Medial meniscus ramp and lateral meniscus posterior root lesions are present in more than a third of primary and revision ACL reconstructions

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.

Revision Anterior Cruciate Ligament Reconstruction and Associated Procedures

Failure of anterior cruciate ligament reconstruction (ACLR) is a common yet devastating complication due to inferior clinical outcomes associated with revision ACLR. Identifying the cause and associated risk factors for failure is the most important consideration during preoperative planning. Special attention to tunnel quality, concomitant injuries, and modifiable risk factors will help determine the optimal approach and staging for revision ACLR. Additional procedures including lateral extra-articular tenodesis and osteotomy may be considered for at-risk populations. The purpose of this review is to explore causes of ACLR failure, clinical indications and appropriate patient evaluation, and technical considerations when performing revision ACLR.

Risk factors and prevalence of ramp lesions in ACL ruptures: An analysis from the registry of the Francophone Arthroscopic Society

PURPOSE

The study aimed to estimate the prevalence of ramp lesions among patients undergoing anterior cruciate ligament (ACL) reconstruction and identify risk factors associated with these lesions.

METHODS

A retrospective, multicentre cohort study was conducted using data from the Francophone Arthroscopic Society's registry, including 5359 patients who underwent ACL reconstruction (ACLR) from June 2020 to June 2023. Potential risk factors for ramp lesion such as patient demographics, revision surgery, pivot shift, side-to-side anteroposterior laxity, medial collateral ligament (MCL) injury, lateral meniscal tear and the volume of ligament remnant were evaluated using multivariate regression analyses. BMI and delay to surgery were also assessed.

RESULTS

Ramp lesions were identified in 822 patients (15.3%). Univariate analysis identified male sex, younger age, revision surgery, lateral meniscal injury, percentage of ACL remnant (all p < 0.0001) and pivot shift (p = 0.0103) as significant risk factors. MCL injury was associated with a lower risk (p < 0.0001). In multivariate analysis, male sex, younger age, revision surgery, lateral meniscal injury and percentage of ACL remnants remained significant risk factors, while MCL injury remained a protective factor. The anteroposterior laxity wasn't a significant predictor in either analysis. In subgroup analysis, there were no differences concerning body mass index (n.s) and the delay to surgery (n.s).

CONCLUSION

The study identified male sex, younger age, revision surgery, lateral meniscal injury and pourcentage of ACL remnant as significant risk factors for ramp lesions, with MCL injury acting as a protective factor. This will help regarding the suspicion and identification of ramp lesions.

LEVEL OF EVIDENCE

Level III.

Male sex, revision surgery, low volume of anterior cruciate ligament remnant, and significant instability are risk factors for Posterior Root Tear of the Lateral Meniscus in patients undergoing Anterior Cruciate Ligament Reconstruction

PURPOSE

This multicenter study aimed to determine the incidence of lateral meniscus posterior root tears (LMPRTs) in patients undergoing ACL reconstruction and identify associated risk factors.

METHODS

We conducted a retrospective, multicenter study using data from the Francophone Arthroscopic Society's registry. The study included all the patients in the registry who underwent ACL reconstruction surgery between June 2020 and June 2023, we excluded incomplete data. We compared delay from injury to surgery between LMPRTs group and No LMPRTs group. Variables investigated as potential risk factors for LMPRTs included age, sex, nature of surgery (primary or revision), pivot shift test result, side-to-side laxity under anesthesia, presence of ACL remnant, occurrence of medial meniscal tear, and presence of collateral ligament injury. Risk factors were analyzed using a logistic regression model.

RESULTS

Among the 5359 patients analyzed, LMPRTs occurred in 7.0% (n=375) of cases during ACL reconstruction. Mean age at surgery was 29.3 +/- 10.3 years old [11-77]. Concerning delay to surgery, the mean time was 8.4 +/- 23.1 weeks [0.0-347.2] in the No LMPRTs group and 6.5 +/- 10.2 weeks [0.2-61.6] in the LMPRTs group (p = 0.109). Univariate analysis revealed that male sex (p < 0.001), revision surgery (p < 0.001), medial meniscal injury (p = 0.007), ACL remnant (0% vs > 70%, <10% vs > 70%, 10 to 30% vs > 70%, 30 to 50% vs > 70%, 50 to 70% vs > 70%; p < 0.001) and higher pivot shift grade (p = 0.011) were significantly associated with a presence of LMPRTs. Age, side-to-side laxity, and collateral ligament injury were not found to be significant risk factor In multivariate analysis : male sex, revision surgery, pivot shift test result and a low volume of ACL remnant remained significant. Side to side laxity was also a significant factor in multivariate analysis.

CONCLUSION

This study identified male sex, revision surgery, low volume of ACL remnant, side to side laxity and higher grade of pivot shift as significant risk factors for LMPRTs during ACL reconstruction.

Increased risk for early revision with quadriceps graft compared with patellar tendon graft in primary ACL reconstructions

PURPOSE

Bone patella-tendon bone (BPTB) and hamstring tendon (HT) autografts are the most used grafts in primary anterior cruciate ligament (ACL) reconstructions (ACLR) in Norway. Quadriceps tendon (QT) autograft has gained more popularity during the past years. The purpose of this study is to compare revision rates and patient-reported outcomes of primary QT with BPTB and HT autograft ACL reconstructions in Norway at 2-year follow-up. It was hypothesized that there would be no difference in 2-year revision rates between all three autografts.

METHODS

Data included primary ACLR without concomitant ligament surgeries, registered in the Norwegian Knee Ligament Register from 2004 through 2021. Revision rates at 2 years were calculated using Kaplan-Meier analysis. Hazard ratios (HR) for revision were estimated using multivariable Cox regression analysis with revision within 2 years as endpoint. Mean change in patient-reported outcome was recorded preoperatively and at 2 years through the Knee Injury and Osteoarthritis Outcome Score (KOOS) subcategories 'Sport' and 'Quality of Life' was measured for patients that were not revised and analysed with multiple linear regression.

RESULTS

A total of 24,790 primary ACLRs were identified, 10,924 with BPTB, 13,263 with HT and 603 with a QT graft. Patients in the QT group were younger (23.5 years), more of them were women (58.2%) and over 50% had surgery <3 months after injury. The QT group had the highest prevalence of meniscal injuries (61.9%). Revision estimates at 2-years were 3.6%, 2.5% and 1.2% for QT, HT and BPTB, respectively (p < 0.001). In a Cox regression analysis with QT as reference, BPTB had a lower risk of revision (HR 0.4, 95% Cl 0.2-0.7, p < 0.001). No significant difference was observed in the revision risk between QT and HT (HR 1.1, 95% Cl 0.7-1.8, n.s.). The two most common reported reasons for revision were: traumatic graft rupture and nontraumatic graft failure. There were no differences between the groups in change of KOOS in subcategories 'Sport' and 'Quality of Life' at 2-years follow-up.

CONCLUSION

The 2-year risk of revision after ACLR with QT was higher than BPTB and similar to HT. No difference was found between the groups in patient-reported outcomes. This study provides valuable insights for both surgeons and patients when making decisions about the choice of autografts in primary ACL reconstructions.

LEVEL OF EVIDENCE

Level II.

Association of Increased Lateral Femoral Condylar Ratio With Lateral Meniscus Posterior Root Tear in Noncontact ACL Injury

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.

A High-Grade Lachman's Exam Predicts a Ramp Tear of the Medial Meniscus in Patients with Anterior Cruciate Ligament Tear: A Prospective Clinical and Radiological Evaluation

Background: Medial meniscus ramp tears are present in 22.9-40.8% of anterior cruciate ligament tears. The diagnosis of ramp tears is difficult on MRI, with sensitivity reported around 48%, which has recently emphasized the importance of proper arthroscopic probing for ramp tears. Methods: A prospective evaluation was performed on patients undergoing a single bundle ACL reconstruction to assess patient demographics, posterior tibial slope, posterior cruciate ligament angle, Lachman's exam, and rotational instability to determine secondary findings associated with medial meniscal ramp tears. Results: A total of 96 patients underwent ACL reconstruction, of these, 63 patients had an isolated ACL tear, and 33 patients had an ACL tear with a concomitant medial meniscus ramp tear. A high-grade Lachman's exam and male sex were associated with medial meniscus ramp tears. There were no differences in posterior tibial slope, posterior cruciate ligament angle, or rotational instability between groups. Conclusions: This study found that a high-grade Lachman's exam and male sex were significantly associated with patients with an ACL tear with a concomitant medial meniscus ramp tear. These findings suggest that an ACL tear with concomitant medial meniscus ramp tear may be better diagnosed based upon the clinical evaluation rather than other secondary radiological findings.

Extrusion and meniscal mobility evaluation in case of ramp lesion injury: a biomechanical feasibility study by 7T magnetic resonance imaging and digital volume correlation

Introduction: The existing body of literature on the biomechanical implications of ramp lesions is limited, leaving a significant gap in our understanding of how these lesions impact joint kinematics and loading in the medial compartment. This cadaveric biomechanical study aims to address this gap by employing an innovative Digital Volume Correlation (DVC) method, utilizing 7 Tesla Magnetic Resonance Imaging (MRI) images under various loading conditions. The primary objective is to conduct a comprehensive comparison of medial meniscal mobility between native knees and knees affected by grade 4 ramp lesions. By focusing on the intricate dynamics of meniscal mobility and extrusion, this work seeks to contribute valuable insights into the biomechanical consequences of medial meniscus ramp lesions. Materials and methods: An initial set of 7T MRI imaging sessions was conducted on two intact native knees, applying load values up to 1500N. Subsequently, a second series of images was captured on these identical knees, with the same loads applied, following the creation through arthroscopy of medial meniscus ramp lesions. The application of DVC enabled the precise determination of the three components of displacement and spatial variations in the medial menisci, both with and without ramp lesions. Results: The measured directional displacements between native knees and injured knees indicate that, following the application of axial compression load, menisci exhibit increased extrusion and posterior mobility as observed through DVC. Discussion: Injuries associated with Subtype 4 medial meniscus ramp lesions appear to elevate meniscal extrusion and posterior mobility during axial compression in the anterior cruciate ligament of intact knees. Following these preliminary results, we plan to expand our experimental approach to encompass individuals undergoing weight-bearing MRI. This expansion aims to identify meniscocapsular and/or meniscotibial insufficiency or rupture in patients, enabling us to proactively reduce the risk of osteoarthritic progression.

Case report: unusual posteromedial capsular lesion with posterior lateral meniscus root tear in two patients with constitutional genu recurvatum presenting after an acute ACL injury

Ramp lesions of the medial meniscus and posterior lateral meniscus root tears (LMPRT) can be present simultaneously in up to 8% of patients undergoing anterior cruciate ligament (ACL) reconstruction. The prevalence of these complex and highly unstable meniscal tears increases exponentially with the severity of the injury. The posteromedial capsule (PMC) has often been disregarded in the past when discussing ligamentous and meniscal injuries, but the recent interest in ramp lesions has drawn surgeons' attention to the posteromedial structures of the ACL injured knee. While the meniscocapsular junction is commonly repaired in unstable ramp lesions, in the current literature there is no report regarding proximal PMC lesions, be they in isolation or associated with complex meniscal injuries.We report here two cases of proximal posteromedial capsular lesions associated with medial meniscus instability and posterior lateral root tears after ACL injury. The first case involves a meniscus ramp lesion associated with a proximal PMC tear and a posteromedial fluid collection in the muscle plane on magnetic resonance in a 22-year-old male soccer player. The second case involves a 21-year-old female soccer player who presented with a PMC lesion after hyperextension/valgus knee injury. The capsular lesions were repaired to restore capsular tension and improve medial meniscus posterior horn stability.

Management of anterior cruciate ligament revision in adults: the 2022 ESSKA consensus: part II-surgical strategy

PURPOSE

The aim of this ESSKA consensus is to give recommendations based on scientific evidence and expert opinion to improve the diagnosis, preoperative planning, indication and surgical strategy in Anterior Cruciate Ligament revision.

METHODS

Part 2, presented herein, followed exactly the same methodology as Part 1: the so-called ESSKA formal consensus derived from the Delphi method. Eighteen questions were ultimately asked. The quality of the answers received the following grades of recommendation: Grade A (high level scientific support), Grade B (scientific presumption), Grade C (low level scientific support) or Grade D (expert opinion). All answers were scored from 1 to 9 by the raters. Once a general consensus had been reached between the steering and rating groups, the question-answer sets were submitted to the peer-review group. A final combined meeting of all the members of the consensus was then held to ratify the document.

RESULTS

The review of the literature revealed a rather low scientific quality of studies examining the surgical strategy in cases of ACL reconstruction failure. Of the 18 questions, only 1 received a Grade A rating; 5, a Grade B rating; and 9, grades of C or D. The three remaining complex questions received further evaluations for each portion of the question and were looked at in more detail for the following grades: B and D; A, C and D; or A, B, C and D. The mean rating of all questions by the rating group was 8.0 + - 1.1. The questions and recommendations are listed in the article.

CONCLUSION

ACL revision surgery, especially the surgical strategy, is a widely debated subject with many different opinions and techniques. The literature reveals a poor level of standardization. Therefore, this international European consensus project is of great importance and clinical relevance for guiding the management of ACL revision in adults.

LEVEL OF EVIDENCE

Level II.

The Proportion of Meniscus Tears Considered Repairable, and Thus Repaired, Increased During a Single Surgeon's Practice of 20 Years

PURPOSE

The purpose of this study was to evaluate practice patterns of a single surgeon with respect to meniscectomy and meniscal repair over a 20-year period at a single institution.

METHODS

A cross-sectional descriptive study was carried out by reviewing the surgical data from the past 20 years (2002-2021) of patients who underwent arthroscopic primary meniscal surgery. Age, sex, knee and meniscus affected, morphology of the meniscal tear, meniscal radial location, location on the axial plane, tissue quality, and associated injuries were recorded. An analysis of the evolution of the characteristics of the meniscal lesions was performed according to the presence of degenerative tissue, the repairability of the lesion, and the treatment performed. Categorical data were represented in contingency tables and compared using the χ2 test for significance of differences, which was set at P < .05.

RESULTS

In total, 1,892 cases were included. A decrease in degenerative meniscal tears was found, from 63.2 in 2002 to 2006 to 9.7% in 2017 to 2021 (P < .001), while repairable tears increased from 1.6% to 82.3% P < .001); in the same periods, arthroscopic partial meniscectomy procedures declined from 75.7% to 17.7% (P < .001) while meniscal repair increased from 0.4% to 81.3% (P < .001). All types of tears increased significantly their repairability, although longitudinal tears, root tears, and ramp lesions showed the highest possibilities for repair.

CONCLUSIONS

In the present study, a drastic change in the attitude toward meniscal preservation in the past 20 years was observed, with a large increase in the proportion of tears considered repairable found in primary arthroscopic surgery (to 80% of cases) and a decrease in degenerative meniscus tears (to less than 10%).

CLINICAL RELEVANCE

In the past 2 decades, arthroscopic knee surgery has evolved such that more meniscus tears are deemed repairable, and fewer tears considered degenerative are indicated for arthroscopy.

Lateral-medial asymmetry of posterior tibial slope and small lateral tibial plateau articular surface depth are morphological factors of lateral meniscus posterior root tears in ACL-injured patients

PURPOSE

To investigate whether knee morphological features, patient characteristics, and intraoperative findings are associated with a lateral meniscus (LM) posterior root tear (LMPRT) in anterior cruciate ligament (ACL) injuries with the integrated data from two academic centres.

METHODS

This retrospective study used registry data acquired prospectively at two academic centres. Patients with ACL reconstruction (ACLR) with LMPRT and no other LM injury were selected (LMPRT group) from each database. The control group included patients who underwent ACLR without LM tears. Patients were matched to the LMPRT group according to age and gender (1:1). Morphological factors evaluated on preoperative magnetic resonance image scans included lateral femoral condyle (LFC) anterior-posterior diameter, height, and depth; lateral tibial plateau (LTP) articular surface (AS) depth and sagittal plane depth; and lateral and medial posterior tibial slopes (PTSs). LFC height and depth ratios, LTP AS depth and sagittal plane depth ratios, and lateral-to-medial slope asymmetry were computed from previous measurements. Patient characteristics and intraoperative findings were extracted and compared between both groups.

RESULTS

The study included 252 patients (126 in each group). The lateral-medial asymmetry of PTS was greater in the LMPRT group (1.2° vs 0.3°, p < 0.05), and the LTP AS depth was smaller in the LMPRT group (31.4 mm vs 33.2 mm, p < 0.01). There were no differences in LFC morphology between the control and LMPRT groups. Pivot shift grade (p < 0.05), percentage of complete ACL tears (p < 0.05), and medial meniscus ramp lesions (p < 0.05) were significantly higher in the LMPRT group.

CONCLUSION

LMPRT was associated with significantly increased lateral-medial asymmetry of PTS and significantly smaller LTP AS depth. LMPRT was also associated with an increase in the preoperative pivot shift grade and the presence of a medial meniscus ramp lesion. These morphological characteristics are rather simple to measure and would serve as helpful indicators to preoperatively detect LMPRT, which is frequently challenging to diagnose preoperatively.

LEVEL OF EVIDENCE

Level III.

Concurrent Repair of Medial Meniscal Ramp Lesions and Lateral Meniscus Root Tears in Patients Undergoing Anterior Cruciate Ligament Reconstruction: The "New Terrible Triad"

Recent studies have suggested that up to 8% of patients with anterior cruciate ligament (ACL) tears can present with a combined medial meniscal ramp lesion (MMRL) and lateral meniscus root tear (LMRT). MMRLs and LMRTs often are missed preoperatively and can increase the risk of ACL graft failure if left untreated. Given the potential synergistic biomechanical consequences and challenging repair techniques used for treatment, our group commonly refers to this presentation (MMRL-LMRT-ACL) as the "new terrible triad" of ACL pathology. This Technical Note aims to describe a systematic approach for arthroscopic assessment and our preferred inside-out and transtibial pull-out repair techniques to efficiently diagnose and treat a combined MMRL and LMRT at the time of ACL reconstruction surgery.

Ramp lesion in anterior cruciate ligament injury: a review of the anatomy, biomechanics, epidemiology, and diagnosis

Ramp lesions, commonly observed in patients with anterior cruciate ligament (ACL) injuries, have been previously defined as longitudinal tears around the meniscocapsular junction. However, the definitions and interpretations of ramp lesions have varied, emphasizing the need to confirm their presence before surgery and the importance of direct visualization using arthroscopy. Recent histological studies have reported new findings on ramp lesions, shedding light on their attachment mechanisms. The anatomical structures around the ramp lesion, such as the posterior horn of medial meniscus (PHMM), semimembranosus (SM), posteromedial (PM) capsule, and meniscotibial ligament (MTL), were assessed regarding how these structures could be attached to each other. The studies of ramp lesions have also contributed to the progression of biomechanical studies explaining the cause and effects of ramp lesions. Ramp lesion has been proven to stabilize the anteroposterior (AP) instability of ACL. In addition, various laboratory studies have demonstrated the relationship between rotational instability of the knee joint and ramp lesions. The analysis of risk factors of ramp lesion helped to understand the injury mechanism of the lesion. Many authors have evaluated the prevalence of ramp lesions in patients with ACL injuries. The development of arthroscopy techniques has influenced the outcomes of ACL reconstruction with the easy detection of ramp lesions. This review article aims to analyze the past findings and recent advancements in anatomical, biomechanical, and epidemiological studies of ramp lesions in patients who underwent ACL reconstruction, and provide various perspectives ramp lesions in patients with ACL reconstruction.

Management after acute rupture of the anterior cruciate ligament (ACL). Part 1: ACL reconstruction has a protective effect on secondary meniscus and cartilage lesions

PURPOSE

The aim of this consensus project was to validate which endogenous and exogenous factors contribute to the development of post-traumatic osteoarthritis and to what extent ACL (anterior cruciate ligament) reconstruction can prevent secondary damage to the knee joint. Based on these findings, an algorithm for the management after ACL rupture should be established.

METHODS

The consensus project was initiated by the Ligament Injuries Committee of the German Knee Society (Deutsche Kniegesellschaft, DKG). A modified Delphi process was used to answer scientific questions. This process was based on key topic complexes previously formed during an initial face-to-face meeting of the steering group with the expert group. For each key topic, a comprehensive review of available literature 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. Consensus was defined a-priori as eighty percent agreement.

RESULTS

Of the 17 final statements, 15 achieved consensus, and 2 have not reached consensus. Results of the consensus were summarized in an algorithm for the management after ACL rupture (infographic/Fig. 2).

CONCLUSION

This consensus process has shown that the development of post-traumatic osteoarthritis is a complex multifactorial process. Exogenous (primary and secondary meniscus lesions) and endogenous factors (varus deformity) play a decisive role. Due to the complex interplay of these factors, an ACL reconstruction cannot always halt post-traumatic osteoarthritis of the knee. However, there is evidence that ACL reconstruction can prevent secondary joint damage such as meniscus lesions and that the success of meniscus repair is higher with simultaneous ACL reconstruction. Therefore, we recommend ACL reconstruction in case of a combined injury of the ACL and a meniscus lesion which is suitable for repair.

LEVEL OF EVIDENCE

Level V.

Association Between Anterior Tibial Subluxation of Lateral Compartment and High-Grade Knee Laxity in Patients With Anterior Cruciate Ligament Deficiency

BACKGROUND

High-grade knee laxity and excessive anterior tibial subluxation (ATS) are correlated with poor clinical outcomes in patients with anterior cruciate ligament (ACL) deficiency and share similar risk factors; however, the association between excessive ATS and high-grade knee laxity remains unclear.

PURPOSE

To identify the association between excessive ATS and high-grade knee laxity in patients with ACL deficiency and determine the possibility that ATS can predict high-grade knee laxity.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

A total of 226 patients who underwent ACL reconstruction between May 2018 and March 2022 were analyzed in the present study; the high-grade group consisted of 113 patients who had a grade 3 result on the preoperative anterior drawer test, Lachman test, or pivot-shift test while under anesthesia, and the low-grade group consisted of 113 matched patients. The ATS values for medial and lateral compartments (ATSMC and ATSLC) were measured on magnetic resonance imaging while patients relaxed the quadriceps in the supine position under no anesthesia. The optimal cutoff values of ATSMC and ATSLC for high-grade knee laxity were determined using receiver operating characteristic curves. Univariate and multivariate logistic regression analyses with stratification were performed to identify the association between excessive ATS and high-grade knee laxity.

RESULTS

Compared with the low-grade group, the high-grade group had a longer time from injury to surgery; higher rates of medial meniscus posterior horn tear (MMPHT), lateral meniscus posterior horn tear (LMPHT), and anterolateral ligament (ALL) abnormality; and larger lateral tibial slope, ATSMC, and ATSLC. The optimal cutoff value was 2.6 mm (sensitivity, 52.2%; specificity, 76.1%) for ATSMC and 4.5 mm (sensitivity, 67.3%; specificity, 64.6%) for ATSLC in predicting high-grade knee laxity. After adjustment for covariates, ATSLC ≥4.5 mm (odds ratio [OR], 2.94; 95% CI, 1.56-5.55; P = .001), MMPHT (OR, 2.62; 95% CI, 1.35-5.08; P = .004), LMPHT (OR, 2.39; 95% CI, 1.20-4.78; P = .014), and ALL abnormality (OR, 2.09; 95% CI, 1.13-3.89; P = .019) were associated with high-grade knee laxity. The association between excessive ATSLC and high-grade knee laxity was validated in patients with acute ACL injury as well as those with chronic ACL injury.

CONCLUSION

Excessive ATSLC was associated with high-grade knee laxity in patients who had ACL deficiency, with a predictive cutoff value of 4.5 mm. This study may help surgeons estimate the degree of knee instability more accurately before anesthesia and may facilitate preliminary surgical decision-making, such as appropriate graft choices and consideration of extra-articular augmentation.

Editorial Commentary: Early Anterior Cruciate Ligament Reconstruction Decreases the Risk of Developing Irreparable Meniscus Tears in Female Athletes

There has been a substantial increase in the participation of women in sports since the passage of Title IX in 1972. With increased participation has come a rise in athletic injuries, including anterior cruciate ligament (ACL) tears. Numerous factors (modifiable and nonmodifiable) contribute to the 2 to 8 times increased risk of ACL tears in female compared with male athletes. The sports with the greatest risk of ACL injury include cutting sports such as soccer (1.1% per season), basketball (0.9% per season), volleyball, and lacrosse. In addition, female patients have a 33.7% greater risk of a subsequent contralateral ACL tear. Approximately 70% of ACL tears are the result of noncontact injuries. Numerous factors contribute to the increased risk of ACL tears in female athletes, including nonmodifiable (hormonal fluctuations, sex differences in knee geometry) and modifiable risk factors (neuromuscular control). Injury-prevention programs focus on modifiable risk factors and have been shown to be incredibly effective, decreasing the risk of ACL tears up to 50%. ACL tears commonly are associated with meniscus tears, including medial meniscus ramp and lateral posterior root lesions; therefore, thorough assessment is critical to identify this pathology. Early ACL reconstruction (i.e., <12 months following injury) increases the likelihood of being able to repair meniscus tears. Given the much greater risk of ACL tears and lower rate of return to sport in female athletes, this group warrants special attention to identify and treat these injuries earlier and subsequently improve overall outcomes.

Low reoperation rate following lateral meniscus root repair: clinical outcomes at 2 years follow-up

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.

Patients With Anterior Cruciate Ligament Rupture and Ipsilateral Segond Fractures Have High Rates of Concurrent Knee Pathology

Purpose

The purpose of this study was to determine the rates of concomitant knee pathology in patients with ACL injuries and Segond fractures.

Methods

A retrospective study is undertaken with patients identified via query of CPT codes for ACL reconstruction from 2014 to 2020. All patients with preoperative radiographs were reviewed for the presence of Segond fractures. Operative reports were analyzed for the presence of concurrent pathology, including meniscus, cartilage, and other ligamentous injuries at the time of arthroscopic ACL reconstruction.

Results

A total of 1,058 patients were included in the study. Segond fractures were identified in 50 (4.7%) patients. Ipsilateral concomitant knee pathology was identified in 84% of Segond patients. Thirty-eight (76%) patients had meniscal pathology with a total 49 meniscal injuries, of which 43 were treated operatively. Multiligamentous injuries were present in 16 patients (32%), with 8 patients undergoing further ligament repair/reconstruction at the time of surgery. Chondral injuries were identified in 13 patients (26%).

Conclusions

A high prevalence of concomitant meniscal, chondral, and ligamentous injuries was found in patients with Segond fractures. These additional injuries may require further operative management and may place patients at increased risk for future instability or degenerative changes. Patients with Segond fractures should be counseled preoperatively on the nature of their injuries and risk of associated pathologies.

Level of Evidence

Level IV, prognostic case series.

The anterior cruciate ligament injury severity scale (ACLISS) is an effective tool to document and categorize the magnitude of associated tissue damage in knees after primary ACL injury and reconstruction

PURPOSE

To develop a tool allowing to classify the magnitude of structural tissue damage occurring in ACL injured knees. The proposed ACL Injury Severity Scale (ACLISS) would provide an easy description and categorization of the wide spectrum of injuries in patients undergoing primary ACL reconstruction, reaching from isolated ACL tears to ACL injuries with a complex association of combined structural damage.

METHODS

A stepwise approach was used to develop the ACLISS. The eligibility of each item was based on a literature search and a consensus between the authors after considering the diagnostic modalities and clinical importance of associated injuries to the menisci, subchondral bone, articular cartilage or collateral ligaments. Then, a retrospective analysis of associated injuries was performed in 100 patients who underwent a primary ACL reconstruction (ACLR) by a single surgeon. This was based on acute preoperative MRI (within 8 weeks after injury) as well as intraoperative arthroscopic findings. Depending on their prevalence, the number of selected items was reduced. Finally, an analysis of the overall scale distribution was performed to classify the patients according to different injury profiles.

RESULTS

A final scoring system of 12 points was developed (12 = highest severity). Six points were attributed to the medial and lateral tibiofemoral compartment respectively. The amount of associated injuries increased with ACLISS grading. The median scale value was 4.5 (lower quartile 3.0; higher quartile 7.0). Based on these quartiles, a score < 4 was considered to be an injury of mild severity (grade I), a score between ≥ 4 and ≤ 7 was defined as moderately severe (grade II) and a score > 7 displayed the most severe cases of ACL injuries (grade III). The knees were graded ACLISS I in 35%, ACLISS II in 49% and ACLISS III in 16% of patients. Overall, damage to the lateral tibiofemoral compartment was predominant (p < 0.01), but a proportional increase of tissue damage could be observed in the medial tibiofemoral compartment with the severity of ACLISS grading (p < 0.01).

CONCLUSIONS

The ACLISS allowed to easily and rapidly identify different injury severity profiles in patients who underwent primary ACLR. Injury severity was associated with an increased involvement of the medial tibiofemoral compartment. The ACLISS is convenient to use in daily clinical practice and represents a feasible grading and documentation tool for a reproducible comparison of clinical data in ACL injured patients.

LEVEL OF EVIDENCE

Level III.

Combined Repair of Medial Meniscal Ramp Lesions and Posterior Root Tears of the Lateral Meniscus During Anterior Cruciate Ligament Reconstruction: A Case Report

CASE

This case report describes the clinical outcomes for 2 patients who underwent a primary or revision anterior cruciate ligament (ACL) reconstruction with a combined inside-out and transtibial pullout repair for a medial meniscal ramp lesion (MMRL) and a lateral meniscus root tear (LMRT), respectively. Promising short-term outcomes were seen at the one-year follow-up for both patients.

CONCLUSIONS

Utilization of these repair techniques can successfully treat a combined MMRL and LMRT injury at the time of primary or revision ACL reconstruction.

High prevalence of meniscal ramp lesions in anterior cruciate ligament injuries

PURPOSE

To evaluate the prevalence of and factors associated with meniscal ramp lesions on magnetic resonance imaging (MRI) in patients with anterior cruciate ligament (ACL) injuries.

METHODS

Data from the Natural Corollaries and Recovery after ACL injury multicentre longitudinal cohort study (NACOX) were analysed. Only patients who underwent MRI were included in this study. All MRI scans were reviewed by an orthopaedic knee surgeon and a musculoskeletal radiologist. The patients were divided into two groups, those with and without ramp lesions according to MRI findings. Univariable and stepwise forward multiple logistic regression analyses were used to evaluate patient characteristics (age, gender, body mass index, pre-injury Tegner activity level, activity at injury) and concomitant injuries on MRI (lateral meniscus, medial collateral ligament [MCL], isolated deep MCL, lateral collateral ligament, pivot-shift-type bone bruising, posteromedial tibial [PMT] bone bruising, medial femoral condyle bone bruising, lateral femoral condyle [LFC] impaction and a Segond fracture) associated with the presence of meniscal ramp lesions.

RESULTS

A total of 253 patients (52.2% males) with a mean age of 25.4 ± 7.1 years were included. The overall prevalence of meniscal ramp lesions was 39.5% (100/253). Univariate analyses showed that contact sports at ACL injury, pivot-shift-type bone bruising, PMT bone bruising, LFC impaction and the presence of a Segond fracture increased the odds of having a meniscal ramp lesion. Stepwise forward multiple logistic regression analysis revealed that the presence of a meniscal ramp lesion was associated with contact sports at ACL injury [odds ratio (OR) 2.50; 95% confidence intervals (CI) 1.32-4.72; P = 0.005], pivot-shift-type bone bruising (OR 1.29; 95% CI 1.01-1.67; P = 0.04), PMT bone bruising (OR 4.62; 95% CI 2.61-8.19; P < 0.001) and the presence of a Segond fracture (OR 4.38; 95% CI 1.40-13.68; P = 0.001).

CONCLUSION

The overall prevalence of meniscal ramp lesions in patients with ACL injuries was high (39.5%). Contact sports at ACL injury, pivot-shift-type bone bruising, PMT bone bruising and the presence of a Segond fracture on MRI were associated with meniscal ramp lesions. Given their high prevalence, meniscal ramp lesions should be systematically searched for on MRI in patients with ACL injuries. Knowledge of the factors associated with meniscal ramp lesions may facilitate their diagnosis, raising surgeons' and radiologists' suspicion of these tears.

LEVEL OF EVIDENCE

III.

Age, male sex, higher posterior tibial slope, deep sulcus sign, bone bruises on the lateral femoral condyle, and concomitant medial meniscal tears are risk factors for lateral meniscal posterior root tears: a systematic review and meta-analysis

PURPOSE

Lateral meniscus posterior root tears (LMPRTs) are commonly found in patients with anterior cruciate ligament (ACL) injuries. However, risk factors for LMPRTs are not well known. This study was designed to systematically review the available evidence regarding risk factors associated with LMPRTs.

METHODS

The PubMed, EMBASE, Cochrane Library, and Web of Science databases were searched for papers containing the key words "lateral meniscus posterior root tears", "LMPRTs" and "risk factor". Inclusion screening, data extraction, and quality assessment of the included articles were conducted independently by two authors. Statistical analysis was conducted to determine risk factors for LMPRTs.

RESULT

Seventeen studies with a total sample size of 6, 589 patients were identified. The pooled prevalence of LMPRTs was 9.6% (range, 5.1-33.8%) for ACL injury. Significant risk factors included a patient age of < 30 [OR = 1.4, 95% CI (1.07, 1.84), p = 0.01], male sex [OR = 1.50, 95% CI (1.24,1.81), p = 0.01], higher body mass index (BMI) [MD = 0.45, 95% CI (0.13, 0.76), p < 0.01], higher lateral posterior tibial slope (LPTS) [MD = 2.22, 95% CI (1.37, 3.07), p < 0.01], deep sulcus sign [OR = 5.76, 95% CI (1.35, 24.52), p < 0.01] and bone bruises on lateral femoral condyle [OR = 4.88, 95% CI (1.27, 18.77), p < 0.01], lateral meniscal extrusion > 1 mm [OR = 5.56, 95% CI (1.52, 20.29), p < 0.01] and > 3 mm [OR = 12.91 95% CI (1.28, 130.01), p < 0.01], medial meniscal tears [OR = 1.40, 95% CI (1.12, 1.75), p < 0.01], and medial ramp lesions [OR = 2.29, 95% CI (1.35, 3.89), p < 0.01].

CONCLUSION

Age below 30, male, higher BMI, higher LPTS, deep sulcus sign, bone bruises on lateral femoral condyle, lateral meniscal extrusion, medial meniscal tear, and medial ramp lesion are risk factors for LMPRTs.

LEVEL OF EVIDENCE

Level IV.

Meniscal resection increases the risk of residual knee laxity even in patients undergoing anatomic double-bundle anterior cruciate ligament reconstruction with eight strands of hamstring autografts

PURPOSE

To compare the midterm clinical outcomes of different meniscal surgeries in patients undergoing anatomic double-bundle anterior cruciate ligament reconstruction (DB-ACLR) with eight strands of hamstring (HT8) autografts and explore the potential predictive risk factors for residual knee laxity.

METHODS

From 2010 to 2017, a total of 410 patients who underwent anatomic trans-tibial DB-ACLR with HT8 autografts (169 patients without meniscal surgery, 105 patients with meniscal repair, and 136 patients with meniscal resection) were included in this study. The equivalent graft diameter was introduced to make the total graft size of DB-ACLR comparable with that of single-bundle ACLR and calculated as the square root of the quadratic sum of the diameter for each bundle. Residual laxity was defined as excessive anterior tibial translation or residual pivot shift at any follow-up visit, while graft rupture was confirmed by second-look arthroscopy or magnetic resonance imaging.

RESULTS

The mean follow-up period was 8.3 ± 2.2 years. The mean equivalent graft diameter was 9.9 ± 0.7 mm. Graft rupture was confirmed in 16 (3.9%) patients, while residual laxity was detected in 72 (17.6%) patients (34 [25.0%] in the meniscal resection group vs. 22 [13.0%] in the no meniscal surgery group, p = 0.021). In the multivariate logistic regression analysis, high-grade preoperative knee laxity (odds ratio OR 2.04, p = 0.020), equivalent graft diameter < 9 mm (OR 3.31 compared with 9-10 mm, p = 0.012; OR 3.28 compared with ≥ 10 mm, p = 0.019), and meniscal resection (OR 1.94 compared with no meniscal surgery, p = 0.045) were associated with residual laxity.

CONCLUSION

During a midterm follow-up, meniscal resection increased the risk of residual knee laxity even in patients undergoing anatomic DB-ACLR with HT8 autografts. Increasing the hamstring graft diameter and preserving the menisci are important strategies for ACLR to restore knee stability.

LEVEL OF EVIDENCE

Level III.

Treatment Trends in Meniscal Pathology in the Setting of Concomitant ACL Injuries in Pediatric and Young Adult Patients: An Insurance Database Study

BACKGROUND

Meniscal pathology is commonly encountered in the setting of anterior cruciate ligament (ACL) rupture and is increasingly common in the pediatric and adolescent population. Studies have shown that over half of individuals presenting with ACL rupture will have concurrent meniscal pathology.

PURPOSE

To define trends in the utilization of meniscal procedures (ie, meniscus repair vs partial meniscectomy) and short-term complications in pediatric and young adult patients with meniscal pathology in the setting of a concurrent ACL reconstruction.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

The IBM MarketScan Commercial Database was utilized to identify ACL reconstruction procedures performed between 2006 and 2018 for individuals aged 5 to 30 years. Annual proportions of meniscectomy and meniscal repair were analyzed, and short-term complications were compared between pediatric/adolescent patients (aged 5-17 years) and young adults (aged 18-30 years).

RESULTS

An overall 40,736 records of individuals <18 years old with ACL tears were included. The pediatric/adolescent population had a significantly lower proportion of concomitant meniscal procedures (56.8%; 23,149/40,736) than the young adult population (59.7%; 33,764/56,515; P < .01). From 2006 to 2018, utilization of meniscal repair in the setting of ACL reconstruction steadily increased (20.1% to 35.1% [+15 percentage points], P < .01), while the proportion with meniscectomy decreased (34.4% to 21.3% [-13.1 percentage points], P < .01). There was no difference in rate of reoperation for repeat meniscal repair or meniscectomy in the pediatric/adolescent population for those undergoing meniscal repair versus meniscectomy within 180 days of primary surgery (1.7% [188/10,766] vs 1.5% [186/12,383]; P = .14).

CONCLUSION

From 2006 to 2018, the proportion of patients receiving ACL reconstruction with concomitant meniscal repair increased (20.1% to 35.1%) while the proportion with meniscectomy decreased (34.4% to 21.3%) in the pediatric/adolescent population. Meniscal repair was not associated with a higher 180-day rate of reoperation for repeat meniscal repair or meniscectomy than meniscectomy in the setting of ACL reconstruction.

Transosseous Meniscus Root Repair in Pediatric Patients and Association With Durable Midterm Outcomes and High Rates of Return to Sports

BACKGROUND

Injuries to the meniscus root attachments result in extrusion of the meniscus, impaired distribution of hoop stresses, and progressive degenerative articular wear. As a result of these deleterious effects, there has been increasing emphasis on repairing meniscus root injuries to restore structure and function.

PURPOSE

To describe meniscus root tear patterns, associated injuries, and outcomes of transosseous meniscus root repair in a series of pediatric patients.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A single-institution retrospective review approved by the institutional review board was performed on consecutive adolescent patients aged <19 years with a meniscus posterior root tear treated with transosseous root repair over 4 years. All patients had a minimum 24-month clinical follow-up. The primary outcomes were revision meniscal surgery, and Lysholm, patient satisfaction, and Tegner activity scores.

RESULTS

A total of 20 patients (11 male and 9 female patients), with a mean age of 15.6 years (range, 13-18 years), met the inclusion criteria. There were 14 lateral meniscus root tears and 6 medial meniscus root tears. Seventeen patients (85%) had an associated ligament tear: 12 anterior cruciate ligament (ACL) tears and 5 posterior cruciate ligament tears. Two root tears occurred in isolation and both were the posterior root of the medial meniscus. The majority of meniscus root tears (n = 14 patients; 70%) were root avulsions (type 5). The mean follow-up was 42 months (range, 25-71 months). One patient underwent secondary surgery on the affected meniscus after a new injury 4 years postoperatively. Patient-reported outcomes were obtained for 16 patients (80%) at a mean 54-month follow-up. The median Lysholm score was 95 (interquartile range [IQR], 90-100). The median patient satisfaction score was 10 (IQR, 8-10). Thirteen of 16 patients (81%) reported returning to the same or higher level of sports after surgery.

CONCLUSION

Meniscus root tears most commonly occur in pediatric patients as root avulsions of the posterior root of the lateral meniscus and in association with ACL tears. This is unique compared with the adult population, in which the medial meniscus posterior root is often injured in isolation from a radial tear adjacent to the root. In our pediatric case series, transosseous root repair resulted in successful outcomes in the majority of patients, with durable results at the midterm follow-up.

Epidemiology of Combined Injuries of the Secondary Stabilizers in ACL-Deficient Knees: Medial Meniscal Ramp Lesion, Lateral Meniscus Root Tear, and ALL Tear: A Prospective Case Series of 602 Patients With ACL Tears From the SANTI Study Group

BACKGROUND

Medial meniscal ramp lesion (MMRL), lateral meniscus root tear (LMRT), and anterolateral ligament (ALL) tear are individual injuries that have been described in patients who have an anterior cruciate ligament (ACL) tear. However, the prevalence of these lesions and their combination has not been defined.

PURPOSES

To define the individual and combined prevalence of MMRL, LMRT, and ALL tears in a case series of patients undergoing ACL reconstruction and to identify the risk factors for combined injuries.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Patients aged >15 years undergoing primary ACL reconstruction between January 2019 and June 2021 were enrolled in the study. A preoperative ultrasound scan was performed to look for an ALL tear. The presence of MMRL and LMRT was determined during a standardized arthroscopy exploration. A multivariate logistic regression model was used to determine the individual effect of patient variables on the risk of associated single, dual, triad, or tetrad injuries (MMRL, LMRT, ALL, ACL), represented by an adjusted odds ratio.

RESULTS

The case series consisted of 602 patients who underwent primary ACL reconstruction. An isolated ACL injury was present in 147 patients (24%). A dual injury was detected in 34 patients (6%) who had ACL-MMRL, 16 (2.65%) who had ACL-LMRT, and 265 (44%) who had ACL-ALL. A triad injury was detected in 80 patients (13.28%) who had ACL-ALL-MMRL, 36 (6%) who had ACL-ALL-LMRT, and 3 (0.5%) who had ACL-MMRL-LMRT. A tetrad injury pattern was detected in 21 patients (3.5%). Multivariate analysis showed that the occurrence of tetrad injury was significantly lower in older patients (adjusted odds ratio by year, 0.93 [95% CI, 0.88-0.99]; P = .028). Identifying LMRT increased the likelihood of finding MMRL-ALL injuries by 2.11 times (95% CI, 1.09-3.12; P = .031).

CONCLUSION

Isolated ACL tear is less common than combined injuries, which are quite frequent. Younger age is a risk factor for combined injuries. The search for damaged secondary stabilizers of the knee must be meticulous and systematic, especially when 1 injured structure has already been diagnosed.

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.

Prevalence and Incidence of Chondral and Meniscal Lesions in Patients Undergoing Primary and Subsequent Revision Anterior Cruciate Ligament Reconstruction: An Analysis of 213 Patients From the SANTI Group

BACKGROUND

Previous studies have shown a higher prevalence of meniscal and chondral lesions at the time of revision anterior cruciate ligament reconstruction (R-ACLR) compared with primary ACLR procedures. However, studies that follow the development of meniscal and chondral status through primary and subsequent R-ACLR are scarce.

PURPOSE

To compare the prevalence of meniscal and chondral injuries in patients undergoing primary ACLR and subsequent R-ACLR.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Patients who underwent ACLR and subsequently needed R-ACLR between January 2009 and February 2018 in a single center were included. A retrospective analysis of prospectively collected data was conducted.

RESULTS

A total of 213 patients were included, with a mean follow-up of 59.7 months. The mean age was 22 years at primary ACLR and 26.1 years at the time of revision. The proportion of meniscal tears was higher at the time of R-ACLR compared with the time of primary reconstruction (70.0% vs 44.6%, respectively; P < .001). Similarly, the prevalence of chondral lesions was significantly higher at the time of revision versus the primary reconstruction (15.5% vs 7.0%, respectively; P = .003).

CONCLUSION

R-ACLR is associated with a higher rate of concomitant meniscal and chondral lesions than primary ACLR.

Grade III pivot shift as an early sign of knee decompensation in chronic ACL-injured knees with bimeniscal tears

PURPOSE

To analyse possible associations between the preoperative pivot shift (PS) test and both patient and injury characteristics in anterior cruciate ligament (ACL)-injured knees, considering previously neglected meniscal injuries such as ramp and root tears. The hypothesis was that a preoperative grade III PS was associated with the amount of intra-articular soft-tissue damage and chronicity of the injury.

METHODS

The cohort involved 376 patients who underwent primary ACL reconstruction (239 males/137 females; median age 26). Patients were examined under anesthesia before surgery, using the PS test. During arthroscopy, intra-articular soft-tissue damage of the injured knee was classified as: (1) partial ACL tear; (2) complete isolated ACL tear; (3) complete ACL tear with one meniscus tear; and (4) complete ACL and bimeniscal tears. Chi-square and Mann-Whitney U tests were used to evaluate whether sex, age, body mass index, sport at injury, mechanism of injury, time from injury and intra-articular damage (structural damage of ACL and menisci) were associated with a grade III PS. Intra-articular damage was further analyzed for two sub-cohorts: acute (time from injury ≤ 6 months) and chronic injuries (> 6 months).

RESULTS

A grade III PS test was observed in 26% of patients. A significant association with PS grading was shown for age, time from injury and intra-articular soft-tissue damage (p < 0.05). Further analyses showed that grade III PS was associated with intra-articular damage in chronic injuries only (p < 0.01). In complete ACL and bimeniscal tears, grade III PS was more frequent in chronic (53%) than in acute knee injuries (26%; p < 0.01). Patients with chronic complete ACL and bimeniscal tears had a grade III PS 3.3 [1.3-8.2] times more often than patients in the acute sub-cohort.

CONCLUSION

In ACL-injured patients, a preoperative grade III PS was mainly associated with a higher amount of intra-articular soft-tissue damage and chronicity of the injury. Patients with complete chronic ACL injuries and bimeniscal tears were more likely to have a preoperative grade III PS than their acute counterparts. This suggests that grade III PS may be an early sign of knee decompensation of dynamic rotational knee laxity in chronic ACL-injured knees with bimeniscal lesions.

LEVEL OF EVIDENCE

Level III.

Combined Meniscus Repair and Anterior Cruciate Ligament Reconstruction

Meniscal tear patterns associated with anterior cruciate ligament (ACL) tears, such as root tears and ramp lesions are common but less easily recognized on magnetic resonance imaging (MRI) compared with a complete radial tear or a locked bucket-handle tear. Timely treatment of these tears improves outcomes in the setting of ACL reconstruction. While physical examination does not enable a definitive diagnosis of meniscal root tears and ramp lesions, high-grade laxity, including a 3+ Lachman and 3+ pivot shift, should raise suspicions for these tear patterns. MRI allows visualization of both root tears and ramp lesions, although the gold standard for diagnosis is probing at the time of arthroscopy due to a high false-negative rate on MRI. Up to 17% of patients with an ACL tear have a lateral meniscal root tear; a contact mechanism and increased posterior slope are both associated with a greater incidence of lateral meniscal root tears and these are repaired with a tunnel technique. Meniscal ramp lesions occur in up to 41% of patients with ACL tears due to a contact mechanism, and we prefer repair with an inside-out technique. More than 60% of complete radial meniscal tears occur in the setting of ACL tears and are preferentially repaired with a hashtag technique for minimally separated tears and a 2-tunnel technique combined with an inside-out repair for more severe tears. Bucket-handle tears are more common in the setting of chronic ACL deficiency; concurrent with ACL reconstruction urgent meniscal repair with an inside-out technique is the gold standard, which allows for precise approximation of the tear with multiple points of fixation for improved biomechanical performance. It is critical to identify and treat these tears during ACL reconstruction because of their role as secondary stabilizers and for long-term chondral protection.

The aspiration test reveals an instability of the posterior horn of the lateral meniscus in almost one-third of ACL-injured patients

PURPOSE

Anterior cruciate ligament (ACL) injuries often lead to associated injuries of the posterior horn of the lateral meniscus (PHLM). Arthroscopic, assessment of PHLM instability may be difficult in the absence of a visible meniscus damage. The main objective of this prospective multi-center study was to compare the ability of the probing and aspiration tests to identify PHLM instability in a population of patients undergoing ACL reconstruction (ACLR) and a control group of patients with an intact ACL undergoing knee arthroscopy.

METHODS

A prospective case-control analysis was performed in three sports medicine centers. One-hundred and three consecutive patients operated for a primary isolated ACLR without structural lateral meniscus damage other than a root tear were included. They were compared to a control group of 29 consecutive patients who had a knee arthroscopy with an intact ACL and no structural lateral meniscus lesion. The probing and aspiration tests were consecutively executed according to previously published methods.

RESULTS

In the control group, no lateral meniscus lesions were visualized during arthroscopy, and both probing and aspiration tests were negative in all patients. In the group of ACL-injured patients, a Forkel type I-III posterolateral meniscus root tear (PLMRT) was found in 12 patients (12%). In this subgroup, the probing test was positive in 4/12 patients (33%) and the aspiration test in 5 additional patients (75%). In 15 patients (15%), an elongation of the posterior root of the lateral meniscus (defined as type IV PLMRT as an addendum to the Forkel classification) could be observed during arthroscopy. In this subgroup, only 1 patient displayed a PHLM instability with the probing test (7%), whereas the aspiration test was positive in 13/15 patients (87%). In the remaining 76 patients (74%), no structural lesion of the PHLM could be identified. Nevertheless, an instability of the PHLM could be identified in 8 of them (11%) with the probing test, and the aspiration test was positive in 2 additional knees (13%) of this apparently normal subgroup. Altogether, in the entire ACL injury cohort, a positive probing test was observed in 13/103 patients (13%) and a positive aspiration test in 32/103 knees (31%) (p < 0.01).

CONCLUSION

Careful observation and examination of the PHLM with the aspiration test revealed a substantial amount of previously undiagnosed lateral meniscus instabilities in ACL-injured knees. The prevalence of PHLM instability as evaluated by the aspiration test was high (31%). The aspiration test was superior to the probing test in detecting an instability of the PHLM in a population of ACL-injured patients.

LEVEL OF EVIDENCE

II.

Ramp lesions are six times more likely to be observed in the presence of a posterior medial tibial bone bruise in ACL-injured patients

PURPOSE

The aim of this study was to determine whether posterior tibial slope (PTS), meniscal slope (MS), and bone bruise pattern (BBP), as observed on magnetic resonance imaging (MRI), differed between patients with or without medial meniscus ramp lesions at the time of anterior cruciate ligament reconstruction (ACLR). The hypothesis was that patients with a ramp lesion had a higher PTS and MS, with a different BBP than patients without a ramp lesion.

METHODS

Fifty-six patients undergoing ACLR were selected from an in-house registry and separated into 2 groups: (1) the RAMP group included patients with a primary ACLR and a medial meniscus ramp lesion diagnosed intraoperatively; (2) the CONTROL group included patients with a primary ACLR without ramp lesion after arthroscopic exploration of the posteromedial knee area. The two groups were matched for age, sex and type of concomitant meniscal lesions. The medial/lateral-PTS/MS and BBP were subjected to blinded evaluation on the preoperative MRI of the reconstructed knee.

RESULTS

Twenty eight patients (21 males; 7 females) were included in each group. No significant difference could be observed between groups in terms of demographical characteristics, PTS, and MS. A posteromedial tibial plateau (PMTP) bone bruise was more often observed in the RAMP group (n = 23/28) compared to the CONTROL group (n = 12/28) (p < 0.01). The RAMP group was 6.1 (95%CI [1.8; 20.8]) times more likely to present a PMTP bone bruise. The likelihood of having a bone bruise in both the medial and lateral compartments was 4.5 (95%CI [1.2; 16.5]) times higher in the RAMP group. However, a BBP only involving the lateral tibiofemoral compartment was more likely to be observed in the CONTROL group (n = 10/28) compared to the RAMP group (n = 3/28, p < 0.05 - odds ratio 4.6 (95%CI [1.1; 19.2]).

CONCLUSION

Ramp lesions were 6.1 and 4.5 times more likely to be observed in the presence of a posteromedial tibia plateau bone bruise or a combined bone bruise respectively in both the medial and lateral tibiofemoral compartment in patients undergoing ACLR. The tibial and meniscal slopes did not differ between patients with or without ramp lesions undergoing ACLR.

LEVEL OF EVIDENCE

Level III.

Leaving the stable ramp lesion unrepaired does not negatively affect clinical and functional outcomes as well as return to sports rates after ACL reconstruction

PURPOSE

To evaluate the effects of untreated stable ramp lesions on clinical and functional outcomes, return to sports rates, and complications of patients who underwent anterior cruciate ligament reconstruction.

METHODS

A total of 879 patients with anterior cruciate ligament rupture were evaluated. Of these, 66 patients [33 patients with anterior cruciate ligament rupture and stable medial meniscal ramp lesion (ramp + group) and 33 patients with isolated anterior cruciate ligament rupture (ramp - group)] with a minimum 3-year of follow-up were included. Stable ramp lesions were not repaired in the ramp + group. Preoperative and postoperative Lachman and pivot-shift grades, Lysholm knee scores, International Knee Documentation Committee score and 12-Item Short Form Health Survey score were compared between groups. The return to sports rates, level of return to sports, time to return to sports and complications were compared.

RESULTS

The mean patient age was 27.8 ± 7.2 years. The mean follow-up period was 47.3 ± 9.4 months. There were no significant differences between groups regarding preoperative and postoperative Lachman and pivot-shift grades, 12-Item Short Form Health Survey mental and physical component summary scores, Lysholm and International Knee Documentation Committee scores, and complication rates (n.s.). Although the return to sports rates (84.8% vs 90.1%) and the level of the return to sports (return to preinjury level: 75% vs 78%) were similar between groups (n.s.), the time to return to sports was significantly longer for patients with ramp lesions (11.1 ± 4.0 vs. 8.7 ± 2.5 months, p = 0.007).

CONCLUSION

Leaving the stable ramp lesion unrepaired does not negatively affect clinical and functional outcomes as well as return to sports rates after ACL reconstruction. However, the time to return to sports is prolonged in patients with ramp lesions In clinical practice, surgeons should be aware that repairing stable ramp lesions is not an absolute necessity and will not affect return to sport rates.

LEVEL OF EVIDENCE

Level III.

Younger age increases the risk of sustaining multiple concomitant injuries with an ACL rupture

PURPOSE

Anterior cruciate ligament (ACL) tears have a major impact on the individual and society. Long term effects may be mediated by injuries that occur concurrently to the ACL tear. The purpose of this study was to describe in a nationwide cohort the traumatic meniscal injuries and bone marrow lesions concomitant to ACL tears, their age and sex distribution and the rate any association with ACL reconstruction.

METHODS

All ACL tears in Iceland from 2006 to 2011 and their concomitant bone marrow lesions and meniscal injuries were identified from MRI reports. These injuries were further classified by location, sex and age. The cohort was divided into under 17, 17-29, 30-49 and above 50 to reflect likely differences in the mechanisms of injury and risk factors that may vary with age. Data from the Icelandic Social Insurance Administration were used identify all those who were operated. Descriptive analysis was performed to show the proportion of ACL injured knees sustaining concomitant injuries and how these injuries varied with age, sex, and subsequent treatment RESULTS: 1365 knees with ACL ruptures were included. Only 13% of knees had no concomitant injury identified. Overall, 57% of knees had a bone marrow lesion in at least one location and 70% of knees had at least one traumatic meniscal injury. A greater number of combined lateral tibial and femoral bone marrow lesion was seen in younger age groups (χ² (3) = 113.32, p < 0.0001). Bruises in the medial compartment were the least common concomitant injuries. More injuries were related to higher chances of ACL reconstruction (OR 1.6, 95% CI 1.4-1.7). Age was associated with risk of all injury types and locations with older age generally being associated with fewer injuries.

CONCLUSION

In an ACL ruptured cohort, the overall incidence of BMLs may be lower and meniscus injuries higher than previously reported. However, these injuries are more prevalent in the younger cohort potentially resulting in a poorer long-term prognosis. Knowledge of the association between age and concomitant injuries will help guide rehabilitation.

LEVEL OF EVIDENCE

II.

Does practice of meniscus surgery change over time? A report of the 2021 'THE MENISCUS' Webinar

Purpose

The aim of this paper was to report the results presented in the session “Does practice of meniscus surgery change over time?” of the 2021 MENISCUS webinar held online on January 30^th 2021.

Method

During the 2021 MENISCUS webinar, an evaluation of meniscus surgery practices was performed by analyzing: (1) The presentation of the results of a survey conducted among ESSKA members and assessing their current practices in the field of meniscus surgery, (2) Four reports by national experts analyzing the trends in Arthroscopic Partial Meniscectomy (APM) and meniscus repair procedures in their respective countries (France, Belgium, Germany and Japan).

Results

(1) ESSKA Survey: Among the 461 respondents, 75% of surgeons claimed to perform more meniscus repairs and 85% less APM than 5 years ago. In ACL-associated meniscus injuries, a majority of surgeons (60%) indicated to perform a meniscal resection in less than 25% of cases. 25% declared to perform meniscus repair in ACL-associated meniscus injuries in less than 25% of cases and 37% in more than 50% of cases. Half of the respondents repair medial or lateral root tears in less than 25% of cases. Less than 20% of respondents were not familiar with the ESSKA consensus.

(2) National trends: In France, between 2005 and 2017, the APM rate decreased by 21.4%, while the repair rate increased by 320%. In Belgium, between 2007 and 2017, the APM rate decreased by 28.6%. In Germany, between 2010 and 2017 the number of APM decreased by 30%, while the number of repair procedures increased by 55%. Finally, in Japan, between 2011 and 2016, the APM ratio (APM/meniscus procedures) decreased by 16% from 91 to 75% while the repair ratio increased from 9 to 25%.

Conclusion

The 2021 ESSKA members' survey as well as statistics from 4 specifically examined countries (Belgium, France, Germany and Japan) suggest there has been a significant shift over the last years in the surgical management of meniscal lesions towards less APM and more conservative treatments.

The aspiration test: an arthroscopic sign of lateral meniscus posterior horn instability

The suspensory mechanism of the posterior horn of the lateral meniscus (PHLM) is an anatomically complex structure including the popliteomeniscal fascicles, the meniscotibial posterior root attachment and the meniscofemoral ligaments. Damage to one or several of these structures – either through knee trauma or congenital abnormalities—can result in an instability of the PHLM that may lead to lateral knee pain, locking sensations or lack of rotational control of the knee (e.g. after anterior cruciate ligament injuries). The diagnosis of PHLM instability is complex due to the lack of reliable clinical tests and imaging signs. Direct visual dynamic inspection via arthroscopy thus remains the gold standard. However, arthroscopic probing of the PHLM is not always reliable and the precise quantification of the amount of subluxation of the PHLM can be difficult. Therefore, the main objective of this report was to describe a quick and easy arthroscopic screening test called “the aspiration test” in order to help surgeons to detect PHLM instability. During the exploration of the lateral tibiofemoral compartment with the knee kept in the figure of 4 position, the arthroscope is placed in the antero-lateral portal and directed towards the lateral tibiofemoral compartment. The aspiration test is then performed by activating the aspiration of the 4-mm shaver when located in the intercondylar notch. In case of a PHLM instability, an excessive displacement of the PHLM is observed. After repair, a second aspiration test allows to verify that the PHLM has been stabilized.