2018.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Lee DW, Moon SG, Kim NR, Chang MS, Kim JG. Medial knee osteoarthritis precedes medial meniscal posterior root tear with an event of painful popping. Orthop Traumatol Surg Res 2018; 104:1009-1015. [PMID: 30107275 DOI: 10.1016/j.otsr.2018.07.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 06/26/2018] [Accepted: 07/02/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND An event of painful popping is a highly predictive clinical sign of medial meniscal posterior root tears (MMPRTs) in middle-aged to older patients. There are lacks of studies about the prevalence of a painful popping event and the condition of the medial compartment at the time of popping event in MMPRTs. HYPOTHESIS We hypothesized that most of MMPRTs with a single painful popping event would show pre-existed pathologic medial meniscal extrusion (MME) and articular cartilage degeneration, and larger contact area of medial femoral condyle to medial tibial plateau could affect the MME. In addition, MME would be correlated with knee osteoarthritis. PATIENTS AND METHODS Thirty-eight patients (mean age 58.5±10.5) who had painful popping within 3 weeks were included. On MRIs, absolute MME, relative percentage of extrusion (RPE), MME-medial femoral condyle (MFC)/medial tibial condyle (MTC) at 0° ratio, and medial compartments' Modified Outerbridge Scale (MOS) were evaluated. Kellgren-Lawrence (K-L) grade was also assessed. RESULTS The MME parameters including absolute MME, RPE, and the ratio between MME and MFC/MTC at 0° were 2.9±1.2mm, 22.0±10.3%, and 3.2±1.3. Patients who with MOS and K-L grade≥2 were 33 (86.8%) and 32 (84.2%). Patients were divided into MME≥3mm (group G, n=20) and MME<3mm (groupL, n=18). The MME parameters were significantly greater in group G than group L (all, p<0.001). The group G had worse osteoarthritis progression in terms of MOS and K-L grade than the group L (p=0.035 and 0.077, respectively) MME≥3mm showed significantly association with MOS≥3 (p=0.045). DISCUSSION More than 80% of MMPRT patients with an event of painful popping within 3 weeks showed that medial compartment degeneration preceded the event of popping. Therefore, identification of MME and articular cartilage degeneration at the time of painful popping in MMPRTs could be helpful when the surgeon determines the most appropriate treatment. LEVEL OF EVIDENCE IV, Case-series.
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Affiliation(s)
- Dhong Won Lee
- Department of Orthopaedic Surgery, KonKuk University Medical Center, 120-1, Neungdong-ro, Gwangjin-gu, 05030 Seoul, Republic of Korea
| | - Sung Gyu Moon
- Department of Radiology, KonKuk University Medical Center, Seoul, Republic of Korea
| | - Na Ra Kim
- Department of Radiology, KonKuk University Medical Center, Seoul, Republic of Korea
| | - Min Seok Chang
- Department of Orthopaedic Surgery, KonKuk University Medical Center, 120-1, Neungdong-ro, Gwangjin-gu, 05030 Seoul, Republic of Korea
| | - Jin Goo Kim
- Department of Orthopaedic Surgery, KonKuk University Medical Center, 120-1, Neungdong-ro, Gwangjin-gu, 05030 Seoul, Republic of Korea.
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Arthroscopic transtibial pullout repair for posterior meniscus root tears. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2018; 31:248-260. [DOI: 10.1007/s00064-018-0574-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 05/08/2018] [Accepted: 05/18/2018] [Indexed: 01/13/2023]
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131
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Xue XH, Lin J, Qi WH, Pan XY. A technique combining "U" shape suture and shared tunneling to treat the posterior cruciate ligament rupture and posterior root tears of the medial meniscus. J Orthop Surg Res 2018; 13:265. [PMID: 30348196 PMCID: PMC6198352 DOI: 10.1186/s13018-018-0973-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 10/12/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The standard treatment of the posterior cruciate ligament (PCL) rupture accompanied with the posterior root of medial meniscus (PRMM) tears is controversial. Our research describes a minimally invasive technique for the PCL rupture accompanied with the PRMM tears. METHODS We described a "U" shape suture and shared tunneling technique to treat the PCL rupture accompanied with PRMM tears. Three patients (ages 28, 42, and 59 years old) who underwent this surgery have been followed up for more than 1 year at most. The MRI was done, and the hospital for special surgery (HSS) score was adopted to evaluate the clinical effect. Firstly, we built both femoral and tibial bone tunnels for the PCL reconstruction. Secondly, we used the suture hook to pass the suture line through the PRMM. Thirdly, we passed the prepared tendon through the bone tunnel and fixed the prepared tendon by an endobutton plate and an interference screw (Smith & Nephew) respectively on the side of the femur and tibia. At last, we used an endobutton plate (Smith & Nephew) outside the tibial bone tunnel to fix the PRMM. RESULTS These three patients did not show any complications. At 1 year after the operation, we found good knee stability, negative posterior drawer test, and normal range of motion compared with the contralateral knee joint. The MRI also showed a good union of the PRMM and PCL. The hospital for special surgery (HSS) score was 90 points. CONCLUSIONS With an ideal therapeutic effect, this technique is worthy to be promoted for patients with the PCL rupture and PRMM tears.
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Affiliation(s)
- Xing-He Xue
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109 Xueyuan Xi Road, Wenzhou, 325000, People's Republic of China.,Zhejiang Provincial Key Laboratory of Orthopaedics, 109 Xueyuan Xi Road, Wenzhou, 325000, People's Republic of China.,The Second School of Medicine, Wenzhou Medical University, 109 Xueyuan Xi Road, Wenzhou, 325000, People's Republic of China
| | - Jian Lin
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109 Xueyuan Xi Road, Wenzhou, 325000, People's Republic of China.,Zhejiang Provincial Key Laboratory of Orthopaedics, 109 Xueyuan Xi Road, Wenzhou, 325000, People's Republic of China.,The Second School of Medicine, Wenzhou Medical University, 109 Xueyuan Xi Road, Wenzhou, 325000, People's Republic of China
| | - Wei-Hui Qi
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109 Xueyuan Xi Road, Wenzhou, 325000, People's Republic of China.,Zhejiang Provincial Key Laboratory of Orthopaedics, 109 Xueyuan Xi Road, Wenzhou, 325000, People's Republic of China.,The Second School of Medicine, Wenzhou Medical University, 109 Xueyuan Xi Road, Wenzhou, 325000, People's Republic of China
| | - Xiao-Yun Pan
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109 Xueyuan Xi Road, Wenzhou, 325000, People's Republic of China. .,Zhejiang Provincial Key Laboratory of Orthopaedics, 109 Xueyuan Xi Road, Wenzhou, 325000, People's Republic of China. .,The Second School of Medicine, Wenzhou Medical University, 109 Xueyuan Xi Road, Wenzhou, 325000, People's Republic of China.
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Na YG, Lee BK, Hwang DH, Choi ES, Sim JA. Can osteoarthritic patients with mild varus deformity be indicated for high tibial osteotomy? Knee 2018; 25:856-865. [PMID: 29933934 DOI: 10.1016/j.knee.2018.05.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 04/03/2018] [Accepted: 05/01/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Whether osteoarthritic patients with mild varus deformity can be indicated for high tibial osteotomy (HTO) is not established. We examined the preoperative characteristics and postoperative outcomes of HTO in patients with mild genu varum compared to patients with greater varus deformity. METHODS Seventy-one patients who underwent HTO were included in this retrospective study. Patients were divided into either mild varus (MV, mechanical femorotibial angle (mFTA) ≤4°, n = 31 (44%)) and greater varus (GV, mFTA >4°, n = 40 (56%)) groups. Preoperative characteristics on single photon emission computed tomography-computed tomography (SPECT-CT), magnetic resonance image and radiograph were evaluated. Alignment parameters and functional outcomes were compared pre- and postoperatively between the groups. RESULTS Preoperative characteristics were similar between the two groups, except the severity of arthritis and coronal alignment. There was no difference in the proportion of hot uptake in the medial compartment; medial meniscus posterior horn root tear, complex or radial tear; bone marrow edema. Full-thickness cartilage defect of medial compartment was more frequent and arthritis grade was also more severe in GV group. Coronal alignment of the MV group was corrected into more valgus than the GV group (4.5° vs. 2.8° in mFTA, P = 0.012). Pre- and postoperative Knee Society knee and function scores were also comparable in the two groups. CONCLUSIONS Mild varus patients are similar to greater varus patients regarding preoperative features and achieve the comparable functional outcome. A selected subset of osteoarthritic patients with mild varus deformity might be indicated for HTO. LEVEL OF EVIDENCE III (Retrospective comparative study).
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Affiliation(s)
- Young Gon Na
- Department of Orthopaedic Surgery, Gachon University Gil Medical Center, Gachon University College of Medicine, 21, Namdong-daero 774 beon-gil, Namdong-gu, Incheon, Republic of Korea
| | - Beom Koo Lee
- Department of Orthopaedic Surgery, Armed Forces Capital Hospital, Seongnam, Gyeonggi-do, 81, Saemaeul-ro 177 beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Do Hyun Hwang
- Department of Orthopaedic Surgery, Gachon University Gil Medical Center, Gachon University College of Medicine, 21, Namdong-daero 774 beon-gil, Namdong-gu, Incheon, Republic of Korea
| | - Eun Seok Choi
- Department of Orthopaedic Surgery, Chungnam Nationl University Hospital, 282, Munhwa-ro, Jung-gu, Daejeon, Republic of Korea
| | - Jae Ang Sim
- Department of Orthopaedic Surgery, Gachon University Gil Medical Center, Gachon University College of Medicine, 21, Namdong-daero 774 beon-gil, Namdong-gu, Incheon, Republic of Korea.
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Hevesi M, Stuart MJ, Krych AJ. Medial Meniscus Root Repair: A Transtibial Pull-Out Surgical Technique. OPER TECHN SPORT MED 2018. [DOI: 10.1053/j.otsm.2018.06.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Furumatsu T, Miyazawa S, Fujii M, Tanaka T, Kodama Y, Ozaki T. Arthroscopic scoring system of meniscal healing following medial meniscus posterior root repair. INTERNATIONAL ORTHOPAEDICS 2018; 43:1239-1245. [PMID: 30069591 DOI: 10.1007/s00264-018-4071-z] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 07/23/2018] [Indexed: 12/20/2022]
Abstract
PURPOSE Medial meniscus posterior root tear (MMPRT) leads to a rapid degradation of articular cartilage. In the treatment of MMPRT, transtibial pullout repair demonstrates a high clinical survival rate. However, there is no reliable method to evaluate the meniscal healing after surgery. We propose an arthroscopic scoring system for evaluating the meniscal healing status. The aim of this study was to investigate the correlations between second-look arthroscopic scores and clinical outcomes after transtibial pullout repair. METHODS Twenty patients who had MMPRTs underwent transtibial pullout repairs. Clinical outcomes were assessed using the Japanese Knee Injury and Osteoarthritis Outcome Score (KOOS) and pain score evaluated by visual analogue scale at preoperatively and 1 year postoperatively. The healing status of repaired MM was assessed at one year post-operatively using a semi-quantitative arthroscopic scoring system (total, 10 points) composed of three evaluation criteria: (i) anteroposterior width of bridging tissues, (ii) stability of the MM posterior root, and (iii) synovial coverage of the sutures. Linear regression analysis was used to assess the correlation between second-look arthroscopic scores and clinical outcomes. RESULTS Transtibial pullout repairs of MMPRTs significantly improved clinical evaluation scores at one year post-operatively. A median of second-look arthroscopic scores was 6.5 (5.75-8). A good correlation was observed between the arthroscopic score and KOOS quality of life (QOL) subscale. A moderate negative correlation between the arthroscopic score and pain score was observed. CONCLUSIONS This study demonstrated that our semi-quantitative scoring system of meniscal healing correlated with the KOOS QOL subscale following MMPRT transtibial pullout repair. Our results suggest that the second-look arthroscopic score using this system may be a useful scale to determine and compare the healing status of the MM posterior root.
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Affiliation(s)
- Takayuki Furumatsu
- Department of Orthopaedic Surgery, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan.
| | - Shinichi Miyazawa
- Department of Orthopaedic Surgery, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Masataka Fujii
- Department of Orthopaedic Surgery, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Takaaki Tanaka
- Department of Orthopaedic Surgery, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Yuya Kodama
- Department of Orthopaedic Surgery, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Toshifumi Ozaki
- Department of Orthopaedic Surgery, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
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A simple cinch is superior to a locking loop for meniscus root repair: a human biomechanical comparison of suture constructs in a transtibial pull-out model. Knee Surg Sports Traumatol Arthrosc 2018; 26:2239-2244. [PMID: 28748490 DOI: 10.1007/s00167-017-4652-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 07/12/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE To determine the cyclic displacement and ultimate failure loads of two clinically relevant suture configurations for repair of medial and lateral meniscus root tears. METHODS A total of 10 matched pair fresh-frozen, human meniscus specimens were randomly assigned to either simple cinch or locking loop meniscus-suture fixation techniques for transtibial pull-out repair in either medial (n = 10 matched pairs) or lateral (n = 10 matched pairs) meniscal root tears. The menisci were subjected to cyclic tensioning at 10-30 N for 1000 cycles at 0.5 Hz, and then post-cycling load to failure was performed at a tensile rate of 0.5 mm/s. RESULTS For both the medial and lateral meniscus, there was significantly less displacement with the cinch stitch at 100, 500 and 1000 cycle counts (p < 0.05). In respect to ultimate load, there was no significant difference in type of repair between the two suture configurations. When comparing ultimate load to failure from the medial to the lateral side, the ultimate load to failure was significantly greater for both suture configurations in the lateral meniscus root repair (p < 0.05). However, there was no significant difference in cyclic displacement between the medial and lateral meniscus. CONCLUSIONS The cinch stitch was significantly better at resisting displacement compared to the locking loop stitch configuration, and had similar ultimate load to failure. The lateral meniscus root repair construct has higher failure loads compared to the medial meniscus, independent of suture configuration.
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Filbay S. Should Surgical Repair Be Recommended Over Nonoperative Management for Medial Meniscus Root Tears? Letter to the Editor. Am J Sports Med 2018; 46:NP43-NP44. [PMID: 30011254 DOI: 10.1177/0363546518783958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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137
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Faucett SC, Geisler BP, Chahla J, Krych AJ, LaPrade RF, Pietzsch JB. Should Surgical Repair Be Recommended Over Nonoperative Management for Medial Meniscus Root Tears? Response. Am J Sports Med 2018; 46:NP44-NP45. [PMID: 30011253 DOI: 10.1177/0363546518783956] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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138
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Siegel MG. Editorial Commentary: "Defer No Time, Delays Have Dangerous Ends" (Henry VI, Shakespeare): Delayed Anterior Cruciate Ligament Reconstruction Has Consequences. Arthroscopy 2018; 34:1918-1920. [PMID: 29804611 DOI: 10.1016/j.arthro.2018.02.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 02/08/2018] [Indexed: 02/02/2023]
Abstract
There continues to be controversy over the timing of anterior cruciate ligament (ACL) surgery. Early or delayed intervention after ACL injury is a topic that has not been settled. The issue is whether ACL tears should have surgery performed in an expedient manner. Or is delay an option with no repercussions to the health of the knee? My associates in nonsurgical specialties wave the New England Journal of Medicine to support their view that surgery is not needed. I routinely espouse the literature confirming that delay of surgery may cause future damage. It is now established that a failure to intervene in a timely manner does cause additional damage. I stand vindicated and can affirm to my colleagues that I have found the answer. There is no longer any doubt or equivocation. Delay in reconstructing an unstable knee does cause damage.
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Balke M, Akoto R, Offerhaus C, Hoeher J. Suture Anchor Refixation of Meniscal Root Tears Without an Additional Portal. Arthrosc Tech 2018; 7:e511-e515. [PMID: 29868427 PMCID: PMC5984481 DOI: 10.1016/j.eats.2018.01.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 01/15/2018] [Indexed: 02/03/2023] Open
Abstract
The biomechanical consequences of a tear of the posterior root of the medial meniscus are comparable to that of a complete meniscectomy. The integrity of the meniscal roots is crucial to enable the important function of load sharing and shock absorption. An untreated root tear leads to extrusion and loss of function of the meniscus causing early degenerative arthritis of the respective knee compartment. Meniscal root repair can be achieved by 2 main techniques: indirect fixation using pullout sutures through a transtibial tunnel with extracortical fixation and direct fixation using suture anchors. Pullout sutures are prone to elongation or abrasion of the suture material due to the length of the bone tunnel. Current suture anchor techniques are challenging as they require an additional posterior portal with higher risk of damage to neurovascular structures. Even with the use of specially designed curved passing devices, secure insertion of the anchor is difficult. We present a technique for suture anchor refixation of the posterior root of the medial meniscus without the need for an additional posterior portal.
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Affiliation(s)
- Maurice Balke
- Sportsclinic Cologne, University of Witten/Herdecke, Cologne-Merheim-Medical-Centre, Cologne, Germany
- Address correspondence to Maurice Balke, M.D., Sportsclinic Cologne, Ostmerheimer-Str. 200, 51109 Cologne, Germany.
| | - Ralph Akoto
- Department of Trauma and Reconstructive Surgery, Division of Knee and Shoulder Surgery, Sports Traumatology, Asklepios Clinic St. Georg, Hamburg, Germany
| | - Christoph Offerhaus
- Sportsclinic Cologne, University of Witten/Herdecke, Cologne-Merheim-Medical-Centre, Cologne, Germany
- Department for Trauma, Orthopaedics, Hand and Reconstructive Surgery, HELIOS-Spital Überlingen, Überlingen, Germany
| | - Juergen Hoeher
- Sportsclinic Cologne, University of Witten/Herdecke, Cologne-Merheim-Medical-Centre, Cologne, Germany
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LaPrade RF. Editorial Commentary: We Know We Need to Fix Knee Meniscal Radial Root Tears-But How Best to Perform the Repairs? Arthroscopy 2018; 34:1069-1071. [PMID: 29622245 DOI: 10.1016/j.arthro.2017.11.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 11/07/2017] [Accepted: 11/08/2017] [Indexed: 02/02/2023]
Abstract
The present work further contributes to building the base of the research pyramid by noting the importance of repairing knee meniscal radial root tears. Because of the extensive biomechanical studies that have now been published on the restoration of joint mechanics and with what I believe results in a higher likelihood of an improved healing environment with securing the meniscus root tear down to bone, I would strongly recommend that when one does see a meniscus root tear that the transtibial pullout root repair technique be considered over a side-to-side repair. The biggest challenge going forward is to validate and improve the healing potential of knee meniscal radial root repairs.
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Partial meniscectomy provides no benefit for symptomatic degenerative medial meniscus posterior root tears. Knee Surg Sports Traumatol Arthrosc 2018; 26:1117-1122. [PMID: 28184957 DOI: 10.1007/s00167-017-4454-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 01/25/2017] [Indexed: 10/20/2022]
Abstract
PURPOSE Medial meniscus posterior root tears (MMPRTs) are recognized as a source of pain and dysfunction, but treatment options remain a challenge. The purpose of the study was to determine (1) the efficacy of partial meniscectomy to treat MMPRTs compared to a matched group of non-operatively treated MMPRTs, and (2) risk factors for worse clinical and radiographic outcome. METHODS This retrospective comparative study was performed to include patients with complete, isolated MMPRTs with documented clinical symptoms and were treated with arthroscopic partial meniscectomy (PMM) and a minimum 2-year follow-up. These patients were then matched by age, gender, and BMI to patients with the same diagnosis who were treated non-operatively. Clinical and radiographic outcomes were compared between the two groups. Analysis was performed to determine risk factors for worse clinical and radiographic outcome in the PMM group alone. RESULTS Overall, 52 patients were included in the study. Twenty-six patients (9M:17F) with a mean age of 55 ± 9 and a mean BMI of 32.8 ± 5.3 were treated with PMM and followed for 5.5 ± 2.0 years (range 2.3-9.3 years). In the PMM group, final median Tegner score was 3, mean IKDC score was 67.8 ± 20, and more patients had grade II or higher arthritis at final follow-up than baseline (91.3 vs. 36%, p < 0.01). Overall, 14 of the 26 patients (54%) treated operatively progressed to total knee arthroplasty at a mean of 54.3 months. There was no significant difference in final Tegner scores, IKDC, K-L grades, progression to arthroplasty, or overall failure rate between the PMM group and non-operative group. Following PMM, female patients had lower final IKDC scores (44.0 ± 2.8 vs. 74.6 ± 16.7, p = 0.02) compared to males, as well as a higher rate of arthroplasty (70.6 vs. 20.0%, p = 0.009). Higher BMI correlated with lower IKDC scores (r = -0.91, p = 0.01) and meniscal extrusion was associated with higher rate of arthritis at final follow-up (p = 0.02). CONCLUSION Partial meniscectomy for a complete MMPRT provides no benefit in halting arthritic progression. Patients who undergo PMM for MMPRTs still progress to significant arthritis, poor clinical outcomes and a high arthroplasty rate (54%) at over 5-year follow-up. Female gender, increased BMI, and meniscus extrusion were associated with worse outcome. STUDY DESIGN Level III.
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142
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Cinque ME, Chahla J, Moatshe G, Faucett SC, Krych AJ, LaPrade RF. Meniscal root tears: a silent epidemic. Br J Sports Med 2018; 52:872-876. [DOI: 10.1136/bjsports-2017-098942] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2018] [Indexed: 12/21/2022]
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143
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Kwak YH, Lee S, Lee MC, Han HS. Large meniscus extrusion ratio is a poor prognostic factor of conservative treatment for medial meniscus posterior root tear. Knee Surg Sports Traumatol Arthrosc 2018; 26:781-786. [PMID: 28197696 DOI: 10.1007/s00167-017-4441-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 01/20/2017] [Indexed: 01/21/2023]
Abstract
PURPOSE The purpose of this study was to find a prognostic factor of medial meniscus posterior root tear (MMPRT) for surgical decision making. METHODS Eighty-eight patients who were diagnosed as acute or subacute MMPRT without severe degeneration of the meniscus were treated conservatively for 3 months. Fifty-seven patients with MMPRT showed good response to conservative treatment (group 1), while the remaining 31 patients who failed to conservative treatment (group 2) received arthroscopic meniscus repair. Their demographic characteristics and radiographic features including hip-knee-ankle angle, joint line convergence angle, Kellgren-Lawrence grade in plain radiographs, meniscus extrusion (ME) ratio (ME-medial femoral condyle ratio, ME-medial tibial plateau ratio, ME-meniscus width ratio), the location of bony edema, and cartilage lesions in MRI were compared. Receiver operating characteristic (ROC) curve analysis was also performed to determine the cut-off values of risk factors. RESULTS The degree of ME-medial femoral condyle and medial tibia plateau ratio of group 2 was significantly higher than group 1 (0.08 and 0.07 vs. 0.1 and 0.09, respectively, both p < 0.001). No significant (n.s.) difference in other variables was found between the two groups. On ROC curve analysis, ME-medial femoral condyle ratio was confirmed as the most reliable prognostic factor of conservative treatment for MMPRT (area under ROC = 0.8). CONCLUSION The large meniscus extrusion ratio was the most reliable poor prognostic factor of conservative treatment for MMPRT. Therefore, for MMPRT patients with large meniscus extrusion, early surgical repair could be considered as the primary treatment option. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Yoon-Ho Kwak
- Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea
| | - Sahnghoon Lee
- Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea
| | - Myung Chul Lee
- Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea
| | - Hyuk-Soo Han
- Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea.
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144
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Novel technique for repairing posterior medial meniscus root tears using porcine knees and biomechanical study. PLoS One 2018; 13:e0192027. [PMID: 29408892 PMCID: PMC5800675 DOI: 10.1371/journal.pone.0192027] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 01/16/2018] [Indexed: 11/19/2022] Open
Abstract
Transtibial pullout suture (TPS) repair of posterior medial meniscus root (PMMR) tears was shown to achieve good clinical outcomes. The purpose of this study was to compare biomechanically, a novel technique designed to repair PMMR tears using tendon graft (TG) and conventional TPS repair. Twelve porcine tibiae (n = 6 each) TG group: flexor digitorum profundus tendon was passed through an incision in the root area, created 5 mm postero-medially along the edge of the attachment area. TPS group: a modified Mason-Allen suture was created using no. 2 FiberWire. The tendon grafts and sutures were threaded through the bone tunnel and then fixed to the anterolateral cortex of the tibia. The two groups underwent cyclic loading followed by a load-to-failure test. Displacements of the constructs after 100, 500, and 1000 loading cycles, and the maximum load, stiffness, and elongation at failure were recorded. The TG technique had significantly lower elongation and higher stiffness compared with the TPS. The maximum load of the TG group was significantly lower than that of the TPS group. Failure modes for all specimens were caused by the suture or graft cutting through the meniscus. Lesser elongation and higher stiffness of the constructs in TG technique over those in the standard TPS technique might be beneficial for postoperative biological healing between the meniscus and tibial plateau. However, a slower rehabilitation program might be necessary due to its relatively lower maximum failure load.
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145
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Chung KS, Noh JM, Ha JK, Ra HJ, Park SB, Kim HK, Kim JG. Survivorship Analysis and Clinical Outcomes of Transtibial Pullout Repair for Medial Meniscus Posterior Root Tears: A 5- to 10-Year Follow-up Study. Arthroscopy 2018; 34:530-535. [PMID: 29183645 DOI: 10.1016/j.arthro.2017.08.266] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 04/26/2017] [Accepted: 08/09/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE This study investigated the clinical outcomes and mid- to long-term survival rates in patients undergoing transtibial pullout repair of medial meniscus posterior root tears (MMPRTs) after a minimum follow-up of 5 years. METHODS Between 2005 and 2011, patients with MMPRTs who had been followed for at least 5 years after undergoing transtibial pullout repair were recruited. Participants were identified using medical records and information in a prospectively collected database. Clinical outcomes were assessed based on a comparison of patient preoperative Lysholm scores and their scores at the final follow-up. A Kaplan-Meier survival analysis was used to investigate the survival rates of repair procedures. Clinical failures were defined as cases requiring conversion to total knee arthroplasty (TKA) or having final Lysholm score <65 or less than their preoperative scores. RESULTS Overall, 91 patients (mean age, 58.7 ± 9.7 years) were included: the mean follow-up duration was 84.8 ± 13.8 months. Among these patients, the mean Lysholm score improved significantly from 51.8 ± 7.9 preoperatively to 83.0 ± 11.1 at the final follow-up (P < .001). Overall, 4 patients failed due to conversion to TKA (n = 1) or having final Lysholm scores <65 or less than the preoperative scores (n = 3). The overall Kaplan-Meier probabilities of survival after repair were 99% at 5 years, 98% at 6 years, 95% at 7 years, and 92% at 8 years. CONCLUSIONS Among patients with MMPRTs, transtibial pullout repair demonstrated a high clinical survival rate and the patients demonstrated clinical improvement, based on mid- and long-term follow-up examinations. LEVEL OF EVIDENCE Level IV, retrospective uncontrolled case series.
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Affiliation(s)
- Kyu Sung Chung
- Department of Orthopedic Surgery, Hanil General Hospital, Seoul, Republic of Korea
| | - June Mo Noh
- Department of Orthopedic Surgery, KonKuk University Medical Center, Seoul, Republic of Korea
| | - Jeong Ku Ha
- Department of Orthopedic Surgery and Sports Medical Center and Sports Medical Research Institute, Seoul Paik Hospital, College of Medicine, Inje University, Seoul, Republic of Korea
| | - Ho Jong Ra
- Department of Orthopedic Surgery, Gangneung Asan Hospital, College of Medicine, Ulsan University, Gangneung, Republic of Korea
| | - Sung Bae Park
- Department of Orthopedic Surgery, Hanil General Hospital, Seoul, Republic of Korea
| | - Hyung Kook Kim
- Department of Orthopedic Surgery, Hanil General Hospital, Seoul, Republic of Korea
| | - Jin Goo Kim
- Department of Orthopedic Surgery, KonKuk University Medical Center, Seoul, Republic of Korea.
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146
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Furumatsu T, Kodama Y, Kamatsuki Y, Hino T, Okazaki Y, Ozaki T. Meniscal Extrusion Progresses Shortly after the Medial Meniscus Posterior Root Tear. Knee Surg Relat Res 2017; 29:295-301. [PMID: 29172390 PMCID: PMC5718799 DOI: 10.5792/ksrr.17.027] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 06/06/2017] [Accepted: 07/03/2017] [Indexed: 11/27/2022] Open
Abstract
Purpose Medial meniscus posterior root tears (MMPRT) induce medial meniscus extrusion (MME). However, the time-dependent extent of MME in patients suffering from the MMPRT remains unclear. This study evaluated the extent of MME after painful popping events that occurred at the onset of the MMPRT. Materials and Methods Thirty-five patients who had an episode of posteromedial painful popping were investigated. All the patients were diagnosed as having an MMPRT by magnetic resonance imaging (MRI) within 12 months after painful popping. Medial meniscus body width (MMBW), absolute MME, and relative MME (100×absolute MME/MMBW) were assessed among three groups divided according to the time after painful popping events: early period (<1 month), subacute period (1–3 months), and chronic period (4–12 months). Results In the early period, absolute and relative MMEs were 3.0 mm and 32.7%, respectively. Absolute MME increased up to 4.2 mm and 5.8 mm during the subacute and chronic periods, respectively. Relative MME also progressed to 49.2% and 60.3% in the subacute and chronic periods, respectively. Conclusions This study demonstrated that absolute and relative MMEs increased progressively within the short period after the onset of symptomatic MMPRT. Our results suggest that early diagnosis of an MMPRT may be important to prevent progression of MME following the MMPRT.
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Affiliation(s)
- Takayuki Furumatsu
- Department of Orthopaedic Surgery, Okayama University Graduate School, Okayama, Japan
| | - Yuya Kodama
- Department of Orthopaedic Surgery, Okayama University Graduate School, Okayama, Japan
| | - Yusuke Kamatsuki
- Department of Orthopaedic Surgery, Okayama University Graduate School, Okayama, Japan
| | - Tomohito Hino
- Department of Orthopaedic Surgery, Okayama University Graduate School, Okayama, Japan
| | - Yoshiki Okazaki
- Department of Orthopaedic Surgery, Okayama University Graduate School, Okayama, Japan
| | - Toshifumi Ozaki
- Department of Orthopaedic Surgery, Okayama University Graduate School, Okayama, Japan
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147
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Cuéllar A, Cuéllar A, Sánchez A, Cuéllar R. Posterior Lateral Meniscus Root Reattachment With Suture Anchors: An Arthroscopic Technique. Arthrosc Tech 2017; 6:e1919-e1925. [PMID: 29416979 PMCID: PMC5797299 DOI: 10.1016/j.eats.2017.07.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 07/11/2017] [Indexed: 02/03/2023] Open
Abstract
The posterior lateral meniscus root (PLMR) provides the circumferential tension required to stabilize the lateral meniscus. Thus, preservation of the PLMR is important to prevent an increase in tibiofemoral contact pressure, which could result in osteoarthritis. We describe an all-arthroscopic approach to the fixation of PLMR using suture anchors through associated posterolateral arthroscopic portals that result in a more favorable inclination of the anchors. Initially, the anatomical insertion site of the root on the tibial plateau is debrided, 1 to 2 anchors are placed through the posterolateral portals into the root's footprint area, and the meniscus is finally sutured from the posterolateral portals. Compression of the meniscus is achieved with bone contact. This technique achieves lateral meniscus root fixation, reducing the risk of subluxation of the meniscus and subsequent osteoarthritis.
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Affiliation(s)
- Adrián Cuéllar
- Department of Traumatology and Orthopaedic Surgery of the Galdakao-Usansolo Hospital, Galdácano, Spain,Address correspondence to Adrián Cuéllar, M.D., Department of Traumatology and Orthopaedic Surgery, Galdakao Hospital, University of Basque Country, c./Labeaga, s/n, Usansolo, Vizcaya 48960, Spain.Department of Traumatology and Orthopaedic SurgeryGaldakao HospitalUniversity of Basque Countryc./Labeaga, s/nUsansoloVizcaya48960Spain
| | - Asier Cuéllar
- Department of Traumatology and Orthopaedic Surgery of the Donostia Universitary Hospital, San Sebastián, Spain
| | - Alberto Sánchez
- Department of Traumatology and Orthopaedic Surgery of the Galdakao-Usansolo Hospital, Galdácano, Spain
| | - Ricardo Cuéllar
- Department of Traumatology and Orthopaedic Surgery of the Donostia Universitary Hospital, San Sebastián, Spain
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Tensile strength of the pullout repair technique for the medial meniscus posterior root tear: a porcine study. INTERNATIONAL ORTHOPAEDICS 2017; 41:2113-2118. [DOI: 10.1007/s00264-017-3561-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 06/26/2017] [Indexed: 11/26/2022]
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149
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Harnden E, Lin T, Wilson A, Reid JB. Technique for Transtibial Knotless Repair of Lateral Meniscus Root Avulsion. Arthrosc Tech 2017; 6:e845-e851. [PMID: 28706841 PMCID: PMC5496117 DOI: 10.1016/j.eats.2017.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 05/21/2017] [Indexed: 02/03/2023] Open
Abstract
Tear of the meniscal root results in loss of circumferential hoop tension in the meniscus and increased tibiofemoral contact pressure, leading to cartilage wear. Repair of the meniscal root can restore function of the meniscus. Many techniques for root repair have recently been described. We present a technique for root repair using a transtibial socket and knotless suture technique that can be performed through standard arthroscopy portals.
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Affiliation(s)
- Emily Harnden
- Address correspondence to Emily Harnden, M.D., Taos Orthopaedic Institute, 1219 Gusdorf Road, Suite A, Taos, NM 87571, U.S.A.Taos Orthopaedic Institute1219 Gusdorf RoadSuite ATaosNM87571U.S.A.
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150
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Woodmass JM, Mohan R, Stuart MJ, Krych AJ. Medial Meniscus Posterior Root Repair Using a Transtibial Technique. Arthrosc Tech 2017; 6:e511-e516. [PMID: 28706793 PMCID: PMC5494976 DOI: 10.1016/j.eats.2016.11.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 11/28/2016] [Indexed: 02/03/2023] Open
Abstract
The meniscal roots are critical in maintaining the normal shock absorbing function of the meniscus. If a meniscal root tear is left untreated, meniscal extrusion can occur rendering the meniscus nonfunctional resulting in degenerative arthritis. Two main repair techniques are described: (1) suture anchors (direct fixation) and (2) sutures pulled through a tibial tunnel (indirect fixation). Meniscal root repair using a suture anchor technique is technically challenging requiring a posterior portal and a curved suture passing device that can be difficult to manipulate within the knee. We present a technique for posterior medial meniscus root repair using 3 sutures (1 leader, 2 cinch), standard arthroscopy portals, and transtibial fixation. Overall, this technique simplifies a challenging procedure and allows for familiarity and efficiency.
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Affiliation(s)
| | | | | | - Aaron J. Krych
- Address correspondence to Aaron J. Krych, M.D., Department of Orthopedic Surgery and the Sports Medicine Center, Mayo Clinic, 200 First St SW, Rochester, MN 55905, U.S.A.Department of Orthopedic Surgery and the Sports Medicine CenterMayo Clinic200 First St SWRochesterMN55905U.S.A.
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