Anterior cruciate ligament reconstruction with concomitant meniscal surgery: a systematic review and meta-analysis of outcomes

Nonanatomic femoral tunnel placement increases the risk of subsequent meniscal surgery after ACLR: Part II-Patients without recurrent ACL injury

PURPOSE

The purpose of this study was to identify risk factors for subsequent meniscal surgery following anterior cruciate ligament (ACL) reconstruction (ACLR) in patients without recurrent ACL injury.

METHODS

Patients aged ≥14 years who underwent primary ACLR with minimum 1-year follow-up and without recurrent ACL injury were retrospectively reviewed. Patient demographics and surgical data at the time of ACLR were collected. Postoperative radiographs were used to measure femoral and tibial tunnel position, and posterior tibial slope. Univariate and multivariate analyses were performed to identify risk factors for subsequent meniscal surgery.

RESULTS

Of 629 ACLRs that fulfilled the inclusion criteria, subsequent meniscal surgery was performed in 65 [10.3%] patients. Multivariate analysis revealed that medial meniscal repair at the time of ACLR, younger age, anterior femoral tunnel position and distal femoral tunnel position were significantly associated with subsequent meniscal surgery (p < 0.001, p = 0.016, p = 0.015, p = 0.035, respectively). The frequency of femoral tunnel placement >10% outside of the literature-established anatomic position was significantly higher in those who underwent subsequent meniscal surgery compared to those who did not (38.3% vs. 20.3%, p = 0.006). Posterior tibial slope and ACL graft type were not significantly associated with subsequent meniscal surgery.

CONCLUSION

Medial meniscal repair at the time of ACLR, younger age and nonanatomic femoral tunnel placement were risk factors for subsequent meniscal surgery in patients without recurrent ACL injury. Femoral tunnel placement <10% outside of the native anatomic position is important to reduce the risk of subsequent meniscal surgery.

LEVEL OF EVIDENCE

Level IV.

Anterior Cruciate Ligament Tear: Individualized Indications for Non-Operative Management

Anterior cruciate ligament (ACL) rupture represents a common sports injury that is mostly managed operatively. However, non-operative treatment can also play a role, despite the limited high-quality published data on ACL tear management. Both methods have shown favorable outcomes, but clear guidelines based on high-quality research are lacking. Several factors should be considered and discussed with the patient before deciding on the best treatment method. These include patient characteristics and expectations, concomitant injuries, and clinical evaluation, with laxity or/and instability being one of the most essential parameters examined. This should eventually lead to an individualized approach for each patient to ensure the best possible outcome. This review aims to delve into all parameters that are related to ACL rupture and guide physicians in choosing the most appropriate treatment method for each patient.

Management of Meniscus Pathology with Concomitant Anterior Cruciate Ligament Injury

PURPOSE OF REVIEW

The purpose of this review is to summarize current clinical knowledge on the prevalence and types of meniscus pathology seen with concomitant anterior cruciate ligament (ACL) injury, as well as surgical techniques, clinical outcomes, and rehabilitation following operative management of these pathologies.

RECENT FINDINGS

Meniscus pathology with concomitant ACL injury is relatively common, with reports of meniscus pathology identified in 21-64% of operative ACL injuries. These concomitant injuries have been associated with increased age and body mass index. Lateral meniscus pathology is more common in acute ACL injury, while medial meniscus pathology is more typical in chronic ACL deficiency. Meniscus tear patterns associated with concomitant ACL injury include meniscus root tears, lateral meniscus oblique radial tears of the posterior horn (14%), and ramp lesions of the medial meniscus (8-24%). These meniscal pathologies with concomitant ACL injury are associated with increased rotational laxity and meniscal extrusion. There is a paucity of comparative studies to determine the optimal meniscus repair technique, as well as rehabilitation protocol, depending on specific tear pattern, location, and ACL reconstruction technique. There has been a substantial increase in recent publications demonstrating the importance of meniscus repair at the time of ACL repair or reconstruction to restore knee biomechanics and reduce the risk of progressive osteoarthritic degeneration. Through these studies, there has been a growing understanding of the meniscus tear patterns commonly identified or nearly missed during ACL reconstruction. Surgical management of meniscal pathology with concomitant ACL injury implements the same principles as utilized in the setting of isolated meniscus repair alone: anatomic reduction, biologic preparation and augmentation, and circumferential compression. Advances in repair techniques have demonstrated promising clinical outcomes, and the ability to restore and preserve the meniscus in pathologies previously deemed irreparable. Further research to determine the optimal surgical technique for specific tear patterns, as well as rehabilitation protocols for meniscus pathology with concomitant ACL injury, is warranted.

Does Concomitant Meniscectomy or Meniscus Repair Affect Muscle Strength, Lower Extremity Balance, and Functional Tests after Anterior Cruciate Ligament Reconstruction?

Background/Objective: The effects of concomitant meniscal tears and their associated treatment on strength, lower extremity balance, and functional status after anterior cruciate ligament reconstruction (ACLR) have not been widely investigated. This study aimed to compare the functional outcomes in patients who underwent ACLR with concomitant treatment of the medial meniscus repair versus meniscectomy when returning to unrestricted physical activity. Methods: A total of 85 patients who underwent primary ACLR with combined meniscal repair (MREP; n = 39) or meniscectomy (MRES; n = 46) were assessed. The dataset included the Functional Movement ScreenTM (FMS) outcomes and single-leg balance test (SLBT) with anterior-posterior, medial-lateral, and overall stability indexes. Isokinetic knee extension and flexion strengths were tested at velocities of 60 deg·s-1 and 180 deg·s-1. The peak torque-to-body weight ratio (PT/BW) and limb symmetry index (LSI) were calculated. Results: In the functional assessment, there was no significant inter-group difference in the composite score of the FMS (MREP: 15.08 pts vs. MRES: 15.13 pts; p > 0.05). The SLBT outcomes in inter-group and inter-extremity comparisons were irrelevant (p > 0.05), too. Significant differences emerged in the inter-group comparison of the knee extension strength in the non-operated extremity at both 60 deg·s-1 and 180 deg·s-1 (p = 0.02). Inter-extremity differences were significant in both the MREP and MRES groups for knee extension and flexion at both angular velocities (all p values < 0.05). For knee extension, the LSI values ranged from 82% to 87%, and for flexion, from 77% to 84%, with no significant inter-group differences. Conclusions: Patients undergoing ACLR with concomitant meniscal repair or resection did not exhibit differences in isokinetic muscle strength, lower extremity balance, and functional tests upon returning to activity. However, participants in both groups demonstrated significant differences between the operated and non-operated extremities as far as the knee joint extensor and flexor strengths are concerned. Therefore, rehabilitation protocols should prioritize equalizing inter-extremity strength differences after the ACLR with additional treatment procedures addressing the menisci.

Engineering Innervated Musculoskeletal Tissues for Regenerative Orthopedics and Disease Modeling

Musculoskeletal (MSK) disorders significantly burden patients and society, resulting in high healthcare costs and productivity loss. These disorders are the leading cause of physical disability, and their prevalence is expected to increase as sedentary lifestyles become common and the global population of the elderly increases. Proper innervation is critical to maintaining MSK function, and nerve damage or dysfunction underlies various MSK disorders, underscoring the potential of restoring nerve function in MSK disorder treatment. However, most MSK tissue engineering strategies have overlooked the significance of innervation. This review first expounds upon innervation in the MSK system and its importance in maintaining MSK homeostasis and functions. This will be followed by strategies for engineering MSK tissues that induce post-implantation in situ innervation or are pre-innervated. Subsequently, research progress in modeling MSK disorders using innervated MSK organoids and organs-on-chips (OoCs) is analyzed. Finally, the future development of engineering innervated MSK tissues to treat MSK disorders and recapitulate disease mechanisms is discussed. This review provides valuable insights into the underlying principles, engineering methods, and applications of innervated MSK tissues, paving the way for the development of targeted, efficacious therapies for various MSK conditions.

Comparison of Functional Outcomes after Anterior Cruciate Ligament Reconstruction with Meniscal Repair for Unstable versus Stable Meniscal Tears

This study aimed to compare functional outcomes including knee muscle strength in the quadriceps and hamstrings, and proprioception, assessed through dynamic postural stability (overall stability index [OSI]) and self-reported outcomes in the operated and non-operated knees between anterior cruciate ligament reconstruction (ACLR) with meniscal repair for unstable (root and radial tears) and stable (longitudinal, horizontal, and bucket handle tears) meniscal tears. A total of 76 patients were randomly selected (41 with ACLR with meniscal repair for unstable meniscal tears and 35 with ACLR with meniscal repair for stable meniscal tears) at three different time points (preoperative, 6 months, and 12 months). Repeated measures analysis of variance was used to investigate the differences in outcomes for between-subject and within-subject factors. In the operated knees, there were no significant differences for functional outcomes between the two groups (all p > 0.05). In the non-operated knees, a significant difference was observed for the OSI between the two groups, which was significantly higher in ACLR with meniscal repair for unstable meniscal tears than for stable meniscal tears at 6 months (p < 0.001). Multiple linear regression analysis showed that age (p = 0.027), preoperative OSI in the operated knees (p = 0.005), and postoperative OSI in the operated knees at 6 months (p = 0.002) were significant and independent predictors for OSI in the non-operated knees at 6 months postoperatively. Therefore, while no differences were observed in functional outcomes between the two groups in the operated knees, dynamic postural stability was poorer at 6 months postoperatively in the non-operated knees of patients with ACLR with meniscal repair for unstable meniscal tears. Furthermore, a significant correlation was observed between preoperative/postoperative dynamic postural stability in the operated knees and postoperative dynamic postural stability in the non-operated knees. Hence, we recommend incorporating balance exercises for both knees in post-surgical rehabilitation, particularly for patients with unstable meniscal tears.

Clinical Outcomes of Different Management Techniques for Medial Meniscal Type 3 Ramp Lesions in Anterior Cruciate Ligament Reconstruction: A Comparative Analysis Between All-inside Repair, Suture Hook Repair, and Lesions Left In Situ

BACKGROUND

There is ongoing debate about the best way to manage ramp lesions at the time of anterior cruciate ligament (ACL) reconstruction (ACLR). Type 3 lesions are not visible by the transnotch approach without superior debridement, making the management debate even more problematic.

PURPOSE/HYPOTHESIS

The purpose of this study was to evaluate the rate of secondary surgical interventions according to the management method of a type 3 ramp lesion concomitant with primary ACLR. The hypothesis was that the rate of secondary ACL or meniscal interventions would be higher in patients who underwent all-inside repair.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective analysis of all patients who underwent primary ACLR with a type 3 ramp lesion between January 2012 and May 2020, regardless of the treatment method, was performed. The main criterion analyzed in this cohort was a secondary surgical intervention, defined as revision ACLR or a reintervention of the repaired meniscus. A survivorship analysis was performed to evaluate secondary surgical interventions in 3 groups: all-inside repair, suture hook repair, and left in situ. The following data were collected preoperatively and at the last follow-up: patient characteristics, time to surgery, side-to-side difference in laxity, pivot shift, Lysholm score, subjective International Knee Documentation Committee score, Knee injury and Osteoarthritis Outcome Score, Tegner score, and meniscal repair failure rate.

RESULTS

A total of 113 patients who underwent type 3 ramp lesion repair concomitant with ACLR were included: 52 (46.0%) in the all-inside repair group, 23 (20.4%) in the suture hook repair group, and 38 (33.6%) in the lesion left in situ group. There were 17 patients (15.0%) who underwent a secondary intervention because of ACL graft failure (n = 6) or meniscal repair failure (n = 15 [4 of whom underwent a concomitant ACL reintervention]). Overall, 62 patients (54.9%) underwent combined ACLR and anterolateral ligament reconstruction, while 51 patients (45.1%) underwent isolated ACLR. In the adjusted Cox model, the type of meniscal repair was not statistically significantly associated with secondary surgical interventions. The only risk factor for secondary surgical interventions in this cohort was isolated ACLR (hazard ratio, 8.077; P = .007).

CONCLUSION

The rates of secondary surgical interventions after medial meniscal type 3 ramp lesion repair concomitant with ACLR were similar regardless of the management method of the meniscal lesion. Despite not being associated with meniscal treatment, this rate was 8 times higher for patients who underwent isolated ACLR in this cohort; this is probably because of the protection that lateral extra-articular procedures provide to the ACL graft.

Clinical outcome of iterative meniscal suture after ACL reconstruction at a minimum of 2 years' follow-up

INTRODUCTION

Failure rates in meniscal suture associated to ACL reconstruction range from 10 to 26.9%, often leading to meniscectomy. In young patients, the wish to conserve the meniscus may lead to iterative suture, if the lesion allows. There are no data available for clinical results of repeat meniscal suture at the same site as the primary lesion in a stabilized knee. The immediate socioeconomic cost, compared to meniscectomy, needs to be taken into account, and benefit needs to be demonstrated. The main aim of the present study was to assess the rate of secondary meniscectomy after iterative meniscal suture in stabilized knees. The study hypothesis was that failure rates are higher in iterative isolated meniscal suture after ligament reconstruction than in primary repair.

MATERIAL AND METHODS

This single-center retrospective study analyzed patients receiving iterative meniscal suture on stable knee, between 2009 and 2019, with a minimum 26 months' follow-up. Twenty-three patients were analyzed: 15 male, 8 female; mean age at iterative suture, 28.1±7.9 years (range, 14-49 years); mean BMI, 24.2±2.9kg/m2 (range, 19-31). Mean time to recurrence was 38.9±25.1 months (range, 6-93 months). Initial ACL graft used the patellar ligament in 69.6% of cases (n=16) and the hamstrings in 30.4% (n=7). Mean differential laximetry before iterative suture was 1.7±0.3mm (range, 1.2-2.3mm). Iterative suture was in the medial meniscus in 69.6% of cases (16/23) and in the lateral meniscus in 30.4% (7/23). Risk factors for failure, defined by requirement for meniscectomy, were assessed. Functional results were assessed on Knee injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee (IKDC) score and Tegner score.

RESULTS

The failure rate was 48% (11/23), incorporating all lesions together. Bucket-handle tear was most frequently associated with failure (91%; p<0.01). There was significant improvement after iterative suture in subjective IKDC score (51.6±15.2 vs. 81.3±15.6; p<0.001) and KOOS scores: symptoms and stiffness, 66.6±13.7 vs. 91.1±7.53 (p<0.001); pain, 79.2±12.7 vs. 93.4±7.4 (p<0.01); function, 91.3±11.2 vs. 97.9±4.44 (p<0.001); quality of life, 38.1±23.2 vs. 62.3±30.1 (p<0.001).

CONCLUSION

The failure rate for iterative meniscal suture on stabilized knee was 48%. Bucket-handle tear was a major risk factor for failure (91%). Despite these high failure rates, functional results systematically improved.

LEVEL OF EVIDENCE

IV.

A comparative analysis of suture-augmented and standard hamstring autograft single-bundle ACL reconstruction outcomes: short-term functional benefits without long-term impact

BACKGROUND

Augmentation of the biologic graft with nonabsorbable suture material during anterior cruciate ligament reconstruction (ACLR) is a relatively new technique to enhance its biomechanical properties and add additional support to the critical process of healing. We aimed to compare the short-term functional patient-reported outcome measures (PROMs) and complication rates of patients treated with either standard single-bundle four-strand hamstring ACLR or added suture augmentation (SA).

METHODS

Patients undergoing arthroscopic ACLR between February 2015-January 2017 and in the standard ACLR group, and between February 2017-September 2019 in the SA-ACLR group operated by adding a no.5 FiberWire® (Arthrex, Naples, FL, USA) braided suture to the hamstring autograft, were retrospectively reviewed and the PROMs were compared. Patients were followed up for a 24-month period and PROMs were assessed by the International Knee Documentation Committee (IKDC) Subjective Knee Form and Tegner-Lysholm knee score. Patients' demographic and clinical characteristics, and postoperative complications including graft retear requiring revision surgery, deep vein thrombois, and surgical site infection were recorded and analyzed.

RESULTS

We included 79 patients with mean age of 31.6 ± 8.3 years in the standard ACLR group, and 90 patients with mean oge of 30.5 ± 7.6 in the SA-ACLR group. There was no statistically significant difference between the two groups in terms of age, sex, body mass index, and medical comorbidities. The values of the IKDC scores increased to 75.8 ± 18.9 in the standard ACLR group, and 85.6 ± 12.6 in the SA-ACLR group, 24 months after the operation (P < 0.05). The 24-month postoperative Tegner-Lysholm scores escalated to 79.3 ± 21.0 in the standard ACLR group and 91.0 ± 13.7 in the SA-ACLR group (P < 0.05). Four (5.1%) patients in the standard ACLR group and 4 (4.4%) in the SA-ACLR group experienced graft retear requiring revision surgery (P > 0.05). Incidence of surgical site infection and deep vein thrombosis showed no significant differences between the two groups, 24 months after ACLR.

CONCLUSION

SA-ACLR is associated with improved short-term functional PROMs compared to the standard hamstring ACLR. Although SA did not reduce the retear rate, and infection and DVT rates did not differ between study groups, superior improvement of PROMs in SA approach, leverages this method for ACLR.

Clinical, Biomechanical, and Self-reported Health Status After ACL Reconstruction With Meniscal Repair in Soccer Players: Results at Minimum 1-Year Follow-up

Background

Performing meniscal repair with anterior cruciate ligament reconstruction (ACLR) has been shown to contribute to the long-term preservation of knee health and gait biomechanics.

Purpose

To evaluate the role of meniscal repair in the performance of semiprofessional soccer players who returned to sport after ACLR.

Study Design

Case series; Level of evidence, 4.

Methods

This study included 51 male soccer players (mean ± SD age, 28.82 ± 5.33 years) who underwent ACLR at a single institution between July 2018 and July 2019. The players were divided into 3 groups according to surgery type: ACLR only (n = 30), ACLR with lateral meniscal repair (n = 9), and ACLR with medial meniscal repair (n = 12). Outcomes were evaluated through clinical examination, self-reported health questionnaires (Cincinnati Knee Rating System, Tegner activity score, Tegner Lysholm Knee Scoring Scale, Tampa Scale of Kinesiophobia, and ACL-Return to Sport After Injury), and biomechanical performance evaluations (balance, strength, coordination, and symmetry tests). Parametric and nonparametric tests were carried out for multiple comparisons.

Results

The mean ± SD follow-up time was 20.75 ± 9.38 months. Although no significant differences emerged in clinical and self-reported health status, almost all the physical parameters tested resulted in lower performance in players treated with ACLR and meniscal repair. Moreover, patients with ACLR with lateral meniscal repair reported higher pain and fear of reinjury, with lower outcomes in terms of strength, symmetry, and coordination as compared with the other 2 groups. Balance abilities were significantly affected in players who underwent meniscal repair as compared with those who underwent ACLR only.

Conclusion

The findings showed that biomechanical performance measures and fear of reinjury were significantly worse in soccer players with associated meniscal repair at a minimum 1-year follow-up, especially in those with a lateral meniscal tear.

Oral non-viral gene delivery platforms for therapeutic applications

Since gene therapy can regulate gene and protein expression directly, it has a great potential to prevent or treat a variety of genetic or acquired diseases through vaccines such as viral infections, cystic fibrosis, and cancer. Owing to their high efficacy, in vivo gene therapy trials are usually conducted intravenously, which is usually costly and invasive. There are several advantages to oral drug administration over intravenous injections, such as better patient compliance, ease of use, and lower cost. However, gene therapy is successful if the oligonucleotides can cross the cell membrane easily and reach the nucleus after the endosomal escape. In order to accomplish this task and deliver the cargo to the intended location, appropriate delivery systems should be introduced. This review summarizes oral delivery systems developed for effective gene delivery, vaccination, and treatment of various diseases. Studies have also shown that oral delivery approaches are potentially applicable to treat various diseases, especially inflammatory bowel disease, stomach, and colorectal cancers. Also, the current review provides an update overview on the development of non-viral and oral gene delivery techniques for gene therapy and vaccination purposes.

The Impact of Meniscal Tear Type and Surgical Treatment on Quadriceps Strength: A Study of Adolescent Patients Post Anterior Cruciate Ligament Reconstruction

BACKGROUND

Treatment of meniscal injuries at the time of anterior cruciate ligament reconstruction (ACLR) can result in restrictions on weightbearing and range of motion in the early rehabilitative phases. What is unknown is the effect of (1) meniscal tear type and location at the time of anterior cruciate ligament injury and (2) meniscal treatment at the time of ACLR on quadriceps strength in adolescents during the late rehabilitative phase.

HYPOTHESIS

Meniscal tears involving the root and requiring repair would adversely affect quadriceps strength at 6 to 9 months postoperatively.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients who underwent ACLR at 1 of 2 research sites between 2013 and 2021 were identified. Adolescent participants were included if they were between the ages of 12 and 20 years at the time of assessment and had undergone primary unilateral ACLR in the previous 6 to 9 months. Participants were subgrouped by meniscal tear type (no tear, nonroot tear, root tear) and meniscal treatment at the time of ACLR (no treatment, meniscectomy, meniscal repair), which were confirmed via chart review. Isokinetic strength testing occurred at 60 deg/s, and quadriceps strength and quadriceps strength limb symmetry index were compared between the meniscal tear type and meniscal procedure subgroups using analysis of covariance while controlling for the effects of age, sex, and ACLR graft source.

RESULTS

An overall 236 patients were included in this analysis (109 male, 127 female; mean ± SD age, 16.0 ± 1.9 years). There were no significant differences in ACLR limb quadriceps strength based on meniscal tear type (P = .61) or meniscal procedure at the time of ACLR (P = .61), after controlling for age, biological sex, and ACLR graft source. Similarly, quadriceps strength limb symmetry index did not differ by meniscal tear type (P = .38) or meniscal procedure at the time of ACLR (P = .40).

CONCLUSION

Meniscal tear type and treatment at the time of ACLR did not affect quadriceps strength or quadriceps strength symmetry in adolescents 6 to 9 months after ACLR.

Medial Meniscal Posterior Horn Suturing Influences Tibial Internal-External Rotation in ACL-Reconstructed Knees

Background

The role of meniscal lesions and repair in combination with anterior cruciate ligament (ACL) injury and reconstruction has not been extensively investigated in vivo and under weightbearing conditions.

Purpose

The purposes of this study were to (1) compare the in vivo knee kinematics between patients with ACL tear and those with combined ACL and medial meniscal tears and (2) investigate kinematic differences between isolated ACL reconstruction and ACL reconstruction plus medial meniscal repair (MR). It was hypothesized that concomitant posterior horn medial meniscal tear and ACL deficiency would affect knee internal-external rotation and anterior-posterior translation but MR would restore these parameters.

Study Design

Controlled laboratory study.

Methods

Nineteen patients who underwent ACL reconstruction were included: 10 had intact menisci (IM group) and 9 had a medial meniscal injury that was repaired during ACL reconstruction using an all-inside technique (MR group). Preoperatively and 18 months postoperatively, active knee kinematics under weightbearing conditions was evaluated during a single-leg squat using a dynamic biplane x-ray imaging system. The general linear model was used to investigate the differences between group (IM vs MR) and time (preoperative vs follow-up) and their interactions.

Results

Tibial internal rotation was higher in the MR group than the IM group both before and after surgery (P = .007). Knee valgus rotation was higher in the MR group preoperatively (P < .001), while no differences were found postoperatively because of an increase of valgus rotation in the IM group, which was significant in the descendant phase (P < .001). Preoperatively, the IM group showed a more medial tibial translation compared with the MR group in the descendant phase (P = .006).

Conclusion

When performing a single-leg squat, patients with ACL-deficient knees and a medial meniscal tear demonstrated a more valgus rotation, tibial internal rotation, and lateral tibial translation versus those with intact menisci. After ACL reconstruction and MR, these patients demonstrated significantly higher tibial internal rotation when compared with patients who underwent isolated ACL reconstruction.

Clinical Relevance

Surgeons should be aware that MR does not fully restore knee kinematics in vivo and under weightbearing conditions in the context of ACL reconstruction.

Clinic and Home-Based Exercise with Blood Flow Restriction Resolves Thigh Muscle Atrophy after Anterior Cruciate Ligament Reconstruction with the Bone-Patellar Tendon-Bone Autograft: A Case Report

Anterior cruciate ligament reconstruction (ACLR) results in thigh muscle atrophy. Of the various interventions proposed to mitigate thigh muscle atrophy, exercise with blood flow restriction (BFR) appears safe and effective. Some literature suggests daily exposure to exercise with BFR may be indicated during the early phase of ACLR rehabilitation; this case report outlines the methodology utilized to prescribe clinic- and home-based BFR within an outpatient rehabilitation program. A 15-year-old male soccer player suffered a left knee injury involving the anterior cruciate ligament and both menisci. He underwent ACLR and completed exercise with BFR as part of his clinic- and home-based rehabilitation program, which included practical blood flow restriction during home-based rehabilitation. After 16 weeks of rehabilitation, surgical limb thigh girth values were objectively larger than the non-surgical limb (surgical, 52.25 cm; non-surgical 50 cm), as well as the multi-frequency bioelectrical impedance analysis of his lower-extremity lean body mass (surgical limb, 10.37 kg; non-surgical limb, 10.02 kg). The findings of this case report suggest that the inclusion of clinic- and home-based BFR within an outpatient rehabilitation program may be indicated to resolve thigh muscle atrophy early after ACLR.

Quadriceps tendon autograft is comparable to hamstring tendon and bone-patella-tendon-bone up to 2 years after isolated primary anterior cruciate ligament reconstruction

PURPOSE

To evaluate the functional and graft survivorship outcomes of the three most common autograft options for primary anterior cruciate ligament reconstruction (ACLR)-hamstring tendon (HT), bone-patella-tendon-bone (BPTB), and quadriceps tendon (QT).

METHODS

Patients captured by the New Zealand ACL registry who underwent a primary ACLR from 2014 to 2020 were considered for the study. Patients with associated knee injury (including meniscus, chondral, osseous, and additional ligamentous injury) and previous knee surgery were excluded. Comparison was made between HT, BPTB, and QT autografts with respect to Marx and KOOS (Knee Osteoarthritis Outcome Score) scores at minimum 2 years follow-up. In addition, graft survivorship was evaluated by comparing all-cause revision per 100 graft years and revision-free proportion at 2 years post-surgery.

RESULTS

2,582 patients (1,921 HT, 558 BPTB, 107 QT) were included in the study. Differences in adjusted functional outcomes between HT and BPTB were found at 12 months (mean Marx; HT 6.2; BPTB 7.1; P < 0.001) (mean KOOS Sport and Recreation; HT 75.1; BPTB 70.5; n.s.) and 24 months (mean KOOS Sports and Recreation; HT 79.2; BPTB 73.9; P < 0.001). QT was comparable to HT and BPTB in all functional scores at 12 months and 2 years. No statistically significant differences were found in revision rate between all three autograft groups up to 2 years post-surgery (revision rate per 100 graft years; HT 1.05; BPTB 0.80; QT 1.68; n.s. HT vs. BPTB; n.s. HT vs. QT; n.s. QT vs. BPTB).

CONCLUSIONS

QT was found to be comparable to both HT and BPTB in all functional scores and revision rates up to 2 years post-surgery.

LEVEL OF EVIDENCE

Level III.

Clinical considerations of anatomy and magnetic resonance imaging in pediatric meniscus tear, with imaging-based treatment options

Background

The incidence of meniscal tears in children has been increasing. Early sport specialization, more intense training activity, and increasing participation in competitive sports may have affected to that increasing trend. Diagnosing acute menisci tear in children is based on suggestive clinical and magnetic resonance imaging findings. There are special particulars in immature menisci, due to relatively good vascular supply. Furthermore, growing skeleton makes differences in injury pattern, and a clinician needs to recognize not only meniscus but also potential injuries in growth plates and ligaments, which are usual in connection with pediatric meniscus leasion. Clinical and imaging investigation prior to treatment is crucial, because non-operative care is considerable, to achieve spontaneous healing, especially in peripherial tears of younger children. Second, repair is preferred always as possible, in spite of resection due to high rate of long-term sequelae after partial meniscectomy. High standard preoperative imaging aid in preparing to the meniscus sparing arthroscopic intervention.

Methods

In this current concept article, the clinical considerations of imaging the injured pediatric knee with a suspected meniscus tear and the treatment options by the imaging findings are reviewed.

Level of evidence

level III.

CLINICAL DIAGNOSIS AND TRAINING OPTIMIZATION ON KNEE SPORTS INJURIES

ABSTRACT Introduction: The knee joint is one of the sites of greatest mechanical stress in the lower limbs. The overload generated by impacts, blows from falls, and torsions in collisions can generate disabling tissue damage that is difficult to recover from. Although lacking clinical diagnosis, some studies have pointed out that implementing functional training in rehabilitation can reduce the period of disability and the harmful effects of immobilization. Objective: Study the clinical diagnosis and the optimization of training for knee sports injuries. Methods: This experiment uses the intra-group comparison method. The method used in the experiment is a rehabilitation training protocol for the knee joint, focusing on quadriceps muscle strength and balance. The training cycle is six times per week for one month. Results: The optimization in exercise training evidenced a good improvement in functional ability and pain condition, reflected in the athletes’ balance ability. After training optimization, 9 out of 12 athletes recovered completely, and three improved significantly. Conclusion: Trainers should follow the physical rehabilitation orders and match them with the athletes’ actual situation, sport types, etc., designing the appropriate sports mode for the athletes to promote training optimization and reduce sports joint injuries. Level of Evidence II; Therapeutic Studies - Outcome Investigation.

Management after acute injury of the anterior cruciate ligament (ACL), part 2: management of the ACL-injured patient

PURPOSE

The aim of this consensus project was to create a treatment algorithm for the management of the ACL-injured patient which can serve as an aid in a shared decision-making process.

METHODS

For this consensus process, a steering and a rating group were formed. In an initial face-to-face meeting, the steering group, together with the expert group, formed various key topic complexes for which various questions were formulated. For each key topic, a structured literature search was performed by the steering group. The results of the literature review were sent to the rating group with the option to give anonymous comments until a final consensus voting was performed. Sufficient consensus was defined as 80% agreement.

RESULTS

During this consensus process, 15 key questions were identified. The literature search for each key question resulted in 24 final statements. Of these 24 final statements, all achieved consensus.

CONCLUSIONS

This consensus process has shown that ACL rupture is a complex injury, and the outcome depends to a large extent on the frequently concomitant injuries (meniscus and/or cartilage damage). These additional injuries as well as various patient-specific factors should play a role in the treatment decision. The present treatment algorithm represents a decision aid within the framework of a shared decision-making process for the ACL-injured patient.

LEVEL OF EVIDENCE

Level V.

Long-term follow-up of bucket-handle meniscal repairs: chondroprotective effect outweighs high failure risk

PURPOSE

Outcomes after repair of bucket-handle meniscal tears tend to be satisfying in the short-term follow-up. However, the literature is scarce regarding long-term data following repair of bucket-handle meniscal tears. The aim of this study was to assess long-term follow-up outcomes, focusing on knee osteoarthritis (OA) development and failure rate, and determine risk factors associated with failure.

METHODS

This is a retrospective cohort study, including all patients with bucket-handle tears within 4 mm of the menisco-synovial junction, who underwent meniscal repair, either isolated or combined with anterior cruciate ligament reconstruction (ACLR) between 2004 and 2015. A combination of all-inside, outside-in, and inside-out repair technique was used in all patients. Patients over 40 years old, concomitant multi-ligamentous injuries, and severe cartilage lesions documented intraoperatively were excluded. During the follow-up, a meniscus was considered healed using Barrett's criteria, while knee OA evaluation was performed according to Kellgren-Lawrence (KL) classification using standing knee radiographs. Patients were assessed preoperatively as well as postoperatively in terms of knee function using International Knee Documentation Committee (IKDC) score, Lysholm score, and Knee injury and Osteoarthritis Outcome Score (KOOS).

RESULTS

In total, the inclusion criteria were met by 66 patients. Median age at the time of operation was 21.9 years (13-39). Median follow-up was 114 (62-176) months. Total failure rate was approximately 33% at median time of 19 (6-39) months. Osteoarthritis was statistically significantly more prevalent in patients with failed repairs (mean KL score: 2.09) in comparison to patients with successful repairs (mean KL score: 0.54) p = 0.001. In addition, successful repairs were associated with higher KOOS score as compared with failed repairs (mean ± SD, 89.6 ± 4.6 vs 77.8 ± 4.9 p < 0.001), higher IKDC score (mean ± SD, 88.2 ± 5.1 vs 79.2 ± 5.2 p < 0.001), and Lysholm score (mean ± SD, 90.3 ± 5.3 vs 78.4 ± 7.8 p < 0.001). Patients with medial meniscus repair had 4.8 higher relative likelihood of failure compared to lateral meniscus [p = 0 .014, OR = 4.8 (95% Cl 1.2, 18.6)]. Patients over 16 years old had 5.7 higher relative likelihood of failure [p = 0 .016, OR = 5.7 (95% Cl 0.04, 0.85)]. Concurrent ACLR did not have a significant effect on the postoperative outcomes.

CONCLUSION

A high rate of clinical failure was observed after meniscal repair of bucket-handle tears. However, successful treatment led to lower rates of knee OA development and better knee function, approximately 10 years postoperatively. Meniscal repair of bucket-handle tears is recommended to improve knee function and prevent knee OA in young patients.

LEVEL OF EVIDENCE

III.

The crevice sign: a new indicator of meniscal instability in ACL reconstructions

PURPOSE

Meniscus preservation is key in knee surgery. The newly documented crevice sign indicates instability of the medial meniscus in ACL-deficient knees. Once the sign is visualised, it is imperative that the stability of the medial meniscus is assessed and potentially treated. It was hypothesized that there would be a strong correlation between the presence of an unstable medial meniscal tear in patients with the crevice sign in ACL-deficient knees.

METHODS

This was a multicenter prospective study carried out to evaluate the incidence of medial meniscal tears in patients with ACL-deficient knees and their correlation with a crevice sign. All patients (128) who had undergone ACL reconstruction between May 2020 and November 2020 were assessed arthroscopically for meniscal stability and divided in to two groups: stable (n = 84) and unstable (n = 44). Thereafter, the presence of the crevice sign was determined in each case.

RESULTS

The populations were comparable in terms of sex and age (Table 1). Fisher's exact test showed a significant association between the presence of the crevice sign and the instability of the medial meniscus (p < 0.001). Descriptive statistics suggest that the presence of crevice sign was associated more frequently to MM instability (38.6% vs 1.2%; p < 0.001). The specificity of this test was 98.8% and its sensitivity was 38.6%. The positive predictive value (PPV) was 94.4% and the negative predictive value (NPV) was 75.5%. Table 1 Descriptions and comparisons of internal meniscus instability of patients by presence of crevice sign Internal meniscus instability (N = 44) Internal meniscus stability (N = 84) Total (N = 128) Gender  N 44 84 128   Male 33 (75.0) 58 (69.0) 91 (71.1)   Female 11 (25.0) 26 (31.0) 37 (28.9) Fisher's exact test (n.s.) Age (years)  N 44 84 128   Mean (ET) 28.6 (9.4) 30.1 (10.2) 29.6 (9.9)   Median (IIQ) 26.5 (22.0;34.5) 27.0 (22.5;37.0) 27.0 (22.0;36.0)   [Min-Max] [14-54] [14-52] [14-54] Wilcoxon test bilateral (n.s.) Crevice sign  N 44 84 128   Absent 27 (61.4) 83 (98.8) 110 (85.9)   Present 17 (38.6) 1 (1.2) 18 (14.1) Fisher's exact test p < 0.001 CONCLUSION: The hypothesis was confirmed since medial meniscal instability was strongly correlated with the existence of the crevice sign and showed high specificity and PPV.

LEVEL OF EVIDENCE

III.

Survival and Risk Factor Analysis of Arthroscopic Ramp Lesion Repair During Anterior Cruciate Ligament Reconstruction

BACKGROUND

There is a lack of research on the management of ramp lesions associated with anterior cruciate ligament (ACL) injuries. Furthermore, there has been no report of the risk factors for failure of ramp lesion sutures, linked to either the technique used (all-inside suture implant vs suture hook through a posteromedial portal) or the type of lesion (location in the red zone or meniscocapsular junction, longitudinal extension, partial- or full-thickness tear).

PURPOSE

To evaluate the results of arthroscopic repair of ramp lesions and determine the risk factors associated with ramp lesion repair failure, with special focus on their subtype and the suture technique.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

All patients who underwent arthroscopic ramp lesion repair in association with ACL reconstruction between November 2015 and January 2018 were evaluated retrospectively. The following parameters were studied: demographics; clinical history; clinical findings including International Knee Documentation Committee score, complications, time from injury to surgery, side-to-side laxity, and pivot shift; and surgical findings including subtype, surgical management, and type and number of sutures. Failure of the ramp lesion repair was defined at secondary arthroscopy.

RESULTS

Among the 248 lesions analyzed, 18 (7.3%) failures were documented. The failures occurred in 21.1% of repairs managed with the all-inside device versus 4.3% of sutures managed with the suture hook (P = .003). Among the 6 factors included in the Cox model, the only one identified as a risk factor for failure was the type of repair (P = .003), with a risk for the all-inside device that was >5-fold higher than that for the suture hook repair (corresponding hazard ratio, 5.1 [95% CI, 1.8-14.5]). No other complications involving the surgical technique or device were registered.

CONCLUSION

An arthroscopic all-inside technique of meniscal repair of ramp lesions appeared to be safe and effective. It provided excellent healing of the repaired meniscus, with an overall failure rate of 7.3%. The type of suture was associated with failure of the ramp lesion repair, with a significantly higher risk with the all-inside device than with suture hook repair sutures.

Effects of different surgical procedures for meniscus injury on two-year clinical and radiological outcomes after anterior cruciate ligament reconstructions. -TMDU MAKS study

BACKGROUND

The treatment of meniscus injuries combined with anterior cruciate ligament (ACL) reconstruction would be important to improve outcomes after ACL reconstruction. However, the effects of treatment methods for meniscus after ACL reconstruction have not been thoroughly investigated. The objective of this study was to investigate the effects of treatment methods for meniscus on clinical and radiological outcomes at 2 years after ACL reconstruction.

METHODS

Three-hundred and eighteen patients with primary ACL reconstruction using autologous hamstring tendon registered in our multicenter study database and who were followed up for 2 years were included. They were then divided into 3 groups, the no meniscal lesion/untreated group (n = 149), the meniscal repair group (n = 139), and the meniscal resection group (n = 30). Patient-based subjective evaluations (Lysholm score, Knee injury and Osteoarthritis Outcome score and International Knee Documentation Committee subjective score), objective evaluations (Lachman test, pivot shift test and KT measurement), and radiological measurements (medial and lateral joint space width) were compared among the 3 groups preoperatively and at 2 years follow-up.

RESULTS

All subjective scores and objective evaluations significantly improved in all groups without significant differences among the groups postoperatively. Regarding radiological findings, the medial joint space width significantly decreased only in the resection group during the 2-year period, and the medial joint space width in the resection group was significantly smaller than that of the other groups at the 2-year follow-up. Moreover, the medial joint space width significantly decreased during the 2-year period when MM was resected.

CONCLUSIONS

In radiological findings, medial meniscus resection decreased medial joint space width two years after ACL reconstruction. On the other hand, treatment methods for meniscus neither significantly affected subjective nor objective findings until the 2-year follow-up.

LEVEL OF EVIDENCE

Ⅱ, Cohort study.

DOES PARTIAL MENISCECTOMY AFFECT ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION RESULTS?

OBJECTIVE

To compare the application of partial meniscectomy concomitant with primary ACL reconstruction, using the graft from the patellar tendon with individuals who underwent only ACL reconstruction, in clinical functional criteria and degree of osteoarthritis (OA), after 10 years of the surgical process.

METHODS

This is a retrospective cross-sectional study with 37 patients who underwent ACL reconstruction with a graft from the patellar tendon, associated or not with partial meniscectomy, divided into 2 groups: with meniscal injury (n = 22) and without meniscal injury (n = 15). Anthropometric data and four outcome measures were used to analyze the results: SF-36 questionnaire, arc of motion assessment, Knee injury and Osteoarthritis Outcome Score (KOOS), and Ahlbäck Radiographic Classification.

RESULTS

No differences were found for health-related quality of life, arc of motion, functional condition and knee OA severity/grade in patients who underwent partial or no meniscectomy in conjunction with ACL reconstruction (p > 0.05).

CONCLUSION

Participants who underwent partial meniscectomy in conjunction with primary ACL reconstruction with a graft from the patellar tendon, after 10 years of the surgical process, showed no significant differences in the clinical functional criteria and severity of knee OA, compared to individuals who underwent only ACL reconstruction. Level of Evidence II, Prognostic study.

Medialer und lateraler Meniskuskorbhenkelriss mit vorderer Kreuzbandruptur

Diese Kasuistik beschreibt den Fall und die Rekonstruktion einer kombinierten medialen und lateralen Korbhenkelläsion des Meniskus mit vorderer Kreuzbandruptur. Als Technik wurde eine Kombination aus Outside-in- und All-inside-Nahttechniken sowie ein ipsilateraler vierfacher Hamstring-Autograft in All-inside-Technik angewendet. Eine 47-jährige Patientin zog sich im Rahmen eines Fahrradsturzes ein Außenrotations-Valgusstress-Trauma des linken Kniegelenks zu. In der Magnetresonanztomographie (MRT) zeigte sich das für die Kombinationsverletzung typische Vierfach-Zeichen, welches auch als Jack-and-Jill-Läsion beschrieben wird. Die Rekonstruktion erfolgte 2 Wochen nach dem Unfall. Eine postoperative Arthrofibrose mit limitierter Knieflexion machte 4 Monate nach initialer Operation eine Revisionsarthroskopie mit Arthrolyse notwendig. Sechs Wochen nach Arthrolyse war die Patientin weiterhin asymptomatisch und erreichte eine aktive Knieflexion von 130°. Die Intention dieser Kasuistik war die Beschreibung dieser seltenen aber komplexen Knieverletzung außerhalb des professionellen Sportbereichs sowie deren operative Versorgung. Die klinischen und radiologischen Verlaufskontrollen zeigten eine regelrechte Rekonstruktion und Reorganisation des medialen und lateralen Meniskus sowie des vorderen Kreuzbands bei freiem und schmerzlosem Bewegungsumfang des Kniegelenks.

Kinematic Alterations After Anterior Cruciate Ligament Reconstruction via Transtibial Techniques With Medial Meniscal Repair Versus Partial Medial Meniscectomy

BACKGROUND

The treatment strategies for meniscal injuries during anterior cruciate ligament (ACL) reconstruction remain a topic of debate.

HYPOTHESIS

After ACL reconstruction, knee kinematics would be affected by different medial meniscal treatment (partial medial meniscectomy [PMM] and medial meniscal repair [MMR]).

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 161 patients underwent primary single-bundle ACL reconstruction and simultaneous medial meniscal treatment. Of these, 32 patients were eligible to participate in the kinematic assessment at 24.8 ± 1.7 months after surgery. Patients were divided into 2 groups: (1) those who underwent MMR (Group MMR; n = 18) and (2) those who underwent PMM (Group PMM; n = 14). Twenty healthy participants (Group Intact) were recruited who were comparable in age, body mass index, and sex. The kinematic parameters were collected using an optical tracking system during treadmill gait. Range of motion and kinematic parameters at key events during the gait cycle were compared between the 3 groups. The primary outcomes were the differences in adduction/abduction and internal/external rotation.

RESULTS

Patients in Group PMM walked with increased adduction as compared with those in Group Intact during the early stance phase (P = .003; η² = 0.172) and midstance phase (P = .003; η² = 0.167). In terms of internal/external rotation, patients in Group PMM walked with significantly larger tibial external rotation when compared with Group MMR by approximately 3.4° to 3.7° (loading response: P = .026, η² = 0.090; midstance: P = .035, η² = 0.093) and Group Intact (P = .028; η² = 0.095) in the early stance phase. In addition, there was significantly increased anterior tibial translation in Groups MMR and PMM compared with Group Intact.

CONCLUSION

ACL reconstruction (via transtibial technique) with concurrent PMM demonstrated larger adduction and external tibial rotation at 24 months of follow-up during level walking.

CLINICAL RELEVANCE

Patients undergoing different medial meniscal treatment strategies in the presence of ACL reconstruction showed distinct knee kinematics. These results suggest that MMR is strongly recommended during ACL reconstructive surgery to reduce the abnormal kinematics close to that of the ACL-intact condition.

The effect of meniscal pathology and management with ACL reconstruction on patient-reported outcomes, strength, and jump performance ten months post-surgery

BACKGROUND

The purpose of this study was to examine the differences in patient-reported outcome measures, isokinetic strength, plyometric ability and ability to meet return to play criteria ten months after anterior cruciate ligament (ACL) reconstruction surgery between those who underwent meniscectomy, those who underwent meniscal repair and those with no meniscal intervention alongside ACL reconstruction surgery.

METHODS

Three hundred and thirteen athletes with clinically and radiologically confirmed ACL ruptures were included in this study. Participants were grouped according to their intra-operative procedures (isolated ACL reconstruction surgery n = 155, ACL reconstruction surgery with meniscectomy n = 128, ACL reconstruction surgery with meniscal repair n = 30). Participants completed patient-reported outcome measures questionnaires (Marx Activity Rating Scale, the ACL Return to Sport after Injury and the International Knee Documentation Committee Score) and completed a battery of objective functional testing including isokinetic dynamometry and jump performance testing (countermovement jump and drop jump) between 9 and 11 months after surgery.

RESULTS

No significant between-group differences were identified in any metric relating to patient-reported outcome measures (p = .611), strength and jump measures (p = .411) or the ability to achieve symmetry-based return to play criteria (p = .575).

CONCLUSIONS

Clinically, these results suggest that concomitant meniscal surgery has no significant effects on patient-reported outcome measures, strength and jump metrics at the return to play stage post-operatively and can inform the pre-operative counselling of those awaiting ACL reconstruction surgery with likely meniscal intervention.

Anterior Cruciate Ligament Reconstruction With Concomitant Meniscal Repair: Is Graft Choice Predictive of Meniscal Repair Success?

Background

When meniscal repair is performed during anterior cruciate ligament (ACL) reconstruction (ACLR), the effect of ACL graft type on meniscal repair outcomes is unclear.

Hypothesis

The authors hypothesized that meniscal repairs would fail at the lowest rate when concomitant ACLR was performed with bone--patellar tendon--bone (BTB) autograft.

Study Design

Cohort study; Level of evidence, 3.

Methods

Patients who underwent meniscal repair at primary ACLR were identified from a longitudinal, prospective cohort. Meniscal repair failures, defined as any subsequent surgical procedure addressing the meniscus, were identified. A logistic regression model was built to assess the association of graft type, patient-specific factors, baseline Marx activity rating score, and meniscal repair location (medial or lateral) with repair failure at 6-year follow-up.

Results

A total of 646 patients were included. Grafts used included BTB autograft (55.7%), soft tissue autograft (33.9%), and various allografts (10.4%). We identified 101 patients (15.6%) with a documented meniscal repair failure. Failure occurred in 74 of 420 (17.6%) isolated medial meniscal repairs, 15 of 187 (8%) isolated lateral meniscal repairs, and 12 of 39 (30.7%) of combined medial and lateral meniscal repairs. Meniscal repair failure occurred in 13.9% of patients with BTB autografts, 17.4% of patients with soft tissue autografts, and 19.4% of patients with allografts. The odds of failure within 6 years of index surgery were increased more than 2-fold with allograft versus BTB autograft (odds ratio = 2.34 [95% confidence interval, 1.12-4.92]; P = .02). There was a trend toward increased meniscal repair failures with soft tissue versus BTB autografts (odds ratio = 1.41 [95% confidence interval, 0.87-2.30]; P = .17). The odds of failure were 68% higher with medial versus lateral repairs (P < .001). There was a significant relationship between baseline Marx activity level and the risk of subsequent meniscal repair failure; patients with either very low (0-1 points) or very high (15-16 points) baseline activity levels were at the highest risk (P = .004).

Conclusion

Meniscal repair location (medial vs lateral) and baseline activity level were the main drivers of meniscal repair outcomes. Graft type was ranked third, demonstrating that meniscal repairs performed with allograft were 2.3 times more likely to fail compared with BTB autograft. There was no significant difference in failure rates between BTB versus soft tissue autografts.

Registration

NCT00463099 (ClinicalTrials.gov identifier).

[Consequences of anterior cruciate ligament rupture: a systematic umbrella review]

INTRODUCTION

 The treatment of an anterior cruciate ligament rupture is still controversial. In particular, this applies to the question of conservative versus surgical treatment. The answer to this question is often based on consequential damage such as the development of posttraumatic osteoarthritis, secondary damage to the meniscus or cartilage, and participation in sports. If there are significant differences in these parameters between the individual treatment options, the results will be of great importance for the development of evidence-based treatment pathways. Therefore, the aim of this work was to evaluate the development of knee osteoarthritis after rupture of the anterior cruciate ligament and the corresponding treatment (conservative or surgical).

MATERIAL AND METHODS

 To answer the above question, a systematic literature search was conducted in Medline via Pubmed, the Cochrane Library and in CINAHL. Only systematic reviews with a minimum follow-up period of 10 years were included. The search was conducted in January 2020 and updated in January 2021. Investigated cohorts included patients with a rupture of the anterior cruciate ligament who had undergone either conservative or surgical treatment. Osteoarthritis was diagnosed either radiologically (recognized scores) or clinically (pain and impaired function). Appropriate reviews were qualitatively evaluated using the AMSTAR-2 questionnaire.

RESULTS

 The literature research initially identified n = 42 reviews from which 14 reviews were included. After full-text review and qualitative evaluation, only n = 2 systematic reviews remained for evaluation. The results of both papers show imprecise data with a high variability. However, it can be assumed with high probability that the development of osteoarthritis of the knee is increased after a rupture of the anterior cruciate ligament. There is no evidence that the incidence of joint degeneration may be reduced by reconstruction of the anterior cruciate ligament, nor is there a difference when comparing conservative and surgical treatment directly.

CONCLUSION

 Patients with an anterior cruciate ligament rupture are likely to be at a greater risk of developing progressive joint degeneration. A protective effect of cruciate ligament surgery has not been found in the evaluated studies. A general argument in favour of cruciate ligament surgery aiming to achieve a protective effect on hyaline articular cartilage seems obsolete based on the results and should therefore not be used in patient education in the future.

Female gender and medial meniscal lesions are associated with increased pain and symptoms following anterior cruciate ligament reconstruction in patients aged over 50 years

PURPOSE

Several studies report satisfactory clinical outcomes following ACLR in older patients, but none evaluated the effects of meniscal and cartilage lesions. The aim was to evaluate the influence of meniscal and cartilage lesions on outcomes of ACLR in patients aged over 50 years.

METHODS

The authors prospectively collected records of 228 patients that underwent primary ACLR, including demographics, time from injury to surgery, whether injuries were work related, and sports level (competitive, recreational, or none). At a minimum follow-up of 6 months, knee injury and osteoarthritis outcome scores (KOOS), International Knee Documentation Committee (IKDC) score and Tegner activity level were recorded, and differential laxity was measured as the side-to-side difference in anterior tibial translation (ATT) using instrumented laximetry devices. Regression analyses were performed to determine associations between outcomes and meniscal and cartilage lesions as well as nine independent variables.

RESULTS

A total of 228 patients aged 54.8 ± 4.3 years at index ACLR were assessed at a follow-up of 14.3 ± 3.8 months. KOOS subcomponents were 85 ± 13 for symptoms, 91 ± 10 for pain, 75 ± 18 for daily activities, 76 ± 18 for sport, and 88 ± 12 for quality of life (QoL). The IKDC score was A for 84 (37%) knees, B for 96 (42%) knees, C for 29 (13%) knees, and D for 8 (4%) knees. Tegner scores showed a decrease (median 0, range -4 to 4) and differential laxity also decreased (median - 4, range - 23.5 to 6.0). KOOS symptoms worsened with higher BMI (p = 0.038), for women (p = 0.007) and for knees that had medial meniscectomy (p = 0.029). KOOS pain worsened with higher BMI (p ≤ 0.001), for women (p = 0.002) and for knees with untreated (p = 0.047) or sutured (p = 0.041) medial meniscal lesions. Differential laxity increased with follow-up (p = 0.024) and in knees with lateral cartilage lesions (p = 0.031).

CONCLUSION

In primary ACLR for patients aged over 50 years, female gender and medial meniscal lesions significantly compromised KOOS symptoms and pain, while lateral cartilage lesions significantly increased differential laxity. Compared to knees with an intact medial meniscus, those with sutured or untreated medial meniscal lesions had worse pain, while those in which the medial meniscus was resected had worse symptoms. These findings are clinically relevant as they could help surgeons with patient selection and adjusting expectations according to their functional demands.

LEVEL OF EVIDENCE

III.

Risk of arthrofibrosis in anatomical anterior cruciate ligament reconstruction: the role of timing and meniscus suture

BACKGROUND

The optimal timing of anterior cruciate ligament (ACL) reconstruction remains controversial. Several studies have shown that early surgery leads to an increased rate of arthrofibrosis and poorer postoperative function. Other studies found no correlation between time of surgery and arthrofibrosis. The influence of simultaneous meniscus treatment is also discussed. Aim of this study was to ascertain whether the timing of surgery and treatment of meniscus influences the occurrence rate of arthrofibrosis.

METHODS

Two hundred and six patients could be included. These were split into two groups. Group 1: surgery within 6 weeks after ACL rupture (n = 68), group 2: surgery after more than 6 weeks (n = 68). In addition, 2 matched groups were created (n = 138 ). Follow-up was 12 months after surgery. The primary endpoint was the rate of subsequent arthrofibrosis procedures (arthroscopic arthrolysis). Secondary endpoints were knee function (knee osteoarthritis outcome score: KOOS), knee pain (numeric rating scale: NRS) and patient satisfaction measured on a 5 point Likert scale.

RESULTS

In 6 of the 68 patients in group 1 (8.8%) and 3 of the 138 patients in group 2 (2.2%) a subsequent arthroscopic arthrolysis was performed (OR 4.4). A simultaneous meniscal suture was performed in 58 patients (30 of them in group 1). Five of the six patients with subsequent arthrolysis in group 1 received meniscal repair (OR for arthrolysis 3.4). There was no difference between the groups in terms of knee function (KOOS), pain (NRS) and patient satisfaction.

CONCLUSION

The rate of subsequent arthroscopic arthrolysis was higher in the acute surgery group. However, most of these subsequent procedures were associated with meniscal repair at index surgery with a more restrictive rehabilitation protocol than after ACL reconstruction without meniscus repair. This allows the assessment that the meniscal suturing poses an increased risk. Therefore, this allows the conclusion that if using an anatomical surgical technique and considering the signs of inflammation with effusion, pain and movement deficit less than 90° there is no increased risk of arthrofibrosis.

Aseptic Revision and Reoperation Risks After Meniscectomy at the Time of Anterior Cruciate Ligament Reconstruction

BACKGROUND

An intact meniscus is considered a secondary stabilizer of the knee after anterior cruciate ligament reconstruction (ACLR). While loss of the meniscus can increase forces on the anterior cruciate ligament graft after reconstruction, it is unclear whether this increased loading affects the success of the graft after ACLR.

PURPOSE

To identify the risk of subsequent knee surgery when meniscectomy, either partial or total, is performed at the time of index ACLR.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

We conducted a matched cohort study using data from the Kaiser Permanente Anterior Cruciate Ligament Reconstruction Registry. Patients were identified who had a primary ACLR performed between January 1, 2005 and December 31, 2016, with up to 12 years of follow-up. The study sample comprised patients with ACLR who had a lateral meniscectomy (n = 2581), medial meniscectomy (n = 1802), or lateral and medial meniscectomies (n = 666). For each meniscectomy subgroup, patients with ACLR alone were matched to patients with a meniscectomy on a number of patient and procedure characteristics. After the application of matching, Cox proportional hazards regression was used to evaluate the risk of aseptic revision, while competing risks regression was used to evaluate the risk of cause-specific ipsilateral reoperation between meniscectomy and ACLR alone. Analysis was performed for each meniscectomy subgroup.

RESULTS

After the application of matching, we failed to observe a difference in aseptic revision risk for patients with ACLR and a meniscectomy-lateral (hazard ratio [HR], 0.80; 95% CI, 0.63-1.02), medial (HR, 0.95; 95% CI, 0.70-1.29), or both (HR, 1.25; 95% CI, 0.77-2.04)-as compared with ACLR alone. When compared with patients who had ACLR alone, patients with a lateral meniscectomy had a higher risk for subsequent lateral meniscectomy (HR, 1.89; 95% CI, 1.18-3.02; P = .008), and those with a medial meniscectomy had a lower risk for manipulation under anesthesia (HR, 0.13; 95% CI, 0.02-0.92; P = .041).

CONCLUSION

No difference in aseptic revision risk was observed for patients undergoing primary ACLR between groups with and without meniscectomy at the time of index surgery. Partial lateral meniscectomy at the time of index ACLR did associate with a higher risk of subsequent lateral meniscectomy.

Treatment after anterior cruciate ligament injury: Panther Symposium ACL Treatment Consensus Group

Treatment strategies for anterior cruciate ligament (ACL) injuries continue to evolve. Evidence supporting best practice guidelines for the management of ACL injury is to a large extent based on studies with low-level evidence. An international consensus group of experts was convened to collaboratively advance towards consensus opinions regarding the best available evidence on operative versus non-operative treatment for ACL injury.The purpose of this study was to report the consensus statements on operative versus non-operative treatment of ACL injuries developed at the ACL Consensus Meeting Panther Symposium 2019. Sixty-six international experts on the management of ACL injuries, representing 18 countries, convened and participated in a process based on the Delphi method of achieving consensus. Proposed consensus statements were drafted by the Scientific Organising Committee and Session Chairs for the three working groups. Panel participants reviewed preliminary statements prior to the meeting and provided initial agreement and comments on the statement via online survey. During the meeting, discussion and debate occurred for each statement, after which a final vote was then held. Eighty per cent agreement was defined a priori as consensus. A total of 11 of 13 statements on operative veresus non-operative treatment of ACL injury reached consensus during the symposium. Nine statements achieved unanimous support; two reached strong consensus; one did not achieve consensus; and one was removed due to redundancy in the information provided.In highly active patients engaged in jumping, cutting and pivoting sports, early anatomical anterior cruciate ligament reconstruction (ACLR) is recommended due to the high risk of secondary meniscus and cartilage injuries with delayed surgery, although a period of progressive rehabilitation to resolve impairments and improve neuromuscular function is recommended. For patients who seek to return to straight plane activities, non-operative treatment with structured, progressive rehabilitation is an acceptable treatment option. However, with persistent functional instability or when episodes of giving way occur, anatomical ACLR is indicated. The consensus statements derived from international leaders in the field will assist clinicians in deciding between operative and non-operative treatment with patients after an ACL injury.Level of evidence: V.

Indirect Magnetic Resonance Arthrography May Help Avoid Second Look Arthroscopy for Assessment of Healing After Bucket Handle Medial Meniscus Repairs: A Prospective Clinico-Radiological Observational Study

OBJECTIVES

The objectives were: (1) to analyze the MRI healing rates of bucket-handle meniscus repair; (2) to compare the accuracy of assessment of meniscus healing for conventional MRI and Indirect Magnetic Resonance Arthrography (IMRA); and (3) to identify patients who may require second-look arthroscopy after meniscus repair.

METHODS

This is a prospective observational case series of thirty-seven patients with repaired bucket-handle medial meniscus tear with a minimum one year follow-up. Meniscus healing rates were assessed on direct MRI and IMRA using Henning's criteria. At the same time, patients' symptoms were evaluated according to Barrett's criteria and functional outcomes were recorded using International Knee Documentation Committee (IKDC) score, Knee Osteoarthritis and Outcomes Score (KOOS) and Tegner-Lysholm scores. A further clinical review was performed 18 months after the imaging to assess the evolution of symptoms.

RESULTS

At a mean of 22.3 ± 7.8 months after the meniscus repair, 56.7% patients showed complete healing and 40.5% patients demonstrated incomplete repair healing on IMRA. 52% patients with complete healing and 40% patients with incomplete healing demonstrated meniscus symptoms. At the second clinical review, 19% patients with complete healing and 20% patients with incomplete healing had meniscus symptoms. There was no co-relation between symptoms, PROMs and healing on MRI.

CONCLUSION

Indirect MR arthrography offers distinct advantages over direct MRI for assessment of meniscus healing, especially in symptomatic patients. Patient-reported outcome measures and symptomatology are not co-related with the healing status of the meniscus and they resolve in the majority on longer follow-up. A more conservative approach guided by IMRA to assess meniscus healing will avoid early re-operations.

Steep posterior slope of the medial tibial plateau is associated with ramp lesions of the medial meniscus and a concomitant anterior cruciate ligament injury

Background

Medial meniscus (MM) tears are associated with both acute and chronic anterior cruciate ligament (ACL) insufficiency and can lead to degenerative changes in the knee. ACL reconstruction (ACLR) combined with the meniscal repair was reported to result in decreased anterior knee joint laxity with evidence of improved patient-reported outcomes in the long term. However, a subtle tear of the MM posterior segment, also known as a ramp lesion, is difficult to detect on conventional magnetic resonance imaging (MRI) and is frequently missed in ACL-deficient knees. However, there are few studies about the associations between bone geometry and ramp lesion of the MM. This study aimed to compare sagittal medial tibial slope (MTS), medial tibial plateau depth (MTPD), and coronal tibial slope (CTS) between ACL-injured knees with and without ramp lesion of the MM. We hypothesised that patients with ramp lesion of the MM and a concomitant ACL injury have a steeper MTS and shallower MTPD than those without ramp lesion of the MM.

Methods

Twenty-seven patients who underwent ACLR (group A), and 15 patients with combined MM repair (group AM) were included in the study. Anterior tibial translation (ATT) was measured under general anaesthesia just before surgery using a knee arthrometer. MRI was performed in the 10°-knee-flexed position. The MTS and MTPD were measured on sagittal view, and the CTS was measured on coronal view. These parameters were compared between the groups. Differences in MRI measurements or patient demographics between the groups were evaluated using the Mann-Whitney U test.

Results

No significant difference was observed in demographic data and post-operative side-to-side difference in ATT between both groups. Pre-operative ATT was significantly higher in group AM than in group A (P < 0.05), whereas post-operative ATT was similar in both groups. Further, Pre-operative ATT was significantly higher in patients with MTS ≥5.0° than in those with MTS <5.0° (P < 0.05). In groups A and AM, the MTS were 3.6° ± 1.8° and 6.2° ± 2.9°, the MTPD were 2.0 ± 0.5 mm and 2.1 ± 0.6 mm, and the CTS were 2.5° ± 1.8° and 2.4° ± 1.6°, respectively. Patients in group AM had a significantly steeper MTS compared to those in group A (P < 0.01), whereas MTPD and CTS were nearly the same in both groups. When the MTS cut-off value was set at 5.0°, the sensitivity and specificity for ACL injury with concomitant ramp lesion of the MM were 0.73 and 0.76, respectively.

Conclusion

A steep posterior slope of the medial tibial plateau is a risk factor for ramp lesion of the MM associated with an ACL injury. Especially in patients with MTS ≥5.0°, an occult MM ramp lesion should be strongly suspected, and surgeons should prepare for MM repair in combination with ACLR.

Recent Trends in Concomitant Meniscal Procedures During Anterior Cruciate Ligament Reconstruction

BACKGROUND

The chondroprotective effect and secondary stabilizing role of the meniscus has been well-established. Meniscal preservation during anterior cruciate ligament reconstruction (ACLR) has been advocated in the literature and supported by advancements in surgical techniques.

PURPOSE

To examine the recent trends in concomitant partial meniscectomy and meniscal repair procedures with ACLR.

STUDY DESIGN

Descriptive epidemiological study.

METHODS

Patients who underwent arthroscopic meniscectomy (Current Procedural Terminology [CPT] codes 29880, 29881), meniscal repair (CPT codes 29882, 29883), and ACLR (CPT code 29888) between 2010 and 2018 were identified using the National Surgical Quality Improvement Program database. We calculated the proportion of patients who underwent each surgery type, stratified by year and by patient age and body mass index (BMI) groups. The Cochran-Armitage test for trend was used to analyze yearly proportions of concomitant meniscal surgery types.

RESULTS

During the 9-year study period, 22,760 patients underwent either isolated ACLR (n = 10,562) or ACLR with concomitant meniscal surgery (either meniscectomy [n = 8931] or meniscal repair [n = 3267]). There was a gradual decrease in the proportion of meniscectomies (from 80.8% of concomitant procedures in 2010 to 63.8% in 2018), while the proportion of meniscal repairs almost doubled (from 19.2% in 2010 to 36.2% in 2018) (trend, P < .001). ACLR with meniscal repair increased in patients aged 35 to 44 years and 45 to 54 years (trend, P = .027) between 2010 and 2018; at the same time, the proportion of normal weight patients decreased by 17.7%, the proportion of overweight patients increased by 13.2%, and increases were seen in BMI groups corresponding to obesity classes 1 to 3 (trend, P < .001). In 2010, the average BMI of patients undergoing ACLR with meniscectomy versus meniscal repair differed by 2 (P = .004), but by 2018 the difference was nonsignificant (28.83 ± 5.80 vs 28.53 ± 5.73; P = .113).

CONCLUSION

Between 2010 and 2018, there was an upward trend in the proportion of meniscal repairs performed during ACLR, with notable increases in the proportion of repairs being performed on older, overweight, and obese patients.

Return to Driving After Anterior Cruciate Ligament Reconstruction: A Systematic Review

Background

Guidelines for return to driving after anterior cruciate ligament reconstruction (ACLR) have not been established.

Purpose

To review the literature pertaining to driving after ACLR and provide evidence-based guidelines to aid clinicians in counseling patients about driving after ACLR.

Study Design

Systematic review; Level of evidence, 4.

Methods

A systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Two independent reviewers searched PubMed, EMBASE, and the Cochrane Library using the terms anterior cruciate ligament, ACL, drive, and driving. Studies reporting on functional recovery after ACLR were included when data regarding return to driving were reported.

Results

Five studies were included. Two studies included patients who underwent right-sided ACLR. Of these, 1 study evaluated bone-patellar tendon-bone autograft and reported that brake response time (BRT) returned to normal approximately 4 to 6 weeks postoperatively. The other study found that BRT returned to normal 3 weeks after allograft ACLR, but 6 weeks elapsed after autograft ACLR before values were not significantly different than controls. One study reported that patients who underwent left-sided hamstring tendon autograft ACLR demonstrated BRTs similar to controls within 2 weeks, while those with right-sided ACLR had significantly slower BRTs until 6 weeks postoperatively. Another study including patients who underwent either right- or left-sided ACLR and employed a manual transmission simulator found that 4 to 6 weeks should elapse after ACLR with hamstring tendon autograft. Survey data from 1 study demonstrated that the mean time for patients to resume driving was 13 and 10 days after right- and left-sided ACLR, respectively.

Conclusion

BRT returned to normal values approximately 4 to 6 weeks after right-sided ACLR and approximately 2 to 3 weeks after left-sided ACLR. According to 1 study in this review, ACLR laterality should be disregarded for patients who drive manual transmission automobiles, as a 4- to 6-week time period was required for driving ability to reach the level of healthy controls. Future studies should aim to elucidate the influence of graft choice and transmission type on return to driving after ACLR.

Yeast microcapsule-mediated oral delivery of IL-1β shRNA for post-traumatic osteoarthritis therapy

Post-traumatic osteoarthritis is a prevalent debilitating joint disease. However, there is no FDA-approved disease-modifying osteoarthritis drug currently. Gene therapy can improve disease progression but lacks an effective delivery system. Here, we constructed an oral drug delivery system by non-virus-mediated interleukin-1β (IL-1β) short hairpin RNA (shRNA) and non-pathogenic yeast to evaluate its effect on osteoarthritis therapy. After recombinant IL-1β shRNA/yeast therapy, yeast microcapsule-mediated oral delivery of IL-1β shRNA greatly reduced the IL-1β expression in intestine macrophage, bone marrow macrophage, and articular cartilage, systematically regulate the inflammatory response. The degeneration of articular cartilage was significantly inhibited in the medial femoral condyle and medial tibial plateau of the knee joint. And the expression of osteoarthritis markers Col X and MMP13 was reduced in the knee joint. Thus, yeast microcapsule-mediated oral delivery of IL-1β shRNA may serve as a novel gene therapy strategy for treating joint degeneration through immunomodulation of the mononuclear phagocyte system from the intestine to subchondral bone marrow and ultimately preserving the articular cartilage joint.

Meniscus repairs in the adolescent population-safe and reliable outcomes: a systematic review

PURPOSE

The purpose of this study was to determine the outcomes of meniscus repair in the adolescent population, including: (1) failure and reoperation rates, (2) clinical and functional results, and (3) activity-related outcomes including return to sport.

METHODS

Two authors independently searched MEDLINE, Cochrane Central Register of Controlled Trials & Cochrane Library, and CINHAL databases for literature related to meniscus repair in an adolescent population according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. No meta-analysis was performed in this qualitative systematic review.

RESULTS

Thirteen studies, including no Level I, one Level II, one Level III, and eleven Level IV studies yielded 466 patients with 503 meniscus repairs. All defined meniscal re-tear as a primary endpoint, with a reported failure rate ranging from 0 to 42% at a follow-up ranging from 22 to 211 months. There were a total of 93 failed repairs. IKDC scores were reported in four studies with a mean improvement ranging from 24 to 42 (P < 0.001). Mean post-operative Lysholm scores were reported in seven studies, ranging from 85 to 96. Additionally, four of those studies provided mean pre-operative Lysholm scores, ranging from 56 to 79, with statistically significant mean score improvements ranging from 17 to 31. Mean post-operative Tegner Activity scores were reported in nine studies, with mean values ranging from 6.2 to 8.

CONCLUSION

This systematic review demonstrates that both subjective and clinical outcomes, including failure rate, Lysholm, IKDC, and Tegner activity scale scores, are good to excellent following meniscal repair in the adolescent population. Further investigations should aim to isolate tear type, location, surgical technique, concomitant procedures, and rehabilitation protocols to overall rate of failure and clinical and functional outcomes.

LEVEL OF EVIDENCE

IV.

Arthroscopic anterior cruciate ligament reconstruction is a reliable option to treat knee instability in patients over 50 years old

PURPOSE

To evaluate return to sport and clinical outcomes with at least 2 years followup after arthroscopic reconstruction ACL in population over 50 years-old.

METHODS

eighty-one patients aged 50 years or older underwent isolated, primary ACL reconstruction with hamstring autograft between 2014 and 2016. In all patients, a period of conservative treatment had failed (minimum 6 months), and they complained of functional instability and/or limitation during daily activity. Patients were assessed preoperatively and at the latest follow-up with a physical examination, return to sports activity, the Lysholm score, the International Knee Documentation Committee scoring system, the Knee injury and Osteoarthritis Outcome Score, and the Tegner activity scale. Data regarding complications and revision surgeries were collected at 2-year follow-up.

RESULTS

At the last follow-up, significant improvement in outcome scores from pre- to postoperative assessments was found. The mean overall IKDC score increased from a preoperative mean of 54.4-82.9 (p < 0.001). Mean preoperative Lysholm score increased from a preoperative mean of 67.4-90.4 (p < 0.001). The mean overall KOOS score increased from a preoperative mean (p < 0.001). Median preoperative Tegner score was 5 (range 2-8) and median postoperative score was 5 (range 1-7). 86% of patients returned to the sport, 51% to their preinjury sports level. Tegner score, before accident, was the only positive influencing factor a return to pre-injury level of the sport.

CONCLUSION

Arthroscopic reconstruction ACL in patients over 50 years-old resulted in excellent functional outcomes, with most patients returning to sport and at the same level they had before the injury.

LEVEL OF EVIDENCE

Level IV.

An Up-to-Date Review of the Meniscus Literature: A Systematic Summary of Systematic Reviews and Meta-analyses

Background:

A large number of systematic reviews and meta-analyses regarding the meniscus have been published.

Purpose:

To provide a qualitative summary of the published systematic reviews and meta-analyses regarding the meniscus.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A systematic search of all meta-analyses and systematic reviews regarding the meniscus and published between July 2009 and July 2019 was performed with PubMed, CINAHL, EMBASE, and the Cochrane database. Published abstracts, narrative reviews, articles not written in English, commentaries, study protocols, and topics that were not focused on the meniscus were excluded. The most pertinent results were extracted and summarized from each study.

Results:

A total of 332 articles were found, of which 142 were included. Included articles were summarized and divided into 16 topics: epidemiology, diagnosis, histology, biomechanics, comorbid pathology, animal models, arthroscopic partial meniscectomy (APM), meniscal repair, meniscal root repairs, meniscal allograft transplantation (MAT), meniscal implants and scaffolds, mesenchymal stem cells and growth factors, postoperative rehabilitation, postoperative imaging assessment, patient-reported outcome measures, and cost-effectiveness. The majority of articles focused on APM (20%), MAT (18%), and meniscal repair (17%).

Conclusion:

This summary of systematic reviews and meta-analyses delivers surgeons a single source of the current evidence regarding the meniscus.

Does Anterior Cruciate Ligament Reconstruction Protect the Meniscus and Its Repair? A Systematic Review

Background:

Anterior cruciate ligament (ACL) tear and meniscal injury often co-occur. The protective effect of early ACL reconstruction (ACLR) on meniscal injury and its repair is not clear. Critical literature review can support or change clinical strategies and identify gaps in the available evidence.

Purpose:

To assess the protective effect of ACLR on the meniscus and provide clinical guidelines for managing ACL tears and subsequent meniscal injury. We aimed to answer the following questions: (1) Does ACLR protect the meniscus from subsequent injury? (2) Does early ACLR reduce secondary meniscal injury compared with delayed ACLR? (3) Does ACLR protect the repaired meniscus?

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A systematic review was performed through use of MEDLINE and Embase electronic databases according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Search terms included ACL, reconstruction, and meniscus. Studies describing primary ACLR and nonoperative treatment in adult patients were included, as well as studies indicating timing of ACLR. The included articles were assessed individually for risk of bias through use of the modified Cochrane Risk of Bias and MINORS (Methodological Index for Nonrandomized Studies) tools.

Results:

One level 2 randomized controlled trial and several level 3 and 4 studies indicated a protective effect of ACLR on meniscal injury compared with nonoperative treatment. There was weak (level 3) evidence of the protective effect of early ACLR on the meniscus. Meniscal repair failure was less frequent in patients with ACL reconstruction than in patients with ACL deficiency (level 4).

Conclusion:

The evidence collected in this review suggests a protective effect of ACLR for subsequent meniscal injury (level 2 evidence). ACLR should be performed within 3 months of injury (level 3 evidence). Meniscal injury requiring surgical repair in the ACL-deficient knee should be treated with repair accompanied by ACLR (level 3 evidence). The paucity of level 2 studies prevents the formation of guidelines based on level 1 evidence. There is a strong clinical need for randomized or prospective trials to provide guidelines on timing of ACLR and meniscal repair.

Treatment after ACL injury: Panther Symposium ACL Treatment Consensus Group

Treatment strategies for ACL injuries continue to evolve. Evidence supporting best practice guidelines to manage ACL injury is largely based on studies with low-level evidence. An international consensus group of experts was convened determine consensus regarding best available evidence on operative versus non-operative treatment for ACL injury. The purpose of this study is to report the consensus statements on operative versus non-operative treatment of ACL injuries developed at the ACL Consensus Meeting Panther Symposium 2019. Sixty-six international experts on the management of ACL injuries, representing 18 countries, convened and participated in a process based on the Delphi method of achieving consensus. Proposed consensus statements were drafted by the Scientific Organising Committee and Session Chairs. Panel participants reviewed preliminary statements prior to the meeting and provided initial agreement and comments on the statement via online survey. During the meeting, discussion and debate occurred for each statement, after which a final vote was then held. Eighty per cent agreement was defined a priori as consensus. A total of 11 of 13 statements on operative versus non-operative treatment of ACL injury reached consensus during the Symposium. Nine statements achieved unanimous support, two reached strong consensus, one did not achieve consensus, and one was removed due to redundancy in the information provided. In highly active patients engaged in jumping, cutting and pivoting sports, early anatomical ACL reconstruction is recommended due to the high risk of secondary meniscus and cartilage injuries with delayed surgery, although a period of progressive rehabilitation to resolve impairments and improve neuromuscular function is recommended. For patients who seek to return to straight plane activities, non-operative treatment with structured, progressive rehabilitation is an acceptable treatment option. However, with persistent functional instability, or when episodes of giving way occur, anatomical ACL reconstruction is indicated. The consensus statements derived from international leaders in the field may assist clinicians in deciding between operative and non-operative treatment with patients after an ACL injury. Level of evidence: Level V

Yeast Cell wall Particle mediated Nanotube-RNA delivery system loaded with miR365 Antagomir for Post-traumatic Osteoarthritis Therapy via Oral Route

Post-traumatic osteoarthritis (PTOA) is an acute injury-induced joint inflammation followed by a gradual degradation of articular cartilage. However, there is no FDA-approved Disease-Modifying Osteoarthritis Drug currently. Although gene therapy with microRNA can improve PTOA progression, there is no effective gene delivery vehicle for orally deliver therapeutics due to the harsh environment of the gastrointestinal tract. In this study, we investigated the effect of yeast cell wall particle (YCWP) mediated nanotube-RNA delivery system on PTOA therapy via oral route. Methods: Nontoxic and degradable AAT and miRNA365 antagomir was self-assembled into miR365 antagomir/AAT (NPs). Then NPs-YCWP oral drug delivery system was constructed by using NPs and non-pathogenic YCWP which can be specifically recognized by macrophages. Moreover, surgical destabilization of the medial meniscus induced PTOA mice model was established to evaluate the therapeutic effect of NPs-YCWP via oral route. Results: Compared with control group, NPs showed higher gene inhibition efficiency both in chondrogenic cell line and primary chondrocytes in vitro. Treatment of macrophages with fluorescently labeled NPs-YCWP, the results showed that NPs-YCWP was successfully engulfed by macrophages and participated in the regulation of gene expression in vitro. Under the protection of YCWP, miR365 antagomir/AAT passes through the gastrointestinal tract without degradation after oral administration. After NPs-YCWP therapy, the results of histological staining, gene and protein expression showed that miR365 antagomir/NPs-YCWP improved the symptom of PTOA. Conclusion: Here, we constructed a biodegradable drug delivery system based on non-pathogenic YCWP and nanotubes, which can be used for PTOA therapy via the oral route. It suggests a new gene therapy strategy with YCWP mediated oral nano drug delivery system may serve as a platform for joint degeneration treatment.

Treatment After Anterior Cruciate Ligament Injury: Panther Symposium ACL Treatment Consensus Group

Treatment strategies for anterior cruciate ligament (ACL) injuries continue to evolve. Evidence supporting best-practice guidelines for the management of ACL injury is to a large extent based on studies with low-level evidence. An international consensus group of experts was convened to collaboratively advance toward consensus opinions regarding the best available evidence on operative versus nonoperative treatment for ACL injury. The purpose of this study was to report the consensus statements on operative versus nonoperative treatment of ACL injuries developed at the ACL Consensus Meeting Panther Symposium 2019. There were 66 international experts on the management of ACL injuries, representing 18 countries, who were convened and participated in a process based on the Delphi method of achieving consensus. Proposed consensus statements were drafted by the scientific organizing committee and session chairs for the 3 working groups. Panel participants reviewed preliminary statements before the meeting and provided initial agreement and comments on the statement via online survey. During the meeting, discussion and debate occurred for each statement, after which a final vote was then held. Ultimately, 80% agreement was defined a priori as consensus. A total of 11 of 13 statements on operative versus nonoperative treatment of ACL injury reached consensus during the symposium. Overall, 9 statements achieved unanimous support, 2 reached strong consensus, 1 did not achieve consensus, and 1 was removed because of redundancy in the information provided. In highly active patients engaged in jumping, cutting, and pivoting sports, early anatomic ACL reconstruction is recommended because of the high risk of secondary meniscal and cartilage injuries with delayed surgery, although a period of progressive rehabilitation to resolve impairments and improve neuromuscular function is recommended. For patients who seek to return to straight-plane activities, nonoperative treatment with structured, progressive rehabilitation is an acceptable treatment option. However, with persistent functional instability, or when episodes of giving way occur, anatomic ACL reconstruction is indicated. The consensus statements derived from international leaders in the field will assist clinicians in deciding between operative and nonoperative treatment with patients after an ACL injury.

All-Inside Quadrupled Semitendinosus Autograft Shows Stability Equivalent to Patellar Tendon Autograft Anterior Cruciate Ligament Reconstruction: Randomized Controlled Trial in Athletes 24 Years or Younger

PURPOSE

To compare clinical outcomes of knee anterior cruciate ligament (ACL) autograft reconstruction using all-inside quadrupled semitendinosus (AIST) versus bone-patellar tendon-bone (BPTB) in a high-risk athletic population 24 years or younger.

METHODS

Skeletally mature candidates younger than 24 years old with an ACL tear were randomized into either the AIST (n = 32) or BPTB (n = 32) group and were followed for 2 years. Magnetic resonance imaging scans were obtained at 1-year follow-up, and radiographs were obtained at 2-year follow-up. All surgeries were performed by a single surgeon using an anteromedial portal to establish the femoral tunnel. The primary outcome measure was KT-1000 stability testing. Secondary outcome measures included International Knee Documentation Committee (IKDC) Knee Evaluation Form, IKDC Subjective Form, Knee Injury and Osteoarthritis Outcome Score, Marx Activity Scale, visual analog pain scale, and SF-12 (Mental and Physical).

RESULTS

At 2-year follow-up, no statistical difference existed with KT-1000-measured side-to-side laxity between AIST (0.3 ± 0.7 mm, 95% confidence interval 0.0-1.0 mm) and BPTB (0.0 ± 0.8 mm, confidence interval CI -0.3 to 1.1 mm) (P = .197). In addition, no statistical differences between the groups were found for IKDC Subjective Form, Knee Injury and Osteoarthritis Outcome Score, Marx, SF-12 Mental, SF-12 Physical, or with regards to imaging findings. Patients with BPTB reported significantly greater postoperative pain scores at days 2 (P = .049), 3 (P = .004), and 7 (P = .015) and had significantly greater kneeling pain at 2 years (P < .019). A return to sport questionnaire at 2 years revealed no significant difference between the groups for returning to preoperative level of sport activity (83% AIST, 74% BPTB; P = .415). Two graft retears (7%; P = .222) occurred in the AIST group. Three patients in the BPTB group experienced ACL tears in the contralateral knee (9%; P = .239).

CONCLUSIONS

ACL reconstruction with an all-inside quadrupled semitendinosus autograft construct is equivalent to patellar BPTB autograft based on KT-1000 stability testing in athletes 24 years or younger.

LEVEL OF EVIDENCE

randomized controlled trial with 92% 2-year follow-up, Level I.

Anterior Cruciate Ligament Reconstruction in Patients Older Than 50 Years: A Systematic Review and Meta-analysis

Background:

There is no consensus regarding the best treatment approach for middle-aged patients with anterior cruciate ligament (ACL) injuries. Chronic ACL-deficient knees are often associated with instability as well as secondary meniscal and cartilage lesions. ACL reconstruction (ACLR) has achieved satisfactory outcomes in younger patients; however, the effectiveness and safety of ACLR in middle-aged patients remain uncertain.

Purpose:

To compare the patient-reported functional scores, arthrometric outcomes, and complications of primary ACLR between older (≥50 years) and younger (<50 years) patients.

Study Design:

Systematic review; Level of evidence, 3.

Methods:

We conducted a systematic review of cohort studies that compared the clinical outcomes of ACLR between patients aged ≥50 years and those aged <50 years. The Cochrane Central Register of Controlled Trials, Embase, and MEDLINE databases were searched for relevant studies. The Methodological Index for Non-randomized Studies (MINORS) criteria was used to assess the risk of bias and conducted a random-effects meta-analysis to combine the data, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to evaluate the overall quality of the body of retrieved evidence. The primary outcome was knee functional outcomes, and secondary outcomes were arthrometric outcomes of ACLR and complications.

Results:

This study included 4 retrospective cohort studies with a total of 287 participants (129 in the older group and 158 in the younger group). All included studies reported significant improvements in clinical outcomes in both groups after ACLR. No significant differences were noted in the improvement of International Knee Documentation Committee (IKDC) scores (mean difference [MD], 0.20 [95% CI, −2.65 to 3.05]; P = .89) and Lysholm scores (MD, −1.98 [95% CI, −6.93 to 2.98]; P = .43) between the 2 groups. No significant differences were observed in anteroposterior stability or risk of complications between the groups.

Conclusion:

ACLR may be performed in middle-aged patients (≥50 years) without concern for inferior clinical and arthrometric results compared with younger patients (<50 years).

Inside-Out Repair of the Meniscus in Concomitant Anterior Cruciate Ligament Reconstruction: Absorbable Versus Nonabsorbable Sutures

PURPOSE

To compare the clinical and magnetic resonance imaging (MRI) outcomes of meniscal repair using absorbable versus nonabsorbable sutures in patients undergoing concomitant anterior cruciate ligament reconstruction.

METHODS

Data of 142 patients who underwent meniscal repair with concomitant anterior cruciate ligament reconstruction using either absorbable or nonabsorbable sutures for longitudinal meniscal tear were retrospectively reviewed. Inside-out suture technique was used for all meniscal repairs. Weight bearing and flexion (>90°) were allowed after 6 weeks postoperatively. Clinical evaluations were assessed by the International Knee Documentation Committee subjective score, Lysholm score, and Tegner activity score preoperatively and at 2-year follow-up. MRI outcomes at 1-year follow-up were compared to identify the successful healing (complete or partial healing) rate and incidence of additional meniscal tears. Subgroup analysis was performed to evaluate the results of medial or lateral meniscus.

RESULTS

Eighty patients underwent meniscal repair using absorbable sutures (mean age, 26.3 ± 11.9 years) and 62 patients with nonabsorbable sutures (mean age, 27.2 ± 10.0 years). There were no differences in zone and length of meniscal tears and stability tests between the groups. At a 2-year follow-up, all clinical scores had improved in both groups but did not differ significantly between the groups. Successful healing rate based on 1-year postoperative MRI was not significantly different between the absorbable and nonabsorbable sutures (93.7% vs 96.8%, P = .469). However, the absorbable sutures showed a lower additional tear incidence than the nonabsorbable sutures (2.5% vs 9.6%, P = .031). Subgroup analysis showed that the successful healing rate was not significantly different between the suture materials in both the medial and lateral menisci.

CONCLUSIONS

The use of absorbable sutures leads to comparable healing rates to and lower incidence of additional tears than nonabsorbable sutures in patients undergoing meniscal repair with anterior cruciate ligament reconstruction.

LEVEL OF EVIDENCE

Level III, retrospective comparative therapeutic trial.

Meniscus Repair Does Not Result in an Inferior Short-term Outcome Compared With Meniscus Resection: An Analysis of 5,378 Patients With Primary Anterior Cruciate Ligament Reconstruction

PURPOSE

To compare the preoperative and 1- and 2-year postoperative Knee Injury and Osteoarthritis Outcome Score (KOOS) subscale scores between isolated anterior cruciate ligament reconstruction (ACLR) and ACLR with additional medial meniscus (MM) and/or lateral meniscus (LM) resection or repair.

METHODS

A total of 5,378 patients who underwent primary ACLR, with no associated ligament injuries, at our institution from January 2005 to December 2015 were included. The KOOS subscale scores were used to evaluate patients preoperatively and at 1- and 2-year postoperative follow-up assessments. Patients who underwent isolated ACLR and those who underwent ACLR with additional MM resection, MM repair, LM resection, LM repair, MM plus LM resection, or MM plus LM repair were compared by use of an analysis of covariance, with age, sex, graft, and cartilage injury as covariates.

RESULTS

Postoperatively, at both 1- and 2-year follow-up assessments, no significant differences were found between the groups for any of the 5 KOOS subscales. Preoperatively, a significant difference between the groups was found for the KOOS Symptoms (P < .001), Pain (P < .001), Activities of Daily Living (ADL) (P < .001), and Sport and Recreation (Sport/Rec) (P = .01) subscale scores. The lowest scores were found for the group undergoing ACLR and MM plus LM repair (Symptoms, 70.1 ± 17.3; Pain, 71.4 ± 18.5; ADL, 80.6 ± 20.5; and Sport/Rec, 35.7 ± 28.1), whereas the mean scores for the other groups ranged from 71.2 ± 18.7 to 76.5 ± 17.1 for Symptoms, from 76.1 ± 17.0 to 80.1 ± 15.5 for Pain, from 84.5 ± 16.8 to 88.1 ± 14.2 for ADL, and from 44.2 ± 28.3 to 49.1 ± 28.5 for Sport/Rec.

CONCLUSIONS

Patients undergoing isolated ACLR and those undergoing ACLR with additional MM and/or LM resection or repair obtained equivalent results for each of the KOOS subscales at the 1- and 2-year postoperative follow-up assessments. Differences between the groups were only detectable preoperatively, with patients undergoing ACLR and MM plus LM repair showing the lowest scores for the KOOS Symptoms, Pain, ADL, and Sport/Rec subscales.

LEVEL OF EVIDENCE

Level III, retrospective comparative therapeutic trial.

Editorial Commentary: Meniscal Repair-Why Bother?

Whether to repair or resect meniscal tears remains a matter of controversy. In theory, partial meniscectomy increases contact pressure, which may result in progressive and early cartilage degeneration and early osteoarthritis. Meniscal preservation is the preferred treatment option, but only a small percentage of meniscal tears are suitable for repair. Two recent registry studies challenge this approach and suggest that partial meniscectomy has similar clinical outcomes in the short term. Whether these findings can be maintained in the long term remains to be seen.

Knee Arthroscopy: The "Crevice Sign," a New Pathognomonic Sign for Unstable Posterior Medial Meniscal Tear in Anterior Cruciate Ligament-Deficient Knees

There has been increased emphasis on medial meniscus repair in the anterior cruciate ligament-reconstructed knee, as this improves stability. We describe an arthroscopic sign of an unstable medial meniscal tear that is diagnostic. The "crevice sign" is a longitudinal fissure located on the distal medial femoral condyle. In the anterior cruciate ligament-deficient knee, there is increased strain on the medial meniscus. A posterior longitudinal medial meniscal tear can occur at the time of the index injury or with subsequent instability events. During this injury, the knee pivots and the anterior edge of the unstable medial meniscus digs into the articular cartilage of the medial femoral condyle, resulting in a longitudinal split of the distal femoral condyle articular cartilage. If this sign is observed during arthroscopy, it is recommended that surgeons thoroughly probe the medial meniscus to ensure no pathology is missed.