Meniscal survival rate after anterior cruciate ligament reconstruction

Biomechanical characteristics of the meniscocapsular junction of the posterior segment of the medial meniscus

PURPOSE

Despite extensive literature available on the mechanical properties of knee ligaments and menisci, research on the mechanical properties of the meniscus-capsular junction (MCJ) is lacking. This study aims to investigate the biomechanical behavior of the MCJ of the medial meniscus using a tensile failure test.

MATERIALS AND METHODS

Seven dissected cadaveric knees were used for biomechanical analysis. Tensile failure tests were performed using an INSTRON ElectroPuls E1000 stress system to measure stress/strain curves, maximum load at failure, elastic limit load, elongation at break, elongation at the elastic limit, and linear stiffness, were collected and analyzed.

RESULTS

All ruptures occurred at the MCJ. The MCJ displayed similar mechanical properties to knee ligaments. Average values were: maximum load at failure (63.9 ± 3.2 N), yield load (52.9 N ± 2.6 N), elongation at break (2.5 mm ± 0.3 mm), elongation at the elastic limit (1.25 mm ± 0.15 mm), strain at break (47.0% ± 3.5%), strain at yield (23.2% ± 2.3%), and stiffness (56.6 ± 9. N/mm-1).

CONCLUSION

The meniscus-capsular junction's mechanical properties are similar to other knee ligaments and may play a role in knee stability. The findings provide insights into the the behavior of the meniscus-capsular junction could have clinical implications for diagnosing and surgical treatment of meniscocapsular lesions.

Concomitant Medial Collateral Ligament Injury Increases the Risk of Revision Anterior Cruciate Ligament Reconstruction

PURPOSE

To compare rates of revisions between patients with isolated anterior cruciate ligament (ACL) reconstruction and those who had concomitant medial collateral ligament (MCL) injuries managed either operatively or nonoperatively at the time of index anterior cruciate ligament reconstruction (ACLR).

METHODS

Using laterality-specific International Classification of Diseases, Tenth Revision (ICD-10) and Current Procedural Terminology (CPT) codes, we queried the PearlDiver-Mariner Database for all patients who underwent ACLR between 2016 and 2020. Patients were included if they were ages 15 or older and had a minimum of 2 years of follow-up after index ACLR. Patients were then divided into cohorts by presence or absence of concomitant MCL injury. The cohort of concomitant MCL injuries was further subdivided into those with MCL injuries managed nonoperatively, with MCL repair, or with MCL reconstruction at the time of index ACLR. Multivariate regression was performed between cohorts to evaluate for factors associated with revision ACLR.

RESULTS

We identified 47,306 patients with isolated ACL injuries and 10,846 with concomitant MCL and ACL injuries. In total, 93% of patients with concomitant MCL injuries had their MCL treated nonoperatively; however, the annual proportion of patients being surgically managed for their MCL injury increased by 70% from 2016 to 2020. Concomitant MCL injury patients had greater odds of undergoing revision ACLR compared with patients with isolated ACL injuries (odds ratio 1.50, 95% confidence interval 1.36-1.66, P < .001). Among patients with concomitant MCL injuries, surgically managed patients had a greater risk of revision ACLR compared with nonoperatively managed MCL injuries (odds ratio 1.39, 95% confidence interval 1.01-1.86, P = .034).

CONCLUSIONS

Despite an increase in operatively managed concomitant MCL injuries, most concomitant MCL injuries were still managed nonoperatively at the time of ACLR. Patients with concomitant MCL injuries, particularly those managed operatively, at the time of ACLR are at increased risk of requiring revision ACLR compared with those with isolated ACL injuries.

LEVEL OF EVIDENCE

Level III, retrospective comparative case series.

Clinical outcome of iterative meniscal suture after ACL reconstruction at a minimum of 2 years' follow-up

INTRODUCTION

Failure rates in meniscal suture associated to ACL reconstruction range from 10 to 26.9%, often leading to meniscectomy. In young patients, the wish to conserve the meniscus may lead to iterative suture, if the lesion allows. There are no data available for clinical results of repeat meniscal suture at the same site as the primary lesion in a stabilized knee. The immediate socioeconomic cost, compared to meniscectomy, needs to be taken into account, and benefit needs to be demonstrated. The main aim of the present study was to assess the rate of secondary meniscectomy after iterative meniscal suture in stabilized knees. The study hypothesis was that failure rates are higher in iterative isolated meniscal suture after ligament reconstruction than in primary repair.

MATERIAL AND METHODS

This single-center retrospective study analyzed patients receiving iterative meniscal suture on stable knee, between 2009 and 2019, with a minimum 26 months' follow-up. Twenty-three patients were analyzed: 15 male, 8 female; mean age at iterative suture, 28.1±7.9 years (range, 14-49 years); mean BMI, 24.2±2.9kg/m2 (range, 19-31). Mean time to recurrence was 38.9±25.1 months (range, 6-93 months). Initial ACL graft used the patellar ligament in 69.6% of cases (n=16) and the hamstrings in 30.4% (n=7). Mean differential laximetry before iterative suture was 1.7±0.3mm (range, 1.2-2.3mm). Iterative suture was in the medial meniscus in 69.6% of cases (16/23) and in the lateral meniscus in 30.4% (7/23). Risk factors for failure, defined by requirement for meniscectomy, were assessed. Functional results were assessed on Knee injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee (IKDC) score and Tegner score.

RESULTS

The failure rate was 48% (11/23), incorporating all lesions together. Bucket-handle tear was most frequently associated with failure (91%; p<0.01). There was significant improvement after iterative suture in subjective IKDC score (51.6±15.2 vs. 81.3±15.6; p<0.001) and KOOS scores: symptoms and stiffness, 66.6±13.7 vs. 91.1±7.53 (p<0.001); pain, 79.2±12.7 vs. 93.4±7.4 (p<0.01); function, 91.3±11.2 vs. 97.9±4.44 (p<0.001); quality of life, 38.1±23.2 vs. 62.3±30.1 (p<0.001).

CONCLUSION

The failure rate for iterative meniscal suture on stabilized knee was 48%. Bucket-handle tear was a major risk factor for failure (91%). Despite these high failure rates, functional results systematically improved.

LEVEL OF EVIDENCE

IV.

Graft failure within 2 years of isolated anterior cruciate ligament reconstruction is associated with increased risk of secondary meniscus tears

PURPOSE

A debilitating complication following anterior cruciate ligament reconstruction is a secondary meniscus tear. Currently, the literature is mixed regarding the risk factors associated with the incidence of secondary meniscus tears. The aim of this study was to investigate risk factors associated with meniscus tears following an isolated primary anterior cruciate ligament reconstruction. ACL graft failure was hypothesized to be the strongest risk factor for secondary meniscal injury occurrence.

METHODS

A retrospective cohort analysis was performed using the PearlDiver Database. Patients with a primary anterior cruciate ligament reconstruction were identified in the database. Patients with concomitant knee ligament injury or meniscus injury present at the time the index procedure were excluded. Patients were grouped to those who had a secondary meniscus tear within 2 years following anterior cruciate ligament reconstruction and those who did not. Univariate analysis and multivariable regression analysis was conducted to identify significant risk factors for a secondary meniscus tear.

RESULTS

There were 25,622 patients meeting criteria for inclusion in this study. Within 2 years from the primary anterior cruciate ligament reconstruction, there were 1,781 patients (7.0%) that experienced a meniscus tear. Graft failure had the highest odds of having a postoperative meniscus tear within 2 years (OR: 4.1; CI 3.5-4.8; p < 0.002). Additional significant risk factors included tobacco use (OR: 2.0; CI 1.0-3.1; p < 0.001), increased Charlson Comorbidity Index (OR: 1.2; CI 1.1-1.4), male gender (OR: 1.1; CI 1.1-1.2; p < 0.001), obesity (OR: 1.1; CI 1.1-1.2; p < 0.001), delayed surgery (OR:1.1; CI 1.1-1.2; p < 0.002), and patients age 30 and older (OR: 1.0; CI 1.0-1.0; p < 0.001).

CONCLUSIONS

This study found that anterior cruciate ligament graft failure is the strongest predictor of post-operative meniscus tears. Other risk factors, including tobacco use, increased CCI, male gender, obesity, delayed surgery, and age 30 and older, were established, with several being modifiable. Therefore, targeted preoperative optimization of modifiable risk factors and postoperative protocols may reduce the risk of secondary meniscus tears.

LEVEL OF EVIDENCE

Level III, prognostic trial.

Clinical and MRI Outcomes of Repaired Peripheral Longitudinal Tears of the Posterior Horn of the Medial Meniscus With ACL Reconstruction: Results According to Tear Size

Background

Arthroscopic repair of longitudinal tears in the medial meniscal posterior horn (MMPH) has been reported to result in high rates of meniscal healing when performed alongside anterior cruciate ligament reconstruction (ACLR). However, studies that have focused on longitudinal tears and their impact on clinical outcomes after arthroscopic repair are insufficient.

Purpose

To investigate the clinical outcome and healing status after concomitant arthroscopic ACLR and repair of MMPH peripheral longitudinal tears, with respect to the tear length.

Study Design

Cohort study; Level of evidence, 3.

Methods

A total of 263 patients who underwent concurrent arthroscopic suture repair of longitudinal tears of the MMPH and ACLR were enrolled. All patients had 2-year postoperative magnetic resonance imaging (MRI) evaluations, and 61% of patients underwent a second-look arthroscopy. The exclusion criteria were partial meniscectomies and multiligament injuries. Patients were assessed pre- and postoperatively for clinical scores, amount of anterior translation, grade of pivot shift, and presence of meniscal tear extension. According to the length of longitudinal tears, patients were classified into 2 groups: (1) patients with tears that were located in the posterior compartment and (2) patients with tears that extended to the midbody of the meniscus. Binary stepwise logistic regression analysis was used to evaluate the risk factors for unhealed menisci as identified by MRI.

Results

A total of 83 patients were included in this study-52 patients (group 1) had MMPH tears without tear extension and 31 patients (group 2) had MMPH tears with tear extension. There were no differences in outcomes between the groups, including the healing rate after meniscal repair (P > .05). Based on postoperative MRI scans, 67 patients (80.7%) were categorized as completely healed and 16 patients (19.3%) as unhealed. There were no significant differences between the completely healed and unhealed groups in outcomes or the rate of preoperative midbody tear extension. Higher body mass index and lower preoperative Lysholm scores were identified as risk factors for unhealed menisci.

Conclusion

Overall, the rate of complete healing of MMPH tears repaired concomitantly with ACLR was 80.7% (67/83), and midbody tear extension did not affect the healing rate of the repaired meniscus. Results indicate that suture repair for unstable MMPH tears should be considered regardless of tear size.

More anterior placement of femoral tunnel position in ACL-R is associated with postoperative meniscus tears

PURPOSE

The purpose of this study was to investigate the relationship between tunnel position in ACL reconstruction (ACL-R) and postoperative meniscus tears.

METHODS

This was a single institution, case-control study of 170 patients status-post ACL-R (2010-2019) separated into two matched groups (sex, age, BMI, graft type). Group 1-symptomatic, operative meniscus tears (both de novo and recurrent) after ACL-R. Group 2-no postoperative meniscus tears. Femoral and tibial tunnel positions were measured by 2 authors via lateral knee radiographs that were used to measure two ratios (a/t and b/h). Ratio a/t was defined as distance from the tunnel center to dorsal most subchondral contour of the lateral femoral condyle (a) divided by total sagittal diameter of the lateral condyle along Blumensaat's line (t). The ratio b/h was defined as distance between the tunnel and Blumensaat's line (b) divided by maximum intercondylar notch height (h). Wilcoxon sign-ranks paired test was used to compare measurements between groups (alpha set at p < 0.05).

RESULTS

Group 1 had average follow up of 45 months and Group 2 had average follow up of 22 months. There were no significant demographic differences between Groups 1 and 2. Group 1-a/t was 32.0% (± 10.2), which was significantly more anterior than group 2, 29.3% (± 7.3; p < 0.05). There was no difference in average femoral tunnel ratio b/h or tibial tunnel placement between groups.

CONCLUSIONS

A relationship exists between more anterior/less anatomic femoral tunnel position and the presence of recurrent or de novo, operative meniscus tears after ACL-R. Surgeons performing ACL-R should strive for recreation of native anatomy via proper tunnel placement to maximize postoperative outcomes.

LEVEL OF EVIDENCE

Level III.

Combined ACL and ALL reconstruction reduces the rate of reoperation for graft failure or secondary meniscal lesions in young athletes

PURPOSE

Graft failure and secondary meniscal tears are major concerns after anterior cruciate ligament (ACL) reconstruction in young athletes. The aim was to evaluate the link between ACL reconstruction with and without anterolateral ligament (ALL) reconstruction and outcomes in young patients participating in pivoting sports.

METHODS

This was a retrospective study of data collected prospectively. Patients less than 20 years, involved in pivoting sports and undergoing primary ACL reconstruction with a quadruple hamstring tendon (4HT) graft or 4HT graft combined with anterolateral ligament reconstruction (4HT + ALL) were included. Survival analysis was performed to identify the prognostic indicators for reoperation due to graft failure or secondary meniscal lesions. Knee laxity was assessed and patient reported outcome measures (PROMs) were collected.

RESULTS

A total of 203 patients (mean (± SD) age: 16.3 ± 2 years) with a mean follow-up of 4.8 ± 0.9 (range: 3.3‒6.8) years were included. There were 101 4HT and 102 4HT + ALL grafts. Graft rupture rates were 11.9% for 4HT grafts and 5.8% for 4HT + ALL grafts (n.s.). There were 9.9% secondary meniscal procedures for 4HT grafts vs. 1.9% for 4HT + ALL grafts (p = 0.02). With reoperation for graft failure or secondary meniscal lesions at final follow-up as the endpoint, survival was better in the 4HT + ALL group (91.4% vs. 77.8%, respectively; p = 0.03). Absence of ALL reconstruction (HR = 4.9 [95%CI: 1.4-17.9]; p = 0.01) and preoperative side-to-side laxity > 3 mm (HR = 3.1 [95%CI: 1.03-9.1]; p = 0.04) were independently associated with an increased rate of reoperations. Mean (± SD) side-to-side laxity was 1.3 ± 1.3 mm (range: - 2 to 5) for 4HT grafts vs. 0.9 ± 1.3 mm (range: - 6 to 4.8) for 4HT + ALL grafts (n.s.) 6 months post-surgery. The rate of return to the same sport at the same level was 42.2% for 4HT grafts vs. 52% for 4HT + ALL grafts (n.s.). There was no significant difference in subjective outcomes including PROMs between the two groups.

CONCLUSION

Combined ALL + ACL reconstruction reduced the rate of graft failure and secondary meniscal injury in young athletes when compared to ACL reconstruction alone. Subjective results were comparable, with a similar rate of complications. Combined reconstruction should be preferred in this young population.

LEVEL OF EVIDENCE

Level IV.

Long-term Natural History of Unrepaired Stable Ramp Lesions: A Retrospective Analysis of 28 Patients With a Minimum Follow-up of 20 Years

BACKGROUND

There is a lack of consensus about whether stable ramp lesions associated with anterior cruciate ligament (ACL) injuries need to be repaired.

PURPOSE/HYPOTHESIS

The purpose of this study was to evaluate how many stable ramp lesions left in situ during ACL reconstruction (ACLR) have subsequently failed after >20 years of follow-up. We hypothesized that ACL-reconstructed knees with ramp lesions left in situ without repair have a high risk of meniscal failure over the long term.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

All patients who underwent arthroscopic ACLR by a single experienced surgeon between January 1998 and December 2000 were evaluated retrospectively. Included were all cases of longitudinal tears in the meniscocapsular junction or the red zone of the posterior horn of the medial meniscus that were left in situ and identified through the anterior portals. Successful anterior probing confirmed a meniscal tear of the posterior segment. A lesion was considered stable if it was ≤2 cm and did not extend beyond the lower pole of the femoral condyle. The following data were collected preoperatively and at the last follow-up: demographics, time to surgery, side-to-side laxity, pivot shift, Lysholm score, subjective International Knee Documentation Committee score, Knee injury and Osteoarthritis Outcome Score, Tegner activity scale, and meniscal failure rate. We defined 2 groups based on our findings: medial meniscal failure versus no medial meniscal failure.

RESULTS

A total of 716 knees underwent primary ACLR during this period. The 39 (5.4%) stable unrepaired ramp lesions identified were included in the case series. Mean ± standard deviation follow-up was 262.1 ± 10.5 months. Eleven patients (28%) were lost to follow-up. Of the remaining patients, 8 (28.6%) had a medial meniscal failure, of which 6 (21.4%) were bucket-handle tears. The average time elapsed before complications was 87.8 ± 52 months (range, 6-156 months). The medial meniscal survival rate was 93% at 5 years, 75% at 10 years, and 71% at 15 and 20 years. The failure event mainly happened between 96 and 120 months (8 and 10 years) after ACLR. No risk factors for failure were found, but some trends appeared, such as older age, higher body mass index, and preoperative rotational instability. All postoperative scores were significantly improved at the last follow-up (P < .0001); 16 patients (57%) returned to their sport of choice.

CONCLUSION

With nearly one-third of patients developing meniscal complications, including a large share of bucket-handle tears and mostly occurring 8 years after the ACLR, it may not be wise to leave stable ramp lesions unrepaired.

Meniscal Repair Outcomes at Greater Than 5 Years: A Systematic Review and Meta-Analysis

BACKGROUND

The utilization of meniscal repair techniques continues to evolve in an effort to maximize the rate of healing. Meniscal repair outcomes at a minimum of 5 years postoperatively appear to better represent the true failure rates. Thus, a systematic review and meta-analysis of the current literature was conducted to assess the rate of failure at a minimum of 5 years after meniscal repair.

METHODS

We performed a systematic review of studies reporting the outcomes of meniscal repair at a minimum of 5 years postoperatively. A standardized search and review strategy was utilized. Failure was defined as recurrent clinical symptoms or a meniscal reintervention to repair or resect the meniscus in any capacity, as defined by the study. When reported, outcomes were assessed relative to anterior cruciate ligament (ACL) status, sex, age, and postoperative rehabilitation protocol. Meta-analyses were performed with a random-effects model.

RESULTS

A total of 27 studies of 1,612 patients and 1,630 meniscal repairs were included in this review and meta-analysis. The pooled overall failure rate was 22.6%, while the failure rate of modern repairs (excluding early-generation all-inside devices) was 19.5%. Medial repairs were significantly more likely to fail compared with lateral repairs (23.9% versus 12.6%, p = 0.04). Failure rates were similar for inside-out (14.2%) and modern all-inside repairs (15.8%). Early-generation all-inside devices had a significantly higher failure rate (30.2%) compared with modern all-inside devices (15.8%, p = 0.01). There was no significant difference in meniscal failure rate between repairs with concomitant ACL reconstruction (21.2%) and repairs in ACL-intact knees (23.3%, p = 0.54).

CONCLUSIONS

Modern meniscal repair had an overall failure rate of 19.5% at a minimum of 5 years postoperatively. Modern all-inside techniques appear to have improved the success rate of meniscal repair compared with use of early-generation all-inside devices. Lateral repairs were significantly more likely to be successful compared with medial repairs, while no difference was seen between patients undergoing meniscal repair with and without concomitant ACL reconstruction.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Suture Hook Versus All-Inside Repair for Longitudinal Tears of the Posterior Horn of the Medial Meniscus Concomitant to Anterior Cruciate Ligament Reconstruction: A Matched-Pair Analysis From the SANTI Study Group

BACKGROUND

Secondary meniscectomy rates after repair of longitudinal tears of the posterior horn of the medial meniscus (PHMM) performed concomitantly with anterior cruciate ligament reconstruction (ACLR) are reported to be as high as 25% with an all inside repair technique. Posteromedial portal suture hook repair is an emerging technique; however, it is unknown whether it confers a significantly reduced secondary meniscectomy rate compared with the current gold standard.

PURPOSE/HYPOTHESIS

The primary objective of this study was to compare the secondary meniscectomy rates of suture hook repair and all inside repair for longitudinal tears of the PHMM performed concomitant to ACLR. The secondary outcome was to determine the risk factors associated with the failure of the repair. It was hypothesized that repair with an all inside device would be associated with higher secondary meniscectomy rates when compared with suture hook repair and that concomitant anterolateral ligament reconstruction (ALLR) would confer improved meniscal repair survivorship.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients with longitudinal tears of the PHMM who underwent meniscal repair during primary ACLR between January 2011 and December 2015 at our institution were eligible for the study. Patients undergoing suture hook repair were propensity matched in a 1:1 ratio to patients who underwent all inside repair. At the end of the study period, secondary meniscectomy rates were determined.

RESULTS

The study population comprised 237 matched pairs. The mean follow up was 97.7 ± 17.3 months. Patients who underwent an all inside repair had a >2-fold higher failure rate compared with patients who underwent suture hook repair through a posteromedial portal (31.2% vs 15.6%; P = .0003). Patients in the suture hook repair group undergoing additional ALLR demonstrated a >3-fold higher meniscal repair survival rate compared with all other subgroups (P = .0014). This association was not seen in the all inside repair group. The only statistically significant risk factor for meniscal repair failure was the suture repair technique (hazard ratio, 2.133 [95% CI, 1.383-3.292]; P = .0008).

CONCLUSION

Suture hook repair through a posteromedial portal is associated with a significantly lower secondary meniscectomy rate when compared with the all inside meniscal repair of longitudinal tears of the PHMM performed at the time of ACLR. Furthermore, patients in the suture hook repair group who underwent an additional ALLR had a significantly better meniscal repair survivorship compared with all other subgroups.

Risk Factors for New Meniscal Tears following Anterior Cruciate Ligament Reconstruction

This study aims to compare the rate of meniscal tears after anterior cruciate ligament (ACL) reconstruction in patients who have undergone concomitant meniscal repair during the index procedure with that in patients who have not undergone such surgery. It also evaluates other risk factors, such as age, gender, race, body mass index (BMI), site of concomitant meniscal surgery, and ACL graft failure. This is a retrospective study conducted at a large tertiary public hospital. Patients who underwent primary anterior cruciate ligament reconstruction (ACLR) surgery with or without concomitant meniscal repair from 2011 to 2016 were identified. Patients with old meniscal tears and previous meniscal surgeries were excluded. The aforementioned demographical, injury, and surgical details were obtained and analyzed using univariate and multivariate logistic regression analysis. Our study cohort included 754 patients. Primary ACLR surgery was performed with meniscal repair in 172 (22.8%) of the patients, with meniscectomy in 202 (26.8%) of the patients, and without concomitant meniscal surgery in 380 (50.4%) of the patients. A total of 81 (10.7%) patients developed meniscal tears after the index procedure. Such tears occurred in 12.2% (21 of 172) of the patients who had undergone concomitant meniscal repair during the index ACLR, and in 10.3% (60 of 582) of the patients who had not undergone concomitant meniscal repair (p = 0.30). On multivariate analysis, only ACL graft failure was significantly associated with new meniscal tears (p < 0.001, odds ratio 18.69, 95% confidence interval 9.18-38.05). ACL graft failure is the only independent risk factor for meniscal tears after ACLR surgery in our large cohort of patients. Concomitant meniscal repair was not an associated risk factor.

Incidência de lesões da rampa meniscal nas reconstruções do ligamento cruzado anterior

Objetivo Avaliar a incidência e o perfil epidemiológico das lesões da rampa meniscal nos pacientes submetidos a cirurgia de reconstrução do ligamento cruzado anterior (LCA), e determinar os fatores de risco relacionados.

Métodos Foram analisados retrospectivamente 824 pacientes submetidos a cirurgia de reconstrução do LCA. Os pacientes que apresentaram instabilidade meniscal medial foram submetidos a avaliação do compartimento posteromedial do joelho. Em caso de lesão, o reparo cirúrgico foi realizado. Potenciais fatores de risco associados às lesões foram analisados.

Resultados A incidência geral de lesões da rampa na população estudada foi de 10,6% (87 lesões em 824 pacientes). A análise multivariada pelo teste do Qui-quadrado demonstrou que a presença de lesões da rampa meniscal foi significativamente associada aos seguintes fatores de risco: lateralidade direita e lesões crônicas. Sexo, idade e atividade esportiva não foram estatisticamente significantes. O futebol foi a causa mais frequente de lesões da rampa relacionadas ao esporte, com 78,2% dos casos. No entanto, não se mostrou ser um fator de risco. De 2014 a 2019, a incidência anual variou de 4,0% a 20,6%.

Conclusão A incidência das lesões da rampa meniscal foi de 10,6% nas cirurgias de reconstrução do LCA, sendo mais frequente em pacientes com lesões crônicas. A incidência anual foi crescente, e variou de 4,0%, em 2014, a 20,6%, em 2019.

Isolated Meniscotibial Ligament Rupture: The Medial Meniscus "Belt Lesion"

Ramp lesions play a major role in both anteroposterior and rotational instability following anterior cruciate ligament rupture. The meniscotibial ligament (MTL) is the most important structure to repair and is the primary stabilizer of the posterior horn of the medial meniscus. The posteroinferior insertion of the MTL on the posterior horn of the medial has been described, forming a posterior "belt." Isolated MTL lesion diagnosis can be challenging, as the absence of a meniscocapsular ligament lesion prevents its correct visualization through transnotch vision. This article details a technique to diagnose and repair the "belt lesion" of the medial meniscus.

Incidence of Associated Lesions of Multiligament Knee Injuries: A Systematic Review and Meta-analysis

Background:

The incidence of concomitant injuries, including meniscal and cartilage injuries, has not been adequately reported in previous studies on multiligament knee injury (MLKI) because their primary focal points have been the degree of ligament injury, treatment strategy, involvement of other soft tissues, and neurovascular injury.

Purpose:

To analyze the incidence of associated lesions in MLKIs, including medial and lateral meniscal injuries, cartilage lesions, and complications.

Study Design:

Systemic review; Level of evidence, 4.

Methods:

The PubMed, Embase, Cochrane Library, CINAHL, and Scopus databases were searched between inception and April 30, 2020. Studies were included if they reported the incidence rates of medial and/or lateral meniscal tears and cartilage injuries in cases of MLKIs. For the meta-analysis, data were extracted on clinical outcomes measured according to the number of medial and/or lateral meniscal tears, cartilage injuries, and complications.

Results:

A total of 45 studies were included in the MLKI analysis (3391 patients). The pooled rate of medial meniscal tears was 30.4% (95% CI, 24.1%-37.1%; P < .0001; I² = 85.8%). The pooled rate of lateral meniscal tears was 27.5% (95% CI, 20.3%-35.3%; P < .0001; I² = 89.6%). The pooled rate of cartilage injuries was 27.5% (95% CI, 22.1%-33.3%; P < .0001; I² = 86.8%). The pooled rates of peroneal nerve injuries, vascular injuries, and arthrofibrosis were 19.2% (95% CI, 14.2%-24.7%; P < .001; I² = 81.3%), 18.4% (95% CI, 13.2%-24.3%; P < .0001; I² = 81.0%), and 11.2% (95% CI, 8.1%-14.7%; P = .0018; I² = 54.0%), respectively.

Conclusion:

The pooled rates of meniscal tears and cartilage injuries concomitant with MLKIs were high, ranging from 27% to 30%, and the pooled rates of peroneal nerve injury, vascular injury, and arthrofibrosis were considerable, ranging from 11% to 19%. The influence of these associated lesions on clinical results should be evaluated in future clinical studies.

Clinical outcome of a new remnant augmentation technique with anatomical double-bundle anterior cruciate ligament reconstruction: Comparison among remnant preservation, resection, and absent groups

Purpose

The aim of this study was to verify the effects of a new remnant augmentation technique with anatomical double-bundle anterior cruciate ligament (ACL) reconstruction for postoperative clinical scores, anterior stability and frequency of complications compared to remnant removal and cases with remnant defects.

Methods

The 105 patients who underwent anatomical double-bundle ACL reconstruction were divided into three groups. If the remnant was a Crain I-III type, remnant-preserving bone tunnel creation was attempted. After the creation of the bone tunnel, good continuity was maintained in 34 patients (preserved group). Due to lost continuity, the remnant was resected in 26 patients (resected group). No identifiable remnant continuity remained (Crain IV) in 45 patients (absent group). The Lysholm knee score, Tegner activity scale, International Knee Documentation Committee (IKDC) subjective score, anterior stability measured using the KT-1000 arthrometer at 2 years postoperatively, and frequency of complications were compared among the three groups. Univariate and multiple linear regression analysis were performed to clarify the factors affecting postoperative anterior stability.

Results

The Lysholm knee score, Tegner activity scale, IKDC subjective score, and frequency of complications were not significantly different among the groups. The mean side-to-side difference of anterior stability was significantly better in the preserved group (0.3 ± 1.6 mm) compared to the resected group (1.6 ± 2.3 mm, p = 0.003) and absent group (1.6 mm ± 1.7, p = 0.009). The multiple linear regression analysis showed remnant preservation significantly related to postoperative anterior stability.

Conclusion

Although there were no differences in clinical scores, the ACL reconstruction with new preservation technique showed good anterior stability and no difference in the frequency of complications.

No significant improvement in neuromuscular proprioception and increased reliance on visual compensation 6 months after ACL reconstruction

Purpose

To determine the contributions of proprioceptive and visual feedbacks for postural control at 6 months following ACLR, and to determine their associations with knee laxity, isokinetic tests and clinical scores.

Study design

Level IV, Case series.

Methods

Fifty volunteers who received ACLR between May 2015 and January 2017 were prospectively enrolled, and at 6 months following ACLR, postural stability was assessed. Somatosensory ratios (somatic proprioception), and visual ratios (visual compensation), were calculated to evaluate the use of sensory inputs for postural control. Univariable regression analyses were performed to determine associations of somatosensory and visual ratios with knee laxity, isokinetic tests and clinical scores.

Results

At 6 months following ACLR, the somatosensory ratio did not change, while the visual ratio decreased significantly from 5.73 ± 4.13 to 3.07 ± 1.96 (p = 0.002), indicating greater reliance on visual cues to maintain balance. Univariable analyses revealed that the somatosensory ratio was significantly lower for patients who performed aquatic therapy (β = -0.50; p = 0.045), but was not associated with knee laxity, muscle strength or clinical scores. An increased visual ratio was associated with patients who received hamstrings tendon autografts (β = 1.32; p = 0.049), but was not associated with knee laxity, muscle strength or clinical scores.

Conclusion

At 6 months following ACLR, visual ratios decreased significantly, while somatosensory ratios did not change. This may suggest that there is little or no improvement in neuromuscular proprioception and therefore greater reliance on visual cues to maintain balance. The clinical relevance of this study is that posturography can provide useful information to help research following ACLR and to predict successful return to play.

Ramp Lesions of the Posterior Segment of the Medial Meniscus: What Is Repaired? A Qualitative Histological Study of the Meniscocapsular and Meniscotibial Attachments

BACKGROUND

Lesions of the posterior segment of the medial meniscus are the most common intraarticular lesions associated with ACL injuries. Ramp lesions are tears in the peripheral attachment of the posterior horn of the medial meniscus. Such injuries are difficult to detect on preoperative MRI. Arthroscopically, the prevalence of these lesions can reach 24%. Anatomical descriptions of the posterior horn of the medial meniscus are becoming clearer, however, histological descriptions are lacking, especially with regard to the presence or absence of capillaries.

QUESTIONS/PURPOSES

The present qualitative histologic study focused on the posterior segment of the medial meniscus and the meniscocapsular and meniscotibial junctions. Specifically, the objective of this study was to analyze the posterior segment of the medial meniscus and the meniscosynovial junction and to determine whether the meniscus tibial ligament exists.

METHODS

We dissected 10 unpaired cadaveric knees (five male, five female, age range 55 to 66 years), five left and five right, from the French "Don du corps" body donation program via a posterior approach to the posteromedial capsule. We excluded specimens with intra-articular abnormalities (ACL rupture, meniscal tear, arthrosis) preceding dissection by arthrotomy. We thus accessed the posterior segment of the medial meniscus and the meniscosynovial junction. The proximal capsule, posterior segment of the medial meniscus, entire meniscal capsular-tibial junction, and a fragment of the tibia were removed en bloc. For each knee, three sagittal spaced sections of the posterior segment of the medial meniscus (Zone 4 as defined by Śmigielski) were performed. Two experienced pathologists performed qualitative histological analysis on the 30 samples after Hematoxylin and eosin staining, and Safranin O staining.

RESULTS

Macroscopically, the meniscotibial attachments were pellucid and homogeneous, as were the meniscocapsular attachments; however, the meniscocapsular attachments appeared to be denser in both the anterior and posterior regions of the capsule. Microscopy of the meniscosynovial junction revealed loose collagen fibers that were partially oriented but not parallel, a cellular network featuring a few fibroblasts and adipocytes, and several capillaries. No between-attachment histologic differences were apparent; both tissues shared a site of attachment to the posterior horn of the medial meniscus. We did not detect the meniscotibial ligament, macroscopically or microscopically.

CONCLUSIONS

A ramp lesion may not be a ligamentous injury because the meniscotibial ligament was not detected. Rather, it appears that a ramp lesion is a tear in the common attachment point between the posterior horn of the medial meniscus and meniscocapsular and meniscotibial junctions. This structure is vascularized, and contains nonoriented low cellularity collagen of moderate density.

CLINICAL RELEVANCE

Based on our results, a better rationale for the recommendation of surgical repair of a ramp appears to be needed, given the absence of a meniscotibial ligament, and the presence of capillaries in the meniscocapsular and meniscotibial attachments.

Editorial Commentary: Ramp Lesion: The Eye Sees Only What the Mind Is Prepared to Comprehend

If our consciousness is not prepared, it is difficult to identify a ramp lesion on preoperative magnetic resonance imaging due to its low sensitivity. In clinical practice, the prevalence of ramp lesion in the anterior cruciate ligament (ACL)-injured knee can be up to 30%, with an increased frequency in chronic ACL injuries and in revision ACL. To identify the ramp lesion, routine arthroscopic exploration of the posteromedial portion of knee using a trans-notch view during ACL reconstruction therefore seems essential. A decrease in reoperation rate for secondary meniscectomy from 25% to 7% since 2013 was published by our department, after the adoption of a systematic repair through a posteromedial portal with a suture hook device for ramp lesions identified at the time of ACL reconstruction.

Very long-term osteoarthritis rate after anterior cruciate ligament reconstruction: 182 cases with 22-year' follow-up

BACKGROUND

Few data are available on the 20-year outcomes of anterior cruciate ligament (ACL) reconstruction. The purpose of this study was to assess the prevalence and risk factors of knee osteoarthritis at least 20 years after ACL reconstruction.

HYPOTHESIS

Factors associated with progression to knee osteoarthritis include meniscal lesions, level of physical activity, injury-to-surgery time, body mass index, residual laxity, tunnel position and cartilage injury.

MATERIAL AND METHODS

One hundred and eighty two patients were included in a multicentre retrospective study conducted in the setting of a SoFCOT symposium. Females contributed two-thirds of the study population. ACL reconstruction was performed arthroscopically in 82% of cases, and a bone-patellar tendon-bone transplant was used in 92.8% of cases. Mean age at surgery was 26±7years. Clinical outcomes were assessed based on the objective and subjective IKDC scores and on the KOOS. Radiographic evidence of osteoarthritis was classified according to the IKDC. Factors evaluated for their ability to predict progression to osteoarthritis included age, sex, body mass index, level of physical activity, injury-to-surgery time, meniscectomy, cartilage injury, tunnel position and residual laxity.

RESULTS

At last follow-up, the objective IKDC score was A (normal) for 48%, B for 35%, and C or D for 17% of the knees. The mean subjective IKDC score was 82.7±13.1. Moderate-to-severe osteoarthritis was present in 29% of cases. The following risk factors for osteoarthritis were identified: medial or lateral meniscectomy, residual laxity, age >30years at surgery, and engaging in a pivoting sport. Meniscectomy was a major contributor to the development of osteoarthritis (17% of knees without vs. 46% with meniscectomy). Finally, the ACL re-tear rate was 13%.

CONCLUSION

ACL reconstruction provides satisfactory knee stability. The risk of subsequent osteoarthritis depends chiefly on the status of the menisci. Residual laxity is also associated with the development of osteoarthritis.

LEVEL OF EVIDENCE

IV, retrospective cohort study.

High incidence of subsequent re-operation following treatments for medial meniscus tears combined with anterior cruciate ligament reconstruction: second-look arthroscopic study

Background

The Multicenter Orthopaedic Outcomes Network (MOON) group recently reported that medial meniscus (MM) repairs are associated with more frequent re-operations when compared to lateral meniscus (LM) repairs. The purpose of this study was to compare the meniscal healing and the incidence of subsequent re-operation of medial and lateral meniscal tears that occurred concurrently with anterior cruciate ligament (ACL) injuries.

Methods

We retrospectively reviewed patients who underwent second-look arthroscopy after primary ACL reconstruction (ACLR) between June 2005 to December 2016. The healing of meniscal tears following repair or left in situ, and re-tear following partial meniscectomy, were evaluated via second-look arthroscopy and compared between medial and lateral meniscus. Moreover, the incidence of subsequent meniscal re-operation after the index ACLR were investigated and compared between medial and lateral meniscus. Subsequent meniscal re-operation was performed in cases of the following three symptomatic meniscus tears: re-tears at the meniscectomy site; new tears; and failed healing of repaired or left in situ meniscus.

Results

There were 148 meniscal tears in 121 patients at index ACLR. There were 62 MM tears, 38 LM tears, and 24 bilateral meniscus tears. At second-look arthroscopy, the “successful healing” rate for tears following repair was higher in LM tears (91.2%) compared to MM tears (80.0%), although it was not statistically significant (p > 0.05). No significant differences were observed in the healing of left in situ tears or re-tear of meniscectomy site between medial and lateral meniscus. Patients with MM tears combined with ACL injuries had a higher incidence of subsequent meniscal re-operation compared to patients with LM tears (25.6% vs 16.1%, p = 0.025).

Conclusions

There was a trend for the successful healing rate to be higher in LM repairs than MM repairs. Subsequent meniscal re-operations after ACLR were more frequent in patients with medial meniscal tears concurrently with ACL injuries in comparison to patients with lateral meniscal tears.

Level of study

Level IV, retrospective case series.

Tibial slope and medial meniscectomy significantly influence short-term knee laxity following ACL reconstruction

PURPOSE

To determine demographic, anatomic, and surgical factors associated with static and dynamic Anterior Tibial Translation (ATT) following ACL reconstruction. The hypothesis was that both static and dynamic ATT would be greater in knees with high tibial slope or that required meniscectomy.

METHODS

The authors prospectively enrolled 280 consecutive patients that had primary ACL reconstruction using hamstring autografts at one center for which preoperative tear type, meniscal tears, and medial tibial slope were documented. A total of 137 were excluded due to concomitant extra-articular tenodesis or surgical antecedents on either knee, and 18 were lost to follow-up, leaving 125 that were evaluated at a minimum of 6 months including: static ATT on monopodal weight-bearing radiographs, and dynamic ATT on differential stress radiographs using the Telos™ device.

RESULTS

Both postoperative static and dynamic ATT were strongly associated with preoperative static and dynamic ATT (respectively, β = 0.068 and β = 0.50, p < 0.001). Multivariable regression confirmed that postoperative static ATT increased with tibial slope (β = 0.24; CI 0.01-0.47; p = 0.042) and in knees that had partial medial meniscectomy (β = 2.05; CI 0.25-3.84; p = 0.025), while dynamic ATT decreased with age (β = - 0.11; CI - 0.16 to - 0.05; p < 0.001), and increased with tibial slope (β = 0.27; CI 0.04-0.49; p = 0.019) and in knees that had partial medial meniscectomy (β = 2.20; CI 0.35-4.05; p = 0.019).

CONCLUSION

Both static and dynamic ATT following ACL reconstruction increased with tibial slope and in knees that had partial medial meniscectomy. These findings could help surgeons tailor their techniques and 'à la carte' rehabilitation protocols, by preserving the menisci and sometimes delaying full weight-bearing and return to sport in patients at risk, and hence improve outcomes and prevent graft failures.

STUDY DESIGN

Cohort study.

LEVEL OF EVIDENCE

V.

Analysis of the trends in arthroscopic meniscectomy and meniscus repair procedures in France from 2005 to 2017

INTRODUCTION

In 2008, the French National Authority for Health (HAS) recommended that "conservative" treatments be adopted for meniscal lesions. This recommendation and the lack of superiority of meniscectomy over non-operative treatment for meniscus degeneration have modified the treatment pathway. However, the impact of these findings on French clinical practice is not known. The objective of this study was to evaluate the change over time in the number of alternative surgical procedures (meniscectomy and meniscus repair) and regional variation in France using data from the French agency for information on hospital care (ATIH).

HYPOTHESIS

We hypothesized that the number of meniscectomy procedures will decrease, and the number of repair procedures will increase over time at various healthcare facilities.

PATIENTS AND METHODS

Between 2005 and 2017, the number of hospitalizations in the Medicine-Surgery-Obstetrics wards for meniscectomy (NFFC003 and NFCC004) or meniscus repair (NFEC001 and NFEC002) was evaluated overall and then based on whether the stay occurred in public or private sector hospitals in France. Data were extracted from the ATIH database and the findings were (1) related to French demographics during the period in question; (2) separated into public or private sector hospitals; (3) distributed into various regions in France and; (4) stratified by patient age.

RESULTS

Between 2005 and 2017, 1,564,461 meniscectomy and 63,142 meniscus repair procedures were done in France. Over this period in the entire country, the meniscectomy rate gradually decreased from 19.80/10,000 inhabitants in 2005 to 15.77/10,000 inhabitants in 2017 (21.4% reduction) (p<0.0001) while the meniscus repair rate increased from 0.42/10,000 inhabitants in 2005 to 1.36/10,000 inhabitants in 2017 (320% increase) (p<0.0001). The largest meniscectomy reduction effort occurred in private sector hospitals, going from 15.79 to 12.01/10,000 inhabitants in 12 years; the decrease was smaller in public hospitals (going from 4.01 to 3.77/10,000 inhabitants) (p<0.0001 in both cases). The change in the procedure ratio between private and public hospitals was asymmetric, with the meniscus repair/meniscectomy ratio clearly increasing more in public hospitals (4% to 12.6%) between 2005 and 2017 than in private hospitals (1.6% to 6.6%) (p<0.0001). We found large regional differences: regions in Eastern France had higher meniscectomy rates, while regions in Western France had higher meniscus repair rates. When the analysis of procedures between 2008 and 2017 was stratified by age, a similar increase in repair procedures was found in all age brackets. Conversely, the reduction in meniscectomy was most apparent before 40 years of age, and the number of meniscectomy procedures was stable after 60 years of age.

CONCLUSION

These findings suggest there has been a significant shift in the surgical management of meniscal injuries towards more conservative treatments. But the large variations between regions in France is evidence of a continued disparity in clinical practices.

LEVEL OF EVIDENCE

IV, retrospective study without control group.

Bridge-Enhanced Anterior Cruciate Ligament Repair: Two-Year Results of a First-in-Human Study

Background

Bridge-enhanced anterior cruciate ligament repair (BEAR) combines suture repair of the anterior cruciate ligament (ACL) with a specific extracellular matrix scaffold (the BEAR scaffold) that is placed in the gap between the torn ends of the ACL to facilitate ligament healing.

Purpose/Hypothesis

The purpose of this study was to report the 12- and 24-month outcomes of patients who underwent the BEAR procedure compared with a nonrandomized concurrent control group who underwent ACL reconstruction (ACLR) with an autograft. We hypothesized that the BEAR group would have physical examination findings, patient-reported outcomes, and adverse events that were similar to those of the ACLR group.

Study Design

Cohort study; Level of evidence, 2.

Methods

Ten patients underwent BEAR, and 10 underwent ACLR with a 4-stranded hamstring autograft. At 24 months, 9 of the 10 BEAR patients and 7 of the 10 ACLR patients completed a study visit. Outcomes reported included International Knee Documentation Committee (IKDC) subjective and objective results, knee anteroposterior (AP) laxity findings via an arthrometer, and functional outcomes.

Results

There were no graft or repair failures in the first 24 months after surgery. The IKDC subjective scores in both groups improved significantly from baseline (P < .0001) at 12 and 24 months, to 84.6 ± 17.2 in the ACLR group and to 91.7 ± 11.7 in the BEAR group. An IKDC objective grade of A (normal) was found in 44% of patients in the BEAR group and in 29% of patients in the ACLR group at 24 months; no patients in either group had C (abnormal) or D (severely abnormal) grades. Arthrometer testing demonstrated mean side-to-side differences in AP laxity that were similar in the 2 groups at 24 months (BEAR, 1.94 ± 2.08 mm; ACLR, 3.14 ± 2.66 mm). Functional hop testing results were similar in the 2 groups at 12 and 24 months after surgery. Hamstring strength indices were significantly higher in the BEAR group compared with the ACLR group (P = .0001).

Conclusion

In this small, first-in-human study, BEAR produced similar outcomes to ACLR with a hamstring autograft. BEAR may result in knee stability and patient-reported outcomes at 2 years sufficient to warrant longer term studies of efficacy in larger groups of patients.

Lateral Meniscal Posterior Root Repair With Anterior Cruciate Ligament Reconstruction Better Restores Knee Stability

BACKGROUND

The effect of lateral meniscal posterior root tear and repair-commonly seen in clinical practice in the setting of anterior cruciate ligament (ACL) reconstruction-is not known.

PURPOSE/HYPOTHESIS

This study evaluated the effect of tear and repair of the lateral meniscal posterior root on the biomechanics of the ACL-reconstructed knee. It was hypothesized that anterior tibial translation would increase under anterior loading and simulated pivot-shift loading with the root tear of the posterior lateral meniscus, while repair of the root tear would reduce it close to the noninjured state.

STUDY DESIGN

Controlled laboratory study.

METHODS

Thirteen fresh-frozen adult human knees were tested with a robotic testing system under 2 loading conditions: (1) an 89.0-N anterior tibial load applied at full extension and 15°, 30°, 60°, and 90° of knee flexion and (2) a combined 7.0-N·m valgus and 5.0-N·m internal tibial torque (simulated pivot-shift test) applied at full extension and 15° and 30° of knee flexion. The following knee states were tested: intact knee, ACL reconstruction and intact lateral meniscus, ACL reconstruction and lateral meniscal posterior root tear, and ACL reconstruction and lateral meniscal posterior root repair.

RESULTS

In the ACL-reconstructed knee, a tear of the lateral meniscal posterior root significantly increased knee laxity under anterior loading by as much as 1 mm. The transosseous pullout suture root repair improved knee stability under anterior tibial and simulated pivot-shift loading. Root repair improved the ACL graft force closer to that of the native ACL under anterior tibial loading.

CONCLUSION

Lateral meniscal posterior root injury further destabilizes the ACL-reconstructed knee, and root repair improves knee stability.

CLINICAL RELEVANCE

This study suggests a rationale for surgical repair of the lateral meniscus, which can restore stability close to that of the premeniscal injury state.

The Cost-Effectiveness of Meniscal Repair Versus Partial Meniscectomy in the Setting of Anterior Cruciate Ligament Reconstruction

PURPOSE

To compare the cost-effectiveness of anterior cruciate ligament (ACL) reconstruction with meniscal repair to ACL reconstruction with partial meniscectomy.

METHODS

A decision-analytic Markov disease progression model with a 40-year horizon was created simulating outcomes after both meniscal repair and partial meniscectomy at the time of ACL reconstruction. Event probabilities, costs, and utilities were used for the index procedures. The development of osteoarthritis and subsequent knee replacement were either calculated or selected from published literature. Difference in cost, difference in quality-adjusted life-years (QALYs), and incremental cost-effective ratio were calculated to determine which index procedure is most cost-effective.

RESULTS

There is total direct cost from ACL reconstruction with meniscus repair of $17,898 compared with that with partial meniscectomy of $24,768 (cost savings of $6,870). There was an estimated gain of 18.00 QALYs after ACL reconstruction with meniscus repair compared with 17.16 QALYs with partial meniscectomy (increase of 0.84 QALYs). In this scenario, meniscus repair is the dominant index procedure at the time of ACL reconstruction.

CONCLUSIONS

Meniscal repair at the time of ACL reconstruction is more cost-effective than partial meniscectomy.

LEVEL OF EVIDENCE

Level IV, economic and decision analysis.

Similar failure rate in immediate post-operative weight bearing versus protected weight bearing following meniscal repair on peripheral, vertical meniscal tears

PURPOSE AND HYPOTHESIS

Post-operative weight bearing after meniscal repair is a point of debate among physicians. This study sought to evaluate whether patients adhering to an immediate WBAT rehabilitation programme have a higher failure rate compared to those adhering to a more traditional, protected, NWB status following meniscal repair. The null hypothesis was that there would be no difference in failure between the two groups.

METHODS

A retrospective review of meniscal repair patients greater than 5 years from surgery was performed for patients receiving meniscal repair treatment. Patients were categorized by post-surgical weight-bearing status, either NWB or WBAT, and then analysed for failure of repair. Failure was defined as re-operation on the torn meniscus. The study controlled for variables including age at surgery, sex, height, weight, and BMI, classification of tear type, acuity of the tear, repair location (medial or lateral), repair location within the meniscus, repair technique, and concomitant procedures.

RESULTS

Re-operations were performed in 61 of 157 patients [38.9%]. There was no difference between weight-bearing groups for failure of meniscus repair (n.s.). The tears were acute vertical tears located in the posterior horn and body. For the 61 patients with re-operation, the average time to re-operation was 2.2 years with 10 [16%] > 5 years from surgery, 17 [28%] 2-5 years from surgery, and 34 [56%] < 2 years from surgery. In isolated meniscal repair patients (n = 62), there was no difference between weight-bearing groups for rate of re-operation (n.s.).

CONCLUSION

Weight bearing as tolerated after meniscal repair for peripheral, vertical tears does not result in a higher failure rate than traditional, non-weight bearing over a five-year follow-up period. The clinical relevance is that, based on these data, it may be appropriate to allow weight bearing as tolerated following meniscal repair of peripheral, vertical tears.

LEVEL OF EVIDENCE

Retrospective cohort study, Level III.

Meniscus repairs can be saved in the event of postoperative septic arthritis

PURPOSE

No systematic studies on optimal treatment of postoperative septic arthritis following arthroscopic meniscus repair are available. The purpose of this study was to retrospectively evaluate the fate of repaired menisci in cases of postoperative septic arthritis, with treatment for infection focused on arthroscopic irrigation and debridement (I&D) and intention to maintain the meniscus.

METHODS

Data of two sports orthopedics centers of the last 10 years were pooled (approximately 25,000 arthroscopic procedures of the knee). All cases of septic arthritis following arthroscopic meniscus repair were identified. These cases were retrospectively evaluated with regard to clinical course and management, especially the number of necessary I&Ds, if eradication was achieved, and if the repaired meniscus was retained or a partial resection was necessary ('early failure'). Patients with initially maintained meniscus repairs were contacted if further meniscus surgery was performed in further follow-up ('late failure').

RESULTS

20 patients with 23 repaired menisci were included. In 65% (13 cases), a concomitant anterior cruciate ligament reconstruction was performed. A mean of 2.0 ± 1.0 (1-4) arthroscopic I&Ds were performed in the treatment of septic arthritis. In two cases, additional open surgery was performed (after outside-in sutures). Eradication was achieved in all cases. Four repaired menisci (17.4%) showed loosened fixation or substantial degradation and were consequently partially resected within treatment for septic arthritis (early failures). The follow-up rate for the 19 initially maintained menisci was 94.7% after 3.0 ± 2.2 years (median 2.8, 0.4-7.8). Three of these underwent further partial resection (13.0%). Cumulative 3-year survival rate (Kaplan-Meier method) of all repairs was 70.7% (95% CI 50.3-91.1%), and for the subgroup of initially maintained menisci 85.6% (95% CI 67.0-100.0%), respectively.

CONCLUSION

Septic arthritis following meniscus repair can be successfully treated with (sequential) arthroscopic I&Ds. There is a considerable rate of early failures, however, in a mid-term follow-up the failure rate of initially retained menisci is low and comparable to what we know from the literature for cases without infection. Therefore, it is generally recommended to try to save the repaired menisci in these cases.

LEVEL OF EVIDENCE

IV, therapeutic case series.

Arthroscopic medial meniscal repair with or without concurrent anterior cruciate ligament reconstruction: A subgroup analysis

BACKGROUND

There are few large-scale, long-term studies comparing medial meniscal repairs with or without concurrent anterior cruciate ligament (ACL) reconstruction.

METHODS

A total of 140 patients who underwent arthroscopic medial meniscal repair were divided into two groups: Group A, meniscus repair only and Group B, meniscus repair with concurrent ACL reconstruction. Clinical assessments in- cluded physical examination findings, Lysholm score, and the International Knee Documentation Committee (IKDC) form. Barret criteria were used for the clinical assessment of healing status. Magnetic resonance imaging (MRI)was obtained to confirmhealing and failure. Subgroups of participants were compared in terms of suture technique, type of tear, and location of tear. KT-2000 arthrometer testing was used for objective evaluation of anterior-posterior knee movement.

RESULTS

Mean follow-up duration was 61 (34-85) months. Clinical outcomes in both groups were significantly improved compared to baseline (P=0.001 vs. P=0.001); however, there was no significant between-group difference in postoperative Lysholm and IKDC scores (P=0.830). The outcomes of three participants (seven percent) in Group A and 11 (11.3%) in Group B were considered as treatment failures (P=0.55). Red-red zone tears had higher scores. Mean postoperative KT2000 arthrometer values of failed participants in Groups A and B were 4.66mm (range, four to six) and 5.2mm (range, two to seven), respectively.

CONCLUSION

Concurrentmedialmeniscus repair and ACL reconstruction did not have clinical superiority over meniscus repair alone. Repairs in the red-red zone appeared to be associated with better outcomes.

Short-term complications in intra- and extra-articular anterior cruciate ligament reconstruction. Comparison with the literature on isolated intra-articular reconstruction. A multicenter study by the French Arthroscopy Society

INTRODUCTION

Lateral tenodesis (LT) is performed to limit the risk of iterative tear following anterior cruciate ligament (ACL) reconstruction in at-risk patients. By adding an extra procedure to isolated ACL graft, LT reconstruction increases operating time and may complicate postoperative course. The objective of the present study was to evaluate the rate of early complications. The study hypothesis was that associating ALL reconstruction to ACL reconstruction does not increase the complications rate found with isolated ACL reconstruction.

MATERIAL AND METHODS

A prospective multicenter study included 392 patients: 70% male; mean age, 29.9 years; treated by associated ACL and LT reconstruction. All adverse events were inventoried.

RESULTS

Mean hospital stay was 2 days, with 46% day-surgery. Walking was resumed at a mean 27 days, with an advantage for patients treated by the hamstring technique. The early postoperative complications rate was 12%, with 1.7% specifically implicating LT reconstruction: pain, hematoma, stiffness in flexion and extension, and infection. There was a 5% rate of surgical revision during the first year, predominantly comprising arthrolysis for extension deficit. The 1-year recurrence rate was 2.8%.

DISCUSSION

The complications rate for combined intra- and extra-articular reconstruction was no higher than for isolated intra-articular ACL reconstruction, with no increase in infection or stiffness rates. The rate of complications specific to ALL reconstruction was low, at 1.7%, and mainly involved fixation error causing lateral soft-tissue impingement.

LEVEL OF EVIDENCE

IV, prospective multicenter study.

Prognostic factors for all-inside meniscal repair. A 87-case series

INTRODUCTION

Repair is indicated for tears in non-degenerative menisci. The literature reports a 15% failure rate for all-inside repair. The aim of the present study was to determine prognostic factors for failure of all-inside meniscal repair. The study hypothesis was that epidemiological, clinical and surgical factors affect success.

MATERIAL AND METHODS

A retrospective study included 87 meniscal repair procedures, with or without anterior cruciate ligament (ACL) tear. Lesions were located in red-red or red-white zones. After freshening, repair comprised an all-inside arthroscopic technique using the FasT-Fix^® system (Smith & Nephew), with (70.1%) or without ligament reconstruction; all ACL tears were reconstructed. Preoperative data comprised: age, gender, smoking status, sports activity, trauma-to-surgery time, body mass index (BMI), frontal morphotype, and IKDC score. Intra- and postoperative data comprised: meniscal lesion characteristics, location, number of sutures, type of ACL reconstruction, presence of chondropathy, authorized postoperative ranges of motion, and IKDC score. Failure was defined by secondary meniscectomy.

RESULTS

At 31 months' follow-up, there were 13 failures (15%). Mean postoperative IKDC score was 88.19 (range: 64.37-98.95). Bucket-handle lesion (P=0.006) and BMI>25 (P=0.014) emerged as significant factors of poor prognosis.

DISCUSSION

The present failure rate matched those reported in the literature. The more extensive the lesion, the higher the risk of failure. High BMI incurs mechanical stresses that increase the risk of failure.

LEVEL OF EVIDENCE

IV, retrospective cohort study.

High failure rate of anterior cruciate ligament reconstruction with bimeniscal repair: A case-control study

BACKGROUND

Bimeniscal lesions are common in patients with anterior cruciate ligament (ACL) tears. However, bimeniscal repair is rarely performed during ACL reconstruction.

OBJECTIVE

To assess outcomes after ACL reconstruction with bimeniscal repair.

HYPOTHESIS

Bimeniscal lesions, even when repaired, are associated with poorer outcomes of ACL reconstruction.

MATERIAL AND METHODS

A retrospective case-control design was used. The cases were 15 patients who underwent ACL reconstruction, without procedures on any other ligaments, combined with bimeniscal repair, between May 2009 and May 2013 (3.2% of all ACL reconstructions during the study period). This group (2-Mc group) was matched on age, gender, body mass index, and time to surgery to 30 patients who underwent ACL reconstruction and had no meniscal lesions (0-Mc group) and to 30 patients who underwent ACL reconstruction and repair of the medial meniscus (1-Mc group). After a mean follow-up of 3.6 years, clinical outcomes were assessed based on the KOOS, Lysholm, and IKDC scores and knee laxity based on TELOS and GNRB measurements. The primary outcome measure was the rate of ACL re-rupture. Secondary outcome measures were functional outcomes and rate of delayed meniscectomy.

RESULTS

The ACL re-rupture rate was significantly higher in the 2-Mc group than in the 0-Mc and 1-Mc groups pooled (20%, vs. 1.7%; P=0.02). The functional scores showed no significant differences across groups. Post-operative differential laxity was significantly greater in the 2-Mc group (3.3mm by TELOS, P=0.02; and 2.5mm by GNRB, P=0.03) than in the 0-Mc and 1-Mc groups pooled. Delayed meniscectomy was performed in none of the 2-Mc group patients and in 2 of the 1-Mc group patients.

CONCLUSION

ACL reconstruction combined with bimeniscal repair is a rarely performed procedure. It is associated with a high ACL re-rupture rate and greater differential laxity. Meniscal outcomes of bimeniscal repair, in contrast, are good.

LEVEL OF EVIDENCE

III, matched case-control study.

Outcomes of Inside-out Meniscal Repair in the Setting of Multiligament Reconstruction in the Knee

BACKGROUND

Limited evidence exists for meniscal repair outcomes in a multiligament reconstruction setting. Purpose/Hypothesis: The purpose of this study was to assess outcomes and failure rates of meniscal repair in patients who underwent multiligament reconstruction compared with patients who underwent multiligament reconstruction but lacked meniscal tears. The authors hypothesized that the outcomes of meniscal repair associated with concomitant multiligament reconstruction would significantly improve from preoperatively to postoperatively at a minimum of 2 years after the index surgery. Secondarily, they hypothesized that this cohort would demonstrate similar outcomes and failure rates compared with the cohort that did not have meniscal lesions at the time of multiligament reconstruction.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Inclusion criteria for the study included radiographically confirmed skeletally mature patients of at least 16 years of age who underwent multiligamentous reconstruction of the knee without previous ipsilateral osteotomy, intra-articular infections, or intra-articular fractures. Patients were included in the experimental group if they underwent inside-out meniscal suture repair with concurrent multiligament reconstruction. Those included in the control group (multiligament reconstruction without a meniscal tear) underwent multiligament reconstruction but did not undergo any type of meniscal surgery. Lysholm, Western Ontario and McMaster Universities Osteoarthritis Index, Short Form-12 physical component summary and mental component summary, Tegner activity scale, and patient satisfaction scores were recorded preoperatively and postoperatively. The failure of meniscal repair was defined as a retear of the meniscus that was confirmed arthroscopically.

RESULTS

There were 43 patients (16 female, 27 male) in the meniscal repair group and 62 patients (25 female, 37 male) in the control group. Follow-up was obtained in 93% of patients with a mean of 3.0 years (range, 2.0-4.7 years). There was a significant improvement between all preoperative and postoperative outcome scores ( P < .05) for both groups. The meniscal repair group had significantly lower preoperative Lysholm and Tegner scores ( P = .009 and P = .02, respectively). There were no significant differences between any other outcome scores preoperatively. The failure rate of the meniscal repair group was 2.7%, consisting of 1 symptomatic meniscal retear. There was no significant difference in any postoperative outcome score at a minimum 2-year follow-up between the 2 groups.

CONCLUSION

Good to excellent patient-reported outcomes were reported for both groups with no significant differences in outcomes between the cohorts. Additionally, the failure rate for inside-out meniscal repair with concomitant multiligament reconstruction was low, regardless of meniscus laterality and tear characteristics. The use of multiple vertical mattress sutures and the biological augmentation resulting from intra-articular cruciate ligament reconstruction tunnel reaming may be partially responsible for the stability of the meniscal repair construct and thereby contribute to the overall improved outcomes and the low failure rate of meniscal repair, despite lower preoperative Lysholm and Tegner scores in the meniscal repair group.

Outcomes After Biologically Augmented Isolated Meniscal Repair With Marrow Venting Are Comparable With Those After Meniscal Repair With Concomitant Anterior Cruciate Ligament Reconstruction

BACKGROUND

Meniscal repair in the setting of anterior cruciate ligament (ACL) reconstruction has demonstrated superior outcomes compared with isolated meniscal repair. Limited evidence exists for the effects of biological augmentation in isolated meniscal repair, particularly as compared with meniscal repair with concomitant ACL reconstruction. Purpose/Hypothesis: The purpose of this study was to compare the outcomes and survivorship of meniscal repair in 2 cohorts of patients: meniscal repair with biological augmentation using a marrow venting procedure (MVP) of the intercondylar notch, and meniscal repair with concomitant ACL reconstruction. We hypothesized that the clinical outcomes and survivorship of meniscal repair with concomitant ACL reconstruction would be improved compared with meniscal repair with biological augmentation.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Inclusion criteria were skeletally mature patients aged ≥16 years who underwent inside-out meniscal repair and either a concomitant MVP of the intercondylar notch or ACL reconstruction. Patients were excluded from this study if they were skeletally immature, underwent meniscus root or radial tear repair, or underwent meniscal repair with concurrent ligamentous reconstruction not limited to the ACL. At the preoperative evaluation and a minimum 2 years after the index meniscal repair procedure, patients were administered a subjective questionnaire. Differences in outcome scores, survivorship, and failure rates between the cohorts were assessed. Failure was defined as reoperation with meniscectomy or revision meniscal repair.

RESULTS

There were 109 patients (52 female, 57 male) who met the inclusion criteria for this study. There were 37 knees in cohort 1 (isolated meniscal repair plus MVP) and 72 knees in cohort 2 (meniscal repair plus ACL reconstruction). The failure status was known in 95 patients, and patient-reported outcome scores were obtained in 89 (82%) patients. Both cohorts demonstrated a significant improvement in all outcome scores, and there was no significant difference in any of the preoperative or postoperative outcome measures. The overall failure rate was 9.5% (9/95). There were 4 (12.9%) failures in cohort 1 and 5 failures (7.8%) in cohort 2, with no significant difference in failures between the cohorts ( P = .429). There was a significant association between failure and female sex ( P = .001).

CONCLUSION

The most important finding in this study was that there was no difference in outcomes in meniscal repair performed with biological augmentation using an MVP versus that performed concomitantly with ACL reconstruction. The similar outcomes reported for meniscal repair with an MVP and meniscal repair with ACL reconstruction may be partly attributed to biological augmentation.