Anterior horn tears of the lateral meniscus in soccer players

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.

LARAI portal provides a safe method for lateral meniscus repair: three-dimensional computed tomography and cadaveric assessment

BACKGROUND

Lateral, All-Round and All-Inside (LARAI) portal is a viewing or working portal for observing and repairing the lesions of the lateral meniscus. However, there are safety concerns about popliteal artery (PA) injuries during the procedure. This study aimed to assess the safe distance between the trajectory of the LARAI portal and PA.

MATERIALS AND METHODS

Both three-dimensional computed tomography (3D-CT) and cadavers were used to simulate the LARAI portal trajectory. In the 3D-CT study, between January 2020 and September 2020, 45 participants who underwent computed tomography angiography were included in the study. The shortest distance from the PA to the simulated trajectory needle (PS) was measured using 3D-CT. Mean -3SD -2 was calculated to assess the safety of the LARAI portal trajectory. If this value was more than zero, the trajectory was considered "safe." In the cadaveric study, lower limbs from seven fresh-frozen cadavers were used to establish the "safe" trajectories of the LARAI portal, and the PS was measured.

RESULTS

In the 3D-CT study, the longest PS (P < 0.001) was found 20 mm lateral to the edge of the patellar tendon trajectory at 0 mm from the posterior cruciate ligament (PCL). Safe trajectories were also found 10 mm, 15 mm, and 20 mm lateral to the edge of the patellar tendon at 0 mm from the PCL, as well as the 20 mm lateral to the edge of the patellar tendon at 3 mm from the PCL. The cadaveric study showed that the average PS of all safe trajectories closely adjoined to PCL was greater than 14 mm.

CONCLUSIONS

The LARAI portal trajectory in the "figure of four" is safe, and the optimal insertion point is 10-20 mm lateral to the edge of the patellar tendon and closely adjoined to the posterolateral margin of the PCL at knee joint line level.

LEVEL OF EVIDENCE

Level IV.

Effect of Anterior Horn Tears of the Lateral Meniscus on Knee Stability

Background

Investigations on the biomechanical characteristics of the anterior horn of the lateral meniscus (AHLM) related to anterior cruciate ligament (ACL) tibial tunnel reaming have revealed increased contact pressure between the femur and tibia, decreased attachment area, and decreased ultimate failure strength.

Purpose/Hypothesis

The purpose of this study was to investigate the influence of a complete radial tear of the AHLM on force distribution in response to applied anterior and posterior drawer forces and internal and external rotation torques. We hypothesized that the AHLM plays an important role in knee stability, primarily at lower knee flexion angles.

Study Design

Controlled laboratory study.

Methods

A total of 9 fresh-frozen cadaveric knee specimens and a robotic testing system were used. Anterior and posterior drawer forces up to 89 N and internal and external rotation torques up to 4 N·m were applied at 0°, 30°, 60°, and 90° of knee flexion. A complete AHLM tear was then made 10 mm from the lateral border of the tibial attachment of the ACL, and the same tests performed in the intact state were repeated. Next, the recorded intact knee motion was reproduced in the AHLM-torn knee, and the change in the resultant force after an AHLM tear was determined by calculating the difference between the 2 states.

Results

In the torn AHLM, the reduction in the resultant force at 0° for external rotation torque (34.8 N) was larger than that at 60° (5.2 N; P < .01) and 90° (6.7 N; P < .01).

Conclusion

The AHLM played a role in facilitating knee stability against an applied posterior drawer force of 89 N and external rotation torque of 4 N·m, especially at lower knee flexion angles.

Clinical Relevance

This study provides information about the effects of AHLM injuries that may occur during single-bundle ACL reconstruction using a round tunnel.

Radial tears in the anterior third of the lateral meniscus are frequently combined with horizontal tears

INTRODUCTION

Radial tears of the lateral meniscus are often located in the junction of the middle and posterior third or posterior tibial attachment. However, we observed that a few cases of radial tears occurred in the anterior third of the lateral meniscus, and in many cases, they were accompanied by horizontal tears.

HYPOTHESIS

Radial tears are more frequently accompanied by horizontal tears in the anterior third of the lateral meniscus than in other regions.

MATERIAL AND METHODS

From July 2006 to May 2019, patients who underwent arthroscopic surgery for radial tears of the lateral meniscus were included. Patients with radial tears in the anterior third of the lateral meniscus were classified into the anterior group and those with radial tears in the middle and posterior third were classified into the comparison group. Magnetic resonance imaging and arthroscopic findings were reviewed to evaluate whether radial tears were accompanied by other types of tears, especially horizontal tears. The incidence of complex tears between the two groups was compared.

RESULTS

Eighty knees in 79 patients were included. The mean age at the time of surgery was 44.1±16.9 years. The anterior group included 30 knees, and 19 (63.3%) of those also had horizontal tears. In the anterior group, all complex tears were accompanied by horizontal tears, and no other types of accompanying tears were observed. The comparison group included 50 knees, and 16 (32%) of those also had other types of tears. Of the 16 complex tears, 14 had horizontal tears and 2 had longitudinal tears. The incidence of complex tear was significantly higher in the anterior group than in the comparison group (p<.001).

CONCLUSION

Radial tears occurring at the anterior third of the lateral meniscus are frequently accompanied by a horizontal tear. It is important to be aware and predict the occurrence of such characteristic tears and to do proper surgical procedures.

LEVEL OF PROOF

IV; Cross-sectional study.

Isolated peripheral longitudinal tears in the anterior-middle segment of medial meniscus among young soccer players: A case series

Introduction

There was little information about the isolated medial meniscal tears in the anterior–middle segment. This study aimed to report the infrequent cases of the isolated medial meniscal tears in the anterior–middle segment related to kicking motion among young soccer players with a short-term postoperative outcome.

Presentation of case

In the retrospective review of the surgical records from 2000 to 2018, there were 15 cases with the corresponding tear. They were all young male soccer players with a mean age of 16.7 years (range: 10–23 years). The cause of injury was kicking motion during playing soccer in all the patients. The most frequent symptom was locking in 80% of the cases. In the arthroscopic evaluation, all the cases presented with a longitudinal (bucket-handle) tear in the anterior–middle segment in the peripheral zone with a length of 25 to 30 mm, while the posterior segment and the cruciate ligaments were intact. Meniscal repair was performed for all the cases. At one year, all the patients could return to play soccer with a pre-injury level without any symptoms. In the second-look arthroscopy at six months among four cases, all meniscal tears healed completely.

Discussion and conclusion

Clinicians should be aware of the possibility of isolated peripheral longitudinal tear in the anterior–middle segment of the medial meniscus, which is related to the kicking motion among young soccer players and mainly causes locking.

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Isolated medial meniscal tears in anterior–middle segment are relatively infrequent.

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These tears cause after kicking motion among young soccer players.

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Longitudinal (bucket-handle) tears are observed in the periphery.

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Clinical outcomes after repair are good.

Clinical and Radiological Outcomes After Isolated Anterior Horn Repair of Medial and Lateral Meniscus at 24 Months' Follow-up, With the Outside-In Technique

Background

The effects of repair of isolated anterior horn meniscus lesions have not been thoroughly described in the literature. We aimed to evaluate outcomes with subjective clinical scores and imaging modalities after repair of isolated anterior horn tears, at 24 months’ follow-up.

Methods

Records of all patients that opted for surgical repair of isolated, anterior horn tears of the medial and lateral meniscus were retrospectively reviewed, between 2016 and 2018. All patients were treated with arthroscopic outside-in technique by the same surgeon. Preoperative and postoperative clinical files were accessed to recover records of preoperative symptomatology, patient-reported scores [International Knee Documentation Committee (IKDC) rating, Lysholm score and Tegner activity level], preoperative and postoperative MRI data and time from injury to surgery.

Results

Mean age of eight patients was 25.25 years (range 18-37 years). Diagnostic preoperative MRI revealed isolated anterior horn tear of the lateral meniscus and medial meniscus in five patients and an isolated anterior horn tear of the medial meniscus in three patients. Mean time from injury to surgical repair was 23.75 days (range 7-43). We considered seven out of eight repairs to be successfully healed. At 24 months’ follow-up: Mean Lysholm score was 92.25 (range 89-95), Tegner activity scale score was 6.5 (range 5-8) and IKDC score was 91.78 (range 87.8-94.4). All scores significantly improved compared to preoperative values (p<0.001).

Conclusions

Outside-in is a reliable technique to repair meniscal anterior horn tears, both medially and laterally, with high healing rates and patient satisfaction in young, active patients.

Efficacy of Arthroscopic Treatment for Concurrent Medial Meniscus Posterior Horn and Lateral Meniscus Anterior Horn Injury: A Retrospective Single Center Study

Objective

To investigate the effectiveness of arthroscopic surgery for combined tears of the posterior horn of the medial meniscus (PHMM) and the anterior horn of the lateral meniscus (AHLM).

Methods

Between September 2009 and December 2013, a retrospective investigation was performed on 48 patients (48 knees) with combined tears of PHMM and AHLM who underwent arthroscopic surgery. All patients underwent magnetic resonance imaging (MRI) diagnosis in the outpatient department. After admission, other basic examinations were performed. PHMM was treated with partial meniscectomy and AHLM was treated with external–internal suture or partial meniscectomy. Curative effect was evaluated according to Lysholm score and IKDC score. The differences of the functions as well as Lysholm and IKDC scores pre‐ and postoperatively were compared, while the diagnostic accuracy of MRI and arthroscopy for PHMM and AHLM were compared.

Results

Seven patients with combined tears of PHMM and AHLM were misdiagnosed during MRI examination when arthroscopy was used as the gold standard. All patients were followed up for an average of 34.58 months (range 10–52 months) and all incisions healed by first intention with no obvious complication. The preoperative and postoperative Lysholm scores were 47.22 ± 2.77 and 87.36 ± 5.45, respectively. The IKDC scores are 54.73 ± 4.65 preoperatively and 89.62 ± 3.71 postoperatively. The positive rates of the diagnosis through MRI and arthroscopic surgery is 85.42% and 100%, respectively. At the last follow‐up, the patients had no pain, weakness, and instability, and tenderness in medial and lateral joint space disappeared. Mcmurray test was weakly positive in four patients. Excellent outcome was achieved in 39 cases, and a good outcome was achieved in five cases; the good to excellent rate was 91.67%.

Conclusion

MRI examination of combined tears of PHMM and AHLM may result in misdiagnosis. Arthroscopic primary repair seemed to be an effective surgical option for treatment of combined tears of PHMM and AHLM.

Arthroscopic Management for the Unstable Inferior Leaf of the Lateral Meniscus Anterior Horn and Associated Cysts through a Direct Inframeniscal Portal: A Retrospective Study

Introduction

To investigate the clinical results of arthroscopic management for the unstable inferior leaf of the lateral meniscus anterior horn and associated cysts through an inframeniscal portal.

Methods

From March 2005 to October 2014, 64 patients with an unstable inferior leaf of the lateral meniscus anterior horn and associated cysts underwent arthroscopic management with an inframeniscal portal. The mean age of the patients was 36.9 years (range, 18 to 49 years). The mean follow-up period was 28 months (range, 24 to 44 months). Clinical results were assessed using physical examination, the Lysholm knee score, and postoperative magnetic resonance scanning.

Results

The median Lysholm score improved significantly at 1 year after surgery and at final follow-up. Magnetic resonance scanning at least one year after the operation revealed no recurrent meniscal tears or cysts. No reoperations were required after an average follow-up of 28 months. All patients reported significant symptomatic relief after the operation. They had full range of motion at three months and returned to normal activities and sports one year after surgery.

Conclusion

The direct inframeniscal portal can provide an effective approach to manage lesions in the anterior horn of the lateral meniscus with predictable clinical outcomes.

Anterior Horn Meniscal Repair Using an Outside-In Suture Technique

The menisci are important structures within the knee that play a critical role in maintaining proper stability, load distribution, and joint lubrication. Injury to the menisci has been found to significantly alter the complex biomechanics of the knee, and thus affect the health and longevity of the native joint. Tears involving the anterior horn are increasingly recognized as an important pathology. Although early treatment of meniscal tears focused primarily on removal of the injured tissue, recent attention on the long-term consequences of partial or total meniscectomy has led to increased attempts at meniscus repair whenever possible. Because of the location of anterior horn tears and the technical difficulty in accessing this location arthroscopically, an outside-in repair technique is ideal for treatment of these lesions. This technical note details our surgical technique of outside-in repair of anterior horn meniscal tears.

Current strategies in meniscal regeneration

The meniscus plays an important role in the biomechanics and tribology of the knee joint. Damage to or disease of the meniscus is now recognized to predispose to the development of osteoarthritis. Treatment of meniscal injury through arthroscopic surgery has become one of the most common orthopedic surgical procedures, and in the United States this can represent 10 to 20% of procedures related to the knee. The meniscus has a limited healing capacity constrained to the vascularized periphery and therefore, surgical repair of the avascular regions is not always feasible. Replacement and repair of the meniscus to treat injuries is being investigated using tissue engineering strategies. Promising as these approaches may be, there are, however, major barriers to overcome before translation to the clinic.

Footballer's Lateral Meniscus: Anterior Horn Tears of the Lateral Meniscus with a Stable Knee

This paper aimed to identify the characteristics of isolated anterior horn tear of the lateral meniscus in footballers who underwent arthroscopic surgery. We identified 8 patients with stable knee and no ligament injury, who had only isolated anterior horn tear of the lateral meniscus between 2007 and 2009. All 8 patients were footballers, comprising 7 men and 1 woman with mean age of 18.6 years. Arthroscopy revealed multiple longitudinal tears in 2 patients, longitudinal tear in 2 patients, degenerative tear in 3 patients, and flap tear in 1 patient. Two patients were treated by repair, five by partial excision, and one by rasping only. The mean Lysholm score was 65 before surgery and recovered to 89 at the last followup, on average 12 months after surgery. Anterior horn tear of the lateral meniscus in footballers with a stable knee is characterized by pain at the anterolateral aspect of the knee during knee extension, especially when kicking a ball, and pain during weight-bearing knee extension, together with MRI finding of hyperintense signal in the anterior horn of the lateral meniscus. Preoperative diagnosis may be possible based on these findings in footballers.

Snapping popliteus tendon in a 21-year-old female

STUDY DESIGN

Case report.

BACKGROUND

Determining the cause of painful snapping on the lateral aspect of the knee can be a challenge. The differential diagnosis includes iliotibial band friction syndrome, lateral meniscus tear, intra-articular loose body, discoid lateral meniscus, snapping biceps femoris tendon, degenerative joint disease, proximal tibiofibular joint instability, and snapping popliteus tendon.

CASE DESCRIPTION

A 21-year-old female presented with a 7-year history of a painful snapping on the lateral aspect of her left knee. She reported the snapping occurred with all activities involving knee flexion and extension, including running and walking. With a diagnosis of snapping iliotibial band, she had received a variety of physical therapy interventions, including various lower extremity stretching and strengthening exercises. Nonsteroidal anti-inflammatory medications were also prescribed by her physician. Conservative and pharmoclogical interventions were unsuccessful in improving her symptoms. Similarly, our attempt with conservative treatment consisting of ice, taping, and a short period of immobilization was not successful.

OUTCOMES

The patient underwent a surgical procedure consisting of removal of a prominent tubercle on the lateral femoral condyle and tenodesis of the popliteus tendon to the proximal aspect of the fibular (lateral) collateral ligament, followed by a postoperative program of physical therapy including range-of-motion and progressive strengthening exercises. At 6 weeks following surgery, the patient had returned to all activities with complete resolution of her symptoms.

DISCUSSION

Painful snapping at the lateral aspect of the knee may be caused by a variety of disorders, including the popliteus tendon. Clinical diagnosis is challenging. Clinical suspicion of a snapping popliteus tendon as a source of the signs and symptoms of the condition is important for inclusion in the differential diagnosis.

LEVEL OF EVIDENCE

Differential diagnosis, level 4.