Return to Sports After Athletes Undergo Meniscal Surgery: A Systematic Review

The management of isolated meniscal tears in skeletally immature children. An international expert consensus

PURPOSE

The prevalence and appreciation of meniscal tears in children have increased in both number and complexity. There is currently a paucity of high-quality evidence that can guide surgeons in treating skeletally immature patients with meniscal injuries. The aim of this study was to develop comprehensive recommendations for the management of isolated meniscal tears in skeletally immature children.

METHODS

An international, two-round, modified Delphi consensus was completed. Included 'experts' were identified as having an established adult knee practice, including children and either: (1) Faculty at an international paediatric knee conference, (2) Active members of complex national paediatric multi-disciplinary groups or (3) Members of faculty on recognised national/international instructional courses aimed at teaching the management of meniscal lesions to knee surgeons. The currently available literature was reviewed, and areas of poor quality, inconclusive or absent evidence were examined and formed the focus of the study. A threshold of 70% was used to define consensus for our study based on other similar Delphi consensus studies in the literature.

RESULTS

A total of 43 experts (Round 1) and 41 experts (Round 2) took part in the Delphi study, including surgeons from Europe, the United States of America and South America. 34 statements were identified exploring three main domains-clinical assessment, management and complex tears (bucket handle, discoid and radial). Following Round 1, consensus was reached on 17 (50%) statements; subsequently, after completion of Round 2, consensus was reached on 28 (82%) statements, leaving six (18%) with no consensus. The areas of no consensus included investigation of painless clicking, the most sensitive clinical test for meniscal pathology, treatment of small radial tears (less than 1/3 width), ability to reduce chronic bucket handle tears and timing of surgery.

CONCLUSIONS

This is the first modified Delphi consensus that provides evidence for surgeons treating skeletally immature children with isolated meniscal tears. A valuable level of consensus was reached on the assessment and management of simple and specialist meniscal tears. These consensus statements can both inform clinical practice and be used in the development of further high-quality research studies.

LEVEL OF EVIDENCE

Level V.

Addressing meniscal deficiency part 1: An umbrella review of systematic reviews and meta-analyses on meniscal allograft transplantation

Purpose

Meniscal injuries are common in the young and active population. There is increasing utilization of surgical interventions like meniscal allograft transplantation (MAT) to restore the protective function of menisci following injury leading to meniscal deficiency. Extensive research and publications exist on the management of meniscal injury and the sequalae of meniscal deficiency. However, a comprehensive synthesis of the existing evidence through an umbrella review is lacking. This study aims to fill this gap by providing a current examination of the literature on MAT.

Methods

A comprehensive search was conducted in the MEDLINE, Embase and Scopus databases to identify relevant systematic reviews and meta-analyses. Studies were screened based on predefined inclusion and exclusion criteria. The quality of the included studies was assessed using the AMSTAR-2 tool.

Results

A total of 41 studies were included in the review, with most published within the last decade. The majority of studies (56.1%) received a 'Critically Low' confidence rating, 26.8% were rated as 'Low', and only 14.6% were rated as 'High' confidence. From the included studies, 51.2% reported on PROMs, with the Lysholm score being the most common. Transplant failure and reoperation rate were reported in 34.1% and 19.5% of studies respectively. Studies on MAT reported favourable short-term outcomes in terms of patient-reported outcome measures (PROMs) but were limited by the lack of randomized control trials and consistent comparison groups.

Conclusions

This umbrella review highlights an increase in interest in MAT but underscores the need for higher-quality reviews with standardized reporting and rigorous methodologies. Future research should focus on long-term outcomes, optimal surgical techniques, patient selection criteria and risk factors for transplant failure. There is also a need for more studies focusing on MAT in pediatric populations. Overall, this review provides a comprehensive assessment of the current state of research in MAT and identifies areas for improvement in future studies.

Level of Evidence

Level IV.

Greater Post-Operative Nutrition Risks Identified in Pediatric and Adolescent Patients after Anterior Cruciate Ligament Reconstruction Regardless of Age and Sex

Systematic detection of risky nutrition behaviors after sports surgery may better promote healing for return-to-sport. The purpose of this study was to assess nutritional behavior differences between patients following anterior cruciate ligament reconstruction (ACLR) and following other lower-extremity orthopedic surgeries. One pediatric sports medicine center was reviewed for a custom Sports Nutrition Assessment for Consultation, which investigates nutrition-related risk factors for youth athletes at their first post-operative visit. Patients reported "Yes" or "No" to eight questions, after which they were offered a nutrition consultation for any response indicating risk. A total of 243 post-ACLR and 242 non-ACLR patients were reviewed. The post-ACLR patients more often reported a change in appetite (p = 0.021), recent weight changes (p = 0.011), a desire to better understand nutrition (p = 0.004), and recommendations to change their body composition (p = 0.032). More post-ACLR patients were identified for a nutrition consultation (p = 0.002), though an equal percentage accepted the consultation between groups. Age and sex were not determined to be significant confounders after matched sub-analysis. The post-ACLR patients more often reported nutrition risks, specifically weight-related issues, regardless of age or sex. Sports surgeons should regularly inquire about nutrition-related concerns with patients and refer to sports dietitians for recovery nutrition support as needed, particularly after ACLR.

Higher odds of meniscectomy compared with meniscus repair in a young patient population with increased neighbourhood disadvantage

OBJECTIVES

To investigate the impact of demographic and socioeconomic factors on the management of isolated meniscus tears in young patients and to identify trends in surgical management of meniscus tears based on surgeon volume.

METHODS

Data from a large healthcare system on patients aged 14-44 years who underwent isolated meniscus surgery between 2016 and 2022 were analysed. Patient demographics, socioeconomic factors and surgeon volume were recorded. Patient age was categorised as 14-29 years and 30-44 years old. Area Deprivation Index (ADI), a measure of neighbourhood disadvantage with increased ADI corresponding to more disadvantage, was grouped as <25th, 25-75th and >75th percentile. Multivariate comparisons were made between procedure groups while univariate comparisons were made between surgeon groups.

RESULTS

The study included 1552 patients treated by 84 orthopaedic surgeons. Older age and higher ADI were associated with higher odds of undergoing meniscectomy. Patients of older age and with non-private insurance were more likely to undergo treatment by a lower-volume knee surgeon. Apart from the year 2022, higher-volume knee surgeons performed significantly higher rates of meniscus repair compared with lower-volume knee surgeons. When controlling for surgeon volume, higher ADI remained a significant predictor of undergoing meniscectomy over meniscus repair.

CONCLUSION

Significant associations exist between patient factors and surgical choices for isolated meniscus tears in younger patients. Patients of older age and with increased neighbourhood disadvantage were more likely to undergo meniscectomy versus meniscus repair. While higher-volume knee surgeons favoured meniscus repair, a growing trend of meniscus repair rates was observed among lower-volume knee surgeons.

LEVEL OF EVIDENCE

Retrospective cohort study, level III.

Current Practices for Rehabilitation After Meniscus Repair: A Survey of Members of the American Orthopaedic Society for Sports Medicine

Background

There is no consensus among sports medicine surgeons in North America on postoperative rehabilitation strategy after meniscus repair. Various meniscal tear types may necessitate a unique range of motion (ROM) and weightbearing rehabilitation protocol.

Purpose

To assess the current landscape of how sports medicine practitioners in the American Orthopedic Society for Sports Medicine (AOSSM) rehabilitate patients after the repair of varying meniscal tears.

Study Design

Cross-sectional study.

Methods

A survey was distributed to 2973 AOSSM members by email. Participants reviewed arthroscopic images and brief patient history from 6 deidentified cases of meniscus repair-in cases 1 to 3, the tears retained hoop integrity (more stable repair), and in cases 4 to 6, the tear patterns represented a loss of hoop integrity. Cases were shuffled before the presentation. For each case, providers were asked at what postoperative time point they would permit (1) partial weightbearing (PWB), (2) full weightbearing (FWB), (3) full ROM, and (4) ROM allowed immediately after surgery.

Results

In total, 451 surveys were completed (15.2% response). The times to PWB and FWB in cases 1 to 3 (median, 0 and 4 weeks, respectively) were significantly lower than those in cases 4 to 6 (median, 4 and 6 weeks, respectively) (P < .001). In tears with retained hoop integrity, the median time to PWB was immediately after surgery, whereas in tears without hoop integrity, the median time to PWB was at 4 weeks postoperatively. Similarly, the median time to FWB in each tear with retained hoop integrity was 4 weeks after surgery, while it was 6 weeks in each tear without hoop integrity. However, regardless of tear type, most providers (67.1%) allowed 0° to 90° of ROM immediately after surgery and allowed full ROM at 6 weeks. Most providers (83.3%) braced the knee after repair regardless of hoop integrity and utilized synovial rasping/trephination with notch microfracture-a much lower proportion of providers utilized biologic augmentation (9%).

Conclusion

Sports medicine practitioners in the AOSSM rehabilitated meniscal tears differently based on hoop integrity, with loss of hoop stresses triggering a more conservative approach. A majority braced and utilized in situ adjuncts for biological healing, while a minority added extrinsic biologics.

Evaluation and Treatment of Knee Pain: A Review

Importance

Approximately 5% of all primary care visits in adults are related to knee pain. Osteoarthritis (OA), patellofemoral pain, and meniscal tears are among the most common causes of knee pain.

Observations

Knee OA, affecting an estimated 654 million people worldwide, is the most likely diagnosis of knee pain in patients aged 45 years or older who present with activity-related knee joint pain with no or less than 30 minutes of morning stiffness (95% sensitivity; 69% specificity). Patellofemoral pain typically affects people younger than 40 years who are physically active and has a lifetime prevalence of approximately 25%. The presence of anterior knee pain during a squat is approximately 91% sensitive and 50% specific for patellofemoral pain. Meniscal tears affect an estimated 12% of the adult population and can occur following acute trauma (eg, twisting injury) in people younger than 40 years. Alternatively, a meniscal tear may be a degenerative condition present in patients with knee OA who are aged 40 years or older. The McMurray test, consisting of concurrent knee rotation (internal or external to test lateral or medial meniscus, respectively) and extension (61% sensitivity; 84% specificity), and joint line tenderness (83% sensitivity; 83% specificity) assist diagnosis of meniscal tears. Radiographic imaging of all patients with possible knee OA is not recommended. First-line management of OA comprises exercise therapy, weight loss (if overweight), education, and self-management programs to empower patients to better manage their condition. Surgical referral for knee joint replacement can be considered for patients with end-stage OA (ie, no or minimal joint space with inability to cope with pain) after using all appropriate conservative options. For patellofemoral pain, hip and knee strengthening exercises in combination with foot orthoses or patellar taping are recommended, with no indication for surgery. Conservative management (exercise therapy for 4-6 weeks) is also appropriate for most meniscal tears. For severe traumatic (eg, bucket-handle) tears, consisting of displaced meniscal tissue, surgery is likely required. For degenerative meniscal tears, exercise therapy is first-line treatment; surgery is not indicated even in the presence of mechanical symptoms (eg, locking, catching).

Conclusions and Relevance

Knee OA, patellofemoral pain, and meniscal tears are common causes of knee pain, can be diagnosed clinically, and can be associated with significant disability. First-line treatment for each condition consists of conservative management, with a focus on exercise, education, and self-management.

Return-to-sport criteria after isolated meniscus suture: Scoping review of the literature

BACKGROUND

Follow-up care including rehabilitation therapy after isolated meniscal repair remains to be standardized. Thus, no standard criteria are available for the return-to-running (RTR) or return-to-sport (RTS). The objective of this study was to identify criteria for RTR and RTS after isolated meniscal repair, based on a review of the literature.

HYPOTHESIS

Return-to-sport criteria after isolated meniscal repair have been published.

METHODS

We performed a scoping review of the literature using the methodology developed by Arksey and O'Malley. The terms "menisc*" and "repair" and "return-to-sport" or "return to play" or "return to run" or "rehabilitation" were used to search the PubMed database on 1st March 2021. All relevant studies were included. All RTR and RTS criteria were identified, analyzed, and classified.

RESULTS

We included 20 studies. Mean RTR and RTS times were 12.9 and 20 weeks, respectively. Clinical, strength, and performance criteria were identified. The clinical criteria included full range-of-motion recovery with no pain, quadriceps wasting, or joint effusion. Strength criteria were a quadriceps and hamstring deficit, no greater than 30% and 15% for RTR and RTS, respectively, compared to the normal side. Performance criteria were successful completion of proprioception, balance, and neuromuscular tests. RTS rates ranged from 80.4% to 100%.

CONCLUSION

Patients must meet clinical, strength, and performance criteria before resuming running and sports. The level of evidence is low, due to the heterogeneity and generally arbitrary choice of criteria. Further large-scale studies are therefore needed to validate and standardize RTR and RTS criteria.

LEVEL OF EVIDENCE

IV.

No differences in knee joint loading between individuals who had a medial or lateral meniscectomy: An ancillary study

BACKGROUND

Arthroscopic partial meniscectomy is a frequently undertaken procedure for traumatic meniscal injuries. The location of knee joint degeneration and long-term prognosis differs between knees who have had a medial or lateral meniscectomy. However, there is no evidence comparing knee loading following a medial or lateral meniscectomy during sporting tasks. This study compared knee loading during walking and running between individuals who either had a medial or lateral meniscectomy.

METHODS

Knee kinematic and kinetic data were collected during walking and running in individuals three to twelve months post-surgery. Participants were grouped according to the location of surgery (medial, n = 12, and lateral, n = 16). An independent t-test compared knee biomechanics between the groups and Hedge's g effects sizes were also conducted.

RESULTS

External knee adduction and knee flexion moments were similar between groups for walking and running with negligible to small effect sizes (effect size, 0.08-0.30). Kinematic (effect size, 0.03-0.22) and spatiotemporal (effect size, 0.02-0.59) outcomes were also similar between the groups.

CONCLUSIONS

The lack of differences in surrogate knee loading variables between medial and lateral meniscectomy groups was unexpected. These findings suggest that combining groups in the short-term period following surgery is applicable. However, the data presented in this study cannot explain the differences in long-term prognosis between medial and lateral meniscectomies.

Off-Season Arthroscopic Partial Meniscectomy in National Collegiate Athletic Association Division I Football Players Has a Longer Return to Sport Time than In-Season Surgery

Purpose

To report the outcomes of routine arthroscopic meniscectomy in National Collegiate Athletic Association (NCAA) Division I Football players.

Methods

NCAA athletes who underwent arthroscopic meniscectomy over 5 years were included. Players who had incomplete data, previous knee surgery, ligamentous injury, and/or microfractures were excluded. Data collected were player position, timing of surgery, procedures performed, return to play (RTP) rate and time, and postoperative performance. Continuous variables were analyzed with Student t-tests or a one-way analysis of variance.

Results

Thirty-six athletes (38 knees) who underwent arthroscopic partial meniscectomy (31 lateral, 7 medial) were included. The mean RTP time was 71 ± 39 days. The mean RTP time in athletes who underwent in-season surgery) was significantly shorter than the RTP in athletes who had off-season surgery (58 ± 41 days vs 85 ± 33 days, P < .05). The mean RTP in 29 athletes (31 knees) with lateral meniscectomy was similar to the 7 athletes (7 knees) who had medial meniscectomy (70 ± 36 vs 77 ± 56, P = .6803). The mean RTP time was similar between football players who underwent isolated lateral meniscectomy and those who had lateral meniscectomy with chondroplasty (61 ± 36 days vs 75±41 days, P = .32). Athletes played an average of 7.7 ± 4.9 games the season they returned; position category and anatomical compartment of the knee lesion had no bearing on number of games played (P = .1864 and P = .425).

Conclusions

NCAA Division 1 football players who underwent arthroscopic partial meniscectomy RTP at approximately 2.5 months' postoperatively. Athletes who underwent off-season surgery had longer RTP time compared with those who underwent in-season surgery. RTP time and performance after surgery did not differ based on player position, anatomical location of the lesions, or chondroplasty at the time of meniscectomy.

Level of Evidence

Level IV, therapeutic case series.

In elite athletes with meniscal injuries, always repair the lateral, think about the medial! A systematic review

PURPOSE

This study aimed to evaluate and compare the time required to return to sports (RTS) after surgery, the rate of revision surgery and the time required for RTS after revision surgery in elite athletes undergoing meniscal repair or partial meniscectomy, particularly analysing the difference between medial and lateral menisci. It was hypothesised that both procedures would entail similar, high rates of RTS, with the lateral meniscus exhibiting higher potential healing postprocedure compared to the medial meniscus.

METHODS

A systematic review was conducted based on the PRISMA guidelines. Quality assessment of the systematic review was performed using the AMSTAR-2 checklist. The following search terms were browsed in the title, abstract and keyword fields: 'meniscus' or 'meniscal' AND 'tear,' 'injury' or 'lesion' AND 'professional,' 'elite' or 'high-level' AND 'athletes,' 'sports,' 'sportsman,' 'soccer,' 'basketball,' 'football' or 'handball'. The resulting measures extracted from the studies were the rate of RTS, level of RTS, complications, revision surgery and subsequent RTS, Tegner, International Knee Documentation Committee (IKDC) and Visual Analogue Scale (VAS).

RESULTS

In this study, the cohort consisted of 421 patients [415 (98.6%) men and 6 (1.4%) women] with a mean age of 23.0 ± 3.0 years. All patients were elite athletes in wrestling, baseball, soccer, rugby or handball. While 327 (77.7%) patients received partial meniscectomy at a mean age of 23.3 ± 2.6 years, 94 (22.3%) patients received meniscal repair at a mean age of 22.1 ± 4.0 years. After partial meniscectomy, 277 patients (84.7%) returned to their competitive sports activity and 256 (78.3%) returned to their pre-injury activity levels. A total of 12 (3.7%) patients required revision surgery because of persistent pain [5 (1.5%) patients], chondrolysis [2 (0.7%) patients] or both chondrolysis and lateral instability [5 (1.5%) patients]. Ten (83.3%) of the twelve patients had involvement of the lateral meniscus, whereas the location of injury was not specified in the remaining two patients. After revision surgery, all patients (100%) resumed sports activity. However, after meniscal repair, 80 (85.1%) athletes returned to their competitive sports activity and 71 (75.5%) returned to their pre-injury activity levels. A total of 16 (17.0%) patients required partial meniscectomy in cases of persistent pain or suture failure. Of these, 4 (25%) patients involved lateral and medial menisci each and 8 (50%) patients were not specified. After revision surgery, more than 80.0% of the patients (13) resumed sports activity.

CONCLUSIONS

In elite athletes with isolated meniscal injury, partial meniscectomy and meniscal suture exhibited similar rates of RTS and return to pre-injury levels. Nonetheless, athletes required more time for RTS after meniscal repair and exhibited an increased rate of revision surgery associated with a reduced rate of RTS after the subsequent surgery. For lateral meniscus tears, meniscectomy was associated with a high rate of revision surgery and risk of chondrolysis, whereas partial medial meniscectomy allowed for rapid RTS but with the potential risk of developing knee osteoarthritis over the years. The findings of this systematic review suggested a suture on the lateral meniscus in elite athletes because of the high healing potential after the procedure, the reduced risk of developing chondrolysis and the high risk of revision surgery after partial meniscectomy. Furthermore, it is important to evaluate several factors while dealing with the medial meniscus. If rapid RTS activity is needed, a hyperselective meniscectomy is recommended; otherwise, a meniscal suture is recommended to avoid accelerated osteoarthritis.

LEVEL OF EVIDENCE

Level IV.

STUDY REGISTRATION

PROSPERO-CRD42022351979 ( https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=351979 ).

Horizontal Cleavage Meniscus Tear Repaired Using a Cerclage Technique

Background:

Horizontal meniscal cleavage tears often occur in older individuals and have a degenerative component. Commonly, these are managed with partial meniscectomy. However, this results in significantly decreased contact area and increased peek contact forces. Arthroscopic repair has shown comparable results with repairs of other tear types.

Indications:

Cerclage repair is performed for a horizontal cleavage tear in individuals without significant arthritis and in whom partial meniscectomy would remove an unacceptably large portion of meniscal tissue.

Technique Description:

Using standard arthroscopy portals, a self-retrieving suture passing device is used to pass a #0 high-strength suture through the periphery of the meniscus. Arthroscopic knots are tied on the superior surface of the meniscus and pushed as far posteriorly as possible. A small 1-cm incision is made just through skin on the proximal, posteromedial border of the tibia. Through this a spinal needle is placed percutaneously to pass a Chia into the joint just posterior to the knot. A curved spinal needle from an outside-in meniscal repair kit may be used as this provides a better trajectory to tears closer to the root attachment. The Chia and suture limbs are retrieved out the front of the knee, and then the suture tails are shuttled out the back of the knee. This is repeated until the repair is complete. The suture limbs are then cut below skin.

Results:

After arthroscopic all-inside repair of horizontal cleavage tears, patients do well. Outcomes are similar to repairs of other meniscal tear types. In all, 80% of patients are satisfied with their results, and there is an 11% to 12% failure rate which is comparable to other types of tear repairs.

Discussion:

All-inside cerclage repair should be considered for individuals sustaining a horizontal cleavage tear. This preserves meniscal tissue compared to partial meniscectomy and yields good healing rates and outcomes. The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Treatment Trends in Meniscal Pathology in the Setting of Concomitant ACL Injuries in Pediatric and Young Adult Patients: An Insurance Database Study

BACKGROUND

Meniscal pathology is commonly encountered in the setting of anterior cruciate ligament (ACL) rupture and is increasingly common in the pediatric and adolescent population. Studies have shown that over half of individuals presenting with ACL rupture will have concurrent meniscal pathology.

PURPOSE

To define trends in the utilization of meniscal procedures (ie, meniscus repair vs partial meniscectomy) and short-term complications in pediatric and young adult patients with meniscal pathology in the setting of a concurrent ACL reconstruction.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

The IBM MarketScan Commercial Database was utilized to identify ACL reconstruction procedures performed between 2006 and 2018 for individuals aged 5 to 30 years. Annual proportions of meniscectomy and meniscal repair were analyzed, and short-term complications were compared between pediatric/adolescent patients (aged 5-17 years) and young adults (aged 18-30 years).

RESULTS

An overall 40,736 records of individuals <18 years old with ACL tears were included. The pediatric/adolescent population had a significantly lower proportion of concomitant meniscal procedures (56.8%; 23,149/40,736) than the young adult population (59.7%; 33,764/56,515; P < .01). From 2006 to 2018, utilization of meniscal repair in the setting of ACL reconstruction steadily increased (20.1% to 35.1% [+15 percentage points], P < .01), while the proportion with meniscectomy decreased (34.4% to 21.3% [-13.1 percentage points], P < .01). There was no difference in rate of reoperation for repeat meniscal repair or meniscectomy in the pediatric/adolescent population for those undergoing meniscal repair versus meniscectomy within 180 days of primary surgery (1.7% [188/10,766] vs 1.5% [186/12,383]; P = .14).

CONCLUSION

From 2006 to 2018, the proportion of patients receiving ACL reconstruction with concomitant meniscal repair increased (20.1% to 35.1%) while the proportion with meniscectomy decreased (34.4% to 21.3%) in the pediatric/adolescent population. Meniscal repair was not associated with a higher 180-day rate of reoperation for repeat meniscal repair or meniscectomy than meniscectomy in the setting of ACL reconstruction.

Variations in common operations in athletes and non-Athletes

Background

Achieving pre-injury activity level after an injury is the fundamental goal of any orthopedic treatment for an athlete. Unfortunately, pre-injury activity levels differ significantly in different patient categories, especially in athletes and non-athlete. Hence, an outcome suitable to a non-athlete may not be adequate for an athlete. This has led to variations in the surgical approach to the same injury in an athlete and non-athlete.There is plenty of literature published comparing the outcome in athletes and non-athletes after a particular surgery. Scattered discussion about variations in these surgeries based on functional demand was done in many publications. But there was a lack of a comprehensive narrative review summarizing variations in common operations among athletes and non-athletes.

Aim

This review attempted to summarize variations in common sports operations between high functional demand patients and low demand patients and discuss the variations from the author's perspective.

Methods

A review of all the relevant papers were conducted focusing on athletes and non-athletes. Most commonly performed sports surgeries were ACL reconstruction, Meniscal repair, PCL reconstruction, and Shoulder instability surgery. A literature search was done for each commonly performed surgery using relevant keywords in PubMed and Google Scholars. Summary of papers pertinent to athletes and non-athletes were compiled to prepare this narrative review.

Results

There is a lack of papers directly comparing results in athletes and non-athletes. However, many research papers discussed surgical variations in athletes (high demand) and non-athletes (low demand) patients. There are controversies in all commonly performed surgeries, and none of the papers gives a definitive guideline on the approach to athletes and non-athlete.

Conclusion

Rather than a common suggestion on surgical variation, an individualized approach would be appropriate to decide on variation in particular surgery in both athletes and non-athletes.

Rehabilitation after anterior cruciate ligament and meniscal injuries: a best-evidence synthesis of systematic reviews for the OPTIKNEE consensus

OBJECTIVE

Synthesise evidence for effectiveness of rehabilitation interventions following ACL and/or meniscal tear on symptomatic, functional, clinical, psychosocial, quality of life and reinjury outcomes.

DESIGN

Overview of systematic reviews with Grading of Recommendations Assessment, Development and Evaluation certainty of evidence.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, SPORTDiscus and Cochrane Library.

ELIGIBILITY CRITERIA

Systematic reviews of randomised controlled trials investigating rehabilitation interventions following ACL and/or meniscal tears in young adults.

RESULTS

We included 22 systematic reviews (142 trials of mostly men) evaluating ACL-injured individuals and none evaluating isolated meniscal injuries. We synthesised data from 16 reviews evaluating 12 different interventions. Moderate-certainty evidence was observed for: (1) neuromuscular electrical stimulation to improve quadriceps strength; (2) open versus closed kinetic chain exercises to be similarly effective for quadriceps strength and self-reported function; (3) structured home-based versus structured in-person rehabilitation to be similarly effective for quadriceps and hamstring strength and self-reported function; and (4) postoperative knee bracing being ineffective for physical function and laxity. There was low-certainty evidence that: (1) preoperative exercise therapy improves self-reported and physical function postoperatively; (2) cryotherapy reduces pain and analgesic use; (3) psychological interventions improve anxiety/fear; and (4) whole body vibration improves quadriceps strength. There was very low-certainty evidence that: (1) protein-based supplements improve quadriceps size; (2) blood flow restriction training improves quadriceps size; (3) neuromuscular control exercises improve quadriceps and hamstring strength and self-reported function; and (4) continuous passive motion has no effect on range of motion.

CONCLUSION

The general level of evidence for rehabilitation after ACL or meniscal tear was low. Moderate-certainty evidence indicates that several rehabilitation types can improve quadriceps strength, while brace use has no effect on knee function/laxity.

Predictive Factors Associated With Short-Term Clinical Outcomes and Time to Return to Activity After Arthroscopic Partial Meniscectomy in Nonathletes

Background:

Although arthroscopic partial meniscectomy is a widely implemented surgical procedure, studies investigating the time to return to activity (RTA) are rare.

Purpose:

To explore which factors are associated with the RTA times after arthroscopic partial meniscectomy and to investigate whether those factors can also improve short-term patient-reported outcomes.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

The authors reviewed the records of patients who underwent isolated partial meniscectomy in their institution from January 2017 to December 2019. Patient and injury characteristics were documented, and time to RTA was obtained via phone interview in January 2021. Pre- and postoperative outcomes were assessed with the Lysholm score and International Knee Documentation Committee (IKDC) score. The chi-square test and independent-samples t test were used to evaluate differences in outcome scores and time to RTA according to the patient and injury characteristics, and risk factors with a P value <.1 in the univariate analysis were used in the binary regression.

Results:

Included were 215 patients (87 men and 128 women; mean age, 33.7 years [range, 24-75 years]). Of these patients, 204 provided information on time to RTA (mean, 3.3 months). By 3 months postoperatively, 49.5% (101/204) of patients could perform activities without knee-related restriction; this improved to 69.6% (142/204) at 6 months and 90.2% (184/204) at 12 months. On multivariate logistic regression analysis, age (OR, 0.39; 95% CI, 0.21-1.19; P = .044) and injury duration (OR, 0.20; 95% CI, 0.19-1.07; P = .032) were significantly associated with the time to RTA. IKDC scores improved significantly from 41.2 preoperatively to 76.7 postoperatively, and in the multivariate logistic regression model, female sex (OR, 2.67; 95% CI, 1.10-6.47; P = .030), body mass index (BMI) ≥27 kg/m² (OR, 2.96; 95% CI, 1.02-8.66; P = .047), and medial meniscal tear (OR, 0.20; 95% CI, 0.04-1.00; P = .050) were associated with inferior outcome scores.

Conclusion:

Patients aged 40 years and younger who underwent partial meniscectomy surgery within 6 months after a meniscal tear were more likely to have a shorter time to RTA, and female patients with obesity (BMI ≥27 kg/m2), especially those with medial meniscal tears, tended to have inferior clinical outcomes.

Return to Play and Player Performance After Meniscal Tear Among Elite-Level European Soccer Players: A Matched Cohort Analysis of Injuries From 2006 to 2016

Background:

Meniscal injuries are extremely common in soccer athletes, and little is known about postrecovery performance.

Purpose:

To (1) identify characteristics associated with return to play (RTP) to the same league level and (2) evaluate long-term effects that injury and management approach may have on player performance.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Using publicly available records, we identified athletes who sustained meniscal tears across the 5 major European soccer leagues (English Premier League, Bundesliga, La Liga, Ligue 1, and Serie A) between 2006 and 2016. Injured athletes were matched to controls 1:2 by demographics and performance. Investigations included rate of RTP to the same league level, reinjury, player characteristics associated with RTP within 2 seasons, long-term availability, field time, and performance metrics standardized to 90 minutes of play during the next 4 seasons.

Results:

A total of 250 players sustaining meniscal tears were included, of which 106 (42%) received surgical management. Median absence was 57.5 days (interquartile range [IQR], 35-92) or 7 games (IQR, 4-12). Rate of RTP was 70%, and the reinjury rate 5% if a player could RTP. Age greater than 30 years was a negative predictor for RTP (odds ratio [OR], 0.62; P = .002), whereas higher preinjury goals per game (OR, 2.80; P = .04) and surgical management (OR, 1.38; P = .002) were positive predictors for RTP. Surgical management was associated with higher long-term availability (P < .01). As compared with the control, there were no significant differences in field time or performance metrics after RTP, either overall or by player position. As compared with nonoperative management, defenders undergoing surgery demonstrated decreased field time. Attackers and midfielders demonstrated similar field time and performance regardless of management.

Conclusion:

RTP of elite soccer athletes sustaining meniscal tear is contingent on age, preinjury performance, and management approach. Those who RTP to the same league level can be expected to demonstrate equivalent field time, performance, and long-term availability as noninjured athletes.

All-Cause Failure Rates Increase With Time Following Meniscal Repair Despite Favorable Outcomes: A Systematic Review and Meta-analysis

PURPOSE

The purpose of this review is to perform a meta-analysis of studies reporting meniscus repair outcomes. Pooled analyses of such studies will provide an accurate estimate of the outcomes that can be expected following meniscal repair at various postoperative time points.

METHODS

A meta-analysis of meniscal repair failure (defined as persistent symptoms, lack of healing on magnetic resonance imaging or revision surgery) and other clinical outcomes was performed following meniscal repair. Patients included had traumatic, nondegenerative meniscal tears, were skeletally mature, and had specific time-points after surgery. Repairs included were performed either in isolation, or with concomitant ACL reconstruction. Because of the inherent heterogeneity of single-arm meta-analyses, pooled analyses were performed using a random-effects model.

RESULTS

Rates of all-cause meniscal repair failure was pooled to be 12% at 0-1 years (95% CI: .09-.16), 15% at 2-3 years (95% CI: .11-.20), and 19% at 4-6 years (95% CI: .13-.24). Sensitivity analysis for studies performing meniscal repair entirely on patients with concomitant ACL reconstruction (ACLR) showed comparable rates of failure at similar time intervals. Development of osteoarthritis, in patients with knees previously free from articular pathologies, was 4% at 2-3 years (95% CI: .02-.07), and 10% at 4-6 years (95% CI: .03-.25).

CONCLUSION

Meniscus repair for traumatic injuries have an all-cause failure rate that increases from 12% to 19% through a time period ranging from 1-6 years following surgery. The failure rates were comparable for patients with meniscal repairs performed with concomitant ACLRs.

LEVEL OF EVIDENCE

IV; Systematic Review of Level II-IV Studies.

An increasing trend of the number of meniscus allograft transplantation in Korea

PURPOSE

Meniscus allograft transplantation (MAT) can be performed to treat symptomatic patients with meniscus-deficient knees. However, the current epidemiologic status of MAT is unknown in many countries, including Korea. This study aimed to investigate the national trends of MAT in Korea which covers MAT procedures by the Korean national health insurance system.

METHODS

Information from the national database was acquired through the Korean Health Insurance Review and Assessment Service (HIRA) from 2010 to 2017. All patients encoded as MAT were included. The total number of MATs and their incidence per 100,000 persons were determined, and the results were stratified by age and sex.

RESULTS

The total number of MATs and their incidence per 100,000 persons per year were 369 and 0.77, respectively, in 2010, which increased to 826 and 1.72, respectively, in 2017. The number of MATs increased by 124% over 8 years. The peaks for the total number of MATs and their incidence were seen in patients in their 20 s in 2010, but in 2017, the peaks were observed in patients who were in their 40 s. MAT was performed more frequently in males (61%) than in females (39%) over the study period.

CONCLUSION

The total number of MATs and their incidence had increased by 124% between 2010 and 2017. The peak treatment age range for MAT changed from 20 years of age in 2010 to 40 years of age in 2017, and MAT was performed more frequently in males than in females.

LEVEL OF EVIDENCE

IV.

Return to Work Following Arthroscopic Meniscal Allograft Transplantation

PURPOSE

Evaluate the ability of patients to return to work (RTW) following arthroscopic meniscal allograft transplantation (MAT) for meniscal deficiency.

METHODS

Consecutive patients undergoing MAT were retrospectively reviewed at a minimum of 2 years postoperatively. Patients completed a subjective work questionnaire, Visual Analogue Scale for pain, Single Assessment Numerical Evaluation, and satisfaction.

RESULTS

Forty-seven patients who were employed within 3 years prior to surgery (average age: 30.2 ± 6.9 years) were contacted at an average of 3.5 ± 0.9 years postoperatively. Forty-six patients (97.8%) returned to work by 2.7 ± 2.6 months postoperatively, and 44 patients (93.6%) returned to the same level of occupational intensity. Patients who held sedentary, light, medium, or high intensity occupations were able to RTW at a rate of 100.0%, 100.0%, 88.9%, and 85.7% (P = 0.4) by 1.1 ± 1.0 months, 2.5 ± 2.5 months, 3.5 ± 3.2 months, and 4.3 ± 2.8 months (P = 0.3) postoperatively. Thirty-eight patients (80.9%) were at least somewhat satisfied, and 43 patients (91.5%) would still have the operation if presented the opportunity. No patient underwent revision MAT or conversion to arthroplasty.

CONCLUSION

In patients with painful meniscal deficiency, MAT provides a high rate of RTW (97.8%) by 2.7 ± 2.6 months postoperatively. However, some patients may be unable to return to their previous level of occupational intensity. Although statistically insignificant, patients with higher intensity occupations may have a lower rate and longer duration until RTW than those with less physically demanding occupations. Information regarding RTW is imperative for appropriately managing postoperative expectations.

Rehabilitation and Return to Play Following Meniscus Repair

Injuries to the meniscus, particularly tears, can have significant negative impacts on pain, function, and quality of life. Preservation of the meniscus is favorable, especially in the athletic and active populations. While first line treatment is often nonoperative in nature, recalcitrant, and more complex tears, typically require surgery. Meniscus repair rates have increased significantly during the last 2 decades as surgical techniques and postoperative outcomes have improved. Longer postoperative timeframes are to be expected when compared with menisectomy, however, accelerated programs have demonstrated favorable outcomes. Rehabilitation and return to play guidelines should reflect the intricacies of the tear type and repair procedure. Close communication with the surgeon is a vital component to optimize patient outcomes. Further, the patient's goals and expected level of return to function, or sport, must be taken into account for a rehabilitation program to be fully successful.

Surgical Treatment of Isolated Meniscal Tears in Competitive Male Wrestlers: Reoperations, Outcomes, and Return to Sport

Background:

Wrestlers are highly active, young athletes prone to meniscal injuries that often require surgery. However, there is a lack of data evaluating the results of meniscal repair or partial meniscectomy in this cohort.

Purpose:

To describe the outcomes (subjective function, return to play, complications, reoperation rates, and progression of osteoarthritis) for treatment (meniscectomy or repair) of meniscal injuries in a cohort of competitive wrestlers.

Study Design:

Case series; Level of evidence, 4.

Methods:

All competitive wrestlers (high school, collegiate, or professional leagues) with a history of a meniscal injury and isolated meniscal surgery at a single institution between 2001 and 2017 were retrospectively identified. Failure was defined as a reinjury of the operative meniscus by clinical or advanced imaging examination, reoperation, or any additional surgical treatment of the meniscus after the index procedure. All patients were contacted for determination of reinjury rates, current sport status, and International Knee Documentation Committee and Tegner activity scores.

Results:

Of 85 male wrestlers with isolated meniscal tears, 34% underwent a meniscal repair, and 66% received a partial meniscectomy. Index surgery failed for 9.4% of the cohort. Among wrestlers treated with initial meniscal repair, 21% required a subsequent partial meniscectomy at a mean 2.2 years, and of those treated with partial meniscectomy, 3% underwent a second operation (P < .001). All secondary operations were revision partial meniscectomies occurring at a mean 3.2 years (95% CI, 0.01-6.4 years) after the index procedure. At final follow-up, 89% of patients were able to return to sport, with 65% returning to wrestling competition. There was significant improvement in the Tegner score from a mean 6.5 (95% CI, 5.9-7.2) preoperatively to 8.3 (95% CI 8.0-8.6) postoperatively (P < .001).

Conclusion:

The reoperation rate after meniscal surgery in wrestlers was quite low, but only 65% returned to competitive wrestling. Meniscal repair and partial meniscectomy improved patient-reported outcomes and activity levels at short-term follow-up. However, 21% of wrestlers treated with initial meniscal repair required a subsequent partial meniscectomy at a mean 2.2 years.

An Up-to-Date Review of the Meniscus Literature: A Systematic Summary of Systematic Reviews and Meta-analyses

Background:

A large number of systematic reviews and meta-analyses regarding the meniscus have been published.

Purpose:

To provide a qualitative summary of the published systematic reviews and meta-analyses regarding the meniscus.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A systematic search of all meta-analyses and systematic reviews regarding the meniscus and published between July 2009 and July 2019 was performed with PubMed, CINAHL, EMBASE, and the Cochrane database. Published abstracts, narrative reviews, articles not written in English, commentaries, study protocols, and topics that were not focused on the meniscus were excluded. The most pertinent results were extracted and summarized from each study.

Results:

A total of 332 articles were found, of which 142 were included. Included articles were summarized and divided into 16 topics: epidemiology, diagnosis, histology, biomechanics, comorbid pathology, animal models, arthroscopic partial meniscectomy (APM), meniscal repair, meniscal root repairs, meniscal allograft transplantation (MAT), meniscal implants and scaffolds, mesenchymal stem cells and growth factors, postoperative rehabilitation, postoperative imaging assessment, patient-reported outcome measures, and cost-effectiveness. The majority of articles focused on APM (20%), MAT (18%), and meniscal repair (17%).

Conclusion:

This summary of systematic reviews and meta-analyses delivers surgeons a single source of the current evidence regarding the meniscus.

National Basketball Association combine performance after a partial meniscectomy

BACKGROUND

An arthroscopic meniscectomy is one of the most common orthopedic procedures in athletes. Return to play rates and deficits in muscle function have been reviewed after meniscectomy, but no study has reviewed functional performance after an isolated partial meniscectomy.

HYPOTHESIS/PURPOSE

To compare the performance of elite-level basketball players after a partial meniscectomy to a control group of players with no previous reported knee injury. We believe that there is no difference between the two groups in functional performance.

STUDY DESIGN

Case Series.

METHODS

Functional performance results from the National Basketball Association (NBA) combine were reviewed between 2000 and 2015. Twelve out of 1092 players were found to have undergone a partial meniscectomy prior to competing in the NBA combine. The partial meniscectomy group was compared to an age-, size-, and position-matched control group with respect to functional performance testing such as the shuttle run test, lane agility test, ¾ court sprint, vertical jump (no step), and vertical jump (max).

RESULTS

The meniscectomy and the control groups that there was no significant difference between the two groups in agility, quickness, sprinting, and jumping ability. However, there was a - 0.596 spearman correlation between months after surgery and agility (p = 0.041), while there was a + 0.690 and + 0.650 spearman correlation between both months after surgery and standing vertical and max vertical (p = 0.013 and p = 0.022).

CONCLUSIONS

Athletes competing in the NBA combine who have undergone a partial meniscectomy perform as well as uninjured athletes in all NBA combine performance testing. Furthermore, as athletes are further out from surgery, they have an improvement in both standing and max vertical jump.

[Damage of the knee posterior cruciate ligament: biomechanics, basic diagnostics, treatment and secondary osteoarthritis prevention directions]

The analysis of literature data was performed on the pathogenesis, diagnosis and treatment of injuries of the posterior cruciate ligament (PCL) of the knee joint. PCL is the largest intra-articular ligament of the knee joint, can withstand the maximum loads compared with other ligaments. It was noted that, in general, in cases of damage to the PCL, it is necessary to use a set of diagnostic methods, and the basic principles for the choice of optimal treatment plan for this patient. It considered the results of the conservative treatment of PCL partial ruptures, and it is indicated that this approach increases the risk of degenerative anatomical structures and functional disorders of the joint. It was noted that it is advisable to conduct surgical treatment to restore the stability of the knee joint and normalize function, while a number of methods for the reconstruction of PCL have been proposed to date. The usage of chondroprotectors for prevention of the secondary osteoarthrosis of the knee joint affected by posterior cruciate ligament rupture was analyzed in the literature data.

Return to Sport and Work After High Tibial Osteotomy With Concomitant Medial Meniscal Allograft Transplant

PURPOSE

(1) To examine the timeline of return to sport (RTS) and return to work (RTW) after high tibial osteotomy (HTO) with concomitant medial meniscal allograft transplant (MAT), (2) to evaluate the degree of function on RTS and RTW, and (3) to identify reasons patients do not return to sport- or work-related activity.

METHODS

Patients undergoing HTO plus MAT were reviewed retrospectively at a minimum of 2 years postoperatively. The exclusion criterion was any concomitant procedure except cartilage restoration for focal full-thickness medial femoral condylar defects. Patients completed a subjective sport and work questionnaire, a visual analog scale for pain, the Single Assessment Numeric Evaluation, and a satisfaction questionnaire.

RESULTS

Twenty-two patients (aged 35.1 ± 8.1 years) were included at 9.3 ± 3.7 years postoperatively. Sixteen patients participated in sports within 3 years before surgery, and 14 patients (87.5%) returned to sport by 9.7 ± 3.8 months postoperatively. Only 7 patients (43.8%) returned to their preinjury status. Eighteen patients were employed within 3 years before surgery, and all patients returned to work; however, only 16 patients (88.9%) returned at the same occupational intensity by 3.1 ± 2.4 months. The rates of RTW for light-, medium-, and heavy-intensity occupations were 100%, 75.0%, and 85.7%, respectively, whereas the duration of RTW was 2.1 months, 2.3 months, and 4.8 months, respectively. Of the patients, 20 (90.9%) reported at least 1 complaint postoperatively, with 13 patients (59.1%) returning to the operating room for recurrent symptoms, including 1 patient who received a knee replacement at 7.75 years postoperatively.

CONCLUSIONS

In patients with medial meniscal deficiency and varus deformity, HTO plus MAT provided high rates of RTS (87.5%) and RTW (100%) by 9.7 months and 3.1 months, respectively. It is imperative that clinicians manage expectations because patients may RTS and RTW after HTO plus MAT; however, return to high-intensity activities or occupations may be unlikely or delayed.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Establishing Clinically Significant Outcomes After Meniscal Allograft Transplantation

Background:

Traditionally, the primary outcome in meniscal allograft transplantation (MAT) has been long-term survivorship; however, short-term clinically significant outcomes are necessary to fully evaluate patient improvement after surgery.

Purpose:

To (1) establish the minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) with respect to patient-reported outcome measures (PROMs) and (2) evaluate preoperative and intraoperative variables correlated with achieving these threshold values.

Study Design:

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

Methods:

A prospectively maintained institutional registry was queried for all MATs performed between 1999 and 2017. The following PROM scores were collected: International Knee Documentation Committee (IKDC) score, Lysholm score, and Knee injury and Osteoarthritis Outcome Score (KOOS). Patients who completed preoperative and postoperative PROMs within a 1-month window were included to calculate the distribution-based MCID at this interval. An anchor question regarding satisfaction with surgery was asked at the same time point and was employed to determine the PASS using nonparametric receiver operating characteristic curve/area under the curve analysis. Multivariate regression analysis was performed to correlate patient demographics, medical history, and concomitant procedures to propensity in achieving the MCID and PASS.

Results:

A total of 98 patients who underwent MAT met the inclusion/exclusion criteria, of whom 10 underwent concomitant ligamentous procedures, 65 underwent concomitant cartilage procedures, and 7 underwent concomitant realignment procedures. The mean patient age was 29.4 ± 9.0 years, and the mean body mass index (BMI) was 26.8 ± 5.2 kg/m². The distribution-based MCID and PASS were determined for the Lysholm score (12.3 and 66.5) and IKDC (9.9 and 36.0) as well as the KOOS Pain (9.9 and N/A ), Symptoms (9.7 and 73.0), Activities of Daily Living (9.5 and N/A), Sport (13.3 and N/A), and Quality of Life (14.6 and 53.0) subscales, respectively. A preoperative Short Form Physical Component Summary (SF PCS) score greater than 32.0 was predictive of postoperative satisfaction. Patients with work-related claims had a reduced likelihood of achieving the MCID for the IKDC and the PASS for the KOOS Symptoms. An increased BMI was also associated with failing to achieve the PASS for the KOOS Quality of Life (QOL).

Conclusion:

This study established the MCID and PASS for the Lysholm score, IKDC, and KOOS in patients undergoing MAT. Workers’ compensation and higher BMI were associated with failing to achieve clinically significant values. Lower preoperative Lysholm, IKDC, and KOOS scores were predictive of achieving the MCID, while higher preoperative SF PCS scores were associated with achieving satisfaction after MAT.