Comparison of two simple stitches and modified Mason-Allen suture for medial meniscus posterior root tear based on the progression of meniscal posterior extrusion: A retrospective cohort study

Diagnosis and Treatment Strategies of Meniscus Root Tears: A Scoping Review

Background

Meniscus root tears comprise 10% to 21% of all meniscal tears. These tears alter knee biomechanics, elevating contact pressure, akin to a meniscectomy. Consequently, they are linked to advanced joint degeneration and cartilage damage in the affected compartment.

Purpose

To systematically evaluate and relate the current literature describing the diagnosis and treatment strategies for meniscus root tears.

Study Design

Scoping review; Level of evidence, 4.

Methods

This review was conducted following the guidelines of the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) extension for scoping reviews. Inclusion criteria encompassed English-language clinical and preclinical research, technical notes, and narrative reviews on meniscus root tears. Exclusion criteria were studies on patellar tendon rupture, studies on medial patellofemoral ligament rupture with additional knee joint ligament injuries, studies of patients <16 years old, and studies involving open fractures. The data were summarized using a descriptive analysis and a thematic analysis.

Results

After 1425 articles were identified, 461 studies were included; 17% (n = 78) were case reports or case series, 15% (n = 71) were technical notes, 9% (n = 41) addressed aspects of diagnosis, 7% (n = 32 ) were narrative reviews, and 5% (n = 21) were systematic reviews or meta-analyses. Studies presenting original data comprised 57% (n = 262) of all included studies, and 97% of the studies were of evidence levels 3 to 5. Contributions were mainly from the United States (n = 123; 27%), Republic of Korea (n = 102; 22%), and Japan (n = 99; 21%). Many studies (n = 216; 47%) focused on the treatment and outcomes of meniscus root tears. A significant chronological surge in the quantity of studies addressing the diagnosis and treatment of meniscus root tears was evident, particularly over the past 3 years. Consensus was found regarding the definition of meniscus root tears, the advantages of early repair, and postoperative rehabilitation protocols. The variations in surgical techniques and operative strategies created the greatest amount of contention, along with clinical assessment and imaging modalities.

Conclusion

High-level evidence studies for diagnosing and managing meniscus root tears were scarce. A consensus has yet to be reached regarding the role of concomitant osteotomy, comparison of repair techniques, the use of a centralization stitch, patient factors affecting outcomes, and long-term outcomes of nonoperative management.

High Tibial Osteotomy With Medial Meniscal Posterior Root Tear Reconstruction Yields Improved Radiographic and Functional Outcomes and Healing Rates Compared With Osteotomy Alone

PURPOSE

To compare preoperative and postoperative clinical and radiologic outcomes between patients undergoing high tibial osteotomy (HTO) with medial meniscal posterior root tear (MMPRT) reconstruction using gracilis tendon graft and those undergoing HTO without MMPRT reconstruction.

METHODS

Patients with MMPRTs who underwent HTO between January 2018 and December 2021 with minimum 2-year follow-up were included. All patients were divided into 2 groups based on whether they underwent meniscal root reconstruction with tendon graft: HTO alone (33 cases) and HTO with MMPRT reconstruction (21 cases). Clinical evaluation included the Lysholm score, International Knee Documentation Committee (IKDC) score, and visual analog scale (VAS) score. Functional recovery and radiologic outcomes of the knees were evaluated at the latest follow-up. Meniscal root healing rates and medial meniscal extrusion according to a second magnetic resonance imaging reading were compared between the 2 groups at the latest follow-up.

RESULTS

The results showed statistically significant improvements in the postoperative Lysholm score, IKDC score, and VAS score in both groups at the latest follow-up (P < .001). Analysis of the minimal clinically important difference for postoperative outcomes revealed that the percentage of patients who reached the minimal clinically important difference threshold was 100% for the Lysholm score, 100% for the IKDC score, and 100% for the VAS score in the HTO-MMPRT reconstruction group. In comparison, the percentages were 87.9% for the Lysholm score, 90.9% for the IKDC score, and 100% for the VAS score in the HTO-alone group. Additionally, compared with the HTO-alone group, the HTO-MMPRT reconstruction group using gracilis tendon graft showed significantly improved meniscal root healing rates (complete healing, 85.7% vs 45.4% [95% confidence interval, 0.003-0.007]; P = .001) and functional recovery (P < .005) at the final follow-up. Additionally, the HTO-MMPRT reconstruction group showed significantly more improvement in the Kellgren-Lawrence grade (10 of 21 knees vs 6 of 33 knees with improved Kellgren-Lawrence grade, P = .033) and medial meniscal extrusion (2.1 ± 1.0 mm vs 3.1 ± 1.6 mm [95% confidence interval, 0.3-1.7 mm]; P = .007) compared with the HTO-alone group.

CONCLUSIONS

HTO with reconstruction of the meniscal root using a tendon graft resulted in improved radiographic and patient-reported outcomes, as well as improved healing rates, compared with HTO alone.

LEVEL OF EVIDENCE

Level III, retrospective case-series comparison.

Modified Mason-Allen vs Two Simple Stitch Fixation for Medial Meniscus Posterior Root Tears: A Systematic Review and Meta-analysis

BACKGROUND

Various suture configurations are available for medial meniscus posterior root tear (MMPRT) repair. The modified Mason-Allen (MMA) technique has been proposed as a refixation technique for MMPRT instead of the conventional 2 simple stitches (TSS). This is in view of its superior biomechanical characteristics.

PURPOSE

To perform a systematic review and meta-analysis to compare MMA and TSS configuration techniques for MMPRT repair and identify any differences between the 2 techniques in terms of clinical outcomes, medial meniscal extrusion (MME), and postoperative healing.

STUDY DESIGN

Meta-analysis; Level of evidence, 4.

METHODS

The Cochrane Controlled Register of Trials, PubMed, Medline, and Embase databases were used to perform a systematic review and meta-analysis using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria with the following search terms: ("meniscus" OR "meniscal injuries") AND ("Mason-Allen" OR "simple stitch" OR "suture techniques"). Data pertaining to all patient-reported outcome measures, postoperative complications, MME, postoperative healing, cartilage degeneration, and progression of knee osteoarthritis were extracted from each study. The pooled outcome data were analyzed using random- and fixed-effects models.

RESULTS

After abstract and full-text screening, 6 clinical studies were included. In total, there were 291 patients; 160 underwent MMA fixation, and 131 underwent the TSS technique. The majority of studies had similar surgical techniques regarding repair technique, suture material, tibial fixation, and number and position of tibial tunnels. There were no differences between the groups in terms of patient-reported outcome measures at 14.2 months. Both techniques were also similar in the degree of postoperative MME and meniscal healing.

CONCLUSION

Both suture configurations were equivalent in terms of clinical outcomes, the extent of meniscal extrusion, and postoperative healing. The TSS technique may offer advantages in terms of faster learning curve and shorter operative time. However, randomized controlled trials with large sample sizes, longer follow-up and assessment of chondral degeneration, and presence of knee osteoarthritis are required to assess whether a true difference exists, as the majority of included studies were limited by their retrospective design.

Risk factors of incomplete healing following medial meniscus posterior root tear repair with gracilis tendon

To evaluate the clinical efficacy and meniscus healing rates of the arthroscopically assisted tendon graft fixation of the medial meniscus posterior root tears (MMPRTs), and to identify some independent risk factors correlated with meniscal root healing status. We conducted a retrospective study with 129 patients who received arthroscopically assisted tendon graft fixation of the MMPRTs between January 2018 and September 2021. Functional recovery of the knee was evaluated and meniscal root healing status was assessed. The associations between different clinical factors and meniscal root healing status were analyzed. 98 (76.0%) patients had complete meniscal root healing with a minimum 2-year follow-up, and the Lysholm score, international knee documentation committee score, and visual analogue scale score were significantly improved at final follow-up (P < 0.001; respectively). Binary logistic regression models analysis and the receiver operating characteristic curve was performed to detect independent risk factors for incomplete healing, and these results indicated that age (OR = 1.095, P = 0.039), body mass index (BMI) (OR = 1.259, P = 0.018), preoperative meniscus extrusion (OR = 5.181, P < 0.001) and varus degree (OR = 7.764, P < 0.001) were the independent risk factors correlated with incomplete healing in patients with repaired MMPRTs. In conclusion, the arthroscopically assisted tendon graft fixation of the MMPRTs can provide good clinical and radiological outcome. Additionally, we identified age > 37.5 years, BMI > 24.5 kg/m2, preoperative meniscus extrusion > 2.7 mm and varus degree > 3.3° as independent risk factors correlated with incomplete meniscus root healing status.

Repair of medial meniscus posterior root tear is effective for root healing and cartilage regeneration in opening wedge high tibial osteotomy

PURPOSE

This study aimed to determine whether the repair of a medial meniscus posterior root tear (MMPRT) is effective for MMPRT healing, cartilage regeneration, and clinical outcomes in opening wedge high tibial osteotomy (OWHTO).

METHODS

This retrospective study included 80 patients who underwent OWHTO and subsequent second-look arthroscopy. The patients were divided into OWHTO-with-MMPRT-repair (n = 40) and OWHTO alone (n = 40) groups, and the healing rates (complete/partial/failure) were compared. Each group was further divided into over- and under-corrected subgroups to compare healing rates. The International Cartilage Repair Society (ICRS) grade, cartilage defect size, Koshino stage, ICRS cartilage repair assessment score of the medial femoral condyle (MFC), and International Knee Documentation Committee (IKDC) scores between the OWHTO-with-MMPRT-repair and OWHTO alone groups were compared according to whether microfracture was performed on the MFC.

RESULTS

The overall healing rate of the MMPRT was higher in the OWHTO-with-MMPRT-repair group than that in the OWHTO alone group (P < 0.001). In addition, in the subgroup analysis, no difference in the MMPRT healing rate between the over-correction and under-correction groups when MMPRT repair was performed (n.s). In contrast, without MMPRT repair, the healing rate was lower in the under-correction group than that in the over-correction group (P = 0.03). Cartilage regeneration of the OWHTO-with-MMPRT-repair group was superior to that of the OWHTO alone group (P < 0.05). The IKDC subjective scores of the OWHTO-with-MMPRT-repair and OWHTO alone groups were 34.5 and 33.1 before surgery (n.s) and 50 and 47.2 at one year after surgery, respectively (n.s). These differences between the two groups for cartilage regeneration and IKDC subjective scores showed the same pattern regardless of microfractures.

CONCLUSIONS

MMPRT repair during OWHTO might improve MMPRT healing, even with under-correction, and cartilage regeneration of MFC, regardless of microfracture. However, OWHTO with MMPRT repair might not improve short-term clinical outcomes compared to OWHTO alone. Further randomized clinical trials are necessary.

LEVEL OF EVIDENCE

III, Retrospective cohort study.

Meniscal Extrusion Measurements After Posterior Medial Meniscus Root Tears: A Systematic Review and Meta-analysis

BACKGROUND

Meniscal extrusion has become increasingly utilized when evaluating meniscus root abnormalities. However, no consensus definition or approach exists on how to measure extrusion.

PURPOSE/HYPOTHESIS

The purpose of this study was to evaluate the extent of heterogeneity in meniscal extrusion measurement techniques and reported extrusion values in knees with posterior medial meniscus root tears (PMMRTs). We hypothesized that meniscal extrusion measurement techniques would vary considerably throughout reported studies, with resultant wide-ranging published extrusion values.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. The inclusion criteria consisted of all clinical and cadaveric studies reporting on meniscal extrusion after PMMRTs, excluding studies lacking data in full extension, those presenting only semiquantitative analyses, articles reporting only differences in meniscal extrusion, and review articles.

RESULTS

A total of 45 studies were included. Imaging modality types included magnetic resonance imaging (89%), 3-dimensional reconstruction with computed tomography (7%), linear displacement transducers (2%), and a combination of magnetic resonance imaging and ultrasound (2%). The 3 most commonly used landmarks to acquire coronal images for meniscal extrusion measurements were the medial collateral ligament (38%), the midpoint of the anterior-posterior length of the medial meniscus (23%), and the middle of the medial femoral condyle (19%). The pooled mean extrusion values according to the measurement location were 3.5 ± 0.7 mm, 3.9 ± 0.8 mm, and 4.5 ± 2.1 mm, respectively, with no significant differences noted between the modality types (P = .23). The pooled mean meniscal extrusion from all included studies was 3.2 ± 2.0 mm.

CONCLUSION

Substantial variation exists in measurement techniques for meniscal extrusion, particularly as it relates to the coronal cross-sectional reference location. Further studies should aim to provide clear descriptions of the measurement method and have uniform measurement methodology to allow comparisons and pooling between studies.

Younger patients, lower BMI, complete meniscus root healing, lower HKA degree and shorter preoperative symptom duration were the independent risk factors correlated with the good correction of MME in patients with repaired MMPRTs

PURPOSE

To evaluate the clinical and radiological outcomes of arthroscopically assisted tendon graft anatomic reinforced reconstruction of the medial meniscus posterior root tears (MMPRTs) and identify relevant factors affecting the correction of medial meniscal extrusion (MME).

METHODS

Fifty-three MMPRTs patients who underwent arthroscopically assisted tendon graft reconstruction of the meniscal root between 2018 and 2020 were evaluated retrospectively. the patients were divided into 2 groups according to the correction of MME (maintained MME group: 32 cases vs. increased MME group: 21 cases). The clinical and radiological outcomes of arthroscopically assisted tendon graft reconstruction of the meniscal root, including postoperative correction of MME and functional recovery of the knee were assessed in this study, and potential independent risk factors that could influence the correction of MME were also evaluated.

RESULTS

The functional recovery of the knee was significantly improved at the end of follow-up (P < 0.001; respectively), furthermore, a comparison of the final functional outcomes between the groups showed that the mean Lysholm score and IKDC score of the maintained MME group were significantly improved than those of increased MME group. 60.4% had good correction of MME, and patients with complete healing had better extrusion correction than those with partial healing and non-healing. Binary logistic regression models analysis indicated that the age (OR = 1.053, P = 0.048), BMI (OR = 1.376, P = 0.004), meniscus root healing status (OR = 7.701, P = 0.005), HKA degree (OR = 1.891, P = 0.011) and preoperative symptom duration (OR = 1.055, P = 0.013) were the independent risk factors correlated with correction of MME. Additionally, the ROC curve demonstrated the cut-off values of the Age, BMI, HKA degree and preoperative symptom duration were 46.0 years, 22.5 kg/m2, 3.2° and 9.5 months, respectively, CONCLUSIONS: The arthroscopically assisted tendon graft anatomic reinforced reconstruction of the meniscal root showed clinical improvement and prevented the progression of postoperative MME. Additionally, younger patients, lower BMI, complete meniscus root healing, lower HKA degree and shorter preoperative symptom duration were the independent risk factors correlated with the good correction of MME in patients with repaired MMPRTs.

LEVEL OF EVIDENCE

Level IV.

Medial meniscus posterior root tear reconstructed with gracilis autograft improve healing rate and patient reported outcome measures

BACKGROUND

Many surgeries have not reversed or prevented progressive symptomatic knee arthritis, and there is no consensus regarding the ideal repair or reconstruction technique for meniscal root treatment. Additionally, there is a lack of studies comparing the clinical efficacy evaluation of different repair techniques. The aim of the present study is to compare the clinical efficacy and healing rates of meniscus root in the treatment of medial meniscus posterior root tear (MMPRT) with the arthroscopically assisted meniscus root reconstruction with gracilis autograft and transtibial pull-out technique.

METHODS

Patients with MMPRT (type II) who received treatment of posterior meniscus root attachment point through the tibial tunnel between January 2018 and April 2019 were included in this study. Patients were divided into 2 groups (arthroscopically assisted gracilis autograft reconstruction technique: 29 cases; transtibial pull-out technique group: 35 cases) according to the different treatment methods. The mean follow-up period was 26.9 ± 2.3 months. The demographics, functional recovery of the knee, and meniscus root healing rates (assessed using knee magnetic resonance imaging (MRI) at the final follow-up) were compared between the two groups.

RESULTS

There was a statistically significant improvement in the Lysholm score, international knee documentation committee (IKDC) score, and visual analogue scale (VAS) score (P < 0.001 in both groups). Additionally, compared with the transtibial pull-out repair group, the arthroscopically assisted reconstruction with gracilis autograft showed significant improvement in the meniscus root healing rates, Lysholm score, and IKDC score at the end of follow-up (P < 0.05).

CONCLUSIONS

Compared with the transtibial pull-out technique, the arthroscopically assisted meniscus root reconstruction with gracilis autograft was advantageous for treating these patients with superior clinical outcome and higher meniscus root healing rates.

LEVEL OF EVIDENCE

Level III.

Increased cleft width during knee flexion is useful for the diagnosis of medial meniscus posterior root tears

PURPOSE

This study aimed to evaluate changes in the cleft width, defined as the distance between the lateral edge of the medial tibial plateau and that of the medial meniscus (MM) posterior root, using open magnetic resonance imaging (MRI) in patients with MM posterior root tear (MMPRT).

METHODS

This study included 25 patients (20 women and 5 men; mean age: 65.2 years) who were diagnosed with MMPRT and underwent pullout repair. Upon coronal imaging, the cleft width was evaluated at the 10° and 90° flexed knee positions. The difference in the cleft width (defined as the cleft width at 90° minus the cleft width at 10°) was also calculated. Upon sagittal imaging, the MM posterior extrusion (MMPE) at 90° was also evaluated. Separate univariate linear regression models were used to determine the association between the time from injury to MRI and radiographic measurements.

RESULTS

The mean cleft width at 10° and 90° was 4.9 ± 2.6 mm and 7.4 ± 3.7 mm, respectively; the mean difference in cleft width was 2.5 ± 1.5 mm, and the mean MMPE at 90° was 3.7 ± 1.3 mm. There was a significant difference in cleft width at 10° and 90° (p < 0.001). The time from injury to MRI was significantly associated with the cleft width at 10° (R = 0.42; p = 0.023), cleft width at 90° (R = 0.59; p = 0.002), the difference in the cleft width (R = 0.62; p = 0.008), and MMPE at 90° (R = 0.53; p = 0.008).

CONCLUSION

This study demonstrates that the cleft width is significantly larger during knee flexion than during knee extension. Increased cleft width during knee flexion ("graben" sign) may help diagnose MMPRT, especially in cases where the cleft sign is unclear during knee extension.

LEVEL OF EVIDENCE

III.