Current concepts in the techniques, indications and outcomes of meniscal repairs

An experimental study of the heterogeneity and anisotropy of porcine meniscal ultimate tensile strength

Characterizing the ultimate tensile strength (UTS) of the meniscus is critical in studying knee damage and pathology. This study aims to determine the UTS of the meniscus with an emphasis on its heterogeneity and anisotropy. We performed tensile tests to failure on the menisci of six month old Yorkshire pigs at a low strain rate. Specimens from the anterior, middle and posterior regions of the meniscus were tested in the radial and circumferential directions. Then the UTS was obtained for each specimen and the data were analyzed statistically, leading to a comprehensive view of the variations in porcine meniscal strength. The middle region has the highest average strength in the circumferential (43.3 ± 4.7 MPa) and radial (12.6 ± 2.2 MPa) directions. This is followed by the anterior and posterior regions, which present similar average values (about 34.0MPa) in circumferential direction. The average strength of each region in the radial direction is approximately one-fourth to one-third of the value in the circumferential direction. This study is novel as it is the first work to focus on the experimental methods to investigate the heterogeneity and anisotropy only for porcine meniscus.

Meniscus Injuries in Soccer

Soccer is considered the most popular sport in the world. The game involves frequent agile maneuvers, such as rapid accelerations/decelerations and pivoting, and carries an inherent risk of high-speed collisions, which can lead to lower extremity injury. Knee and meniscus injuries can cause significant pain and disability, precluding participation in the sport. Understanding the diagnosis and management of meniscal injuries in soccer players is essential to the care of these athletes. This paper reviews meniscal anatomy, biomechanics, and mechanisms of injury; discusses the work-up, diagnosis, and management of meniscus injuries; and reports on rehabilitation, return to sport, and outcomes after meniscal injuries in soccer players.

Decreasing Incidence of Partial Meniscectomy, and Increasing Incidence of Meniscus Preservation Surgery from 2010-2020 in the United States

PURPOSE

The aim of the present study was to characterize the incidence of meniscus surgery from 2010 to 2020 in the United States, using the metrics of age, sex, type of meniscus surgery, and Charlson Comorbidity Index (CCI).

METHODS

A retrospective analysis was performed using the PearlDiver national insurance claims database from 2010-2020. Meniscus surgeries were identified using Current Procedural Terminology codes. Patients were stratified by procedure type, age, biological sex, and Charlson Comorbidity Index (CCI) scores. Compound annual growth rate (CAGR) analysis and analysis of variance (ANOVA) were performed to analyze the trends and demographic variables between cohorts.

RESULTS

Of 2,053,884 meniscus surgeries, 94.7% were meniscectomies, 0.3% were open repairs, 4.9% were arthroscopic repairs, and 0.1% were meniscal transplantations. CAGR analysis displayed a 4.0% decrease per year in total meniscus surgery. For individual procedure types, the largest decrease was in meniscectomy, and the largest increase was in open repair. Patients undergoing meniscal transplantation were youngest, with the lowest CCI. Meniscectomy patients were oldest, and open repair patients had the highest average CCI. Most procedures were performed on female patients (52.4%), and patients in the 50-59-year age group (30.4%).

CONCLUSIONS

There was a sustained decrease in the incidence of total meniscus surgeries from 2010-2020. Meniscectomy was the procedure with the highest incidence, however, it showed the most significant decline in usage over the study period. Conversely, meniscal repair and transplantation procedures increased during the study period.

Pulsed radiofrequency of iPACK (interspace between the popliteal artery and the posterior knee capsule) for pain control following meniscus repair - A case report

Adequate postoperative pain control is an essential factor for the success of rehabilitation programs after meniscus repair (MR). The pulsed radiofrequency of the interspace between the popliteal artery and the posterior knee capsule (PRF-iPACK) is a recently developed method. This study aimed to evaluate the use of PRF-iPACK in patients who underwent MR. We performed PRF-iPACK guided by ultrasonography for patients who underwent MR with aggravated pain. PRF-iPACK was performed following MR four weeks after surgery. The pain was evaluated using the visual analogue scale (VAS), Lysholm score, and the Euroqol-5 Dimension (EQ-5D). In this study, two patients participated. For the results, a week and three months after treatment, the mean VAS score, Lysholm score, and EQ5D improved from 7 to 1 and 0 respectively, and 42 to 86 and 90 respectively, and 0.48 to 0.82 and 0.92 respectively. We concluded that PRF-iPACK is an adequate and safe procedure for managing postoperative pain after MR. It may enhance the postoperative rehabilitation program.

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.

Heterotopic ossification postsuperficial medial collateral ligament pie-crusting: a case report

Anterior cruciate ligament and meniscus tears are common among sports injuries. There are different techniques for addressing anterior cruciate ligament and meniscus tears, with distinct indications, advantages, and disadvantages. We present the case of a 23-year-old male who underwent right anterior cruciate ligament reconstruction and posterior horn medial meniscus repair using an all-inside technique via superficial medial collateral ligament (sMCL) pie-crusting. Clinical examination and radiological investigations a few months later identified calcifications on the medial side of the right knee. We diagnosed the patient with heterotopic ossification post-sMCL pie-crusting; no apparent causal factors were present. To our knowledge, there have been no documented instances of heterotopic ossification following sMCL pie-crusting. In conclusion, heterotopic ossification may occur after sMCL pie-crusting; further studies are needed on this subject.

Neither All-Inside, nor Inside-Out, nor Outside-In Repair Demonstrates Superior Biomechanical Properties for Vertical Meniscal Tears: A Systematic Review of Human Cadaveric Studies

PURPOSE

To systematically review the literature regarding the biomechanical properties of different repair techniques and fixation methods for vertically oriented meniscal tears.

METHODS

Human cadaveric studies evaluating the biomechanical properties of different repair techniques for vertically oriented meniscal tears were identified using the PubMed, EMBASE, and Cumulative Index to Nursing & Allied Health databases. Primary outcomes included load to failure, displacement, stiffness, peak contact pressure, and contact area of repaired menisci. Repair techniques from included studies were reclassified into a total of 19 distinct all-inside (AI), inside-out (IO), or outside-in (OI) techniques.

RESULTS

Sixteen studies were included (420 total menisci). Contact pressure and area were restored to intact-state values across all 5 compressive load studies at low knee flexion angles but not at greater knee flexion angles (i.e., >60°). There were no significant differences in contact pressure or area between AI, IO, and OI techniques across all studies. Some studies demonstrated statistically significant advantages in tensile properties with IO techniques when compared with AI techniques, whereas others found AI techniques to be superior. No studies directly compared tensile properties of OI techniques with those of AI or IO techniques. Vertical mattress suture configurations resulted in significantly greater load to failure and decreased displacement compared with horizontal mattress configurations in 67% of studies comparing the 2 techniques. There was no difference in the rate of tissue failure in AI (66.97%), IO (60.38%), or OI (66.67%, χ2 = 0.83, P = .66) techniques.

CONCLUSIONS

Contact mechanics are reliably restored after repair of vertical meniscal tears at low flexion angles but inconsistently restored at greater flexion angles, regardless of technique. Vertical mattress configurations outperformed horizontal mattress configurations under tensile load. There are conflicting data regarding the comparison of tensile properties between AI and IO techniques. Ultimately, neither AI, IO, nor OI repair demonstrated superior biomechanical properties in the present literature.

CLINICAL RELEVANCE

Several repair techniques demonstrate favorable biomechanical properties for vertical meniscal tears under tensile and compressive loads. Neither AI, IO, nor OI repair techniques demonstrate superior biomechanical properties at this time.

Anterior Cruciate Ligament Reconstruction Using Bone-Patellar Tendon-Bone Autograft With Lateral Compartment Meniscectomy or Chondroplasty Does Not Lead to Decreased Return to Sport and Activity Compared With No Lateral Pathology

Purpose

To investigate the influence of lateral meniscal and cartilage pathology on the outcome after anterior cruciate ligament (ACL) reconstruction in patients who participate in pivoting sports.

Methods

Using a single-surgeon patient registry, patients undergoing an anterior cruciate ligament reconstruction (ACLR) using bone-patellar tendon-bone autograft were evaluated with minimum 2-year patient reported outcomes evaluated using Marx, Tegner, Lysholm, and International Knee Documentation Committee scales. Patients were divided into 3 groups: isolated ACL surgery, ACLR with a partial lateral meniscectomy, or a ACLR with partial lateral meniscectomy and lateral compartment chondroplasty.

Results

A total of 98 patients met inclusion criteria. Using the isolated ACL reconstruction group as a control, we found that Marx scores were greater in patients who additionally underwent a partial lateral meniscectomy at 1 year (P = .016). There were no significant differences between the ACL-only group and the ACL with partial lateral meniscectomy and chondroplasty group. Within the partial meniscectomy cohort comparing the patients with red-white zone tears with the patients with white-white zone tear, we found there were no significant differences when compared with the ACL-only control. There were no significant differences appreciated between groups using the International Knee Documentation Committee, Lysholm, and Tegner scales.

Conclusions

ACL reconstruction using bone-patellar tendon-bone autograft with anteromedial portal drilling technique does not have any significant short-term (2-year outcome) differences in return to activity and patient-reported outcomes compared with if patients additionally have a partial lateral meniscectomy and/or lateral compartment chondroplasty. Additional partial lateral meniscectomy showed significantly greater Marx scores at 1 and 2 years' postoperatively.

Level of Evidence

Level III, retrospective cohort study.

Segond fracture: an indicator for increased risk of lateral meniscus injury in patients with acute anterior cruciate ligament ruptures

PURPOSE

The purpose of this study was to investigate the incidence and anatomic distribution of meniscus injury in patients who have sustained acute ACL injuries with and without concomitant Segond fracture. We hypothesized that patients who have sustained a torn ACL with a concomitant Segond fracture would have a higher incidence of lateral meniscal injuries than patients with an isolated ACL injury.

METHODS

Patients who underwent ACL reconstruction from 2012 to 2022 were retrospectively reviewed. Segond fractures were identified on knee radiographs. Inclusion criteria were age 18-40, injury during sports activity, and reconstruction within 90 days of injury. Sports activity, anatomic location of meniscus injury, and meniscus treatment were documented. Multivariable regression was used to identify predictors of meniscus injury/treatment.

RESULTS

There were 25 of 603 (4.1%) patients who had an ACL tear with concomitant Segond fracture. The incidence of lateral meniscus injury in the Segond group (72%) was significantly higher than in the non-Segond cohort (49%; p = 0.024). A significantly smaller proportion of medial meniscus injuries among patients with Segond fractures were repaired (23.1%) compared to the non-Segond group (54.2%; p = 0.043). Multivariate analysis found patients with Segond fractures to have increased odds of lateral meniscus injury (OR 2.68; [1.09, 6.60], p = 0.032) and were less likely to have medial meniscus injuries repaired (OR 0.35; [0.15, 0.81], p = 0.014). Additionally, males had increased odds of lateral meniscus injury (OR 1.54; [1.08 - 2.91], p = 0.017), which were more likely to require repair (OR 1.48; [1.02, 2.14], p = 0.038).

CONCLUSIONS

Among acute ACL injuries, the incidence of lateral meniscus injury is greater among patients with Segond fractures. Patients with Segond fracture were less likely to undergo repair of medial meniscal injuries.

Composite Zonal Scaffolds of Collagen I/II for Meniscus Regeneration

The meniscus is divided into three zones according to its vascularity: an external vascularized red-red zone mainly comprising collagen I, a red-white interphase zone mainly comprising collagens I and II, and an internal white-white zone rich in collagen II. Known scaffolds used to treat meniscal injuries do not reflect the chemical composition of the vascular areas of the meniscus. Therefore, in this study, four composite zonal scaffolds (named A, B, C, and D) were developed and characterized; the developed scaffolds exhibited the main chemical components of the external (collagen I), interphase (collagens I/II), and internal (collagen II) zones of the meniscus. Noncomposite scaffolds were also produced (named E), which had the same shape as the composite scaffolds but were entirely made of collagen I. The composite zonal scaffolds were prepared using different concentrations of collagen I and the same concentration of collagen II and were either cross-linked with genipin or not cross-linked. Porous, biodegradable, and hydrophilic scaffolds with an expected chemical composition were obtained. Their pore size was smaller than the size reported for the meniscus substitutes; however, all scaffolds allowed the adhesion and proliferation of human adipose-derived stem cells (hADSCs) and were not cytotoxic. Data from enzymatic degradation and hADSC proliferation assays were considered for choosing the cross-linked composite scaffolds along with the collagen I scaffold and to test if composite zonal scaffolds seeded with hADSC and cultured with differentiation medium produced fibrocartilage-like tissue different from that formed in noncomposite scaffolds. After 21 days of culture, hADSCs seeded on composite scaffolds afforded an extracellular matrix with aggrecan, whereas hADSCs seeded on noncomposite collagen I scaffolds formed a matrix-like fibrocartilage without aggrecan.

Comparison of Partial Meniscectomy With Meniscal Repair With Respect to Functional Outcome

Introduction Meniscus tear is a commonly encountered sports-related injury requiring surgical intervention due to knee mobility dysfunction and discomfort. Previously, it has been thought that these are non-functional vestigial structures and they used to be excised commonly. Recent studies have shown that meniscal repair gives superior results when compared with partial meniscectomy. Methods This quasi-experimental study was conducted at the Orthopedics Department, Khyber Teaching Hospital, Peshawar, Pakistan. A total of 92 patients of both genders with meniscal injuries were included. Forty-six of them underwent meniscal repair (Group A), and 46 underwent partial meniscectomy (Group B). Functional outcome was noted after 12 weeks and recorded. Results The age range was from 18 to 50 years with a mean of 28.630±6.64 years in Group A and 29.630±8.12 years in Group B. Functional outcome was excellent in 44 (95.7%) patients who underwent meniscal repair as compared to 23 (50%) patients who underwent partial meniscectomy (P= 0.000). Conclusion It is concluded that meniscal repair should be pursued over partial meniscectomy when surgically treating meniscal tears.

Meniscectomy Reimbursement and Utilization Are Declining at Different Rates Across the United States

PURPOSE

To evaluate how arthroscopic meniscectomy utilization, reimbursement, physician billing practices, and patient populations have changed within the Medicare population from 2013 to 2021 at a national level and regional level.

METHODS

The Medicare Physician & Other Practitioners database was queried for all episodes of 2-compartment and single-compartment arthroscopic meniscectomy between 2013 and 2021. Utilization per 10,000 beneficiaries and average inflation-adjusted reimbursement were assessed. Physician practice styles, measured through changes in the services billed, and Medicare beneficiary demographic characteristics were extracted each year. The Kruskal-Wallis test was performed to compare regions.

RESULTS

Between 2013 and 2021, two-compartment meniscectomy utilization per 10,000 Medicare beneficiaries declined by 54.9% and single-compartment meniscectomy utilization declined by 54.2%. Average reimbursement declined by 9.3% and 12.5% for 2-compartment meniscectomy and single-compartment meniscectomy, respectively. In 2021, the South had the highest utilization of both 2-compartment (3.8/10,000) and single-compartment (4.7/10,000) meniscectomies while having the lowest average reimbursement for 2-compartment meniscectomy ($383.02, P < .001). Nationally, the average number of beneficiaries per surgeon performing single-compartment meniscectomy declined by 3.8% whereas the average number of billable services performed per beneficiary increased by 46.6%. The comorbidity risk score of these patients decreased by 8.7%, with the West having the healthiest patients in 2021.

CONCLUSIONS

Meniscectomy utilization and reimbursement have been declining nationally within the Medicare population. Surgeons in the South performed the most meniscectomies while having among the lowest reimbursement. The practice patterns of surgeons performing meniscectomies have been changing, with surgeons performing nearly 50% more total billable services per beneficiary while performing fewer unique billable services. Additionally, the patient population of surgeons who perform meniscectomy was healthier in 2021 than in 2013.

CLINICAL RELEVANCE

This study highlights changes in meniscectomy utilization and reimbursement over time in the face of changing evidence of meniscectomy use in elderly patients and new Medicare legislature regarding reimbursement.

Non-operative Management of Acute Knee Injuries

PURPOSE OF REVIEW

Acute knee injuries are commonly encountered in both the clinical and sideline setting and may be treated operatively or non-operatively. This article describes an evidence-based approach to non-operative acute knee injury. This includes history, physical exam, imaging, and initial management. In addition, the non-operative management of three such injuries-ligament injury, meniscus injury, and patellar dislocation injury-will be discussed via a case-based practical approach.

RECENT FINDINGS

Aside from grade III ACL tears, most acute knee ligament injuries, especially in the absence of other concurrent injuries, can be treated non-operatively. There is new evidence that acute traumatic meniscus tears in those younger than 40 can be successfully treated non-operatively and can do equally, as well as those that undergo surgery, at 1 year out from injury. Based on the current literature, a short period of knee bracing in extension with progression to weightbearing to tolerance is recommended after initial patellar dislocation. Many of the most common acute knee injuries, including MCL tears, meniscus tears, and patellar dislocations, can be managed non-operatively. A detailed systemic approach to initial evaluation, including pertinent history, physical exam, and appropriate imaging, is essential and complementary to the subsequent non-operative treatment algorithm.

Biomechanical Comparison of the Simple Suture Technique, Meniscal Matrix-Assisted Repair, and a Novel Meniscus Cap Suture Technique for Complex Meniscal Repair

Background

Meniscal repair is the gold standard for simple morphology tears. However, when the morphology and chronicity of the tear are less favorable, the success of the standard techniques is reduced.

Purpose/Hypothesis

To compare meniscal repair augmented by a new bioresorbable implant (Meniscus Cap) versus a traditional simple suture technique and the currently available augmented repair collagen matrix meniscus wrapping technique. It was hypothesized that the Meniscus Cap suture technique would increase ultimate failure load and less displacement during cyclic loading.

Study Design

Controlled laboratory study.

Methods

A total of 80 fresh porcine menisci were harvested. Complex tears were created in 60 menisci, and 20 intact menisci were tested as the control group. Repairs were performed on the 60 meniscal tears using 1 of the 3 techniques (20 menisci each): an inside-out H-suture group (SS), the collagen matrix wrapping technique (CMW), and the Meniscus Cap bioresorbable implant group (CM). The menisci were subjected to 500 loading cycles from 4 to 20 N at a frequency of 1 Hz, and the total displacement was recorded. Then, the specimens underwent load to failure testing at a rate of 3.15 mm/s, and the failure mode was noted.

Results

After 500 cycles of cyclic loading, there were no significant differences in displacement between the controls and CM group (0.524 vs 0.448 mm; P = .95). The displacement after the CM was significantly smaller compared with the CMW and the SS (0.448 vs 1.077 mm [P = .0009] and 0.448 vs 0.848 mm [P = .04], respectively). The ultimate load to failure was significantly greater for the controls and the CM group compared with the SS and CMW groups (controls, 1278.7 N and CM, 628.5 N vs CMW, 380.1 N and SS, 345.1 N; P < .05). The failure mode was suture breakage (suture failure) for all repairs.

Conclusion

In a porcine specimen meniscal repair model, the biomechanical properties of a novel Meniscus Cap repair technique were superior to that of the simple suture and CMW techniques.

Clinical Relevance

The results suggest that the Meniscal Cap repair technique may provide sufficient primary stability of the meniscal fixation even in the cases of complex meniscal tears.

Meniscectomy is associated with a higher rate of osteoarthritis compared to meniscal repair following acute tears: a meta-analysis

PURPOSE

Meniscal tears are common and may impair knee function and biomechanics. This meta-analysis compared meniscal repair versus resection in patients with symptomatic meniscal tears in terms of patient-reported outcomes measures (PROMs), joint width, surgical failure, and rate of progression to osteoarthritis (OA) at conventional radiography.

METHODS

This study was conducted according to the 2020 PRISMA statement. In August 2023, the following databases were accessed: PubMed, Web of Science, Google Scholar, and Embase. Two reviewers independently performed the analysis and a methodological quality assessment of the included studies. All the clinical investigations which compared repair versus resection of meniscal tears were accessed.

RESULTS

Data from 20 studies (31,783 patients) were collected. The mean BMI was 28.28 ± 3.2 kg/m2, and the mean age was 37.6 ± 14.0 years. The mean time elapsed from injury to surgery was 12.1 ± 10.2 months and the mean medial joint width was 4.9 ± 0.8 mm. Between studies comparability at baseline was found in age, women, BMI, time from injury to surgery and length of the follow-up, PROMs, medial joint width, and stage of OA. The resection group demonstrated a greater Lysholm score (P = 0.02). No difference was found in the International Knee Documentation Committee (P = 0.2). Nine studies reported data on the rate of failures at a mean of 63.00 ± 24.7 months. No difference was found between the two groups in terms of persistent meniscal symptoms (P = 0.8). Six studies reported data on the rate of progression to total knee arthroplasty at a mean of 48.0 ± 14.7 months follow-up. The repair group evidenced a lower rate of progression to knee arthroplasty (P = 0.0001). Six studies reported data on the rate of advanced knee OA at a mean of 48.0 ± 14.7 months of follow-up. The repair group evidenced a lower rate of advanced knee OA (P = 0.0001). No difference was found in the mean joint space width (P = 0.09).

CONCLUSION

Meniscal repair is associated with a lower progression to knee osteoarthritis at approximately six years of follow-up compared to partial meniscectomy. No difference in PROMs, medial joint width, and failures were evidenced.

LEVEL OF EVIDENCE

Level III, meta-analysis.

Outcomes of Meniscal Repair in Patients Aged 40 and Above: A Systematic Review

PURPOSE

Meniscal injuries are increasingly common in older age groups. Age is often cited as a contraindication to undergoing meniscal repair due to concerns regarding failure rates. There has recently, however, been an increasing shift towards repair in older populations. The purpose of this study was to review outcomes of meniscal repair in patients over the age of 40.

METHODS

A systematic search of the following databases was conducted of PubMed, SCOPUS, Web of Science, and Cochrane Library to identify studies reporting failure rates of patients over 40 with meniscal injuries undergoing repair. The definition of meniscus failure was noted for each study evaluated in this systematic review. Further data surrounding clinical and radiological outcomes were recorded and evaluated, when available.

RESULTS

Thirteen studies were included in this review, encompassing a total of 316 meniscal repairs in patients over the age of 40 years. The overall failure rate was found to be 15.5% (49/316) (range 0-33.3%). There was no difference in the failure rate in those over 40 vs. under 40, and the two groups had equivalent functional outcomes.

CONCLUSIONS

Age should not be considered a contra-indication for meniscal repair. Appropriately selected older patients can have acceptably low failure rates with meniscal repair and similar functional outcomes to those under the age of forty. Meniscal repairs in those over 40 achieved better functional outcomes than patients of the same age group who underwent meniscectomy.

Differences in postoperative knee function based on concomitant treatment of lateral meniscal injury in the setting of primary ACL reconstruction

BACKGROUND

Concomitant lateral meniscal (LM) injuries are common in acute anterior cruciate ligament (ACL) ruptures. However, the effect of addressing these injuries with various treatment methods during primary ACL reconstruction (ACLR) on patient-reported outcomes (PROs) is unknown. Therefore, the purpose of this study was to compare postoperative Knee injury and Osteoarthritis Outcome Score (KOOS) at 2-, 5-, and 10-years after isolated primary ACLR to primary ACLR with various treatment methods to address concomitant LM injury.

METHODS

This study was based on data from the Swedish National Knee Ligament Registry. Patients ≥ 15 years with data on postoperative KOOS who underwent primary ACLR between the years 2005 and 2018 were included in this study. The study population was divided into five groups: 1) Isolated ACLR, 2) ACLR + LM repair, 3) ACLR + LM resection, 4) ACLR + LM injury left in situ, and 5) ACLR + LM repair + LM resection. Patients with concomitant medial meniscal or other surgically treated ligament injuries were excluded.

RESULTS

Of 31,819 included patients, 24% had LM injury. After post hoc comparisons, significantly lower scores were found for the KOOS Symptoms subscale in ACLR + LM repair group compared to isolated ACLR (76.0 vs 78.3, p = 0.0097) and ACLR + LM injury left in situ groups (76.0 vs 78.3, p = 0.041) at 2-year follow-up. However, at 10-year follow-up, no differences were found between ACLR + LM repair and isolated ACLR, but ACLR + LM resection resulted in significantly lower KOOS Symptoms scores compared to isolated ACLR (80.4 vs 82.3, p = 0.041).

CONCLUSION

The results of this study suggest that LM injury during ACLR is associated with lower KOOS scores, particularly in the Symptoms subscale, at short- and long-term follow-up. However, this finding falls below minimal clinical important difference and therefore may not be clinically relevant.

LEVEL OF EVIDENCE

III.

Platelet-Rich Plasma and Marrow Venting May Serve as Cost-Effective Augmentation Techniques for Isolated Meniscal Repair: A Decision-Analytical Markov Model-Based Analysis

PURPOSE

To evaluate the cost-effectiveness of 3 isolated meniscal repair (IMR) treatment strategies: platelet-rich plasma (PRP)-augmented IMR, IMR with a marrow venting procedure (MVP), and IMR without biological augmentation.

METHODS

A Markov model was developed to evaluate the baseline case: a young adult patient meeting the indications for IMR. Health utility values, failure rates, and transition probabilities were derived from the published literature. Costs were determined based on the typical patient undergoing IMR at an outpatient surgery center. Outcome measures included costs, quality-adjusted life-years (QALYs), and the incremental cost-effectiveness ratio (ICER).

RESULTS

Total costs of IMR with an MVP were $8,250; PRP-augmented IMR, $12,031; and IMR without PRP or an MVP, $13,326. PRP-augmented IMR resulted in an additional 2.16 QALYs, whereas IMR with an MVP produced slightly fewer QALYs, at 2.13. Non-augmented repair produced a modeled gain of 2.02 QALYs. The ICER comparing PRP-augmented IMR versus MVP-augmented IMR was $161,742/QALY, which fell well above the $50,000 willingness-to-pay threshold.

CONCLUSIONS

IMR with biological augmentation (MVP or PRP) resulted in a higher number of QALYs and lower costs than non-augmented IMR, suggesting that biological augmentation is cost-effective. Total costs of IMR with an MVP were significantly lower than those of PRP-augmented IMR, whereas the number of additional QALYs produced by PRP-augmented IMR was only slightly higher than that produced by IMR with an MVP. As a result, neither treatment dominated over the other. However, because the ICER of PRP-augmented IMR fell well above the $50,000 willingness-to-pay threshold, IMR with an MVP was determined to be the overall cost-effective treatment strategy in the setting of young adult patients with isolated meniscal tears.

LEVEL OF EVIDENCE

Level III, economic and decision analysis.

MRI in the Diagnosis of Bucket Handle Tears: What Is the Current Situation?

Introduction The purpose of this study was to determine the utility of current magnetic resonance imaging (MRI) in the diagnosis of bucket-handle meniscal tears. Materials and methods Patients treated for arthroscopic meniscal tears between March 2019 and March 2022 were reviewed. The current study included all patients with bucket handle tears diagnosed arthroscopically and having MRI scans (n=51). A control group of 58 individuals with similar demographic characteristics and meniscal tears apart from bucket handle tears was also formed. The assessment of bucket handle and non-bucket handle tears was performed blindly by a musculoskeletal (MSK) radiologist with 20 years of experience and a trainee radiologist, achieving consensus on group allocation. The MRIs were examined for various findings, including the presence of a bucket handle tear, tear location, presence of anterior cruciate ligament (ACL) rupture, intercondyler notch sign, double anterior horn sign, flipped meniscus sign, double posterior cruciate ligament (PCL) sign, absent bow sign, and the disproportionate posterior horn sign. These well-known signs, detailed in the literature, were evaluated. Additionally, less studied and less commonly known signs such as the V sign and double anterior cruciate ligament sign were assessed. The V sign appears similarly to the letter V, resulting from the displacement of the bucket handle tear and the angle of the intact meniscus on axial images. The double anterior cruciate ligament sign is the appearance formed by the compression of the displaced meniscal part behind the anterior cruciate ligament in bucket handle tears. Results Following the retrospective evaluation of MRI scans, 44 out of 51 tears diagnosed as bucket handle tears by arthroscopy were accurately identified (sensitivity: 86.27%). The same conclusion was reached for MRI scans in 52 out of 58 tears where arthroscopy did not detect a bucket handle tear (specificity: 89.66%). The most prevalent MRI signs in patients with bucket handle tears identified by arthroscopy in the study were the intercondylar notch sign (84.31%), V sign (72.55%), double PCL sign (56.86%), double anterior horn sign (49.02%), absent bow sign (43.14%), flipped meniscus sign (19.61%), disproportionate posterior horn sign (9.80%), and double ACL sign (5.88%). The intercondylar notch sign, V sign, and double PCL sign exhibited the highest sensitivity, while flipped meniscus, disproportionate posterior horn, and double ACL sign demonstrated the highest specificity. Conclusion MRI demonstrates a high level of sensitivity and specificity in identifying meniscal bucket handle tears, particularly when considering the eight MRI signs investigated in this study.

The "Under, Over" Technique for Repair of a Peripheral Bucket-Handle Meniscus Tear With Circumferential Compression Stitches

The benefits of preserving the meniscus are well-established. Several arthroscopic meniscal repair techniques have been described, such as the inside-out, outside-in, and all-inside. All-inside self-retrieving suture devices can be used to repair vertical, horizontal, and radial tears. However, this technique becomes difficult with large tears, as the jaw of the device cannot reach the peripheral edge of the meniscal tear. We present an all-inside technique using circumferential compression stitches to address large peripheral meniscus tears.

Histological Analysis of Regenerative Properties in Human Glenoid Labral Regions

BACKGROUND

The healing capacity of the human glenoid labrum varies by tear location. Current evidence suggests that the healing capacity of meniscal and cartilage injuries relates to cellular composition and vascularity. However, little is known about the histological characteristics of the glenoid labrum and how they may affect healing potential in specific anatomic regions.

HYPOTHESIS

Regenerative characteristics of the glenoid labrum differ based on the anatomic region.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Human glenoid labra from fresh unpreserved cadavers were transversely sectioned in different anatomic regions. Masson trichrome stain was used to determine dense and loose extracellular matrix regions and vessel densities. Hematoxylin and eosin, Ki-67+, and CD90+/CD105+ stains were performed to determine total, proliferative, and progenitor cell densities, respectively. Regression models demonstrated relationships between vascular area, progenitor cell quantity, and probability of successful operation.

RESULTS

Among all labral aspects, the superior glenoid labrum had the highest percentage (56.8% ± 6.9%) of dense extracellular matrix or avascular tissue (P < .1). The vascular region of the superior labrum had the fewest total cells (321 ± 135 cells/mm2; P < .01) and progenitor cells (20 ± 4 cells/mm2; P < .001). Vascular area was directly correlated with progenitor cell quantity (P = .006002). An increase in probability of successful operation was associated with a linear increase in vascular area (R2 = 0.765) and an exponential increase in progenitor cell quantity (R2 = 0.795). Subsequently, quadratic models of vascularity and progenitor cell quantity around the labral clock were used to assess relative healing potential. Quadratic models for percentage vascular area (P = 6.35e-07) and weighted progenitor cell density (P = 3.03e-05) around the labral clock showed that percentage vascular area and progenitor cell quantity increased as labral tissue neared the inferior aspect and diminished near the superior aspect.

CONCLUSION

Anatomic regions of the glenoid labrum differ in extracellular matrix composition, vascularity, and cell composition. The superior glenoid labrum is deficient in vascularity and progenitor cells, which may explain the high failure rates for repairs in this location.

CLINICAL RELEVANCE

Improved understanding of the composition of distinct glenoid labral positions may help to improve therapeutic strategies for labral pathology.

Advanced glycation end-product accumulation differs by location and sex in aged osteoarthritic human menisci

OBJECTIVE

There is a clear link between increasing age and meniscus degeneration, leading to increased injury, osteoarthritis (OA) progression, and often total knee replacement. Advanced glycation end-products (AGEs) are non-enzymatic crosslinks and adducts that accumulate in collagen with age, altering tissue mechanics and cell function, ultimately leading to increased injury and inflammation. AGEs, both fluorescent and non-fluorescent, play a central role in age-related degradation of tissues throughout the body; however, little is known about their role in meniscus degeneration. The objective of this study was to characterize changes in aged OA menisci, specifically evaluating zonal AGE accumulation, to gain a better understanding of changes that may lead to age-related meniscal degeneration.

METHOD

Deidentified human menisci (N = 48, 52-84 years old) were obtained from subjects undergoing total knee replacement. Changes in extracellular matrix (ECM) were assessed by gross morphology, confocal analysis, and biochemical assays. Deoxyribonucleic acid (DNA), glycosaminoglycan (GAG), collagen, and AGE accumulation were compared with patient age, zonal region, and patient sex.

RESULTS

There were minimal changes in DNA, GAG, and collagen concentration with age or zone. However, collagen fraying and AGEs increased with age, with more AGEs accumulating in the meniscal horns compared to the central body and in male menisci compared to females.

CONCLUSIONS

Overall, this work provides greater insights into regional changes that occur in human menisci with age and OA. These results suggest AGEs may play a role in the degeneration of the meniscus, with AGEs being a possible target to reduce age-related tears, degeneration, and OA progression.

The Interplay of Biomechanical and Biological Changes Following Meniscus Injury

PURPOSE OF REVIEW

Meniscus injury often leads to joint degeneration and post-traumatic osteoarthritis (PTOA) development. Therefore, the purpose of this review is to outline the current understanding of biomechanical and biological repercussions following meniscus injury and how these changes impact meniscus repair and PTOA development. Moreover, we identify key gaps in knowledge that must be further investigated to improve meniscus healing and prevent PTOA.

RECENT FINDINGS

Following meniscus injury, both biomechanical and biological alterations frequently occur in multiple tissues in the joint. Biomechanically, meniscus tears compromise the ability of the meniscus to transfer load in the joint, making the cartilage more vulnerable to increased strain. Biologically, the post-injury environment is often characterized by an increase in pro-inflammatory cytokines, catabolic enzymes, and immune cells. These multi-faceted changes have a significant interplay and result in an environment that opposes tissue repair and contributes to PTOA development. Additionally, degenerative changes associated with OA may cause a feedback cycle, negatively impacting the healing capacity of the meniscus. Strides have been made towards understanding post-injury biological and biomechanical changes in the joint, their interplay, and how they affect healing and PTOA development. However, in order to improve clinical treatments to promote meniscus healing and prevent PTOA development, there is an urgent need to understand the physiologic changes in the joint following injury. In particular, work is needed on the in vivo characterization of the temporal biomechanical and biological changes that occur in patients following meniscus injury and how these changes contribute to PTOA development.

Factors Influencing the Initial Constraint Level of the Knee Joint and Its Effect on Clinical Outcomes After ACL Reconstruction With Hamstring Graft

Background

A force-based tension protocol that uses a certain amount of tension at graft fixation could still give rise to variations in initial constraint levels of the knee joint in terms of side-to-side difference (SSD) in anterior translation.

Purpose

To investigate the factors influencing the initial constraint level in anterior cruciate ligament (ACL)-reconstructed knees and compare outcomes according to the level of constraint in terms of anterior translation SSD.

Study Design

Cohort study; Level of evidence, 3.

Methods

Included were 113 patients who underwent ipsilateral ACL reconstruction using an autologous hamstring graft and had minimum 2-year follow-up outcomes. All grafts were tensioned and fixed at 80 N using a tensioner at the time of graft fixation. The patients were classified into the following 2 groups according to the initial anterior translation SSD, measured using the KT-2000 arthrometer: a physiologic constraint group with restored anterior laxity ≤2 mm (group P; n = 66) and a high-constraint group with restored anterior laxity >2 mm (group H; n = 47). Clinical outcomes were compared between the groups, and preoperative and intraoperative variables were evaluated to identify factors affecting the initial constraint level.

Results

Between group P and group H, generalized joint laxity (P = .005), posterior tibial slope (P = .022), and anterior translation measured in the contralateral knee (P < .001) were found to differ significantly. Measured anterior translation in the contralateral knee was the only significant predictor of high initial graft tension (P = .001). No significant differences were found between the groups regarding clinical outcomes and subsequent surgery.

Conclusion

Greater anterior translation measured in the contralateral knee was an independent predictor of a more constrained knee after ACL reconstruction. The short-term clinical outcomes after ACL reconstruction were comparable, regardless of the initial constraint level in terms of anterior translation SSD.

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

Background

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

Methods

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

Level of evidence

level III.

Current and Future Applications of Fluorescence Guidance in Orthopaedic Surgery

Fluorescence-guided surgery (FGS) is an evolving field that seeks to identify important anatomic structures or physiologic phenomena with helpful relevance to the execution of surgical procedures. Fluorescence labeling occurs generally via the administration of fluorescent reporters that may be molecularly targeted, enzyme-activated, or untargeted, vascular probes. Fluorescence guidance has substantially changed care strategies in numerous surgical fields; however, investigation and adoption in orthopaedic surgery have lagged. FGS shows the potential for improving patient care in orthopaedics via several applications including disease diagnosis, perfusion-based tissue healing capacity assessment, infection/tumor eradication, and anatomic structure identification. This review highlights current and future applications of fluorescence guidance in orthopaedics and identifies key challenges to translation and potential solutions.

Meniscal Injuries in Patients Aged 40 Years or Older: A Comparative Study Between Meniscal Repair and Partial Meniscectomy

Introduction Meniscal tears represent one of the most frequent knee injuries and are the most common cause of knee surgery. Historically, age has been considered an independent factor contraindicating meniscal repair due to the assumption that meniscal injuries in this population are frequently chronic tears, mostly with a degenerative tear pattern, and low healing potential. However, recent literature has questioned this paradigm with studies reporting successful outcomes with meniscal repair in older patients. Our study aimed to evaluate and compare the short-term clinical outcomes of meniscal repair versus partial meniscectomy in patients aged ≥40 years old. Methods A retrospective study was conducted that included patients over the age of 40 years, diagnosed with meniscal tears, that underwent arthroscopically assisted meniscal repair or partial meniscectomy between 01 January and 31 December 2020. The patients were divided into two groups: Group 1- partial meniscectomy (PM) and Group 2- meniscal repair (MR). The clinical evaluation was performed 24 months after the surgery, and the studied variables were: function (Tegner Lysholm Knee Scoring Scale), pain (Visual Analogue Scale), patient satisfaction, and failure rate.  Results Fifty-one patients met the inclusion criteria, and 7 were excluded due to loss of follow-up during telephone contact. Thus, the final sample consisted of 44 patients (mean age 52.18y), both groups with 22 patients. In both groups, we found an improvement in pain 2 years after the surgery, with a decrease in the VAS value between the pre and post-surgery. On average, the VAS score decreased from 7.9 to 4.5 in the group subjected to partial meniscectomy, and from 7.5 to 3.2 in the meniscal repair. This was statistically significant in both groups, with a p-value <0.01, but not between them (p-value = 0.363). Comparing the degree of satisfaction between both groups, we found no statistically significant difference between them (p=0.167). Regarding the functional outcome (Tegner Lysholm Knee Scoring Scale), the group that underwent the meniscal repair obtained a statistically superior score compared to the partial meniscectomy group (77.55 vs. 64.77; p-value 0.033). The failure rate was exactly equal in both groups (4.5%), therefore no statistically significant difference was found in this variable.  Conclusion Age, as an independent factor, should not be considered a contraindication for meniscus repair. In fact, if technically possible, meniscal repair should always be performed as it is associated with better functional outcomes, similar failure rates, and may be protective against the development and progression of arthritis.

[Translated article] Three years follow-up outcome of 4-strand semitendinous-gracilis anterior ligament reconstruction in women: A matched-cohort study

INTRODUCTION

Women carry out a greater risk of anterior cruciate ligament (ACL) rupture. However, outcomes following ACL reconstruction remain unclear. The aim of this study was to analyse the outcomes in women following ACL reconstruction and compare these outcomes with men.

MATERIAL AND METHODS

Retrospective study of a prospective database of patients treated with ACL reconstruction between January 2017 and December 2018. Outcome measures included Tegner activity scale, Lysholm scale, EVA scale, and IKDC evaluation form. Clinical significance was measured with minimally clinical important difference, and patient acceptable symptom state.

RESULTS

A total of 33 women were matched with 99 men. The mean follow-up was 36 months. Women showed significant improvement from preoperative PROs to the latest follow-up, with no differences between groups. In patients under 25 years old, there was less significant IKDC subjective score in women compared to men. There were no significant differences in frequency of patients achieving MCID and PASS in women compared with men.

CONCLUSIONS

At 3-year following 4-strand semitendinosus-gracilis anterior ligament reconstruction, women showed significant improvements in PROs, with no differences compared to men.

Outcome of 4-strand semitendinosus-gracilis anterior ligament reconstruction in women: A matched-cohort study

INTRODUCTION

Women carry out a greater risk of anterior cruciate ligament (ACL) rupture. However, outcomes following ACL reconstruction remain unclear. The aim of this study was to analyze the outcomes in women following ACL reconstruction and compare these outcomes with men.

MATERIAL AND METHODS

Retrospective study of a prospective database of patients treated with ACL reconstruction between January 2017 and December 2018. Outcome measures included Tegner activity scale, Lysholm scale, EVA scale, and IKDC evaluation form. Clinical significance was measured with minimally clinical important difference, and patient acceptable symptom state.

RESULTS

A total of 33 women were matched with 99 men. The mean follow-up was 36 months. Women showed significant improvement from preoperative PROs to the latest follow-up, with no differences between groups. In patients under 25 years old, there was less significant IKDC subjective score in women compared to men. There were no significant differences in frequency of patients achieving MCID and PASS in women compared with men.

CONCLUSIONS

At 3-year following 4-strand semitendinosus-gracilis anterior ligament reconstruction, women showed significant improvements in PROs, with no differences compared to men.

Mid-term study on the effects of arthroscopic discoid lateral meniscus plasty on patellofemoral joint: An observational study

In the present study, we aimed to investigate the clinical outcomes of arthroscopic discoid lateral meniscus (DLM) plasty and the adaptive changes in the patellofemoral joint after surgery. From September 2010 to March 2012, 25 patients with DLM injuries who underwent arthroscopic meniscus plasty were enrolled in the prospective study. All patients underwent clinical evaluation before the operation and at the last follow-up, and imaging evaluation was performed by upright magnetic resonance imaging before and 1 month after the operation as well as at the last follow-up. Clinical evaluation included Lysholm score, Kujala score, McMurray's sign, patellar mobility, patella grind test, and quadriceps atrophy. Imaging evaluation included bisect offset index, patella tilt angle (PTA), and cartilage damage. Lysholm score, Kujala score, McMurray's sign, and quadriceps atrophy at the last follow-up were significantly improved compared with the preoperative levels (P < .05). At the last follow-up, there were no statistical differences in patella mobility and patella grind test compared with the preoperative levels. In addition, bisect offset index and PTA showed a dynamic trend of rising and then falling over time (P < .05). At 1 month after the operation, bisect offset index and PTA were significantly increased compared with the preoperative levels or the values at the last follow-up (P < .05), while there were no differences between the preoperation and the last follow-up. Cartilage damage became worse with time (P < 0.05), and the 2 were positively correlated (Spearman = 0.368). At the last follow-up, the degree of cartilage damage was significantly increased compared with the preoperative level (P < .017), while there was no significant difference between the 1-month postoperative grade and the preoperational grade or the last follow-up grade. The effect of arthroscopic DLM plasty on the patellofemoral joint was dynamic, with the position of the patella deviating in the early stages and recovering in the mid-term, especially when the knee was in the biomechanical standing position. In addition, the patellofemoral joint cartilage might undergo accelerated degeneration after the operation, while the mid-term effect of the operation was positive, and the patellofemoral joint function was acceptable.

Injury to the Posterior Horn of the Lateral Meniscus from a Misplaced Tibial Tunnel for Anterior Cruciate Ligament Reconstruction: A Case Report

BACKGROUND Posterior meniscal root avulsions can cause meniscal extrusion, joint space narrowing, and progressive knee arthritis. Iatrogenic posterior meniscal root avulsions after malpositioning of the transtibial tunnels during anterior cruciate ligament (ACL) reconstruction can account for poor long-term outcomes seen in some patients following ACL reconstruction. Therefore, correct transtibial tunnel placement during ACL reconstruction is essential to avoid iatrogenic meniscal damage. CASE REPORT A 32-year-old man presented with 1 year of right knee pain and instability following a non-contact twisting injury sustained while playing soccer. An ACL tear with no meniscal involvement was diagnosed at an outside institution. A double-bundle reconstruction was performed at that time. Three months after surgery, a medial partial meniscectomy was performed after a medial meniscal tear and failure to reduce initial symptoms during the index procedure. Advanced imaging at our institution 6 months later demonstrated an iatrogenic lateral posterior meniscal root avulsions after malpositioning of the transtibial tunnels. Given the ACL graft integrity upon arthroscopic evaluation, the root tear was repaired using a 2-tunnel transtibial pull-out technique. Advanced imaging 1 year after surgery showed a well-maintained meniscal repair with no extrusion. CONCLUSIONS Accurate transtibial tunnel placement during ACL reconstructive surgery is vital to avoid meniscal root detachment and the associated complications resulting in poor patient outcomes from this iatrogenic injury. Clinicians treating patients with a history of cruciate ligament reconstruction presenting with postoperative pain and instability should consider this pathology in their differential diagnosis.

The Effects of Korean Medicine Treatment for Meniscus Tears: A Retrospective Chart Review

Changes in symptoms and dysfunction related to meniscus tears following the use of Korean medicine for ≥ 4 days were studied. The medical charts of 53 cases of diagnosed meniscus tears (magnetic resonance imaging) with an admission Numeric Rating Scale (NRS) score ≥ 4, between 2017 and 2022 were retrospectively reviewed. Treatments included acupuncture, pharmacopuncture, herbal treatment, Chuna therapy, and physiotherapy. The NRS, Western Ontario and McMaster Universities Osteoarthritis Index, and European Quality of Life 5 Dimensions were performed at admission and discharge. There were 42 females and 11 males in this study. Patients were more likely to be in their 60s (38.18%), have an unknown etiology (81.13%), and have complex tears (50.94%). After receiving a combination of alternative Korean medicine during hospitalization, the mean NRS score improved from 6.82 ± 1.19 to 3.66 ± 1.83 (p < 0.001), the Western Ontario and McMaster Universities Osteoarthritis Index score improved from 46.47 ± 20.99 to 37.98 ± 19.23 (p < 0.001), and the mean European Quality of Life Five Dimensions score improved from 0.61 ± 0.18 to 0.68 ± 0.14 (p < 0.001) after treatment. These results suggest that Korean medicine treatment of meniscus tears alleviated pain and improved physical function.

Arthroscopic Meniscal Repair With Second-Generation Platelet-Rich Fibrin Clot Augmentation

Meniscal tears are among the most common injuries in the knee, and partial as well as total meniscectomy has been advocated as the treatment for meniscal injury. Over the years, the role of the meniscus as a shock absorber, load transmitter, and secondary anterior stabilizer, along with its proprioceptive and lubrication role, has been well established, and meniscal repair is recommended, especially in younger individuals. Factors such as tear location, pattern, chronicity, size, and extent; repair technique; and patient age and habits can influence meniscal repair, and to enhance meniscal healing, a variety of augmentation techniques have been introduced. These include needling, trephination, synovial abrasion, and the use of adjuvants such as platelet-rich plasma, platelet clots, fibrin clots, bone marrow clots, and stem cells. A second-generation platelet derivative called "platelet-rich fibrin" (PRF) has predictable platelet, growth factor, and cell mediator concentrations without using any anticoagulants. We describe a reproducible and simple way to harvest PRF and create and use a PRF clot, along with detailed instructions on how to integrate the clot with a meniscal repair arthroscopically.

Meniscal Root Tears: An Update Focused on Preoperative and Postoperative MRI Findings

Meniscal root tears represent radial tears or avulsions of the meniscal cartilage at the tibial attachment site that profoundly affect meniscal biomechanics and kinematics. Meniscal root tears have the functional effect of a total meniscectomy and can lead to rapid degenerative change with development of early knee osteoarthritis (OA). A growing range of arthroscopic surgical techniques have been developed to repair meniscal root tears with the aim of restoring joint kinematics and contact pressures and delaying the development of OA. With increased understanding of the anatomy and biomechanics of the meniscal root, meniscal root injury repair has become the treatment of choice in knees with nonadvanced OA. This article reviews the anatomy and biomechanics of the meniscal roots, clinical and imaging diagnostic criteria of meniscal root tears, correlation between arthroscopy and MRI in the diagnosis and classification of meniscal root tears, and expected and abnormal MRI findings after meniscal root repair. Familiarity with MRI signs and classifications of meniscal root tears, as well as with root repair surgical techniques, can aid radiologists in correctly reporting preoperative and postoperative MRI findings.

True all inside meniscus repair using the popliteus tendon

The popliteus tendon is a useful anchor point to repair the posterior horn of the lateral meniscus. We describe a new, economical technique that does not violate the neurovascular structures, using an antegrade suture passer and a 2-0 fiberwire to repair the posterior segment including posterior horn of the lateral meniscus taking bites through the capsule and meniscus or the popliteus tendon and meniscus with no anchors in the capsule or popliteus. 9 patients were operated upon using this technique and the mean IKDC score improved from 24.2 to 84, p < 0.01, mean pre op Tegner improved from 1.88 to 6.63 p < 0.01, median hop test from 0 to 4, p = 0 at a mean 15.2 months post surgery. 8 patients had a negative Lachman and 1 grade 2 Lachman at 12 months follow up but was asymptomatic. The Barret's criteria was negative for all 9 patients at latest follow up.

Higher healing rate after meniscal repair with concomitant ACL reconstruction for tears located in vascular zone 1 compared to zone 2: a systematic review and meta-analysis

PURPOSE

The purpose of this study was to determine and compare the percentage of completely healed meniscal tears after arthroscopic repair combined with anterior cruciate ligament reconstruction (ACLR) for the different vascular zones of the meniscus.

METHODS

PubMed, Embase, Web of Science, Cochrane library and Emcare were searched on 19 May 2020 for articles reporting healing rates after arthroscopic meniscal repair with concomitant ACLR for the different meniscal vascular zones as assessed by second-look arthroscopy. Data on meniscal tears were extracted as located in zones 1, 2 or 3, according to the Cooper classification. Studies were graded in quality using a modified Newcastle-Ottawa Scale. Pooled analyses were performed utilizing a random-effects model. Meta-analyses were performed using R version 3.6.2 and SPSS statistical software version 25.0. The study was registered with PROSPERO (ID:CRD42020176175).

RESULTS

Ten observational cohort studies met the inclusion criteria, accounting for 758 meniscal tear repairs in total. The pooled overall proportion of healing was 78% (95% CI 72-84%). The mean weighted proportion of healing was 83% (95% CI 76-90%) for studies (n = 10) reporting zone 1 tears and 69% (95% CI 59-79%) for studies (n = 9) reporting zone 2 tears. No study reported healing rates for zone 3 tears. The pooled overall odds ratio was 2.5 (95% CI 1.00-6.02), indicating zone 1 tears as 2.5 times more likely to heal than zone 2 tears.

CONCLUSION

This study demonstrates that meniscal tears localized in vascular zone 1 were more likely to heal than those in zone 2.

LEVEL OF EVIDENCE

IV.

Meniscus Tear: Pathology, Incidence, and Management

Meniscus tears are a common orthopedic pathology and planning a single, effective treatment is challenging. The diagnosis of meniscal tears requires detailed history-taking, physical examinations, special diagnostic tests, and most likely magnetic resonance imaging (MRI) to confirm the lesion. A good understanding of the meniscal structure including vascularity, zones, function, and affected movements with associated symptoms plays a crucial role in establishing an optimal management plan. A careful assessment of the patient's characteristics, comorbidities, post-repair rehabilitation, and patient’s overall function and satisfaction are also important for ideal management. While conservative management is commonly implemented and the only option for certain patients, partial meniscectomy remains to be the most performed treatment procedure. However, partial meniscectomy is no longer the first-line therapy due to the limitation of certain patient characteristics and side effects in the long run. Instead, meniscal repair has been shown to have better long-term outcomes and is therefore recommended for all tears, especially for young patients with acute traumatic lesions. Tissue engineering has been of high interest in the current research with promising therapeutic results. This review critically evaluates and compares the management of meniscal tears with surgical versus comprehensive management using the current literature.

Inside-Out Approach to Meniscus Repair: Still the Gold Standard?

PURPOSE OF REVIEW

The purpose of this review is to provide an up-to-date summary on the current literature and trends regarding use of the inside-out approach to meniscus repair. Additionally, the paper describes the authors preferred techniques for inside-out meniscus repair utilizing posteromedial and posterolateral exposures.

RECENT FINDINGS

There has been a substantial increase in recent publications regarding meniscus repair. However, comparisons regarding the optimal repair technique have not been conclusive. Despite the recent increase in use of all-inside devices, multiple investigations with short-to-mid-term follow-up have demonstrated similar rates of meniscus healing between inside-out and all-inside repair techniques. Similarly, current literature describes comparable failure rates of around 20%. There are variations in the profile of complications, with all-inside devices having more implant-related complications and inside-out techniques with higher neurovascular injuries. Inside-out meniscus repair is a versatile, cost-effective technique that remains the gold standard for management of most meniscus tear patterns. Through a thoughtful approach, efficient suture retrieval and repair can be performed while protecting critical neurovascular structures. All-inside meniscus repair devices have increased in popularity and surgeon access, but this technique is not without limitations and comparisons to inside-out meniscus repair demonstrates equivocal outcomes.

Automated Decellularization of Musculoskeletal Tissues with High Extracellular Matrix Retention

Manual tissue decellularization is an onerous process that requires the application of many sequential treatments by an operator and can be prone to user error and result variability. While automated decellularization devices have been previously reported, with advances being made in recent years toward open-source platforms, previous automated decellularization devices have been reliant on hardware or software components that are closed-source and proprietary. The aim of the current work was to develop and validate a full open-source automated decellularization system to be available for others to adopt. The open-source decellularization apparatus is a low-cost (<$2000) device that may easily be adapted to an array of decellularization protocols, with an example parts' list provided herein. The automated decellularization device was used to decellularize hyaline cartilage, knee meniscus, and tendon tissues. Cartilage, meniscus, and tendon tissue demonstrated 97%, 99%, and 96% reduction in DNA content after decellularization, respectively, and with effective decellularization confirmed visually via histology. High retentions of glycosaminoglycans (GAGs), collagen, and other proteins were observed in meniscus and tendon following decellularization. Results with manual decellularization with meniscus tissue were consistent with the automated decellularization process. Decellularized cartilage (DCC) demonstrated a 34% decrease in GAG content, while the protein and collagen content did not significantly change. The current study demonstrated that native-like decellularized tissues were produced reproducibly using the reported open-source automated decellularization platform, providing an adoptable platform for production of decellularized tissues by others. Impact statement Decellularized extracellular matrix (ECM)-based materials are appealing for tissue engineering, but production of these materials is historically time-intensive, tedious, and prone to user error. Adoption of an automated system may be a barrier for many research groups due to cost and complexity. In this article, a low-cost open-source platform for automated decellularization is presented. This method is validated by decellularizing porcine musculoskeletal tissues and demonstrating the native-like compositional properties of these decellularized tissues. The ability to produce decellularized tissue in an automated manner is useful for further research of ECM-based materials and potential clinical applications.

Failure and Complication Rates in Common Sports and Arthroscopic Procedures: Reality Check

Expectations following sports medicine and arthroscopic procedures have been elevated because of captivating modern-day media coverage of high-profile athletic injuries, surgery, and rapid return to sports. Unfortunately, this general perception may be misleading, and orthopedic sports medicine physicians must be aware of the harsh reality of the trials and tribulations associated with the subspecialty. The purpose of this review article is to provide an updated brief overview of the complications and failure rates associated with common arthroscopic procedures including rotator cuff repair, biceps tenodesis, Bankart procedure, Latarjet procedure, anterior cruciate ligament reconstruction, anterior cruciate ligament repair, meniscal repair, tibial tubercle osteotomy, and medial patellofemoral ligament reconstruction. Highlighting the complications is the first step toward early recognition, enhancing preventative measures, and successful management.

Biochemical Characteristics and Clinical Result of Bone Marrow-Derived Fibrin Clot for Repair of Isolated Meniscal Injury in the Avascular Zone

PURPOSE

To characterize bone marrow aspirate-derived fibrin clot (BMA clot) and evaluate the clinical result of meniscal repair with a BMA clot for isolated meniscal injury in the avascular zone.

METHODS

Blood counts of total leukocytes, platelets, and concentrations of basic fibroblast growth factor (bFGF), transforming growth factor β (TGF-β), and stromal cell-derived factor 1 (SDF-1) were analyzed with BMA, peripheral blood (PB), BMA clot, and PB clot from 5 patients treated for meniscal repair. In addition, a retrospective analysis of 30 patients with isolated avascular meniscal injuries who underwent repair with a BMA clot was performed to assess rate failure. Avascular meniscal injury was identified as horizontal tear, radial tear, and flap tear. Clinical failure was defined as the presence of 1 or more of Barrett's criteria. Anatomic failure was defined as the existence of equivalent signal intensity to intra-articular fluid along the repair area on follow-up magnetic resonance imaging (MRI). Patients' demographic and clinical data were compared between the overall failure group and the success group.

RESULTS

The bFGF, TGF-β, and SDF-1 levels of BMA clots were more highly concentrated compared with PB clots. The Lysholm scores and meniscal status evaluated by MRI were significantly improved from preoperatively to postoperatively (both P < .001). The Kellgren-Lawrence grading of knee radiographs did not significantly differ pre- and postoperatively (P = .140). Rates of clinical failure, anatomic failure, and retear were 10%, 6.7%, and 3.3%, respectively. The demographic characteristics and surgical and postoperative status did not significantly differ between the overall failure group and the success group.

CONCLUSIONS

BMA clots had increased levels of cytokines compared to PB clots. The retrospective analysis revealed that the rates of clinical failure and anatomic failure after meniscal repair with a BMA clot for isolated avascular meniscal injury were 10% and 6.7%, respectively.

LEVEL OF EVIDENCE

Level IV, case series.

Meniscal Tear and ACL Injury Detection Model Based on AlexNet and Iterative ReliefF

Magnetic resonance (MR) is one of the special imaging techniques used to diagnose orthopedics and traumatology. In this study, a new method has been proposed to detect highly accurate automatic meniscal tear and anterior cruciate ligament (ACL) injuries. In this study, images in three different slices were collected. These are the sagittal, coronal, and axial slices, respectively. Images taken from each slice were categorized in 3 different ways: sagittal database (sDB), coronal database (cDB), and axial database (aDB). The proposed model in the study uses deep feature extraction. In this context, deep features have been obtained by using fully-connected layers of AlexNet architecture. In the second stage of the study, the most significant features were selected using the iterative RelifF (IRF) algorithm. In the last step of the application, the features are classified by using the k-nearest neighbor (kNN) method. Three datasets were used in the study. These datasets, sDB, and cDB, have four classes and consist of 442 and 457 images, respectively. The aDB used in the study has two class labels and consists of 190 images. The model proposed within the scope of the study was applied in 3 datasets. In this context, 98.42%, 100%, and 100% accuracy values were obtained for sDB, cDB, and aDB datasets, respectively. The study results showed that the proposed method detected meniscal tear and anterior cruciate ligament (ACL) injuries with high accuracy.

Comparative clinical outcomes of different therapies for traumatic meniscal tears in adults: A protocol for systematic review and network meta-analysis

BACKGROUND

Meniscus tears are usually classified as degenerative or traumatic tears according to their pathogenesis. At present, traumatic meniscal tears are generally believed to have high healing potential. In recent years, multiple treatments have been described for traumatic meniscal tears, such as the inside-out technique, outside-in technique, all-inside technique, biological augmentation of meniscal repair, meniscectomy, and non-surgical treatment. However, the functional recovery of the knee joint and healing of the meniscus after treatment are quite different from the results reported in the literature, which requires more reliable evidence-based medical findings. This study will evaluate evidence from multiple types of research comparing different therapies for traumatic meniscal tears in adults.

METHODS

We will search the EMBASE, Cochrane Library (the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials [CENTRAL], Cochrane Methodology Register), PubMed, Web of Science (Science and Social Science Citation Index), China Knowledge Network, CBM, Wanfang data, and VIP electronic databases from their inception to August 10, 2021, with no language restrictions. We will also manually search Baidu and Google Scholar to identify randomized controlled studies, non-randomized controlled studies, and cohort studies on the treatment of traumatic meniscal tears. Two researchers will independently screen the literature, extract the data, and evaluate the quality of the studies. Software programs, including Microsoft Access, Excel, Stata (Version 15), WinBUGS (Version 1.4.3), and ADDIS (Version 1.16.8), were used to analyze and manipulate the data.

RESULTS

In this study, the main outcomes were physical function and healing rate, based on the Western Ontario and McMaster Universities Osteoarthritis Index, Lysholm Knee Scoring Scale, Knee Injury and Osteoarthritis Outcome Score, Functional Recovery Scale, and clinical healing rate. The secondary indexes included total cost, cost-effectiveness ratio, incremental cost-effectiveness ratio, Tegner activity scale score, visual analogue scale, numerical rating scale, and meniscal tear complications.

CONCLUSIONS

This systematic review will provide reliable evidence-based findings for the clinical application of different therapies for traumatic meniscal tears in adults.

Meniscus repair with simultaneous anterior cruciate ligament reconstruction: Clinical outcomes, failure rates and subsequent processing

PURPOSE

To retrospectively analyze the clinical outcomes of meniscus repair with simultaneous anterior cruciate ligament (ACL) reconstruction and explore the causes of failure of meniscus repair.

METHODS

From May 2013 to July 2018, the clinical data of 165 patients who were treated with meniscus surgery and simultaneous ACL reconstruction, including 69 cases of meniscus repair (repair group) and 96 cases of partial meniscectomy (partial meniscectomy group) were retrospectively analyzed. The exclusion criteria were as follows: (1) ACL rupture associated with fracture, collateral ligament injury, or complex ligament injury; (2) a history of knee surgery; or (3) a significant degree of osteoarthritis. The 69 patients in the repair group were divided into the non-failure group (62 cases) and the failure group (7 cases) depending on the repair effect. Postoperative outcomes of the repair group and the partial meniscectomy group were compared. General conditions and postoperative outcomes of the failure group and the non-failure group were compared. During the median follow-up period of 28 months (range, 4 - 65 months) after the second arthroscopy, postoperative outcomes of seven patients in the failure group were summarized. SPSS 25.0 statistical software was used for statistical analysis. A p value less than 0.05 was considered statistically significant.

RESULTS

Seven patients in the failure group who underwent the second arthroscopy were followed up for (30 ± 17.4) months and their postoperative outcomes were summarized. Compared with the partial meniscectomy group, the International Knee Documentation Committee scores of patients in the repair group improved significantly (p = 0.031). Compared with the non-failure group, more patients in the failure group were younger than 24 years (p = 0.030). The median follow-up period was 39.5 months. All patients recovered well after subsequent partial meniscectomy and relieved clinical symptoms. Visual analog scale scores decreased significantly (p = 0.026), and the International Knee Documentation Committee and Lysholm scores improved significantly (p = 0.046 for both).

CONCLUSION

The failure rate of meniscus repair in this study was 10.1% (7/69), all of which were medial meniscus tears. However, the surgical outcomes of ACL reconstruction were not affected, and there might be a role for graft protection. Therefore, meniscus retears can be successful treated by performing subsequent partial meniscectomy in patients with repair failure.

Complex Meniscus Tears Treated with Collagen Matrix Wrapping and Bone Marrow Blood Injection: Clinical Effectiveness and Survivorship after a Minimum of 5 Years' Follow-Up

Purpose. To determine the 5-year success rate of the "all-inside" technique of arthroscopic meniscus suture and collagen membrane wrapping along with bone marrow blood injection, to evaluate the progression of degenerative changes and the impact of simultaneous anteriro cruciate ligament (ACL) reconstruction. Methods. Fifty-four consecutive patients with complex meniscal tears were treated with the previously described technique. The subjective scores (International Knee Documentation Committee 2000, Lysholm, EQ-5D-5L) and Barret clinical criteria of meniscal healing were recorded. Magnetic resonance images (MRIs) were assessed at 2 and 5 years postoperatively, using the Whole-Organ Magnetic Resonance Imaging Score (WORMS) criteria. Kaplan-Meier survival analyses were performed in order to assess the survivorship after the index procedure. Thirty-nine patients were divided into 2 groups: group A-isolated meniscus repair and group B-meniscus repair with concurrent ACL reconstruction. Results. Fifty-four patients were treated and 44 were available for analysis. There was a statistically significant improvement in subjective scores and clinical assessment between the preoperative, 2-year follow-up, and 5-year follow-up time points. EQ-5D-5L utility value was 0.9 ± 1 at final follow-up. The WORMS osteoarthritis severity grade had increased from 6.9 ± 5.0 points at the 2-year follow-up to 11.1 ± 9.6 points at the 5-year follow-up (P < 0.001). There was a significant difference between the groups after 60 months. The overall survival rate at final follow-up was 88%. Conclusions. The treatment option evaluated in this study has shown very good mid-term clinical and MRI-based outcomes as well as a favorable survival rate. Simultaneous ACL reconstruction is likely a factor for osteoarthritis progression.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Biomechanical Analysis of Segmental Medial Meniscal Transplantation in a Human Cadaveric Model

BACKGROUND

Meniscal deficiency has been reported to increase contact pressures in the affected tibiofemoral joint, possibly leading to degenerative changes. Current surgical options include meniscal allograft transplantation and insertion of segmental meniscal scaffolds. Little is known about segmental meniscal allograft transplantation.

PURPOSE

To evaluate the effectiveness of segmental medial meniscal allograft transplantation in the setting of partial medial meniscectomy in restoring native knee loading characteristics.

STUDY DESIGN

Controlled laboratory study.

METHODS

Ten fresh-frozen human cadaveric knees underwent central midbody medial meniscectomy and subsequent segmental medial meniscal allograft transplantation. Knees were loaded in a dynamic tensile testing machine to 1000 N for 20 seconds at 0°, 30°, 60°, and 90° of flexion. Four conditions were tested: (1) intact medial meniscus, (2) deficient medial meniscus, (3) segmental medial meniscal transplant fixed with 7 meniscocapsular sutures, and (4) segmental medial meniscal transplant fixed with 7 meniscocapsular sutures and 1 suture fixed through 2 bone tunnels. Submeniscal medial and lateral pressure-mapping sensors assessed mean contact pressure, peak contact pressure, mean contact area, and pressure mapping. Two-factor random-intercepts linear mixed effects models compared pressure and contact area measurements among experimental conditions.

RESULTS

The meniscal-deficient state demonstrated a significantly higher mean contact pressure than all other testing conditions (mean difference, ≥0.35 MPa; P < .001 for all comparisons) and a significantly smaller total contact area as compared with all other testing conditions (mean difference, ≤140 mm²; P < .001 for all comparisons). There were no significant differences in mean contact pressure or total contact area among the intact, transplant, or transplant-with-tunnel groups or in any outcome measure across all comparisons in the lateral compartment. No significant differences existed in center of pressure and relative pressure distribution across testing conditions.

CONCLUSION

Segmental medial meniscal allograft transplantation restored the medial compartment mean contact pressure and mean contact area to values measured in the intact medial compartment.

CLINICAL RELEVANCE

Segmental medial meniscal transplantation may provide an alternative to full meniscal transplantation by addressing only the deficient portion of the meniscus with transplanted tissue. Additional work is required to validate long-term fixation strength and biologic integration.

Fabrication of decellularized meniscus extracellular matrix according to inner cartilaginous, middle transitional, and outer fibrous zones result in zone-specific protein expression useful for precise replication of meniscus zones

Meniscus is a fibrocartilage composite tissue with three different microstructual zones, inner fibrocartilage, middle transitional, and outer fibrous zone. We hypothesized that decellularized meniscus extracellular matrix (DMECM) would have different characteristics according to zone of origin. We aimed to compare zone-specific DMECM in terms of biochemical characteristics and cellular interactions associated with tissue engineering. Micronized DMECM was fabricated from porcine meniscus divided into three microstructural zones. Characterization of DMECM was done by biochemical and proteomic analysis. Inner DMECM showed the highest glycosaminoglycan content, while middle DMECM showed the highest collagen content among groups. Proteomic analysis showed significant differences among DMECM groups. Inner DMECM showed better adhesion and migration potential to meniscus cells compared to other groups. DMECM resulted in expression of zone-specific differentiation markers when co-cultured with synovial mesenchymal stem cells (SMSCs). SMSCs combined with inner DMECM showed the highest glycosaminoglycan in vivo. Outer DMECM constructs, on the other hand, showed more fibrous tissue features, while middle DMECM constructs showed both inner and outer zone characteristics. In conclusion, DMECM showed different characteristics according to microstructural zones, and such material may be useful for zone-specific tissue engineering of meniscus.

Meniscus Repair Techniques

The menisci play a vital role in maintaining knee function and protecting the chondral surfaces. Acute and chronic tears are common injuries among both young athletes and older patients with early degenerative changes. The progression of physiological derangement and chondral injury after meniscus injury and meniscectomy have prompted interest in expanding meniscus repair techniques. Recent literature encourages an attempt at repair in tear patterns previously declared irreparable if the tissue quality allows. The orthopedic surgeon should understand the multitude of techniques available to them and be prepared to combine techniques to optimize the quality of their repair construct. While biological augmentation may show some promising early results, the quality of the current data precludes strong recommendations in their favor.

Training Surgeons to Perform Arthroscopic All-Inside Meniscal Repair: A Randomized Controlled Trial Evaluating the Effectiveness of a Novel Cognitive Task Analysis Teaching Tool, Imperial College London/University College London Meniscus Repair Cognitive Task Analysis (IUMeRCTA)

BACKGROUND

All-inside meniscal repair is an increasingly common technique for the surgical treatment of meniscal tears. There are currently no standardized techniques for training residents in this procedure. Cognitive task analysis (CTA) is a method of analyzing and standardizing key steps in a procedure that allows training to be conducted in a validated and reproducible manner.

PURPOSE

(1) To design a digital CTA teaching tool for a standardized all-inside meniscal repair. (2) To evaluate whether CTA-trained residents would perform better in a meniscal repair task compared with a control group who underwent traditional apprenticeship methods of training.

STUDY DESIGN

Controlled laboratory study.

METHODS

Three expert knee surgeons were interviewed using a modified Delphi method to generate a consensus among the ideal technical steps, cognitive decision points, and common errors and solutions for an all-inside meniscal repair. This written information was then combined with visual and audio components and integrated onto a digital platform to create the Imperial College London/University College London Meniscus Repair Cognitive Task Analysis (IUMeRCTA) tool. Eighteen novice residents were randomized into an intervention group (digital CTA tool) and control group (equipment instruction manual). Both groups performed an all-inside meniscal repair on high-fidelity, phantom knee models and were assessed by expert surgeons, blinded to the interventions, using a validated global rating scale (GRS). After a power calculation, median GRS scores were compared between groups using the Mann-Whitney U test; significance was set at P < .05.

RESULTS

For the IUMeRCTA tool design, the procedure was divided into 55 steps across 9 phases: (1) preoperative planning, (2) theater and patient setup, (3) portal placement, (4) meniscal examination, (5) tear reduction, (6) suture planning, (7) suture insertion, (8) repair completion, and (9) postoperative care and rehabilitation. For the trial, the intervention group (mean ± SD GRS, 32 ± 2.9) performed significantly better than did the control group (GRS, 24 ± 3.3; P < .001).

CONCLUSION

This is the first CTA tool to demonstrate objective benefits in training novices to perform an arthroscopic all-inside meniscal repair.

CLINICAL RELEVANCE

The IUMeRCTA tool is an easily accessible and effective adjunct to traditional teaching that enhances learning the all-inside meniscal repair for novice surgeons.