1
|
Gopinatth V, Batra AK, Chahla J, Smith MV, Matava MJ, Brophy RH, Knapik DM. Degenerative Meniscus Tears Treated Nonoperatively With Platelet-Rich Plasma Yield Variable Clinical and Imaging Outcomes: A Systematic Review. Arthrosc Sports Med Rehabil 2024; 6:100916. [PMID: 38525288 PMCID: PMC10960087 DOI: 10.1016/j.asmr.2024.100916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 02/14/2024] [Indexed: 03/26/2024] Open
Abstract
Purpose To perform a systematic review on clinical and radiologic outcomes for meniscus tears treated nonoperatively with platelet-rich plasma (PRP). Methods A literature search was performed according to the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using keywords and Boolean operators in SCOPUS, PubMed, Medline, and the Cochrane Central Register for Controlled Trials in April 2023. Inclusion criteria were limited to Level I to IV human studies reporting on outcomes of meniscus tears treated nonoperatively with PRP. Results A total of 6 studies, consisting of 184 patients, were identified. There was 1 Level I study and 5 Level IV studies. Mean patient age was 47.8 ± 7.9 years, with 62% (n = 114/184) being female. The medial meniscus was treated in 95.7% (n = 157/164) of patients. Mean follow-up ranged from 75.9 days to 31.9 months. Meniscus tears were generally described as chronic, degenerative, or intrasubstance. In 4 studies, magnetic resonance imaging revealed variable improvement in meniscus grade with complete healing in 0% to 44% of patients and partial healing in 0% to 40% of patients. Four of 5 studies reported significant statistical improvement in pain from baseline to final follow-up. Studies reporting on clinical outcomes showed significant improvements Lysholm score (2 studies), Knee injury and Osteoarthritis Outcome Score total score (2 studies), and Tegner score (1 study). Successful return to sport occurred in 60% to 100% of patients. Two studies reported that most patients were either very satisfied or satisfied following treatment. Conclusions The use of PRP injections for the treatment of meniscus tears led to variable results based on postoperative magnetic resonance evaluation and improvements in clinical outcomes, although the clinical significance remains unclear. The heterogeneity of PRP protocols, short-term follow-up, and lack of comparative studies limit findings. Level of Evidence Level IV, systematic review of Level I to IV studies.
Collapse
Affiliation(s)
- Varun Gopinatth
- Saint Louis University School of Medicine, St. Louis, Missouri, U.S.A
| | - Anjay K. Batra
- Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Jorge Chahla
- Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Matthew V. Smith
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Matthew J. Matava
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Robert H. Brophy
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Derrick M. Knapik
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| |
Collapse
|
2
|
Chahla J, Knapik DM, Jawanda H, Allende F, Rivarola H, McCormick JR, LaPrade RF, Jackson GR. Meniscal Radial Tears: A Classification System Based on Tear Morphology. Arthrosc Tech 2024; 13:102888. [PMID: 38584632 PMCID: PMC10995731 DOI: 10.1016/j.eats.2023.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 11/04/2023] [Indexed: 04/09/2024] Open
Abstract
Appropriate management of radial meniscal tears is complex, with continued efforts focused on optimizing diagnostic methods for identification to help dictate treatment, especially as surgical indications for repair have expanded, coupled with improvements in surgical techniques and instrumentation. Currently, no standardized classification system for radial meniscal tears exists, limiting the ability to accurately characterize injury patterns and guide surgical decision-making.
Collapse
Affiliation(s)
- Jorge Chahla
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Derrick M Knapik
- Department of Orthopaedic Surgery, Washington University and Barnes-Jewish Orthopedic Center, Chesterfield, Missouri, U.S.A
| | - Harkirat Jawanda
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Felicitas Allende
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Horacio Rivarola
- Department of Orthopaedic Surgery, Hospital Universitario Austral, Buenos Aires, Argentina
| | - Johnathon R McCormick
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | | | - Garrett R Jackson
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| |
Collapse
|
3
|
Choi NH, Yang BS, Lee DM, Lee CR. Association of Increased Lateral Femoral Condylar Ratio With Lateral Meniscus Posterior Root Tear in Noncontact ACL Injury. Orthop J Sports Med 2024; 12:23259671231224023. [PMID: 38435716 PMCID: PMC10908231 DOI: 10.1177/23259671231224023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 08/10/2023] [Indexed: 03/05/2024] Open
Abstract
Background In the setting of anterior cruciate ligament (ACL) injury, lateral meniscus posterior root tears (LMPRTs) are less readily diagnosed on preoperative magnetic resonance imaging (MRI). Therefore, to predict LMPRTs in ACL injuries, it is necessary to understand the risk factors associated with them. Purpose/Hypothesis The purpose of this study was to investigate the association of lateral femoral condylar ratio (LFCR) with LMPRTs in ACL injuries. It was hypothesized that an increased LFCR would be associated with LMPRTs in noncontact ACL injuries. Study Design Cohort study; Level of evidence, 3. Methods Enrolled were consecutive patients who underwent primary acute (<6 weeks from injury) ACL reconstruction after noncontact injury and had LMPRT confirmed on preoperative MRI and arthroscopically (combined group; n = 62) as well as patients who underwent isolated acute ACL reconstruction (isolated group; n = 80) who were matched to the combined group by age, height, and body mass index (BMI). All patients underwent surgery between January 1999 and November 2021. LFCR and posterior tibial slope (PTS) were measured and compared between the isolated and combined groups. The area under the receiver operating characteristic curve (AUC) was calculated to determine the cutoff for detecting increased risk of LMPRTs. Results The demographic characteristics of the 2 groups did not differ significantly, nor did the PTS. The LFCR was a significant factor (odds ratio [OR], 1.23; P = .001) associated with LMPRT. Patient age, height, BMI, and PTS were not associated with LMPRT. The AUC (0.66; 95% CI, 0.57-0.75) for LFCR had a sensitivity of 39% and specificity of 90% to predict LMPRT. The calculated cutoff associated with an increased risk for LMPRT when compared with the isolated group was 67.0% (OR, 4.98; 95% CI, 2.10-11.79). Conclusion Increased LFCR was associated with the presence of LMPRTs in patients with acute ACL injuries. The LFCR may provide surgeons with additional information regarding the risk of having a concomitant LMPRT when planning ACL reconstructions.
Collapse
Affiliation(s)
- Nam-Hong Choi
- Department of Orthopedic Surgery, Eulji Medical Center, Seoul, Republic of Korea
| | - Bong-Seok Yang
- Department of Orthopaedic Surgery, Shihwa Medical Center, Siheung, Republic of Korea
| | - Dong-Min Lee
- Department of Orthopedic Surgery, Gwangmyeong Sungae Hospital, Gwangmyeong, Republic of Korea
| | - Choong-Ryul Lee
- Department of Orthopedic Surgery, Gwangmyeong Sungae Hospital, Gwangmyeong, Republic of Korea
| |
Collapse
|
4
|
Nabeki S, Okada Y, Teramoto A, Shibata Y, Takahashi K, Shiwaku K, Kamiya T, Watanabe K, Fujimiya M, Fujie H, Yamashita T. The function of cruciate ligaments in bi-cruciate retaining Total knee arthroplasty with asymmetrical design. Clin Biomech (Bristol, Avon) 2023; 107:106038. [PMID: 37421831 DOI: 10.1016/j.clinbiomech.2023.106038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 06/28/2023] [Accepted: 07/03/2023] [Indexed: 07/10/2023]
Abstract
BACKGROUND Bi-cruciate retaining total knee arthroplasty with an asymmetrical design may improve knee function and clinical outcomes. This study aimed to compare the kinematics, anteroposterior laxity, and in situ forces of the anterior and posterior cruciate ligaments of knees subjected to this treatment with those of healthy knees. METHODS Seven fresh-frozen cadaveric knees were tested using a robotic/universal force-moment sensor system. The kinematics during passive flexion-extension motion and anteroposterior laxity for native knee, treated knee, and treated knee with cruciate ligament transection states were investigated. The motions of the intact and treated knees during each test were repeated after anterior/posterior cruciate ligament transection to calculate the in situ force in the ligaments. FINDINGS The screw-home movement of normal knees disappeared after treatment. The in situ force of the anterior cruciate ligament in treated knees was higher than that in intact knees at ˃15° during flexion and at 60° and 90° against an anterior force. The in situ force of the posterior cruciate ligament in treated knees was higher at 0°, 15°, and 30° during flexion and at all flexion angles against a posterior force. INTERPRETATION The screw-home movement of normal knees decreased, and the in situ force of the anterior and posterior cruciate ligaments increased after treatment.
Collapse
Affiliation(s)
- Shogo Nabeki
- Department of Orthopedic Surgery, Sapporo Medical University, Minami 1-jo Nishi 16-chome, Chuo-ku, Sapporo 060-8543, Japan
| | - Yohei Okada
- Department of Orthopedic Surgery, Sapporo Medical University, Minami 1-jo Nishi 16-chome, Chuo-ku, Sapporo 060-8543, Japan
| | - Atsushi Teramoto
- Department of Orthopedic Surgery, Sapporo Medical University, Minami 1-jo Nishi 16-chome, Chuo-ku, Sapporo 060-8543, Japan.
| | - Yasuraku Shibata
- Tokyo Metropolitan University, 1-1 Minamiosawa, Hachioji-shi, Tokyo 192-0397, Japan
| | - Katsunori Takahashi
- Department of Orthopedic Surgery, Sapporo Medical University, Minami 1-jo Nishi 16-chome, Chuo-ku, Sapporo 060-8543, Japan
| | - Kousuke Shiwaku
- Department of Orthopedic Surgery, Sapporo Medical University, Minami 1-jo Nishi 16-chome, Chuo-ku, Sapporo 060-8543, Japan
| | - Tomoaki Kamiya
- Department of Orthopedic Surgery, Sapporo Medical University, Minami 1-jo Nishi 16-chome, Chuo-ku, Sapporo 060-8543, Japan
| | - Kota Watanabe
- Second Division of Physical Therapy, Sapporo Medical University School of Health Sciences, Minami 1-jo Nishi 17-chome, Chuo-ku, Sapporo 060-8556, Japan
| | - Mineko Fujimiya
- 2nd Department of Anatomy, Sapporo Medical University, Minami 1-jo Nishi 17-chome, Chuo-ku, Sapporo 060-8556, Japan
| | - Hiromichi Fujie
- Tokyo Metropolitan University, 1-1 Minamiosawa, Hachioji-shi, Tokyo 192-0397, Japan
| | - Toshihiko Yamashita
- Department of Orthopedic Surgery, Sapporo Medical University, Minami 1-jo Nishi 16-chome, Chuo-ku, Sapporo 060-8543, Japan
| |
Collapse
|
5
|
Simonetta R, Russo A, Palco M, Costa GG, Mariani PP. Meniscus tears treatment: The good, the bad and the ugly-patterns classification and practical guide. World J Orthop 2023; 14:171-185. [PMID: 37155506 PMCID: PMC10122773 DOI: 10.5312/wjo.v14.i4.171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 01/22/2023] [Accepted: 03/31/2023] [Indexed: 04/18/2023] Open
Abstract
Over the years, several studies demonstrated the crucial role of knee menisci in joint biomechanics. As a result, save the meniscus has become the new imperative nowadays, and more and more studies addressed this topic. The huge amount of data on this topic may create confusion in those who want to approach this surgery. The aim of this review is to provide a practical guide for treatment of meniscus tears, including an overview of technical aspects, outcomes in the literature and personal tips. Taking inspiration from a famous movie directed by Sergio Leone in 1966, the authors classified meniscus tears in three categories: The good, the bad and the ugly lesions. The inclusion in each group was determined by the lesion pattern, its biomechanical effects on knee joint, the technical challenge, and prognosis. This classification is not intended to substitute the currently proposed classifications on meniscus tears but aims at offering a reader-friendly narrative review of an otherwise difficult topic. Furthermore, the authors provide a concise premise to deal with some aspects of menisci phylogeny, anatomy and biomechanics.
Collapse
Affiliation(s)
- Roberto Simonetta
- Department of Orthopaedic and Traumatology, Villa del Sole Clinic, Catanzaro 88100, Italy
| | - Arcangelo Russo
- Orthopaedic and Traumatology Unit, Umberto I Hospital, Enna 94100, Italy
| | - Michelangelo Palco
- Department of Orthopaedic and Traumatology, Villa del Sole Clinic, Catanzaro 88100, Italy
| | | | - Pier Paolo Mariani
- Department of Orthopaedic and Traumatology, Villa Stuart Sport Clinic-FIFA Medical Centre of Excellence, Roma 00135, Italy
| |
Collapse
|
6
|
Low reoperation rate following lateral meniscus root repair: clinical outcomes at 2 years follow-up. Knee Surg Sports Traumatol Arthrosc 2023; 31:495-502. [PMID: 35908114 DOI: 10.1007/s00167-022-07075-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 07/13/2022] [Indexed: 02/07/2023]
Abstract
PURPOSE The aim of this study was to review the outcomes of lateral meniscus posterior root tears repair at the time of ACL reconstruction at a minimum 2-year follow-up. METHODS Between March 2015 and August 2018, 2017 patients underwent primary ACL reconstruction and were considered for study eligibility. Lateral meniscus posterior root tears were identified arthroscopically, and repair was performed with a transtibial pull-out suture technique or a side-to-side suture technique. Clinical outcomes were recorded at the time of physical examination. At the end of the study period, patients were contacted to determine whether they had required reoperation. RESULTS Lateral meniscus posterior root tears were identified in 153 out of the 2,017 primary ACL reconstructions (7.6%). Ninety-nine patients were included for analysis: 23 transtibial pull-out sutures and 76 side-to-side repairs. At a mean follow-up of 42 ± 10 months, one patient (1%) had undergone reoperation for failure of the side-to-side repair. There were 11 reoperations in 10 patients (10.1%), including 6 cyclops syndrome, 1 graft rupture, 1 tibial bone cyst, 1 medial and 1 lateral meniscus repair failure, and 1 arthrolysis. Postoperatively, ninety (90.9%) patients were graded A for the IKDC objective score and 9 (9.1%) patients were graded B, with an IKDC subjective score of 86.9 ± 7.6, a Lysholm score of 90.7 ± 6.7 and a median Tegner Activity Scale of 6 (3-9). All of their objective and subjective evaluations improved after surgery (p < 0.001) except for the Tegner Activity Scale. Ten patients underwent second look arthroscopy (10.1%), lateral meniscus healing was observed in 9 out of 10 patients (90%). CONCLUSION This study demonstrated that lateral meniscus posterior root tear repair is a safe procedure with a very low reoperation rate at a minimum follow-up of 2 years. LEVEL OF EVIDENCE IV.
Collapse
|
7
|
Jeon YS, Alsomali K, Yang SW, Lee OJ, Kang B, Wang JH. Posterior Horn Lateral Meniscal Oblique Radial Tear in Acute Anterior Cruciate Ligament Reconstruction Incidence and Outcomes After All-Inside Repair: Clinical and Second-Look Arthroscopic Evaluation. Am J Sports Med 2022; 50:3796-3804. [PMID: 36322384 DOI: 10.1177/03635465221126506] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The term posterior horn lateral meniscal oblique radial tear (LMORT) has emerged to characterize the tear patterns of the lateral meniscus in many patients with acute anterior cruciate ligament (ACL) injury. There is a lack of data regarding the exact incidence according to the types of LMORT and clinical outcomes. PURPOSES (1) To investigate the incidence of LMORT according to type in patients with acute ACL reconstruction (ACLR) and (2) to identify healing status after repair of LMORT via second-look arthroscopy and clinical outcomes. STUDY DESIGN Case series; Level of evidence: 4. METHODS Patients who underwent primary ACLR within 6 months of injury were retrospectively reviewed. The LMORT was classified into 4 types based on the severity and distance from the root: type 1 (partial tear <10 mm from the root), type 2 (complete tear <10 mm from the root), type 3 (partial tear >10 mm from the root), type 4a (complete tear >10 mm from the root), and type 4b (type 4a with longitudinal tear at the meniscocapsular junction). Only patients with LMORT were isolated, and the clinical outcomes were compared according to the healing status of LMORT in second-look arthroscopy. RESULTS Of 635 patients with ACLR, LMORT was identified in 97 patients (15.3%), and type 4 LMORT accounted for the largest proportion (n = 62; 32.6%) of 190 lateral meniscal tears. In 79 patients with LMORT who satisfied the 2-year follow-up period, all patient-reported outcomes (PROs), including the Lysholm (preoperative, 64.1; postoperative, 88.2) and International Knee Documentation Committee subjective (preoperative, 50.5; postoperative, 82.9) scores, were significantly improved (P < .001) 31.8 months postoperatively. Of the 61 patients who underwent second-look arthroscopy, 49 (80.3%) were classified into the complete healing group. There was no significant difference in postoperative PROs between the complete and partial healing groups. CONCLUSION The incidence of LMORT was 15.3% in patients with acute ACL injury, and type 4 LMORT was the most common type. Complete healing of LMORT was achieved in 80.3% of patients who underwent second-look arthroscopy, and the PROs were significantly improved postoperatively. Good clinical results can be achieved if the LMORT is repaired as much as possible during ACLR.
Collapse
Affiliation(s)
- Young-Sik Jeon
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University College of Medicine, Gangnam-gu, Seoul, Republic of Korea
| | - Khalid Alsomali
- Department of Orthopedic Surgery, King Fahad Military Medical Complex, Dhahran, Saudi Arabia
| | - Seong Wook Yang
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University College of Medicine, Gangnam-gu, Seoul, Republic of Korea
| | - Oei Jong Lee
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University College of Medicine, Gangnam-gu, Seoul, Republic of Korea
| | - Byoungyoul Kang
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University College of Medicine, Gangnam-gu, Seoul, Republic of Korea
| | - Joon Ho Wang
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University College of Medicine, Gangnam-gu, Seoul, Republic of Korea
| |
Collapse
|
8
|
Gupta A, Sanchez M, Storaci HW, Rohde MS, Sherman SL, Shea KG. Transtibial Repair of Lateral Meniscus Posterior Root Tears Improves Contact Biomechanics in Pediatric Cadavers. Arthrosc Sports Med Rehabil 2022; 4:e2011-e2018. [PMID: 36579044 PMCID: PMC9791837 DOI: 10.1016/j.asmr.2022.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 08/24/2022] [Indexed: 12/23/2022] Open
Abstract
Purpose A paucity of data exists on the treatment of pediatric lateral meniscus root tears (LMPRTs). This study aims to characterize the biomechanics of the lateral knee joint in pediatric cadavers following LMPRT and root repair. Our hypotheses were: (1) compared with the intact state, LMPRT would be associated with decreased contact area; (2) compared with the intact state, LMPRT would be associated with increased contact pressures; and (3) compared with LMPRT, root repair would restore contact area and pressures toward intact meniscus values. Methods Eight cadaver knees (ages 8-12 years) underwent contact area and pressure testing of the lateral compartment. Tekscan pressure mapping sensors covering the tibial plateau were inserted underneath the lateral meniscus. Appropriate pressure load equivalents were applied by a robot at degrees of flexion: 0, 30, 60. Three meniscus conditions were tested: (1) intact, (2) complete root tear, and (3) repaired root tear. Root repairs were performed with transtibial pullout sutures. Statistical analysis was performed. Results Root tear significantly decreased mean contact area at 30° (P = .0279) and 60° (P = .0397). Root repair increased mean contact area and did not significantly differ from intact states. Differences in contact pressures between meniscus states were not statistically significant. Relative to the intact state. the greatest increase in contact pressures occurred between 0° and 30°. Root repair decreased mean contact pressures at 0° and 30°. At 60°, mean contact pressures of the repair state were closer in magnitude to the tear state than the intact state. Conclusions: LMPRT decreases contact area and increases contact pressures in the lateral knee compartment. Repair of LMPRT improves tibiofemoral contact area at high (>30°) degrees of flexion and contact pressures at low (<30°) degrees of flexion. Clinical Relevance Transosseous pullout repair is a clinically validated treatment for LMPRT. This study provides baseline biomechanics data of transtibial pullout repair of pediatric LMPRTs.
Collapse
Affiliation(s)
- Anshal Gupta
- Address correspondence to Anshal Gupta, M.T.M., Stanford Medicine Department of Orthopedic Surgery, 450 Broadway, MC: 6342, Pavilion C, 4th Floor, Redwood City, CA, 94063-3132.
| | | | | | | | | | | |
Collapse
|
9
|
Meniscus surface texture is associated with degenerative changes in biological and biomechanical properties. Sci Rep 2022; 12:11977. [PMID: 35831482 PMCID: PMC9279509 DOI: 10.1038/s41598-022-16206-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 07/06/2022] [Indexed: 11/08/2022] Open
Abstract
Meniscal degeneration is defined by semi-quantitative assessment of multiple histological findings and has been implicated in biomechanical dysfunction, yet little is known about its relationship with biological properties. This paper aimed to quantitatively evaluate degenerative findings in human meniscus to examine their relationship with gene expression and biomechanical properties, and to extract histological findings that reflect biological properties like gene expression and cytokine secretion. This study included lateral menisci of 29 patients who underwent total knee arthroplasty. The menisci were divided into six samples. For each sample, Pauli's histological evaluation and corresponding quantitative assessment (surface roughness, DNA content, collagen orientation, and GAG content) were performed, with surface roughness showing the highest correlation with the histological evaluation in a single correlation analysis (r = 0.66, p < 0.0001) and multivariate analysis (p < 0.0001). Furthermore, surface roughness was associated with gene expression related to meniscal degeneration and with tangent modulus which decreases with increasing degeneration (r = - 0.49, p = 0.0002). When meniscal tissue was classified by surface integrity, inflammatory cytokine secretion tended to be higher in severe degenerated menisci. These results suggest that the evaluation of meniscal surface texture could predict the degree of degeneration and inflammatory cytokine secretion.
Collapse
|
10
|
Tanaka A, Tsujii A, Shimomura K, Yonetani Y, Hamada M. Two Uncommon Complications Related to Suture Knots After Meniscal All-Inside Suture Repair: A Case Report. JBJS Case Connect 2022; 12:01709767-202209000-00028. [PMID: 36040073 DOI: 10.2106/jbjs.cc.22.00014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
CASE A 17-year-old male patient suffered a radial lateral meniscus tear and underwent an arthroscopic all-inside suture repair. After 7 months, the patient experienced catching. Magnetic resonance imaging and computed tomography revealed an intra-articular loose body without calcification, which was removed surgically. The excised specimen was histopathologically confirmed to be a necrotic meniscus fragment with a suture knot. In addition, cartilage damage because of suspected impingement by a residual suture knot was observed. After removing the loose body and knot, the patient's symptoms were relieved, and he returned to sports. CONCLUSION Suture knot-related complications should be considered while performing meniscal repairs.
Collapse
Affiliation(s)
- Ayaka Tanaka
- Department of Orthopaedic Surgery, Japan Community Health Care Organization Hoshigaoka Medical Center, Osaka, Japan
| | - Akira Tsujii
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Kazunori Shimomura
- Department of Orthopaedic Surgery, Japan Community Health Care Organization Hoshigaoka Medical Center, Osaka, Japan
| | - Yasukazu Yonetani
- Department of Orthopaedic Surgery, Japan Community Health Care Organization Hoshigaoka Medical Center, Osaka, Japan
| | - Masayuki Hamada
- Department of Orthopaedic Surgery, Japan Community Health Care Organization Hoshigaoka Medical Center, Osaka, Japan
| |
Collapse
|
11
|
Hirose T, Mae T, Ogasawara I, Yamakawa S, Nakata K, Ohori T, Tsujii A, Okada S. Meniscal Displacement and Loss of Load-Transmission Function After Radial Tear of the Lateral Meniscus in a Porcine Model: New Insights Into the Functional Dynamics of the Injured Meniscus. Am J Sports Med 2022; 50:1850-1857. [PMID: 35416074 DOI: 10.1177/03635465221090543] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Meniscal extrusion/translation has been used as an index for meniscal treatment. However, the relationship between meniscal displacement and the degree of meniscal tear or load-transmission function of the lateral meniscus (LM) remains unclear. PURPOSE To clarify the relationship between the width of the radial tear of the LM and (1) meniscal displacement or (2) resultant force through the meniscus under axial compressive load in the porcine model. STUDY DESIGN Controlled laboratory study. METHODS Eight intact porcine knees with or without a partial radial tear at the midbody of the LM (involving 30%, 60%, or 90% of its width) were investigated. Reflective markers were attached to the outer wall of the anterior, anteromiddle, posteromiddle, and posterior segments of the LM. A 300-N axial load was applied at 2 flexion angles (30° and 60°), and the 3-dimensional forces and trajectories of the knees were recorded. Marker movements were simultaneously tracked using a motion capture camera system. After total meniscectomy of the LM, the recorded knee trajectories were reproduced, and the resultant force through the LM was calculated (a force carried only by the meniscus in response to a load applied to the whole knee joint). RESULTS At both flexion angles, the change in distance (mean ± SD) between the anterior and posterior markers under load increased significantly more in the anteroposterior direction in LMs with a 90% tear than in intact LMs (30°, 0.4 ± 0.3 vs 1.4 ± 0.8 mm, P = .004; 60°, 0.1 ± 0.7 vs 1.4 ± 1.0 mm, P < .001 [intact vs 90% tear]). The change in distance between the anteromiddle and posteromiddle markers at 30° also significantly increased in LMs with a 90% tear (0.2 ± 0.2 vs 1.3 ± 1.2 mm, P = .02 [intact vs 90% tear]). The resultant force was significantly lower in LMs with a 90% tear than in intact LMs (30°, 125 ± 47 vs 48 ± 20 N, P < .001; 60°, 93 ± 46 vs 43 ± 11 N, P = .002 [intact vs 90% tear]). We found no significant differences in either meniscal displacements or resultant forces between intact LMs and those with 30% or 60% tears. CONCLUSION LMs with a 90%-width midbody radial tear lost load-transmission function with their displacement relative to the tibia primarily in the anteroposterior direction in the porcine model. CLINICAL RELEVANCE Even 1 mm of displacement after meniscal injury is evidence that the load-transmission function of the meniscus is greatly impaired. When a displaced torn LM is diagnosed in preoperative imaging, meniscal repair surgery should be considered.
Collapse
Affiliation(s)
- Takehito Hirose
- Department of Orthopaedic Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Tatsuo Mae
- Department of Sports Medical Biomechanics, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Issei Ogasawara
- Department of Health and Sports Sciences, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Satoshi Yamakawa
- Department of Sports Medical Biomechanics, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Ken Nakata
- Department of Health and Sports Sciences, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Tomoki Ohori
- Department of Orthopaedic Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Akira Tsujii
- Department of Orthopaedic Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Seiji Okada
- Department of Orthopaedic Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| |
Collapse
|
12
|
Hamada M, Tsujii A. Editorial Commentary: All-Inside Double-Vertical Cross-Suture is an Effective Technique for Knee Meniscus Radial Tear Repair, but There is No Gold-Standard Evaluation Tool for Evaluating Healing and Function of the Repaired Meniscus. Arthroscopy 2022; 38:1930-1932. [PMID: 35660186 DOI: 10.1016/j.arthro.2021.12.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 12/18/2021] [Indexed: 02/02/2023]
Abstract
Treatment of radial tears of the lateral meniscus is challenging. Previous studies after repairing radial tears showed low healing rates. Various suture techniques are now being developed, and biomechanical and clinical studies using these new techniques are underway. Amid development, the all-inside double vertical cross-suture technique seemed to be effective. However, limited evaluations after meniscal repair might not fully reveal whether the repaired meniscus can maintain its function. Because the best single method that can completely evaluate meniscal healing and its function after repair is still lacking, we should introduce various assessments and consider them in a comprehensive way.
Collapse
|
13
|
Yeh SH, Hsu FW, Chen KH, Chiang ER, Chang MC, Ma HL. Repairing Complete Radial Tears of the Lateral Meniscus: Arthroscopic All-Inside Double Vertical Cross-Suture Technique Is Effective and Safe With 2-Year Minimum Follow-Up. Arthroscopy 2022; 38:1919-1929. [PMID: 34838645 DOI: 10.1016/j.arthro.2021.11.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 11/08/2021] [Accepted: 11/12/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To assess the failure rate and clinical outcomes of the all-inside, double-vertical, cross-suture technique in repairing complete radial tears of the lateral meniscus. METHOD We retrospectively reviewed records of patients with this injury on whom the present technique was employed at our institution between 2011 and 2018, with at least 24 months of follow-up. Six months postoperatively, the meniscus healing and extrusion status were evaluated through magnetic resonance imaging. Preoperative and postoperative knee function, measured through IKDC, Lysholm knee, and Tegner activity scale scores, were compared. RESULTS In total, 27 patients underwent the procedure. The preoperative mean (standard deviation) IKDC score, Lysholm knee score, and Tegner activity scale scores were 53.4 ± 5.3, 63.2 ± 9.3, and 4 ± .7, respectively. At the last follow-up (≥24 months postoperatively), these scores increased to 92.1 ± 2.6, 90.8 ± 4.2, and 6.1 ± 1.3, respectively (all P < .05). Complete healing of the meniscus was observed in 23 patients, and 4 patients had meniscus retear or nonhealing. The overall retear or nonhealing rate was 14.8%. Healing rates between those with isolated radial tears (87.5%) and those with combined anterior cruciate ligament rupture (84.2%; P = .826) were comparable. No difference was observed in the progression of coronal and sagittal meniscus extrusion (P = .133 and .797, respectively). CONCLUSION In patients with complete radial tears of the lateral meniscus, the arthroscopic all-inside double vertical cross-suture repair technique resulted in an 85.2% healing rate, improvements in functional outcomes and activity levels, and no identifiable progression of meniscus extrusion. The all-inside double vertical cross-suture technique is effective and safe for the repair of radial tears of the meniscus. LEVEL OF EVIDENCE Level IV, retrospective case series.
Collapse
Affiliation(s)
- Shih-Han Yeh
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Surgery, School of Medicine, National Yang-Ming University, Taipei, Taiwan; Department of Surgery, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Orthopedic Surgery, Taoyuan General Hospital, Ministry of Health & Welfare, Taoyuan, Taiwan
| | - Fang-Wei Hsu
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Orthopedic Surgery, Taoyuan General Hospital, Ministry of Health & Welfare, Taoyuan, Taiwan; Orthopedics Department of Kuang Tien General Hospital, Taichung, Taiwan
| | - Kun-Hui Chen
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Surgery, School of Medicine, National Yang-Ming University, Taipei, Taiwan; Department of Surgery, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Orthopedic Surgery, Taoyuan General Hospital, Ministry of Health & Welfare, Taoyuan, Taiwan
| | - En-Rung Chiang
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Surgery, School of Medicine, National Yang-Ming University, Taipei, Taiwan; Department of Surgery, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Orthopedic Surgery, Taoyuan General Hospital, Ministry of Health & Welfare, Taoyuan, Taiwan
| | - Ming-Chau Chang
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Surgery, School of Medicine, National Yang-Ming University, Taipei, Taiwan; Department of Surgery, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Orthopedic Surgery, Taoyuan General Hospital, Ministry of Health & Welfare, Taoyuan, Taiwan
| | - Hsiao-Li Ma
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Surgery, School of Medicine, National Yang-Ming University, Taipei, Taiwan; Department of Surgery, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Orthopedic Surgery, Taoyuan General Hospital, Ministry of Health & Welfare, Taoyuan, Taiwan.
| |
Collapse
|
14
|
Kohno Y, Koga H, Ozeki N, Matsuda J, Mizuno M, Katano H, Sekiya I. Biomechanical analysis of a centralization procedure for extruded lateral meniscus after meniscectomy in porcine knee joints. J Orthop Res 2022; 40:1097-1103. [PMID: 34314533 PMCID: PMC9292650 DOI: 10.1002/jor.25146] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 06/02/2021] [Accepted: 07/13/2021] [Indexed: 02/04/2023]
Abstract
The recently developed arthroscopic centralization for lateral meniscal extrusion has obtained satisfactory short-term clinical and radiological results and improves the meniscus biomechanical properties. However, the effectiveness of treatment for meniscus extrusion after partial meniscectomy still requires elucidation. This study investigated the effect of centralization with modifications from a mechanical viewpoint. Porcine knee joints (N = 6) were set in a universal tester under the following conditions: (1) Intact; (2) Meniscectomy: Inner half of the posterior half meniscus was removed; (3) Extrusion: Posterior meniscus was dislocated laterally by transecting the posterior root and the meniscotibial ligament; (4) Centralization-1: Centralization procedure using one anchor; (5) Centralization-2: Centralization procedure using two anchors; and (6) Centralization-ad: Centralization with capsular advancement using two anchors. Load distributions and contact pressure in the meniscus and tibial cartilage were evaluated with an axial compressive force of 200 N. After meniscectomy, the tibial cartilage load increased and that of the medial margin of the posterior part of the meniscus decreased. When the meniscus was extruded, the load was concentrated only on the tibial cartilage. Centralization-1 increased the load on the meniscus, while Centralization-2 further increased the meniscus load but decreased the tibial cartilage load. Centralization-ad further decreased the load on the tibial plateau. The average contact pressure of the tibial cartilage was significantly higher in the Extrusion group than in the Intact group or the Centralization-ad group. From a biomechanical viewpoint, centralization with capsular advancement was the most effective of the tested procedures for treatment for an extruded meniscus after partial meniscectomy.
Collapse
Affiliation(s)
- Yuji Kohno
- Center for Stem Cells and Regenerative MedicineTokyo Medical and Dental UniversityTokyoJapan
| | - Hideyuki Koga
- Department of Joint Surgery and Sports MedicineTokyo Medical and Dental UniversityTokyoJapan
| | - Nobutake Ozeki
- Center for Stem Cells and Regenerative MedicineTokyo Medical and Dental UniversityTokyoJapan
| | - Junpei Matsuda
- Center for Stem Cells and Regenerative MedicineTokyo Medical and Dental UniversityTokyoJapan
| | - Mitsuru Mizuno
- Center for Stem Cells and Regenerative MedicineTokyo Medical and Dental UniversityTokyoJapan
| | - Hisako Katano
- Center for Stem Cells and Regenerative MedicineTokyo Medical and Dental UniversityTokyoJapan
| | - Ichiro Sekiya
- Center for Stem Cells and Regenerative MedicineTokyo Medical and Dental UniversityTokyoJapan
| |
Collapse
|
15
|
Familiari F, Palco M, Russo R, Moatshe G, Simonetta R. Arthroscopic Repair of Posterior Root Tears of the Lateral Meniscus with All-Suture Anchor. Arthrosc Tech 2022; 11:e781-e787. [PMID: 35646560 PMCID: PMC9134100 DOI: 10.1016/j.eats.2021.12.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Meniscus root tears are increasingly being recognized and treated because of improved awareness and diagnostics. These injuries commonly occur in combination with knee ligament injuries. Untreated posterior meniscus root teats have been demonstrated to increase contact pressure and decrease contact area, ultimately leading to unfavorable joint loading and development of early osteoarthritis. Posterior lateral meniscus root tears (PLMRTs) also have been reported to increase anterior tibial translation and pivot shift in anterior cruciate ligament-deficient knees. Therefore, it is crucial to repair meniscal root tears when possible to restore knee joint loading and kinematics. Several techniques for repair of the PLMRT have been described. In this Technical Note, we describe our preferred technique for repair of PLMRT using an all-suture anchor. This technique is reproducible, does not need a tunnel, mitigates bungee effect of transtibial technique, and the anchor can easily be inserted on the footprint without a need for a guide.
Collapse
Affiliation(s)
- Filippo Familiari
- Department of Orthopaedics and Trauma Surgery, Magna Graecia University, Catanzaro, Italy
| | - Michelangelo Palco
- Department of Biomedical, Dental and Morphological and Functional Images, Section of Orthopaedic and Traumatology, University of Messina, Messina, Italy
| | - Raffaella Russo
- Department of Orthopaedics and Trauma Surgery, Villa del Sole Clinic, Catanzaro, Italy
| | - Gilbert Moatshe
- Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
- Oslo Sport Trauma Research Center, Norwegian School of Sports Science, Oslo, Norway
| | - Roberto Simonetta
- Department of Orthopaedics and Trauma Surgery, Villa del Sole Clinic, Catanzaro, Italy
| |
Collapse
|
16
|
Biomechanical consequences of anterior root detachment of the lateral meniscus and its reinsertion. Sci Rep 2022; 12:6182. [PMID: 35418662 PMCID: PMC9007958 DOI: 10.1038/s41598-022-10229-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 04/04/2022] [Indexed: 12/05/2022] Open
Abstract
Treatment of posterior meniscal roots tears evolved after biomechanical evidence of increased pressures on the tibiofemoral cartilage produced by this lesion and the subsequent accelerated development of arthritis or osteonecrosis observed clinically. However, little is known about the consequences of the detachment of the anterior roots. This in-vitro study analyzes the biomechanical changes in the tibiofemoral joint caused by avulsion of the anterior root of the lateral meniscus. The effectiveness of surgical root re-insertion to restore the pre-injured conditions is also evaluated. Using cadaveric knees at flexion angles from 0° to 90°, results show that the lesion significantly reduces the contact area and raises the pressure on the tibiofemoral cartilage of the injured compartment at all angles. Said modifications become larger at low flexion angles, which are the most frequent positions adopted by the knee in daily and sports activities, where they result similar to total meniscectomy. In-situ repair partially restores the contact biomechanics. Consequently, careful attention should be paid to proper diagnosis and treatment of detached anterior roots since the observed altered knee contact might induce similar degenerative problems in the cartilage as with completely detached posterior roots.
Collapse
|
17
|
Smith PA, Bezold WA, Cook CR, Krych AJ, Stuart MJ, Wijdicks C, Cook JL. Kinematic Analysis of Lateral Meniscal Oblique Radial Tears in the Anterior Cruciate Ligament-Deficient Knee. Am J Sports Med 2021; 49:3898-3905. [PMID: 34699272 DOI: 10.1177/03635465211052521] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Lateral meniscal oblique radial tears (LMORT) occur frequently in conjunction with anterior cruciate ligament (ACL) disruption and are anatomically distinct from meniscus root tears. HYPOTHESIS/PURPOSE The purpose of this study was to characterize the effects of LMORT types 3 (LMORT3) and 4 (LMORT4) lesions on joint stability and meniscal extrusion in ACL-deficient knees. Our hypothesis was that both lesions would promote significant increases in anterior translation and meniscal extrusion, with the LMORT4 lesion having a greater effect. STUDY DESIGN Controlled laboratory study. METHODS Two matched pairs of cadaveric knees (n = 4) were used to optimize the testing sequence. Additional cadaveric knees with LMORT3 (n = 8) and LMORT4 (n = 8) lesions created after ACL transection underwent robotic kinematic testing for anterior drawer and pivot-shift simulations with associated ultrasound-measured meniscal extrusion at clinically relevant knee flexion angles. RESULTS Optimization testing showed no differences on the effect of LMORT4 lesions for anterior translation and lateral meniscal extrusion with ACL-intact versus ACL-deficient knees. ACL deficiency and LMORT3 and LMORT4 lesions with ACL deficiency were associated with significantly greater anterior translation compared with ACL-intact state for both anterior drawer and pivot-shift testing at all flexion angles (P < .001). ACL deficiency with either LMORT3 or LMORT4 lesion was associated with significantly greater anterior translation than was ACL deficiency only (P < .005) for anterior drawer testing at 90° of flexion. Meniscal extrusion was greater with LMORT3 and LMORT4 lesions compared with ACL deficiency only (P < .05) for anterior drawer at 60° of flexion and for pivot shift at 15° of flexion. The LMORT4 lesion demonstrated increased anterior translation for anterior drawer (P = .003) at 60° of flexion (12%) as well as for pivot shift at 15° of flexion (7%) and 30° of flexion (13%) (P < .005) compared with ACL deficiency only. CONCLUSION In this cadaveric model, the addition of an LMORT3 or LMORT4 lesion increased anterior laxity for both the anterior drawer and the pivot shift when compared with an isolated ACL tear. Lateral meniscal extrusion was also exacerbated by these LMORT lesions. CLINICAL RELEVANCE LMORT lesions, distinct from meniscus root tears, occur frequently in conjunction with ACL tears. This study characterized the biomechanical consequences of LMORT3 and LMORT4 lesions on joint stability and meniscal function, highlighting the importance of diagnosing and treating LMORT lesions at the time of ACL reconstruction.
Collapse
Affiliation(s)
| | - Will A Bezold
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri, USA.,Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, USA
| | - Cristi R Cook
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri, USA.,Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, USA
| | - Aaron J Krych
- Department of Orthopaedic Surgery, Mayo Clinic Hospital, Rochester, Minnesota, USA
| | - Michael J Stuart
- Department of Orthopaedic Surgery, Mayo Clinic Hospital, Rochester, Minnesota, USA
| | | | - James L Cook
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri, USA.,Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, USA
| |
Collapse
|