Combined Meniscus Repair and Anterior Cruciate Ligament Reconstruction

Complications in Anterior Cruciate Ligament Surgery and How to Avoid Them

Complications following anterior cruciate ligament (ACL) reconstruction can be detrimental to a patient's recovery and limit their ability to successfully return to sport. Arthrofibrosis, graft failure, and infection are a few examples of complications that can arise. Therefore, it is important for surgeons to recognize that each step during perioperative surgical decision making can impact patients' risk for such complications. The purpose of this paper is to discuss common complications following ACL reconstruction and how surgeons can avoid or reduce the risk of complications.

Editorial Commentary: Various Meniscal Repair Techniques Show Similar Biomechanical and Clinical Outcomes, and Horizontal Suture Orientation Is Best Avoided

Knee meniscal repair shows favorable outcomes, especially if associated with anterior cruciate ligament reconstruction. However, a favorable clinical outcome does not mean that the meniscus has healed. There is no difference in clinical outcomes between all-inside and inside-out meniscal repair techniques. The all-inside technique is faster and associated with a lower incidence of neurovascular injuries. In terms of biomechanical studies, protocols vary, and no meniscal repair technique (all-inside, inside-out, or outside-in) is clearly superior to any other technique regarding tensile load, tissue failure rate, or restoration of contact mechanics. That said, a vertically oriented meniscal suture captures circumferential collagen bundles and is superior in strength to any horizontal meniscal stitch. A horizontal meniscal stitch orientation should be avoided.

A Modified Suture Hook Technique for Lateral Meniscus Tears: Chinese Union Suture Procedure (CUSP)

Tears in the lateral meniscus, especially the body and posterior horn, are a common sports medicine injury, and severe cases require arthroscopic treatment. However, the narrow space in the posterolateral compartment of the knee joint makes the surgeon's operation inconvenient. Here we have proposed a suture technique suitable for lateral meniscus posterior horn/body injuries known as the Chinese Union Suture Procedure. The introduction of the posteromedial-transseptal portal allows for a suitable angle of operation for suture hooks in case of injuries to the posterior horn of the lateral meniscus or the popliteal hiatus area of the lateral meniscus. The use of the continuous sewing machine-like suture technique allows surgeons to more quickly and flexibly address meniscus tears. We have also introduced a retractor as an auxiliary tool for portal establishment. In conclusion, our improved technique enables vertical mattress suturing for meniscus tears, and it allows for tying knots on the tibial surface of the meniscus, which is challenging to achieve with traditional all-inside suture hook techniques. Our technique combines flexibility, speed, and cost-effectiveness, making it valuable for clinical applications.

Meniscal Ramp Lesion Repair Without the Need for a Posteromedial Portal

Medial meniscal ramp injury has gained the attention of orthopaedic surgeons in recent years. It consists of a tear of the peripheral insertion of the posterior horn of the medial meniscus. Its prevalence in anterior cruciate ligament reconstruction varies between 9% and 40% according to different studies. Ramp lesions cannot always be diagnosed using magnetic resonance imaging scans. To identify ramp lesions, the arthroscope should be introduced into the posteromedial compartment of the knee during the routine examination of the knee (Gillquist maneuver). Not all authors advocate systematically repairing ramp injuries of the medial meniscus, especially when these injuries are small and stable. They have historically been repaired using an outside-in technique using a hook-type suture passed through a posteromedial portal. In this study, we present our all-inside suture technique without the use of a posteromedial portal.

Arthroscopic Lateral Meniscus Root Repair With Reverse Suture Anchor Technique

The stability of the knee joint is crucially dependent on the integrity of the lateral meniscus posterior root, which is often accompanied by anterior cruciate ligament injury. Anchor suture repair for lateral meniscus posterior root injury not only achieves better biomechanical effects but also ensures favorable prognosis. However, the placement of anchors often requires the establishment of a posterior approach, and the insertion of an anchor is a technical challenge. In light of this, we have applied the technique of reverse anchor fixation for repairing the lateral meniscus posterior root, which not only simplifies the procedure but also effectively reduces the "bungee effect."

A High-Grade Lachman's Exam Predicts a Ramp Tear of the Medial Meniscus in Patients with Anterior Cruciate Ligament Tear: A Prospective Clinical and Radiological Evaluation

Background: Medial meniscus ramp tears are present in 22.9-40.8% of anterior cruciate ligament tears. The diagnosis of ramp tears is difficult on MRI, with sensitivity reported around 48%, which has recently emphasized the importance of proper arthroscopic probing for ramp tears. Methods: A prospective evaluation was performed on patients undergoing a single bundle ACL reconstruction to assess patient demographics, posterior tibial slope, posterior cruciate ligament angle, Lachman's exam, and rotational instability to determine secondary findings associated with medial meniscal ramp tears. Results: A total of 96 patients underwent ACL reconstruction, of these, 63 patients had an isolated ACL tear, and 33 patients had an ACL tear with a concomitant medial meniscus ramp tear. A high-grade Lachman's exam and male sex were associated with medial meniscus ramp tears. There were no differences in posterior tibial slope, posterior cruciate ligament angle, or rotational instability between groups. Conclusions: This study found that a high-grade Lachman's exam and male sex were significantly associated with patients with an ACL tear with a concomitant medial meniscus ramp tear. These findings suggest that an ACL tear with concomitant medial meniscus ramp tear may be better diagnosed based upon the clinical evaluation rather than other secondary radiological findings.

Medial meniscal lesions increase antero-posterior laxity in knees with anterior cruciate ligament injury

PURPOSE

The aim of this study was to quantify the impact of concomitant meniscal lesions on knee laxity using a triaxial accelerometer in a large population of patients affected by anterior cruciate ligament (ACL) injury.

METHODS

A total of 326 consecutive patients (261 men and 65 women, mean age 31.3 ± 11.3) undergoing primary ACL reconstruction, were preoperatively evaluated through Lachman and pivot shift tests using a triaxial accelerometer to quantify knee laxity. An analysis based on the presence of meniscal tears assessed during surgery was performed to evaluate the impact of meniscal lesions on knee laxity.

RESULTS

The anterior tibial translation (Lachman test) presented significantly higher values in patients with medial meniscal lesions (7.3 ± 1.7 mm, p = 0.049) and both medial and lateral meniscal lesions (7.7 ± 1.6 mm, p = 0.001) compared to patients without concomitant meniscal lesions (6.7 ± 1.3 mm). Moreover, patients with both medial and lateral meniscal lesions presented significantly higher values of anterior tibial translation compared to patients with lateral meniscal lesions (p = 0.049). No statistically significant differences were found between the groups in terms of tibial acceleration (pivot shift test).

CONCLUSION

This study demonstrated that the contribution of concomitant meniscal lesions to knee laxity can be objectively quantified using a triaxial accelerometer in ACL-injured knees. In particular, medial meniscus lesions, alone or in association with lateral meniscus lesions, determine a significant increase of the anterior tibial translation compared to knees without meniscus tears.

LEVEL OF EVIDENCE

Level IV.

Prevalence of post-traumatic osteoarthritis after anterior cruciate ligament injury remains high despite advances in surgical techniques

Aims

The aim of this study was to report the pooled prevalence of post-traumatic osteoarthritis (PTOA) and examine whether the risk of developing PTOA after anterior cruciate ligament (ACL) injury has decreased in recent decades.

Methods

The PubMed and Web of Science databases were searched from 1 January 1980 to 11 May 2022. Patient series, observational studies, and clinical trials having reported the prevalence of radiologically confirmed PTOA after ACL injury, with at least a ten-year follow-up, were included. All studies were analyzed simultaneously, and separate analyses of the operative and nonoperative knees were performed. The prevalence of PTOA was calculated separately for each study, and pooled prevalence was reported with 95% confidence intervals (CIs) using either a fixed or random effects model. To examine the effect of the year of injury on the prevalence, a logit transformed meta-regression analysis was used with a maximum-likelihood estimator. Results from meta-regression analyses were reported with the unstandardized coefficient (β).

Results

The pooled prevalence of PTOA was 37.9% (95% CI 32.1 to 44) for operatively treated ACL injuries with a median follow-up of 14.6 years (interquartile range (IQR) 10.6 to 16.7). For nonoperatively treated ACL injuries, the prevalence was 40.5% (95% CI 28.9 to 53.3), with a median of follow-up of 15 years (IQR 11.7 to 20.0). The association between the year of operation and the prevalence of PTOA was weak and imprecise and not related to the choice of treatment (operative β -0.038 (95% CI -0.076 to 0.000) and nonoperative β -0.011 (95% CI -0.101 to 0.079)).

Conclusion

The initial injury, irrespective of management, has, by the balance of probability, resulted in PTOA within 20 years. In addition, the prevalence of PTOA has only slightly decreased during past decades. Therefore, further research is warranted to develop strategies to prevent the development of PTOA after ACL injuries.

Delaying ACL reconstruction is associated with increased rates of medial meniscal tear

PURPOSE

The aim of this study was to evaluate the relationship between the time from injury to ACL reconstruction (ACLR) and the rate as well as repairability of meniscal tears. Secondary aims were to evaluate the relationship between meniscal injury and Tegner Activity Scale, age, BMI, and gender.

METHODS

Between 2012 and 2022, 1,840 consecutive ACLRs were performed. A total of 1,317 ACLRs were included with a mean patient age of 31.2 years ± 10.5 [16-60]. Meniscal tear was assessed during arthroscopy using the ISAKOS classification. Time from injury to ACLR, Tegner Activity Scale, age, BMI and gender were analysed in uni- and then in multivariate analyses. Patients were divided into four groups according to the time from injury to surgery: < 3 months (427; 32%), 3-6 months (388; 29%), 6-12 months (248; 19%) and > 12 months (254; 19%).

RESULTS

Delaying ACLR > 12 months significantly increased the rate of medial meniscal (MM) injury (OR 1.14; p < 0.001). No correlation was found between a 3- or 6-month time from injury to surgery and MM tear. Performing ACLR > 3, 6, or 12 months after injury did not significantly increase the rate of lateral meniscal (LM) injury. Increasing Tegner activity scale was significantly associated with a lower rate of MM injury (OR 0.90; p = 0.020). An age > 30 years (OR 1.07; p = 0.025) and male gender (OR 1.13; p < 0.0001) was also associated with an increased rate of MM injury. Age > 30 years decreased the rate of MM repair (OR 0.85; p < 0.001). Male gender increased the rate of LM tear (OR 1.10; p = 0.001).

CONCLUSION

Performing ACLR more than 12 months after injury was associated with increased rates of MM injury but not with lower rates of repairable lesions. An increased pre-injury Tegner activity score was associated with a decreased rate of MM tear. Age > 30 years was associated with an increased rate of MM tear with concomitant ACL injury and a decreased rate of repairability of MM tear. ACLR should be performed within 12 months from injury to prevent from the risk of MM injury.

LEVEL OF EVIDENCE

Level III.

Meniscal Ramp Repair: Double-Row Anatomic Repair in Acute Anterior Cruciate Ligament Tears

The surgical management of medial meniscus ramp lesions can be challenging. Currently, repairs are performed via a trans-notch view, combined with a single posteromedial working portal. This technique, however, does not allow for a direct and complete visualization of the structures being injured, making a precise appreciation of the injured structures, as well as an anatomical repair, difficult. To overcome this limitation, a 2-portal posteromedial approach has recently been described. It allows better visualization of the mediolateral extent of the tear and a precise identification of the injured structures. In this Technical Note, an anatomic repair technique using this approach is presented. It consists of a double-row of sutures to repair individually both the meniscotibial and meniscocapsular ligament, thus restoring the 2 main components of the posterior horn of the medial meniscus to their natural insertion site.