Self-reported patient outcomes at a minimum of 5 years after allograft anterior cruciate ligament reconstruction with or without medial meniscus transplantation: an age-, sex-, and activity level-matched comparison in patients aged approximately 50 years

Tunnel Overlap Occurs 25% of the Time With Simultaneous Anterior Cruciate Ligament Reconstruction and Lateral Meniscal Root Repair

Purpose

To assess the risk of socket-tunnel overlap for posterior medial or lateral meniscal root repair combined with anterior cruciate ligament reconstruction (ACLR) using artificial tibias and computed tomography scans for 3-dimensional modeling.

Methods

Artificial tibias (n = 27; n = 3/subgroup) were allocated to groups based on inclination of socket-tunnels (55°, 60°, 65°) created for posterior root of the medial meniscus (MMPR) and lateral meniscus posterior root (LMPR) repair, and ACLR. Three standardized socket-tunnels were created: one for the ACL and one for each posterior meniscal root insertion. Computed tomography scans were performed and sequentially processed using computer software to produce 3-dimensional models for assessment of socket-tunnel overlap. Statistical analysis was performed with Kruskal-Wallis and Mann-Whitney U tests. Significance was set at P < .05.

Results

The present study found no significant risk of tunnel overlap when drilling for combined ACLR and MMPR repair, whereas 7 cases of tunnel overlap occurred between ACL tunnels and LMPR (25.9% of cases). No subgroup or specific pattern of angulation consistently presented significantly safer distances than other subgroups for all distances measured.

Conclusions

This study demonstrated 25.9% rate of overlap for combined LMPR repair and ACLR, compared with 0% for MMPR repair with ACLR. Lower ACL drilling angle (55 or 60°) combined with greater lateral meniscus drilling angle (65°) produced no socket-tunnel overlap.

Clinical Relevance

Socket-tunnel overlap during meniscal root repair combined with ACLR may compromise graft integrity and lead to impaired fixation and treatment failure of either the ACL, the meniscus, or both. Despite this, risk for socket-tunnel overlap has not been well characterized.

Optimizing Socket-Tunnel Position for Meniscal Allograft Transplantation Combined With ACL Reconstruction: A 3D Model Analysis

Background

Socket-tunnel overlap during meniscal allograft transplantation (MAT) combined with anterior cruciate ligament reconstruction (ACLR) may compromise graft integrity and lead to impaired fixation and treatment failure.

Purpose/Hypothesis

The purpose of this study was to determine optimal socket-tunnel drilling parameters for medial and lateral MAT with concurrent ACLR using artificial tibias and computed tomography (CT) scans for 3-dimensional (3D) modeling. It was hypothesized that clinically relevant socket tunnels could be created to allow for concurrent medial or lateral MAT and ACLR without significant risk for overlap at varying tunnel guide angles.

Study Design

Descriptive laboratory study.

Methods

A total of 27 artificial right tibias (3 per subgroup) were allocated to 9 experimental groups based on the inclination of the socket tunnels (55°, 60°, and 65°) created for simulating medial and lateral MAT and ACLR. Five standardized socket tunnels were created for each tibia using arthroscopic guides: one for the ACL tibial insertion and one for each meniscus root insertion. CT scans were performed for all specimens and sequentially processed using computer software to produce 3D models for quantitative assessment of socket-tunnel overlap risk. Statistical analysis was performed with Kruskal-Wallis and Mann-Whitney U tests.

Results

No subgroup consistently presented significantly safer distances than other subgroups for all distances measured. Three cases (11%) and 24 cases (~90%) of tunnel overlap occurred between the ACL tunnel and tunnels for medial and lateral MAT, respectively. Most socket-tunnel overlap (25 of 27; 92.6%) occurred between sockets at depths ranging between 6.3 and 10 mm from the articular surface. For ACLR and posterior root of the lateral meniscus setting, the guide set at 65° increased socket-tunnel distances.

Conclusion

When combined ACLR and MAT using socket tunnels for graft fixation is performed, the highest risk for tibial socket-tunnel overlap involves the ACLR tibial socket and the lateral meniscus anterior root socket at a depth of 6 to 10 mm from the tibial articular surface.

Clinical Relevance

Setting tibial guides at 65° to the tibial articular surface with the tunnel entry point anteromedial and socket aperture location within the designated anatomic "footprint" will minimize the risk for socket-tunnel overlap.

MENISCAL ALLOGRAFT TRANSPLANTATION COMBINED WITH ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION: A SYSTEMATIC REVIEW

Introduction

To evaluate the clinical and functional outcomes of meniscal allograft transplantation (MAT) with anterior cruciate ligament reconstruction (ACLR) in a single surgical stage through a systematic review of the currently available evidence.

Methods

A systematic search of the PubMed and Google Scholar databases, with no publication date limit, until December 2022 was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Follow-up studies and case series published in English involving patients undergoing a combination of ACLR and MAT were included. The quality of these studies was assessed using the Methodological Index for Non-Randomized Studies (MINORS) checklist. A systematic review of the International Knee Documentation Committee (IKDC), Lysholm and Tegner activity scores was conducted.

Results

Seven studies involving 154 patients were included. The mean follow-up was 5,3 years. The mean age at the time of the surgery was of 35.3 years. All studies used the Lysholm Knee score, IKDC score or Tegner activity score to measure clinical outcomes post-operatively and the mean improvements were 26.7, 24.7, and 1.8 respectively. The rate to return to sport was 75.5 %. No intra-operative complications were reported. The post-operative complication rate was 11.6%.

Conclusions

MAT combined with ACLR procedure showed good clinical results up to an average of 5 years of follow-up. More studies need to be conducted that can better understand the long-term effects of this combined procedure.

Do Outcomes of Meniscal Allograft Transplantation Differ Based on Age and Sex? A Comparative Group Analysis

PURPOSE

To analyze the effect of patient age, sex, and associated preoperative factors on patient-reported outcome (PRO) measures and graft survival following primary meniscal allograft transplantation (MAT).

METHODS

A prospectively collected database was retrospectively reviewed to identify patients who underwent primary MAT with a minimum of 2 years of follow up between 1999 and 2017. Demographic, intraoperative, and postoperative outcome data were collected for each patient. Postoperative outcomes were stratified based on age and sex, and comparative statistical analysis was performed between sexes, both >40 and <40.

RESULTS

A total of 238 patients underwent primary MAT during the study period, of which 212 patients (mean age, 28.5 ± 9.0 years; range, 15.01-53.67 years) met the inclusion criteria with a mean follow-up of 5.1 ± 3.4 years (range 2.0-15.9 years). At final follow-up, patients ≥40 and <40 years of age demonstrated statistically significant improvements in nearly all PRO scores (P < .05 for both groups). There were no significant differences between either group for achievement of minimal clinically important difference for International Knee Documentation Committee (P = .48) or Knee Injury and Osteoarthritis Outcome Score symptoms (P = .76). Because of insufficient numbers, a statistically significant difference could not be demonstrated in reoperation rate (≥40: 1.49 ± 1.77 years, <40: 1.87 ± 1.98 years, P = .591), failure rate (≥40: 7/32 [21.9%], <40: 19/180 [10.6%], P = .072), or complication rate (≥40: 2/32 [6.3%], <40: 12/180 [6.7%], P = .930) based on age. Both sexes showed a significant improvement in PROs, whereas female patients were more likely to undergo revision surgery (P = .033), with no significant differences based on time to reoperation, failure, or complication rates.

CONCLUSIONS

PROs similarly improved following MAT in both patients aged ≥40 and those <40 at final follow-up with no significant differences in minimal clinically important difference achievement rate, complication rate, reoperation rate, time to reoperation, or failure rate between groups. Female patients may be more likely to undergo revision surgery after MAT.

LEVEL OF EVIDENCE

III; therapeutic retrospective comparison study.

Anterior cruciate ligament reconstruction in the over-50s. A prospective comparative study between surgical and functional treatment

INTRODUCTION

In patients aged over-50 years, although data are sparse, results of anterior cruciate ligament (ACL) surgery are good if selection is correctly performed. However, non-operative treatment is usually proposed for this age group, as patients generally prefer just to scale down their sports activities. Non-operative results are acceptable, but with a high risk of residual instability, secondary lesions and lifestyle alteration. The main aim of the present study was to compare results between surgical versus non-surgical treatment of ACL tear in over-50 year-olds. Secondary objectives comprised assessing prognostic factors for poor functional outcome, and comparing the 2 groups epidemiologically to identify clinical decision-making factors. The study hypothesis was that results are comparable between operative and non-operative treatment of ACL tear.

MATERIAL AND METHOD

Three hundred twenty patients were followed up prospectively: 92 non-surgical (NS group) and 288 surgical (S group). Classical epidemiological data were collected. Clinical laxity, differential laximetry, KOOS, IKDC, Tegner and ACL-RSI scores and radiologic assessment were collected pre- and postoperatively, as were intraoperative data. Early and late complications were collected.

RESULTS

All patients were followed up. Patients were principally female, and were older, less athletic, with more stable knee and less severe functional impact in the NS group. Functional scores improved in both groups, and especially in group S, where sports scores were also better. In the NS group, laximetry at follow-up correlated with preoperative marked pivot-shift (p=0.024). Severe differential laxity was predictive of poor IKDC score (p=0.06). In the S group, laximetry at follow-up correlated with preoperative explosive pivot-shift (p<0.001), lateral meniscal lesion (p=0.007), use of hamstring tendon (p=0.007), and non-operated early complications (p=0.004). Factors for poor global KOOS score in group S comprised female gender (p<0.001), high BMI (p<0.001) and skiing (p=0.038). Factors for poor Tegner scores comprised skiing or team sport (p<0.05), isolated moderate medial osteoarthritis (p=0.01), and non-operated early complications (p=0.022). Factors for poor IKDC score comprised female gender (p=0.064), and non-operated early complications (p=0.019). Complications did not differ between groups.

DISCUSSION/CONCLUSION

Results were satisfactory in both groups, with significant improvement in functional scores, but were better in group S. For NS patients, pivot sport was barely feasible and sports activity scores decreased. In case of severe laxity at diagnosis, surgical treatment should be proposed.

LEVEL OF EVIDENCE

III; non-randomized prospective comparative series.

Centralized anterior bone plug results in less graft extrusion in patients undergoing medial meniscus allograft transplantation following anterior cruciate ligament reconstruction

PURPOSE

This study was performed to analyze the effect of anterior bone plug positioning on clinical and radiological outcomes in patients undergoing medial meniscus allograft transplantation (M-MAT) following anterior cruciate ligament reconstruction (ACLR).

METHODS

Data from 24 patients who underwent M-MAT following meniscectomy and ACLR from November 2008 to June 2017 were retrospectively investigated. Patients were divided into either the centrally positioned group (group C) or the medially positioned group (group M) based on the location of the anterior bone plug for M-MAT. Clinical and radiographic follow-up was performed at two years postoperatively. International Cartilage Repair Society (ICRS) grades of chondral lesion, graft extrusion, and meniscus signal intensity were evaluated by magnetic resonance imaging (MRI) at one year postoperatively.

RESULTS

There were no significant differences in demographics including follow-up time of two years between the two groups. There were no significant differences in postoperative subjective International Knee Documentation Committee (IKDC), Lysholm, and Tegner scores between groups. Furthermore, there were no significant differences in osteoarthritis progression or ICRS grade on MRI. However, group C showed significantly less absolute graft extrusion (P = .008) and relative graft extrusion (P < .0001) on one-year follow-up MRI, relative to group M. Meniscus signal intensity tended to be better in group C, although this difference was not statistically significant (P = .092).

CONCLUSION

The centrally positioned group showed significantly less graft extrusion on MRI compared to the medially positioned group; however, there were no statistically significant differences in clinical outcomes between the two groups.

Meniscal allograft transplantation combined with anterior cruciate ligament reconstruction provides good mid-term clinical outcome

PURPOSE

Aim of this study is to document if combined meniscal allograft transplantation (MAT) and ACL reconstruction can improve knee function, reduce pain and allow patients with meniscal defect and ACL lesion to resume sport activities.

METHODS

Fifty MAT, arthroscopically performed without bone plugs and combined with one-stage primary or revision ACL reconstruction, with or without high tibial osteotomy (HTO), were included. Patients (aged 38.2 ± 10.6 years, 87% males) were evaluated at a mean follow-up of 5 years with Lysholm, Tegner and VAS scores. Patient satisfaction was also recorded, together with complications and failures.

RESULTS

VAS and Lysholm scores improved significantly (from 63.7 to 24.5 and from 60.6 to 82.7, respectively, p < 0.001), while the Tegner score did not reach pre-injury values (p < 0.001), but it improved significantly compared to pre-surgery values (from 2.8 to 4.6, p < 0.001). Medial MAT reported significantly better results compared to lateral MAT. Patients undergoing concomitant HTO reported a significantly higher decrease of VAS. Younger patients with higher pre-operative pain and lower activity level presented higher satisfaction. Eight patients needed a reoperation. Three patients were considered surgical failures while four were considered clinical failures, for a total of 15% failures.

CONCLUSIONS

Meniscal allograft transplantation combined with ACL reconstruction represents a safe and suitable treatment, which should be considered as a suitable option in the clinical practice. All evaluated patient profiles, ACL injury in a patient with post-meniscectomy syndrome, failed ACL reconstruction in patients with a meniscus defect, and ACL reconstruction in patients with malalignment due to meniscal defect, benefited from the combined MAT procedure at medium-term follow-up.

LEVEL OF EVIDENCE

IV.

Higher survivorship following meniscal allograft transplantation in less worn knees justifies earlier referral for symptomatic patients: experience from 240 patients

PURPOSE

To analyse the clinical outcome and survivorship of meniscal allograft transplantation (MAT), performed in a single unit, specifically to assess the impact of concomitant operations and the influence of articular cartilage lesions on outcome.

METHOD

A prospective case series analysis of 240 patients undergoing MAT with follow-up greater than 12 months (range 1-10 years) was performed. Group A represented patients with good chondral surfaces (ICRS 0-3A); Group B had good chondral surfaces with concomitant realignment osteotomy. Group C had good chondral surfaces with ACL reconstruction performed at the same time. Groups D and E had bare bone on one or both surfaces respectively. Kaplan-Meier survivorship and PROMS including Lysholm, KOOS, Tegner, and IKDC subjective scores were analysed.

RESULTS

Overall survivorship was 96.7% at 1 year, 87% at 5 years and 82.2% at 7 years. Groups A-C (knees without significant chondral damage) had significantly improved survivorship (95% at 5 years) compared to Groups D, E (full-thickness chondral wear) with 77% survivorship at 5 years. Survivorship and PROMS were equivalent between Groups A-C. Groups D and E had similar PROMS to Group A, but did have a higher failure rate. Overall 27% required further operative intervention.

CONCLUSIONS

Meniscal transplantation is clinically effective in treating patients with symptomatic meniscal deficiency. Where indicated, the addition of osteotomy or ACL reconstruction achieves results similar to patients undergoing simple meniscal transplantation in stable and normally aligned knees. Survivorship is lower in patients with full-thickness chondral loss and future treatments should, therefore, be directed at improving success in this at-risk group. The results support encouragement for earlier referral of symptomatic patients to a specialist meniscal reconstruction centre before a significant chondral damage is sustained.

LEVEL OF EVIDENCE

III.

Patients With Concomitant Intra-articular Lesions at Index Surgery Deteriorate in Their Knee Injury and Osteoarthritis Outcome Score in the Long Term More Than Patients With Isolated Anterior Cruciate Ligament Rupture: A Study From the Swedish National Anterior Cruciate Ligament Register

PURPOSE

To analyze and compare clinical outcomes after anterior cruciate ligament (ACL) reconstruction 5 and 10 years postsurgery between patients with concomitant intra-articular injuries and those with isolated ACL injury at reconstruction.

METHODS

Registrations were made using a web-based protocol by physicians for baseline and surgical data. Patients registered their Knee Injury and Osteoarthritis Outcome Score (KOOS) preoperatively and at 5 and 10 years postsurgery. The exclusion criteria for the present study were revisions of previously unregistered ACL surgeries, non-ACL surgeries, patients for whom 10-year follow-up data had not yet been collected, and the proportion of index surgeries that were revision or contralateral interventions.

RESULTS

There were 1,295 KOOS scores available for patients 5 years postsurgery, and 1,023 10 years postsurgery from a baseline of 2,751 index reconstructions. A deterioration between the 5- and 10-year scores was observed for patients with concomitant meniscus injury on the KOOS subscales for pain (P = .015), symptoms (P = .005), sport and recreation (P = .011), and knee-related quality of life (QoL) (P = .03) compared with patients with isolated ACL injury. Correspondingly, KOOS subscale score deterioration was seen for combined concomitant cartilage and meniscus injuries for pain (P = .005), symptoms (P = .009), sport and recreation (P = .006), and QoL (P < .001). The largest deteriorations were found in sport and recreation (-5.9 points; confidence interval [CI] -10.1, -1.1) and QoL (-6.5 points; CI -10.3, -2.8) subscale scores for patients with concomitant meniscal and cartilage injuries. A similar pattern was not seen between patients with concomitant cartilage injury and isolated ACL injury.

CONCLUSIONS

The present study reveals that concomitant meniscus injuries at the index operation, either in isolation or in combination with cartilage lesions, render a deterioration of scores on the KOOS outcome subscales for pain, sport and recreation, and quality of life between 5- and 10-year postsurgery follow-up of ACL-reconstructed patients. No such deterioration was seen for patients who had isolated ACL injury.

LEVEL OF EVIDENCE

Level III, retrospective analysis of prospectively collected data.

Meniscal allograft transplantation: a meta-analysis

PURPOSE

This meta-analysis evaluates the mid- to long-term survival outcome of MAT (meniscal allograft transplantation). Potential prognosticators, with particular focus on chondral status and age of the patient at the time of transplantation, were also analysed.

STUDY DESIGN

Meta-analysis.

METHODS

An online database search was performed using following search string: "meniscal allograft transplantation" and "outcome". A total of 65 articles were analysed for a total of 3157 performed MAT with a mean follow-up of 5.4 years. Subjective and clinical data was analysed.

RESULTS

The subjective and objective results of 2977 patients (3157 allografts) were analysed; 70% were male, 30% were female. Thirty-eight percent received an isolated MAT. All other patients underwent at least one concomitant procedure. Lysholm, Knee injury and Osteoarthritis Outcome (KOOS), International Knee Documentation Committee (IKDC) and Visual Analogue Scale (VAS) scores were analysed. All scores showed a good patient satisfaction at long-term follow-up. The mean overall survival rate was 80.9%. Complication rates were comparable to standard meniscal repair surgery. There was a degenerative evolution in osteoarthritis with at least one grade in 1760 radiographically analysed patients. Concomitant procedures seem to have no effect on the outcome. Age at transplantation is a negative prognosticator. The body mass index (BMI) of the patient shows a slightly negative correlation with the outcome of MAT.

CONCLUSIONS

MAT is a viable solution for the younger patient with chronic pain in the meniscectomised knee joint. The complications are not severe and comparable to meniscal repair. The overall failure rate at final follow-up is acceptable and the allograft heals well in most cases, but MAT cannot be seen as a definitive solution for post-meniscectomy pain. The correct approach to the chronic painful total meniscectomised knee joint thus requires consideration of all pathologies including alignment, stability, meniscal abnormality and cartilage degeneration. It requires possibly combined but appropriate action in that order.

Is There Any Benefit in Anterior Cruciate Ligament Reconstruction in Patients Older Than 60 Years?

BACKGROUND

Results of anterior cruciate ligament (ACL) reconstruction are traditionally excellent in younger and nonarthritic patients. During the past few decades, people older than 60 years have become more active than ever, with more demanding physical lifestyles. An increase also has been noted in active patients with diagnosed ACL injuries. More patients are requesting treatment for ACL deficiency in hopes of returning to preinjury levels of activity.

PURPOSE

The aims of this study were to evaluate the results of ACL reconstruction in patients older than 60 years in terms of functional recovery, return to sports, and postoperative incidence of osteoarthritis and to compare their results with published results of different age groups.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Consecutive patients older than 60 years with isolated ACL tear and no established osteoarthritic lesions (Ahlbäck grade 1 or no arthritis) who were treated from 2008 to 2013 were retrospectively included in this study. Primary ACL reconstruction was performed with the same technique in all patients by means of single-bundle autologous hamstring tendon graft. Meniscal injuries were treated with partial debridement when required. No further treatment on cartilage lesions was performed. Postoperative rehabilitation was the same in every case. The International Knee Documentation Committee (IKDC) objective grade, Lysholm score, and Knee injury and Osteoarthritis Outcome Score (KOOS) were assessed before and after surgery, and the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) score was recorded during the final follow-up. Postoperative incidence of osteoarthritis was evaluated on weightbearing radiographs during final follow-up, and anteroposterior laxity was measured pre- and postoperatively with the use of stress radiographs.

RESULTS

Twelve patients with mean age (±SD) of 61.0 ± 1.4 years at the time of surgery were included. They were followed-up for a mean period of 49.6 ± 24.0 months. Eight patients had associated meniscal tears, and 6 patients had International Cartilage Repair Society stage 1 or 2 chondral lesions. Preoperatively, the objective IKDC grades were B in 4 patients, C in 5, and D in 3. After surgery, the IKDC grades were A in 4 patients, B in 7, and grade C in 1. The mean subjective IKDC and Lysholm scores were a respective 43.4 ± 8.4 and 55.7 ± 12.4 preoperatively and 83.8 ± 9.4 and 93.2 ± 9.0 at the final follow-up ( P < .05). Ten patients (83%) reported recovery of sports activities, with 6 patients (50%) reaching the same level as before injury. The mean ACL-RSI score was 76.2%. Preoperatively, 50% (n = 6) of patients had Ahlbäck stage 1 medial compartment arthritis, versus 58% (n = 7) at the final follow-up ( P = nonsignificant). The side-to-side difference in anterior tibial translation on stress radiographs was 7.2 ± 6.4 mm preoperatively and 1.9 ± 4.3 mm postoperatively ( P < .05). No major complications were reported.

CONCLUSION

ACL reconstruction in active patients older than 60 years without arthritis restored knee stability in all treated cases. In these patients, as in younger age groups, ACL reconstruction showed good results on functional recovery while not increasing the risk of midterm functional knee deterioration or evolution of knee arthritis. The majority of patients returned to activities at their preinjury level. These data show that older and active patients with nonarthritic ACL-deficient knees need not be excluded from surgical treatment.

Prospective Clinical and Radiographic Outcomes After Concomitant Anterior Cruciate Ligament Reconstruction and Meniscal Allograft Transplantation at a Mean 5-Year Follow-up

BACKGROUND

Concomitant anterior cruciate ligament reconstruction and meniscal allograft transplantation (ACLR/MAT) has demonstrated short-term success in small, retrospective cohort studies. Patient- and disease-specific predictors of success after ACLR/MAT are largely unknown.

PURPOSE

To (1) prospectively evaluate the subjective and objective clinical and radiographic outcomes after ACLR/MAT and (2) conduct a subgroup analysis to identify patient- or disease-related factors that correlate with failure.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Patient-reported outcomes (PROs) were prospectively collected on 40 patients undergoing concomitant ACLR/MAT. Nineteen athletes responded to return-to-sport data. Clinical data (physical examination including Lachman and pivot-shift testing and KT-1000 arthrometer testing) were obtained on 28 patients who returned for an evaluation, while 24 of those patients additionally had radiographic data (progression of Kellgren-Lawrence [KL] grade and joint-space narrowing) evaluated. Reoperations and failures were documented for all patients at their final follow-up.

RESULTS

The overall cohort of 40 patients had a mean age of 30.3 ± 9.6 years (range, 16.0-54.0 years) and a mean body mass index of 27.7 ± 4.2 kg/m². The mean follow-up time was 5.7 ± 3.2 years (range, 1.7-16.5 years). There were 33 (83%) medial meniscal transplants performed compared with 7 (17%) lateral meniscal transplants. Patients underwent a mean of 2.9 ± 1.9 prior surgical procedures. Nineteen patients underwent concomitant procedures, including, most commonly, 9 hardware removals and 9 osteochondral allografts. There were significant improvements in 11 of 14 PRO measures as well as a 50% return-to-sport rate. Knee stability significantly improved in 28 patients who returned for a physical examination, and KT-1000 arthrometer testing indicated no differences between the affected and unaffected sides at final follow-up (mean, 0.9 ± 1.5 mm [range, -2 to 4 mm] in comparison to contralateral knee at 30 lb of testing; mean, 0.9 ± 1.9 mm [range, -4 to 4 mm] in comparison to contralateral knee at maximum manual strength). Significant improvements were seen in patients with Lachman grade ≥2A at final follow-up (18% vs 97%, respectively; P < .01) and with pivot shift ≥1+ at final follow-up (36% vs 94%, respectively; P < .01) compared with preoperatively. For the 24 patients with radiographic data, no significant joint-space decrease was recorded in the medial compartment for medial MAT-treated patients or the lateral compartment for lateral MAT-treated patients. The mean KL grade increased from 0.7 ± 0.8 to 1.6 ± 0.9 at final follow-up ( P < .01). There were no major (0%) and 2 minor (5%) complications, which constituted early postoperative drainage treated successfully with oral antibiotics. While 35% of patients underwent reoperations, the majority of these were simple arthroscopic debridements and occurred after nearly 4 years from the index surgery. The overall survival rate at final follow-up was 80%. Failures occurred at a mean of 7.3 years, and those who converted to arthroplasty did so at a mean of 8.3 years from the time of index ACLR/MAT. Patients with failed grafts were more frequently associated with workers' compensation claims (38% vs 13%, respectively) and less frequently self-identified as athletes (13% vs 56%, respectively) compared with patients with intact grafts.

CONCLUSION

Concomitant ACLR/MAT can provide significant improvements in clinical outcomes and enhancement in objective knee stability and was associated with an insignificant degree of radiographic joint-space narrowing changes with a 5-year survivorship of more than 80% for those with data available. Athlete status may be a preoperative predictor of midterm survival.

How Are We Measuring Patient Satisfaction After Anterior Cruciate Ligament Reconstruction?

BACKGROUND

Reconstruction of the anterior cruciate ligament (ACL) is one of the most common orthopaedic operations in the United States. The long-term impact of ACL reconstruction is controversial, however, as longer term data have failed to demonstrate that ACL reconstruction helps alter the natural history of early onset osteoarthritis that occurs after ACL injury. There is significant interest in evaluating the value of ACL reconstruction surgeries.

PURPOSE

To examine the quality of patient satisfaction reporting after ACL reconstruction surgery.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review of the MEDLINE database was performed using the PubMed interface. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines as well as the PRISMA checklist were employed. The initial search yielded 267 studies. The inclusion criteria were: English language, US patient population, clinical outcome study of ACL reconstruction surgery, and reporting of patient satisfaction included in the study. Study quality was assessed using the Newcastle-Ottawa scale.

RESULTS

A total of 22 studies met the inclusion criteria. These studies comprised a total of 1984 patients with a mean age of 31.9 years at the time of surgery and a mean follow-up period of 59.3 months. The majority of studies were evidence level 4 (n = 18; 81.8%), had a mean Newcastle-Ottawa scale score of 5.5, and were published before 2006 (n = 17; 77.3%); 5 studies (22.7%) failed to clearly describe their method for determining patient satisfaction. The most commonly used method for assessing satisfaction was a 0 to 10 satisfaction scale (n = 11; 50.0%). Among studies using a 0 to 10 scale, mean satisfaction ranged from 7.4 to 10.0. Patient-reported outcome and objective functional measures for ACL stability and knee function were positively correlated with patient satisfaction. Degenerative knee change was negatively correlated with satisfaction.

CONCLUSION

The level of evidence for studies reporting patient satisfaction is low, and the methodologies for reporting patient satisfaction are variable. Additionally, within the past decade there has been a significant decline in the inclusion of this outcome measure within published ACL studies. As sports surgeons are increasingly called on to demonstrate the value of operative procedures, attention should be paid to understanding and reporting patient satisfaction.

Does meniscus removal affect ACL-deficient knee laxity? An in vivo study

PURPOSE

The purpose of the present study was to determine, in vivo, the effect of different types of meniscectomy on an ACL-deficient knee.

METHODS

Using a computer-assisted navigation system, 56 consecutive patients (45 men and 11 women) were subjected to a biomechanical testing with Lachman test (AP30), drawer test (AP90), internal/external rotation test, varus/valgus rotation test and pivot-shift test. The patients were divided into three groups according to the status of the medial meniscus. Group BH, 8 patients with bucket-handle tear of medial meniscus underwent a subtotal meniscectomy; Group PHB, 19 patients with posterior horn body of medial meniscus tear underwent a partial meniscectomy; and Group CG with isolated ACL rupture, as a control group, with 29 patients.

RESULTS

A significant difference in anterior tibial translation was seen at 30 grades and in 90 grades between BH and PHB groups compared to the CG. In response to pivot-shift test, no significant differences in terms of AREA and POSTERIOR ACC were found among the three groups (n.s). Concerning the anterior displacement of the pivot shift a statistically significant differences among the three tested groups was found.

CONCLUSION

The present study shows that meniscal defects significantly affect the kinematics of an ACL-deficient knee in terms of anterior tibial translation under static and dynamic testing.

Concomitant Arthroscopic Meniscal Allograft Transplantation and Anterior Cruciate Ligament Reconstruction

In recent decades, arthroscopic meniscal allograft transplantation (MAT) has been refined as a robust option for the treatment of evolving unicompartmental tibiofemoral arthrosis in the setting of meniscal deficiency. It is imperative that the MAT be performed in a knee with anatomic stability and alignment to reduce aberrant biomechanical forces experienced by the allograft tissue to maintain its durability. Thus, in an anterior cruciate ligament (ACL)-deficient knee, ACL reconstruction (ACLR) must be performed to restore the stable knee environment for the MAT to succeed. Although these operations can be performed in staged fashion, a single-stage procedure with concomitant MAT and ACLR is an option. Its performance is technically demanding and requires careful consideration as to the intraoperative setup, incisions, graft options, surgical tools, and procedural order to properly secure the transplanted meniscal allograft and restore a functional, anatomic ACL. We present our preferred technique for concomitant arthroscopic MAT and ACLR, as well as some potential pitfalls and pearls to avoid pitfalls.

Long-term Survivorship and Function of Meniscus Transplantation

BACKGROUND

Clinical outcomes and survivorship of meniscus transplants remain unclear, especially when magnetic resonance imaging (MRI) and weightbearing radiographic findings are included as endpoints. Many studies calculate survivorship based only on subsequent operative procedures.

PURPOSE

We prospectively determined long-term survivorship and functional outcomes of 72 consecutive meniscus transplants. The effects of articular cartilage damage, concurrent osteochondral autograft transfer (20 knees), patient age, and tibiofemoral compartment were evaluated.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

The long-term function and survival rates of 69 of 72 consecutive medial and lateral bone-meniscus-bone transplants (96% follow-up) were determined. Survival endpoints of reoperations, MRI failure (grade 3 signal intensity, extrusion >50% of meniscal width), meniscal tear on examination, and radiographic loss of joint space provided a worst-case outcome. Long-term functional analysis was performed in 58 transplants a mean of 11.9 ± 3.2 years postoperatively. The Cincinnati and International Knee Documentation Committee rating systems were used to evaluate outcomes.

RESULTS

For all transplants, the estimated probability of survival was 85% at 2 years, 77% at 5 years, 69% at 7 years, 45% at 10 years, and 19% at 15 years. There were significant improvements for pain, swelling, walking, stair climbing, and patient knee rating (P < .05). Further surgery was performed in 37 cases. Knees that had concurrent osteochondral autograft transfer had significantly lower survival rates beginning at the seventh postoperative year; however, there was no significant difference in the long-term symptom, function, and patient perception scores between these knees and the rest of the cohort. The factors of articular cartilage damage (grade 2B/3 vs none), patient age (<30 years vs 30-49 years), and tibiofemoral compartment (medial vs lateral) had no significant effect on the survival, symptom, or functional analyses.

CONCLUSION

A survival analysis that includes reoperations, MRI, radiographs, and a comprehensive examination provides a worst-case but realistic analysis of transplant function. Many patients experienced a short- and long-term benefit of reduced symptoms and improved function. However, meniscus transplants undergo a deleterious remodeling process and eventually fail. Patients should be advised that the procedure is not curative in the long term, and additional surgery will likely be required.

Meniscus tear surgery and meniscus replacement

OBJECTIVE

the menisci are easily injured and difficult to repair. The aim of this study was to analyze the current state of meniscal surgery aimed at preserving morphology and conserving the biomechanics of the knee to prevent joint degeneration.

METHODOLOGY

a search of the electronic medical literature database Medline was conducted, from http://www.ncbi.nlm.nih.gov/pubmed. The search was not limited by language. Candidate articles were identified by searching for those that included the keywords meniscus, surgery, suture, implant, allograft. The limits were included for clinical research and clinical trials. Basic research was not included. The studies selected were evaluated and classified in three different categories: basic science, reconstruction (suture and meniscectomy) and implants (scaffolds and allograft).

RESULTS

the consequences of meniscectomy performed at a young age can lead to a joint cartilage degeneration twenty years later. There are few surgical options for the repair of meniscal injuries in order both to preserve the meniscus and to ensure the long term survival of the knee joint, meniscectomy, repair, suturing the tear, or reconstruction, when a meniscal allograft or synthetic substitute is used to replace the meniscus, but the biomechanical properties of the native meniscus are not reproduced entirely by the scaffolds that exist today.

CONCLUSION

therapies that successfully repair or replace the meniscus are therefore likely to prevent or delay osteoarthritis progression.

Meniscal allograft transplantation. Part 2: systematic review of transplant timing, outcomes, return to competition, associated procedures, and prevention of osteoarthritis

PURPOSE

To provide a systematic review of the literature regarding five topics in meniscal allograft transplantation (MAT): optimal timing for transplantation, outcomes, return to competition, associated procedures, and prevention of osteoarthritis.

METHODS

A systematic literature search was conducted using the PubMed (MEDLINE), ScienceDirect, and EBSCO-CINAHL databases. Articles were classified only in one topic, but information contained could be reported into other topics. Information was classified according to type of study (animal, in vitro human, and in vivo human) and level of evidence (for in vivo human studies). Specific inclusion criteria were determined for the outcomes and prevention of osteoarthritis topics.

RESULTS

Twenty-four studies were finally included: two optimal timing, seven outcomes, three return to competitive sport, 16 MAT and associated procedures, and 5 MAT and prevention of osteoarthritis (some studies were categorized in more than one topic). These studies corresponded to 2 animal studies and 31 in vivo human studies (1 level II, 1 level III, and 29 level IV).

CONCLUSIONS

The principal conclusions were as follows: (a) there is no evidence to support that MAT has to be performed at the same time or immediately after meniscectomy to prevent development of postmeniscectomy syndrome; (b) MAT successfully improves symptoms, function, and quality of life at 7-to-14 years of follow-up (level IV evidence); (c) the overall failure rate (need for knee arthroplasty) is 10-29% at long-term follow-up; (d) MAT allows return to same level of competition in 75-85% of patients at short- to mid-term follow-up (only three studies level IV evidence with small sample size); (e) associated cartilage procedures or anterior cruciate ligament reconstruction to MAT does not worsen the results; (f) MAT may prevent progression of cartilage damaged at long-term follow-up, but may not prevent degeneration in previously healthy cartilage.

LEVEL OF EVIDENCE

Systematic review of level II-IV studies, Level IV.

Meniscal allograft transplantation in a symptomatic meniscal deficient knee: a systematic review

PURPOSE

The primary objective of this study was to perform an updated systematic review and meta-analysis of meniscal allograft transplantation using patient reported outcome measures at final follow-up as the outcome tool. The secondary objective was to provide an up to date review of the indications, associated procedures, operative technique, rehabilitation, failures, complications, radiological outcomes, and graft healing.

METHODS

Medline, Embase and CENTRAL databases, trials registries, and Web-of Science were searched for studies using pre-defined eligibility criteria. Included studies were reviewed with Lysholm, International Knee Documentation Committee (IKDC) and Tegner scores, failures and complications pooled. Studies were also qualitatively assessed.

RESULTS

There were 1,332 patients (1,374 knees) in 35 studies eligible for analysis. The mean follow-up was 5.1 years. Across all studies, Lysholm scores improved from 55.7 to 81.3, IKDC scores from 47.0 to 70.0, and Tegner activity scores from 3.1 to 4.7 between pre-operative and final follow-up assessments, respectively. The mean failure rate across all studies was 10.6% at 4.8 years, and complication rate was 13.9% at 4.7 years. There is a high risk of bias across the studies due to study design and missing outcomes.

CONCLUSION

Based on current evidence, meniscal allograft transplantation appears to be an effective intervention for patients with a symptomatic meniscal deficient knee. This should ideally be confirmed with a randomised controlled trial. There is not currently enough evidence to determine whether it is chondroprotective.

Preserving knee function following osteoarthritis diagnosis: a sustainability theory and social ecology clinical commentary

To sustain natural systems, there must be an ongoing balance between environmental, social, and economic considerations. A key element of sustainability theory is to identify the most vulnerable surroundings. The most vulnerable knee tissue is the articular cartilage as it is the last line of osteoarthritis (OA) defense. This tissue has a poor capacity for healing. Based on sustainability theory and social ecology concepts we propose that several key factors contribute to knee function preservation. Factors include health history, genetic predisposition, personal behaviors, and socio-environmental factors in addition to local-regional-global physiological system function. Addressing only some of these factors or any one factor in isolation may lead to less than optimal treatment effectiveness. The purpose of this commentary is to introduce a medical, surgical and rehabilitation management approach for patients with knee OA that considers more than physical function improvement. This approach also considers social, emotional, and environmental factors to better ensure patient satisfaction, fulfilled expectations and successful outcomes. A clinical care pathway is presented for a 57-year-old patient with medial compartment knee OA who is contemplating early arthroplasty versus a knee function preservation treatment approach. Early arthroplasty refers to high revision likelihood based on a minimum 15 year prosthesis life-expectancy.

Lateral meniscus allograft transplantation: clinical and anatomic outcomes after arthroscopic implantation with tibial tunnels versus open implantation without tunnels

Meniscus allograft transplantation (MAT) is used to treat patients with knee pain after total or subtotal meniscectomy. The graft can be inserted during open or arthroscopic surgery. The objectives are anatomic horn positioning and strong fixation to the bone and capsule of an appropriately sized graft.

HYPOTHESIS

Arthroscopic MAT with trans-tibial bone fixation ensures better mid-term functional outcomes and limits allograft extrusion.

PATIENTS AND METHODS

We conducted a retrospective single-centre study of 23 consecutive patients who underwent MAT between 2001 and 2010. Among them, 11 had open surgery and anchoring of the horns without tunnels and 12 had arthroscopically-assisted surgery with bony fixation of the horns through trans-tibial tunnels. The two groups were comparable at baseline. Mean follow-up was 66.1 months. Post-operative outcomes were assessed using the IKDC score and KOOS, standard radiographs of both knees, and either magnetic resonance imaging or computed arthrotomography. We measured joint space narrowing, meniscal extrusion in the sagittal and coronal planes; and the degree of cartilage coverage by the graft using an index developed for this study.

RESULTS

The overall failure rate was 17.4% (4/23, two cases each of complete and partial graft removal). Joint space narrowing increased by 28% versus the pre-operative value (P=0.009). IKDC and KOOS values were not significantly different between the two groups. Absolute meniscus extrusion was greater in the arthroscopy group (4mm vs. 3mm, P=0.03).

DISCUSSION

Osteoarthritis of the transplanted compartment is unavoidable. Open surgery is associated with less meniscal extrusion. The clinical outcomes are independent from the technique used. Other factors require investigation, including graft rehabilitation, quality peripheral suturing, and intermeniscal ligament reconstruction.

LEVEL OF EVIDENCE

IV, retrospective study.

Indications and limits of meniscal allografts

Meniscal allograft transplantation has emerged as a useful treatment for carefully selected patients. The aim of this review of meniscal allograft transplantation is to put this procedure into a clinical perspective. Since there still is a lack of consensus on how the success of meniscal transplantation should be evaluated it is difficult to compare study outcomes. Nevertheless, almost all studies report an increase in patient satisfaction and improvement in pain and function. Clinical and functional outcome is improved in the majority of patients. Progression of cartilage degeneration according to MRI and radiological criteria was halted in a number of patients, indicating a chondroprotective effect. Joint space narrowing is only significantly progressive at long-term follow-up. On magnetic resonance imaging, shrinkage is seen after some years, but more in lyophilized allografts. Second-look arthroscopy usually shows good healing to the capsule. Overall, the clinical results of this type of surgery are encouraging and long-lasting in a well selected patient population who suffered a total meniscectomy. Meniscal allografting appears to becoming the golden standard therapy for these type of patients.

Arthroscopic combined medial and lateral meniscus transplantation after double-tunnel, double-bundle anterior cruciate ligament reconstruction in the same knee

Meniscus transplantation in combination with anterior cruciate ligament (ACL) reconstruction has been used in the treatment of patients with meniscus and ACL deficiency. However, there have been no reports of arthroscopic surgery and the outcome of both medial and lateral meniscus allograft transplantation after double-tunnel, double-bundle ACL reconstruction. Herein, we report the case of a young male who received arthroscopic lateral and medial meniscectomy and ACL tibialis allograft reconstruction performed with the double-tunnel and double-bundle technique approximately 8 months after a knee injury. Approximately 4 months postoperatively he began to experience pain and weakness in the operated knee and subsequently underwent arthroscopic lateral and medial meniscus allograft transplantation in the same procedure. Second-look arthroscopy and magnetic resonance imaging revealed the meniscal allografts to have normal shape and the ACL grafts to be relatively intact at 18 and 30 months after surgery. His knee appeared stable and the range of motion was normal. Our hypothesis was that knee stability could reliably be restored with this combined procedure and the meniscal grafts and ACL graft could provide protection for each other. We suggest that medial and lateral meniscus allografts for one patient should be from the same donor. In the operation, attention must be paid to the direction of the bone tunnels used to fix the horns of the meniscal grafts to avoid communication with other tunnels in the tibial plateau.

Anterior cruciate ligament allograft surgery: underreporting of graft source, graft processing, and donor age

BACKGROUND

There has been much controversy regarding the effects of sterilization techniques and graft history on the structural integrity of allograft ligaments used in reconstruction of the anterior cruciate ligament. The purpose of this review was to comprehensively examine anterior cruciate ligament allograft studies published in the last decade to evaluate the extent to which tissue source, tissue processing techniques, and donor age are reported.

METHODS

The authors reviewed 202 articles published from 1999 through November 2009, of which 68 retrospective, prospective, biomechanical, and histology studies evaluating 4689 allografts were included.

RESULTS

The majority of studies do not accurately report key elements of graft history including tissue bank, processing or sterilization technique, or donor age. Underreporting was particularly prominent in clinical studies as compared with basic science studies. Limited reporting of allograft processing, allograft source, and donor age raises serious questions regarding the generalizability of published studies of allograft tissue for anterior cruciate ligament reconstruction. Conclusion/

CLINICAL RELEVANCE

Orthopaedic surgeons who use allograft tissue must understand the tissue treatments being used (ie, preservation methods, chemical and sterilization processes) to best inform their patients regarding the risks, benefits, and long-term outcomes when such tissues are used. A complete understanding of the implanted tissue, as well as surgeon and recipient demographics, is necessary to ensure appropriate and predictable long-term outcomes.

Twenty-six years of meniscal allograft transplantation: is it still experimental? A meta-analysis of 44 trials

PURPOSE

since the first meniscal allograft transplantation in 1984, thousands of patients with postmeniscectomy symptoms have been treated by allograft replacement. This study aims the collection, presentation and meta-analysis of published trials reporting outcomes of meniscal allograft transplantation to establish its safety and reproducibility.

METHODS

a literature search was conducted and the abstracts of all English-language trials with a more than 6 months' clinical, radiological and/or histological follow-up in human subjects were reviewed. Forty-four trials representing 1,136 grafts in 1,068 patients were analyzed. To assess the methodological quality of the collected data, original and modified Coleman methodology scores were determined for all included papers.

RESULTS

the outcomes of 678 medial and 458 lateral grafts in 613 male, 265 female and 190 nondefined patients with a mean age of 34.8 years were presented. The outcome was assessed using 12 scoring systems, 4 imaging modalities, second-look arthroscopy and/or histological analysis. Whatever the follow-up period and the scoring system used, patients continuously showed clinical improvement. The average original Coleman scores were 45.9 ± 8.4 (range 25-59). The average modified Coleman scores were 43.7 ± 9.1 (range 24-62).

CONCLUSIONS

all studies reported a continuously satisfactory outcome with restoration of working capacity in these active patients. The complication and failure rates are considered acceptable by all authors. Salvage procedures included osteotomy and arthroplasty without secondary difficulties. Meniscal allograft transplantation can be considered as safe and reliable for the treatment of refractory postmeniscectomy symptoms in selected patients.

LEVEL OF EVIDENCE

IV.

Meniscal allograft transplantation

PURPOSE

Meniscal allograft transplantation (MAT) has become an accepted treatment option for patients undergoing meniscectomy with recalcitrant pain in the corresponding compartment. Whether MAT can oppose cartilage degeneration is unclear. Our purpose was to perform a systematic review of available literature to answer the following: (1) Does MAT prevent advancing chondrosis? (2) Who is the ideal candidate for MAT? (3) What is the survival time for allograft in a stable knee? (4) Can MAT be successful when performed with concomitant procedures? (5) Is there an outcome difference between medial and lateral meniscal allograft transplants? (6) What is the expected function of a knee that has undergone MAT?

METHODS

Two authors performed a systematic review of the literature pertaining to MAT. Included in the review are studies with at least 2 years' follow-up, studies with validated outcome measures, and studies in which the allograft meniscal horns were secured with bony fixation.

RESULTS

We identified 14 clinical articles that satisfied our inclusion and exclusion criteria. Thirteen of the articles provided Level IV evidence, and one article provided Level III evidence.

CONCLUSIONS

MAT can result in alleviation of knee pain, improvement in knee function, and good patient satisfaction if performed in the optimal candidate. Improvements in both objective and subjective outcome measures were shown in relatively young patients without significant chondromalacia who underwent concomitant procedures for cartilage defects, limb malalignment, and/or knee instability. We detected no significant difference in outcomes when comparing medial and lateral meniscal allograft transplants. We detected no significant difference when comparing isolated MAT with MAT performed with concomitant procedures.

LEVEL OF EVIDENCE

Level IV, systematic review of Level III and IV studies.

The effect of medial meniscectomy and meniscal allograft transplantation on knee and anterior cruciate ligament biomechanics

PURPOSE

Our purpose was to evaluate the effect of meniscectomy and meniscal allograft transplant on anterior cruciate ligament (ACL) and knee biomechanics.

METHODS

A differential variable reluctance transducer was placed in the ACL of 10 human cadaveric knees to record strain. Tibial displacement from a neutral reference was recorded relative to the position of the femur. Testing was performed at 30 degrees, 60 degrees, and 90 degrees of knee flexion. Six cycles of anterior-posterior loads were applied to the limit of 150 N. After a testing cycle, a medial meniscectomy was performed and the testing cycle was repeated. A meniscal allograft transplant was performed, and a final testing cycle was conducted. ACL strain and tibial displacement in the meniscectomy and meniscal allograft states were compared with the intact-knee state.

RESULTS

Tibial displacement after meniscectomy significantly increased at all angles. The meniscal allograft transplant restored tibial displacement to normal values at 30 degrees and 90 degrees. ACL strain increased significantly after meniscectomy at 60 degrees and 90 degrees of flexion, and meniscal allograft transplant returned the strain values to normal at 60 degrees and 90 degrees.

CONCLUSIONS

In most cases medial meniscectomy produced a significant increase in tibial displacement relative to the femur, and meniscal allograft transplantation restored displacement values to normal. Meniscectomy increased ACL strain and meniscal allograft transplant restored strain values to normal in 2 of 3 tested flexion angles.

CLINICAL RELEVANCE

The absence of the medial meniscus exposes the ACL to increased strain, whereas meniscal allograft lowered the strain on the native ACL. This could have implications for those patients undergoing ACL reconstruction who have concomitant removal of the medial meniscus.

The role of anterior cruciate ligament reconstruction in the older patients, 55 years or above

Anterior cruciate ligament (ACL) deficiency can result in symptomatic functional instability of the knee regardless of the patient's age. We reviewed a single surgeon database of 908 ACL reconstructions carried out in the last 20 years for symptomatic instability. 14 patients were identified who were 55 years or above at surgery (mean: 60 years, range 55-75 years). Patients were evaluated clinically and with clinical outcome scoring and KT-1000 arthrometry assessment. 12 patients (86%) were available to attend for follow-up at a mean 9 years after ACL reconstruction. The median pre-injury Tegner score was 5.5 (range 1-7) and the median pre-operative Lysholm score was 33 (range 15-67). Initially, one patient had a good result but subsequently the patient undergone total knee replacement 5 years after ACL reconstruction. For the remainder, at the most recent review, the median Lysholm score had improved to 79 (range 43-100, P < 0.05) although it had deteriorated from the maximum achieved post-op score of 85.5 (range 53-100, P < 0.05); and the Tegner score had declined to 3 (range 1-5, P < 0.05). KT-1000 testing demonstrated a mean side-to-side difference improvement in laxity from 4.6 +/- 1.3 mm (range 3-7) to 1.5 +/- 1.2 mm (range 0-4, P < 0.05) and >2 mm difference in only one knee (for which it was known that the graft had failed at 11 years after ACL reconstruction). At review, the same knee was the only one that demonstrated a pivot shift. ACL reconstruction with autograft in the above-55 patient with minimal osteoarthritis is a safe procedure that returns stability to the knee and permits a return to a reasonable level of activity.

Meniscal allograft transplantation

Meniscal allograft transplantation has emerged as a treatment option for selected meniscus-deficient patients to restore normal meniscal function and forestall progressive joint degeneration. Contraindications include diffuse subchondral bone exposure, axial malalignment, and instability. However, a knee may be rendered suitable for meniscus transplantation if combined with chondral resurfacing, osteotomy, and/or ligament reconstruction. Although numerous studies have reported improved clinical outcomes with meniscal allograft transplantation, high-quality studies with control groups are lacking in the literature. This article describes the current indications, graft types and sizing, surgical techniques, and a review of the literature with a focus on the role of concomitant procedures.

The effect of anterior cruciate ligament reconstruction on kinematics of the knee with combined anterior cruciate ligament injury and subtotal medial meniscectomy: an in vitro robotic investigation

PURPOSE

The aims of this study were to determine: (1) the kinematic effect of subtotal medial meniscectomy on the anterior cruciate ligament (ACL)-deficient knee and (2) the effect of ACL reconstruction on kinematics of the knee with combined ACL deficiency and subtotal medial meniscectomy under anterior tibial and simulated quadriceps loads.

METHODS

Eight human cadaveric knees were sequentially tested using a robotic testing system under 4 conditions: intact, ACL deficiency, ACL deficiency with subtotal medial meniscectomy, and single-bundle ACL reconstruction using a bone-patellar tendon-bone graft. Knee kinematics were measured at 0 degrees, 15 degrees, 30 degrees, 60 degrees, and 90 degrees of flexion under an anterior tibial load of 130 N and a quadriceps muscle load of 400 N.

RESULTS

Subtotal medial meniscectomy in the ACL-deficient knee significantly increased anterior and lateral tibial translations under the anterior tibial and quadriceps loads (P < .05). These kinematic changes were larger at high flexion (>or=60 degrees) than at low flexion angles. ACL reconstruction in knees with ACL deficiency and subtotal medial meniscectomy significantly reduced the increased anterior tibial translation, but could not restore anterior translation to the intact level with differences ranging from 2.6 mm at 0 degrees to 5.5 mm at 30 degrees of flexion. ACL reconstruction did not significantly affect the medial-lateral translation and internal-external tibial rotation in the presence of subtotal meniscectomy.

CONCLUSIONS

Subtotal medial meniscectomy in knees with ACL deficiency altered knee kinematics, especially at high flexion angles. ACL reconstruction significantly reduced the increased tibial translation in knees with combined ACL deficiency and subtotal medial meniscectomy, but could not restore the knee kinematics to the intact knee level.

CLINICAL RELEVANCE

This study suggests that meniscus is an important secondary stabilizer against anterior and lateral tibial translations and should be preserved in the setting of ACL reconstruction for restoration of optimal knee kinematics and function.