Bucket-handle meniscal lesions: magnetic resonance imaging criteria for reparability

In-office needle arthroscopy is a cost-effective alternative for operating room diversion in medial meniscectomy: a financial analysis

BACKGROUND

In-office needle arthroscopy (IONA) has been described as a diagnostic alternative to magnetic resonance imaging (MRI) for intra-articular pathology. However, few studies have analyzed its impact on cost and wait times when used as a therapeutic intervention. The purpose of this study was to investigate the impact on cost and wait times associated with offering IONA for partial medial meniscectomy as an alternative to traditional operating room (OR) arthroscopy for patients with irreparable medial meniscus tears on MRI.

METHODS

Two models were created comparing the existing care pathway (current state) to a proposed future state utilizing IONA. Data sources were accounting data from an academically affiliated hospital in Canada and supplemented with literature values. A Monte Carlo simulation combined with DuPont analysis running 10,000 simulations was conducted to calculate the revenue, expenses, profits, and effect on surgical waitlists (i.e., throughput) between the states. Sensitivity analyses examined the influence of patient preference and revision rates on profit and throughput. Two-sample Student's t test was performed (p < .05).

RESULTS

An average of 198 (standard deviation (SD) 31) patients underwent arthroscopic meniscectomy or repair each year from 2016 to 2020. The IONA revision rate was calculated as 20.3%. Compared to the current state, annual expenses in the IONA pathway were significantly reduced ($266,912.68 versus $281,415.23, p < .0001), while improving throughput by 21.2% (3.54%). Sensitivity analysis revealed 10% of patients need to select IONA over traditional OR arthroscopy with the revision rate remaining below 40% for the proposed state profit to be higher than the current state.

CONCLUSIONS

IONA is a cost-effective alternative to traditional OR arthroscopy in patients undergoing partial medial meniscectomy. The next steps are to assess patients' perceptions of IONA as an alternative to traditional OR arthroscopy, and to carry out clinical trials to determine the efficacy, patient-reported outcome metrics, and complications of IONA.

The Reliability of 3-T Magnetic Resonance Imaging to Identify Arthroscopic Features of Meniscal Tears and Its Utility to Predict Meniscal Tear Reparability

BACKGROUND

The ability to predict meniscus tear reparability based on preoperative magnetic resonance imaging (MRI) is desirable for postoperative planning; however, the accuracy of predictive methods varies widely within the orthopaedic and radiology literature.

PURPOSE/HYPOTHESIS

The purpose was to determine if the higher resolution offered by 3-T MRI improves the accuracy of predicting reparability compared with previous investigations using 1.5-T MRI. Our hypothesis was that a higher field strength of 3-T MRI would result in improved reliability assessments and predictions of meniscus tear reparability compared with previous studies utilizing a 1.5-T MRI platform.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 2.

METHODS

A total of 44 patients who underwent meniscus repair were matched by age, sex, and body mass index to 43 patients who underwent partial meniscectomy. Overall, 2 orthopaedic surgeons and 2 musculoskeletal radiologists independently and blindly reviewed the preoperative MRI scans for all 87 patients. For each meniscus tear, reviewers evaluated the following criteria: tear pattern, tear length, tear distance from the meniscocapsular junction, tear thickness, and integrity of any inner meniscal fragment. The resultant data were then applied to 5 different approaches for predicting meniscal reparability.

RESULTS

The accuracy for all examined prediction methods was poor, ranging from 55% (3-point method) to 72% (classification tree method) among all reviewers. Interobserver reliability for examined criteria was also poor, with kappa values ranging from 0.07 (inner meniscal fragment status) to 0.40 (tear pattern).

CONCLUSION

MRI continues to be a poor predictor of meniscus tear reparability as assessed by arthroscopic criteria, even when using higher resolution 3-T scanners. Interobserver reliability in this setting can be poor, even among experienced clinicians.

Evidence-based Risk Stratification for Sport Medicine Procedures During the COVID-19 Pandemic

Orthopaedic practices have been markedly affected by the emergence of the COVID-19 pandemic. Despite the ban on elective procedures, it is impossible to define the medical urgency of a case solely on whether a case is on an elective surgery schedule. Orthopaedic surgical procedures should consider COVID-19-associated risks and an assimilation of all available disease dependent, disease independent, and logistical information that is tailored to each patient, institution, and region. Using an evidence-based risk stratification of clinical urgency, we provide a framework for prioritization of orthopaedic sport medicine procedures that encompasses such factors. This can be used to facilitate the risk-benefit assessment of the timing and setting of a procedure during the COVID-19 pandemic.

Arthroscopically Repaired Bucket-Handle Meniscus Tears: Patient Demographics, Postoperative Outcomes, and a Comparison of Success and Failure Cases

OBJECTIVE

To define patient demographics, preoperative, and intraoperative surgical variables associated with successful or failed repair of bucket-handle meniscal tears.

DESIGN

All patients who underwent arthroscopic repair of a bucket-handle meniscus tear at a single institution between May 2011 and July 2016 with minimum 6-month follow-up were retrospectively identified. Patient demographic, preoperative (including imaging), and operative variables were collected and evaluated. A Kaplan-Meier curve was generated to demonstrate meniscus repair survivorship.

RESULTS

In total, 75 patients (78 knees) with an average age of 26.53 ± 10.67 years met inclusion criteria. The average follow-up was 23.41 ± 16.43 months. Fifteen knees (19.2%) suffered re-tear of the repaired meniscus at an average 12.24 ± 9.50 months postoperatively. Survival analysis demonstrated 93.6% survival at 6 months, 84.6% survival at 1 year, 78.4% survival at 2 years, and 69.9% survival at 3 years. There was significant improvement from baseline to time of final follow-up in all patient-reported outcome (P < 0.05) except Marx score (P = 0.933) and SF-12 Mental Subscale (P = 0.807). The absence of other knee pathology (including ligament tear, contralateral compartment meniscal tear, or cartilage lesions) noted intraoperatively was the only variable significantly associated with repair failure (P = 0.024). Concurrent anterior cruciate ligament reconstruction (vs. no concurrent anterior cruciate ligament reconstruction) trended toward significance (P = 0.059) as a factor associated with successful repair.

CONCLUSIONS

With the exception of the absence of other knee pathology (including ligament tear, contralateral compartment meniscal tear, or cartilage lesions) noted intraoperatively, no other variables were significantly associated with re-tear. The results are relatively durable with 84.6% survival at 1 year. Surgeons should attempt meniscal repair when presented with a bucket-handle tear.

Using only MRI is moderately reliable in the prediction of meniscal tear reparability

PURPOSE

The purpose of this study was to evaluate the role of surgeons' experience with meniscal repairs and meniscectomy decisions, and to determine the factors affecting the disagreement between meniscal repairs and meniscectomy decisions.

METHODS

In total, 223 patients with meniscal tears, 106 meniscal repairs, and 117 meniscectomies were included. Six orthopedic surgeons (3: > 5 years; 3: < 5 years' arthroscopy experience) were blinded, and they independently reviewed all preoperative MR images for over a month. Their reviews were compared with arthroscopic interventions performed by a surgeon with > 10 years' arthroscopy experience. Reparability-associated factors were also evaluated using multivariate logistic regression.

RESULTS

The first and second evaluation results did not differ significantly between groups (n.s.). There was good agreement between MRI predictions and arthroscopic interventions for both groups (< 5 years' experience: k = 0.248, agreement 62.3%; > 5 years' experience: k = 0.351, agreement 67.3%). Sex, side, and distance of tear from the meniscocapsular junction were not significantly different between agreements and disagreements. Disagreement regarding meniscectomy was significantly higher than those regarding meniscus repair (p = 0.002). Concomitant anterior cruciate ligament (ACL) injury, osteochondral lesions, and medial meniscal tear increased the likelihood of meniscal repair (p = 0.0063, p = 0.0010, and p = 0.0369, respectively). An increased risk of disagreement between MRI and surgical procedure was found in the presence of bucket-handle, horizontal or complex tear, chronic tear, high sports activity and expectation level.

CONCLUSION

Surgeon's experience level may influence the prediction of meniscus reparability. Concomitant ACL injury, osteochondral lesions, and presence of medial meniscal tear increase the likelihood of meniscal repair. Tear type, tear chronicity, patient's activity and expectation level may influence the surgeon's operative decision in addition to MRI.

LEVEL OF EVIDENCE

III.

Role of MRI in predicting meniscal tear reparability

OBJECTIVE

To elucidate the role of MRI in predicting meniscal tear reparability according to tear type and location in relation to vascular zones.

MATERIALS AND METHODS

In this retrospective study, two readers evaluated 79 pre-surgical MRIs of meniscal tears arthroscopically treated with meniscectomy or meniscal repair. Tears were classified according to type into vertical, horizontal, radial, complex, flaps and bucket handle and were considered reparable if the distance measured from the tear to the menisco-capsular junction was less than or equal to 5 mm. Predictions were compared with the surgical procedure performed in arthroscopy. We assessed the diagnostic performance of MRI, agreement between MRI and arthroscopy, and interrater agreement. Then, we conducted an ROC analysis on the distances measured by the first reader and built a multivariate logistic regression model.

RESULTS

MRI had a sensitivity, specificity, PPV, NPV and accuracy, respectively, of 85%, 79%, 86%, 76% and 83% in predicting meniscal tear reparability. Correct predictions for the specific tear pattern were 76% for vertical, 84% for horizontal, 88% for radial, 86% for complex, 84% for flaps and 86% for bucket handle. Agreement between the two readers' predictions and arthroscopy was good (k = 0.65 and 0.61, respectively). Inter-rater agreement was almost excellent (k = 0.79). The ROC analysis revealed sensitivity and specificity of 73% and 83% with a cutoff value of <4 mm (p < 0.001). Anterior cruciate ligament injury and medial meniscal tear increased the likelihood of meniscal tear reparability.

CONCLUSIONS

MRI can be a reliable and accurate tool to predict the reparability of meniscal tears, with higher prediction rates for bucket-handle tears.

Spontaneous healing of a displaced bucket-handle tear of the lateral meniscus in a child

Bucket-handle tears less frequently occur in the lateral meniscus than in the medial meniscus. An 11-year-old male patient complained of painful swelling and locking due to a displaced bucket-handle tear of the lateral meniscus. We recommended an arthroscopic surgery; however, the patient left the hospital without surgical treatment. Six weeks afterwards, he returned without any complain of pain and he regained full range of motion. The final follow-up magnetic resonance imaging showed reduction of the torn meniscal fragment without any signal changes suggestive of a meniscal tear. We report a rare case of an isolated displaced bucket-handle tear of the lateral meniscus in an 11-year-old patient that healed spontaneously without surgical intervention.

Lateral meniscocapsular separation in patients with tibial plateau fractures: detection with magnetic resonance imaging

OBJECTIVE

This study aimed to retrospectively evaluate magnetic resonance imaging findings for the detection of lateral meniscocapsular separation (LMCS) in patients with tibial plateau fractures. We hypothesize that patients with LMCS have greater perimeniscal abnormal signal or greater distance between the lateral meniscus (LM) and the lateral collateral ligament (LCL) than patients without LMCS.

METHODS

The study group included 16 patients with LMCS and 11 patients with normal LMCS who underwent surgery due to tibial plateau fracture. Magnetic resonance images were assessed for the width of perimeniscal abnormal signals on 3 orthogonal planes. The distance between LM and LCL was measured on coronal images. Nonparametric tests were performed.

RESULTS

The thickness of perimeniscal abnormal signals was increased in the patient group than in control group (median, 10.00 [interquartile range, 9.00-12.70] mm vs 3.39 [2.45-3.67] mm at axial images [P < 0.001]; 8.60 [3.75-11.26] mm vs 2.73 [1.64-4.38] mm at coronal images [P = 0.015]; 13.57 [9.50-15.04] mm vs 4.65 [0-5.89] mm at sagittal images [P = 0.002], respectively). Sixteen patients in the patient group had involvement around the whole LM, whereas none of the patients in the control group had involvement around the whole LM (P < 0.001). The distance between LM and LCL was increased in the patient group than in the control group (9.00 [7.47-10.75] mm vs 5.11 [4.38-7.07] mm [P = 0.002], respectively). The cutoff value of 7 mm thickness of abnormal signal and distance between LM and LCL showed an accuracy of 96% (26/27 patients) and 85% (23/27 patients), respectively.

CONCLUSIONS

Patients with perimeniscal signal greater than 7 mm or distance between LM and LCL greater than 7 mm have high likelihood of LMCS.

Change of signal intensity in the displaced medial meniscus after its reduction on MRI

PURPOSE

To compare magnetic resonance (MR) signal intensity in the medial meniscus at the time of displacement and after its reduction in patients with a displaced bucket-handle tear of the meniscus associated with anterior cruciate ligament (ACL) injury.

METHODS

Nine chronic ACL-deficient patients (3 male, 6 female, mean age 29 years) with locking due to a displaced fragment of the medial meniscus following a bucket-handle tear were involved in this study. In all patients, the following two-stage surgeries were planned as follows: first operation, arthroscopic reduction of the meniscus; second operation, meniscal repair and ACL reconstruction after immobilization for 1-2 weeks. Magnetic resonance imaging (MRI) evaluation using coronal T2*-weighted images was performed when the knee was locked and after the meniscus was reduced. Signal intensity before and after meniscal reduction was compared in the same patients.

RESULTS

In 8 of the 9 patients, the displaced fragment exhibited high signal intensity in 1 patient and mildly high in 7 patients. After its reduction, the signal intensity changed to low in all 8 patients.

CONCLUSIONS

A high-intensity signal in the displaced fragment of the medial meniscus may change to low after its reduction to its original position. Therefore, at the time of decision-making regarding meniscus repair for a displaced meniscus in a locked knee, surgeons should give priority to arthroscopic findings rather than to signal intensity on MRI.

LEVEL OF EVIDENCE

Diagnostic study, Level III.

Bucket-handle meniscal tear in a 5-year-old child

Bucket-handle meniscus tears are a common athletic injury that occur frequently in the adult population but are extremely rare in young children. A 5-year-old male patient presented with left knee pain after a minor fall to the ground. Complaints of pain with full weight-bearing, locking of the joint during walking, a significant limp, 45° flexion contracture of the knee, and an inability to bring the leg into full extension were noted during examination. MRI showed a large bucket-handle medial meniscal tear. The patient made a full recovery after undergoing arthroscopic repair surgery. Level of evidence Case report, Level IV.

Can the reparability of meniscal tears be predicted with magnetic resonance imaging?

BACKGROUND

Historically, magnetic resonance imaging (MRI) has been very useful in diagnosing meniscal tears but not as valuable in predicting whether a meniscal tear is reparable. Given that several recent studies suggested that MRI can be used to predict tear reparability, the topic has resurfaced as a controversy in the orthopaedic and radiology literatures.

HYPOTHESIS

Experienced musculoskeletal radiologists can use MRI to predict the reparability of meniscal tears with good to excellent accuracy using the same arthroscopic criteria used by surgeons intraoperatively.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 3.

METHODS

Fifty-eight patients with meniscal tears treated with repair were matched by age and sex with 61 patients with tears treated with meniscectomy. Two senior musculoskeletal radiologists independently and blindly reviewed preoperative MRI of these 119 meniscal tears. Using established arthroscopic criteria, the radiologists were asked to grade each tear 0 to 4, with 1 point for each of the following: a tear larger than 10 mm, within 3 mm of the meniscosynovial junction, greater than 50% thickness, and with an intact inner meniscal fragment. Only a tear with a score of 4 would be predicted to be reparable.

RESULTS

The 2 radiologists' ability to correctly estimate reparability was poor, with 58.0% and 62.7% correct predictions (κ = 0.155 and 0.250, respectively). Interrater reliability assessment showed that the raters agreed on a score of 4 (reparable) versus <4 (not reparable) 73.7% of the time (κ = 0.434) but came to identical scores only 38.1% of the time (κ = 0.156). Determining the status of the inner fragment was the most predictive individual criterion and the only one to reach statistical significance (χ(2) = 14.9, P <.001).

CONCLUSION

Magnetic resonance imaging is not an effective or efficient predictor of reparability of meniscal tears with the current arthroscopic criteria.

Simultaneous bicompartmental bucket handle meniscal tears with a clinically competent Anterior Cruciate Ligament

Bucket handle meniscal tears (BHMT) of the knee occur infrequently (approximately 10% of meniscal injuries). Simultaneous, bicompartmental BHMT are extremely rare. Previously, these have only been reported in association with a ruptured anterior cruciate ligament (ACL). The pathomechanism of this injury was thought to be due to the lack of knee stability following the ACL injury. We present a case of a 38 year old male patient with bicompartmental BHMT with a clinically competent ACL. This highlights the need for clinical and radiological suspicion of simultaneous BHMTs even in the presence of an intact ACL.

Simultaneous bicompartmental bucket-handle meniscal tears with intact anterior cruciate ligament: a case report

Introduction

Bucket handle tear of the menisci is a common type of lesion resulting from injury to the knee joint. Bucket handle injury of both menisci in almost all cases is associated with a lesion to either the anterior or the posterior cruciate ligament of the knee joint. We describe a case of acute bucket-handle tear of the medial and lateral menisci with intact anterior and posterior cruciate ligaments in a dancer. To the best of our knowledge, there are no previous reports of this type of injury in the literature.

Case presentation

A 28-year-old Caucasian Greek woman presented to the emergency department after sustaining an injury to her right knee during dancing. An MRI evaluation demonstrated tears in both menisci of the right knee, while the anterior and posterior cruciate ligaments were found to be intact. A partial medial and lateral meniscectomy was then performed. At a follow-up examination six months after her injury, clinical tests demonstrated that our patient's right knee was stable, had a full range of motion and had no tenderness. She was satisfied with the outcome of the operation and returned to her pre-injury activities.

Conclusion

We present the first case in the literature that describes a combined bucket-handle injury of both the medial and lateral menisci with an intact anterior cruciate ligament. The clinical examination of the anterior cruciate ligament was unremarkable, with no signs of deficiency or rupture. The posterior cruciate ligament was also intact. On magnetic resonance imaging, the ligaments were visualised as intact in all their length. These findings were confirmed by arthroscopic evaluation.

Meniscal repair

The meniscus plays an important role in preventing osteoarthritis of the knee. Repair of a meniscal lesion should be strongly considered if the tear is peripheral and longitudinal, with concurrent anterior cruciate ligament reconstruction, and in younger patients. The probability of healing is decreased in complex or degenerative tears, central tears, and tears in unstable knees. Age or extension of the tear into the avascular area are not exclusion criteria. Numerous repair techniques are available, and suture repair seems to provide superior biomechanical stability. However, the clinical success rate does not correlate well with the mechanical strength of the repair technique. Biologic factors might be of greater importance to the success of meniscal repair than the surgical technique. Therefore, the decision on the most appropriate repair technique should not rely on biomechanical parameters alone. Contemporary all-inside repair systems have decreased the operating time and the level of surgical skill required. Despite the ease of use, there is a potential for complications because of the close proximity of vessels, nerves, and tendons, of which the surgeon should be aware. There is no clear consensus on postoperative rehabilitation. Weight bearing in extension would most likely not be crucial in typical longitudinal lesions. However, higher degrees of flexion, particularly with weight bearing, give rise to large excursions of the menisci and to shear motions, and should therefore be advised carefully. Long-term studies show a decline in success rates with time. Further studies are needed to clarify the factors relevant to the healing of the menisci. Tissue engineering techniques to enhance the healing in situ are promising but have not yet evolved to a practicable level.

Second-look arthroscopic evaluation of bucket-handle meniscus tear repairs with anterior cruciate ligament reconstruction: 67 consecutive cases

PURPOSE

To evaluate arthroscopic second-look bucket-handle meniscus tear (BHMT) repairs using different suturing techniques.

METHODS

Between May 2002 and September 2006, 122 consecutive cases underwent arthroscopic repair surgery, including 40 males and 24 females (63 with concurrent anterior cruciate ligament [ACL] injury and 1 isolated BHMT) having 67 (60 medial and 7 lateral) repairs available for second-look arthroscopy evaluation. Inclusion criteria for reparability included reducible tears involving red-red and red-white zone without obvious additional complex tears and tissue degeneration, and concurrent ACL injury and/or isolated BHMT. Patients were excluded if they had combined ligaments injuries other than ACL. The arthroscopic suturing techniques, classified according to different involvement of meniscus zones, consisted of typical inside-out and all-inside suture repair with suture hook.

RESULTS

In a series of 64 second-look cases with 67 repairs, which showed healing after an average of 26 months (range, 14 to 66 mos), 55 repairs (82.1%) were completely healed (and clinically asymptomatic) in 53 cases; 5 cases (5 repairs; 7.5%) had joint line tenderness (incompletely healed and clinically asymptomatic); and 7 repairs (6 medial, and 1 lateral; 10.4%) failed, with recurrent locking or catching in 4 cases (and clinically asymptomatic in 2 cases). The overall success rate, including completely healed and incompletely healed cases, was 89.6%. Four failures occurred in failed ACL-reconstructed knees.

CONCLUSIONS

For large bucket-handle meniscus tears involving red-red and red-white zones, an arthroscopic hybrid suture technique with ACL reconstruction achieves high anatomic healing results, with an overall meniscal healing rate of 89.6%, including 82.1% completely healed and 7.5% incompletely healed. The failure rate was 10.4% in the average 26-month follow-up period.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Magnetic resonance imaging as a tool to predict reparability of longitudinal full-thickness meniscus lesions

Prediction of meniscus reparability is useful for surgeons to optimise surgical scheduling and to inform patients about postoperative management. This study was designed to determine the accuracy of MRI in predicting the reparability of longitudinal full-thickness meniscus lesions. We studied 100 MRIs of longitudinal full-thickness medial or lateral meniscus lesions located from the meniscosynovial junction to the axial part of the meniscus. The MRI criteria of reparability were a peripheral rim smaller than 4 mm and a lesion longer than 10 mm. At arthroscopy the menisci were considered as reparable when the lesion was located in red-red or red-white zones and when it was more than 1 cm in length. A heterogeneous or homogeneous aspect of the meniscus body was also considered. The length of the meniscus lesion averaged 17.6 mm and the thickness of the rim 3.4 mm. A heterogeneous signal of the axial fragment and of the rim was found in 11 cases and in 48 cases, respectively. In 90 cases, there was no difference between the MRI-predicted reparability and the arthroscopic findings. Global sensitivity of MRI to determine reparability of full-thickness meniscus lesions was 94%, increasing to 96% for the medial meniscus and dropping to 83% for the lateral meniscus. Global specificity was 81%, and was higher for the lateral meniscus (90%) than for the medial one (82%). Global positive predictive value was 0.94 and global negative predictive value was 0.82. A heterogeneous aspect of the rim did not compromise arthroscopic reparability whereas a heterogeneous aspect of the axial fragment indicated an irreparable meniscus. The described MRI criteria can predict meniscus reparability. Their accuracy is limited for lateral meniscus lesions close to the popliteal hiatus and for very young active patients in whom repair of white-white lesions can be attempted. Longitudinal full-thickness meniscus lesions are a good indication for repair in young active patients.