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Wang M, Lee DYH. Meniscus root tears: what is the hype? Singapore Med J 2024:00077293-990000000-00147. [PMID: 39287513 DOI: 10.4103/singaporemedj.smj-2023-115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 04/11/2024] [Indexed: 09/19/2024]
Abstract
ABSTRACT Meniscus root tears are increasingly being studied due to their importance in meniscus function. Meniscus root tears can increase the joint contact pressure significantly, similar to a total meniscectomy. This may cause rapid progression of joint degeneration and produce inferior clinical outcome. Historically, they were treated with partial meniscectomy, which did not change the natural history. New repair techniques such as transtibial pull-out repair and suture anchor repair have improved the clinical outcome. This review article summarises the anatomy of the meniscus, the pathology of meniscus root tears and different repair techniques with their clinical outcomes.
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Affiliation(s)
- Ming Wang
- Department of Orthopaedic Surgery, National University Hospital, Singapore
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Saithna A, Helito CP, Bin Abd Razak HR, Cristiani R. Secondary restraints in ACL reconstruction: State-of-the-art. J ISAKOS 2024; 9:759-768. [PMID: 38734309 DOI: 10.1016/j.jisako.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 03/07/2024] [Accepted: 05/04/2024] [Indexed: 05/13/2024]
Abstract
At-risk patients continue to experience a high likelihood of graft rupture after anterior cruciate ligament (ACL) reconstruction (ACLR). This narrative review seeks to provide the reader with an evidence-based synopsis of state-of-the-art concepts related to secondary restraint lesions, and how addressing them surgically might result in improved outcomes of ACLR.
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Affiliation(s)
- Adnan Saithna
- Department of Orthopedic Surgery, University of Arizona, Tucson, AZ, 85724, USA; AZBSC Orthopedics, 7649 E Pinnacle Peak Rd, Scottsdale, AZ, 85255, USA.
| | - Camilo Partezani Helito
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Rua Dr. Ovídio Pires de Campos, 333 - Cerqueira Cesar, São Paulo, SP, CEP: 05403-010, Brazil; Hospital Sírio Libanês, Rua Dona Adma Jafet, 91 - Bela Vista, São Paulo, SP, CEP 01308-050, Brazil
| | - Hamid Rahmatullah Bin Abd Razak
- Total Orthopaedic Care & Surgery, Novena Medical Centre, 10 Sinaran Drive, 307506 Singapore; SingHealth Duke-NUS Musculoskeletal Sciences Academic Clinical Programme, 20 College Road, Academia Level 4, 169865, Singapore
| | - Riccardo Cristiani
- Department of Molecular Medicine and Surgery, Stockholm Sports Trauma Research Center, Karolinska Institutet, Stockholm, Sweden; Capio Artro Clinic, FIFA Medical Centre of Excellence, Sophiahemmet Hospital, Valhallavägen 91, 11486, Stockholm, Sweden
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Alsaleh NS, Alnasser AA, Alqahtani AA. A case report of simultaneous tears of the medial and lateral posterior meniscal roots with an intact ACL graft. Int J Surg Case Rep 2024; 121:109971. [PMID: 38954967 PMCID: PMC11263624 DOI: 10.1016/j.ijscr.2024.109971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2024] [Revised: 06/23/2024] [Accepted: 06/26/2024] [Indexed: 07/04/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE Meniscal root tears are defined as soft-tissue and/or osseous injuries that rip or avulse within one centimeter of the meniscal insertion to the tibial plateau. These injuries impact around 100,000 patients a year and make up 10 % to 21 % of all meniscal tears. Meniscal extrusion frequently happens when there are root rips, and the transmission of circumferential hoop loads is hampered. CASE PRESENTATION We present one case of a 28-year-old male who complained of pain and stiffness in his left knee since 2 years after undergoing ACL reconstruction using a hamstring autograft. His examination revealed joint line tenderness on both the medial and lateral sides of the left knee. Further investigations involving X-ray and MRI established the diagnosis of both medial and lateral meniscal root tears, which were surgically managed using the transtibial pullout technique. DISCUSSION The biomechanical implications of meniscal root tears, such as loss of hoop forces and increased tibiofemoral contact pressures, underscore the importance of timely diagnosis and management. The literature advocates surgical treatment for managing root tears, as leaving them without surgical intervention can lead to functional outcomes similar to those of total meniscectomy. CONCLUSION This case report presents both menisci posterior root tears with an intact ACL graft which is unique in that they commonly tear in conjuction with ACL. These kind of injuries necessitates prompt diagnosis and surgical intervention to protect the knee from early arthritic changes.
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Okimura S, Suzuki T, Ikeda Y, Shiwaku K, Hamaoka K, Horita K, Teramoto A. Temporal changes in tibiofemoral relationship following anterior cruciate ligament injury: Implications for rotational dynamics and clinical outcomes. J Exp Orthop 2024; 11:e70014. [PMID: 39253541 PMCID: PMC11382131 DOI: 10.1002/jeo2.70014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2024] [Accepted: 07/10/2024] [Indexed: 09/11/2024] Open
Abstract
Purpose This study aims to elucidate changes in the tibiofemoral relationship over time following anterior cruciate ligament (ACL) injury, and investigate the correlation between the tibiofemoral relationship and patient-related outcome measures (PROMs). Methods Overall, 203 primary ACL reconstructions were performed using autologous hamstring grafts. Medial and lateral anterior tibial translation (ATT) in the sagittal plane and tibial tubercle-trochlear groove (TT-TG) distance in the axial plane were measured using pre-operative magnetic resonance imaging and post-operative computed tomography. The difference between pre-operative and post-operative values for each parameter was calculated: ΔMesdial ATT, ΔLateral ATT and ΔTT-TG distance. The correlation between each calculated value and the time elapsed since ACL injury, and the correlation between each calculated value and PROMs-evaluated using the Knee Injury and Osteoarthritis Outcome Score (KOOS)-were assessed. Results Sixty-four patients were enroled. Medial ATT, lateral ATT and TT-TG distance were significantly different pre-operatively compared to post-operative values, with the tibia translating anteriorly and rotating internally relative to the femur. ΔMedial ATT, ΔLateral ATT and ΔTT-TG distance were 1.6, 8.8 and -4.8 mm, respectively. A negative correlation was observed between the ΔTT-TG distance and the time elapsed since the injury (r = -0.44, p < 0.01). No correlation was found between ΔMedial ATT and the time elapsed since the injury, nor between ΔLateral ATT and the time elapsed since the injury. Neither the ΔMedial ATT, ΔLateral ATT, nor ΔTT-TG distance correlated with the pre-operative or post-operative KOOS subscale scores. Conclusions The tibia underwent internal rotation relative to the femur over time following ACL injury, highlighting the importance of assessing rotational changes in ACL-injured knees. Level of Evidence Level Ⅲ.
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Affiliation(s)
- Shinichiro Okimura
- Department of Orthopaedic Surgery Obihiro Kyokai Hospital Obihiro Hokkaido Japan
| | - Tomoyuki Suzuki
- Department of Orthopaedic Surgery Sapporo Maruyama Orthopaedic Hospital Sapporo Hokkaido Japan
| | - Yasutoshi Ikeda
- Department of Orthopaedic Surgery Sapporo Medical University School of Medicine Sapporo Hokkaido Japan
| | - Kousuke Shiwaku
- Department of Orthopaedic Surgery Sapporo Medical University School of Medicine Sapporo Hokkaido Japan
| | - Kodai Hamaoka
- Department of Orthopaedic Surgery Obihiro Kyokai Hospital Obihiro Hokkaido Japan
| | - Kazushi Horita
- Department of Orthopaedic Surgery Sapporo Medical University School of Medicine Sapporo Hokkaido Japan
| | - Atsushi Teramoto
- Department of Orthopaedic Surgery Sapporo Medical University School of Medicine Sapporo Hokkaido Japan
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Lambrey PJ, Fayard JM, Graveleau N, Toanen C, Noailles T, Letartre R, Barth J, Cavaignac E, Bouguennec N, Thaunat M. Male sex, revision surgery, low volume of anterior cruciate ligament remnant, and significant instability are risk factors for Posterior Root Tear of the Lateral Meniscus in patients undergoing Anterior Cruciate Ligament Reconstruction. Arthroscopy 2024:S0749-8063(24)00410-9. [PMID: 38876444 DOI: 10.1016/j.arthro.2024.05.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 05/13/2024] [Accepted: 05/19/2024] [Indexed: 06/16/2024]
Abstract
PURPOSE This multicenter study aimed to determine the incidence of lateral meniscus posterior root tears (LMPRTs) in patients undergoing ACL reconstruction and identify associated risk factors. METHODS We conducted a retrospective, multicenter study using data from the Francophone Arthroscopic Society's registry. The study included all the patients in the registry who underwent ACL reconstruction surgery between June 2020 and June 2023, we excluded incomplete data. We compared delay from injury to surgery between LMPRTs group and No LMPRTs group. Variables investigated as potential risk factors for LMPRTs included age, sex, nature of surgery (primary or revision), pivot shift test result, side-to-side laxity under anesthesia, presence of ACL remnant, occurrence of medial meniscal tear, and presence of collateral ligament injury. Risk factors were analyzed using a logistic regression model. RESULTS Among the 5359 patients analyzed, LMPRTs occurred in 7.0% (n=375) of cases during ACL reconstruction. Mean age at surgery was 29.3 +/- 10.3 years old [11-77]. Concerning delay to surgery, the mean time was 8.4 +/- 23.1 weeks [0.0-347.2] in the No LMPRTs group and 6.5 +/- 10.2 weeks [0.2-61.6] in the LMPRTs group (p = 0.109). Univariate analysis revealed that male sex (p < 0.001), revision surgery (p < 0.001), medial meniscal injury (p = 0.007), ACL remnant (0% vs > 70%, <10% vs > 70%, 10 to 30% vs > 70%, 30 to 50% vs > 70%, 50 to 70% vs > 70%; p < 0.001) and higher pivot shift grade (p = 0.011) were significantly associated with a presence of LMPRTs. Age, side-to-side laxity, and collateral ligament injury were not found to be significant risk factor In multivariate analysis : male sex, revision surgery, pivot shift test result and a low volume of ACL remnant remained significant. Side to side laxity was also a significant factor in multivariate analysis. CONCLUSION This study identified male sex, revision surgery, low volume of ACL remnant, side to side laxity and higher grade of pivot shift as significant risk factors for LMPRTs during ACL reconstruction.
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Affiliation(s)
- Pierre-Jean Lambrey
- Ramsay Santé, Hôpital privé Jean Mermoz, Centre Orthopédique Santy, FIFA Medical Center of Excellence, 69008 Lyon, France
| | - Jean-Marie Fayard
- Ramsay Santé, Hôpital privé Jean Mermoz, Centre Orthopédique Santy, FIFA Medical Center of Excellence, 69008 Lyon, France
| | | | - Cécile Toanen
- Service de Chirurgie Orthopédique, Centre Hospitalier Départemental Vendée, La Roche-sur-Yon, France
| | - Thibaut Noailles
- Département de Chirurgie Orthopédique, Polyclinique de Bordeaux Nord, 15, rue Claude-Boucher, 33000 Bordeaux, France
| | - Romain Letartre
- Ramsay santé, Hôpital privé la Louvière - 126 Rue de la Louvière, 59800 Lille, France
| | - Johannes Barth
- Centre Ostéo articulaire des Cèdres -5 Chemin des Tropiques - Parc Sud Galaxie, 38130, Echirolles
| | - Etienne Cavaignac
- Clinique Universitaire du Sport - 1 Place du Docteur Joseph Baylac, 31300 Toulouse, France
| | | | - Mathieu Thaunat
- Ramsay Santé, Hôpital privé Jean Mermoz, Centre Orthopédique Santy, FIFA Medical Center of Excellence, 69008 Lyon, France.
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Becker R, Nebelung W. [Magnetic resonance imaging of the knee joint : What does the orthopedic surgeon expect from the radiologist?]. RADIOLOGIE (HEIDELBERG, GERMANY) 2024; 64:244-253. [PMID: 38206367 DOI: 10.1007/s00117-023-01255-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/14/2023] [Indexed: 01/12/2024]
Abstract
Magnet resonance imaging (MRI) offers a precise visualization of structural changes with high sensitivity and specificity. However, not all these soft tissue damages or bony lesions are clinically relevant or require treatment. Therefore, it is important to provide the radiologist with a specific clinical request when asking for an MRI examination of the knee. In this article, all important anatomical structures of the knee joint will be addressed with emphasis on the relevant questions for the radiologist. Based on the clinical examination, the MRI provides information about the damage of anatomical structures. This information is of utmost importance for therapeutic decision-making in order to allow an adequate and personalized treatment of patients.
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Affiliation(s)
- Roland Becker
- Zentrum für Orthopädie und Unfallchirurgie, Universitätsklinikum Brandenburg an der Havel, Hochstr. 29, 14770, Brandenburg, Deutschland.
| | - Wolfgang Nebelung
- Orthopädisch Unfallchirurgische Praxisklinik Neuss-Düsseldorf, Plange Mühle 4, 40221, Düsseldorf, Deutschland
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Choi NH, Yang BS, Lee DM, Lee CR. Association of Increased Lateral Femoral Condylar Ratio With Lateral Meniscus Posterior Root Tear in Noncontact ACL Injury. Orthop J Sports Med 2024; 12:23259671231224023. [PMID: 38435716 PMCID: PMC10908231 DOI: 10.1177/23259671231224023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 08/10/2023] [Indexed: 03/05/2024] Open
Abstract
Background In the setting of anterior cruciate ligament (ACL) injury, lateral meniscus posterior root tears (LMPRTs) are less readily diagnosed on preoperative magnetic resonance imaging (MRI). Therefore, to predict LMPRTs in ACL injuries, it is necessary to understand the risk factors associated with them. Purpose/Hypothesis The purpose of this study was to investigate the association of lateral femoral condylar ratio (LFCR) with LMPRTs in ACL injuries. It was hypothesized that an increased LFCR would be associated with LMPRTs in noncontact ACL injuries. Study Design Cohort study; Level of evidence, 3. Methods Enrolled were consecutive patients who underwent primary acute (<6 weeks from injury) ACL reconstruction after noncontact injury and had LMPRT confirmed on preoperative MRI and arthroscopically (combined group; n = 62) as well as patients who underwent isolated acute ACL reconstruction (isolated group; n = 80) who were matched to the combined group by age, height, and body mass index (BMI). All patients underwent surgery between January 1999 and November 2021. LFCR and posterior tibial slope (PTS) were measured and compared between the isolated and combined groups. The area under the receiver operating characteristic curve (AUC) was calculated to determine the cutoff for detecting increased risk of LMPRTs. Results The demographic characteristics of the 2 groups did not differ significantly, nor did the PTS. The LFCR was a significant factor (odds ratio [OR], 1.23; P = .001) associated with LMPRT. Patient age, height, BMI, and PTS were not associated with LMPRT. The AUC (0.66; 95% CI, 0.57-0.75) for LFCR had a sensitivity of 39% and specificity of 90% to predict LMPRT. The calculated cutoff associated with an increased risk for LMPRT when compared with the isolated group was 67.0% (OR, 4.98; 95% CI, 2.10-11.79). Conclusion Increased LFCR was associated with the presence of LMPRTs in patients with acute ACL injuries. The LFCR may provide surgeons with additional information regarding the risk of having a concomitant LMPRT when planning ACL reconstructions.
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Affiliation(s)
- Nam-Hong Choi
- Department of Orthopedic Surgery, Eulji Medical Center, Seoul, Republic of Korea
| | - Bong-Seok Yang
- Department of Orthopaedic Surgery, Shihwa Medical Center, Siheung, Republic of Korea
| | - Dong-Min Lee
- Department of Orthopedic Surgery, Gwangmyeong Sungae Hospital, Gwangmyeong, Republic of Korea
| | - Choong-Ryul Lee
- Department of Orthopedic Surgery, Gwangmyeong Sungae Hospital, Gwangmyeong, Republic of Korea
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Yang CP, Hung SF, Lin KY, Hung YC, Chen YJ, Yao SY, Chiu CH, Chan YS. The increased lateral tibial slope may result in inferior long-term clinical outcome after DB-ACL reconstruction. Arch Orthop Trauma Surg 2024; 144:619-626. [PMID: 37962635 PMCID: PMC10822791 DOI: 10.1007/s00402-023-05114-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 10/13/2023] [Indexed: 11/15/2023]
Abstract
PURPOSE To determine if there is a correlation between lateral tibial slope and long-term clinical results in patients who underwent double-bundle ACL reconstruction. METHODS We retrospectively reviewed patients that received double-bundle ACL reconstruction at a single institution by a single surgeon from January 2011 to December 2014. All the magnetic resonance imaging were reviewed and lateral tibial slopes (LTS) were recorded by an experienced surgeon and rechecked by the other two authors of this study that specialized in orthopedic knee surgery. The relationship between PROMs measurement and lateral tibial slope were analyzed. The patients were then separated into two groups (LTS > 7.4° and < 7.4°) according to the previous study. RESULTS A total of 119 patients were enrolled in this study. All enrolled patients were followed for at least 8 years. The PROMS result were negatively correlated with the lateral tibial slope (p values all < 0.001). The patients with high lateral tibial slope had significantly lower PROMS values (Lysholm 94.26 ± 5.61 vs 80.15 ± 8.28, p = 0.013; IKDC 82.99 ± 4.55 vs 70.09 ± 7.15, p = 0.003; Tegner 9.32 ± 0.95 vs 6.85 ± 1.99, p < 0.001). Finally, the LTS cutoff value between patients with "Good" and "Fair" Lysholm score in our study was 7.55 degrees. CONCLUSIONS Patients with high lateral tibial slope may result in inferior long-term subjective outcomes. The using of double-bundle ACL reconstruction along cannot overcome the negative impact caused by steep lateral tibial slope. A lateral tibial slope of 7.55° may be used as a cut-off for a good clinical outcome. LEVEL OF EVIDENCE III retrospective comparative prognostic trial.
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Affiliation(s)
- Cheng-Pang Yang
- Comprehensive Sports Medicine Center, Taoyuan Chang Gung Memorial Hospital, Taoyuan City, 333, Taiwan
- Department of Orthopedic Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan City, 333, Taiwan
| | - Shih-Feng Hung
- Department of Orthopedic Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan City, 333, Taiwan
- Department of Orthopedic Surgery, Taoyuan General Hospital, Ministry of Health and Welfare, Taoyuan City, 333, Taiwan
| | - Keng-Yi Lin
- Department of Orthopedic Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan City, 333, Taiwan
| | - Yu-Chieh Hung
- Department of Orthopedic Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan City, 333, Taiwan
| | - Yi-Jou Chen
- Department of Orthopedic Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan City, 333, Taiwan
| | - Shang-Yu Yao
- Department of Orthopedic Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan City, 333, Taiwan
| | - Chih-Hao Chiu
- Comprehensive Sports Medicine Center, Taoyuan Chang Gung Memorial Hospital, Taoyuan City, 333, Taiwan
- Department of Orthopedic Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan City, 333, Taiwan
| | - Yi-Sheng Chan
- Department of Orthopedic Surgery, Keelung Chang Gung Memorial Hospital, No. 222, Mai-Chin Rd, Keelung City, 204, Taiwan.
- Comprehensive Sports Medicine Center, Taoyuan Chang Gung Memorial Hospital, Taoyuan City, 333, Taiwan.
- Department of Orthopedic Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan City, 333, Taiwan.
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Familiari F, Tollefson LV, Izzo A, Mercurio M, LaPrade RF, Di Vico G. A High-Grade Lachman's Exam Predicts a Ramp Tear of the Medial Meniscus in Patients with Anterior Cruciate Ligament Tear: A Prospective Clinical and Radiological Evaluation. J Clin Med 2024; 13:683. [PMID: 38337378 PMCID: PMC10856171 DOI: 10.3390/jcm13030683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 01/17/2024] [Accepted: 01/23/2024] [Indexed: 02/12/2024] Open
Abstract
Background: Medial meniscus ramp tears are present in 22.9-40.8% of anterior cruciate ligament tears. The diagnosis of ramp tears is difficult on MRI, with sensitivity reported around 48%, which has recently emphasized the importance of proper arthroscopic probing for ramp tears. Methods: A prospective evaluation was performed on patients undergoing a single bundle ACL reconstruction to assess patient demographics, posterior tibial slope, posterior cruciate ligament angle, Lachman's exam, and rotational instability to determine secondary findings associated with medial meniscal ramp tears. Results: A total of 96 patients underwent ACL reconstruction, of these, 63 patients had an isolated ACL tear, and 33 patients had an ACL tear with a concomitant medial meniscus ramp tear. A high-grade Lachman's exam and male sex were associated with medial meniscus ramp tears. There were no differences in posterior tibial slope, posterior cruciate ligament angle, or rotational instability between groups. Conclusions: This study found that a high-grade Lachman's exam and male sex were significantly associated with patients with an ACL tear with a concomitant medial meniscus ramp tear. These findings suggest that an ACL tear with concomitant medial meniscus ramp tear may be better diagnosed based upon the clinical evaluation rather than other secondary radiological findings.
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Affiliation(s)
- Filippo Familiari
- Department of Orthopaedic and Trauma Surgery, Magna Graecia University, 88100 Catanzaro, Italy;
- Research Center on Musculoskeletal Health, MusculoSkeletal Health@UMG, Magna Graecia University, 88100 Catanzaro, Italy
| | - Luke V. Tollefson
- Twin Cities Orthopedics, Edina, MN 55435, USA; (L.V.T.); (A.I.); (R.F.L.)
| | - Antonio Izzo
- Twin Cities Orthopedics, Edina, MN 55435, USA; (L.V.T.); (A.I.); (R.F.L.)
- Department of Public Health, Trauma and Orthopaedics, University Federico II, 80138 Napoli, Italy
| | - Michele Mercurio
- Department of Orthopaedic and Trauma Surgery, Magna Graecia University, 88100 Catanzaro, Italy;
- Research Center on Musculoskeletal Health, MusculoSkeletal Health@UMG, Magna Graecia University, 88100 Catanzaro, Italy
| | - Robert F. LaPrade
- Twin Cities Orthopedics, Edina, MN 55435, USA; (L.V.T.); (A.I.); (R.F.L.)
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Therrien E, Langhans MT, Lamba A, Daniel AV, Stuart MJ, Levy BA, Smith PA, Krych AJ. Outcomes of Lateral Meniscal Oblique Radial Tear Repair Compared With Intact Meniscus After ACL Reconstruction: A Cohort Study. Orthop J Sports Med 2023; 11:23259671231216102. [PMID: 38107847 PMCID: PMC10722935 DOI: 10.1177/23259671231216102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 06/29/2023] [Indexed: 12/19/2023] Open
Abstract
Background Recently, the posterior horn lateral meniscal oblique radial tear (LMORT) was identified in 12% of acute anterior cruciate ligament (ACL) injuries. However, patient-reported outcomes for repair of this relatively common tear have not been reported. Purpose To determine the minimum 2-year functional outcomes after LMORT repair at the time of ACL reconstruction (ACLR) compared to a matched cohort of patients who underwent isolated ACLR (iACLR). Study Design Cohort study; Level of evidence, 3. Methods Included were 100 patients (mean age at surgery, 21 years; range, 13-45 years) who underwent primary ACLR between 2010 and 2018. The mean follow-up period was 4.1 ± 2.0 years (range, 2.0-9.2 years). A total of 50 patients with surgically repaired LMORT type 3 or type 4 lesions, defined as partial or complete tears >10 mm from the root (LMORT group) were matched 1:1 based on age, date of surgery, and graft choice with 50 patients who underwent iACLR (iACLR group). The postoperative outcomes were compared between groups using the International Knee Documentation Committee subjective score (sIKDC) and the Tegner activity scale. An updated medical history was obtained via the electronic medical record to determine any subsequent complications and reoperations. Results There was 1 ACL graft failure in each group as well as 5 (10%) reoperations per group. None of the patients in the LMORT group necessitated a lateral meniscal revision repair or partial meniscectomy. The LMORT and iACLR groups reported comparable sIKDC scores (92.5 ± 6.8 vs 91.9 ± 8.2, respectively; P = .712) as well as Tegner scores (6.7 ± 1.8 vs 6.6 ± 1.8, respectively; P = .910) at final follow-up. No failures of the LMORT repairs were reported. Conclusion The study findings demonstrated that reoperations, graft failure rates, patient-reported outcomes, and patient activity levels at ≥2 years after type 3 and 4 LMORT repairs at the time of ACLR compared favorably with those of a matched cohort of patients who underwent iACLR with intact meniscus.
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Affiliation(s)
- Erik Therrien
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mark T. Langhans
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Abhinav Lamba
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Adam V. Daniel
- Department of Orthopedic Surgery, Columbia Orthopaedic Group, Columbia, Missouri, USA
| | - Michael J. Stuart
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Bruce A. Levy
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Patrick A. Smith
- Department of Orthopedic Surgery, Columbia Orthopaedic Group, Columbia, Missouri, USA
- Department of Orthopedic Surgery, University of Missouri, Columbia, Missouri, USA
| | - Aaron J. Krych
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
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11
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Yoshihara A, Siboni R, Nakagawa Y, Mouton C, Jacquet C, Nakamura T, Sekiya I, Seil R, Koga H. Lateral-medial asymmetry of posterior tibial slope and small lateral tibial plateau articular surface depth are morphological factors of lateral meniscus posterior root tears in ACL-injured patients. Knee Surg Sports Traumatol Arthrosc 2023; 31:3594-3603. [PMID: 36656347 DOI: 10.1007/s00167-023-07317-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 01/04/2023] [Indexed: 01/20/2023]
Abstract
PURPOSE To investigate whether knee morphological features, patient characteristics, and intraoperative findings are associated with a lateral meniscus (LM) posterior root tear (LMPRT) in anterior cruciate ligament (ACL) injuries with the integrated data from two academic centres. METHODS This retrospective study used registry data acquired prospectively at two academic centres. Patients with ACL reconstruction (ACLR) with LMPRT and no other LM injury were selected (LMPRT group) from each database. The control group included patients who underwent ACLR without LM tears. Patients were matched to the LMPRT group according to age and gender (1:1). Morphological factors evaluated on preoperative magnetic resonance image scans included lateral femoral condyle (LFC) anterior-posterior diameter, height, and depth; lateral tibial plateau (LTP) articular surface (AS) depth and sagittal plane depth; and lateral and medial posterior tibial slopes (PTSs). LFC height and depth ratios, LTP AS depth and sagittal plane depth ratios, and lateral-to-medial slope asymmetry were computed from previous measurements. Patient characteristics and intraoperative findings were extracted and compared between both groups. RESULTS The study included 252 patients (126 in each group). The lateral-medial asymmetry of PTS was greater in the LMPRT group (1.2° vs 0.3°, p < 0.05), and the LTP AS depth was smaller in the LMPRT group (31.4 mm vs 33.2 mm, p < 0.01). There were no differences in LFC morphology between the control and LMPRT groups. Pivot shift grade (p < 0.05), percentage of complete ACL tears (p < 0.05), and medial meniscus ramp lesions (p < 0.05) were significantly higher in the LMPRT group. CONCLUSION LMPRT was associated with significantly increased lateral-medial asymmetry of PTS and significantly smaller LTP AS depth. LMPRT was also associated with an increase in the preoperative pivot shift grade and the presence of a medial meniscus ramp lesion. These morphological characteristics are rather simple to measure and would serve as helpful indicators to preoperatively detect LMPRT, which is frequently challenging to diagnose preoperatively. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Aritoshi Yoshihara
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-Ku, Tokyo, 113-8519, Japan
| | - Renaud Siboni
- Department of Orthopaedic Surgery, Centre Hospitalier Luxembourg-Clinique d'Eich, Luxembourg, Luxembourg
- Department of Orthopedics Surgery, Reims Teaching Hospital, Reims, France
| | - Yusuke Nakagawa
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-Ku, Tokyo, 113-8519, Japan
| | - Caroline Mouton
- Department of Orthopaedic Surgery, Centre Hospitalier Luxembourg-Clinique d'Eich, Luxembourg, Luxembourg
- Sports Medicine and Science, Luxembourg Institute of Research in Orthopaedics, Luxembourg, Luxembourg
| | - Christophe Jacquet
- Department of Orthopaedic Surgery, Centre Hospitalier Luxembourg-Clinique d'Eich, Luxembourg, Luxembourg
- Department of Orthopaedic Surgery and Traumatology, Institute for Movement and Locomotion, St. Marguerite Hospital, Marseille, France
| | - Tomomasa Nakamura
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-Ku, Tokyo, 113-8519, Japan
| | - Ichiro Sekiya
- Center for Stem Cell and Regenerative Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Romain Seil
- Department of Orthopaedic Surgery, Centre Hospitalier Luxembourg-Clinique d'Eich, Luxembourg, Luxembourg
- Sports Medicine and Science, Luxembourg Institute of Research in Orthopaedics, Luxembourg, Luxembourg
- Orthopaedics, Sports Medicine and Digital Methods, Human Motion, Luxembourg, Luxembourg
| | - Hideyuki Koga
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-Ku, Tokyo, 113-8519, Japan.
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Reist H, Vacek PM, Endres N, Tourville TW, Failla M, Geeslin A, Geeslin M, Borah A, Krug M, Choquette R, Toth M, Beynnon BD. Risk Factors for Concomitant Meniscal Injury With Sport-Related Anterior Cruciate Ligament Injury. Orthop J Sports Med 2023; 11:23259671231196492. [PMID: 37693810 PMCID: PMC10492489 DOI: 10.1177/23259671231196492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 06/07/2023] [Indexed: 09/12/2023] Open
Abstract
Background Previous studies of concomitant meniscal injury in athletes with anterior cruciate ligament (ACL) injury have examined age, sex, body mass index (BMI), injury mechanism, and time from injury to surgery as potential risk factors. Purpose To identify additional risk factors for concomitant meniscal injury, including preinjury joint laxity and lower extremity alignment, in athletes with sport-related ACL injury. Study Design Cross-sectional study; Level of evidence, 3. Methods This study included 180 participants aged 13 to 26 years who underwent ACL reconstruction (ACLR) after a first-time ACL injury sustained during participation in sport. Contralateral lower extremity alignment and joint laxity were used as surrogate measures for the injured knee before trauma. Concomitant meniscal tear patterns were identified at the time of ACLR. Sex-specific analyses were conducted. Results Concomitant meniscal injury was observed in 60.6% of the subjects. The prevalence of concomitant injury was higher in male than female participants (69.9% vs 54.2%; P = .035) due to a higher prevalence of lateral meniscal injuries (56.2% vs 38.3%; P = .018). Among male patients, there was a significant difference in the prevalence of concomitant lateral meniscal tear according to sport participation (≥9 vs <9 h/week: 67.4% vs 35.7%; P = .032). Among male patients, the likelihood of concomitant injury to both the lateral and medial menisci increased by 28.8% for each 1-mm decrease in navicular drop. Among female patients, the likelihood of concomitant injury to the lateral meniscus increased by 15% per degree increase in genu recurvatum and 14% per degree decrease in standing quadriceps angle, with similar effects on the likelihood of concurrent injury to both the lateral and medial menisci. Conclusion Measures of lower extremity alignment and genu recurvatum previously identified as risk factors for ACL injury were also associated with concomitant meniscal injury in female patients while other risk factors, including BMI and joint laxity, were not. Increased time spent participating in sport and navicular drop were associated with concomitant meniscal injury in male patients.
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Affiliation(s)
- Hailee Reist
- Department of Orthopedics and Rehabilitation, Robert Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
| | - Pamela M. Vacek
- Department of Medical Biostatistics, Robert Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
| | - Nathan Endres
- Department of Orthopedics and Rehabilitation, Robert Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
| | - Timothy W. Tourville
- Department of Rehabilitation and Movement Science, College of Nursing and Health Sciences, University of Vermont, Burlington, Vermont, USA
| | - Mathew Failla
- Department of Rehabilitation and Movement Science, College of Nursing and Health Sciences, University of Vermont, Burlington, Vermont, USA
| | - Andrew Geeslin
- Department of Orthopedics and Rehabilitation, Robert Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
| | - Matthew Geeslin
- Department of Radiology, Robert Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
| | - Andy Borah
- Department of Orthopedics and Rehabilitation, Robert Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
| | - Mickey Krug
- Department of Orthopedics and Rehabilitation, Robert Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
| | - Rebecca Choquette
- Department of Orthopedics and Rehabilitation, Robert Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
| | - Mike Toth
- Department of Orthopedics and Rehabilitation, Robert Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
- Department of Medicine, Robert Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
| | - Bruce D. Beynnon
- Department of Orthopedics and Rehabilitation, Robert Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
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Cuvillier M, Marot V, Bukvić F, Lucena T, Martinel V, Bérard E, Cavaignac E. Evaluation of the All-Inside Technique for the Repair of Lateral Meniscus Root Tears at 1 Year After ACL Reconstruction. Orthop J Sports Med 2023; 11:23259671221149716. [PMID: 37359979 PMCID: PMC10286189 DOI: 10.1177/23259671221149716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 10/21/2022] [Indexed: 06/28/2023] Open
Abstract
Background The presence of a lateral meniscus root tear (LMRT) in patients with an anterior cruciate ligament (ACL) tear makes the knee more unstable and increases the risk of osteoarthritis and osteonecrosis. An all-inside suture repair technique without bone tunnels has been proposed to treat LMRT. Purpose To compare the 1-year postoperative findings between patients who underwent ACL reconstruction combined with LMRT repair (LMRT group) and patients who underwent isolated ACL reconstruction (control group). Study Design Cohort study; Level of evidence, 3. Methods The LMRT group consisted of 19 patients, and the control group consisted of 56 patients. In this study, the authors compared the postoperative magnetic resonance imaging (MRI) findings (meniscal extrusion, ghost sign, and hyperintensity in the tibial plateau beneath the LMRT), functional outcomes (International Knee Documentation Committee [IKDC], Lysholm, and Tegner scores), and reoperation rate between groups. The primary endpoint was analyzed by comparing, in the LMRT group, the 1-sided 97.5% confidence interval (CI) of the mean lateral meniscal extrusion at 1 year to the limit of noninferiority (fixed at 0.51). To take into account imbalanced baseline characteristics between groups, adjusted mean meniscal extrusion (with 1-sided 97.5% CI) was assessed using a linear regression model. Results The mean follow-up was 12.2 months (range, 7.7-14.7 months) in the control group and 11.5 months (range, 7.1-13.0 months) in the LMRT group (P = .06). For meniscal extrusion, the LMRT group was noninferior to the control group. The mean meniscal extrusion was 2.19 mm (97.5% CI, -infinity to 2.68 mm) in the LMRT group and 2.03 mm (97.5% CI,-infinity to 2.27 mm) in the control group, indicating that the upper boundary of the 1-sided 97.5% CI in the LMRT group was less than the noninferiority threshold of 2.78 (ie, 2.27 mm + 0.51 mm = 2.78 mm). There was a statistically significant difference in the IKDC score between the LMRT and control groups (77.2 ± 8.1 vs 80.3 ± 7.3, respectively; P = .04). There was no between-group difference in the other MRI parameters, the Lysholm and Tegner scores, or the reoperation rate. Conclusion There was no significant difference in extrusion on MRI or clinical outcomes at 1-year follow-up in patients who underwent ACL reconstruction with all-inside LMRT repair compared with patients who did not have an LMRT.
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Affiliation(s)
- Marianne Cuvillier
- Jean Monnet University, Mines Saint-Étienne, INSERM, U1059, SAINBIOSE, University Hospital of Saint-Etienne, Orthopedics, Trauma and Bone & Joint Infection Center, Saint Etienne, France
| | - Vincent Marot
- Hospital Nostra Senyora de Meritxell, Orthopedics Units, Escaldes, Andorra
| | - Frane Bukvić
- Department of Orthopedic Surgery and Trauma, Pierre-Paul Riquet Hospital, Toulouse, France
| | - Thibaut Lucena
- Department of Orthopedic Surgery and Trauma, Pierre-Paul Riquet Hospital, Toulouse, France
| | - Vincent Martinel
- Orthopedic Group Ormeau Pyrénées, Polyclinique de l’Ormeau ELSAN, Tarbes, France
| | - Emilie Bérard
- Department of Epidemiology, Health Economics and Public Health, UMR 1295 CERPOP, University of Toulouse, INSERM, UPS, Toulouse University Hospital (CHU de Toulouse), Toulouse, France
| | - Etienne Cavaignac
- Department of Orthopedic Surgery and Trauma, Pierre-Paul Riquet Hospital, Toulouse, France
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14
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Thomas B, de Villeneuve Florent B, Alexandre F, Martine P, Akash S, Corentin P, Matthieu O, Christophe J. Patients with meniscus posterolateral root tears repair during ACL reconstruction achieve comparable post-operative outcome than patients with isolated ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2023:10.1007/s00167-023-07415-x. [PMID: 37079048 DOI: 10.1007/s00167-023-07415-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 04/05/2023] [Indexed: 04/21/2023]
Abstract
PURPOSE Lateral posterior meniscal root tear (LPMRT) repair, at the time of anterior cruciate ligament (ACL) reconstruction are increasingly being performed. The aim of this study was to compare the clinical and functional outcomes, as well as the complication rates at a minimum of 2 years follow-up, between an isolated ACL reconstruction group with intact menisci and a combined ACL reconstruction and LPMRT repair group. METHODS All patients who underwent combined ACL reconstruction and LPMRT repair between 2016 and 2020 were included in the study. They were matched with an isolated ACL reconstruction group with intact menisci based on age, gender and the pre-injury IKDC score. The KOOS, ACLRSI Tegner-Lysholm score and the TELOS-test were collected pre- and postoperatively; complications (re-rupture, recurrence or persistence of a high grade pivot shift, new meniscal injury) were recorded. All LPMRTs were repaired using transtibial pull-out technique. RESULTS After matching, 100 patients were included in this study (mean age 29.6 ± 1.0 years and mean follow-up 42.9 ± 7.3 months): 50 patients in the isolated ACL reconstruction group with intact menisci (group A) and 50 in the combined ACL reconstruction and LPMRT repair group (group B). Preoperatively, patients in group B had significant lower KOOS scores (Global 55.9 ± 2.9 vs. 64.6 ± 2.3, p = 0.02), but similar ACLRSI, TEGNER and TELOS scores. At the last follow-up, all functional scores had improved, and no significant difference between the two groups on any score was observed. There was also no difference in terms of complications rates. CONCLUSION At a minimum of 2 years follow-up (mean follow-up 42.9 months), LPMRT repair during ACL reconstruction has no significant difference in terms of post-operative functional outcomes compared to the isolated ACL reconstruction group. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Bard Thomas
- CNRS, ISM UMR 7287, Aix-Marseille University, 13288, Marseille Cedex 09, France
- Department of Orthopedic Surgery and Traumatology, Institute of Movement and Locomotion, University Institute of Movement and Locomotion, St. Marguerite Hospital 270 Boulevard Sainte Marguerite, BP 29, 13274, Marseille, France
| | - Bernard de Villeneuve Florent
- CNRS, ISM UMR 7287, Aix-Marseille University, 13288, Marseille Cedex 09, France
- Department of Orthopedic Surgery and Traumatology, Institute of Movement and Locomotion, University Institute of Movement and Locomotion, St. Marguerite Hospital 270 Boulevard Sainte Marguerite, BP 29, 13274, Marseille, France
| | - Ferreira Alexandre
- CNRS, ISM UMR 7287, Aix-Marseille University, 13288, Marseille Cedex 09, France
- Department of Orthopedic Surgery and Traumatology, Institute of Movement and Locomotion, University Institute of Movement and Locomotion, St. Marguerite Hospital 270 Boulevard Sainte Marguerite, BP 29, 13274, Marseille, France
| | - Pithioux Martine
- CNRS, ISM UMR 7287, Aix-Marseille University, 13288, Marseille Cedex 09, France
- Department of Orthopedic Surgery and Traumatology, Institute of Movement and Locomotion, University Institute of Movement and Locomotion, St. Marguerite Hospital 270 Boulevard Sainte Marguerite, BP 29, 13274, Marseille, France
| | - Sharma Akash
- CNRS, ISM UMR 7287, Aix-Marseille University, 13288, Marseille Cedex 09, France
- Department of Orthopedic Surgery and Traumatology, Institute of Movement and Locomotion, University Institute of Movement and Locomotion, St. Marguerite Hospital 270 Boulevard Sainte Marguerite, BP 29, 13274, Marseille, France
| | - Pangaud Corentin
- CNRS, ISM UMR 7287, Aix-Marseille University, 13288, Marseille Cedex 09, France
- Department of Orthopedic Surgery and Traumatology, Institute of Movement and Locomotion, University Institute of Movement and Locomotion, St. Marguerite Hospital 270 Boulevard Sainte Marguerite, BP 29, 13274, Marseille, France
| | - Ollivier Matthieu
- CNRS, ISM UMR 7287, Aix-Marseille University, 13288, Marseille Cedex 09, France.
- Department of Orthopedic Surgery and Traumatology, Institute of Movement and Locomotion, University Institute of Movement and Locomotion, St. Marguerite Hospital 270 Boulevard Sainte Marguerite, BP 29, 13274, Marseille, France.
| | - Jacquet Christophe
- CNRS, ISM UMR 7287, Aix-Marseille University, 13288, Marseille Cedex 09, France
- Department of Orthopedic Surgery and Traumatology, Institute of Movement and Locomotion, University Institute of Movement and Locomotion, St. Marguerite Hospital 270 Boulevard Sainte Marguerite, BP 29, 13274, Marseille, France
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15
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Low reoperation rate following lateral meniscus root repair: clinical outcomes at 2 years follow-up. Knee Surg Sports Traumatol Arthrosc 2023; 31:495-502. [PMID: 35908114 DOI: 10.1007/s00167-022-07075-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 07/13/2022] [Indexed: 02/07/2023]
Abstract
PURPOSE The aim of this study was to review the outcomes of lateral meniscus posterior root tears repair at the time of ACL reconstruction at a minimum 2-year follow-up. METHODS Between March 2015 and August 2018, 2017 patients underwent primary ACL reconstruction and were considered for study eligibility. Lateral meniscus posterior root tears were identified arthroscopically, and repair was performed with a transtibial pull-out suture technique or a side-to-side suture technique. Clinical outcomes were recorded at the time of physical examination. At the end of the study period, patients were contacted to determine whether they had required reoperation. RESULTS Lateral meniscus posterior root tears were identified in 153 out of the 2,017 primary ACL reconstructions (7.6%). Ninety-nine patients were included for analysis: 23 transtibial pull-out sutures and 76 side-to-side repairs. At a mean follow-up of 42 ± 10 months, one patient (1%) had undergone reoperation for failure of the side-to-side repair. There were 11 reoperations in 10 patients (10.1%), including 6 cyclops syndrome, 1 graft rupture, 1 tibial bone cyst, 1 medial and 1 lateral meniscus repair failure, and 1 arthrolysis. Postoperatively, ninety (90.9%) patients were graded A for the IKDC objective score and 9 (9.1%) patients were graded B, with an IKDC subjective score of 86.9 ± 7.6, a Lysholm score of 90.7 ± 6.7 and a median Tegner Activity Scale of 6 (3-9). All of their objective and subjective evaluations improved after surgery (p < 0.001) except for the Tegner Activity Scale. Ten patients underwent second look arthroscopy (10.1%), lateral meniscus healing was observed in 9 out of 10 patients (90%). CONCLUSION This study demonstrated that lateral meniscus posterior root tear repair is a safe procedure with a very low reoperation rate at a minimum follow-up of 2 years. LEVEL OF EVIDENCE IV.
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16
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Seiter M, Douglass BW, Brady AW, Dornan GJ, Brown JR, Hackett TR. In situ repair of segmental loss posterior lateral meniscal root tears outperforms meniscofemoral ligament imbrication in the ACL reconstructed knee. J Exp Orthop 2023; 10:8. [PMID: 36697992 PMCID: PMC9877254 DOI: 10.1186/s40634-023-00572-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 01/12/2023] [Indexed: 01/27/2023] Open
Abstract
PURPOSE The purpose of this study was to compare the biomechanical effect of in-situ repair of posterior lateral meniscal root (PLMR) tear with segmental meniscal loss, with and without meniscofemoral ligament (MFL) imbrication, on anterior cruciate ligament (ACL) graft force and knee joint kinematics. METHODS Ten fresh-frozen cadaveric knee specimens underwent kinematic evaluation in five states: 1) Native, 2) ACLR, 3) Segmental PLMR loss, 4) In-situ PLMR repair, and 5) MFL augmentation. Kinematic evaluation consisted of five tests, each performed at full extension and at 30° of flexion: 1) Anterior drawer, 2) Internal Rotation, 3) External Rotation, 4) Varus, and 5) Valgus. Additionally, a simulated pivot shift test was performed. Knee kinematics and ACL graft force were measured. RESULTS PLMR tear did not significantly increase ACL graft force in any test. However, PLMR repair significantly reduced ACL graft force compared to the ACLR alone (over constraint -26.6 N, p = 0.001). PLMR tear significantly increased ATT during the pivot shift test (+ 2.7 mm, p = 0.0001), and PLMR repair restored native laxity. MFL augmentation did not improve the mechanics. CONCLUSIONS In-situ PLMR repair eliminated pivot shift laxity through ATT and reduced force on the ACL graft, indicating that this procedure may be ACL graft-protective. MFL augmentation was not shown to have any effect on graft force or knee kinematics and untreated PLMR tears may place an ACL graft at higher risk. This study suggests concomitant repair to minimize additional forces on the ACL graft.
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Affiliation(s)
- Max Seiter
- grid.419649.70000 0001 0367 5968Steadman Philippon Research Institute, Vail, CO USA
| | - Brenton W. Douglass
- grid.419649.70000 0001 0367 5968Steadman Philippon Research Institute, Vail, CO USA
| | - Alex W. Brady
- grid.419649.70000 0001 0367 5968Steadman Philippon Research Institute, Vail, CO USA
| | - Grant J. Dornan
- grid.419649.70000 0001 0367 5968Steadman Philippon Research Institute, Vail, CO USA
| | - Justin R. Brown
- grid.419649.70000 0001 0367 5968Steadman Philippon Research Institute, Vail, CO USA
| | - Thomas R. Hackett
- grid.419649.70000 0001 0367 5968Steadman Philippon Research Institute, Vail, CO USA
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17
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Xu Z, Li Y, Rao J, Jin Y, Huang Y, Xu X, Liu Y, Tian S. Biomechanical assessment of disease outcome in surgical interventions for medial meniscal posterior root tears: a finite element analysis. BMC Musculoskelet Disord 2022; 23:1093. [PMID: 36517757 PMCID: PMC9749342 DOI: 10.1186/s12891-022-06069-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 12/07/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The adverse consequences of medial meniscus posterior root tears have become increasingly familiar to surgeons, and treatment strategies have become increasingly abundant. In this paper, the finite element gait analysis method was used to explore the differences in the biomechanical characteristics of the knee joint under different conditions. METHODS Based on CT computed tomography and MR images, (I) an intact knee (IK) model with bone, cartilage, meniscus and main ligaments was established. Based on this model, the posterior root of the medial meniscus was resected, and (ii) the partial tear (PT) model, (iii) the entire radial tear (ERT) model, and (iv) the entire oblique tear (EOT) model were established according to the scope and degree of resection. Then, the (v) meniscus repair (MR) model and (vi) partial meniscectomy (PM) model were developed according to the operation method. The differences in stress, displacement and contact area among different models were evaluated under ISO gait loading conditions. RESULTS Under gait loading, there was no significant difference in the maximum stress of the medial and lateral tibiofemoral joints among the six models. Compared with the medial tibiofemoral joint stress of the IK model, the stress of the PM model increased by 8.3%, while that of the MR model decreased by 18.9%; at the same time, the contact stress of the medial tibiofemoral joint of the ERT and EOT models increased by 17.9 and 25.3%, respectively. The displacement of the medial meniscus in the ERT and EOT models was significantly larger than that in the IK model (P < 0.05), and the tibial and femoral contact areas of these two models were lower than those of the IK model (P < 0.05). CONCLUSIONS The integrity of the posterior root of the medial meniscus plays an important role in maintaining normal tibial-femoral joint contact mechanics. Partial meniscectomy is not beneficial for improving the tibial-thigh contact situation. Meniscal repair has a positive effect on restoring the normal biomechanical properties of the medial meniscus.
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Affiliation(s)
- Zhi Xu
- Department of Orthopaedics, Zhangjiagang Fifth People’s Hospital, Zhangjiagang, 215600 Jiangsu China ,grid.267139.80000 0000 9188 055XCollege of Continuing Education, University of Shanghai for Science and Technology, Shanghai, 200000 China
| | - Yuwan Li
- grid.411642.40000 0004 0605 3760Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing, 100191 China
| | - Jingcheng Rao
- grid.428392.60000 0004 1800 1685Department of Orthopaedics, Suqian Hospital of Nanjing Drum Tower Hospital Group, Suqian, 223800 Jiangsu China
| | - Ying Jin
- grid.413390.c0000 0004 1757 6938Department of Orthopaedics, The Affiliated Hospital of Zunyi Medical University, No.149 Dalian Road, Zunyi, 563000 Guizhou China
| | - Yushun Huang
- Department of Orthopaedics, Jen Ching memorial Hospital, Kunshan, 215300 Jiangsu China
| | - Xing Xu
- Department of Medicine, Zhijin People’s Hospital, Zhijin, 552100 Guizhou China
| | - Yi Liu
- grid.413390.c0000 0004 1757 6938Department of Orthopaedics, The Affiliated Hospital of Zunyi Medical University, No.149 Dalian Road, Zunyi, 563000 Guizhou China
| | - Shoujin Tian
- grid.460159.fDepartment of Orthopaedics, Zhangjiagang First People’s Hospital, No.68 Jiyang West Road, Zhangjiagang, 215600 Jiangsu China
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Diermeier T, Tisherman RE, Wilson K, Takeuchi S, Suzuki T, Chan CK, Debski RE, Onishi K, Musahl V. The lateral meniscus extrudes with and without root tear evaluated using ultrasound. J ISAKOS 2022; 7:195-200. [PMID: 36182072 DOI: 10.1016/j.jisako.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 07/10/2022] [Accepted: 08/03/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE The purpose of the current study was to measure extrusion of the intact lateral meniscus as a function of knee flexion angle and loading condition and to compare the changes in extrusion with a posterior root tear using a robotic testing system and ultrasound. STUDY DESIGN Controlled laboratory study. METHODS Eight fresh-frozen cadaveric knees were subjected to external loading conditions (passive path position (no external load), 200 axial compression, 5-N-m internal tibial torque, 5-N-m valgus torque) at full extension, 30°, 60° and 90° of flexion using a robotic testing system. A linear array transducer was placed in the longitudinal orientation. Extrusion and kinematics data were recorded for two meniscus states: intact and posterior lateral root deficiency. Therefore, a complete radial root tear in the lateral meniscus at 10 mm from the tibial insertion was made in all 8 cadaveric knees using arthroscopy. The resultant forces in the lateral meniscus were also quantified by reproducing recorded paths after the removal of the lateral meniscus. RESULTS A lateral meniscus root tear resulted in a statistically significant increase (up to 250%) of extrusion for the lateral meniscus (p < 0.05) in comparison to the intact lateral meniscus for all externally applied loads. Without external load (passive path position), significant differences were also found between the intact and posterior lateral root deficient meniscus except at full extension (1.0 ± 0.7 mm vs. 1.9 ± 0.4 mm) and 30° of flexion (1.4 ± 0.5 mm vs. 1.8 ± 0.5 mm). Overall, with increasing flexion angle, lateral meniscus extrusion decreased for the intact as well as for the posterior lateral root deficient meniscus, with the lowest measurements in response to internal tibial torque at 90° of flexion (-3.3 ± 1.1 mm). Knee kinematics were similar whether intact or posterior lateral root tear (n.s.). Ultrasound measurement of lateral meniscus extrusion showed good inter-rater (0.65 [0.30-0.97]-0.71 [0.34-0.94]) and excellent intra-rater reliability (0.81 [0.43-0.99]). CONCLUSION Dynamic Ultrasound is a reliable diagnostic modality to measure the lateral meniscus extrusion which can be helpful in the diagnosis and quantification of lateral meniscal root tears. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Theresa Diermeier
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, 15203, USA; Unfallkrankenhaus Berlin, Berlin, Germany
| | - Robert E Tisherman
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, 15203, USA; Department of Orthopaedic Surgery, Center for Sports Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kevin Wilson
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, 15203, USA; Department of Orthopaedic Surgery, Center for Sports Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Satoshi Takeuchi
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, 15203, USA; Department of Orthopaedic Surgery, Center for Sports Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Tomoyuki Suzuki
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, 15203, USA; Department of Orthopedic Surgery, School of Medicine, Sapporo Medical University, Sapporo, Japan; Orthopaedic Robotics Laboratory, Departments of Orthopaedic Surgery and Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Calvin K Chan
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, 15203, USA; Orthopaedic Robotics Laboratory, Departments of Orthopaedic Surgery and Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Richard E Debski
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, 15203, USA; Orthopaedic Robotics Laboratory, Departments of Orthopaedic Surgery and Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kentaro Onishi
- Department of Orthopaedic Surgery, Center for Sports Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Physical Medicine and Rehabilitation, Pittsburgh, PA, USA
| | - Volker Musahl
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, 15203, USA; Department of Orthopaedic Surgery, Center for Sports Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
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Age, male sex, higher posterior tibial slope, deep sulcus sign, bone bruises on the lateral femoral condyle, and concomitant medial meniscal tears are risk factors for lateral meniscal posterior root tears: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 2022; 30:4144-4155. [PMID: 35429241 DOI: 10.1007/s00167-022-06967-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 03/29/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Lateral meniscus posterior root tears (LMPRTs) are commonly found in patients with anterior cruciate ligament (ACL) injuries. However, risk factors for LMPRTs are not well known. This study was designed to systematically review the available evidence regarding risk factors associated with LMPRTs. METHODS The PubMed, EMBASE, Cochrane Library, and Web of Science databases were searched for papers containing the key words "lateral meniscus posterior root tears", "LMPRTs" and "risk factor". Inclusion screening, data extraction, and quality assessment of the included articles were conducted independently by two authors. Statistical analysis was conducted to determine risk factors for LMPRTs. RESULT Seventeen studies with a total sample size of 6, 589 patients were identified. The pooled prevalence of LMPRTs was 9.6% (range, 5.1-33.8%) for ACL injury. Significant risk factors included a patient age of < 30 [OR = 1.4, 95% CI (1.07, 1.84), p = 0.01], male sex [OR = 1.50, 95% CI (1.24,1.81), p = 0.01], higher body mass index (BMI) [MD = 0.45, 95% CI (0.13, 0.76), p < 0.01], higher lateral posterior tibial slope (LPTS) [MD = 2.22, 95% CI (1.37, 3.07), p < 0.01], deep sulcus sign [OR = 5.76, 95% CI (1.35, 24.52), p < 0.01] and bone bruises on lateral femoral condyle [OR = 4.88, 95% CI (1.27, 18.77), p < 0.01], lateral meniscal extrusion > 1 mm [OR = 5.56, 95% CI (1.52, 20.29), p < 0.01] and > 3 mm [OR = 12.91 95% CI (1.28, 130.01), p < 0.01], medial meniscal tears [OR = 1.40, 95% CI (1.12, 1.75), p < 0.01], and medial ramp lesions [OR = 2.29, 95% CI (1.35, 3.89), p < 0.01]. CONCLUSION Age below 30, male, higher BMI, higher LPTS, deep sulcus sign, bone bruises on lateral femoral condyle, lateral meniscal extrusion, medial meniscal tear, and medial ramp lesion are risk factors for LMPRTs. LEVEL OF EVIDENCE Level IV.
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20
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Jeon YS, Alsomali K, Yang SW, Lee OJ, Kang B, Wang JH. Posterior Horn Lateral Meniscal Oblique Radial Tear in Acute Anterior Cruciate Ligament Reconstruction Incidence and Outcomes After All-Inside Repair: Clinical and Second-Look Arthroscopic Evaluation. Am J Sports Med 2022; 50:3796-3804. [PMID: 36322384 DOI: 10.1177/03635465221126506] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The term posterior horn lateral meniscal oblique radial tear (LMORT) has emerged to characterize the tear patterns of the lateral meniscus in many patients with acute anterior cruciate ligament (ACL) injury. There is a lack of data regarding the exact incidence according to the types of LMORT and clinical outcomes. PURPOSES (1) To investigate the incidence of LMORT according to type in patients with acute ACL reconstruction (ACLR) and (2) to identify healing status after repair of LMORT via second-look arthroscopy and clinical outcomes. STUDY DESIGN Case series; Level of evidence: 4. METHODS Patients who underwent primary ACLR within 6 months of injury were retrospectively reviewed. The LMORT was classified into 4 types based on the severity and distance from the root: type 1 (partial tear <10 mm from the root), type 2 (complete tear <10 mm from the root), type 3 (partial tear >10 mm from the root), type 4a (complete tear >10 mm from the root), and type 4b (type 4a with longitudinal tear at the meniscocapsular junction). Only patients with LMORT were isolated, and the clinical outcomes were compared according to the healing status of LMORT in second-look arthroscopy. RESULTS Of 635 patients with ACLR, LMORT was identified in 97 patients (15.3%), and type 4 LMORT accounted for the largest proportion (n = 62; 32.6%) of 190 lateral meniscal tears. In 79 patients with LMORT who satisfied the 2-year follow-up period, all patient-reported outcomes (PROs), including the Lysholm (preoperative, 64.1; postoperative, 88.2) and International Knee Documentation Committee subjective (preoperative, 50.5; postoperative, 82.9) scores, were significantly improved (P < .001) 31.8 months postoperatively. Of the 61 patients who underwent second-look arthroscopy, 49 (80.3%) were classified into the complete healing group. There was no significant difference in postoperative PROs between the complete and partial healing groups. CONCLUSION The incidence of LMORT was 15.3% in patients with acute ACL injury, and type 4 LMORT was the most common type. Complete healing of LMORT was achieved in 80.3% of patients who underwent second-look arthroscopy, and the PROs were significantly improved postoperatively. Good clinical results can be achieved if the LMORT is repaired as much as possible during ACLR.
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Affiliation(s)
- Young-Sik Jeon
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University College of Medicine, Gangnam-gu, Seoul, Republic of Korea
| | - Khalid Alsomali
- Department of Orthopedic Surgery, King Fahad Military Medical Complex, Dhahran, Saudi Arabia
| | - Seong Wook Yang
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University College of Medicine, Gangnam-gu, Seoul, Republic of Korea
| | - Oei Jong Lee
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University College of Medicine, Gangnam-gu, Seoul, Republic of Korea
| | - Byoungyoul Kang
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University College of Medicine, Gangnam-gu, Seoul, Republic of Korea
| | - Joon Ho Wang
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University College of Medicine, Gangnam-gu, Seoul, Republic of Korea
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Liu A, Cui W, Yang W, Li C, Yan S, Xin Z, Wu H. Anterior Tibial Subluxation of Lateral Compartment Is Associated With High-Grade Rotatory Instability for Acute But Not Chronic Anterior Cruciate Ligament Injuries: An Magnetic Resonance Imaging Case-Control Study. Arthroscopy 2022; 38:2852-2860. [PMID: 35550417 DOI: 10.1016/j.arthro.2022.04.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 04/07/2022] [Accepted: 04/19/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE To investigate whether anterior tibial subluxation obtained from magnetic resonance imaging (MRI) could be a predictor of high-grade rotatory instability for anterior cruciate ligament (ACL) injuries, including acute and chronic cases. METHODS From September 2016 to August 2018, we retrospectively investigated 163 patients with ACL injuries who subsequently underwent primary ACL reconstruction. Among them, 30 patients with high-grade rotatory instability (grade II/III pivot shift) were included in the high-grade group, and their age and sex were matched 1:2 to low-grade cases (<grade II pivot shift). On preoperative MRI, we measured anterior tibial subluxation, posterior tibial slope, as well as the time from injury to surgery. Meniscal lesions were documented from arthroscopy. Multivariable logistic regression was used to determine predictors of high-grade rotatory instability. Furthermore, subgroup comparisons between 2 groups were divided into acute (≤3 months) and chronic (>3 months) phases. RESULTS The high-grade group had a larger anterior tibial subluxation of lateral compartment (8.1 mm vs 5.9 mm; P =.004) than the low-grade group, whereas no significant difference was found in anterior tibial subluxation of medial compartment (P > .05). Moreover, high-grade anterior tibial subluxation of lateral compartment (≥6 mm) was found to be an independent predictor (odds ratio, 12.992; P = .011) associated with concomitant meniscal tears after ACL injuries. Anterior tibial subluxation of lateral compartment demonstrated statistical significance between the two groups when comparing subgroups within 3 months but not beyond 3 months. CONCLUSION In ACL-injured patients, high-grade anterior tibial subluxation of lateral compartment (≥6 mm) could be a unique predictor of high-grade knee rotatory instability for acute but not chronic injuries. Prolonged time from injury to surgery and lateral meniscus tears were risk factors for high-grade rotatory laxity in chronic patients. LEVEL OF EVIDENCE Level III, retrospective prognostic trial.
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Affiliation(s)
- An Liu
- Department of Orthopedics, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China, Orthopedics Research Institute of Zhejiang University, Hangzhou, China
| | - Wushi Cui
- Department of Orthopedics, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China, Orthopedics Research Institute of Zhejiang University, Hangzhou, China
| | - Weinan Yang
- Department of Orthopedics, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China, Orthopedics Research Institute of Zhejiang University, Hangzhou, China
| | - Congsun Li
- Department of Orthopedics, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China, Orthopedics Research Institute of Zhejiang University, Hangzhou, China
| | - Shigui Yan
- Department of Orthopedics, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China, Orthopedics Research Institute of Zhejiang University, Hangzhou, China
| | - Zengfeng Xin
- Department of Orthopedics, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China, Orthopedics Research Institute of Zhejiang University, Hangzhou, China.
| | - Haobo Wu
- Department of Orthopedics, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China, Orthopedics Research Institute of Zhejiang University, Hangzhou, China.
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Monaco E, Carrozzo A, Saithna A, Conteduca F, Annibaldi A, Marzilli F, Minucci M, Sonnery-Cottet B, Ferretti A. Isolated ACL Reconstruction Versus ACL Reconstruction Combined With Lateral Extra-articular Tenodesis: A Comparative Study of Clinical Outcomes in Adolescent Patients. Am J Sports Med 2022; 50:3244-3255. [PMID: 36113005 DOI: 10.1177/03635465221118377] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Young patients undergoing anterior cruciate ligament (ACL) reconstruction (ACLR) are at a particularly high risk of graft ruptures compared with adults. Recent studies have demonstrated significant reductions in ACL graft rupture rates in high-risk adult populations when a lateral extra-articular procedure is performed, but comparative studies in pediatric and adolescent populations are currently lacking in the literature. PURPOSE/HYPOTHESIS The purpose of this study was to compare the clinical outcomes of isolated ACLR versus combined ACLR and lateral extra-articular tenodesis (LET) when using the Arnold-Coker modification of the MacIntosh procedure in early adolescent patients. The hypothesis was that combined procedures would be associated with a significantly reduced risk of graft ruptures. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS A retrospective analysis of consecutive early adolescent patients who underwent ACLR using a hamstring tendon autograft with or without the Arnold-Coker modification of the MacIntosh procedure was conducted. Patients with ≥1 additional risk factors for a graft rupture were offered LET in addition to ACLR (pivot-shift grade 2 or 3, high level of sporting activity defined as Tegner activity score ≥7, participation in pivoting sports, and Segond fractures). Clinical outcomes including graft rupture rates, patient-reported outcome measure scores (Knee injury and Osteoarthritis Outcome Score and subjective International Knee Documentation Committee), knee stability, return-to-sports rates, reoperation rates, and complications were assessed. Comparisons between variables were assessed with the chi-square or Fisher exact test for categorical variables and the Student or Wilcoxon test for quantitative variables. Multivariate analyses were undertaken to evaluate risk factors for a graft rupture. RESULTS A total of 111 patients with a mean follow-up of 43.8 ± 17.6 months (range, 24-89 months) were included in the study; 40 patients underwent isolated ACLR, and 71 underwent ACLR + LET. The addition of LET to ACLR was associated with a significantly lower graft rupture rate compared with isolated ACLR (0.0% vs 15.0%, respectively; odds ratio, 15.91 [95% CI, 1.81-139.44]; P = .012). It was also associated with significantly better knee stability (pivot-shift grade 3: 0.0% vs 11.4%, respectively; P = .021) (side-to-side anteroposterior laxity difference >5 mm: 0.0% vs 17.1%, respectively; P = .003) and Tegner activity scores (7 vs 6, respectively; P = .010). There were no significant differences between the groups regarding the Patient Acceptable Symptom State for the patient-reported outcome measures, nor for any of the other outcome measures evaluated, and no differences in the rate of non-graft rupture related reoperations or complications. The ACLR + LET group exceeded the minimal clinically important difference with respect to the Tegner activity scale. CONCLUSION In a retrospective comparative cohort study of adolescents, combined ACLR and LET was associated with a significantly lower graft rupture rate and no difference in non-graft rupture related reoperations or complications compared with isolated ACLR.
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Affiliation(s)
- Edoardo Monaco
- Orthopaedic Unit, Sant'Andrea University Hospital, La Sapienza University, Rome, Italy
| | - Alessandro Carrozzo
- Orthopaedic Unit, Sant'Andrea University Hospital, La Sapienza University, Rome, Italy
| | | | - Fabio Conteduca
- Orthopaedic Unit, Sant'Andrea University Hospital, La Sapienza University, Rome, Italy
| | - Alessandro Annibaldi
- Orthopaedic Unit, Sant'Andrea University Hospital, La Sapienza University, Rome, Italy
| | - Fabio Marzilli
- Orthopaedic Unit, Sant'Andrea University Hospital, La Sapienza University, Rome, Italy
| | - Marta Minucci
- Orthopaedic Unit, Sant'Andrea University Hospital, La Sapienza University, Rome, Italy
| | | | - Andrea Ferretti
- Orthopaedic Unit, Sant'Andrea University Hospital, La Sapienza University, Rome, Italy
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Transtibial Pullout Repair of Lateral Meniscus Posterior Root Tear with Tissue Loss: A Case with Anterior Cruciate Ligament Injury and Medial Meniscus Tear. Case Rep Orthop 2022; 2022:9776388. [PMID: 36092283 PMCID: PMC9453023 DOI: 10.1155/2022/9776388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 07/21/2022] [Accepted: 08/11/2022] [Indexed: 11/18/2022] Open
Abstract
Lateral meniscus (LM) posterior root tear (LMPRT) is mainly caused by trauma, especially trauma associated with anterior cruciate ligament (ACL) injuries. Although a transtibial pullout repair or a side-to-side repair is commonly performed for LMPRT, to the best of our knowledge, there is no clinical report of LMPRT with tissue loss using the pullout technique. Thus, the purpose of this report was to describe a clinical, radiographic, and arthroscopic outcome after pullout repair for a case of LMPRT with a large defect with a chronic ACL tear and complex medial meniscus (MM) tears. A 31-year-old man complained of knee pain and restricted range of motion after twisting his knee when he stepped on an iron pipe. The patient had a football-related injury to his right knee 14 years before presentation, and since then, the patient's knee has given out more than 10 times but was left unassessed. Magnetic resonance imaging showed LMPRT with tissue loss, ACL tears, and complex MM tears. Transtibial pullout repair of the LMPRT with ACL reconstruction and MM repairs were performed. Following the pullout repair of the LMPRT, an approximately 6 mm gap remained between the LM posterior root and root insertion. However, magnetic resonance imaging and second-look arthroscopy at 1 year postoperatively revealed meniscal healing, gap filling with some regeneration tissue, of the LM posterior root. Furthermore, the lateral meniscus extrusion in the coronal plane improved from 3.1 mm (preoperative) to 1.6 mm (1 year postoperatively). Transtibial pullout repair with the remaining gap could be a viable treatment option for LMPRT with tissue loss, combined with ACL reconstruction.
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24
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Schlechter J, Pak T, Gornick B, McDonald E. Magnetic Resonance Imaging of Lateral Meniscus Root Tears in the Pediatric and Adolescent Knee: Is the Diagnosis Missed, Mentioned, or Made? Orthop J Sports Med 2022; 10:23259671221114629. [PMID: 35935342 PMCID: PMC9350503 DOI: 10.1177/23259671221114629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 04/20/2022] [Indexed: 12/02/2022] Open
Abstract
Background Failure to address meniscus root tears may place undue loads on anterior cruciate ligament (ACL) reconstructive surgery in the adult population. Because the intraoperative management of lateral meniscus posterior root tears (LMPRTs) may diverge from standard meniscal work and requires specialty items, preoperative diagnosis may be advantageous. Purpose To evaluate the reliability of radiologist interpretations of preoperative knee magnetic resonance imaging (MRI) scans of lateral meniscus root pathology in a mixed pediatric and adolescent population. Study Design Cohort study (diagnosis); Level of evidence, 2. Methods A retrospective review of medical records was performed to identify patients younger than 18 years with an arthroscopically confirmed LMPRT who underwent knee arthroscopy between March 1, 2010, and April 1, 2020. Arthroscopic findings were compared with the reading radiologist's preoperative MRI interpretations, and patients were stratified into 2 groups: (1) LMPRT diagnosis made preoperatively or (2) diagnosis missed or only mentioned to describe pathology nonspecific to the root. Variables such as body mass index (BMI), open physes, time from injury to MRI, time from MRI to surgery, MRI magnet field strength, musculoskeletal radiologist designation, insurance type, and tear grade were assessed between groups. Results Overall, 1116 knee arthroscopies were performed, with 49 LMPRTs found; all 49 LMRPTs were found concomitantly with ACL tears (49/535; 9.2%). The average patient age was 15.97 years (range, 11.52-17.97 years). There were 50 MRI scans for 49 patients. An LMPRT was diagnosed based on preoperative MRI scans in 12 of these 50 scans (24%) and mentioned or missed in 38 of the 50 scans (76%). No significant difference was seen between the diagnosis-made versus diagnosis-mentioned/missed groups in BMI, skeletal maturity, time from injury to MRI, time from MRI to surgery, MRI magnet strength, fellowship training of the reading radiologist, tear grade, or insurance type. Conclusion In 76% of patients, a definitive diagnosis of LMPRT was not made on preoperative MRI scans. Notably, all LMPRTs found intraoperatively were found concomitantly with ACL tears.
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Affiliation(s)
- John Schlechter
- Children’s Hospital of Orange County, Orange, California, USA
- Riverside University Health System, Moreno Valley, California,
USA
| | - Theresa Pak
- Riverside University Health System, Moreno Valley, California,
USA
| | - Bryn Gornick
- Children’s Hospital of Orange County, Orange, California, USA
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25
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Clifton Willimon S, Busch MT, Murata A, Perkins CA. Transosseous Meniscus Root Repair in Pediatric Patients and Association With Durable Midterm Outcomes and High Rates of Return to Sports. Am J Sports Med 2022; 50:2070-2074. [PMID: 35616531 DOI: 10.1177/03635465221096474] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Injuries to the meniscus root attachments result in extrusion of the meniscus, impaired distribution of hoop stresses, and progressive degenerative articular wear. As a result of these deleterious effects, there has been increasing emphasis on repairing meniscus root injuries to restore structure and function. PURPOSE To describe meniscus root tear patterns, associated injuries, and outcomes of transosseous meniscus root repair in a series of pediatric patients. STUDY DESIGN Case series; Level of evidence, 4. METHODS A single-institution retrospective review approved by the institutional review board was performed on consecutive adolescent patients aged <19 years with a meniscus posterior root tear treated with transosseous root repair over 4 years. All patients had a minimum 24-month clinical follow-up. The primary outcomes were revision meniscal surgery, and Lysholm, patient satisfaction, and Tegner activity scores. RESULTS A total of 20 patients (11 male and 9 female patients), with a mean age of 15.6 years (range, 13-18 years), met the inclusion criteria. There were 14 lateral meniscus root tears and 6 medial meniscus root tears. Seventeen patients (85%) had an associated ligament tear: 12 anterior cruciate ligament (ACL) tears and 5 posterior cruciate ligament tears. Two root tears occurred in isolation and both were the posterior root of the medial meniscus. The majority of meniscus root tears (n = 14 patients; 70%) were root avulsions (type 5). The mean follow-up was 42 months (range, 25-71 months). One patient underwent secondary surgery on the affected meniscus after a new injury 4 years postoperatively. Patient-reported outcomes were obtained for 16 patients (80%) at a mean 54-month follow-up. The median Lysholm score was 95 (interquartile range [IQR], 90-100). The median patient satisfaction score was 10 (IQR, 8-10). Thirteen of 16 patients (81%) reported returning to the same or higher level of sports after surgery. CONCLUSION Meniscus root tears most commonly occur in pediatric patients as root avulsions of the posterior root of the lateral meniscus and in association with ACL tears. This is unique compared with the adult population, in which the medial meniscus posterior root is often injured in isolation from a radial tear adjacent to the root. In our pediatric case series, transosseous root repair resulted in successful outcomes in the majority of patients, with durable results at the midterm follow-up.
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Affiliation(s)
| | | | - Asahi Murata
- Children's Healthcare of Atlanta, Atlanta, Georgia, USA
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Gracia G, Cavaignac M, Marot V, Mouarbes D, Laumonerie P, Cavaignac E. Epidemiology of Combined Injuries of the Secondary Stabilizers in ACL-Deficient Knees: Medial Meniscal Ramp Lesion, Lateral Meniscus Root Tear, and ALL Tear: A Prospective Case Series of 602 Patients With ACL Tears From the SANTI Study Group. Am J Sports Med 2022; 50:1843-1849. [PMID: 35416066 DOI: 10.1177/03635465221092767] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Medial meniscal ramp lesion (MMRL), lateral meniscus root tear (LMRT), and anterolateral ligament (ALL) tear are individual injuries that have been described in patients who have an anterior cruciate ligament (ACL) tear. However, the prevalence of these lesions and their combination has not been defined. PURPOSES To define the individual and combined prevalence of MMRL, LMRT, and ALL tears in a case series of patients undergoing ACL reconstruction and to identify the risk factors for combined injuries. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS Patients aged >15 years undergoing primary ACL reconstruction between January 2019 and June 2021 were enrolled in the study. A preoperative ultrasound scan was performed to look for an ALL tear. The presence of MMRL and LMRT was determined during a standardized arthroscopy exploration. A multivariate logistic regression model was used to determine the individual effect of patient variables on the risk of associated single, dual, triad, or tetrad injuries (MMRL, LMRT, ALL, ACL), represented by an adjusted odds ratio. RESULTS The case series consisted of 602 patients who underwent primary ACL reconstruction. An isolated ACL injury was present in 147 patients (24%). A dual injury was detected in 34 patients (6%) who had ACL-MMRL, 16 (2.65%) who had ACL-LMRT, and 265 (44%) who had ACL-ALL. A triad injury was detected in 80 patients (13.28%) who had ACL-ALL-MMRL, 36 (6%) who had ACL-ALL-LMRT, and 3 (0.5%) who had ACL-MMRL-LMRT. A tetrad injury pattern was detected in 21 patients (3.5%). Multivariate analysis showed that the occurrence of tetrad injury was significantly lower in older patients (adjusted odds ratio by year, 0.93 [95% CI, 0.88-0.99]; P = .028). Identifying LMRT increased the likelihood of finding MMRL-ALL injuries by 2.11 times (95% CI, 1.09-3.12; P = .031). CONCLUSION Isolated ACL tear is less common than combined injuries, which are quite frequent. Younger age is a risk factor for combined injuries. The search for damaged secondary stabilizers of the knee must be meticulous and systematic, especially when 1 injured structure has already been diagnosed.
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Affiliation(s)
- Gauthier Gracia
- Department of Orthopaedic Surgery, Polyclinique Côte Basque Sud, Saint-Jean-de-Luz, France
| | | | - Vincent Marot
- Department of Orthopedic Surgery and Trauma, Pierre-Paul Riquet Hospital, Toulouse, France
| | - Dany Mouarbes
- Department of Orthopedic Surgery and Trauma, Pierre-Paul Riquet Hospital, Toulouse, France
| | | | - Etienne Cavaignac
- Department of Orthopedic Surgery and Trauma, Pierre-Paul Riquet Hospital, Toulouse, France
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Magosch A, Jacquet C, Nührenbörger C, Mouton C, Seil R. Grade III pivot shift as an early sign of knee decompensation in chronic ACL-injured knees with bimeniscal tears. Knee Surg Sports Traumatol Arthrosc 2022; 30:1611-1619. [PMID: 34302192 DOI: 10.1007/s00167-021-06673-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 07/16/2021] [Indexed: 01/26/2023]
Abstract
PURPOSE To analyse possible associations between the preoperative pivot shift (PS) test and both patient and injury characteristics in anterior cruciate ligament (ACL)-injured knees, considering previously neglected meniscal injuries such as ramp and root tears. The hypothesis was that a preoperative grade III PS was associated with the amount of intra-articular soft-tissue damage and chronicity of the injury. METHODS The cohort involved 376 patients who underwent primary ACL reconstruction (239 males/137 females; median age 26). Patients were examined under anesthesia before surgery, using the PS test. During arthroscopy, intra-articular soft-tissue damage of the injured knee was classified as: (1) partial ACL tear; (2) complete isolated ACL tear; (3) complete ACL tear with one meniscus tear; and (4) complete ACL and bimeniscal tears. Chi-square and Mann-Whitney U tests were used to evaluate whether sex, age, body mass index, sport at injury, mechanism of injury, time from injury and intra-articular damage (structural damage of ACL and menisci) were associated with a grade III PS. Intra-articular damage was further analyzed for two sub-cohorts: acute (time from injury ≤ 6 months) and chronic injuries (> 6 months). RESULTS A grade III PS test was observed in 26% of patients. A significant association with PS grading was shown for age, time from injury and intra-articular soft-tissue damage (p < 0.05). Further analyses showed that grade III PS was associated with intra-articular damage in chronic injuries only (p < 0.01). In complete ACL and bimeniscal tears, grade III PS was more frequent in chronic (53%) than in acute knee injuries (26%; p < 0.01). Patients with chronic complete ACL and bimeniscal tears had a grade III PS 3.3 [1.3-8.2] times more often than patients in the acute sub-cohort. CONCLUSION In ACL-injured patients, a preoperative grade III PS was mainly associated with a higher amount of intra-articular soft-tissue damage and chronicity of the injury. Patients with complete chronic ACL injuries and bimeniscal tears were more likely to have a preoperative grade III PS than their acute counterparts. This suggests that grade III PS may be an early sign of knee decompensation of dynamic rotational knee laxity in chronic ACL-injured knees with bimeniscal lesions. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Amanda Magosch
- Sports Clinic, Centre Hospitalier de Luxembourg-Clinique d'Eich, 78 Rue d'Eich, 1460, Luxembourg, Luxembourg
| | - Christophe Jacquet
- Institute for Movement and Locomotion (IML), Department of Orthopedic Surgery and Traumatology, St. Marguerite Hospital, Marseille, France
| | - Christian Nührenbörger
- Sports Clinic, Centre Hospitalier de Luxembourg-Clinique d'Eich, 78 Rue d'Eich, 1460, Luxembourg, Luxembourg.,Luxembourg Institute of Research in Orthopaedics, Sports Medicine and Science, Luxembourg, Luxembourg
| | - Caroline Mouton
- Sports Clinic, Centre Hospitalier de Luxembourg-Clinique d'Eich, 78 Rue d'Eich, 1460, Luxembourg, Luxembourg.,Luxembourg Institute of Research in Orthopaedics, Sports Medicine and Science, Luxembourg, Luxembourg
| | - Romain Seil
- Sports Clinic, Centre Hospitalier de Luxembourg-Clinique d'Eich, 78 Rue d'Eich, 1460, Luxembourg, Luxembourg. .,Luxembourg Institute of Research in Orthopaedics, Sports Medicine and Science, Luxembourg, Luxembourg. .,Human Motion, Orthopaedics, Sports Medicine and Digital Methods, Luxembourg Institute of Health, Strassen, Luxembourg.
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Borque KA, Jones M, Cohen M, Johnson D, Williams A. Evidence-based rationale for treatment of meniscal lesions in athletes. Knee Surg Sports Traumatol Arthrosc 2022; 30:1511-1519. [PMID: 34415368 DOI: 10.1007/s00167-021-06694-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 08/10/2021] [Indexed: 12/16/2022]
Abstract
Meniscal injuries in elite athletes are a common cause of missed game time and even have the potential to be career shortening. In this patient group, care must be paid not only to the pathology, but also to a player's contract status, time in the season, specific demands of his/her sport and position on the field, and future consequences. Successful treatment requires the clinician to understand the player's goals and needs, communicate effectively between all stakeholders, and a have knowledge of the challenges posed by the different types of meniscal tear seen in this population. Paramount is the distinction between injuries to the medial and lateral meniscus. Deficiency of the lateral meniscus, as a result of a tear or a meniscectomy, leads to frequent early problems and inexorably to chondral degeneration thereby affecting an athlete's ability to perform. Therefore, it is strongly recommended to repair the majority of lateral meniscal tears. Medial meniscal tears pose a more challenging treatment dilemma, as the success of partial meniscectomy in achieving reproducible, early return to play must be balanced against the long-term degenerative consequences. Many meniscal tears are correctly treated non-operatively.Level of evidence V.
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Affiliation(s)
- Kyle A Borque
- Houston Methodist Orthopedics and Sports Medicine, Houston, USA
| | | | - Moises Cohen
- Departamento de Ortopedia e Traumatologia, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Darren Johnson
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY, USA
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Shekhar A, Tapasvi S, Williams A. Outcomes of Combined Lateral Meniscus Posterior Root Repair and Anterior Cruciate Ligament Reconstruction. Orthop J Sports Med 2022; 10:23259671221083318. [PMID: 35299712 PMCID: PMC8921756 DOI: 10.1177/23259671221083318] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 12/08/2021] [Indexed: 12/01/2022] Open
Abstract
Background: Lateral meniscus posterior root tears (LMPRTs) almost always occur in association with anterior cruciate ligament (ACL) tears. Their repair is advocated to restore the stabilizing and load-sharing functions of the meniscus. Purpose: To study the functional outcomes of combined arthroscopic repair of LMPRTs and ACL reconstruction (ACLR). Study Design: Case series; Level of evidence, 4. Methods: The authors evaluated patients who underwent simultaneous arthroscopic ACLR and LMPRT repair. All patients had chronic injuries, with a mean time since ACL rupture of 7.9 months. Patient characteristics, Lachman and pivot-shift test results, type of LMPRT, associated injuries, and surgery details were documented. Pre- and postoperative functional status was assessed using the International Knee Documentation Committee (IKDC) score, Knee injury and Osteoarthritis Outcome Score (KOOS), and Lysholm score. An independent single-tunnel transtibial repair using 2 SutureTapes was performed for Forkel type 1 and 3 tear root avulsions, while side-to-side suture repair was performed for type 2 radial/oblique tears. The Wilcoxon signed rank test and minimal clinically important difference (MCID) of the IKDC score were used for statistical analysis. Results: Included were 25 patients with a mean age of 29.6 ± 6.5 years. Of these, 22 patients (88%; 95% CI, 73.1%-100%) had a high-grade (grade 2 or 3) preoperative pivot shift. Diagnosis of the LMPRT on magnetic resonance imaging (MRI) scans was possible only in 5 patients (20%). At final evaluation, performed at 37.4 ± 7.1 months postoperatively, all functional scores had improved significantly from preoperatively: IKDC score, from 47.6 ± 9.5 to 81.8 ± 11.5; KOOS, from 45.5 ± 10.9 to 86.5 ± 10.3, and Lysholm score, from 49.0 ± 11.5 to 88.8 ± 7.6 (P < .001 for all). Twenty-four patients (96%) achieved the MCID for the IKDC score. All knees had a negative pivot shift at final analysis, and no patient underwent revision ACLR or LMPRT repair. Conclusion: LMPRT repair combined with ACLR led to good short-term clinical outcomes in this study. An LMPRT may frequently go undetected on preoperative MRI scans, but a high-grade pivot shift is present in a large majority of these patients.
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Jacquet C, Mouton C, Magosch A, Komnos GA, Menetrey J, Ollivier M, Seil R. The aspiration test reveals an instability of the posterior horn of the lateral meniscus in almost one-third of ACL-injured patients. Knee Surg Sports Traumatol Arthrosc 2022; 30:2329-2335. [PMID: 34839369 PMCID: PMC9206618 DOI: 10.1007/s00167-021-06806-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 11/11/2021] [Indexed: 01/12/2023]
Abstract
PURPOSE Anterior cruciate ligament (ACL) injuries often lead to associated injuries of the posterior horn of the lateral meniscus (PHLM). Arthroscopic, assessment of PHLM instability may be difficult in the absence of a visible meniscus damage. The main objective of this prospective multi-center study was to compare the ability of the probing and aspiration tests to identify PHLM instability in a population of patients undergoing ACL reconstruction (ACLR) and a control group of patients with an intact ACL undergoing knee arthroscopy. METHODS A prospective case-control analysis was performed in three sports medicine centers. One-hundred and three consecutive patients operated for a primary isolated ACLR without structural lateral meniscus damage other than a root tear were included. They were compared to a control group of 29 consecutive patients who had a knee arthroscopy with an intact ACL and no structural lateral meniscus lesion. The probing and aspiration tests were consecutively executed according to previously published methods. RESULTS In the control group, no lateral meniscus lesions were visualized during arthroscopy, and both probing and aspiration tests were negative in all patients. In the group of ACL-injured patients, a Forkel type I-III posterolateral meniscus root tear (PLMRT) was found in 12 patients (12%). In this subgroup, the probing test was positive in 4/12 patients (33%) and the aspiration test in 5 additional patients (75%). In 15 patients (15%), an elongation of the posterior root of the lateral meniscus (defined as type IV PLMRT as an addendum to the Forkel classification) could be observed during arthroscopy. In this subgroup, only 1 patient displayed a PHLM instability with the probing test (7%), whereas the aspiration test was positive in 13/15 patients (87%). In the remaining 76 patients (74%), no structural lesion of the PHLM could be identified. Nevertheless, an instability of the PHLM could be identified in 8 of them (11%) with the probing test, and the aspiration test was positive in 2 additional knees (13%) of this apparently normal subgroup. Altogether, in the entire ACL injury cohort, a positive probing test was observed in 13/103 patients (13%) and a positive aspiration test in 32/103 knees (31%) (p < 0.01). CONCLUSION Careful observation and examination of the PHLM with the aspiration test revealed a substantial amount of previously undiagnosed lateral meniscus instabilities in ACL-injured knees. The prevalence of PHLM instability as evaluated by the aspiration test was high (31%). The aspiration test was superior to the probing test in detecting an instability of the PHLM in a population of ACL-injured patients. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Christophe Jacquet
- Department of Orthopedic Surgery and Traumatology, Institute for Movement and Locomotion (IML), St. Marguerite Hospital, Marseille, France
| | - Caroline Mouton
- Sports Clinic, Centre Hospitalier de Luxembourg, Clinique d'Eich, 78, rue d' Eich, 1460, Luxembourg, Luxembourg
- Luxembourg Institute of Research in Orthopaedics, Sports Medicine and Science, Luxembourg, Luxembourg
| | - Amanda Magosch
- Sports Clinic, Centre Hospitalier de Luxembourg, Clinique d'Eich, 78, rue d' Eich, 1460, Luxembourg, Luxembourg
| | - George A Komnos
- Centre de Medecine du Sport et de l'Exercice, Swiss Olympic Medical Center, Hirslanden Clinique la Colline, Geneva, Switzerland
| | - Jacques Menetrey
- Centre de Medecine du Sport et de l'Exercice, Swiss Olympic Medical Center, Hirslanden Clinique la Colline, Geneva, Switzerland
- Service de Chirurgie Orthopédique, University Hospital of Geneva, Geneva, Switzerland
| | - Matthieu Ollivier
- Department of Orthopedic Surgery and Traumatology, Institute for Movement and Locomotion (IML), St. Marguerite Hospital, Marseille, France
| | - Romain Seil
- Sports Clinic, Centre Hospitalier de Luxembourg, Clinique d'Eich, 78, rue d' Eich, 1460, Luxembourg, Luxembourg.
- Luxembourg Institute of Research in Orthopaedics, Sports Medicine and Science, Luxembourg, Luxembourg.
- Human Motion, Orthopaedics, Sports Medicine and Digital Methods, Luxembourg Institute of Health, Luxembourg, Luxembourg.
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Kim SH, Seo JH, Kim DA, Lee JW, Kim KI, Lee SH. Steep posterior lateral tibial slope, bone contusion on lateral compartments and combined medial collateral ligament injury are associated with the increased risk of lateral meniscal tear. Knee Surg Sports Traumatol Arthrosc 2022; 30:298-308. [PMID: 33687540 DOI: 10.1007/s00167-021-06504-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 02/10/2021] [Indexed: 12/19/2022]
Abstract
PURPOSE To determine the risk factors for lateral meniscus and root tears in patients with acute anterior cruciate ligament (ACL) injuries. METHODS A total of 226 patients undergoing acute ACL reconstruction were included in the study sample. Exclusion criteria were revisions, fractures, chronic cases, and multiple ligament injuries, with the exception of medial collateral ligament (MCL) injuries. The patients were divided into groups based on the presence of lateral meniscus and root tears by arthroscopy. Binary logistic regression was used to analyze risk factors including age, sex, body mass index (BMI), injury mechanism (contact/non-contact), Segond fracture, side-to-side laxity, location of bone contusion, medial and lateral tibial and meniscal slope, mechanical axis angle, and grade of pivot shift. RESULTS Overall lateral meniscus (LM) tears were identified in 97 patients (42.9%), and LM root tears were found in 22 patients (9.7%). The risk of an LM tear in ACL-injured knees increased with bone contusion on LTP (odds ratio [OR], 3.5; 95% confidence interval [CI] 1.419-8.634; P = 0.007), steeper lateral tibial slope (OR, 1.133; 95% CI 1.003-1.28; P = 0.045), MCL injury (OR, 2.618; 95% CI 1.444-4.746; P = 0.002), and non-contact injury mechanism (OR, 3.132; 95% CI 1.446-6.785; P = 0.004) in logistic regression analysis. The risk of LM root tear in ACL-injured knees increased with high-grade pivot shift (OR, 9.127; 95% CI 2.821-29.525; P = 0.000) and steeper lateral tibial slope (OR, 1.293; 95% CI 1.061-1.576; P = 0.011). CONCLUSION The increased risk of LM lesions in acute ACL-injured knees should be considered if significant risk factors including bone contusion on lateral compartments, MCL injury, and a steeper lateral tibial slope are present. Moreover, high-grade rotational injury with steeper lateral tibial slope are also significant risk factors for LM root tears, and therefore care should be taken by clinicians not to miss such lesions. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Seong Hwan Kim
- Department of Orthopedic Surgery, Hyundae General Hospital, Chung-Ang Univ., Namyangju-Si, Kyunggi-Do, Korea
- Department of Orthopedic Surgery, Chung-Ang University Hospital, 102, Heukseok-ro, Dongjak-gu, Seoul, Korea
| | - Jeung-Hwan Seo
- Department of Orthopaedic Surgery, Center for Joint Diseases and Rheumatism, Kyung Hee University Hospital at Gangdong, 892 Dongnam-ro, Gangdong-gu, Seoul, 134-727, Korea
| | - Dae-An Kim
- Department of Orthopaedic Surgery, Center for Joint Diseases and Rheumatism, Kyung Hee University Hospital at Gangdong, 892 Dongnam-ro, Gangdong-gu, Seoul, 134-727, Korea
| | - Joong-Won Lee
- Department of Orthopaedic Surgery, Center for Joint Diseases and Rheumatism, Kyung Hee University Hospital at Gangdong, 892 Dongnam-ro, Gangdong-gu, Seoul, 134-727, Korea
| | - Kang-Il Kim
- Department of Orthopaedic Surgery, Center for Joint Diseases and Rheumatism, Kyung Hee University Hospital at Gangdong, 892 Dongnam-ro, Gangdong-gu, Seoul, 134-727, Korea
| | - Sang Hak Lee
- Department of Orthopaedic Surgery, Center for Joint Diseases and Rheumatism, Kyung Hee University Hospital at Gangdong, 892 Dongnam-ro, Gangdong-gu, Seoul, 134-727, Korea.
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Bernholt D, DePhillipo NN, Aman ZS, Samuelsen BT, Kennedy MI, LaPrade RF. Increased posterior tibial slope results in increased incidence of posterior lateral meniscal root tears in ACL reconstruction patients. Knee Surg Sports Traumatol Arthrosc 2021; 29:3883-3891. [PMID: 33527197 DOI: 10.1007/s00167-021-06456-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 01/12/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE While the association with acute anterior cruciate ligament (ACL) tears has been established, other risk factors and associated pathologies which occur with a concomitant lateral meniscal posterior root tear (LMPRT) are not well defined. The purpose of this study was to compare the risk factors and concomitant pathologies between patients with LMPRT and patients without LMPRTs in the setting of a primary ACL tear. METHODS Patients with a LMPRT identified at the time of primary ACL reconstruction by a single surgeon were identified. These patients were matched by age and sex to patients undergoing primary ACL reconstruction who were not found to have lateral meniscus root tears (control group) in a 1:1 ratio. Lateral posterior tibial slope (PTS), medial PTS, lateral femoral condyle height and depth, lateral tibial plateau depth, and lateral tibial plateau subluxation were measured on MRI. Anteroposterior full-limb alignment radiographs were used to measure the medial proximal tibia angle (MPTA), the mechanical lateral distal femoral angle (mLDFA), and the mechanical weightbearing axis for the injured extremity. RESULTS One-hundred three patients were included in both the LMPRT group and the matched control group. Patients with a LMPRT had a significantly steeper lateral PTS (9.1° vs. 7.0°, p = 0.001), a steeper medial PTS (7.0° vs. 6.0°, p = 0.03), and a greater lateral-to-medial slope asymmetry (2.0° vs. 1.0°, p = 0.001). There were no differences in lateral femoral condyle depth or height, lateral tibial plateau depth, lateral tibial plateau subluxation, MPTA, mLDFA, or mechanical weightbearing axis between groups. There was a significantly increased incidence of medial meniscus ramp lesions in patients with lateral meniscus posterior root tears compared with controls (34.0% vs. 15.5%, odds ratio: 2.8, p = 0.002). There were no associations with concomitant ligament injuries, medial meniscus root tears, or non-ramp tears based on case/control grouping. CONCLUSION In conclusion, LMPRTs in the setting of primary ACL injuries were associated with significantly increased lateral and medial PTSs, and increased asymmetry between lateral and medial PTSs. In addition, clinicians should be aware of the increased incidence of concurrent medial meniscal ramp lesions in patients with LMPRTs. Knowledge of these associations helps guide clinical decision-making and counselling of patients in the setting of ACL tears with concomitant LMPRTs. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- David Bernholt
- Campbell Clinic Orthopaedics, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Nicholas N DePhillipo
- Twin Cities Orthopedics, 4010 West 65th Street, Edina, MN, 55435, USA
- Department of Sports Medicine, Oslo Sports Trauma Research Center, Norwegian School of Sport Sciences, Oslo, Norway
| | | | | | | | - Robert F LaPrade
- Twin Cities Orthopedics, 4010 West 65th Street, Edina, MN, 55435, USA.
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Magosch A, Mouton C, Nührenbörger C, Seil R. Medial meniscus ramp and lateral meniscus posterior root lesions are present in more than a third of primary and revision ACL reconstructions. Knee Surg Sports Traumatol Arthrosc 2021; 29:3059-3067. [PMID: 33165632 DOI: 10.1007/s00167-020-06352-3] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 10/26/2020] [Indexed: 01/26/2023]
Abstract
PURPOSE The purpose of this study was (1) to describe the meniscus tear pattern in anterior cruciate ligament (ACL)-injured patients, with a special focus on medial meniscus (MM) ramp lesions and lateral meniscus (LM) root tears and (2) to determine whether patient and injury characteristics were associated with meniscus tear patterns. METHODS Data from 358 cases of ACL primary and revision reconstruction surgeries were extracted from a center-based registry. During arthroscopy, the presence of associated meniscus lesions was documented by systematically inspecting the anterior and posterior tibiofemoral compartments. With a special focus on MM ramp lesions and LM root tears, groups of different injury tear patterns were formed. Chi-square tests were used to determine whether these groups differed with respect to various patient and injury characteristics, including gender, previous ipsilateral ACL injuries, the injury's relation to sport, person contact during injury and the type of ACL tear. Median age at surgery and body mass index were compared between groups using the Kruskal-Wallis test. Significance was set at p < 0.05. RESULTS Two hundred and thirty-nine ACL injuries (67%) showed additional meniscal injuries, of which 125 (52%) involved the MM ramp and/or the LM root. Ramp lesions were more frequent in males (23% vs 12% in females, p < 0.01), in contact injuries (28% vs 16% in non-contact, p < 0.05) and in complete ACL tears (21% vs 5% in partial, p < 0.05). Combined injuries of the MM ramp and the LM root showed a higher percentage of contact injuries compared to non-contact injuries (10% vs 4%, p < 0.05). CONCLUSION Two-thirds of all ACL injuries showed a concomitant meniscus injury, of which half involved the biomechanically relevant, but previously often undiagnosed RLMM or the PRLM. These findings provide evidence that until recently about half of ACL-associated meniscus injuries were not properly identified. Ramp lesions were more frequent in males, contact injuries and in complete ACL tears. These findings stress the need for a systematic assessment and a better understanding of the pathomechanism of these specific injuries which may have an important impact on knee biomechanics and the outcome of ACL reconstruction. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Amanda Magosch
- Sports Clinic, Centre Hospitalier de Luxembourg-Clinique d'Eich, 78, rue d' Eich, 1460, Luxembourg, Luxembourg
| | - Caroline Mouton
- Sports Clinic, Centre Hospitalier de Luxembourg-Clinique d'Eich, 78, rue d' Eich, 1460, Luxembourg, Luxembourg
- Luxembourg Institute of Research in Orthopaedics, Sports Medicine and Science, Luxembourg, Luxembourg
| | - Christian Nührenbörger
- Sports Clinic, Centre Hospitalier de Luxembourg-Clinique d'Eich, 78, rue d' Eich, 1460, Luxembourg, Luxembourg
- Luxembourg Institute of Research in Orthopaedics, Sports Medicine and Science, Luxembourg, Luxembourg
| | - Romain Seil
- Sports Clinic, Centre Hospitalier de Luxembourg-Clinique d'Eich, 78, rue d' Eich, 1460, Luxembourg, Luxembourg.
- Luxembourg Institute of Research in Orthopaedics, Sports Medicine and Science, Luxembourg, Luxembourg.
- Sports Medicine Research Laboratory, Luxembourg Institute of Health, Luxembourg, Luxembourg.
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Leafblad ND, Keyt LK, Cook CS, Smith PA, Stuart MJ, Krych AJ. Good Surgical Outcomes After Concomitant Repair of Double Radial Tears of the Lateral Meniscus and Anterior Cruciate Ligament Reconstruction. Arthrosc Sports Med Rehabil 2021; 3:e989-e996. [PMID: 34430877 PMCID: PMC8365194 DOI: 10.1016/j.asmr.2021.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 02/04/2021] [Indexed: 11/17/2022] Open
Abstract
Purpose To describe double radial tears of the lateral meniscus (LM), report early clinical treatment outcomes, and determine reoperation and failure rates. Methods Twenty-one (N = 21) consecutive cases of arthroscopic-treated lateral meniscus double radial tears treated between 2012 and 2018 were reviewed, including 15 males (71.4%) and 6 females (28.6%). Meniscus repairs were all performed at the time of anterior cruciate ligament (ACL) reconstruction. Patients with associated fractures or prior surgeries were excluded. Concomitant injuries were reported, as were preinjury and postoperative Tegner scores, preoperative and postoperative visual analogue pain scale (VAS) scores, and postoperative International Knee Documentation Committee (IKDC) subjective scores. Reoperation and failure rates were documented. Results Twenty-one (N = 21) tears were located in the posterior horn of the meniscus near the root attachment; 15 (71.4%) underwent all-inside repair, 4 (19.0%) underwent transtibial pull-through repair, 1 (4.8%) was partially debrided, and 1 (4.8%) was left untreated. Twenty-one tears (N = 21) were in the body of the meniscus; 7 (33.3%) were repaired, 7 (33.3%) were partially debrided, and 7 (33.3%) were left untreated. Thirteen patients (62%) had associated medial collateral ligament (MCL) injuries. Mean follow-up was 2.6 years. VAS at rest and with activity improved by 2.1 points (P < .001) and 3.1 points (P = .017) after surgery. The mean postoperative Tegner activity score was 6.4, and the mean IKDC score was 83.2 at final follow-up. Reoperation was required in 5 patients (23.8%), and the surgical treatment failed in 1 patient (4.7%). Conclusions Double radial tears of the LM are uncommon injuries that occur in the setting of ACL tears, usually combined with MCL injury. The variety of surgical treatment techniques have a low failure rate at short-term follow-up. Patients tend to have good clinical outcomes with improvement in pain and overall function after surgically treating these injuries with simultaneous ACL reconstruction. Level of Evidence Level IV, therapeutic study, case series
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Affiliation(s)
- Nels D Leafblad
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Lucas K Keyt
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Corey S Cook
- Columbia Orthopaedic Group, Columbia, Missouri, U.S.A
| | | | - Michael J Stuart
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Aaron J Krych
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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35
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Mazza D, Monaco E, Daggett M, Annibaldi A, Pagnotta SM, Carrozzo A, Ferretti A. Combined ACL and Segond Repair in Combined Acute Proximal ACL Tears and Segond Fracture. Arthrosc Tech 2021; 10:e2151-e2156. [PMID: 34504755 PMCID: PMC8417392 DOI: 10.1016/j.eats.2021.05.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 05/18/2021] [Indexed: 02/03/2023] Open
Abstract
A renewed interest in anterior cruciate ligament preservation has been noted using arthroscopic primary repair in patients with proximal tears, but the main concern remained the control of the rotational instability. Segond fracture occurs in less than 10% of cases of acute anterolateral instability, but it can result in continued rotation instability. The aim of this study is to describe the surgical technique to acutely repair both the anterior cruciate ligament and Segond fracture in the acute setting.
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Affiliation(s)
- Daniele Mazza
- University of Rome “Sapienza”, Sant’Andrea Hospital, Rome, Italy
| | - Edoardo Monaco
- University of Rome “Sapienza”, Sant’Andrea Hospital, Rome, Italy,Address correspondence to Edoardo Monaco, M.D., University of Rome La Sapienza, Sant’Andrea Hospital, Rome (Italy), Via di Grottarossa 1039 – Rome, Italy.
| | | | | | | | | | - Andrea Ferretti
- University of Rome “Sapienza”, Sant’Andrea Hospital, Rome, Italy
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36
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Ciatti R, Gabrielli A, Iannella G, Mariani PP. Arthroscopic incidence of lateral meniscal root avulsion in patients with anterior cruciate ligament injury. J Orthop Traumatol 2021; 22:30. [PMID: 34274999 PMCID: PMC8286212 DOI: 10.1186/s10195-021-00591-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 06/28/2021] [Indexed: 11/21/2022] Open
Abstract
Background To arthroscopically evaluate the incidence of lateral meniscal root avulsion (LMRA) and associated intra-articular injuries in patients undergoing anterior cruciate ligament (ACL) reconstruction. Materials and Methods From April 2014 to March 2017, 532 consecutive patients were diagnosed as having an ACL injury and underwent arthroscopic ACL reconstruction. The diagnosis of LMRA was made arthroscopically. The effects of gender, activity, grade of laxity, time from injury, and concomitant meniscal lesions were analyzed. Results Among 532 patients, 497 (93.4%) underwent primary ACL reconstruction and 35 (6.5%) underwent revision procedures. 383 were acute or subacute injuries (less than 6 months from injury to surgery) and 149 chronic (more than 6 months). Average age was 30.4 years (DS: ± 11.04); there were 422 (79.3%) males and 110 (20.6%) females. A LMRA associated with the ACL injury was detected in 72 cases (13.5%), with a significant prevalence observed in males (\documentclass[12pt]{minimal}
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\begin{document}$${\chi ^2}$$\end{document}χ2 = 4.65; P = 0.031, statistically significant). In the 149 patients with a chronic injury, 27 patients had LMRA (18.1%), while 45 of the 383 patients with an acute or subacute injury had LMRA (11.7%). There was a tendency, albeit not significant (\documentclass[12pt]{minimal}
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\begin{document}$${\chi ^2}$$\end{document}χ2 = 3.721; P = 0.054), for the prevalence to increase with time since the initial ACL injury. LMRA was significantly associated (\documentclass[12pt]{minimal}
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\begin{document}$${\chi ^2}$$\end{document}χ2 = 7.81; P = 0.006) with a meniscocapsular tear of the posterior horn of the medial meniscus (ramp lesion). No other significant associations, such as with severity of A-P translation (as measured by KT-2000) or activity level, were detected. Conclusion LMRA is a relatively common injury associated with both acute and chronic ACL tears. A relatively high incidence in cases of chronic ACL insufficiency suggests that LMRAs do not heal spontaneously or that they may appear with time, even when absent at the time of the initial injury. Level of evidence Level III, cross-sectional study.
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Affiliation(s)
- Riccardo Ciatti
- Casa Di Cura Villa Stuart. Via Trionfale, Rome, 5952 00135, Italy
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Acute Primary Repair of the Anterior Cruciate Ligament With Anterolateral Ligament Augmentation. Arthrosc Tech 2021; 10:e1633-e1639. [PMID: 34258215 PMCID: PMC8252825 DOI: 10.1016/j.eats.2021.03.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 03/02/2021] [Indexed: 02/03/2023] Open
Abstract
Acute injuries of the anterior cruciate ligament are often associated with concurrent injuries to the structures of the anterolateral complex, specifically the anterolateral ligament. Some injury patterns of the anterior cruciate ligament involve tearing of the majority of the ligament from the femoral origin, leaving a large, viable ligament remnant. In these patients, a repair of the anterior cruciate ligament back to the femoral origin can be undertaken. Subsequently, percutaneous repair of the anterolateral ligament can be performed through anatomical, percutaneous suture tape augmentation. The combined technique of anterior cruciate ligament repair with anterolateral ligament reinforcement is presented.
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Mitchell BC, Siow MY, Bastrom T, Bomar JD, Pennock AT, Parvaresh K, Edmonds EW. Predictive Value of the Magnetic Resonance Imaging-Based Coronal Lateral Collateral Ligament Sign on Adolescent Anterior Cruciate Ligament Reconstruction Graft Failure. Am J Sports Med 2021; 49:935-940. [PMID: 33617286 DOI: 10.1177/0363546521988939] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The coronal lateral collateral ligament (LCL) sign is the presence of the full length of the LCL visualized on a single coronal magnetic resonance imaging (MRI) slice at the posterolateral corner of the knee. The coronal LCL sign has been shown to be associated with elevated measures of anterior tibial translation and internal rotation in the setting of anterior cruciate ligament (ACL) tear. HYPOTHESIS The coronal LCL sign (with greater anterior translation, internal rotation, and posterior slope of the tibia) will indicate a greater risk for graft failure after ACL reconstructive surgery. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Retrospective review was performed of adolescent patients with ACL reconstruction: a cohort without graft failure and a cohort with graft failure. MRI was utilized to measure tibial translation and femorotibial rotation and to identify the coronal LCL sign. The posterior tibial slope was measured on lateral radiographs. Patient-reported outcomes were collected. RESULTS We identified 114 patients with no graft failure and 39 patients with graft failure who met all criteria, with a mean follow-up time of 3.5 years (range, 2-9.4 years). Anterior tibial translation was associated with anterolateral complex injury (P < .001) but not graft failure (P = .06). Internal tibial rotation was associated with anterolateral complex injury (P < .001) and graft failure (P = .042). Posterior tibial slope was associated with graft failure (P = .044). The coronal LCL sign was associated with anterolateral complex injury (P < .001) and graft failure (P = .013), with an odds ratio of 4.3 for graft failure (95% CI, 1.6-11.6; P = .003). Subjective patient-reported outcomes and return to previous level of sport were not associated with failure. Comparison of MRI before and after ACL reconstruction in the graft failure cohort demonstrated a reduced value in internal rotation (P = .003) but no change in coronal LCL sign (P = .922). CONCLUSION Our study demonstrates that tibial internal rotation and posterior slope are independent predictors of ACL graft failure in adolescents. Although the value of internal rotation could be improved with ACL reconstruction, the presence of the coronal LCL sign persisted over time and was predictive of graft rupture (without the need to make measurements or memorize values of significant risk). Together, these factors indicate that greater initial knee deformity after initial ACL tear predicts greater risk for future graft failure.
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Affiliation(s)
- Brendon C Mitchell
- Department of Orthopaedic Surgery, University of California-San Diego, San Diego, California, USA
| | - Matthew Y Siow
- Department of Orthopaedic Surgery, University of California-San Diego, San Diego, California, USA
| | - Tracey Bastrom
- Division of Orthopaedic Surgery, Rady Children's Hospital, San Diego, California, USA
| | - James D Bomar
- Division of Orthopaedic Surgery, Rady Children's Hospital, San Diego, California, USA
| | - Andrew T Pennock
- Division of Orthopaedic Surgery, Rady Children's Hospital, San Diego, California, USA
| | - Kevin Parvaresh
- Department of Orthopaedic Surgery, Rush Medical Center, Chicago, Illinois, USA
| | - Eric W Edmonds
- Division of Orthopaedic Surgery, Rady Children's Hospital, San Diego, California, USA
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Uffmann W, ElAttrache N, Nelson T, Eberlein SA, Wang J, Howard DR, Metzger MF. Posterior Lateral Meniscal Root Tears Increase Strain on the Reconstructed Anterior Cruciate Ligament: A Cadaveric Study. Arthrosc Sports Med Rehabil 2021; 3:e505-e513. [PMID: 34027462 PMCID: PMC8129456 DOI: 10.1016/j.asmr.2020.11.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Accepted: 11/25/2020] [Indexed: 11/30/2022] Open
Abstract
Purpose To quantify the amount of strain across an anterior cruciate ligament reconstruction (ACLR) before and after a lateral meniscus (LM) posterior root complex tear and determine whether a meniscal root repair effectively protects the ACLR against excessive strain. Methods Fresh-frozen cadaveric knees were tested with an 88-N anterior drawer force and an internal and external torque of 5-Nm applied at 0°, 15°, 30°, 60°, and 90° of flexion. A simulated pivot shift was also applied at 0, 15, and 30° of flexion. Rotation and translation of the tibia, and strain across the ACL graft were recorded. Testing was repeated for the following four conditions: ACL-intact, ACLR with intact LM, ACLR with LM posterior root complex tear, and ACLR with root repair. Results The kinematic data from 12 fresh frozen cadaveric knees underwent analysis. Only 11 specimens had usable strain data. Sectioning the meniscofemoral ligaments and the LM posterior root increased rotational and translational laxity at 30° of knee flexion. ACLR graft strain significantly increased when an anterior load and internal torque were applied. Repair of the LM posterior root reduced strain when the knee was internally rotated but was unable to normalize strain when an anterior force was applied. Conclusions This cadaveric biomechanical study suggests injury to the LM posterior root complex increases rotational and anterior laxity of the knee and places increased strain across reconstructed ACL grafts. Subsequent root repair did not result in a statistically significant reduction in strain. Clinical Relevance This study provides quantitative data on the implications of a LM posterior root injury in the setting of an ACL reconstruction to help guide clinical decision-making.
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Affiliation(s)
- William Uffmann
- Cedars-Sinai Kerlan-Jobe Institute, Cedars-Sinai Medical Center, Los Angeles, California, U.S.A
| | - Neal ElAttrache
- Cedars-Sinai Kerlan-Jobe Institute, Cedars-Sinai Medical Center, Los Angeles, California, U.S.A
| | - Trevor Nelson
- Orthopaedic Biomechanics Laboratory, Cedars-Sinai Medical Center, Los Angeles, California, U.S.A
| | - Sam A Eberlein
- Orthopaedic Biomechanics Laboratory, Cedars-Sinai Medical Center, Los Angeles, California, U.S.A
| | - Juntian Wang
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California, U.S.A
| | - Daniel R Howard
- Somers Orthopaedic Surgery & Sports Medicine, Carmel, New York, U.S.A
| | - Melodie F Metzger
- Orthopaedic Biomechanics Laboratory, Cedars-Sinai Medical Center, Los Angeles, California, U.S.A.,Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California, U.S.A
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Leyes M, Flores-Lozano C, de Rus I, Salvador MG, Buenadicha EM, Villarreal-Villarreal G. Repair of the Posterior Lateral Meniscal Root Tear: Suture Anchor Fixation Through the Outside-In Anterior Cruciate Ligament Reconstruction Femoral Tunnel. Arthrosc Tech 2021; 10:e151-e158. [PMID: 33532222 PMCID: PMC7823102 DOI: 10.1016/j.eats.2020.09.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 09/20/2020] [Indexed: 02/03/2023] Open
Abstract
Posterior lateral meniscus root tears are defined as tears that occur within 9 mm of the posterior lateral meniscus insertion or as avulsions of the insertion. If root tears are left unrepaired, functional alterations and early degenerative changes occur in the affected compartment. Several surgical techniques have been described to reattach the posterior horn of the lateral meniscus, including transtibial pull-out technique and side-to-side repair technique. This surgical technique reports an alternative way to repair posterior lateral meniscus root tears that are associated with or without an anterior cruciate ligament graft tear. The technique involves the placement of a suture anchor on the lateral meniscus root footprint through the outside-in anterior cruciate ligament femoral tunnel, which minimizes the possibility of iatrogenic lesions and facilitates repair.
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Affiliation(s)
| | | | | | | | | | - Gregorio Villarreal-Villarreal
- Department of Orthopaedics and Traumatology. Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México,Address correspondence to Gregorio Villarreal-Villarreal, M.D., Department of Orthopaedics and Traumatology, Universidad Autónoma de Nuevo León, Francisco I, Madero y Av. Gonzalitos S/N, Col. Mitras Centro, Postal code: 64460, Monterrey, Nuevo León, México.
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Tang X, Marshall B, Wang JH, Zhu J, Li J, Linde MA, Smolinski P, Fu FH. Partial meniscectomy does not affect the biomechanics of anterior cruciate ligament reconstructed knee with a lateral posterior meniscal root tear. Knee Surg Sports Traumatol Arthrosc 2020; 28:3481-3487. [PMID: 32889558 DOI: 10.1007/s00167-020-06209-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 08/03/2020] [Indexed: 01/14/2023]
Abstract
PURPOSE The purpose of this study was to determine the effects of a lateral meniscus posterior root tear, partial meniscectomy, and total meniscectomy on knee biomechanics in the setting of anterior cruciate ligament (ACL) reconstruction. METHODS Thirteen fresh-frozen cadaver knees were tested with a robotic testing system under an 89.0-N anterior tibial load at full extension (FE), 15°, 30°, 60° and 90° of knee flexion and a simulated pivot-shift loading (7.0 Nm valgus and 5.0 Nm internal tibial rotation) at FE, 15° and 30° of knee flexion. Anterior tibial translation (ATT) and the in-situ force of ACL graft under the different loadings were measured in four knee states: (1) ACL reconstruction with intact lateral meniscus (Intact meniscus), (2) ACL reconstruction with lateral meniscal posterior root tear (Root tear), (3) ACL reconstruction with lateral posterior partial meniscectomy (Partial meniscectomy) and (4) ACL reconstruction with total lateral meniscectomy (Total meniscectomy). RESULTS Under anterior tibial loading, compared with an intact meniscus, root tear significantly increased ATT at 15° and 30° of knee flexion (p < 0.05) and partial meniscectomy had almost same increased ATT as with root tear at any knee flexion between FE and 90°. Under simulated pivot-shift loading, total meniscectomy increased ATT compared with intact meniscus, root tear, partial meniscectomy at FE (p < 0.05). CONCLUSION Under anterior tibial and simulated pivot-shift loading, partial meniscectomy has no significant effect on the stability of ACL-reconstructed knee with lateral meniscal posterior root tear, while total meniscectomy increased laxity at less than 30° of knee flexion. Clinically, in cases of irreparable meniscal root tears or persistent pain a partial meniscectomy can be considered in the setting of ACL reconstruction.
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Affiliation(s)
- Xin Tang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, China
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Suite 1011, Pittsburgh, PA, 15213, USA
| | - Brandon Marshall
- Department of Mechanical Engineering and Material Science Engineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Joon Ho Wang
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Suite 1011, Pittsburgh, PA, 15213, USA
| | - Junjun Zhu
- Department of Mechanical Engineering and Material Science Engineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jian Li
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Monica A Linde
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Suite 1011, Pittsburgh, PA, 15213, USA
| | - Patrick Smolinski
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Suite 1011, Pittsburgh, PA, 15213, USA
- Department of Mechanical Engineering and Material Science Engineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Freddie H Fu
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Suite 1011, Pittsburgh, PA, 15213, USA.
- Department of Mechanical Engineering and Material Science Engineering, University of Pittsburgh, Pittsburgh, PA, USA.
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Helito CP, Melo LDP, Guimarães TM, Sobrado MF, Helito PVP, Pécora JR, Gobbi RG. Alternative Techniques for Lateral and Medial Posterior Root Meniscus Repair Without Special Instruments. Arthrosc Tech 2020; 9:e1017-e1025. [PMID: 32714813 PMCID: PMC7372599 DOI: 10.1016/j.eats.2020.03.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 03/29/2020] [Indexed: 02/03/2023] Open
Abstract
Improved understanding and treatment of posterior medial and lateral meniscus root tears have attracted increasing interest. These lesions significantly compromise meniscal function, which can result in an outcome resembling total meniscectomy, and are also a potential cause of knee instability. Despite facilitating repair procedures and reducing the operative time for these lesions, all-inside meniscal repair devices are not available in all circumstances or registered for use in all countries worldwide. Furthermore, all-inside arthroscopic devices can be expensive. Therefore, low-cost alternatives for the treatment of these lesions must be identified. We present 2 efficient and safe techniques: an outside-in technique for repairing medial meniscus root tears and a technique using a simple needle inserted through the transtibial tunnel for lateral meniscal root repairs, neither of which requires the use of specific instruments, thus enabling appropriate treatment of posterior medial and lateral meniscus root tears.
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Affiliation(s)
- Camilo Partezani Helito
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil,Hospital Sírio Libanês, SP, Brazil
| | - Lucas da Ponte Melo
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
| | - Tales Mollica Guimarães
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
| | - Marcel Faraco Sobrado
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil,Hospital Sírio Libanês, SP, Brazil,Address correspondence to Marcel Faraco Sobrado, M.D., Rua Dr. Ovídio Pires de Campos, 333, Cerqueira Cesar, São Paulo, SP, CEP: 05403-010, Brazil.
| | - Paulo Victor Partezani Helito
- Hospital Sírio Libanês, SP, Brazil,Grupo de radiologia musculoesqueléticas, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - José Ricardo Pécora
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
| | - Riccardo Gomes Gobbi
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
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Krych AJ, LaPrade MD, Cook CS, Leland D, Keyt LK, Stuart MJ, Smith PA. Lateral Meniscal Oblique Radial Tears Are Common With ACL Injury: A Classification System Based on Arthroscopic Tear Patterns in 600 Consecutive Patients. Orthop J Sports Med 2020; 8:2325967120921737. [PMID: 32490027 PMCID: PMC7238316 DOI: 10.1177/2325967120921737] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 02/13/2020] [Indexed: 12/02/2022] Open
Abstract
Background: Meniscal root tears and ramp lesions have been rigorously characterized in
recent literature. However, one of the most common lateral meniscal injuries
identified with an acute anterior cruciate ligament (ACL) disruption, a
posterior horn lateral meniscal oblique radial tear (LMORT), has not been
thoroughly described. Purpose: To determine the incidence of all meniscal tears and, more specifically, the
incidence of posterior horn LMORTs in a multicenter cohort of consecutive,
acute ACL reconstructions. Additionally, the authors aimed to develop a new
classification system to help guide treatment of posterior horn LMORTs. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A multicenter retrospective cohort design was used to analyze 200 consecutive
cases of acute ACL reconstruction from each of 3 different surgeons, for a
total of 600 patients. The operative notes and intraoperative photos were
analyzed to determine the incidence and laterality of all meniscal tears. A
classification system based on tear characterization was then used to
categorize tear patterns into similar groups. Results: A total of 396 (66%) of the 600 patients with acute ACL disruption had
concomitant meniscal tears. Specifically, 187 (31%) had a lateral meniscal
injury, 89 (15%) had a medial meniscal injury, and 122 (20%) had both medial
and lateral meniscal injuries. The most common lateral meniscal tear was an
LMORT; 71 (18%) patients with meniscal tears had a posterior horn LMORT.
Overall, the incidence of ACL injury with a concomitant posterior horn LMORT
was 12%. A classification was developed, which included type 1 tear (partial
thickness <10 mm from the root attachment), type 2 tear (complete radial
oblique tear that extended <10 mm from root), type 3 tear (incomplete
LMORT that extended >10 mm from root), and type 4 tear (complete LMORT
>10 mm from root). Conclusion: In 600 consecutive acute ACL reconstructions, the incidence of concomitant
ACL injury with meniscal injury was 66%, and posterior horn LMORTs
represented a large proportion of all meniscal tears (12%). A classification
scheme was developed for posterior horn LMORTs to aid reporting and clinical
decision making for these common tears.
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Affiliation(s)
- Aaron J Krych
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthew D LaPrade
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Corey S Cook
- Department of Orthopedic Surgery, Columbia Orthopedic Group, Columbia, Missouri, USA
| | - Devin Leland
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Lucas K Keyt
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael J Stuart
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Patrick A Smith
- Department of Orthopedic Surgery, Columbia Orthopedic Group, Columbia, Missouri, USA.,Department of Orthopedic Surgery, Columbia Orthopedic Group, Columbia, Missouri, USA
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DePhillipo NN, Dekker TJ, Aman ZS, Bernholt D, Grantham WJ, LaPrade RF. Incidence and Healing Rates of Meniscal Tears in Patients Undergoing Repair During the First Stage of 2-Stage Revision Anterior Cruciate Ligament Reconstruction. Am J Sports Med 2019; 47:3389-3395. [PMID: 31693386 DOI: 10.1177/0363546519878421] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Meniscal tears, including tears at the root attachment, have been associated with tears of the anterior cruciate ligament (ACL) in both primary and revision settings. However, there is a paucity of literature reporting the healing rates of meniscal repair during 2-stage revision ACL reconstruction (ACLR). PURPOSE To evaluate the healing rates of meniscal repairs performed during 2-stage revision ACLR in ACL-deficient knees and to report the incidence of meniscus root tears in patients undergoing primary ACLR as compared with revision ACLR. STUDY DESIGN Case series; Level of evidence, 4. METHODS Patients who underwent primary and revision ACLR by a single surgeon were retrospectively identified. Revision ACLRs were grouped according to 1- or 2-stage ACLR. Meniscal tears were grouped according to laterality (medial, lateral) and location of tears. Meniscal repair technique was recorded, including transtibial or inside-out. Meniscal repair healing was assessed via second-look arthroscopy at the time of second-stage revision ACLR. RESULTS There were 1168 patients identified who underwent ACLR: 851 primary and 317 revision procedures. Sixty-four patients underwent meniscal repair during first-stage bone grafting in ACL-deficient knees, with an overall healing rate of 86%. The healing rates were 82.3% for meniscus root tears via the transtibial repair technique and 92.4% for meniscal peripheral tears via the inside-out repair technique. Meniscus root tears had overall incidences of 15.5% and 26.2% in primary and revision ACLRs, respectively. The incidence of lateral meniscus posterior root tears was approximately 4 times higher than of medial meniscus posterior root tears in both primary (12.2% vs 3.2%) and revision (20.5% vs 5.6%) ACLRs. CONCLUSION A high incidence of meniscus root tears was found in patients undergoing revision ACLRs as compared with primary ACLRs. Meniscal repairs have a high rate of healing and success when performed during the first stage of revision ACLR in ACL-deficient knees.
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Affiliation(s)
- Nicholas N DePhillipo
- The Steadman Clinic, Vail, Colorado, USA.,Oslo Sports Trauma Research Center, Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway.,Twin Cities Orthopedics, Edina, Minnesota, USA
| | | | - Zachary S Aman
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | | | | | - Robert F LaPrade
- The Steadman Clinic, Vail, Colorado, USA.,Twin Cities Orthopedics, Edina, Minnesota, USA
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Leafblad ND, Leland DP, Camp CL, Stuart MJ, Krych AJ. Arthroscopic Repair of Double Radial Tears of the Lateral Meniscus. Arthrosc Tech 2019; 8:e541-e547. [PMID: 31334008 PMCID: PMC6620528 DOI: 10.1016/j.eats.2019.01.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 01/28/2019] [Indexed: 02/08/2023] Open
Abstract
Double radial tears of the lateral meniscus are rare injuries that typically occur in the setting of an acute anterior cruciate ligament rupture. Full-thickness radial tears of the meniscus body and root render the meniscus nonfunctional from a loss of hoop stress resistance. Repair of these tears can normalize contact pressures in the lateral compartment and delay arthritic changes. We describe our technique for repairing a lateral meniscus body radial tear and concomitant posterior root tear, via inside-out suture repair and transtibial suture repair, respectively. This investigation was performed at Mayo Clinic.
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Affiliation(s)
| | | | | | | | - Aaron J. Krych
- Address correspondence to Aaron J. Krych, M.D., Mayo Clinic, 200 First St SW, Rochester, Minnesota 55905, U.S.A.
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