Diagnostic values of 3 methods for evaluating meniscal healing status after meniscal repair: comparison among second-look arthroscopy, clinical assessment, and magnetic resonance imaging

Do MRI Results Represent Functional Outcomes Following Arthroscopic Repair of an Isolated Meniscus Tear in Young Patients?-A Prospective Comparative Cohort Study

BACKGROUND

The use of postoperative MRI to assess the healing status of repaired menisci is a long-standing issue. This study evaluates and compares functional and MRI outcomes following an arthroscopic meniscus repair procedure with the aim of postoperative MRI diagnostic accuracy clarification in young patients.

METHODS

A total of 35 patients under 18 years old who underwent isolated meniscus repair were included. The Pedi-IKDC score, Lysholm score, and Tegner activity index (TAS) were compared between the groups formed according to the Stroller and Crues three-grade classification of postoperative MRI-based evaluations. Grade 3 MRI views were classified as unhealed, grade 2 as partially healed, and grade 1 as fully healed within the repaired meniscus, whereas grade 3 cases were considered unsuccessful due to MRI evaluation.

RESULTS

MRI assessment revealed 4 cases of grade 1 (11.4%), 14 cases of grade 2 (40.8%), and 17 cases of grade 3 (48.0%) lesions. Pedi-IKDC and TAS scores were significantly higher among MRI grade 2 patients than among MRI grade 3 patients (p < 0.05). Weak negative correlations between MRI grades and all functional scales were found (p < 0.05). ROC analysis showed that Pedi-IKDC and TAS scores could correctly classify 77% and 71% of MRI grade 3 patients, respectively. The optimal cut-off values to detect grade 3 patients were 88.74 for the Pedi-IKDC score and 4.5 for the TAS score.

CONCLUSIONS

To conclude, established functional score cut-off values may help identify unhealed meniscus repair patients.

Steep Posterior Tibial Slope and Excessive Anterior Tibial Translation Are Associated With Increased Sagittal Meniscal Extrusion After Posterior Lateral Meniscus Root Repair Combined With Anterior Cruciate Ligament Reconstruction

Purpose

To (1) evaluate the clinical and radiographic outcomes of patients with primary anterior cruciate ligament reconstruction (ACLR) with type II posterior lateral meniscus root tear (PLMRT) repair and (2) identify whether increased anterior tibial subluxation of the lateral compartment (ATSLC) and steeper posterior tibial slope (PTS) are associated with sagittal lateral meniscal extrusion (LME).

Methods

Patients who underwent primary anatomic ACLR with concomitant type II PLMRTs using the all-inside side-to-side repair technique between November 2014 and September 2020 were identified. To be included, patients must have had a minimum of 2 years follow-up. All patients, including those with ATSLC and PTS and sagittal and coronal LME, were retrospectively reviewed clinically and radiologically. The patients were divided into 2 subgroups according to the occurrence of sagittal LME.

Results

Forty patients were included in this study with a mean follow-up of 44 months (range, 24-94 months). In general, the postoperative parameters, including grade of pivot shift, side-to-side difference, ATSLC, Lysholm score, and International Knee Documentation Committee (IKDC) score, were significantly improved compared with the preoperative ones. However, postoperative sagittal LME was detected to be significantly larger than the preoperative one. Minimal clinically important difference (MCID) analysis for postoperative outcomes showed that the rate of patients who achieved MCID thresholds was 100% for Lysholm, 95% for IKDC, 42.50% for coronal LME, 62.50% for sagittal LME, 40% for ATSLC, and 100% for side-to-side difference. Further comparisons, where patients were divided into 2 subgroups according to the occurrence of sagittal LME, showed significant differences in PTS, ATSLC, and coronal LME.

Conclusions

Clinical outcomes after type II PLMRT repair with primary ACLR were significantly improved, except for LME, at the 2-year postoperative follow-up. After repair of type II PLMRT injuries, the presence of sagittal LME was associated with increased PTS and ATSLC.

Level of Evidence

Level III, retrospective cohort study.

Association Between MRI Signal Intensity of the Repaired Lateral Meniscus and Residual Anterolateral Knee Laxity After ACL Reconstruction

Background

Anterolateral knee laxity (ALLx) has been linked to tears of the lateral meniscus (LM) and anterior cruciate ligament (ACL) injury.

Purpose

To investigate the longitudinal relationship between the signal intensity (SI) of the repaired LM on magnetic resonance imaging (MRI) and residual ALLx after ACL reconstruction (ACLR).

Study Design

Cohort study; Level of evidence, 3.

Methods

Included were 87 patients who underwent double-bundle ACLR and lateral meniscal repair (mean age, 23.5 years; body mass index, 23.7 kg/m2; 56 women) at a single institution between 2010 and 2019. Proton density-weighted (PDW) and T2-weighted (T2W) MRI was performed at 3, 6, and 12 months postoperatively, and the SI ratio (SIR) was calculated as (SI of the repaired LM)/(SI of the posterior cruciate ligament). At the 12-month follow-up, ALLx was evaluated using the pivot-shift test; an International Knee Documentation Committee grade ≥1 indicated residual ALLx.

Results

Overall, 12 patients (13.8%) exhibited ALLx at 12 months postoperatively. At 3 months postoperatively, the SIR on PDW images (SIR-PDW) was significantly higher in patients with ALLx versus those without ALLx (1.98 ± 0.77 vs 1.49 ± 0.52, respectively; P = .007); there was no difference in the SIR on T2W images between the groups. SIR-PDW at 3 months postoperatively was correlated negatively with patient age (r = -0.308, P = .004). When patients were stratified into a younger (≤22 years; n = 53; ALLx = 7 [13.2%]) and an older (>22 years; n = 34; ALLx = 5 [14.7%]) group, the area under the receiver operating characteristic curves (AUCs) for SIR-PDW in the younger group were statistically significant for predicting the prevalence of ALLx at all follow-up times (AUCs, 0.733-0.788) with optimal cutoff values of 2.00 at 3 months, 1.50 at 6 months, and 1.50 at 12 months. Logistic regression analysis revealed that if younger patients consistently had higher SIR-PDW values than the cutoff values, they were more likely to have residual ALLx (odds ratios, 10.24-23.57).

Conclusion

For younger patients who underwent both ACLR and lateral meniscal repair, higher MRI SI of the repaired LM was associated with a higher prevalence of residual ALLx.

MRI Criteria for Healing at 1 Year After Repair of a Traumatic Meniscal Tear

BACKGROUND

Meniscal repair for a traumatic meniscal tear is increasingly used to preserve the meniscus. Interpreting postoperative magnetic resonance imaging (MRI) scans remains challenging, especially in symptomatic patients. There is a lack of reliable MRI criteria to affirm the healed character of a traumatic meniscal injury repair.

PURPOSE

To identify relevant MRI criteria for meniscal healing after meniscal repair.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

We prospectively included all patients with a traumatic meniscal injury who underwent either an isolated meniscal repair or a repair during a concomitant anterior cruciate ligament reconstruction. A standardized preoperative and postoperative clinical evaluation was performed, along with collection of functional scores-Knee injury and Osteoarthritis Outcome Score, International Knee Documentation Committee, Lysholm Score, and 36-Item Short Form Health Survey. An MRI scan was performed 1 year postoperatively and compared with the preoperative MRI scan. The following MRI aspects were analyzed: variation of morphology and fat-saturated (FS) T2 intensity signal and pre- and postoperative tear diastasis measurement.

RESULTS

Fifty patients (age, mean ± SD, 28.7 ± 8.5 years [range, 16-45 years]) who were 1 year postoperative were included. All patients were considered clinically healed had the same MRI characteristics. A signal change (FS T2) was observed from a high signal intensity fluid to a nonfluid moderate signal intensity. The morphology of the lesion was more complex: from the initial lesion, line ramifications appeared, creating the appearance of tree branches. The tear diastasis decreased (from 2.3 ± 0.5 mm [range, 1.3-3.5] to 1.1 ± 0.28 mm [range, 0.5-1.5]).

CONCLUSION

MRI criteria confirming meniscal healing after traumatic meniscal repair at 1 year were identified: a change in the intrameniscal signal becoming nonfluid and moderate in intensity; a reduction in tear diastasis to <1.5 mm; and a change in the signal morphology of the repaired meniscus.

Efficacy of meniscus suture absorbability on meniscus healing success rate via second-look arthroscopy after meniscal repair: a systematic review and meta-analysis

BACKGROUND

To preserve the meniscus's function, repairing the torn meniscus has become a common understanding. After which, the search for the ideal suture material is continuous. However, it is still controversial about the efficacy of suture absorbability on meniscus healing.

METHODS

This review is designed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

INCLUSION CRITERIA

(1) Studies on meniscus repair; (2) Second-look arthroscopy was performed; (3) The meniscus was repaired by absorbable and non-absorbable sutures; (4) The healing condition of repaired meniscus via second-look arthroscopy was described.

EXCLUSION CRITERIA

(1) Animal studies, cadaveric studies, or in vitro research; (2) Meniscus transplantation; (3) Open meniscus repair; (4) Reviews, meta-analysis, case reports, letters, and comments; (5) non-English studies. MEDLINE, Embase, and Cochrane Database were searched up to October 2022. Risk of bias and methodology quality of included literature were assessed according to ROBINS-I and the modified Coleman Methodological Scale (MCMS). Descriptive analysis was performed, and meta-analysis was completed by RevMan5.4.1.

RESULTS

Four studies were included in the systematic review. Among them, three studies were brought into the meta-analysis, including 1 cohort study and 2 case series studies about 130 patients with meniscal tears combined with anterior cruciate ligament injury. Forty-two cases were repaired by absorbable sutures, and 88 were repaired by non-absorbable sutures. Using the fixed effect model, there was a statistical difference in the healing success rate between the absorbable and the non-absorbable groups [RR1.20, 95%CI (1.03, 1.40)].

CONCLUSION

In early and limited studies, insufficient evidence supports that non-absorbable sutures in meniscus repair surgery could improve meniscal healing success rate under second-look arthroscopy compared with absorbable sutures. In contrast, available data suggest that absorbable sutures have an advantage in meniscal healing.

TRIAL REGISTRATION

The review was registered in the PROSPERO System Review International Pre-Registration System (Registration number CRD42021283739).

Clinical outcome and healing rate after meniscal bucket handle tear repair

BACKGROUND

Reports combining patient-reported outcome measures, clinical evaluation, and radiographic assessment of postoperative healing after arthroscopic repair of bucket-handle meniscal tears (BHMT) are scarce.

METHODS

Patients who underwent arthroscopic repair for acute traumatic BHMTs between October 2011 and March 2016 with a minimum follow-up of two years were included. Postoperative outcome scores comprised the International Knee Documentation Society Score (IKDC), Lysholm score, Tegner activity score (TAS), and visual analog scale (VAS) for pain. Clinical meniscal healing failure was assessed according to Barrett's criteria. Side-to-side difference in knee laxity was measured using KT-2000. Radiographic healing was assessed by 3-Tesla magnetic resonance imaging (MRI) and classified according to Henning's criteria at final follow-up.

RESULTS

Forty patients with a mean age of 32.0 ± 11.5 years were available for follow-up after 51.8 ± 14.3 months. Revision surgery by means of arthroscopic partial meniscectomy was performed in four patients (10%) prior to the follow-up visit. The clinical healing rate was 83.3% at final follow-up. Mean IKDC score was 82.8 ± 13.8 and Lysholm score was 77.4 ± 24.8. Of all patients, 87.5% reached or exceeded the patient-acceptable symptomatic state (PASS) criteria for the IKDC score at final follow-up. The median TAS was 6 and VAS for pain was 0.46 ± 0.9. Side-to-side difference in knee laxity was higher in patients with concomitant ACL reconstruction (2.1 ± 2.7 mm) compared to isolated BHMTs (1.0 ± 2.0 mm). MR examination showed 69.4% healed, 25.0% partially healed, and 5.6% unhealed menisci.

CONCLUSION

Patients who underwent repair for acute traumatic BHMTs achieved good to excellent clinical outcome along with a high rate of meniscal healing at a minimum follow-up of two years. Clinical and radiological healing rates were similarly satisfactory and most patients exceeded the PASS criteria for the IKDC score. Patients were able to reach a high postoperative activity level.

LEVEL OF EVIDENCE

Case Series; IV.

Arthroscopic repair of degenerative medial meniscus tears in patients aged over 45 years resulted in favorable clinical outcomes and low clinical failure rates at a minimum 2-year follow-up

PURPOSE

This study aimed to investigate clinical and radiological results of arthroscopic repair for isolated medial degenerative meniscus tears (DMTs) in patients over 45 years old at a minimum 2-year follow-up.

METHODS

From 2013 to 2017, patients aged over 45 years with isolated medial DMT refractory to conservative management or with true mechanical symptoms who had undergone arthroscopic repair were retrospectively reviewed. Arthroscopic meniscus repair was performed using all-inside or all-inside and inside-out technique in combination with bone marrow venting procedure. Tear patterns were classified according to arthroscopic findings. Magnetic resonance imaging (MRI) and outcome evaluations, including Lysholm score, Tegner activity score, and International Knee Documentation Committee (IKDC) score, were evaluated preoperatively and at the final follow-up. International Cartilage Repair Society grades of the medial compartments and MRI signal at tear sites were assessed preoperatively and at the final follow-up. A grade 0 to 2 signal at the repair site suggested a healed meniscus, whereas a grade 3 signal suggested an unhealed meniscus. Clinical failure was determined according to Barrett criteria.

RESULTS

Twenty-seven patients (mean age, 57.7 ± 7.4 years) were enrolled. The mean follow-up was 52.0 ± 15.6 months. Among tear patterns, 48% were complex tears, 30% were horizontal tears, and 22% were other patterns. The mean Lysholm score and IKDC score significantly improved from 53 ± 25 to 89 ± 15 (p < 0.001) and 34 ± 24 to 72 ± 15 (p < 0.001) at the final follow-up, respectively. The median Tegner activity score significantly improved from 1 (range 1-4) to 4 (range 2-7, p < 0.001). Three (11%) patients were considered clinical failures, and five patients (19%) had cartilage lesion progression. At the final follow-up, MRI showed grade 0 in one (4%) patient, grade 1 in nine (33%) patients, grade 2 in six (22%) patients, and grade 3 in eleven (41%) patients.

CONCLUSION

Arthroscopic repair of isolated medial DMT refractory to conservative management or with true mechanical symptoms in patients aged over 45 years had good to excellent clinical outcomes with low clinical failure rates, despite unhealed menisci being observed on MRI in 41% of patients at a mean 4.3-year follow-up. Arthroscopic repair could be a treatment option for these patients.

LEVEL OF EVIDENCE

IV.

Comparison of Cases with Anterior Cruciate Ligament Reconstruction Accompanied by Simultaneous Medial Meniscus Bucket Handle Tear Repair and Isolated Medial Meniscus Bucket Handle Tear Repair

The aim of this study was to evaluate the success of the all-inside repair technique for medial bucket-handle meniscus tear (BHMT) and the factors affecting healing. A total of 36 patients with BHMT who were operated between 2012 and 2018 and completed final follow-up examinations were included in the study. Functional evaluation was made with the International Knee Documentation Committee (IKDC) score, Lysholm score, and Tegner score. Healing was evaluated on magnetic resonance imaging (MRI) slices. The patients were evaluated with respect to the effect on healing of factors such as demographic data, body mass index (BMI), smoking status, anterior cruciate ligament tear reconstruction (ACLTR) applied at the same time as BHMT repair, and the tear being chronic or acute. The mean age of the patients was 28.6 ± 8.6 years (range,18-46 years), the mean follow-up period was 25.8 ± 13.9 months (range, 13-59 months), and BMI was mean 25.6 ± 3.5 kg/m² (range, 20.1-30.5 kg/m²). The meniscus tears were acute in 16 (44.4%) patients and chronic in 20 (55.6%). ACLTR was applied together with BHMT repair in 25 patients. The hybrid technique, as the outside-in technique in addition to the all-inside technique, was applied to 12 (33.3%) patients, where there was seen to be extension to the anterior horn. The failure rate was determined as 27.8% according to the postoperative MRI evaluation and the Barrett criteria. No positive or negative statistically significant effect on healing was determined of chronic BHMT or of simultaneous application of ACLTR (p = 1.00 and 0.457, respectively). Cigarette smoking and high BMI were determined to have a statistically significant negative effect on healing (p = 0.026 and 0.007, respectively). In conclusion, it can be seen that the success of the all-inside technique for BHMT remains controversial. Due to the features of the application, it can be used in meniscus tears of the posterior horn only. In the current study, with the success rate of 72.2% of the all-inside technique in meniscus body tears, it was seen that a high success rate could not be achieved.

Meniscal Root Tears: An Update Focused on Preoperative and Postoperative MRI Findings

Meniscal root tears represent radial tears or avulsions of the meniscal cartilage at the tibial attachment site that profoundly affect meniscal biomechanics and kinematics. Meniscal root tears have the functional effect of a total meniscectomy and can lead to rapid degenerative change with development of early knee osteoarthritis (OA). A growing range of arthroscopic surgical techniques have been developed to repair meniscal root tears with the aim of restoring joint kinematics and contact pressures and delaying the development of OA. With increased understanding of the anatomy and biomechanics of the meniscal root, meniscal root injury repair has become the treatment of choice in knees with nonadvanced OA. This article reviews the anatomy and biomechanics of the meniscal roots, clinical and imaging diagnostic criteria of meniscal root tears, correlation between arthroscopy and MRI in the diagnosis and classification of meniscal root tears, and expected and abnormal MRI findings after meniscal root repair. Familiarity with MRI signs and classifications of meniscal root tears, as well as with root repair surgical techniques, can aid radiologists in correctly reporting preoperative and postoperative MRI findings.

Meniscus Repair Part 2: Technical Aspects, Biologic Augmentation, Rehabilitation, and Outcomes

Multiple meniscal repair techniques exist, and successful healing and excellent patient outcomes have been reported with a variety of all-inside and open techniques. Increased awareness and recognition of root tears and meniscocapsular separations are topics of recent interest. The ideal treatment of these injuries remains uncertain, and definitive recommendations regarding their treatment are lacking. Postoperative protocols regarding weight bearing and range of motion are controversial and require future study. The role of biologics in the augmentation of meniscal repair remains unclear but promising. An evidence-based individualized approach for meniscal repair focusing on clinical outcomes and value is essential.

Second-look arthroscopy after meniscus repair and synovial mesenchymal stem cell transplantation to treat degenerative flaps and radial tears of the medial meniscus: A case report

BACKGROUND

The purpose of this study was to compare arthroscopic findings of a degenerative flap and radial tear of the medial meniscus (MM) before and one year after treatment by meniscus repair and synovial mesenchymal stem cell (MSC) transplantation.

METHODS

Patients with a degenerative flap and radial MM tear that would generally be treated by meniscectomy were included. The patients ranged in age from 45 to 62 years and all underwent meniscus repair and synovium harvest at time 0. The digested synovium was cultured with autologous serum for 12 days, and an average of 4 × 10⁷ MSCs were transplanted at two weeks. A second-look arthroscopy was performed at 52 weeks (n = 6). The average duration of symptoms was 24 months. For flap tears, arthroscopic findings were quantified in terms of the presence, stability, and smoothness of the meniscus at each zone and area. The Lysholm score was evaluated throughout the 52 week follow-up.

RESULTS

Four patients with MM flap tears showed deficiencies in the central area at the posterior junctional zone before treatment, but this zone was completely restored to a stable and smooth condition in two patients and partially restored in the other two patients. The arthroscopy score for a flap tear at the central area of the posterior junctional zone was 0.3 ± 0.5 before treatment and 4.3 ± 2.1 after treatment. The score was significantly higher after treatment (p < 0.05, n = 4). The original radial MM tears in two patients were healed one year after treatment. Lysholm scores were significantly higher at 4 and 52 weeks after treatment than before treatment (n = 6).

CONCLUSIONS

Arthroscopic findings for a degenerative flap and radial tear of the MM were improved at the central area of the posterior junctional zone one year after meniscus repair and MSC transplantation.

Higher healing rate after meniscal repair with concomitant ACL reconstruction for tears located in vascular zone 1 compared to zone 2: a systematic review and meta-analysis

PURPOSE

The purpose of this study was to determine and compare the percentage of completely healed meniscal tears after arthroscopic repair combined with anterior cruciate ligament reconstruction (ACLR) for the different vascular zones of the meniscus.

METHODS

PubMed, Embase, Web of Science, Cochrane library and Emcare were searched on 19 May 2020 for articles reporting healing rates after arthroscopic meniscal repair with concomitant ACLR for the different meniscal vascular zones as assessed by second-look arthroscopy. Data on meniscal tears were extracted as located in zones 1, 2 or 3, according to the Cooper classification. Studies were graded in quality using a modified Newcastle-Ottawa Scale. Pooled analyses were performed utilizing a random-effects model. Meta-analyses were performed using R version 3.6.2 and SPSS statistical software version 25.0. The study was registered with PROSPERO (ID:CRD42020176175).

RESULTS

Ten observational cohort studies met the inclusion criteria, accounting for 758 meniscal tear repairs in total. The pooled overall proportion of healing was 78% (95% CI 72-84%). The mean weighted proportion of healing was 83% (95% CI 76-90%) for studies (n = 10) reporting zone 1 tears and 69% (95% CI 59-79%) for studies (n = 9) reporting zone 2 tears. No study reported healing rates for zone 3 tears. The pooled overall odds ratio was 2.5 (95% CI 1.00-6.02), indicating zone 1 tears as 2.5 times more likely to heal than zone 2 tears.

CONCLUSION

This study demonstrates that meniscal tears localized in vascular zone 1 were more likely to heal than those in zone 2.

LEVEL OF EVIDENCE

IV.

What Is the Failure Rate After Arthroscopic Repair of Bucket-Handle Meniscal Tears? A Systematic Review and Meta-analysis

BACKGROUND

Meniscal repair has become the treatment of choice for meniscal tears, especially in the subset of bucket-handle meniscal tears (BHMTs). However, a comprehensive estimate of the corresponding failure rate is not available, thus maintaining doubts about the healing potential of these tears. Furthermore, a wide range of factors to predict high failure rates have been reported but with conflicting evidence.

PURPOSE

To determine the failure rate after arthroscopic repair of BHMTs as reported in the literature, compare this with the failure rate of simple meniscal tears extracted from the same studies, and analyze the influence of factors previously reported to be predictive of meniscal repair failure.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 4.

METHODS

A systematic search was conducted by 2 independent reviewers using principal bibliographic databases (PubMed, Scopus, Cochrane Library, and EMBASE). After a stepwise exclusion process, 38 articles met the inclusion criteria. Failure rate data were analyzed with a random-effects proportional meta-analysis (weighted for individual study size), and forest plots were constructed to determine any statistically significant differences between BHMTs versus simple tears (longitudinal, radial, or horizontal), medial versus lateral BHMTs, isolated procedures versus repairs with concomitant anterior cruciate ligament reconstruction, and tears in red-red versus red-white zones. Moreover, a meta-regression analysis was conducted to evaluate the effect of patient age and sex, suture technique (in-out or all-inside), time from injury to surgery, mean number of stitches, and length of follow-up on failure rates.

RESULTS

The pooled failure rate was 14.8% (95% CI, 11.3%-18.3%; I² = 77.2%). A total of 17 studies provided failure rates of both BHMT repairs (46/311 repairs) and simple tear repairs (54/546 repairs), demonstrating a significantly higher failure rate for BHMT repairs (risk ratio [RR] = 1.50; 95% CI, 1.05-2.15; I² = 0%; P = .03). Medial BHMT repairs (RR = 1.94; 95% CI, 1.25-3.01; I² = 0%; P = .003) and isolated repairs (RR = 1.77; 95% CI, 1.15-2.72; I² = 0%; P = .009) had statistically higher risk of failure, but no statistically significant difference was found between tears in red-red versus red-white zones. Among the other factors evaluated with meta-regression, only the mean number of stitches showed a statistically significant effect on failure rates.

CONCLUSION

Based on the currently available literature, this systematic review provides a reasonably comprehensive analysis of failure rate after arthroscopic BHMT repair; failure is estimated to occur in 14.8% of cases. Medial tears and isolated repairs were the 2 major predictors of failure.

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

Background:

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

Purpose:

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

Study Design:

Systematic review; Level of evidence, 4.

Methods:

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

Results:

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

Conclusion:

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

Clinical and Radiological Outcomes After Isolated Anterior Horn Repair of Medial and Lateral Meniscus at 24 Months' Follow-up, With the Outside-In Technique

Background

The effects of repair of isolated anterior horn meniscus lesions have not been thoroughly described in the literature. We aimed to evaluate outcomes with subjective clinical scores and imaging modalities after repair of isolated anterior horn tears, at 24 months’ follow-up.

Methods

Records of all patients that opted for surgical repair of isolated, anterior horn tears of the medial and lateral meniscus were retrospectively reviewed, between 2016 and 2018. All patients were treated with arthroscopic outside-in technique by the same surgeon. Preoperative and postoperative clinical files were accessed to recover records of preoperative symptomatology, patient-reported scores [International Knee Documentation Committee (IKDC) rating, Lysholm score and Tegner activity level], preoperative and postoperative MRI data and time from injury to surgery.

Results

Mean age of eight patients was 25.25 years (range 18-37 years). Diagnostic preoperative MRI revealed isolated anterior horn tear of the lateral meniscus and medial meniscus in five patients and an isolated anterior horn tear of the medial meniscus in three patients. Mean time from injury to surgical repair was 23.75 days (range 7-43). We considered seven out of eight repairs to be successfully healed. At 24 months’ follow-up: Mean Lysholm score was 92.25 (range 89-95), Tegner activity scale score was 6.5 (range 5-8) and IKDC score was 91.78 (range 87.8-94.4). All scores significantly improved compared to preoperative values (p<0.001).

Conclusions

Outside-in is a reliable technique to repair meniscal anterior horn tears, both medially and laterally, with high healing rates and patient satisfaction in young, active patients.

Mesenchymal stem cells for enhancing biological healing after meniscal injuries

The meniscus is a semilunar fibrocartilage structure that plays important roles in maintaining normal knee biomechanics and function. The roles of the meniscus, including load distribution, force transmission, shock absorption, joint stability, lubrication, and proprioception, have been well established. Injury to the meniscus can disrupt overall joint stability and cause various symptoms including pain, swelling, giving-way, and locking. Unless treated properly, it can lead to early degeneration of the knee joint. Because meniscal injuries remain a significant challenge due to its low intrinsic healing potential, most notably in avascular and aneural inner two-thirds of the area, more efficient repair methods are needed. Mesenchymal stem cells (MSCs) have been investigated for their therapeutic potential in vitro and in vivo. Thus far, the application of MSCs, including bone marrow-derived, synovium-derived, and adipose-derived MSCs, has shown promising results in preclinical studies in different animal models. These preclinical studies could be categorized into intra-articular injection and tissue-engineered construct application according to delivery method. Despite promising results in preclinical studies, there is still a lack of clinical evidence. This review describes the basic knowledge, current treatment, and recent studies regarding the application of MSCs in treating meniscal injuries. Future directions for MSC-based approaches to enhance meniscal healing are suggested.

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

Background:

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

Hypothesis:

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

Study Design:

Case series; Level of evidence, 4.

Methods:

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

Results:

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

Conclusion:

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

Registration:

NCT03037242 (ClinicalTrials.gov identifier).

Meniscus Repair Techniques

The menisci play a vital role in maintaining knee function and protecting the chondral surfaces. Acute and chronic tears are common injuries among both young athletes and older patients with early degenerative changes. The progression of physiological derangement and chondral injury after meniscus injury and meniscectomy have prompted interest in expanding meniscus repair techniques. Recent literature encourages an attempt at repair in tear patterns previously declared irreparable if the tissue quality allows. The orthopedic surgeon should understand the multitude of techniques available to them and be prepared to combine techniques to optimize the quality of their repair construct. While biological augmentation may show some promising early results, the quality of the current data precludes strong recommendations in their favor.

Mid-term evaluation of clinical and functional outcomes after arthroscopic medial longitudinal and bucket-handle meniscus repair

OBJECTIVES

The aim of this study was to evaluate clinical and functional outcomes following the arthroscopic medial meniscal repair.

PATIENTS AND METHODS

A total of 50 patients (42 males, 8 females; mean age: 32.9±7.6 years; range, 17 to 48 years) who underwent arthroscopic repair for longitudinal and bucket-handle medial meniscal tears between March 2005 and October 2011 were retrospectively evaluated. The patients were divided into two groups as those having a longitudinal tear (patient group, n=31) and having a bucket-handle tear (control group, n=19). Preoperative and final follow-up functional outcomes were evaluated using the Lysholm Knee Score (LKS), International Knee Documentation Committee (IKDC) score, Tegner Activity Scale (TAS) score, and Knee Injury and Osteoarthritis Outcome Score (KOOS).

RESULTS

The mean follow-up was 61.7±22.8 (range, 36 to 110) months. The mean preoperative LKS, IKDC score, TAS, and KOOS scores were significantly improved at the final postoperative follow-up (p<0.05). There was no significant difference in functional outcome scores between longitudinal and bucket-handle repairs (p>0.05), and isolated repairs and concomitant meniscal repair and anterior cruciate ligament reconstruction (p>0.05).

CONCLUSION

Arthroscopic meniscal repair provides similar mid-term functional and clinical outcomes for longitudinal and bucket-handle medial meniscal tears. Concomitant meniscal repair does not seem to affect meniscal healing.

Bucket handle meniscus tears in low-resource settings can be successfully treated with a cost-effective technique

PURPOSE

In regions of the world where resources can limit medical care (limited-resource settings, LRS), most meniscal tears are often treated with meniscectomy. A simple, low-cost option for meniscal repair has been developed. We sought to evaluate patient reported outcomes (PROMs) and clinical failure rates of bucket handle meniscus tears (BHTs) treated with meniscal repair in a LRS.

METHODS

We prospectively enrolled patients over 18 who were treated for BHT with meniscal repair in a LRS. Meniscal repair was primarily accomplished using an outside-in technique. Pre-injury and final follow-up PROMs were recorded. Clinical failure was defined as the need for re-operation or symptoms that prevented the patient from returning to recreational activities or work responsibilities.

RESULTS

Nineteen patients with a mean age of 25.4 years were eligible. Two patients sustained a clinical failure (10.5%). At mean follow-up of 40.6 months, there was significant improvement in all PROMs from baseline. Subgroup analysis revealed no significant difference in the failure group compared to the success group in number of knots used, pre-injury Tegner score, number of devices used, suture type, or technique.

CONCLUSION

Bucket-handle meniscal tears can be repaired using a low-cost technique resulting in satisfactory healing rates and excellent outcomes.

Patient-reported evaluation on giving way is important for return to preinjury activity level after Anterior Cruciate Ligament reconstruction

PURPOSE

The present study evaluated the rate of returning to the preinjury level of competitive sports after ACLR and influential factors.

METHODS

After excluding composite ligament injury cases, 96 patients with a Tegner activity score of ≥ 6 who were managed between April 2015 and March 2016 and had been followed for ≥ 2 years were included in the present study. The patients were evaluated for instability, and the following data were collected: second-look arthroscopy findings, muscle strength, and International Knee Documentation Committee (IKDC) subjective score (follow-up rate: 88.1%).

RESULTS

The rate of returning to the preinjury level of competitive sports was 62/96 (64.6%). Only the total IKDC subjective score (odds ratio, 1.052; 95% confidence interval 1.004-1.102; p = 0.035) and the subjectively evaluated item about giving way (odds ratio, 1.762; 95% confidence interval 1.066-2.911; p = 0.027) were independently associated with the returning to the preinjury level of competitive sports after ACLR in the logistic regression analysis.

CONCLUSION

The rate of returning to the preinjury level of competitive sports after ACLR was 64.6%, even if a good knee stability and healing status of the sutured meniscus were acquired after ACLR. The IKDC subjective score, especially the item about giving way, was significantly associated with the returning to the preinjury level of competitive sports. The factors assessed by patient-reported evaluations concerning giving way that may be related to functional performance, including brain activity, are important to consider to improve the rate of returning to the preinjury level of competitive sports.

LEVEL OF EVIDENCE

III.

Indirect Magnetic Resonance Arthrography May Help Avoid Second Look Arthroscopy for Assessment of Healing After Bucket Handle Medial Meniscus Repairs: A Prospective Clinico-Radiological Observational Study

OBJECTIVES

The objectives were: (1) to analyze the MRI healing rates of bucket-handle meniscus repair; (2) to compare the accuracy of assessment of meniscus healing for conventional MRI and Indirect Magnetic Resonance Arthrography (IMRA); and (3) to identify patients who may require second-look arthroscopy after meniscus repair.

METHODS

This is a prospective observational case series of thirty-seven patients with repaired bucket-handle medial meniscus tear with a minimum one year follow-up. Meniscus healing rates were assessed on direct MRI and IMRA using Henning's criteria. At the same time, patients' symptoms were evaluated according to Barrett's criteria and functional outcomes were recorded using International Knee Documentation Committee (IKDC) score, Knee Osteoarthritis and Outcomes Score (KOOS) and Tegner-Lysholm scores. A further clinical review was performed 18 months after the imaging to assess the evolution of symptoms.

RESULTS

At a mean of 22.3 ± 7.8 months after the meniscus repair, 56.7% patients showed complete healing and 40.5% patients demonstrated incomplete repair healing on IMRA. 52% patients with complete healing and 40% patients with incomplete healing demonstrated meniscus symptoms. At the second clinical review, 19% patients with complete healing and 20% patients with incomplete healing had meniscus symptoms. There was no co-relation between symptoms, PROMs and healing on MRI.

CONCLUSION

Indirect MR arthrography offers distinct advantages over direct MRI for assessment of meniscus healing, especially in symptomatic patients. Patient-reported outcome measures and symptomatology are not co-related with the healing status of the meniscus and they resolve in the majority on longer follow-up. A more conservative approach guided by IMRA to assess meniscus healing will avoid early re-operations.

Postoperative Knee and Shoulder

Arthroscopic surgery in the knee most commonly addresses ligament, meniscal, or articular cartilage abnormalities. Similarly, arthroscopic surgery of the shoulder most commonly addresses tendon and labral abnormalities. The expected postoperative MRI findings depend on both the procedure performed and the time since surgery. Identifying complications and failed procedures relies on both clinical and imaging evaluations.

A novel surgical technique for arthroscopic repair of type II posterior lateral meniscal root tear

BACKGROUND

Several suture repair techniques have been reported for radial tear close to the posterior lateral meniscal root (type II PLMRT). However, no study has evaluated the clinical results after repair using the FasT-Fix system. This paper describes a novel H-plasty surgical repair technique and reports its clinical results.

METHODS

From January 2015 to January 2017, 47 patients underwent repair of type II PLMRT with concomitant anterior cruciate ligament reconstruction and were included in this study. Assessments performed preoperatively and at final follow-up included the Lysholm score, subjective International Knee Documentation Committee (IKDC) score, and knee stability assessments (pivot-shift test, Lachman test, KNEELAX arthrometer side-to-side difference). Magnetic resonance imaging was used to compare the lateral meniscal extrusion pre- versus postoperatively. Second-look arthroscopy was performed to evaluate the meniscal healing in 38 cases.

RESULTS

Forty-seven patients were followed up for an average of 30.7 months (range 18-46 months). No patients experienced meniscal mechanical symptoms. At final follow-up, there were significant improvements in the Lysholm score, IKDC score, knee stability assessments, and lateral meniscal extrusion compared with the preoperative values. In the 38 of 47 patients that underwent second-look arthroscopy after an average of 17.5 months (range 14-19 months), all repairs (100%) were completely healed.

CONCLUSIONS

The novel H-plasty repair using the FasT-Fix system was an effective surgical treatment for type II PLMRT. Considering the satisfactory clinical results and the convenience of the surgery, H-plasty repair is recommended to be used preferentially.

The relationship between ACL reconstruction and meniscal repair: quality of life, sports return, and meniscal failure rate-2- to 12-year follow-up

Background

Few studies have approached in a long-term follow-up of meniscal repair at an amateur level, specially studying variables as a quality of life and failure rate. The purpose of this review is to study medium to long-term clinical results in patients at amateur sports patients, that have required meniscal sutures at our center, with or without ACL reconstruction. We evaluate the objective function of the knee, as well as patients’ return to sports activities, quality of life, and the rate of failed repair and study of the possible reasons.

Methods

This was an observational retrospective study. Ninety-two patients who regularly perform amateur sports activities (Tegner 4 to 7) were assessed, with a minimum follow-up period of 2 years, divided into 2 groups: group 1, isolated meniscal suture (43 cases) and group 2, associated to ACL reconstruction (49 cases). Each patient made this test in 2019: Lysholm and Tegner (validated for Spanish) before a knee injury and after surgery, motivation to return to sports activity (Likert scale with 3 items: low, regular, or high), and quality of life through SD-12 test.

Results

High return to amateur sports rate (92%) was even higher in the isolated meniscal repair group in comparison to the group with associated ACL. We have not found statistically significant differences between sports return and age, gender, injured meniscus, chondral injuries, preoperative Tegner score, or motivation. No significant differences in physical or mental health fields between both groups. Meniscal repair failed in 12 patients (13%). Higher rate of failure in isolated bucket-handle tear injuries (p < 0.0062). No statistically significant association was found between the other variables studied.

Conclusions

Good results with 92% of sports return, low rate of complications, and low retear rate, even lower when is associated with ACL reconstruction and in external meniscus repair, and high values at SF-12 between 2 groups.

Platelet-Rich Plasma Augmentation in Meniscal Repair Surgery: A Systematic Review of Comparative Studies

PURPOSE

To systematically review the literature on meniscal repair surgery and assess functional and radiographic outcomes of platelet-rich plasma (PRP)-augmented repair compared with standard repair techniques.

METHODS

A systematic review of the literature was completed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines using the PubMed, MEDLINE, Embase, and Cochrane databases. The inclusion criteria included all human studies testing PRP augmentation of meniscal repair written in the English language. All cadaveric, animal, and basic science studies were excluded from review. The quality of the included publications was assessed prior to data extraction through the Jadad score. Risk of bias was further determined by Methodological Index for Non-randomized Studies (MINORS) and Cochrane risk-of-bias assessments. Heterogeneity in outcomes reported across studies was evaluated using I² statistic calculations.

RESULTS

A total of 5 studies (1 with Level I evidence; 1, Level II; and 3, Level III) met the inclusion criteria for this review, all comparing PRP augmentation of meniscal repair surgery versus meniscal repair with no augmentation. Overall quality and risk of bias in the included studies varied substantially (Jadad score, 1-5; Methodological Index for Non-randomized Studies score, 7-18). Three comparative studies found no significant difference in outcome or failure, whereas the other two showed a significant improvement in PRP-augmented repairs at final follow-up. Two studies assessed healing with postoperative magnetic resonance imaging or second-look arthroscopy, with both showing significantly improved outcomes in the PRP-treated groups (P < .01 and P = .048). PRP preparation techniques and composition differed among all studies and were inconsistently reported.

CONCLUSIONS

In early and limited investigations, there is insufficient evidence to support PRP augmentation of meniscal repair surgery improving functional and radiographic outcomes and resulting in lower failure rates compared with standard repair techniques. There is considerable heterogeneity in the reporting and preparation of PRP used for augmentation.

LEVEL OF EVIDENCE

Level III, systematic review of Level I to III studies.

Magnetic resonance imaging can increase the diagnostic accuracy in symptomatic meniscal repair patients

PURPOSE

The purpose of this study was to evaluate meniscal repair healing in symptomatic patients through combined clinical assessment, magnetic resonance imaging (MRI) and re-arthroscopy. This study investigated the diagnostic accuracy of MRI and clinical assessment in determining failed meniscal repair in symptomatic meniscal repair patients, as verified by re-arthroscopy.

METHODS

Eighty patients were included. All had undergone a primary meniscal repair followed by an MRI and re-arthroscopy due to clinical symptoms of a meniscal lesion. A validated semi-quantitative scoring system was employed for identifying MRI-diagnosed healing failure. The clinical assessment was divided into joint swelling, joint-line tenderness, locking and a positive McMurray's test. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of MRI and positive clinical findings were calculated using second-look arthroscopy as a standard.

RESULTS

The MRI results showed healing of 22 (27.5%) of the menisci and 58 (72.5%) unhealed menisci, whereas second-look arthroscopy identified 15 (19%) healed menisci and 65 (81%) unhealed menisci. The isolated MRI findings were 0.85, 0.8, 0.95 and 0.55 for sensitivity, specificity, PPV and NPV, respectively. The PPVs of the clinical assessments were 0.78, 0.85 and 0.94, with one, two and three clinical findings, respectively. A grade 3 MRI combined with joint-line tenderness presented a PPV of 0.98.

CONCLUSION

A supplementary MRI will increase diagnostic accuracy when fewer than three clinical findings are present in a symptomatic meniscal repair patient. The clinical relevance of this finding is that MRI contributes to enhancing the diagnostic accuracy of an unhealed meniscal repair when there are limited clinical signs of meniscal pathology.

LEVEL OF EVIDENCE

III.

Management of traumatic meniscus tears: the 2019 ESSKA meniscus consensus

PURPOSE

The importance of meniscus integrity in the prevention of early osteoarthritis is well known, and preservation is accepted as the primary goal. The purpose of the ESSKA (European Society for Sports Traumatology, Knee Surgery and Arthroscopy) European consensus on traumatic meniscus tears was to provide recommendations for the treatment of meniscus tears based on both scientific evidence and the clinical experience of knee experts.

METHODS

Three groups of surgeons and scientists elaborated and ratified the so-called formal consensus process to define the recommendations for the management of traumatic meniscus tears. A traumatic meniscus tear was defined as a tear with an acute onset of symptoms caused by a sufficient trauma. The expert groups included a steering group of eight European surgeons and scientists, a rating group of another nineteen European surgeons, and a peer review group. The steering group prepared twenty-seven question and answer sets based on the scientific literature. The quality of the answers received grades of A (a high level of scientific support), B (scientific presumption), C (a low level of scientific support) or D (expert opinion). These question and answer sets were then submitted to and evaluated by the rating group. All answers were scored from 1 (= totally inappropriate) to 9 (= totally appropriate) points. Thereafter, the comments of the members of the rating group were incorporated by the steering group and the consensus was submitted to the rating group a second time. Once a general consensus was reached between the steering and rating groups, the finalized question and answer sets were submitted for final review by the peer review group composed of representatives of the ESSKA-affiliated national societies. Eighteen representatives replied.

RESULTS

The review of the literature revealed a rather low scientific quality of studies examining the treatment of traumatic meniscus tears. Of the 27 questions, only one question received a grade of A (a high level of scientific support), and another received a grade of B (scientific presumption). The remaining questions received grades of C and D. The mean rating of all questions by the rating group was 8.2 (95% confidence interval 8.1-8.4). A general agreement that MRI should be performed on a systematic basis was not achieved. However, MRI was recommended when arthroscopy would be considered to identify concomitant pathologies. In this case, the indication for MRI should be determined by a musculoskeletal specialist. Based on our data, stable left in situ lateral meniscus tears appear to show a better prognosis than medial tears. When repair is required, surgery should be performed as early as possible. Evidence that biological enhancement such as needling or the application of platelet-rich plasma would improve healing was not identified. Preservation of the meniscus should be considered as the first line of treatment because of an inferior clinical and radiological long-term outcome after partial meniscectomy compared to meniscus repair.

DISCUSSION

The consensus was generated to present the best possible recommendations for the treatment of traumatic meniscus tears and provides some groundwork for a clinical decision-making process regarding the treatment of meniscus tears. Preservation of the meniscus should be the first line of treatment when possible, because the clinical and radiological long-term outcomes are worse after partial meniscectomy than after meniscus preservation. The consensus clearly states that numerous meniscus tears that were considered irreparable should be repaired, e.g., older tears, tears in obese patients, long tears, etc. LEVEL OF EVIDENCE: II.

Factors Predicting Failure Rates and Patient-Reported Outcome Measures After Arthroscopic Meniscal Repair

PURPOSE

To identify factors that affect patient-reported outcome measures (PROMs) and failure rates after arthroscopic meniscal repair.

METHODS

Embase, Embase Classic, and MEDLINE were searched on August 7, 2015, December 23, 2016, and March 11, 2018, for factors associated with PROMs and failure rates after arthroscopic meniscal repair. We excluded studies that (1) were non-English language, (2) did not use human patients, (3) were nonclinical, (4) did not analyze for factors that predicted PROMs or failure rates, and (5) were below Level IV evidence. Studies were graded into higher and lower quality using the Downs and Black scale.

RESULTS

A total of 34 articles met our criteria, and 32 were graded. We identified 16 articles as higher quality. Among higher-quality studies, factors that significantly predicted reduced failure rates were concurrent anterior cruciate ligament reconstruction (ACLR) (n = 6) and reduced tear complexity (n = 4). Factors that did not significantly impact failure rates were side of repair (n = 8), sex (n = 7), time from injury to surgery (n = 7), age (n = 7), rim width (n = 6), and tear length (n = 5). Factors predicting better PROMs were time from injury to surgery of less than 3 months (n = 1), Outerbridge scores below grade 3 or 4 (n = 2), and reduced varus alignment (n = 2). Factors that did not significantly impact PROMs were equipment used (n = 3) and concurrent ACLR (n = 1).

CONCLUSIONS

Factors affecting failure rates and PROMs after arthroscopic meniscal repair were identified. However, more and higher-quality studies supported concurrent ACLR and less complex tears as predictors of lower failure rates. PROMs were negatively affected by a longer time from injury to surgery, higher Outerbridge scores, and greater varus alignment before surgery.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II to IV studies.

In-Office Needle Arthroscopy: A Systematic Review of Indications and Clinical Utility

PURPOSE

This review explores the current literature regarding both the clinical indications and utility of minimally invasive in-office needle arthroscopy (IONA) relative to conventional imaging modalities.

METHODS

In compliance with R-AMSTAR (Revised Assessment of Multiple Systematic Reviews) and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines, 3 databases (MEDLINE, Embase, and PubMed) were searched in July 2018, in addition to the conference abstract databases of 5 prominent meetings between 2013 and 2018, for studies using IONA for diagnostic purposes. Study quality was assessed with the Methodological Index for Non-Randomized Studies (MINORS) criteria.

RESULTS

Among 932 conference abstracts and 369 studies identified, 11 publications involving 404 patients (395 knees and 9 shoulders) were included, with 9 clinical studies and 2 cost analyses. The median Methodological Index for Non-Randomized Studies (MINORS) score was 9 for noncomparative and 23 for comparative studies. Among the 9 clinical studies, IONA had a superior sensitivity, specificity, positive predictive value, and negative predictive value to magnetic resonance imaging (MRI) in the evaluation of knee osteoarthritis, anterior cruciate ligament insufficiency, and meniscal tears. IONA was comparable or inferior to MRI in the same parameters for the diagnosis of osteochondral defects and rotator cuff tears. In the 2 cost analyses, IONA had lower costs when used in place of MRI for treatment algorithms involving medial meniscal tears and rotator cuff tears but not lateral meniscal tears.

CONCLUSIONS

IONA holds potential for cost savings and improved diagnostic accuracy relative to MRI, primarily for intra-articular meniscal, ligamentous, and chondral defects of the knee. However, its current indications for use in other joints are limited to rotator cuff tears in the shoulder, making its diagnostic value in other joints much more limited. The current quality and breadth of evidence are significantly lacking, with numerous practical shortcomings. To improve acceptance of IONA, priority should be placed on establishing defined protocols, indications, contraindications, and patient perspectives for the procedure.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II, III, and IV studies.

Evaluation of Midterm Clinical and Radiographic Outcomes of Arthroscopically Repaired Vertical Longitudinal and Bucket-Handle Lateral Meniscal Tears

Background:

Lateral meniscal tears in the stable knee are rare. There are few comparative studies evaluating functional and radiological outcomes of vertical longitudinal and bucket-handle lateral meniscal tears.

Purpose:

To evaluate the midterm clinical and radiological outcomes of arthroscopically repaired traumatic vertical longitudinal and bucket-handle lateral meniscal tears.

Study Design:

Case series; Level of evidence, 4.

Methods:

A total of 43 full-thickness lateral meniscal repairs, including 22 (51.2%) for vertical longitudinal tears and 21 (48.8%) for bucket-handle tears, were evaluated. A clinical assessment was performed according to the Barrett criteria, and patient outcomes were measured with the Lysholm knee score, Tegner activity scale, and overall satisfaction scale. Magnetic resonance imaging was used as the radiological re-examination method preoperatively and at final follow-up. A subgroup analysis examining isolated repair versus repair with concurrent anterior cruciate ligament (ACL) reconstruction was performed.

Results:

The mean follow-up period was 63.2 months (range, 24-86 months). Based on clinical and radiological outcomes, 38 of the 43 repairs (88.3%) were successful, and the remaining 5 (11.6%) cases were considered to be failures. Overall, the combined results for both groups demonstrated an improvement in the Lysholm score, Tegner score, and patient satisfaction. There was no significant difference in the postoperative Lysholm score (91.4 vs 87.0, respectively; P = .223), Tegner score (5.4 vs 5.5, respectively; P = .872), or patient satisfaction (7.2 vs 7.4, respectively; P = .624) between bucket-handle repair and vertical longitudinal repair. The subgroup analysis demonstrated no difference in outcome scores for isolated repair versus repair with concurrent ACL reconstruction. Smoking was identified as a risk factor for repair failure.

Conclusion:

Comparable clinical and radiological outcomes were obtained after vertical longitudinal and bucket-handle lateral meniscal repairs using the all-inside or hybrid suture technique with different suture configurations, regardless of whether ACL reconstruction was performed. Smoking was identified as a risk factor for failure.

Comparison of Tibial Tuberosity-Trochlear Groove (TT-TG) distances between different anterior cruciate ligament reconstructions: A retrospective clinical and imaging study

BACKGROUND:

Previous studies showed that compared with single-bundle (SB) precedures, double-bundle (DB) anterior cruciate ligament (ACL) reconstruction perform better.

OBJECTIVE:

To make assurance that distance of TT-TG may be altered along with ACL rupture and reconstruction.

METHODS:

Imaging study of 201 patients’s related cases by MRI and CT scans.

RESULTS:

Compared with the intact knee’s overall mean TT-TG value, the mean overall pre/postoperative TT-TG values showed a significant difference. For SB reconstruction, the mean pre/postoperative TT-TG values were 15.67± 2.46 mm and 14.72± 2.48 mm, respectively. Postoperative and intact knee TT-TG values were significantly different (p< 0.001). For DB reconstruction, the pre/postoperative mean TT-TG values were 15.11± 1.99 mm and 13.11± 1.71 mm. Postoperative and intact knee TT-TG values were not significantly different (p= 0.141).

CONCLUSIONS:

The increased TT-TG value from a ruptured ACL was significantly restored after ACL reconstruction. The TT-TG value after SB reconstruction was still obviously larger than that of the intact knee. It showed no significant difference between the postoperative TT-TG of the DB group and intact knees. The original TT-TG values of the knees were much closer to restoration after DB reconstruction.

High short-term return to sports rate despite an ongoing healing process after acute meniscus repair in young athletes

PURPOSE

Acute meniscus repair in young athletes is always a challenge due to the long rehabilitation process and time to return to sport (RTS). The purpose was to investigate signal alterations in short-term follow-up after acute meniscus repair on specific magnetic resonance imaging (MRI) scan sequences. It was hypothesized that (1) MRI signal changes over the first postoperative healing phase and represent a continuous healing process and (2) meniscus healing properties correlates with clinical outcomes and RTS.

METHODS

Young athletes with traumatic meniscus lesion and arthroscopic meniscus repair within 6 weeks and available preoperative MRI were enrolled. Clinical examination, outcome scores (IKDC, KOOS, Lysholm Score, Tegner activity score) and RTS were surveyed preoperatively and 6 and 12 weeks and 6 months after surgery. Radiological follow-up examinations were performed 2, 4, 6, 12 weeks and 6 months after operation using a 3T-MRI. Evaluation was based on ISAKOS meniscus classification system, meniscus healing were classified according to Henning's criteria.

RESULTS

At final follow-up (FU) 30 patients (28 month, 2 week) with a total of 35 meniscus tears (19 medial, 16 lateral) were included. Clinical scores improved significantly after surgery: IKDC Score (preOP: 39.4 ± 18.5, final FU: 78.8 ± 15.3) KOOS (preOP: 45.7 ± 22.1, final FU: 82.7 ± 12.5) and Lysholm Score (preOP: 42.8 ± 23.7, final FU: 84.4 ± 13.8) (p < 0.01). Tegner activity score showed a steadily increase to 4 (range 3-9) at 6 months but did not reached the pre-injury level of 6 (range 3-9). RTS rate was 100% whereof 44.8% reached their pre-injury level. MRI examination revealed a continuous healing process and menisci were classified as 55.9% healed, 35.3% partially healed and 8.8% non-healed at final FU.

CONCLUSION

This study showed that MRI signal alterations of the meniscus steadily occur within the first 6 months postoperatively. MRI reveals an ongoing healing process at final FU that have to be carefully considered when RTS is discussed with high demanding patients. However, young athletes provide good clinical results and RTS rate even though MRI alterations are still present.

LEVEL OF EVIDENCE

Therapeutic study, prospective case series, Level IV.

3D-MRI combined with signal-to-noise ratio measurement can improve the diagnostic accuracy and sensitivity in evaluating meniscal healing status after meniscal repair

PURPOSE

This study compared the diagnostic accuracy of second-look arthroscopy, clinical assessment, and magnetic resonance imaging (MRI) in evaluating meniscal healing following repair. To explore the application of 3D-MRI sequences with signal-to-noise ratio (SNR) measurements and the analysis of sensitivity and accuracy in evaluating meniscal healing status after meniscal repair.

METHODS

This study included 75 patients (75 menisci; mean age, 25.4 ± 6.6 years) who underwent arthroscopic meniscal repair (medial menisci, 45; and lateral menisci, 29). Follow-up evaluation included clinical assessment, magnetic resonance imaging (MRI), and second-look arthroscopy (mean follow-up, 10.2 ± 3.4 months). The criteria defined for unhealed menisci were: on arthroscopy, presence of cleft; on clinical assessment, presence of joint-line tenderness, swelling, locking, or positive McMurray test; on MRI, grade III signal intensity at the site of repair. Finally, the SNR on 3D-MRI of the healed and the unhealed groups were compared.

RESULTS

On second-look arthroscopy, 68 (90.7%) menisci were found to be completely healed. With the arthroscopic healing rate as the standard, the clinical healing rate was 69.3% (63 menisci) [sensitivity, 85.7%; specificity, 75.0%; accuracy, 76.0%; positive predictive value (PPV), 26.1%; negative predictive value (NPV), 98.1%]. Similarly, the sensitivity, specificity, accuracy, PPV and NPV, respectively, for MRI in four sequences were as follows: 2D-T2W-Sag: 71.4, 79.4, 78.7, 26.3, and 96.4%; 2D-T2W-Cor: 71.4, 82.4, 81.3, 29.4, and 96.6%; 3D-PDW-Sag: 100.0, 50.0, 54.7, 17.1, and 100.0%; 3D-PDW-Cor: 100.0, 58.8, 62.7, 20.0, and 100.0%. The mean SNRs of the healed group (3D-PDW-Sag, 66.7 ± 11.9; 3D-PDW-Cor, 63.9 ± 12.4) were significantly lesser than that of the unhealed group (3D-PDW-Sag, 89.2 ± 9.6; 3D-PDW-Cor, 82.2 ± 18.5) (P < 0.05). Identifying grade 3 meniscal damage on 3D-PDW images prior to applying the different SNR cut-off points revealed SNR values 80 in the sagittal plane and 70 in the coronal plane as having better diagnostic accuracy and sensitivity. The clinical relevance of the study was that 3D-MRI combined with SNR measurement may be a noninvasive and accurate method of assessment clinically, and a reliable alternative to second-look arthroscopy.

LEVEL OF EVIDENCE

III.

Current concepts in the techniques, indications and outcomes of meniscal repairs

Knee arthroscopy for meniscal tears is one of the most commonly performed orthopaedic procedures. In recent years, there has been an increasing incidence of meniscal repairs, as there are concerns that meniscectomy predisposes patients to early osteoarthritis. Indications for meniscal repair are increasing and can now be performed in older patients who are active, even if the tear is in the avascular zone. Options for meniscal tear management broadly fall into three categories: non-operative management, meniscal repair or meniscectomy. With limited evidence directly comparing each of these options optimal management strategies can be difficult. Decision making requires thorough assessment of patient factors (e.g. age and comorbidities) and tear characteristics (e.g. location and reducibility). The purpose of this paper is, therefore, to review the management options of meniscal tears and summarize the evidence for meniscal tear repair.

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.

Anterolateral Ligament Reconstruction Protects the Repaired Medial Meniscus: A Comparative Study of 383 Anterior Cruciate Ligament Reconstructions From the SANTI Study Group With a Minimum Follow-up of 2 Years

BACKGROUND

The prevalence of osteoarthritis after successful meniscal repair is significantly less than that after failed meniscal repair.

PURPOSE

To determine whether the addition of anterolateral ligament reconstruction (ALLR) confers a protective effect on medial meniscal repair performed at the time of anterior cruciate ligament reconstruction (ACLR).

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Retrospective analysis of prospectively collected data was performed to include all patients who had undergone primary ACLR with concomitant posterior horn medial meniscal repair through a posteromedial portal between January 2013 and August 2015. ACLR autograft choice was bone-patellar tendon-bone, hamstring tendons (or quadrupled hamstring tendons), or quadrupled semitendinosus tendon graft with or without ALLR. At the end of the study period, all patients were contacted to determine if they had undergone reoperation. A Kaplan-Meier survival curve was plotted, and a Cox proportional hazards regression model was used to perform multivariate analysis.

RESULTS

A total of 383 patients (mean ± SD age, 27.4 ± 9.2 years) were included with a mean follow-up of 37.4 months (range, 24-54.9 months): 194 patients underwent an isolated ACLR, and 189 underwent a combined ACLR + ALLR. At final follow-up, there was no significant difference between groups in postoperative side-to-side laxity (isolated ACLR group, 0.9 ± 0.9 mm [min to max, -1 to 3]; ACLR + ALLR group, 0.8 ± 1.0 mm [min to max, -2 to 3]; P = .2120) or Lysholm score (isolated ACLR group, 93.0 [95% CI, 91.3-94.7]; ACLR + ALLR group, 93.7 [95% CI, 92.3-95.1]; P = .556). Forty-three patients (11.2%) underwent reoperation for failure of the medial meniscal repair or a new tear. The survival rates of meniscal repair at 36 months were 91.2% (95% CI, 85.4%-94.8) in the ACLR + ALLR group and 83.8% (95% CI, 77.1%-88.7%; P = .033) in the ACLR group. The probability of failure of medial meniscal repair was >2 times lower in patients with ACLR + ALLR as compared with patients with isolated ACLR (hazard ratio, 0.443; 95% CI, 0.218-0.866). No other prognosticators of meniscal repair failure were identified.

CONCLUSION

Combined ACLR and ALLR is associated with a significantly lower rate of failure of medial meniscal repairs when compared with those performed at the time of isolated ACLR.

Imaging the Postoperative Knee Meniscus: An Evidence-Based Review

OBJECTIVE

Unenhanced MRI, indirect MR arthrography, direct MR arthrography, and CT arthrography are each currently used to evaluate patients with recurrent knee pain after meniscus surgery. The purpose of this study is to review the evidence for the use of these examinations in patients with suspected recurrent meniscus tear.

CONCLUSION

Direct and indirect MR arthrography are superior to conventional MRI for the assessment of the postoperative meniscus after meniscus repair or partial meniscectomy involving more than 25% of the meniscus.

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.

Factors Affecting the Outcomes of Arthroscopically Repaired Traumatic Vertical Longitudinal Medial Meniscal Tears

BACKGROUND

Although numerous studies have assessed arthroscopic medial meniscal repairs, few studies have focused on factors affecting outcomes of vertical longitudinal and bucket-handle repairs.

PURPOSE

To evaluate the factors affecting clinical outcomes of arthroscopically repaired traumatic vertical longitudinal and bucket-handle medial meniscal tears.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A total of 223 patients underwent arthroscopic repair for medial meniscal tears between 2007 and 2012; 140 patients had isolated tears or concurrent anterior cruciate ligament (ACL) reconstruction, and 80 patients (76 men, 4 women; mean age, 29.1 years; range, 18-49 years) had vertical longitudinal tears and were included in the study. Pre- and postoperative functional status was assessed using physical examinations with Lysholm and International Knee Documentation Committee (IKDC) scores. Barrett criteria were used for clinical assessment of meniscal healing, and magnetic resonance imaging (MRI) was used as the radiologic assessment method. The effects of tear location, length, chronicity, and type; suturing technique; concurrent ACL reconstruction; and patient age, sex, and smoking habits were also investigated.

RESULTS

The mean follow-up period was 51.2 ± 9.4 months (range, 34-85 months). The mean Lysholm and IKDC scores improved at final follow-up (both Ps <.001). According to clinical scores, Barrett criteria, and MRI, failure was noted in 12 patients (15%). There were no significant differences in age, tear length, tear type, concurrent ACL rupture, suturing technique, or location of the meniscal repair between the success and failure groups. Failure rates were higher for red-white zone tears than for red-red zone tears (10/30, 33.3% vs 2/50, 4%; P = .004). Tear chronicity significantly affected failure rates. Early repairs had higher healing rates than late repairs (100% vs 73.4%; P = .008). Failure rates were higher for smokers than for nonsmokers (9/24, 37.5% vs 3/56, 5.3%; P = .008).

CONCLUSION

Peripheral tears and early repairs have better outcomes and patient satisfaction. Smoking adversely affects meniscal healing.

COMBINED INSIDE-OUT AND ALL-INSIDE TECHNIQUE IN BUCKET-HANDLE MENISCUS TEARS

OBJECTIVE

To determine the outcomes after combined inside-out and all-inside repair technique of bucket-handle meniscus tears.

METHODS

A retrospective review was made of patients with bucket-handle meniscus tears repaired with combined techniques, using the all-inside technique in posterior meniscal tears and the inside-out technique in the middle part of the meniscal tears. Meniscal healing was assessed clinically using Barrett's criteria and MRI.

RESULTS

The study comprised 52 patients with a mean age of 28.4 years old (range, 19-52 years old). The mean follow-up period was 31.3 months (range, 24-59 months). Two patients had ACL re-rupture, and complete meniscal healing was achieved in all but one patient. Although improved from preoperative status, Tegner and Lysholm scores were lower in the ACL reconstructed patients than in the intact ACL patients.

CONCLUSION

Combined inside-out and all-inside meniscal repair technique is a successful and cost-effective treatment method in bucket-handle meniscus tears. Level of Evidence IV, Therapeutic Study.

Chondrogenic Effect of Intra-articular Hypertonic-Dextrose (Prolotherapy) in Severe Knee Osteoarthritis

BACKGROUND

Dextrose injection is reported to improve knee osteoarthritis (KOA)-related clinical outcomes, but its effect on articular cartilage is unknown. A chondrogenic effect of dextrose injection has been proposed.

OBJECTIVE

To assess biological and clinical effects of intra-articular hypertonic dextrose injections (prolotherapy) in painful KOA.

DESIGN

Case series with blinded arthroscopic evaluation before and after treatment.

SETTING

Physical medicine and day surgery practice.

PARTICIPANTS

Symptomatic KOA for at least 6 months, arthroscopy-confirmed medial compartment exposed subchondral bone, and temporary pain relief with intra-articular lidocaine injection.

INTERVENTION

Four to 6 monthly 10-mL intra-articular injections with 12.5% dextrose.

MAIN OUTCOME MEASURES

Visual cartilage growth assessment of 9 standardized medial condyle zones in each of 6 participants by 3 arthroscopy readers masked to pre-/postinjection status (total 54 zones evaluated per reader); biopsy of a cartilage growth area posttreatment, evaluated using hematoxylin and eosin and Safranin-O stains, quantitative polarized light microscopy, and immunohistologic cartilage typing; self-reported knee specific quality of life using the Western Ontario McMaster University Osteoarthritis Index (WOMAC, 0-100 points).

RESULTS

Six participants (1 female and 5 male) with median age of 71 years, WOMAC composite score of 57.5 points, and a 9-year pain duration received a median of 6 dextrose injections and follow-up arthroscopy at 7.75 months (range 4.5-9.5 months). In 19 of 54 zone comparisons, all 3 readers agreed that the posttreatment zone showed cartilage growth compared with the pretreatment zone. Biopsy specimens showed metabolically active cartilage with variable cellular organization, fiber parallelism, and cartilage typing patterns consistent with fibro- and hyaline-like cartilage. Compared with baseline status, the median WOMAC score improved 13 points (P = .013). Self-limited soreness after methylene blue instillation was noted.

CONCLUSIONS

Positive clinical and chondrogenic effects were seen after prolotherapy with hypertonic dextrose injection in participants with symptomatic grade IV KOA, suggesting disease-modifying effects and the need for confirmation in controlled studies. Minimally invasive arthroscopy (single-compartment, single-portal) enabled collection of robust intra-articular data.

LEVEL OF EVIDENCE

IV.

Complex Meniscus Tears Treated with Collagen Matrix Wrapping and Bone Marrow Blood Injection: A 2-Year Clinical Follow-Up

OBJECTIVE

To collect and analyze the 2-year follow-up clinical and MRI results of patients treated with an arthroscopic technique of collagen membrane-based meniscus repair.

DESIGN

53 consecutive patients with combined (horizontal and radial or longitudinal component) and complex meniscal tears (tear extended through avascular zones or/and composed with two or more morphological tear pattern) were treated with an "all-inside" arthroscopic suture of meniscus and wrapping with a collagen membrane (Chondro-Gide) technique with bone marrow blood injection. The IKDC 2000 subjective score, IKDC 2000 clinical evaluation score, Lysholm score and Barret clinical criteria of meniscal healing were recorded. All patients were examinated by MRI 2 years postoperatively, using modified WORMS criteria for meniscal integrity.

RESULTS

The 2 year follow-up was achieved in 50 cases. Of these, 2 patients were excluded from the evaluation due to incomplete data and 2 patients underwent partial meniscectomy and were classified as failures. In 46 patients (86.8% of the intended to treat cases), a statistically significant improvement in IKDC 2000 subjective, Lysholm scores and IKDC 2000 clinical assessment between preoperative and the 2-year follow-up time points were obsereved. Barret criteria demonstrated an improved clinical outcome between pre- and post-operative values. MRI revealed a non-homogeneous signal without meniscal tear (WORMS grade 1) in 76% of the operated menisci (13% WORMS grade 2).

CONCLUSIONS

The 2-year follow-up data demonstrate that this technique is safe and can offer an additional tool to save the meniscus in the patients otherwise scheduled for meniscal removal. Level of evidence IV.

Current status of second-look arthroscopy after meniscal allograft transplantation: review of the literature

INTRODUCTION

Clinical assessments do not accurately reflect the status of meniscal transplants and cannot evaluate the graft condition itself and joint preservation effects of meniscal allograft transplantation correctly. The purpose of this review was to assess the need and to ascertain the indication and the role of second-look arthroscopy for objective evaluation after MAT.

MATERIALS AND METHODS

We performed a literature search to identify all published clinical studies on MAT with the following medical subject heading (MeSH) terms: "meniscus," "meniscal transplant," "transplantation and allograft," "meniscal and transplant." Include in the review are studies with at least 6 months clinical, radiological, and/or histological follow-up in human subjects. Evaluation method of MAT was reviewed with an aim to describe the frequency of second-look arthroscopy, its feasibility, patient compliance, purposes, and results.

RESULTS

We identified 15 clinical studies that satisfied our inclusion and exclusion criteria. Only two studies always performed second-look arthroscopies. Most of the second-look arthroscopy was conducted mainly for the objective evaluation of meniscal allograft transplantation but, in several studies, arthroscopy was performed to treatment of other knee problem.

CONCLUSIONS

Although second-look arthroscopy has inevitably ethical issues, especially for asymptomatic and well-functioning knees, in this review, it could be a more dependable method available to detect meniscal healing if performed for certain indications such as a symptomatic patient with a magnetic resonance image indicating abnormalities.

Quantitative Ultrashort Echo Time Magnetic Resonance Imaging Evaluation of Postoperative Menisci: a Pilot Study

BACKGROUND

Magnetic resonance imaging (MRI) visualization of meniscal signal is particularly challenging as the highly organized ultrastructure of meniscal fibrocartilage yields very short T2 values (∼6 ms) and a paucity of signal intensity during conventional image acquisition.

QUESTION/PURPOSE

The purpose of this study was to evaluate the feasibility of imaging postoperative menisci using an experimental, quantitative ultrashort echo time (UTE) MRI pulse sequence. This sequence acquires short echo images (echo time (TE) ∼0.3 ms) to produce multi-echo images for quantitative T2* calculations that provide an objective measure of collagen organization.

PATIENTS AND METHODS

MRI scans of the knee were acquired at 6- and 12-month intervals on a clinical 3.0 T scanner following meniscal surgery in eight patients (ages 13-41), four of whom underwent repair and the other four partial meniscectomy. Conventional MRI sequences were qualitatively evaluated for meniscal morphology and signal and correlated with quantitative UTE results.

RESULTS

A wide range of mean T2* values for both postsurgical groups was measured, and these values changed for each patient between the 6- and 12-month intervals. In many instances, the UTE sequence demonstrated quantitative differences between the two time intervals that were not detected with conventional sequences.

CONCLUSIONS

This pilot study presents preliminary, observational data to be used as a baseline for future studies. Although the T2* values did not reveal a trend in either group or correlate with expected signal changes on conventional MRI, we speculate that the UTE sequence may detect ultrastructural alterations in meniscal composition that are otherwise not perceived with routine fast spin echo (FSE) sequences.

Comparison of postoperative magnetic resonance imaging and second-look arthroscopy for evaluating meniscal allograft transplantation

PURPOSE

The aim of this study was to compare the magnetic resonance imaging (MRI) evaluation of transplanted meniscal allograft with second-look arthroscopy and evaluate the sensitivity, specificity, and accuracy of MRI for assessing graft status.

METHODS

From 1996 to 2012, among 290 knees that underwent meniscal allograft transplantation and received follow-up examination for more than 1 year, those knees that underwent second-look arthroscopy were reviewed. Patients with no postoperative MRI and patients with a time gap between postoperative MRI and second-look arthroscopy of more than 3 months were excluded. Anatomically, the meniscus was divided into 3 segments: anterior one-third, mid body, and posterior one-third. Each part of the meniscus was evaluated using both methods. Grade 3 MRI signal intensity was diagnosed as a meniscal tear radiologically. By use of second-look arthroscopy as the standard, the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of postoperative MRI were assessed in each segment of the grafts.

RESULTS

Twenty knees were retrospectively enrolled. The specificity, PPV, and accuracy for the anterior one-third were lower than those for the mid body and posterior one-third (specificity of 35.3% v 91.7% and 90%, respectively; PPV of 21.4% v 87.5% and 90.9%, respectively; and accuracy of 45% v 90% and 95%, respectively). However, the sensitivity and NPV were similar among the anterior one-third, mid body, and posterior one-third (sensitivity of 100%, 87.5%, and 100%, respectively; and NPV of 100%, 91.7%, and 100%, respectively). There were no significant differences in the comparison between the diagnostic MRI values of lateral grafts and medial grafts. Of 5 cases that showed grade 3 signal at only the anterior one-third section, 60% had no clinical signs. There were no graft tears in any cases.

CONCLUSIONS

The anterior one-third of grafts showed low specificity, PPV, and accuracy of postoperative MRI compared with the mid body and posterior one-third. MRI tended to grade the anterior one-third more poorly than second-look arthroscopy. These features should be considered when evaluating transplanted meniscal allografts on postoperative MRI.

LEVEL OF EVIDENCE

Level III, study of non-consecutive patients evaluating a diagnostic test with a gold standard.