Arthroscopic pullout suture repair of posterior root tear of the medial meniscus: radiographic and clinical results with a 2-year follow-up

Lateral meniscus posterior root repairs show superior healing, reduced meniscal extrusion and improved clinical outcomes compared to medial meniscus posterior root repairs: A systematic review

PURPOSE

To systematically review and summarize the available literature on (1) postoperative healing rates, meniscal extrusion (ME) and clinical outcomes following lateral (LMPRR) versus medial (MMPRR) root repair and (2) potential correlations between residual ME and healing outcomes.

METHODS

A comprehensive literature search was conducted using the Scopus, PubMed and Embase databases. Clinical studies evaluating healing status on second-look arthroscopy and magnetic resonance imaging (MRI) after LMPRR and MMPRR were included. Study quality was assessed using the Methodological Index for Non-Randomized Studies criteria and the modified Coleman Methodology Score.

RESULTS

Twenty-three studies comprising 871 patients with LMPRR (n = 406) and MMPRR (n = 465) were included. Overall, 223 (54.9% of total) and 149 (32.04% of total) patients underwent second-look arthroscopy in the LMPRR and MMPRR groups, respectively. Complete root healing was observed in 190 (85.2%) patients in the LMPRR group versus 78 (52.3%) in the MMPRR group (p < 0.001). There were six (2.7%) failed repairs in the LMPRR group compared to 21 (14.09%) in the MMPRR group (p < 0.001). On postoperative MRI, 109 (75.7%) root repairs were healed in the LMPRR group compared to 192 (53.3%) in the MMPRR group (p < 0.001). Failure rates were lower after all-inside and transtibial pullout repairs in the LMPRR group but higher in the MMPRR group, with no significant mean difference between preoperative and postoperative ME in the MMPRR group (p = 0.95). Significantly better clinical outcomes were observed in the LMPRR group compared to the MMPRR group. A greater degree of postoperative ME was associated with lower healing rates (R = -0.78, p < 0.0005). Postoperative ME did not influence clinical outcomes (R = 0.28, p = 0.29).

CONCLUSIONS

Lateral meniscus posterior root repairs showed higher healing rates compared to MMPRR on both second-look arthroscopy and postoperative MRI. Meniscal extrusion decreased after LMPRR but not after MMPRR. Greater residual ME correlated inversely with healing rates, as more extrusion was associated with lower healing. Postoperative clinical improvement did not affect ME or healing status.

STUDY DESIGN

Systematic review of level III and IV studies.

LEVEL OF EVIDENCE

Level IV.

Biomechanical evaluation of the effect of arthroscopic suture passing instruments on the posterior meniscal root

BACKGROUND

The study aimed to biomechanically evaluate the effect of arthroscopic suture passing instruments used in the treatment of meniscal root tears on the meniscal suture interface in the root region.

METHODS

A total of 40 intact lateral menisci, obtained during total knee arthroplasty, were procured for the purpose of conducting a biomechanical study. The menisci were randomly assigned to one of two distinct test groups: Group 1 using the Accu-Pass Suture Shuttle (cannulated) and Group 2 using the First-pass Mini Suture Passer (non-cannulated), with each group consisting of n = 20 samples. Maximum failure load, stiffness, and displacement values were obtained using a uniaxial universal tensile testing machine.

RESULTS

When the groups were compared in terms of average maximum failure load (Group 1: 152.5N ± 50.7, Group 2: 162.5N ± 54.4), no statistically significant difference was observed (P = 0.549). At the moment of maximum failure load, the displacement values of both groups were similar (P = 0.502). In the comparison conducted for both groups in terms of preconditioning and postconditioning stiffness, no significant difference was detected between groups (P-values were 0.252 and 0.210, respectively).

CONCLUSION

In our study, the tissue laceration size created by suture passers at the meniscus-suture interface within the root region was indirectly tested based on the influence of tensile forces. Both suture passers (cannulated and non-cannulated) are similar in terms of maximum failure load, stiffness, and displacement amounts. This study indicates that there is no difference between suture passers for root tears and supports the usability of both methods during surgery.

Posterior Meniscus Root Repair Using a Retensionable Knotless All-Suture Anchor

Meniscus root injuries lead to increased tibiofemoral contact pressures and rapid progression of osteoarthritis. Early recognition and treatment with a meniscal root repair can restore biomechanics and help preserve the joint. The transtibial pullout repair and suture anchor repair are the most commonly used techniques to achieve anatomic fixation of the meniscal root. Still, each method presents distinct advantages and disadvantages. This Technical Note aims to describe a vastly simplified, more efficient, and reproducible posterior lateral meniscal root repair using a retensionable knotless all-suture anchor.

Degenerative medial and lateral menisci root tears: demographics, clinical presentation, imaging features, and associated findings

PURPOSE

(I) Characterize the demographics and clinical features of patients with meniscal root tears (MRT); (II) analyze the morphology, extent, and grade of MRT on MRI; (III) evaluate associated abnormalities on imaging; and (IV) evaluate the associations between imaging findings, demographics, clinical features, and joint structural abnormalities.

MATERIAL AND METHODS

A search was performed to identify meniscal root tears. Age, sex, BMI, and pain were recorded. Knee radiographs and MRI were reviewed. Presence, grade and morphology of MRT, meniscal extrusion, insufficiency fractures, as well as joint structural abnormalities were scored. For goals (I), (II), and (III), tabulations for categorical variables and mean for continuous variables were computed. MRT findings variables were described using percentages. For goal (IV), adjusted linear and logistic regression were employed.

RESULTS

Ninety-six patients with a mean age of 56.6 years (69 females) and mean BMI of 28.9 kg/m2 were included; 88 of the MRT were located at the posterior horn of the medial meniscus (PHMM), and 82% were radial tear. The mean tear diameter was 3.8 mm, and 78/96 tears presented with meniscal extrusion. Nineteen patients presented with subchondral insufficiency fracture (SIF), which was significantly associated with the gap of the tear (p = 0.001) and grade of the meniscal root lesion (p = 0.005).

CONCLUSION

MRT typically found in middle-aged to older overweight and obese women. Lesions were mostly radial tears and located at PHMM and were frequently associated with meniscal extrusion and SIF. Moreover, the presence of SIF was significantly associated with the gap width and grade of root tear.

Satisfactory Clinical Outcome, Complications, and Provisional Results of Meniscus Centralization with Medial Meniscus Root Repair for the Extruded Medial Meniscus at Mean 2-Year Follow-Up

PURPOSE

To describe the patient-reported clinical outcomes following medial meniscus root repair with meniscus centralization and to identify common complications and detail provisional results.

METHODS

Patients undergoing medial meniscus root repair with meniscus centralization from 2020 to 2022 were identified using an institutional database. Patients were followed prospectively using postoperative Tegner Activity Scale, visual analog scale (VAS) for pain, Knee Injury and Osteoarthritis Outcome Score, Joint Replacement, International Knee Documentation Committee score, and a Likert score for improvement, surgery satisfaction, and subsequent surgeries at minimum 1-year follow-up with mean 2-year follow-up. Demographics, injury characteristics, and surgical details were also collected.

RESULTS

Twenty-five patients (age: 50 ± 11 years; sex: 76% female; body mass index: 33 ± 8) were included in this study. Postoperative Tegner score was maintained at preoperative levels (P = .233), and VAS at rest, VAS with use, Knee Injury and Osteoarthritis Outcome Score, Joint Replacement, and International Knee Documentation Committee improved significantly postoperatively (P = .003; P < .001, P < .001, P = .023, respectively). Eighty-eight percent of patients reported subjective improvement in their knee at final follow-up. Postoperative radiographs did not show any significant osteoarthritis progression, and no patients had undergone a revision meniscus surgery or total knee arthroplasty at the time of follow-up.

CONCLUSIONS

At minimum 1-year follow-up and mean 2-year follow-up, patients undergoing medial meniscus root repair with meniscus centralization demonstrated significant postoperative improvements in pain, function, and quality of life and reported high rates of surgery satisfaction. There was no evidence of significant arthritic progression on postoperative imaging, and no patients underwent revision meniscus surgery or total knee arthroplasty.

LEVEL OF EVIDENCE

Level IV, case series.

Age influence on resistance and deformation of the human sutured meniscal horn in the immediate postoperative period

Introduction: To preserve knee function, surgical repair is indicated when a meniscal root disinsertion occurs. However, this surgery has not yet achieved complete recovery of the joint´s natural biomechanics, with the meniscus-suture interface identified as a potentially determining factor. Knowing the deformation and resistance behavior of the sutured meniscal horn and whether these properties are preserved as the patient ages could greatly contribute to improving repair outcomes. Methods: A cadaveric experimental study was conducted on human sutured menisci classified into three n = 22 age groups (young ≤55; 55 < middle-aged ≤75; 75 < old) were subjected to load-to-failure test by suture pulling. Meniscal thickness at the suture hole was measured and the applied traction force and tissue deformation in the suture area in the direction of traction were recorded during the test. The traction load that initiated the meniscal cut-out, F c , maximum load borne by the meniscus, F u , tissue stress at the cut-out initiation, S c , and equivalent stiffness modulus at the suture area, m s , were calculated. Results: At the tissue level, the resistance in terms of S c decrease with age (young: 47.2 MPa; middle-aged: 44.7 MPa; old: 33.8 MPa) being significantly different between the young and the old group (p = 0.015). Mean meniscal thickness increased with age (young: 2.50 mm; middle-aged: 2.92 mm; old: 3.38 mm; p = 0.001). Probably due to thickening, no differences in resistance were found at the specimen level, i.e., in F c (overall mean 58.2 N) and F u (overall mean 73.6 N). As for elasticity, m s was lower in the old group than in the young group (57.5 MPa vs. 113.6 MPa, p = 0.02) and the middle-aged one (57.5 MPa vs. 108.0 MPa, p = 0.04). Conclusion: Regarding the influence of age on the sutured meniscal horn tissue, in vitro experimentation revealed that meniscal horn specimens older than 75 years old had a more elastic tissue which was less resistant to cut-out than younger menisci at the suture hole area. However, a thickening of the meniscal horns with age, which was also found, leveled out the difference in the force that initiated the tear, as well as in the maximum force borne by the meniscus in the load-to-failure test.

Rehabilitation after Repair of Medial Meniscus Posterior Root Tears: A Systematic Review of the Literature

Background

There is no consensus established on postoperative rehabilitation after medial meniscus posterior root tear (MMPRT) repair, including when and how physicians can apply range of motion (ROM) exercise, weight-bearing (WB), brace use, and return to sports (RTS). The purpose of this study was to systematically review the literature on postoperative rehabilitation characteristics of MMPRT repair regarding ROM, WB, brace use, and RTS.

Methods

A literature search was performed using the Medline/PubMed, Cochrane Central Register of Controlled Trials, and Embase databases. The inclusion criteria were English language, human clinical studies, and studies describing rehabilitation protocols after MMPRT repair such as ROM, WB, brace use, and RTS. Abstracts, case reports, cohort studies, controlled laboratory studies, human cadaveric or animal studies, systematic reviews, and meta-analyses were excluded.

Results

Thirteen studies were included. Of the 12 ROM studies, ROM was started immediately within 1 or 2 days after operation in 6 studies and after 2 to 3 weeks of knee immobilization in the rest. Of the 13 WB studies, partial weight-bearing was initiated 1 to 4 weeks after operation in 8 studies and 6 weeks in the rest. Of the 9 brace studies, patients were immobilized by a splint for 2 weeks in 3 studies, and in the rest, a brace with full extension was applied for 3 to 6 weeks after several days of splint application. Of the 7 RTS studies, RTS was allowed at 6 months in 6 studies and 5 to 7 months in 1 study.

Conclusions

This systematic review revealed conservative rehabilitation protocols were more widely adapted as ROM and WB were restricted at certain degrees during postoperative periods in most protocols analyzed. However, it is impossible to identify a consensus on rehabilitation protocols as the protocols analyzed in this review were distinct each other and heterogeneous. In the future, a well-designed comparative study among different rehabilitation protocols is essential to establish a consensus.

Comparison of medial tibiofemoral joint mechanics between all-suture anchors and transtibial pullout technique for posterior medial meniscal root tears

BACKGROUND

The posterior medial meniscal root tear (PMMRT) seriously impacts the tibiofemoral joint biomechanics. Two available techniques for PMMRT repair include the transtibial pullout (TPO) repair and all-suture anchor (ASA) repair techniques. These techniques have not been compared biomechanically.

METHODS

A total of 20 fresh porcine cadaveric knee specimens were used. All 20 knees were randomly and evenly distributed into four groups (five specimens per group): (1) intact posterior meniscal root, (2) PMMRT, (3) TPO repair technique for PMMRT, and (4) ASA repair technique for PMMRT. The tibiofemoral contact mechanics were investigated using a pressure sensor. All knee specimens were tested by being loaded with 600 N axial compressive force at three different flexion angles (0°, 45°, and 90°). The contact surface area, contact pressure, peak pressure, and time-zero displacement were recorded.

RESULTS

The PMMRT caused a significant decrease in contact surface area, an increase in contact pressure, and peak pressure from the reference values observed in the intact meniscus group (P = 0.05, 0.016, and 0.008, respectively). After fixation, no significant difference was observed between the ASA and intact group. Meanwhile, significant differences were found between the TPO and intact group in terms of contact surface area, contact pressure, and peak pressure. In the comparison between the two techniques, the ASA group demonstrated higher contact surface area than the TPO group at the average knee flexion angle (p = 0.05).

CONCLUSION

For most testing conditions, the ASA technique demonstrated superior biomechanical property in terms of contact surface area compared with the TPO technique under compressive loading conditions. The ASA technique could also restore the tibiofemoral contact mechanics to be comparable with those of the native intact knee. Meanwhile, a significant difference in tibiofemoral mechanics, compared with the intact knee, could be observed in the TPO technique.

Medial Meniscus Posterior Root Tear: How Far Have We Come and What Remains?

Medial meniscus posterior root tears (MMRTs), defined as tears or avulsions that occur within 1 cm of the tibial attachment of the medial meniscus posterior root, lead to biomechanically detrimental knee conditions by creating a functionally meniscal-deficient status. Given their biomechanical significance, MMRTs have recently been gaining increasing interest. Accordingly, numerous studies have been conducted on the anatomy, biomechanics, clinical features, diagnosis, and treatment of MMRTs, and extensive knowledge has been accumulated. Although a consensus has not yet been reached on several issues, such as surgical indications, surgical techniques, and rehabilitation protocols, this article aimed to comprehensively review the current knowledge on MMRTs and to introduce the author's treatment strategies.

Reprint of: Outcomes of Arthroscopic All-Inside Repair Are Improved Compared to Transtibial Pull-Out Repair of Medial Meniscus Posterior Root Tears

PURPOSE

The purpose of the present study was to compare the clinical outcomes of patients who underwent an all-inside repair (with a bony trough) versus transtibial pull-out repair in medial meniscus posterior root tears (MMPRTs).

METHODS

We retrospectively investigated consecutive patients who underwent MMPRT repairs in nonacute tears in age over 40 from November 2015 to June 2019. All patients were divided into a transtibial pull-out repair group and an all-inside repair group. Different surgical techniques were used during different time frames. All patients were followed-up for a minimum of 2 years. The data collected included the International Knee Documentation Committee (IKDC) Subjective, Lysholm, and Tegner activity scores. Magnetic resonance imaging (MRI) was performed at the 1-year follow-up to assess meniscus extrusion, signal intensity, and healing.

RESULTS

The final cohort consisted of 28 patients in the all-inside repair group and 16 in the transtibial pull-out repair group. In the all-inside repair group, the IKDC Subjective, Lysholm, and Tegner scores improved significantly at the 2-year follow-up. In the transtibial pull-out repair group, the IKDC Subjective, Lysholm, and Tegner scores did not improve significantly at the 2-year follow-up. Postoperative extrusion ratio increased in both groups, and patient-reported outcomes at follow-up did not differ between the two groups The change in the extrusion ratio was significantly less in the all-inside repair group (P = .009), as was the postoperative meniscus signal (P = .011). Postoperative MRI revealed significantly better healing in the all-inside group (P = .041).

CONCLUSION

All-inside repair improved the functional outcome scores. Radiologically, all-inside repair was better than transtibial pull-out repair. All-inside repair may be a viable MMPRT treatment option.

LEVEL OF EVIDENCE

III, retrospective cohort study.

Single Femoral Tunnel for Anterior Cruciate Ligament Reconstruction With Bone-Patellar Tendon-Bone Graft and Lemaire's Extra-Articular Tenodesis as a Good Alternative for Combined Anterior Cruciate Ligament and Anterolateral Ligament Revision Surgeries

The literature has shown a significant decrease in failure rates when the anterior cruciate ligament (ACL) reconstruction was associated with an extra-articular reinforcement technique such as the anterolateral ligament (ALL) or the iliotibial band tenodesis (ITBT) using the modified Lemaire technique. As much as there is a progressive decrease in the failure rates of ACL reconstructions when the ALL reconstruction technique is associated, there are still and will be cases that will result in graft rupture. These cases will require more alternatives for revision, which are always challenging for the surgeon, where the lateral approaches represent complicating factors, especially because of the distortion of the lateral anatomy (by the previous approach for ALL reconstruction), previous reconstruction tunnels, and the presence of fixation materials. We present here a safe technique that offers great stability to the fixation of the graft and is easy to perform, using a single tunnel for the passage of the ACL and ITBT grafts, allowing a single fixation for both. In this way, we performed a lower-cost surgery, with a lower risk of lateral condyle fracture and tunnel confluence. This technique is indicated to be used in cases of revision after failure of combined ACL reconstruction with ALL.

Repair of meniscus root tear - Is there a difference between medial meniscus root repair and lateral meniscus root repair? A systematic review and meta-analysis

PURPOSE

Complete meniscus root tear is associated with meniscus extrusion; this causes a loss of meniscus function and accelerated osteoarthritis of the knee. Existing small-scale retrospective case-control studies suggested that the outcomes were different between medial and lateral meniscus root repair. This meta-analysis aims to study whether such discrepancies exist via a systematic review of the available evidence in the literature.

METHODS

Studies evaluating the outcomes of surgical repair of posterior meniscus root tears, with reassessment MRI or second-look arthroscopy, were identified through a systematic search of PubMed, Embase, and Cochrane Library. The degree of meniscus extrusion, healing status of the repaired meniscus root, and functional outcome scores after repair were the outcomes of interest.

RESULTS

Among the 732 studies identified, 20 studies were included in this systematic review. 624 knees and 122 knees underwent MMPRT and LMPRT repair, respectively. The amount of meniscus extrusion following MMPRT repair was 3.8 ± 1.7 mm, which was significantly larger than the 0.9 ± 1.2 mm observed after LMPRT repair (p < 0.001). Significantly better healing outcomes were observed on reassessment MRI after LMPRT repair (p < 0.001). The postoperative Lysholm score and IKDC score was also significantly better after LMPRT than MMPRT repair (p < 0.001).

CONCLUSIONS

LMPRT repairs resulted in significantly less meniscus extrusion, substantially better healing outcomes on MRI, and superior Lysholm/IKDC scores, when compared to MMPRT repair. This is the first meta-analysis we are aware of that systematically reviews the differences in the clinical, radiographic, and arthroscopic results of MMPRT and LMPRT repair.

Medial Meniscal Extrusion in Patients With Medial Meniscus Root Tears: A Systematic Review and Meta-analysis

Background

Medial meniscal extrusion (MME) has received significant interest because of its correlation with medial meniscus root tears (MMRTs), its potential as a diagnostic tool, and its significance in the progression of knee osteoarthritis (OA).

Purpose

To (1) evaluate if MMRTs significantly increase MME compared with nonroot tears (NRTs) and no tears and (2) determine the clinical outcomes of increased MME.

Study Design

Systematic review; Level of evidence, 4.

Methods

Electronic database searches of PubMed, Embase, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials were conducted on June 6, 2022, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 checklist criteria. The searches were conducted using the keywords "meniscus tear" and "extrusion." No restrictions were placed on the date of publication. Quality and sensitivity assessments were conducted on included studies. Major MME was defined as an extrusion ≥3 mm.

Results

Twenty-two studies involving 7882 knees were included. Compared with patients with NRTs, those with MMRTs had a 1.12-mm greater mean absolute meniscal extrusion (AME) and were 3.45 times more likely to have major MME (P < .001 for both). Compared with patients with no tears, those with MMRTs had a 2.13-mm greater AME (P < .001). Within patients with MMRT, those with widely displaced MMRT had a 1.01-mm greater AME compared with nondisplaced MMRT (P < .001). Patients with OA had a 0.73-mm greater AME and were 3.86 times more likely to have major MME compared with patients without OA (P < .001 for both). Within patients who were not stratified according to MMRT, NRT, or no tears, those who eventually developed OA had a 0.79-mm greater AME than those who did not have OA (P = .02).

Conclusion

Patients with MMRTs had higher MME values compared with those with other types of meniscal tears and those without any meniscal tears. Patients with knee OA were more likely to have higher MME compared with those without OA.

Healing of the Torn Anterior Horn of Rabbit Medial Meniscus to Bone after Transtibial Pull-Out Repair and Autologous Platelet-Rich Plasma Gel Injection

OBJECTIVES

The transtibial pull-out repair (TP) is a relatively new method for treating meniscal root tear; however, the clinical evaluation of its healing effect remains controversial. Due to ethical constraints and limitations of imaging techniques in humans, here we dynamically observe the healing effects of TP and TP with platelet-rich plasma gel (PRG) at the histological level using an animal model.

METHODS

Platelet-rich plasma (PRP) and PRG of rabbits were prepared. Platelet-derived growth factor (PDGF) and transforming growth factor-β1 (TGF-β1) levels in PRP and PRG were determined using an enzyme-linked immunosorbent assay. A rabbit model of anterior horn tear of the medial meniscus and TP surgery were created. PRG was injected between the anterior horn of the medial meniscus and the tibial tunnel. Rabbits were divided into three groups: the anterior horn tear group (Tear group), the anterior horn tear + TP group (TP group), and the anterior horn tear + TP + PRG group (TP + PRG group). The healing effect was observed dynamically using histopathological studies and biomechanical experiments.

RESULTS

The platelet content in PRP significantly increased to approximately 4.57 times that of whole blood. PDGF and TGF-β1 concentrations in PRG increased to 2.46 and 4.15 times those in PRP, respectively. Hematoxylin and eosin (H&E) and Masson staining showed that the number of inflammatory cells in healing tissue decreased and the collagen fibers significantly increased in TP and TP + PRG groups at 4, 8, and 12 weeks postoperatively compared to those in Tear group. Neatly arranged, interlaced, and dense collagen fibers were found between the anterior horn and bone at 12 weeks. H&E and toluidine blue staining showed that the injury to the femoral condyle cartilage was alleviated. The healing performance in TP + PRG group was better and faster than that in TP group. The maximum tensile fracture strength of the meniscus progressively increased at 8 and 12 weeks postoperatively.

CONCLUSIONS

Anterior horn injury of the medial meniscus in rabbits can be repaired using the TP technique, and the addition of autologous PRG to the bone tunnel promotes early healing of the meniscus and bone postoperatively. Meanwhile, both treatments can reduce the secondary damage to the cartilage due to osteoarthritis.

Outcomes of Arthroscopic All-Inside Repair Are Improved Compared to Transtibial Pull-Out Repair of Medial Meniscus Posterior Root Tears

PURPOSE

The purpose of the present study was to compare the clinical outcomes of patients who underwent an all-inside repair (with a bony trough) versus transtibial pull-out repair in medial meniscus posterior root tears (MMPRTs).

METHODS

We retrospectively investigated consecutive patients who underwent MMPRT repairs in nonacute tears in age over 40 from November 2015 to June 2019. All patients were divided into a transtibial pull-out repair group and an all-inside repair group. Different surgical techniques were used during different time frames. All patients were followed-up for a minimum of 2 years. The data collected included the International Knee Documentation Committee (IKDC) Subjective, Lysholm, and Tegner activity scores. Magnetic resonance imaging (MRI) was performed at the 1-year follow-up to assess meniscus extrusion, signal intensity, and healing.

RESULTS

The final cohort consisted of 28 patients in the all-inside repair group and 16 in the transtibial pull-out repair group. In the all-inside repair group, the IKDC Subjective, Lysholm, and Tegner scores improved significantly at the 2-year follow-up. In the transtibial pull-out repair group, the IKDC Subjective, Lysholm, and Tegner scores did not improve significantly at the 2-year follow-up. Postoperative extrusion ratio increased in both groups, and patient-reported outcomes at follow-up did not differ between the two groups The change in the extrusion ratio was significantly less in the all-inside repair group (P = .009), as was the postoperative meniscus signal (P = .011). Postoperative MRI revealed significantly better healing in the all-inside group (P = .041).

CONCLUSION

All-inside repair improved the functional outcome scores. Radiologically, all-inside repair was better than transtibial pull-out repair. All-inside repair may be a viable MMPRT treatment option.

LEVEL OF EVIDENCE

III, retrospective cohort study.

Clinical evaluation of suture materials for transtibial pullout repair of medial meniscus posterior root tear

BACKGROUND

There are no recommendations for specific suture materials in transtibial pullout repair of medial meniscus posterior root tears. This study aimed to evaluate the clinical outcomes of transtibial pullout repair of medial meniscus posterior root tears using ultrahigh-molecular-weight polyethylene sutures and suture tape.

METHODS

We retrospectively reviewed the data of 36 patients (27 women and 9 men, mean age 64.1 years) who had undergone transtibial pullout repair of medial meniscus posterior root tears between November 2018 and December 2019. Two groups of 18 patients each received either two different cord-like sutures or suture tape. Clinical parameters were assessed preoperatively and on second-look arthroscopy (mean postoperative period 12 months). The meniscal healing status was assessed using a previously published scoring system (ranging from 0 to 10), and the incidence rate of suture cut-out was assessed on second-look arthroscopy.

RESULTS

All clinical scores significantly improved in both groups, with no significant between-group differences on second-look arthroscopy. The arthroscopic meniscal healing scores significantly differed between sutures (mean 6.7 points) and suture tape (mean 7.4 points; p = 0.044). No significant between-group difference in the suture cut-out rate was observed.

CONCLUSIONS

This study found no significant differences in the clinical outcomes between ultrahigh-molecular-weight polyethylene sutures and suture tape. Favorable clinical outcomes were obtained using both types of suture; however, the usefulness of suture tape appears to be limited.

Osteonecrosis of the Knee: Not all Bone Edema is the Same

Knee pain is among the most common complaints that an orthopedic surgeon may see in practice. It is often worked up with X-rays and MRI, leading to a myriad of potential diagnoses ranging from minimal edema patterns to various types of osteonecrosis. Similarities in certain causes can pose diagnostic challenges. The purpose of this review was to present the 3 types of osteonecrosis observed in the knee as well as additional causes to consider to help aid in the diagnosis and treatment..

Posterior Root Medial Meniscus Tear With Medial Opening Wedge High Tibial Osteotomy: A Step-By-Step Systematic Arthroscopic Repair Technique

Medial meniscus root repair is often combined with correction of knee varus alignment by performing an opening wedge high tibial osteotomy (HTO) in patients with varus knee malalignment, particularly in those with suspected long-term medial meniscus root tear (MRT). Before planning a corrective alignment treatment, radiographic imaging of the knee alignment is recommended to assess a medial joint space and the tibiofemoral axis. Because HTO can reduce pressure on the repair site, new alignment may promote healing in the attachment of the MR repair. When HTO is used with meniscus root repair (MRR), the tunnel convergence remains a major concern. We describe an arthroscopic technique for treating chronic MRT with knee malalignment using the technique of arthroscopic posterior MRR with HTO. This approach was used to enhance anatomic healing of the meniscus root, decrease the load to the medial knee compartment to achieve MRR, and stop progressive osteoarthritis of the medial knee compartment.

Arthroscopic Meniscal Healing following Medial Meniscus Posterior Root Repair: A Comparison between Two Suture Materials

Recently, transtibial pullout repair of the medial meniscus (MM) posterior root tear (PRT) has become widely accepted and provides satisfactory clinical outcomes. Widening after cyclic loading or ultimate failure load using different suture materials and configurations has been studied. However, no study has compared the clinical outcomes using different suture materials. This study aimed to evaluate the clinical outcomes after performing MMPRT pullout repair using different suture materials. We hypothesized that better clinical outcomes would be achieved using ultra-high molecular weight polyethylene (UHMWPE) tape compared with a normal polyester suture. Thirty-seven patients who underwent MM posterior root repair between November 2019 and May 2020 were retrospectively investigated. Pullout repair was performed using a hollow no. 0 polyester suture (n = 14) and UHMWPE tape (n = 23). Clinical outcomes were assessed preoperatively and at 1 year postoperatively, using the Lysholm knee score, Knee Injury and Osteoarthritis Outcome Score, and visual analogue scale (VAS) pain score. The meniscal healing status was assessed using an arthroscopic scoring system (range: 0-10). All clinical scores were improved significantly in both groups. However, significantly higher meniscal healing scores and decreased VAS pain scores were observed in the UHMWPE group (7.3 ± 0.9 and 7.7 ± 11.3, respectively) than in the polyester group (5.6 ± 2.1 and 18.4 ± 18.6, respectively; p < 0.01). Suture cut-out and loss of the root continuity were observed in some cases (three cases [21.4%] in the polyester suture group and one case [4.3%] in the UHMWPE tape group). Both suture materials led to satisfactory clinical outcomes at 1 year postoperatively, whereas the UHMWPE tape was useful for obtaining good meniscal healing and decreasing the VAS pain score.

Posterior-Medial Meniscal Root Repair Through Lateral Tibial Tunnel Combined With Medial Opening Osteotomy and Homologous Graft

When there is a rupture in the meniscal roots or close to them, the menisci suddenly and considerably reduce their capacity to absorb the axial mechanical load that passes through the knee, quickly leading to the development of a process of chondral degeneration. The varus deformity of the lower limb (when the mechanical axis crosses the medial compartment of the knee) favors this type of injury owing to the overload in the medial compartment. When the patient has both varus deformity and medial meniscal posterior root injury, there is a clear indication for surgical realignment of the affected lower limb. There is still not a consensus regarding combining meniscal root repair with corrective osteotomy, although there is a tendency to perform both procedures aiming at long-term joint preservation. We present a safe alternative technique for simultaneous medial meniscal posterior root repair using a lateral tibial transosseous tunnel associated with a valgus-producing high tibial osteotomy with homologous bone grafting, allowing a full return to daily activities and sports.

Correlation of factors affecting correction of meniscal extrusion and outcome after medial meniscus root repair

INTRODUCTION

Meniscus extrusion in medial meniscus posterior root tears (MMPRT) is a consistent MRI finding and correction of extrusion is a primary objective of the meniscal root repair. The purpose of the study is to evaluate feasibility of correction of extrusion and correlation of various factors affecting the postoperative extrusion correction and outcomes in all degenerative medial meniscus posterior roots (MMPRTs).

METHODS

A retrospective study of patients who presented with degenerative MMPRTs following trivial incident (Jun 2014 and Aug 2018) and included isolated Laprade type 2 root tear with extrusion in MRI. Patients with ligament injuries, tricompartmental arthritis, malalignment (> 50) and irreparable meniscal tears excluded. All patients underwent arthroscopic trans-tibial tunnel suture pull-out repair. A screening MRI was taken at a 6-month follow-up and functional scores (IKDC and Lysholm's) at final follow-up. The effects of age, gender, duration of symptoms, hip-knee-ankle angle on weight-bearing X-rays, ICRS grading of cartilage status, and MRI data (extrusion distance, tunnel location and healing status of meniscus) on outcomes were analysed.

RESULTS

MMPRT (n = 54) with a mean follow-up of 34.6 months (24-48). Mean functional outcomes improved postoperatively IKDC (43.40 ± 5.16-78.65 ± 5.11, p < 0.001) and Lysholm's (65.27 ± 4.28-83.16 ± 4.83, p < 0.001) scores at final follow-up. 57.4% (31) had good correction of extrusion, 3.7% (2) no correction and 38.8% (21) showed increase in extrusion postoperatively. Of all the factors we explored, age, ICRS (low grade) and knee varus (less 2.5 degree) affected extrusion correction. Patients with healed (41 patients), partially healed (9 patients) and anatomic tunnel placement (46 patients) had better extrusion correction than those with non-healing (4 patients) and non-anatomical tunnel (8 patients).

CONCLUSION

Patients younger than 50 years, with low grade cartilage damage (ICRS 1, 2), lower KL grade and varus alignment (< 2.50) had good correction of extrusion. Correction of extrusion/progression of extrusion did not influence the clinical outcome at the short-term. The progression of meniscal extrusion is inevitable even after successful repair in elderly and high-risk patients.

STUDY DESIGN

Retrospective Case series, level of evidence IV.

Examining the Efficacy of Medial Meniscus Posterior Root Repair: A Meta-analysis and Systematic Review of Biomechanical and Clinical Outcomes

BACKGROUND

Medial meniscus posterior root (MMPR) injuries accelerate the progression of osteoarthritis. While partial meniscectomy was once considered the gold standard for treatment, meniscus root repair has become increasingly utilized with reported improvements in clinical and biomechanical outcomes.

PURPOSE

To perform a systematic review of biomechanical outcomes and a meta-analysis of clinical and radiographic outcomes after MMPR repair.

STUDY DESIGN

Meta-analysis and systematic review; Level of evidence, 4.

METHODS

The PubMed, Embase, and Cochrane databases were queried in August 2021 for studies reporting biomechanical, clinical, and radiographic outcomes after MMPR repair. Biomechanical studies were assessed for main results and conclusions. Data including study characteristics, cohort demographics, and outcomes were extracted. Included clinical studies were analyzed with a random-effects meta-analysis of proportions for binary outcomes or continuous outcomes for mean differences between preoperative and postoperative time points. Subgroup analysis for studies reporting repair outcomes with concomitant high tibial osteotomy (HTO) was performed where appropriate.

RESULTS

A total of 13 biomechanical studies were identified and reported an overall improvement in mean and peak contact pressures after MMPR repair. There were 24 clinical studies, consisting of 876 patients (877 knees), identified, with 3 studies (106 knees) reporting outcomes with concomitant HTO. The mean patient age was 57.1 years (range, 23-74 years), with a mean follow-up of 27.7 months (range, 2-64 months). Overall, clinical outcomes (Lysholm, Hospital for Special Surgery, International Knee Documentation Committee, visual analog scale for pain, Tegner, and Knee injury and Osteoarthritis Outcome Score scores) were noted to improve postoperatively compared with preoperatively, with improved Lysholm scores in patients undergoing concomitant HTO versus MMPR repair alone. Meniscal extrusion was not significantly improved after MMPR repair compared with preoperative measurements. The progression in Kellgren-Lawrence grades from grade 0 to grades 1 to 3 occurred in 5.9% (21/354) of patients after repair, with no patients progressing from grades 1 to 3 to grade 4.

CONCLUSION

MMPR repair generally improved biomechanical outcomes and led to improved patient-reported outcomes with greater improvements noted in patients undergoing concomitant HTO. Repair did not significantly improve meniscal extrusion, while only 5.9% of patients were noted to progress to low-grade osteoarthritis. The high level of heterogeneity in the included biomechanical and clinical investigations emphasizes the need for more well-designed studies that evaluate outcomes after MMPR repair.

Arthroscopic Medial Meniscus Posterior Root Repair with Centralization Using Knotless Suture Anchors

Medial meniscus posterior root tears can lead to rapid progression of knee arthritis because of loss of the stress distribution function of the meniscus. Medial meniscus root repair can restore stress distribution and improve clinical outcome. In cases of medial meniscus root tears with meniscal extrusion, centralization may help reduce extrusion and protect the root repair. Presented here is a technique for transtibial medial meniscus root repair with centralization using knotless suture anchors, building on previously developed techniques.

Risk of interference between the tibial tunnel and locking screws in medial meniscus posterior root repair and open wedge high tibial osteotomy

PURPOSE

To evaluate whether the frequency of interference between locking screws for the plate fixation and tibial tunnels differs depending on the tibial tunnel positions in a surgical simulation of the transtibial pull-out repair of medial meniscus posterior root tears (MMPRTs) in patients undergoing biplanar open wedge high tibial osteotomy (OWHTO).

METHODS

Sixty-five patients (75 knees) who underwent OWHTO with TomoFix small plate (Depuy Synthes, PA, USA) for medial knee osteoarthritis with varus malalignment were enrolled in this study. Surgical simulation of transtibial pull-out repair of MMPRTs was performed using postoperative computed tomography images. The tibial tunnel was created in the anatomical attachment area of the medial meniscus posterior root. Another aperture of the tibial tunnel was created on the anteromedial (AM) tibial cortex, the posteromedial (PM) tibial cortex, and the anterolateral (AL) tibial cortex in the proximal tibial fragment. The frequency of interference between the tibial tunnel and A-D locking screws was compared in the 3 tibial tunnel positions. In each tibial tunnel position, the locking plate position with and without interference between the tibial tunnel and at least one locking screw was compared.

RESULTS

For screw A, the frequency of interference with the tibial tunnel in the AL position was higher than that in the AM (P = 0.048) and PM positions (P <  0.001). For screws B and C, the frequency of interference with the tibial tunnel in the AM position was higher than that in the PM (P <  0.001, P = 0.007) and AL positions (P <  0.001, P = 0.001), respectively. For screw D, there was no difference in the frequency of interference with the tibial tunnel among the three positions. The frequency of interference between the tibial tunnel and at least one screw in the AM position was 100%, which was higher than that in the PM (P <  0.001) and AL positions (P <  0.001). In the PM position, the locking plate was placed more posteriorly in the group where the locking screw interfered with the tibial tunnel. In the AL position, the locking plate was placed more parallel to the medial/lateral axis of the tibial plateau in the interference group.

CONCLUSION

Making the tibial tunnel in the AM position should be avoided because interference with locking screws was inevitable. When the tibial tunnel is created in the PM position, interference between the tibial tunnel and screw C should be paid attention. Anterior placement of the locking plate could be useful to prevent interference between locking screws and the tibial tunnel in the PM position. In addition, when the tibial tunnel is created in the AL position, interference between the tibial tunnel and especially screw A among screws A-C should be paid attention. Placing the locking plate in an anteromedial direction could be useful to prevent interference between locking screws and the tibial tunnel in the AL position.

LEVEL OF EVIDENCE

IV.

Midterm Outcomes of Posterior Medial Meniscus Root Tear Repair: A Systematic Review

BACKGROUND

Whereas there has been growing interest in surgical repair of posterior medial meniscus root tears (PMMRTs), our understanding of the medium- and long-term results of this procedure is still evolving.

PURPOSE

To report midterm clinical outcomes from PMMRT repairs.

STUDY DESIGN

Systematic review.

METHODS

A literature review for this systematic analysis was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We identified studies that reported the results of arthroscopic repair of PMMRTs. Functional and imaging outcomes were reviewed and summarized.

RESULTS

In total, 28 studies with a total of 994 patients (83% female) with an overall mean age of 57.1 were included in this review. Clinical outcomes (Lysholm, International Knee Documentation Committee, Hospital for Special Surgery, and Tegner scores) were improved at final follow-up in all studies. Of patients, 49% had radiographic progression of at least 1 grade in the Kellgren-Lawrence scale at a mean follow-up of 4.0 years in 11 studies. Cartilage degeneration had progressed at least 1 grade on magnetic resonance imaging scans in 23% of patients at a mean follow-up of 31.6 months in 4 studies.

CONCLUSION

PMMRT repairs provide a functional benefit with consistent improvements in clinical outcome scores. There is some evidence that PMMRT repair slows the progression of osteoarthritis but does not prevent it at midterm follow-up.

Meniscal Root Tears and Extrusion Are Significantly Associated with the Development of Accelerated Knee Osteoarthritis: Data from the Osteoarthritis Initiative

OBJECTIVE

To identify joint structural risk factors, measured using quantitative compositional and semiquantitative magnetic resonance imaging (MRI) scoring, associated with the development of accelerated knee osteoarthritis (AKOA) compared with a more normal rate of knee osteoarthritis (OA) development.

DESIGN

From the Osteoarthritis Initiative we selected knees with no radiographic OA (Kellgren-Lawrence grade [KL] 0/1) that developed advanced-stage OA (KL 3/4; AKOA) within a 4-year timeframe and a comparison group with a more normal rate of OA development (KL 0/1 to KL 2 in 4 years). MRIs at the beginning of the 4-year timeframe were assessed for cartilage T2 values and structural abnormalities using a modified Whole-Organ Magnetic Resonance Imaging Score (WORMS). Associations of MRI findings with AKOA versus normal OA were assessed using multivariable logistic regression models.

RESULTS

A total of 106 AKOA and 168 subjects with normal OA development were included. Mean cartilage T2 values were not significantly associated with AKOA (odds ratio [OR] 1.06; 95% confidence interval [CI] 0.82-1.36). Risk factors for AKOA development included higher meniscus maximum scores (OR 1.37; 95% CI 1.11-1.68), presence of meniscal extrusion (OR 6.30; 95% CI 2.57-15.49), presence of root tears (OR 4.64; 95% CI 1.61-13.34), and higher medial tibia cartilage lesion scores (OR 1.96; 95% CI 1.19-3.24).

CONCLUSIONS

We identified meniscal damage, especially meniscal extrusion and meniscal root tears as risk factors for AKOA development. These findings contribute to identifying subjects at risk of AKOA at an early stage when preventative measures targeting modifiable risk factors such as meniscal repair surgery could still be effective.

Outcomes after Surgical Repair of Medial Meniscal Root Tears: A Review

At the present time, there is a paucity of literature regarding medial meniscal posterior root repair and outcomes. This review seeks to examine the currently available data to further elucidate the clinical risks and benefits and any associated risks of medial meniscal posterior root repair. A systematic literature search was performed up to July 2018 in the databases of Medline via PubMed, EBSCOhost, and EMBASE. The results were reviewed independently by two authors and appropriate articles were reviewed and eligibility determined based on established criteria. The best-evidence synthesis was subsequently used. Thirteen studies (324 patients) were included in this review with a mean patient age of 54 years. There were no control studies with nonoperative treatment of medial meniscal posterior root tears. All studies included a minimum of 10 patients in a case series or case-control manner. Of patients treated with medial meniscal posterior root repair, 62.43% demonstrated complete healing on follow-up magnetic resonance imaging (MRI) or second-look arthroscopy. Among them, 32.60% demonstrated incomplete healing, loosening of the construct, or excessive scar tissues formation. Also, 4.97% demonstrated complete failure or retearing of the construction. At a mean follow-up period of 33 months, patients demonstrated a mean improvement in Lysholm's score of 30.5 (p < 0.00001), International Knee Documentation Committee (IKDC) score of 31.9 (p < 0.00001), and HSS Knee Score of 38.3 (p < .00001). Surgical repair of medial meniscus posterior root tears appears to result in highly satisfying subjective outcomes. Patients included in this review meet criteria for both statistically and clinically significant improvement, based on published guidelines for minimal clinically important difference. Despite this, however, postoperative MRI and second-look arthroscopy demonstrate a relatively high rate of incomplete healing (32.60%) or retearing and failure of the construct (4.97%). More highly powered studies are required to confirm these findings.

Meniscal Extrusion: A Narrative Review

Background:

Meniscal extrusion, referred to as an external displacement of the meniscus, is a commonly encountered but often overlooked magnetic resonance imaging finding in the knee joint. Meniscal extrusion alters the biomechanical properties of the meniscus, leading to accelerated cartilage degeneration and early osteoarthritic changes. The literature contains discrepancies about meniscal extrusion on topics ranging from definition to diagnosis. This narrative review outlines the pathogenesis, natural history, diagnosis, and treatment of meniscal extrusion.

Purpose:

To review the current literature on meniscal extrusion, from pathogenesis to treatment, and to provide recommendations for future research.

Study Design:

Narrative review.

Methods:

A computer-based search of the PubMed, Ovid Medline, and Cochrane Library databases was used to perform a comprehensive literature review on meniscal extrusion. A total of 81 studies was ultimately included in the review.

Results:

The literature review highlighted the current ambiguity in definition, difficulty in clinical diagnosis, and low level of awareness of this condition. This review covers all aspects related to meniscal extrusion and identifies many of its lesser known aspects.

Conclusion:

In the current literature, meniscal extrusion remains a lesser known albeit common condition because of its relatively silent nature along with lack of knowledge among orthopaedic surgeons. Further studies are warranted to provide better understanding and management of this condition.

Second-Look Arthroscopic Evaluation of Healing Rates After Arthroscopic Repair of Meniscal Tears: A Systematic Review and Meta-analysis

Background:

Evaluation of meniscal healing status after repair is important, as it allows the surgeon to inform patients whether they can increase their activities or return to sports.

Purpose:

To identify the healing rates after arthroscopic repair of meniscal tears via second-look arthroscopic evaluation.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

Searches of PubMed, Embase, Scopus, and the Cochrane databases were conducted to identify relevant studies published before June 1, 2020. Studies were eligible for this meta-analysis if they provided data regarding healing status of the meniscus at second-look arthroscopy. Random-effects meta-analyses were generated to provide pooled meniscal healing estimates. We further performed subgroup analysis to investigate the healing rates of the meniscus under different situations.

Results:

A total of 41 studies with 1908 individuals were included in the study. The pooled analysis showed the complete healing rate was 74% (95% confidence interval [CI], 67%-80%), the partial healing rate was 10% (95% CI, 6%-16%), and the failure rate was 12% (95% CI, 10%-15%) for arthroscopic repair of meniscal tears via second-look arthroscopic evaluation. Sensitivity analysis demonstrated that no individual study affected the overall healing rate by >1%. Subgroup analysis found higher meniscal healing rates in patients with the following characteristics: age <40 years, male, body mass index <26, red-red tear location, tear in posterior horn, vertical tear, outside-in technique, repair concomitant with anterior cruciate ligament reconstruction, weight-restricted rehabilitation, and time interval from meniscal repair to second-look arthroscopy >12 months.

Conclusion:

In this systematic review, the complete healing rate was 74%, the partial healing rate was 10%, and the failure rate was 12% for arthroscopic repair of meniscal tears via second-look arthroscopic evaluation.

Improvement of clinical and radiological outcomes of root repair patients with advanced articular cartilage degeneration and osteoarthritis

PURPOSE

The main purpose of this study was to investigate clinical and radiological outcomes of medial meniscus posterior root tear (MMPRT) repair in knees with advanced articular cartilage degeneration and osteoarthritis compared to those with minimal degenerative change.

METHODS

Thirty-three knees underwent MMPRT repair using an arthroscopic pullout repair tibial tunnel technique. Clinical scores including Lysholm Score, International Knee Documentation Committee (IKDC) Score and Knee injury and Osteoarthritis Outcome (KOOS) Score were collected preoperatively and sequentially at 6 months, 12 months and mean final follow-up of 39.4 months. Kellgren-Lawrence (K-L) osteoarthritis grade, Outerbridge classification of cartilage degeneration and the presence of bone marrow oedema on MRI were also evaluated.

RESULTS

All clinical scores improved at final follow-up for knees with K-L grade ≥ 2 osteoarthritis (p < 0.001), with no significant difference compared to K-L 0/1. Patients with Outerbridge class 3/4 cartilage degeneration also reported improvements in clinical scores, albeit lower than those with class 2 degeneration (p < 0.05). During recovery, the majority of patients reported clinical improvements by 6 months, and six patients further improved by at least 15 points in IKDC score between 6 and 12 months. Osteoarthritis progressed in 10 of 31 knees (32%), with an overall mean pre-operative K-L grade of 1.6 ± 0.9 compared to 2.0 ± 0.9 at final follow-up (n.s.). No knees progressed to K-L 4 or underwent re-operation. Pre-operative bone marrow oedema was present in 17 knees (52%), all of which had signal localised to the medial tibia or femur. Oedema had resolved in all but 5 knees post-operatively (p < 0.01).

CONCLUSION

Arthroscopic repair of medial meniscus posterior root tears is associated with improved outcomes in knees with advanced cartilage degeneration and osteoarthritis. Meaningful improvements in clinical outcomes can be achieved beyond 6 months, thus success of the operation is best determined at the 12-month mark. Oedema signal significantly improved post-operatively, however a relatively high proportion of knees had K-L progression.

LEVEL OF EVIDENCE

IV - Case Series.

Does meniscectomy have any advantage over conservative treatment in middle-aged patients with degenerative medial meniscus posterior root tear?

Background

The best treatment for degenerative medial meniscus posterior root tear (MMPRT) remains controversial. This study aimed to compare the clinical and radiological outcomes of arthroscopic meniscectomy and conservative treatment for degenerative MMPRT.

Methods

From January 2007 to December 2014, 146 patients (Meniscectomy group, 90; Conservative group, 56) were evaluated. Clinical outcomes were assessed using the Visual Analog Scale, International Knee Documentation Committee subjective scoring scale, Tegner activity scale, and Lysholm knee scoring scale at the final follow-up. Radiologic outcomes evaluated the progression of osteoarthritis (OA) according to the Kellgren-Lawrence (K-L) classification. We compared the hip-knee-ankle angle (HKAA), medial proximal tibial angle, tibial posterior slope angle, and width of medial joint space. After an average follow-up of 6.3 years, the survivorship was analyzed using the Kaplan–Meier method.

Results

All clinical outcomes were significantly improved in both groups after treatment, with no significant differences between the two groups at the final follow-up. The progression of OA according to the K-L classification, HKAA and width of medial joint space was significantly advanced in the meniscectomy group (p = 0.03, 0.04, 0.03, respectively). The 10-year survival rates in the meniscectomy and conservative groups were 87 and 88%, respectively.

Conclusions

This study demonstrated that both conservative treatment and meniscectomy provided symptomatic relief. However, it was confirmed that OA progression was more severe in the meniscectomy. We conclude that arthroscopic meniscectomy had no advantage over conservative treatment in terms of clinical outcomes and OA progression in middle-aged patients with MMPRT.

Level of evidence

Level III; retrospective comparative study.

Good Surgical Outcomes After Concomitant Repair of Double Radial Tears of the Lateral Meniscus and Anterior Cruciate Ligament Reconstruction

Purpose

To describe double radial tears of the lateral meniscus (LM), report early clinical treatment outcomes, and determine reoperation and failure rates.

Methods

Twenty-one (N = 21) consecutive cases of arthroscopic-treated lateral meniscus double radial tears treated between 2012 and 2018 were reviewed, including 15 males (71.4%) and 6 females (28.6%). Meniscus repairs were all performed at the time of anterior cruciate ligament (ACL) reconstruction. Patients with associated fractures or prior surgeries were excluded. Concomitant injuries were reported, as were preinjury and postoperative Tegner scores, preoperative and postoperative visual analogue pain scale (VAS) scores, and postoperative International Knee Documentation Committee (IKDC) subjective scores. Reoperation and failure rates were documented.

Results

Twenty-one (N = 21) tears were located in the posterior horn of the meniscus near the root attachment; 15 (71.4%) underwent all-inside repair, 4 (19.0%) underwent transtibial pull-through repair, 1 (4.8%) was partially debrided, and 1 (4.8%) was left untreated. Twenty-one tears (N = 21) were in the body of the meniscus; 7 (33.3%) were repaired, 7 (33.3%) were partially debrided, and 7 (33.3%) were left untreated. Thirteen patients (62%) had associated medial collateral ligament (MCL) injuries. Mean follow-up was 2.6 years. VAS at rest and with activity improved by 2.1 points (P < .001) and 3.1 points (P = .017) after surgery. The mean postoperative Tegner activity score was 6.4, and the mean IKDC score was 83.2 at final follow-up. Reoperation was required in 5 patients (23.8%), and the surgical treatment failed in 1 patient (4.7%).

Conclusions

Double radial tears of the LM are uncommon injuries that occur in the setting of ACL tears, usually combined with MCL injury. The variety of surgical treatment techniques have a low failure rate at short-term follow-up. Patients tend to have good clinical outcomes with improvement in pain and overall function after surgically treating these injuries with simultaneous ACL reconstruction.

Level of Evidence

Level IV, therapeutic study, case series

Association Between Transtibial Meniscus Root Repair and Rate of Meniscal Healing and Extrusion on Postoperative Magnetic Resonance Imaging: A Prospective Multicenter Study

Background:

Prospective studies evaluating second-look imaging of meniscus root repair using a transtibial pull-out technique are limited; therefore, optimal surgical indications and the technique for meniscus root repair remain uncertain.

Hypothesis:

It was hypothesized that there would be a high rate of healing, improvement in meniscal extrusion, and prevention of articular cartilage degeneration and subchondral bone abnormalities after meniscus root repair.

Study Design:

Case series; Level of evidence, 4.

Methods:

Consecutive patients undergoing transtibial root repair were prospectively enrolled at 2 orthopaedic centers between March 2017 and January 2019. Pre- and postoperative magnetic resonance imaging (MRI) scans were reviewed by a musculoskeletal radiologist in a blinded fashion for meniscal healing, quantification of extrusion, articular cartilage grade, subchondral bone changes, and coronary/meniscotibial ligament abnormalities. Given persistent extrusion observed on postoperative MRI scans, an additional 10 patients gave consent and were enrolled for immediate (before weightbearing) postoperative MRI scans.

Results:

A total of 45 patients (16 male, 29 female; mean ± standard deviation age, 42.3 ± 12.9 years; body mass index, 31.6) were prospectively enrolled in the study; there were 47 meniscus root repairs: 29 medial and 18 lateral (2 with both). Postoperative MRI was obtained at an average of 6.3 months (range, 5.1-8 months); 98% of meniscal repairs had evidence of healing. Mean extrusion increased significantly, from 1.9 ± 1.5 mm preoperatively to 2.6 ± 1.4 mm postoperatively (P = .03). There was no significant progression of chondromalacia grade, subchondral edema, insufficiency fracture, subchondral cysts, or subchondral collapse. In the additional 10-patient cohort, the mean preoperative extrusion (1.6 ± 1.2 mm) was not significantly different from that immediately postoperatively (2.0 ± 1.0 mm; P = .23).

Conclusion:

Prospective MRI analysis of transtibial meniscus root repair confirmed a high rate of meniscal healing and no observable progression of cartilage degeneration or subchondral bone abnormalities at the short-term follow-up. However, meniscal extrusion worsened in the first 6 months after surgery.

Registration:

NCT03037242 (ClinicalTrials.gov identifier).

Meniscal Ramp Lesions and Root Tears: A Review of the Current Literature

The importance of the menisci in providing joint stability and their role in load transmission within the knee are well understood. A growing body of literature has emerged on 2 distinct injury patterns to these crucial anatomic structures, ramp lesions and root tears. Ramp lesions may be characterized as tears at the posterior meniscocapsular junction, while root tears involve bony or soft tissue avulsion of the meniscal insertions at the anterior or posterior intercondylar regions. In this 2-part review, we present an overview of the current available literature on ramp lesions and meniscal root tears, summarizing the unique anatomic considerations, etiology, biomechanics, management decisions, clinical outcomes pertinent to these very distinct injuries.

The efficacy of meniscus posterior root tears repair: A systematic review and meta-analysis

PURPOSE

To report of efficacy repair treatment for meniscus posterior root tears repair.

METHODS

We systematically searched databases including PubMed, Embase, and Cochrane Library for relevant articles. Coleman Methodology Score was used for a quality assessment of the included studies. A meta-analysis was performed to analyze for efficacy of MMPRTs repair.

RESULTS

Twenty-two studies, 14 level III and 8 level IV, were included in this systematic review, with a total of 926 cases. Studies comparing repair with either meniscectomy or conservative treatment found greater improvement and slower progression of Kellgrene-Lawrence grade with meniscal repair. Decreased meniscus extrusion is beneficial to the prognosis of patients undergoing MMPRTs repair. As treatment efficacy, the Lysholm score increased 28.87 (P < 0.001), IKDC score increased 31.73. The overall pooled event rates of progression of K-L grade is 0.200. Difference of Lysholm score and IKDC score between repair and meniscectomy were 8.72 and 9.67.

CONCLUSIONS

The clinical subjective score after MMPRT repair was significantly improved compared with the preoperative status. Considering the progression of joint K-L grade, it can prevent the progression of arthrosis to some extent, but not completely. Decreased meniscus extrusion is beneficial to the prognosis of patients undergoing MMPRTs repair. Based on these results, MMPRTs repair cloud result favorable outcomes.

Remodified Mason-Allen suture technique concomitant with high tibial osteotomy for medial meniscus posterior root tears improved the healing of the repaired root and suppressed osteoarthritis progression

PURPOSE

To evaluate the results of the remodified Mason-Allen suture technique concomitant with high tibial osteotomy (HTO) for medial meniscal posterior root tears (MMPRTs). The hypothesis was that this procedure would improve clinical results, prevent progression of knee osteoarthritis and increase the healing rate of the repaired root.

METHODS

Total 17 patients of mean 51.5 ± 4.4 years who were underwent this combined procedure for MMPRT completed this study. Lysholm and Hospital for Special Surgery (HSS) scores, Kellgren-Lawrence (KL) grade reflecting osteoarthritis progression were evaluated preoperatively and at the last follow-up. Medial meniscus extrusion (MME) was measured on magnetic resonance imaging preoperatively and at mean 26.1 ± 2.3 months postoperatively. Second-look arthroscopy was performed at mean 25.1 ± 5.3 months postoperatively. The healing status of the repaired root was classified as complete, partial and failed healing. The Outerbridge (OB) grade of the medial femoral condyle (MFC) was compared between index surgery and second-look arthroscopy.

RESULTS

Mean follow-up duration was 66.4 ± 6.5 months. Mean Lysholm and HSS mean scores improved significantly from preoperatively to the last follow-up: Lysholm: 56.9 ± 5.4 to 83.5 ± 6.0 (P < 0.001); HSS: 56.1 ± 6.0 to 81.7 ± 7.7 (P < 0.001). The mean mechanical alignment of the lower extremity was corrected from varus to the neutral range at the last follow-up. The preoperative KL grade was not significantly different from the KL grade at the last follow-up (P = 0.071). On MRI, mean MME increased from 3.0 ± 0.7 mm to 3.1 ± 0.7 mm (P = 0.046). Second-look arthroscopy showed 64.7% complete, 29.4% partial and 5.9% failed healing of the repaired root. The initial OB grade of the MFC showed no progression (P = 0.103).

CONCLUSIONS

The remodified Mason-Allen suture technique concomitant with HTO for MMPRTs significantly improved clinical outcomes and suppressed OA progression at 66.4 months. However, this procedure produced limited complete healing of the repaired roots in 64.7% of patients.

LEVEL OF EVIDENCE

IV.

The role of MRI in evaluation of arthroscopic transtibial pullout repair for medial meniscus posterior root tears

Medial meniscus posterior root tears (MMPRT) can lead to meniscal extrusion, loss of hoop tension, loss of load-sharing ability and increased contact pressure. Currently, the most commonly used technique for root repair is arthroscopic transtibial pullout repair (ATPR). This article aims to illustrate both normal and abnormal postoperative imaging findings of the MMPRT repair performed with ATPR, with emphasis on MRI. The radiologist must highlight the tunnel position, the reduction of the medial meniscus posterior root to its anatomical attachment, the signs of root healing (continuity and lower signal intensity), and eventual meniscal extrusion or signs of osteoarthritis.

A New Clinical Sign for Diagnosing Medial Meniscus Posterior Root Tear

Background

In the presence of medial meniscus posterior root tear (MMPRT), there is a possibility of reduced compression of meniscal tissue in hyperflexion as the intra-articular mobility of the meniscus increases. This phenomenon can be mimicked during clinical examination.

Purpose

To describe, evaluate, and validate the diagnostic performance of a new clinical indicator, the Akmese sign, for the diagnosis of an MMPRT.

Study Design

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

Methods

In this study, we prospectively enrolled patients aged 18 to 55 years who were scheduled for arthroscopic surgery after a diagnosis of medial meniscal lesion at a single institution between January 2016 and January 2018. All of the patients underwent preoperative examination for the Akmese sign. All surgeries were performed by a single surgeon with more than 5 years of experience in sports injury surgery, who was blinded to the Akmese sign results.

Results

A total of 273 patients with a mean age of 42.4 ± 5.3 years met the study criteria. The Akmese sign was identified as positive in 33 patients, and MMPRT was confirmed during arthroscopy in 36 cases. The performance parameters of the Akmese sign were a sensitivity of 86.1%, specificity of 99.1%, Youden index of 0.85, and kappa index of 0.88.

Conclusion

This study showed that the Akmese sign is a useful new physical examination test that can help clinicians distinguish MMPRTs from other meniscal medial meniscal pathology.

Arthroscopic Medial Meniscal Posterior Root Repair With Transtibial Luggage-Tag and Horizontal Mattress Sutures

Medial meniscal posterior root repair techniques have shown positive yet varied results in the literature. The decision to perform repair has improved clinical outcomes in many situations, although the healing rate is approximately 64% and the repair strength is roughly one-third of the native root strength, with meniscal extrusion being common. We present a technique based on biomechanical evidence to obtain a strong anatomic posterior root repair to restore nearly normal knee mechanics, combining an increased size of footprint under the lateral aspect of the medial meniscal horn for healing and a luggage-tag suture with a posteriorly placed horizontal mattress suture. The horizontal mattress suture is passed to capture the circumferential fibers of the meniscus and the luggage-tag suture is passed to capture the radial fibers of the meniscal body, through a single transtibial tunnel. The aim of this repair is to restore the normal meniscal function.

Factors Related to Meniscal Extrusion and Cartilage Lesions in Medial Meniscus Root Tears

The purpose of this study was to identify factors affecting medial meniscus extrusion and cartilage degeneration in medial meniscus root tears (MMRT) and to determine the optimal cut-off values for the factors that predict disease severity. We retrospectively evaluated 86 consecutive patients diagnosed with an isolated MMRT by magnetic resonance imaging (MRI) examinations and arthroscopic procedures for 2 years. Patient-specific factors such as age, sex, the time between injury and MRI (mTIME), the time between injury and surgery (sTIME), the time between MRI and surgery (dTIME), Kellgren-Lawrence (KL) grades, and the mechanical tibiofemoral axis angle (mTFA) were documented. Regression analyses and receiver operating characteristic (ROC) curve analyses were performed. The mTIME was only positively correlated with meniscal extrusion (r = 0.425, p < 0.001). The patients who had grades 3 and 4 cartilage lesions had only significantly higher KL grades and longer sTIME than the patients who had lower grades of cartilage lesion (6.5 months [interquartile range (IQ): 3.0-12.0) vs. 2.5 months [IQ: 0.9-3.9]; p < 0.001). The cut-off value of mTIME and sTIME were 2.5 and 6 months. Relapse times greater than 2.5 months and 6 months after a specific event were associated with a 7.8-fold increased risk for meniscus extrusion and an 18.2-fold increased risk for cartilage lesions, respectively. The risk of medial extrusion of the meniscus and the severity of articular cartilage lesions increased with time after an injury. The period of time from 2.5 to 6 months after traumatic event might be a critical window for intervention in the patients with MMRT to perform the repair in the status which the meniscus did not extrude more than 3 mm and the cartilage lesion did not progress more than grade 3. This study is a retrospective and uncontrolled case series and reflects level IV of evidence.

Safety, Feasibility, and Radiographic Outcomes of the Anterior Meniscal Takedown Technique to Approach Chondral Defects on the Tibia and Posterior Femoral Condyle: A Matched Control Study

OBJECTIVE

Takedown of the anterior meniscus to facilitate exposure of the cartilage defects located on the tibial plateau and/or posterior femoral condyle with subsequent reattachment is being performed clinically; however, clinical evidence is lacking to support the safety of this technique. The aim of this study was therefore to investigate whether meniscal extrusion develops after patients undergo meniscus takedown and transosseous refixation during autologous chondrocyte implantation (ACI).

DESIGN

We analyzed data from 124 patients with a mean follow-up of 6.8 ± 2.5 years. Sixty-two patients who underwent (ACI) with anterior meniscus takedown and refixation by the senior surgeon (TM), were compared with a matched control group of patients who underwent ACI without meniscus takedown. Meniscal extrusion was investigated by measuring the absolute value and the relative percentage of extrusion (RPE) on 1.5-T magnetic resonance images (MRI) at final follow-up. The number of menisci with radial displacement greater or lesser than 3 mm was determined. In cases where a preoperative MRI was available, both pre- and postoperative meniscal extrusion was evaluated (n = 30) in those patients undergoing meniscal takedown.

RESULTS

There was no significant difference in either absolute meniscus extrusion, RPE, or extrusion rate in patients with and without meniscus takedown. Among patients with meniscal takedown and both pre- and postoperative MRI scans, absolute meniscus extrusion, RPE, and extrusion rate showed no significant differences.

CONCLUSION

Meniscal takedown and subsequent transosseous refixation is a safe and effective technique for exposure of the tibial plateau and posterior femoral condyle.

Comparison of the Radiologic, Arthroscopic, and Clinical Outcomes between Repaired versus Unrepaired Medial Meniscus Posterior Horn Root Tear During Open Wedge High Tibial Osteotomy

The efficacy and outcomes for the concurrent repair of medial meniscus posterior horn root tear (MMPHRT) during open wedge high tibial osteotomy (OWHTO) are unclear. This study compared the radiologic, arthroscopic, and clinical outcomes between repaired and unrepaired MMPHRT during OWHTO. Fifty-seven patients were prospectively enrolled from 2014 to 2016. The radiologic, arthroscopic, and clinical outcomes were compared between 25 patients who underwent OWHTO with all-inside repair of MMPRT using FasT-Fix (repaired group) and 32 patients who underwent OWHTO without repair of MMPRT (unrepaired group) with a mean 2-year follow up in both groups. The meniscal healing status was classified as complete, partial, or no healing, according to second-look arthroscopic findings. The medial meniscal extrusion (MME) was evaluated using magnetic resonance imaging. The width of medial joint space, joint line convergence angle (JLCA), posterior tibial slope (PTS), Kellgren-Lawrence (KL) grade, hip-knee-ankle angle, and weight-bearing line ratio was evaluated on simple standing. The clinical outcomes were evaluated using the Knee Society score and the Western Ontario and McMaster University score. Healing rates (partial and complete) of the MMPHRT showed a statistical difference between the two groups (repaired group vs. unrepaired group, 19/25 (76%) vs. 13/32 (40.6%), p = 0.008). The postoperative MME showed no statistical differences between groups (repaired versus unrepaired group: 4.5 ± 1.3 mm vs. 4.5 ± 2.1 mm, p = 0.909). The postoperative width of medial joint space, JLCA, PTS, and KL grade all showed no statistical differences between groups after 2 years of OWHTO. Other radiologic parameters and clinical outcomes showed no statistical differences between groups. Repair of the MMPHRT during OWHTO showed a superior healing rate to the unrepaired MMPHRT. However, repair of the MMPHRT was not related to the radiologic and clinical outcomes. Therefore, there is no clear evidence of the need for the MMPHRT repair during OWHTO.

Arthroscopic Centralization of the Extruded Medial Meniscus

Tears of the posterior medial meniscus root commonly result in extrusion of the meniscus and disruption of tibiofemoral contact mechanics. Transtibial pull-through repair of the root often results in healing of the tear, but postoperative extrusion may persist. In this scenario, the meniscus is unlikely to be chondroprotective. Therefore, an additional centralization procedure is necessary to improve the extrusion. Biomechanical studies have demonstrated that centralization can improve meniscus mechanics and potentially reduce the risk of osteoarthritis. This Technical Note describes an arthroscopic technique for medial meniscus posterior root repair that combines transtibial pullout and centralization sutures.

Clinical and Radiological Outcomes of Meniscal Repair Versus Partial Meniscectomy for Medial Meniscus Root Tears: A Systematic Review and Meta-analysis

Background:

Given the superiority of meniscal repair over partial meniscectomy according to biomechanical data, the clinical outcomes of meniscal repair are likely to be better than those of partial meniscectomy for a medial meniscus root tear (MMRT).

Purpose/Hypothesis:

This review was designed to compare the clinical and radiological results between meniscal repair and partial meniscectomy for MMRTs. It was hypothesized that meniscal repair would result in better clinical and radiological results compared with partial meniscectomy.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

Studies were included in the review if they (1) included patients with MMRTs who underwent primary arthroscopic meniscal repair or partial meniscectomy and (2) analyzed validated patient-reported outcomes and/or radiological evaluations. Summary odds ratios (ORs) with 95% CIs were calculated to compare partial meniscectomy with meniscal repair for each outcome.

Results:

A total of 13 studies were included. The mean duration of follow-up was 33.5 and 47.2 months in the meniscal repair group and partial meniscectomy group, respectively. The change in the Lysholm score from preoperatively to postoperatively was statistically significantly in favor of meniscal repair (OR, 2.20 [95% CI, 1.55-3.12]), while no difference was found with respect to the change in the Tegner score between the 2 surgical approaches (OR, 1.21 [95% CI, 0.65-2.24]). The prevalence of postoperative severe knee osteoarthritis (OR, 0.31 [95% CI, 0.17-0.54]) as well as that of reoperations (OR, 0.05 [95% CI, 0.01-0.19]) were significantly in favor of meniscal repair.

Conclusion

Better outcomes were seen after meniscal repair compared with partial meniscectomy for MMRTs, with greater improvements in Lysholm scores, and lower rates of progression to knee osteoarthritis, and lower reoperation rate.

Investigating the Chronology of Meniscus Root Tears: Do Medial Meniscus Posterior Root Tears Cause Extrusion or the Other Way Around?

Background

Meniscus root tears are increasingly being recognized. Meniscal extrusion has previously been associated with medial root tears; however, the relationship between secondary meniscal restraints, such as the meniscotibial (MT) ligament, extrusion, and root tears has yet to be formally evaluated.

Purpose

To better understand the association between MT ligament competence, medial meniscal extrusion, and medial meniscus posterior root tears (MMPRTs) as well as to determine the progression of meniscal extrusion over time.

Study Design

Case series; Level of evidence, 4.

Methods

Serial magnetic resonance imaging (MRI) scans were reviewed for patients who showed evidence of medial meniscal extrusion and MMPRTs on at least 1 of ≥2 available MRI scans. All patients were symptomatic at the time of diagnosis. All MRI scans were analyzed independently by 2 board-certified musculoskeletal radiologists. MT ligament disruption, medial meniscal extrusion, and MMPRTs were recorded for each MRI scan. The time between MRI scans, presence of insufficiency fractures, and Outerbridge classification for the medial femur and tibia were also evaluated.

Results

Overall, 27 knees in 26 patients were included in this study, with a total of 63 MRI scans analyzed (21 knees with 2 MRI scans, 3 with 3 MRI scans, and 3 with 4 MRI scans). All patients demonstrated clear medial meniscal extrusion and MT ligament disruption before the subsequent development of MMPRTs (P < .001). Mean extrusion at the time of initial MRI was 3.3 ± 1.1 mm and increased significantly to 5.5 ± 1.8 mm at the time of first imaging with an identified MMPRT (P < .001). The mean time between initial MRI and the first identification of an MMPRT on later MRI was 1.7 ± 1.6 years.

Conclusion

In a sample of 27 symptomatic knees with serial MRI scans both before and after an MMPRT diagnosis, all patients demonstrated MT ligament disruption and associated meniscal extrusion before the development of subsequent medial meniscus root tears. These findings suggest that MT ligament disruption and medial meniscal extrusion represent early and predisposing events contributing to MMPRTs. Therefore, this provides a possible explanation of why meniscal extrusion is not corrected with medial meniscus root repair.

Progression of radiographic osteoarthritis after partial meniscectomy in degenerative medial meniscal posterior root tears was greater in varus- than in neutral-aligned knees: a minimum 5-year follow-up

PURPOSE

To perform a radiographic assessment of osteoarthritis, progression after partial meniscectomy (PM) in degenerative medial meniscus posterior root tears (MMPRTs) in relation to preoperative mechanical axis (MA). The hypothesis is that neutral-aligned knees with degenerative MMPRTs have better radiographic outcomes than those of varus-aligned knees after arthroscopic PM.

METHODS

Records of 114 patients with degenerative MMPRTs and Kellgren-Lawrence (KL) grade ≤ 2 osteoarthritis, who underwent PM, had preoperative weight-bearing hip-to-ankle radiographs from 2004 to 2014, and were followed-up for at least 5 years were reviewed retrospectively. The mean follow-up period was 8.3 ± 2.8 years. Preoperative MA values were used to classify the patients into either a Neutral (N valgus 3° to varus 3°; n = 60) or Varus-aligned group (V varus > 3°; n = 54). Joint space width (JSW; mm) and KL grade (0/1/2/3/4) were measured preoperatively and finally on weight-bearing 45° flexion posteroanterior and anteroposterior radiographs, respectively.

RESULTS

Preoperative JSW and KL grade did not differ significantly between the groups (N vs V; JSW 3.64 ± 0.83 vs 3.44 ± 0.81, P = 0.201; KL grade, 2/31/27/0/0 vs 0/22/32/0/0, P = 0.162); however, the final JSW and KL grade differed significantly between the groups (N vs V; JSW 3.03 ± 0.78 vs 2.07 ± 0.87; KL grade, 0/21/23/13/3 vs 0/10/26/21/6, both P < 0.001). The N group showed significantly less KL progression compared with the V group (N vs V; progression/no progression, 27/33 vs 42/12, P = 0.001).

CONCLUSION

The progression of radiographic osteoarthritis after PM for degenerative MMPRTs was greater in varus-aligned knees than in neutral-aligned knees. PM should be considered cautiously in patients with varus-aligned knees.

LEVEL OF EVIDENCE

Retrospective comparative study, Level III.

Degenerative medial meniscus posterior root tear and non-root tear do not show differences in joint survival and clinical outcome after partial meniscectomy

PURPOSE

No comparative studies of outcomes between degenerative medial meniscus posterior root tear (MM PRT) and non-root tear (NRT) have been conducted. This study aimed to compare joint survival and clinical outcome between MM PRT and MM NRT after partial meniscectomy with proper control of confounding factors.

METHODS

One hundred and ten patients each in MM PRT and MM NRT groups who underwent arthroscopic partial meniscectomy were retrospectively evaluated through propensity score matching. Joint survival was assessed on the basis of surgical and radiographic failures. Clinical outcomes were assessed using the Lysholm score.

RESULTS

The confounding variables were well balanced between the groups, with standardized mean differences of < 0.2 after propensity score matching. Failures occurred in 30 (27.3%) and 35 patients (31.8%) in the MM PRT group and MM NRT group, respectively. The estimated mean survival times were 12.5 years (95% confidence interval [CI] 11.5-13.5) and 11.7 years (10.7-12.7), respectively. There were no significant differences in the overall survival rate and Lysholm score between the two groups (n.s.).

CONCLUSION

In middle-aged patients with degenerative MM PRT, joint survival and clinical outcome showed comparable results with those with MM NRT after partial meniscectomy. Arthroscopic partial meniscectomy is one of the effective treatments for MM PRT with consideration of various patient factors.

LEVEL OF EVIDENCE

III.

The menisci and articular cartilage: a life-long fascination

The menisci and articular cartilage of the knee have a close embryological, anatomical and functional relationship, which explains why often a pathology of one also affects the other.

Traumatic meniscus tears should be repaired, when possible, to protect the articular cartilage.

Traumatic articular cartilage lesions can be treated with success using biological treatment options such as microfracture or microdrilling, autologous chondrocyte transplantation (ACT), or osteochondral transplantation (OCT) depending on the depth and area of the lesion.

Degenerative cartilage and meniscus lesions often occur together, and osteoarthritis is already present or impending. Most degenerative meniscus lesions should be treated first conservatively and, after failed conservative treatment, should undergo arthroscopic partial meniscus resection. Degenerative cartilage lesions should also be treated conservatively initially and then surgically; thereby treating the cartilage defect itself and also maintaining the axis of the leg if necessary.

Tears of the meniscus roots are devastating injuries to the knee and should be repaired e.g. by transtibial re-fixation.

The clinical role of ‘ramp’ lesions of the meniscus is still under investigation.

Cite this article: EFORT Open Rev 2020;5:652-662. DOI: 10.1302/2058-5241.5.200016

Stress radiography findings in medial meniscus posterior root tears

BACKGROUND

The present study aimed to evaluate stress radiography and magnetic resonance imaging (MRI) findings in medial meniscus posterior root tears (MMPRTs).

METHODS

The study included 27 patients (26 females, mean age, 53.52 years) who underwent high tibial osteotomy and in whom medial menisci were concurrently examined arthroscopically. Preoperative stress radiographs and MRI series in 14 cases with root tears (MMPRT group, detected arthroscopically) and in 13 cases without tears (control group) were evaluated. Joint spaces measured on the stress radiographs were compared between the operated and opposite knees in each group.

RESULTS

On the varus stress radiographs, the mean lateral joint space of the operated knees was significantly wider than that of the opposite knees in the MMPRT group (P = 0.007). Upon MRI studies, meniscal extrusion was significantly more common in the MMPRT group than in the control group. Moreover, the amount of meniscal extrusion was correlated with the tear size.

CONCLUSIONS

Widening of the lateral joint space on the varus stress radiography was higher in the cases with root tears. Therefore, we propose that stress radiographs can be helpful in the diagnosis of MMPRT.