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Feroe AG, Clark SC, Hevesi M, Okoroha KR, Saris DBF, Krych AJ, Tagliero AJ. Management of Meniscus Pathology with Concomitant Anterior Cruciate Ligament Injury. Curr Rev Musculoskelet Med 2024; 17:321-334. [PMID: 38822979 PMCID: PMC11219633 DOI: 10.1007/s12178-024-09906-x] [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] [Accepted: 05/20/2024] [Indexed: 06/03/2024]
Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize current clinical knowledge on the prevalence and types of meniscus pathology seen with concomitant anterior cruciate ligament (ACL) injury, as well as surgical techniques, clinical outcomes, and rehabilitation following operative management of these pathologies. RECENT FINDINGS Meniscus pathology with concomitant ACL injury is relatively common, with reports of meniscus pathology identified in 21-64% of operative ACL injuries. These concomitant injuries have been associated with increased age and body mass index. Lateral meniscus pathology is more common in acute ACL injury, while medial meniscus pathology is more typical in chronic ACL deficiency. Meniscus tear patterns associated with concomitant ACL injury include meniscus root tears, lateral meniscus oblique radial tears of the posterior horn (14%), and ramp lesions of the medial meniscus (8-24%). These meniscal pathologies with concomitant ACL injury are associated with increased rotational laxity and meniscal extrusion. There is a paucity of comparative studies to determine the optimal meniscus repair technique, as well as rehabilitation protocol, depending on specific tear pattern, location, and ACL reconstruction technique. There has been a substantial increase in recent publications demonstrating the importance of meniscus repair at the time of ACL repair or reconstruction to restore knee biomechanics and reduce the risk of progressive osteoarthritic degeneration. Through these studies, there has been a growing understanding of the meniscus tear patterns commonly identified or nearly missed during ACL reconstruction. Surgical management of meniscal pathology with concomitant ACL injury implements the same principles as utilized in the setting of isolated meniscus repair alone: anatomic reduction, biologic preparation and augmentation, and circumferential compression. Advances in repair techniques have demonstrated promising clinical outcomes, and the ability to restore and preserve the meniscus in pathologies previously deemed irreparable. Further research to determine the optimal surgical technique for specific tear patterns, as well as rehabilitation protocols for meniscus pathology with concomitant ACL injury, is warranted.
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Affiliation(s)
- Aliya G Feroe
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Sean C Clark
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Mario Hevesi
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Kelechi R Okoroha
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Daniel B F Saris
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Aaron J Krych
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Adam J Tagliero
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
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DeFroda S, Bourbon de Albuquerque J, Bezold W, Cook CR, Nuelle CW, Stannard JP, Cook JL. Tunnel Overlap Occurs 25% of the Time With Simultaneous Anterior Cruciate Ligament Reconstruction and Lateral Meniscal Root Repair. Arthrosc Sports Med Rehabil 2024; 6:100917. [PMID: 39006781 PMCID: PMC11240026 DOI: 10.1016/j.asmr.2024.100917] [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: 08/21/2023] [Accepted: 02/15/2024] [Indexed: 07/16/2024] Open
Abstract
Purpose To assess the risk of socket-tunnel overlap for posterior medial or lateral meniscal root repair combined with anterior cruciate ligament reconstruction (ACLR) using artificial tibias and computed tomography scans for 3-dimensional modeling. Methods Artificial tibias (n = 27; n = 3/subgroup) were allocated to groups based on inclination of socket-tunnels (55°, 60°, 65°) created for posterior root of the medial meniscus (MMPR) and lateral meniscus posterior root (LMPR) repair, and ACLR. Three standardized socket-tunnels were created: one for the ACL and one for each posterior meniscal root insertion. Computed tomography scans were performed and sequentially processed using computer software to produce 3-dimensional models for assessment of socket-tunnel overlap. Statistical analysis was performed with Kruskal-Wallis and Mann-Whitney U tests. Significance was set at P < .05. Results The present study found no significant risk of tunnel overlap when drilling for combined ACLR and MMPR repair, whereas 7 cases of tunnel overlap occurred between ACL tunnels and LMPR (25.9% of cases). No subgroup or specific pattern of angulation consistently presented significantly safer distances than other subgroups for all distances measured. Conclusions This study demonstrated 25.9% rate of overlap for combined LMPR repair and ACLR, compared with 0% for MMPR repair with ACLR. Lower ACL drilling angle (55 or 60°) combined with greater lateral meniscus drilling angle (65°) produced no socket-tunnel overlap. Clinical Relevance Socket-tunnel overlap during meniscal root repair combined with ACLR may compromise graft integrity and lead to impaired fixation and treatment failure of either the ACL, the meniscus, or both. Despite this, risk for socket-tunnel overlap has not been well characterized.
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Affiliation(s)
- Steven DeFroda
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A
| | - João Bourbon de Albuquerque
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri, U.S.A
| | - Will Bezold
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri, U.S.A
| | - Cristi R Cook
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri, U.S.A
| | - Clayton W Nuelle
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A
| | - James P Stannard
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri, U.S.A
| | - James L Cook
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri, U.S.A
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DeFroda S, Bourbon de Albuquerque J, Bezold W, Cook CR, Nuelle CW, Stannard JP, Cook JL. Optimizing Socket-Tunnel Position for Meniscal Allograft Transplantation Combined With ACL Reconstruction: A 3D Model Analysis. Orthop J Sports Med 2024; 12:23259671241246277. [PMID: 38845611 PMCID: PMC11155341 DOI: 10.1177/23259671241246277] [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: 10/18/2023] [Accepted: 10/24/2023] [Indexed: 06/09/2024] Open
Abstract
Background Socket-tunnel overlap during meniscal allograft transplantation (MAT) combined with anterior cruciate ligament reconstruction (ACLR) may compromise graft integrity and lead to impaired fixation and treatment failure. Purpose/Hypothesis The purpose of this study was to determine optimal socket-tunnel drilling parameters for medial and lateral MAT with concurrent ACLR using artificial tibias and computed tomography (CT) scans for 3-dimensional (3D) modeling. It was hypothesized that clinically relevant socket tunnels could be created to allow for concurrent medial or lateral MAT and ACLR without significant risk for overlap at varying tunnel guide angles. Study Design Descriptive laboratory study. Methods A total of 27 artificial right tibias (3 per subgroup) were allocated to 9 experimental groups based on the inclination of the socket tunnels (55°, 60°, and 65°) created for simulating medial and lateral MAT and ACLR. Five standardized socket tunnels were created for each tibia using arthroscopic guides: one for the ACL tibial insertion and one for each meniscus root insertion. CT scans were performed for all specimens and sequentially processed using computer software to produce 3D models for quantitative assessment of socket-tunnel overlap risk. Statistical analysis was performed with Kruskal-Wallis and Mann-Whitney U tests. Results No subgroup consistently presented significantly safer distances than other subgroups for all distances measured. Three cases (11%) and 24 cases (~90%) of tunnel overlap occurred between the ACL tunnel and tunnels for medial and lateral MAT, respectively. Most socket-tunnel overlap (25 of 27; 92.6%) occurred between sockets at depths ranging between 6.3 and 10 mm from the articular surface. For ACLR and posterior root of the lateral meniscus setting, the guide set at 65° increased socket-tunnel distances. Conclusion When combined ACLR and MAT using socket tunnels for graft fixation is performed, the highest risk for tibial socket-tunnel overlap involves the ACLR tibial socket and the lateral meniscus anterior root socket at a depth of 6 to 10 mm from the tibial articular surface. Clinical Relevance Setting tibial guides at 65° to the tibial articular surface with the tunnel entry point anteromedial and socket aperture location within the designated anatomic "footprint" will minimize the risk for socket-tunnel overlap.
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Affiliation(s)
- Steven DeFroda
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, USA
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri, USA
| | - João Bourbon de Albuquerque
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, USA
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri, USA
| | - Will Bezold
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, USA
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri, USA
| | - Cristi R. Cook
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, USA
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri, USA
| | - Clayton W. Nuelle
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, USA
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri, USA
| | - James P. Stannard
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, USA
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri, USA
| | - James L. Cook
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, USA
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri, USA
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Hui C, Salipas A, Cavanagh J. A Convergent Tibial Tunnel Technique for Concomitant Anterior Cruciate Ligament Reconstruction and Meniscal Root Repair. Arthrosc Tech 2024; 13:102918. [PMID: 38690342 PMCID: PMC11056734 DOI: 10.1016/j.eats.2024.102918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 12/09/2023] [Indexed: 05/02/2024] Open
Abstract
Modern arthroscopic knee-reconstruction techniques involve the use of multiple bone tunnels and fixation devices to restore the anatomy and stability of the knee after traumatic injury. In these injuries, however, tunnel collision can be problematic, especially when combining anterior cruciate ligament reconstruction with meniscal root repairs or multiligament reconstructions. We describe a multiple tibial tunnel technique to allow fixation of both anterior cruciate ligament graft and meniscal roots through convergence to a single tibial cortical aperture.
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Affiliation(s)
- Catherine Hui
- Glen Sather Sports Medicine Clinic, University of Alberta, Edmonton, Alberta, Canada
- Kaye Edmonton Clinic, Edmonton, Canada
| | - Andrew Salipas
- Glen Sather Sports Medicine Clinic, University of Alberta, Edmonton, Alberta, Canada
- Kaye Edmonton Clinic, Edmonton, Canada
- Department of Orthopaedic Surgery, Monash Health, Dandenong, Victoria, Australia
| | - Joseph Cavanagh
- Glen Sather Sports Medicine Clinic, University of Alberta, Edmonton, Alberta, Canada
- Kaye Edmonton Clinic, Edmonton, Canada
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Mameri ES, Kerzner B, Jackson GR, Jawanda H, Khan ZA, Kaplan DJ, Chahla J. Top Ten Pearls for a Successful Transtibial Pull-Out Repair of Medial Meniscal Posterior Root Tears With a Concomitant Centralization Stitch. Arthrosc Tech 2023; 12:e1039-e1049. [PMID: 37533905 PMCID: PMC10390883 DOI: 10.1016/j.eats.2023.02.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 02/06/2023] [Accepted: 02/19/2023] [Indexed: 08/04/2023] Open
Abstract
Although historically overlooked, medial meniscus posterior root (MMPR) tears are now increasingly recognized as a substantial cause of biomechanical impairment and morbidity. MMPR tears, when left untreated, are strongly correlated to meniscal extrusion and ultimately lead to altered kinematics and loading functionally equivalent to a total meniscectomy. To prevent progressive joint degeneration and alleviate pain while re-establishing native joint kinematics, MMPR repair is generally recommended in appropriately selected patients. In this Technical Note, the authors describe a detailed checklist with 10 crucial points of emphasis when performing the gold-standard transtibial pull-out repair of the MMPR, with an additional centralization stitch, providing technical pearls backed up by previous literature and ample experience treating this condition.
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Affiliation(s)
- Enzo S. Mameri
- Midwest Orthopaedics at Rush, Chicago, Illinois
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
- Escola Paulista de Medicina, Federal University of São Paulo, São Paulo - SP, Brazil
- Instituto Brasil de Tecnologias da Saúde, Rio de Janeiro - RJ, Brazil
| | - Benjamin Kerzner
- Midwest Orthopaedics at Rush, Chicago, Illinois
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Garrett R. Jackson
- Midwest Orthopaedics at Rush, Chicago, Illinois
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Harry Jawanda
- Midwest Orthopaedics at Rush, Chicago, Illinois
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Zeeshan A. Khan
- Midwest Orthopaedics at Rush, Chicago, Illinois
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Daniel J. Kaplan
- Midwest Orthopaedics at Rush, Chicago, Illinois
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Jorge Chahla
- Midwest Orthopaedics at Rush, Chicago, Illinois
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
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Vadhera AS, DeFroda SF, Lee JS, Singh H, Gursoy S, Kunze KN, Verma NN, Chahla J. Treatment of an Iatrogenic Lateral Meniscal Root Tear After ACL Reconstruction. VIDEO JOURNAL OF SPORTS MEDICINE 2023. [DOI: 10.1177/26350254221141904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Background: The meniscal roots are essential for preserving the structural and biomechanical properties of the tibiofemoral joint. Posterior meniscal root avulsions can cause meniscal extrusion, joint space narrowing, and progressive knee arthritis. Iatrogenic avulsions after malpositioning of the transtibial tunnels during anterior cruciate ligament (ACL) reconstruction have previously been reported in the literature to account for poor long-term outcomes seen in some patients following ACL reconstruction. Therefore, correct transtibial tunnel placement during ACL reconstruction is essential to avoid iatrogenic meniscal damage. Indication: Patients are indicated for surgery when presenting with a verified, symptomatic, complete meniscal root tear seen on advanced imaging or diagnostic arthroscopy. Contraindications for a root repair include the development of advanced osteoarthritis in the ipsilateral compartment, older age, and malalignment in the affected compartment. Technique Description: The ACL graft was appreciated and noted to be vertical and posterior relative to its native anatomical position, violating the lateral posterior horn root attachment. A full lateral posterior meniscal root avulsion was then confirmed directly adjacent to the graft tunnel. A curette was used to prepare the footprint of the lateral meniscal root on the posterolateral tibia for the 2-tunnel transtibial pull-out tunnels, and a grasper was used to position the torn meniscal root back into its anatomical site. Two ultrabraided sutures were passed through the posterior horn of the lateral meniscus using a suture passer. These were then passed through the tunnels into the body of the meniscal root and reduced to its native anatomical position. The suture repair was then secured over an Endobutton Fixation Device at 90° of knee flexion through each tunnel into its native anatomical position while confirming its adequate tension by viewing arthroscopically. Results: Within 2 years postoperatively, patients are expected to have improved overall knee-specific quality of life, reduced pain, and a successful return to activities. Discussion/Conclusion: This injury underscores the importance of an accurate tibial tunnel placement during ACL reconstruction to avoid posterior meniscal root injuries and other associated complications. Physicians should consider such pathology in the differential diagnosis of patients presenting with persistent pain and instability following a primary ACL reconstruction. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.
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Affiliation(s)
- Amar S. Vadhera
- Division of Sports Medicine, Department of Orthopaedic Surgery, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
- Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA
| | - Steven F. DeFroda
- Division of Sports Medicine, University of Missouri, Columbia, Missouri, USA
| | - Jonathan S. Lee
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Harsh Singh
- Division of Sports Medicine, Department of Orthopaedic Surgery, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
| | - Safa Gursoy
- Department of Orthopaedic Surgery, Faculty of Medicine, Acibadem University, Istanbul, Turkey
| | - Kyle N. Kunze
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York City, New York, USA
| | - Nikhil N. Verma
- Division of Sports Medicine, Department of Orthopaedic Surgery, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
| | - Jorge Chahla
- Division of Sports Medicine, Department of Orthopaedic Surgery, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
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