The role of meniscal repair for prevention of early onset of osteoarthritis

Reoperation Rates of Meniscal Repair Is Associated with A Higher Reoperation Rate than Meniscectomy in Patients Aged 40 and Older

PURPOSE

To compare the long-term reoperation-rates of meniscectomy and meniscal repair, and to determine patient and surgical factors associated with earlier reoperation, among patients ≥40 years.

METHODS

A retrospective study was conducted using the IBM MarketScan Commercial Claims and Encounters Database from January 1, 2006 through December 31, 2020. Patients 40 and older who received a meniscectomy or a meniscal repair with a minimum 1 year follow-up were included. The primary outcome was ipsilateral knee reoperation during the study period. Kaplan-Meier survival curves were used to determine differences in reoperation rates for meniscal repair and meniscectomy over time. Multivariable cox regression analysis was performed to identify factors associated with earlier time-to-reoperation.

RESULTS

A total of 3026 patients (2,367 meniscectomy, 659 meniscal repair) were included. Mean follow-up was 14.5 ± 0.29 years (range: 1.0-14.91 years). There were no significant differences in baseline demographic characteristics of follow-up between the two groups. The survival curves of the two procedures significantly differed (P=0.02), and the overall reoperation rate was higher after meniscal repair than meniscectomy (13.5% vs. 10.1%, P=0.01). However, the incidence of subsequent ipsilateral meniscectomy, meniscal repair, and knee arthroplasty procedures did not significantly differ. Multivariable cox regression analysis identified meniscal repair, obesity, concomitant ACL reconstruction, and increasing age as being significant risks for earlier reoperation, and male sex was protective.

CONCLUSION

In a population of patients aged ≥40 with surgically treated meniscal tears and 14.5-year average follow-up, meniscal repair was associated with higher overall reoperation with shorter survival times compared to meniscectomy. However, the indications for the two procedures likely differed. Additionally, obesity, older age, female sex, and concomitant ACLR were risk factors for earlier reoperation.

Does concomitant meniscus repair and meniscectomy show different efficacy in anterior cruciate ligament reconstruction? A systematic review and meta-analysis

Aims

Currently, it is advised to perform meniscal repair instead of meniscectomy in certain cases of primary anterior cruciate ligament reconstruction (ACLR). However, the level of evidence is low. Therefore, this study aimed to compare the effectiveness of meniscectomy and meniscus repair in addition to ACLR.

Methods

The systematic search was conducted in three online databases (EMBASE, MEDLINE, and Cochrane) from inception until October 2021 for the literature on primary ACLR and concomitant meniscal surgery. Eligible studies compared the following outcomes between meniscal repair and meniscectomy groups: the Knee injury and Osteoarthritis Outcome Score (KOOS), Lysholm score, International Knee Documentation Committee (IKDC) score, and KT-arthrometer examinations. Lastly, we calculated pooled mean differences (MDs) with 95 % confidence intervals (CIs) from the change between pre- and post-intervention values.

Results

Of 10,565 studies, 22 met the inclusion criteria, with a follow-up between 6 and 43 months. We found no difference when comparing the KOOS subscale changes-only in the KOOS pain subscale (MD = -1.6; CI: -2.48, -0.72). However, these results were not clinically significant. We analyzed the lateral and media meniscal injuries separately and concluded the same results regarding KOOS changes. We found no significant differences in the Lysholm score change (MD = -2.61; CI: -5.51, 0.29), changes in IKDC score (MD = 1.08; CI: -4.05, 6.21) or the change for the KT-arthrometer side-to-side difference (MD = -0.50; CI: -1.06, 0.06).

Conclusion

Based on our result, we did not find a clinically significant difference between meniscus repair and meniscectomy during primary ACLR regarding patient-reported outcomes in a short-term follow-up.

Translational potential

Our research supports the prompt integration of findings into clinical practice for treating meniscus injuries during ACL reconstruction. We recommend considering both meniscus repair and meniscectomy, as the available data indicate their effectiveness. Further studies are necessary to assess the long-term impacts, particularly on osteoarthritis, and to identify patient subgroups that may benefit most from each technique.

Fibrin clot augmentation of high-risk meniscal repairs may result in clinical healing in up to 90% of cases

OBJECTIVE

While meniscal repair is preferable to meniscectomy, some cases may be at higher risk of failure if repaired. Incorporating fibrin clot (FC) into the repair has been proposed to improve healing rates. The purpose of this study was to determine the failure rates, patient reported outcome measures (PROMs) and complications of FC augmented meniscal repair for cases considered to be at higher risk of failure.

METHODS

A retrospective case series of all patients undergoing FC augmented repair of isolated meniscus tears between January 2016 and September 2021 was undertaken. All cases were thought be at higher risk of failure; they included chronic, radial, complex, horizontal cleavage, and tears not in the red-red zone. Patients were excluded if they had a concomitant anterior cruciate ligament (ACL) reconstruction or if the repair was done through an open incision. The primary outcome was clinical failure defined as further repair or debridement. Secondary outcomes were PROMs and surgical complications. PROMs collected were Lysholm score, Knee injury and Osteoarthritis Outcome Score, Oxford Knee Score and the Tegner score.

RESULTS

Fifty one inside-out meniscal repairs using FC were performed in 50 patients (62% male). The mean age was 34 years (range 14-70). The median time from injury to repair was 122 days (range 4-1565). The medial meniscus was repaired in 63% of cases. Tear types included radial (31%) and complex (39%) and 71% of cases included repair of the white-white zone. 16% of cases were revision meniscal repairs. FC was used in 43% of isolated meniscal repairs during the study period. All patients were followed up to a median of 46 months (range 22-87 months). PROMs at a median of 30 months post-operatively showed statistically significant improvements. Five patients (10%) underwent further surgery for failure after median 21 months. Two patients (4%) reported sensory disturbance around their skin wounds, no other complications were reported. 13% of medial meniscal repairs failed, whereas only 5% of lateral meniscal repairs failed (p ​= ​0.4).

CONCLUSIONS

FC augmented meniscal repair performed for tears considered to be at higher risk of failure may result in acceptably low rates of clinical failure.

LEVEL OF EVIDENCE

Level IV, case series.

Biodegradable Tyramine Functional Gelatin/6 Arms-PLA Inks Compatible with 3D Two Photon-Polymerization Printing and Meniscus Tissue Regeneration

The meniscus regeneration can present major challenges such as mimicking tissue microstructuration or triggering cell regeneration. In the case of lesions that require a personalized approach, photoprinting offers the possibility of designing resolutive biomaterial structures. The photo-cross-linkable ink composition determines the process ease and the final network properties. In this study, we designed a range of hybrid inks composed of gelatin(G) and 6-PLA arms(P) that were photo-cross-linked using tyramine groups. The photo-cross-linking efficiency, mechanical properties, degradation, and biological interactions of inks with different G/P mass ratios were studied. The G50P50 network properties were suitable for meniscus regeneration, with Young's modulus of 6.5 MPa, degradation in 2 months, and good cell proliferation. We then confirmed the potential of these inks to produce high-resolution microstructures by printing well-defined microstructures using two-photon polymerization. These hybrid inks offer new perspectives for biocompatible, degradable, and microstructured tissue engineering scaffold creation.

Corneal aberrations are associated with low-energy meniscus injuries

BACKGROUND

Visual impairment can cause balance problems. Therefore, visual impairment caused by an increase in corneal deviations can lead to sudden and unstable loads in the lower extremities. We aimed to investigate the possible relationship between low-energy meniscal injuries and corneal structural measures.

METHODS

This prospective, observational study included individuals aged between 18-40 years with a normal body-mass index. The study group consisted of 54 patients with grade 2 or 3 meniscus injuries after low-energy activity. The control group consisted of 54 healthy individuals without any complaints in the knee joint. The corneal parameters of all participants were evaluated with a Scheimpflug corneal topography and specular microscopy device. Simulated keratometry (SimK), minimum central corneal thickness (MCCT), cylindrical diopter (ClyD), corneal volume (CVol) spheric aberrations (SphAbb), high-order aberration (HOA), coma values, and endothelial parameters were recorded.

RESULTS

The research and control groups were similar in terms of age, body mass index, and gender distribution. There was no significant difference between the groups in the corneal SimK and CylD, parameters. However, HOA, Coma, SphAbb, and cell variability (Cv) values were significantly higher in the study group, and contrarily MCCT, CVol, and endothelial count (Cd) values were significantly lower.

CONCLUSIONS

Our findings suggest that individuals with relatively lower MCCT values tend to develop meniscal damage after low-energy activity. Hence, the loss of corneal strength in these patients may be a sign of possible weakness in the meniscus. The HOA value above 0.26, the coma value above 0.16, and the SphAbb value above 0.1 may significantly increase the possible meniscus injury.

Does Concomitant Meniscectomy or Meniscus Repair Affect Muscle Strength, Lower Extremity Balance, and Functional Tests after Anterior Cruciate Ligament Reconstruction?

Background/Objective: The effects of concomitant meniscal tears and their associated treatment on strength, lower extremity balance, and functional status after anterior cruciate ligament reconstruction (ACLR) have not been widely investigated. This study aimed to compare the functional outcomes in patients who underwent ACLR with concomitant treatment of the medial meniscus repair versus meniscectomy when returning to unrestricted physical activity. Methods: A total of 85 patients who underwent primary ACLR with combined meniscal repair (MREP; n = 39) or meniscectomy (MRES; n = 46) were assessed. The dataset included the Functional Movement ScreenTM (FMS) outcomes and single-leg balance test (SLBT) with anterior-posterior, medial-lateral, and overall stability indexes. Isokinetic knee extension and flexion strengths were tested at velocities of 60 deg·s-1 and 180 deg·s-1. The peak torque-to-body weight ratio (PT/BW) and limb symmetry index (LSI) were calculated. Results: In the functional assessment, there was no significant inter-group difference in the composite score of the FMS (MREP: 15.08 pts vs. MRES: 15.13 pts; p > 0.05). The SLBT outcomes in inter-group and inter-extremity comparisons were irrelevant (p > 0.05), too. Significant differences emerged in the inter-group comparison of the knee extension strength in the non-operated extremity at both 60 deg·s-1 and 180 deg·s-1 (p = 0.02). Inter-extremity differences were significant in both the MREP and MRES groups for knee extension and flexion at both angular velocities (all p values < 0.05). For knee extension, the LSI values ranged from 82% to 87%, and for flexion, from 77% to 84%, with no significant inter-group differences. Conclusions: Patients undergoing ACLR with concomitant meniscal repair or resection did not exhibit differences in isokinetic muscle strength, lower extremity balance, and functional tests upon returning to activity. However, participants in both groups demonstrated significant differences between the operated and non-operated extremities as far as the knee joint extensor and flexor strengths are concerned. Therefore, rehabilitation protocols should prioritize equalizing inter-extremity strength differences after the ACLR with additional treatment procedures addressing the menisci.

[Complex knee injuries in football : Management from injury to return to competition]

BACKGROUND

Knee joint injuries are a regular and serious injury in football, often resulting in a long period of absence for players and are, therefore, a significant disadvantage for clubs. The various structures of the knee joint, such as ligaments, meniscus or cartilage, are exposed to the risk of injury due to different sport-specific situations in football and require different and specific therapeutic approaches for their adequate healing.

TREATMENT

Both surgical and conservative treatment measures have been well investigated scientifically, especially for knee joint injuries in football, so that a successful and sustainable return to play on field is highly possible. Only in professional football is there a deviation from the usual standard of treatment in special situations in order to meet the demands and goals of professional footballers. In order to do address different subpopulations in football in the various injury types, both in treatment and in the return to play decision and, thus, sustainable secondary prevention, in addition to knowledge of scientific evidence on knee joint injuries, basic experience in the sport in which the patients with knee joint injuries are active is also useful.

Diagnostic impacts on management of soft tissue injuries associated with tibial plateau fractures: A narrative review

INTRODUCTION

Currently there is no consensus on the need for investigating knee ligamentous and meniscal injuries in a patient with a tibial plateau fracture. Consequently, many soft tissue injuries are likely undiagnosed and therefore untreated. The impact this has on long term knee outcomes is not well defined. We aimed to identify the impacts of various diagnostic methods on the management of meniscal injuries associated with tibial plateau fractures and evaluate the clinical outcomes.

MATERIALS AND METHODS

We performed a systematic review using Pubmed, Medline, Embase, CINAHL and Cochrane following Cochrane guidelines. We included studies that operatively managed tibial plateau fractures and soft tissue injuries, which were diagnosed with either preoperative MRI, intra-operative arthroscopy or arthrotomy.

RESULTS

18 articles with 884 people, with a mean age of 46.4 years were included. Soft tissue injuries were detected on MRI (32-73%) and arthroscopy (12-70%), of which the most common were lateral meniscal injuries (7-64% of tibial plateau fractures). When identified by arthroscopy and arthrotomy, these injuries were almost always treated, either by repair or debridement. The clinical outcomes of these patients were poorly reported, with a heterogenous use of patient reported outcome measures, and follow up time points. There were no randomised trials or control groups for comparative analysis, however operative treatment yielded good to excellent outcomes.

CONCLUSION

There is a high incidence of concomitant soft tissue injuries with tibial plateau fractures, particularly lateral meniscal injuries. There are 2 main approaches to meniscal injuries: surgeons who don't investigate, don't treat, whilst surgeons who do investigate often do surgically treat. Although studies that treated these injuries achieved good to excellent results, the currently available evidence doesn't confirm treatment superiority. As there is plausibility for better outcomes, randomised studies are needed to further investigate this clinical question.

A bibliometric and visualized analysis of meniscus suture based on the WOS core collection from 2010 to 2022: A review

Meniscus suture is an important treatment method for meniscus injury and contributes to the preservation of proprioception, restoration of knee biomechanics and alleviation of progressive osteoarthritis. However, there are few visualized analyses concerning the present studies of meniscus suture. This paper aims to evaluate the global trends, highlights and frontiers of meniscus suture. A bibliometric analysis was conducted based on the results of studies related to meniscus suture from web of science core collection. VOSviewer, GraphPad Prism, Microsoft Excel and R-bibliometrix were utilized for the bibliometric analysis of country and institution distribution, chronological distribution, source journals analysis, prolific authors and institutions analysis, keywords analysis, and reference co-citation analysis. A total of 950 publications on meniscus suture from 177 different sources were retrieved over the set time span. These publications were completed by 3177 authors from 1112 institutions in 54 countries. The United States was the most prolific country with 7960 citations and 348 publications (36.63%). Furumatsu Takayuki acted as the most prolific author (51 publications), while Robert F LaPrade with 1398 citations was the most-cited author. And more papers were published in the core journals, including American Journal of Sports Medicine, Arthroscopy-The Journal of Arthroscopic and Related Surgery, Knee Surgery Sports Traumatology Arthroscopy and Arthroscopy Techniques. Furthermore, "meniscus healing," "meniscus root tear" seem to be the emerging research hotspots. Notably, the publication trend concerning the all-inside suture technique has been rising during the past decade. The number of research publications on meniscus suture has been continuously risen since 2010. The authors, publications and institutions from the United States and East Asia were still the mainstays in this field. And the all-inside suture may become the mainstream surgical technique in the future, with meniscus healing and meniscus root tears being research highlights recently.

Machine learning can accurately predict risk factors for all-cause reoperation after ACLR: creating a clinical tool to improve patient counseling and outcomes

PURPOSE

Identifying predictive factors for all-cause reoperation after anterior cruciate ligament reconstruction could inform clinical decision making and improve risk mitigation. The primary purposes of this study are to (1) determine the incidence of all-cause reoperation after anterior cruciate ligament reconstruction, (2) identify predictors of reoperation after anterior cruciate ligament reconstruction using machine learning methodology, and (3) compare the predictive capacity of the machine learning methods to that of traditional logistic regression.

METHODS

A longitudinal geographical database was utilized to identify patients with a diagnosis of new anterior cruciate ligament injury. Eight machine learning models were appraised on their ability to predict all-cause reoperation after anterior cruciate ligament reconstruction. Model performance was evaluated via area under the receiver operating characteristics curve. To explore modeling interpretability and radiomic feature influence on the predictions, we utilized a game-theory-based method through SHapley Additive exPlanations.

RESULTS

A total of 1400 patients underwent anterior cruciate ligament reconstruction with a mean postoperative follow-up of 9 years. Two-hundred and eighteen (16%) patients experienced a reoperation after anterior cruciate ligament reconstruction, of which 6% of these were revision ACL reconstruction. SHapley Additive exPlanations plots identified the following risk factors as predictive for all-cause reoperation: diagnosis of systemic inflammatory disease, distal tear location, concomitant medial collateral ligament repair, higher visual analog scale pain score prior to surgery, hamstring autograft, tibial fixation via radial expansion device, younger age at initial injury, and concomitant meniscal repair. Pertinent negatives, when compared to previous studies, included sex and timing of surgery. XGBoost was the best-performing model (area under the receiver operating characteristics curve of 0.77) and outperformed logistic regression in this regard.

CONCLUSIONS

All-cause reoperation after anterior cruciate ligament reconstruction occurred at a rate of 16%. Machine learning models outperformed traditional statistics and identified diagnosis of systemic inflammatory disease, distal tear location, concomitant medial collateral ligament repair, higher visual analog scale pain score prior to surgery, hamstring autograft, tibial fixation via radial expansion device, younger age at initial injury, and concomitant meniscal repair as predictive risk factors for reoperation. Pertinent negatives, when compared to previous studies, included sex and timing of surgery. These models will allow surgeons to tabulate individualized risk for future reoperation for patients undergoing anterior cruciate ligament reconstruction.

LEVEL OF EVIDENCE

III.

Differences in postoperative knee function based on concomitant treatment of lateral meniscal injury in the setting of primary ACL reconstruction

BACKGROUND

Concomitant lateral meniscal (LM) injuries are common in acute anterior cruciate ligament (ACL) ruptures. However, the effect of addressing these injuries with various treatment methods during primary ACL reconstruction (ACLR) on patient-reported outcomes (PROs) is unknown. Therefore, the purpose of this study was to compare postoperative Knee injury and Osteoarthritis Outcome Score (KOOS) at 2-, 5-, and 10-years after isolated primary ACLR to primary ACLR with various treatment methods to address concomitant LM injury.

METHODS

This study was based on data from the Swedish National Knee Ligament Registry. Patients ≥ 15 years with data on postoperative KOOS who underwent primary ACLR between the years 2005 and 2018 were included in this study. The study population was divided into five groups: 1) Isolated ACLR, 2) ACLR + LM repair, 3) ACLR + LM resection, 4) ACLR + LM injury left in situ, and 5) ACLR + LM repair + LM resection. Patients with concomitant medial meniscal or other surgically treated ligament injuries were excluded.

RESULTS

Of 31,819 included patients, 24% had LM injury. After post hoc comparisons, significantly lower scores were found for the KOOS Symptoms subscale in ACLR + LM repair group compared to isolated ACLR (76.0 vs 78.3, p = 0.0097) and ACLR + LM injury left in situ groups (76.0 vs 78.3, p = 0.041) at 2-year follow-up. However, at 10-year follow-up, no differences were found between ACLR + LM repair and isolated ACLR, but ACLR + LM resection resulted in significantly lower KOOS Symptoms scores compared to isolated ACLR (80.4 vs 82.3, p = 0.041).

CONCLUSION

The results of this study suggest that LM injury during ACLR is associated with lower KOOS scores, particularly in the Symptoms subscale, at short- and long-term follow-up. However, this finding falls below minimal clinical important difference and therefore may not be clinically relevant.

LEVEL OF EVIDENCE

III.

Failure rate, return-to-sports and magnetic resonance imaging after meniscal repair: 119 patients with 7 years mean follow up

BACKGROUND

One of the most important factors to consider in relation to meniscal repair is the high failure rate reported in the existing literature.

AIM

To evaluate failure rates, return to sports (RTS) rate, clinical outcomes and magnetic resonance image (MRI) evaluation after meniscus suture repair for longitudinal tears at a minimum 2-year-follow-up.

METHODS

We conducted a retrospective review of meniscal repairs between January 2004 and December 2018. All patients treated for longitudinal tears associated or not with an anterior cruciate ligament reconstruction (ACL-R) were included. Meniscal ramp lesions, radial and root tears, associated with multiligament injuries, tibial fracture and meniscal allograft transplants were excluded. Surgical details and failure rate, defined as symptomatic patients who underwent a revision surgery, were analyzed. As isolated bucket handle tears (BHTs) were usually associated with higher failure rates, we compared BHTs and not BHTs associated or not with an ACL-R. Since 2014, the inside-out technique using cannulas and suture needles with 2-0 Tycron began to predominate. In addition, the number of stitches per repair was increased. In view of differences in surgical technique, we compared two different cohorts: before and after 2014. We recorded the RTS according to the level achieved and the time to RTS. Lysholm and IKDC scores were recorded. Patients were studied with x-rays and MRI as standard postoperative control.

RESULTS

One hundred and nineteen patients were included with a mean follow up of 7 years (SD: 4.08). Overall failure rate was 20.3% at a mean 20.1 mo. No statistically significant differences were found when comparing failure for medial and lateral meniscal repair (22.7% and 15.3%, P = 0.36), BHTs and not BHTs (26% and 17.6%, P = 0.27), isolated or associated with an ACL-R (22.9% and 18%, P = 0.47), or when comparing only BHTs associated with an ACL-R (23% and 27.7%, P = 0.9) or not. When comparing cohorts before and after 2014, we found a significant decrease in the overall failure rate from 26% to 11% (P < 0.03). Isolated lesions presented a decrease from 28% to 6.6% (P = 0.02), BHTs from 34% to 8% (P = 0.09) and those associated with an ACL-R from 25% to 10% (P = 0.09). Mean RTS time was 6.5 mo in isolated lesions and 8.64 mo when associated with an ACL-R. Overall, 56% of patients returned to the same sport activity level. Mean pre and postoperative Lysholm scores were 64 and 85 (P = 0.02), and IKDC 58 and 70 (P = 0.03). Out of 84 asymptomatic patients evaluated with MRI, 39% were classified as "not healed" and 61% as "healed".

CONCLUSION

Even though the overall failure rate of our series was 20.3%, we found a statistically significant decrease from 26% to 11%, not only for isolated lesions, but also for BHT's and those associated with an ACL-R when comparing our series in two different cohorts, most probably due to improvements in surgical technique.

Long-term Quality of Life in Patients After ACL Reconstruction With Concomitant Meniscal Injury Treatment: Patient-Reported Outcomes at Minimum 10-Year Follow-up

Background

Long-term studies of patients after anterior cruciate ligament (ACL) reconstruction with or without concomitant meniscal tear treatment are limited.

Purposes

To (1) report postoperative outcomes after anatomic ACL reconstruction with a hamstring autograft, (2) investigate how concomitant treatment of meniscal injury could affect these outcomes, and (3) evaluate the association between quality of life and activity levels at a minimum 10-year follow-up.

Study Design

Cohort study; Level of evidence, 3.

Methods

Patients treated with a unilateral, anatomic ACL reconstruction between 2005 and 2011 were investigated. The following patient-reported outcome measures (PROMs) were reported for the overall sample as well as a subsample of patients with meniscal injury: International Knee Documentation Committee Subjective Knee Form (IKDC-SKF), Knee injury and Osteoarthritis Outcome Score (KOOS), Lysholm knee score, Tegner activity scale, 5-level EQ-5D (EQ-5D-5L), and patient satisfaction. Sex, age, body mass index (BMI), and meniscal injury treatment (meniscectomy vs meniscal repair) were examined as patient-specific risk factors regarding long-term activity and quality of life.

Results

Overall, 106 patients, 90 men (85%) and 16 women (15%), were enrolled in the study, with a mean follow-up of 13.2 years. The ACL retear rate was 2.8%. The mean scores were 80.6 ± 16.7 (IKDC-SKF), 87.4 ± 15.0 (KOOS), 90.5 ± 11.5 (Lysholm), 5.6 ± 1.9 (Tegner), and 91.8 ± 14.5 (EQ-5D-5L). The majority (90.6%) of patients considered their knee state satisfactory during follow-up. When compared with patients who underwent meniscal repair, patients who underwent meniscectomy had statistically significantly lower scores on all PROMs except for the Tegner and EQ-5D-5L (P < .05 for all). The mean difference between the 2 groups was ≥7 points on all PROM scores. Patient sex, age, and BMI did not affect PROM scores. There was a statistically significant, strong positive correlation between quality of life and activity.

Conclusion

Patients had few or no symptoms and considered their knee state satisfactory 13.2 years after anatomic ACL reconstruction. Patients with concomitant meniscal tears having undergone meniscal repair had improved PROMs compared with those treated with meniscectomy. Finally, participation in activities of daily living and sports was interrelated with quality of life and was not affected by patient age, sex, or BMI.

Arthroscopic Meniscus Repair Using an All-Inside, All-Suture, Knotless Device

With an increased appreciation of the importance an intact meniscus has on normal knee kinematics and function, more meniscal tears are being treated with a repair rather than partial meniscectomy. There are several techniques for repairing torn meniscal tissue, including the outside-in, inside-out, and all-inside repairs. Each technique comes with its advantages and drawbacks. The inside-out and outside-in techniques allow for greater control of the repair using knots outside the joint capsule; however, they pose a risk for neurovascular injury and require additional incisions. Arthroscopic all-inside repairs have seen increasing popularity, but with current techniques, fixation is achieved either with intra-articular knots or extra-articular implants, leading to variable outcomes and the potential for postoperative complications. This technical note describes the use of SuperBall, an all-inside meniscus repair device that provides an all-arthroscopic approach, no intraarticular knots or implants, and surgeon-guided tensioning of the meniscus repair.

Repair of a meniscus tear within 3 weeks after trauma significantly reduces the likelihood of a recurrent tear compared with later repairs

PURPOSE

To evaluate the potential benefit of meniscus tear repair within 3 weeks after rupture compared with more than 3 weeks after rupture.

METHODS

Ninety-one patients (95 menisci) underwent repair within 3 weeks after meniscus rupture [Group 1] and 15 patients (17 menisci) [Group 2] underwent repair more than 3 weeks after rupture. The posterior part of the ruptured meniscus was repaired with Contour Arrows^®, using a Crossbow as the insertion instrument, whereas the middle third was repaired by inserting PDS 2.0 stitches using a Meniscus Mender^® outside-in device. The patients were followed-up for a mean(SD) 8.9 years (range: 1-12 years).

RESULTS

Of the 91 patients (95 menisci) in Group 1, 88 (96.7%) healed without complications. One meniscus in one patient did not heal after 11 months, requiring resection. Two other menisci in two other patients showed partially healed tears. This part was removed while preserving most of the meniscus (failure rate: 3/91 patients: 3.3%). The other 88 patients recovered without complaints and participated in sports without restraint. Four menisci in four patients experienced a second sports-related incident, resulting in a renewed tear between 12 months and 3 years. These tears were repaired successfully again. Of the 15 patients in Group 2, 12 (80.0%) healed without complications. The ruptured part of the remaining menisci in the other three patients, (20%) was removed, with all patients remaining symptom-free until the end of follow-up. Rates of treatment failure differed significantly in these two groups (3.3% vs 20.0%, p = 0.04).

CONCLUSIONS

The overall failure rate was significantly lower in patients who underwent meniscus repair within 3 weeks than in those who underwent repair at 3 weeks (or more) after the trauma. Thus, early repair of meniscus tears is beneficial, and can prevent failure of meniscus repair surgery.

LEVEL OF EVIDENCE

III.

Meniscal Suture Influence on Driving Ability 6 Weeks after Anterior Cruciate Ligament Reconstruction with Hamstring Autograft

The purpose of this study was to determine if driving ability 6 weeks after anterior cruciate ligament (ACL) reconstruction is affected by the addition of a meniscal suture. It was also hypothesized that no differences in the driving performance would be found between right or left knee surgery subgroups. A total of 82 people participated in this prospective cohort study: 36 healthy controls, 26 patients undergoing isolated ACL (iACL) reconstruction with hamstring autograft, and 20 patients undergoing ACL and meniscal suture (ACL-MS) reconstruction. ACL-MS group followed a weight-bearing and movement restriction protocol during the first 2 postoperative weeks, whereas patients undergoing iACL could start range-of-motion exercises and full weight-bearing ambulation on the first postoperative day. A driving simulator that reproduced real-life driving conditions was used to evaluate driving ability. The software analyzed multiple driving and braking variables. Driving performance in the sixth postoperative week was compared with that of a healthy control group. Subgroup analysis considering additional procedures (iACL, ACL-MS) and the side of the operated knee (right, left) was also performed. No statistically significant differences were found in the demographic characteristics nor in the driving performance (collisions, p = 0.897; sidewalk invasions, p = 0.749; pedestrian impact, p = 0.983) between iACL, ACL-MS, and control groups. No statistically significant differences were found in right-left subgroup analysis. The results of the present study show that patients in their sixth postoperative week after right or left ACL reconstruction showed similar driving performance as compared with a healthy control group, regardless of associating or not a meniscal suture, suggesting it is safe to resume driving 6 weeks after the mentioned surgeries.

Smoking Has No Influence on Outcomes after Repair of the Medial Meniscus in the Hypo and Avascular Zones-A Pilot Study

Complete loss of the meniscus inevitably leads to knee joint degeneration. Smoking is an important factor predicting poor outcome in orthopedics; however, data about its role in meniscus surgery are inconclusive. Smoking could be an important negative factor in isolated meniscus repair. The aim of this paper was to determine the influence of smoking on functional outcomes after isolated all-inside medial meniscus repair. This study included 50 consecutive patients with isolated, traumatic tear of the medial meniscus who underwent knee joint arthroscopy between 2016 and 2019. All-inside arthroscopic repair of the medial meniscus was performed in each case. All patients followed a uniform, postoperative rehabilitation protocol for 8 weeks. The follow-up examination was based on the functional scores at 3 and 6 months postoperatively. According to smoking status there were 17 smokers and 33 non-smokers. The mean number of cigarettes smoked per day was 11, for a mean of 7.4 years, and the mean pack-years index value was 4.9. There was no correlation between smoking years, number of cigarettes smoked per day, pack-years index, and functional outcomes. The arthroscopic inspection of the knee joints revealed cartilage lesions (≤IIº) in eight subjects, suggesting the secondary pathology to the meniscus tear. In this study, we found no evidence of an association between smoking indices and functional outcomes after all-inside repair of chronic medial meniscus tear. The nature of the chronic meniscal tear could be smoking-resistant owing to the poor blood supply to the sites in which these specific lesions occur.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level IV.

STUDY REGISTRATION

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

The meniscal tear outcome (METRO) review: A systematic review summarising the clinical course and outcomes of patients with a meniscal tear

BACKGROUND

Meniscal tears affect 222 per 100,000 of the population and can be managed non-operatively or operatively with an arthroscopic partial meniscectomy (APM), meniscal repair or meniscal transplantation. The purpose of this review is to summarise the outcomes following treatment with a meniscal tear and explore correlations between outcomes.

METHOD

A systematic review was performed of MEDLINE, EMBASE, AMED and the Cochrane Central Register of Controlled Trials to identify prospective studies describing the outcomes of patients with a meniscal tear. Comparisons were made of outcomes between APM and non-operative groups. Outcomes were graphically presented over time for all treatment interventions. Pearson's correlations were calculated between outcome timepoints.

RESULTS

35 studies were included, 28 reported outcomes following APM; four following meniscal repair and three following meniscal transplant. Graphical plots demonstrated a sustained improvement for all treatment interventions. A moderate to very strong correlation was reported between baseline and three-month outcomes. In the medium term, there was small significant difference in outcome between APM and non-operative measures (SMD 0.17; 95 % CI 0.04, 0.29), however, this was not clinically significant.

CONCLUSIONS

Patients with a meniscal tear demonstrated a sustained initial improvement in function scores, which was true of all treatments examined. APM may have little benefit in older people, however, previous trials did not include patients who meet the current indications for surgery as a result the findings should not be generalised to all patients with a meniscal tear. Further trials are required in patients who meet current operative indications.

Current Controversies in Arthroscopic Partial Meniscectomy

PURPOSE OF REVIEW

Given the continued controversy among orthopedic surgeons regarding the indications and benefits of arthroscopic partial meniscectomy (APM), this review summarizes the current literature, indications, and outcomes of partial meniscectomy to treat symptomatic meniscal tears.

RECENT FINDINGS

In patients with symptomatic meniscal tears, the location and tear pattern play a vital role in clinical management. Tears in the central white-white zone are less amenable to repair due to poor vascularity. Patients may be indicated for APM or non-surgical intervention depending on the tear pattern and symptoms. Non-surgical management for meniscal pathology includes non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy (PT), and intraarticular injections to reduce inflammation and relieve symptoms. There have been several landmark multicenter randomized controlled trials (RCTs) studying the outcomes of APM compared to PT or sham surgery in symptomatic degenerative meniscal tears. These most notably include the 2013 Meniscal Tear in Osteoarthritis Research (MeTeOR) Trial, the 2018 ESCAPE trial, and the sham surgery-controlled Finnish Degenerative Meniscal Lesion Study (FIDELITY), which failed to identify substantial benefits of APM over nonoperative treatment or even placebo surgery. Despite an abundance of literature exploring outcomes of APM for degenerative meniscus tears, there is little consensus among surgeons about the drivers of good outcomes following APM. It is often difficult to determine if the presenting symptoms are secondary to the meniscus pathology or the degenerative disease in patients with concomitant OA. A central tenet of managing meniscal pathology is to preserve tissue whenever possible. Most RCTs show that exercise therapy may be non-inferior to APM in degenerative tears if repair is not possible. Given this evidence, patients who fail nonoperative treatment should be counseled regarding the risks of APM before proceeding to surgical management.

Anterior cruciate ligament reconstruction with lateral plasty restores anterior-posterior laxity in the case of concurrent partial medial meniscectomy

PURPOSE

To evaluate the in vivo knee laxity in the presence of a partial medial meniscectomy before and after a single-bundle ACL reconstruction with a lateral plasty (SBLP) and to compare it with the knee laxity after a single-bundle ACL reconstruction (SB).

METHODS

One-hundred and one patients with ACL tear were enrolled in the study and grouped according to the surgical technique and the meniscus treatment: regarding the SBLP technique (n = 55), 31 patients underwent isolated ACL reconstruction ("SBLP Isolated ACL Group"), while 24 patients underwent combined ACL reconstruction and partial medial meniscectomy ("SBLP ACL + MM Group"); regarding the SB technique (n = 46), 33 patients underwent isolated ACL reconstruction ("SB Isolated ACL Group"), while 13 patients underwent combined ACL reconstruction and partial medial meniscectomy ("SB ACL + MM Group"). Anterior-posterior clinical laxity at 30° (AP30) and 90° (AP90) of knee flexion was quantified before and after surgery through a surgical navigation system dedicated to kinematic assessment.

RESULTS

In the ACL-deficient status, the antero-posterior laxity was significantly higher in the presence of a combined MM in both the AP30 and the AP90, with no differences between the two surgical techniques. After the ACL reconstruction, both AP30 and AP90 translations decreased significantly (p < 0.0001) compared to the ACL-deficient status. No differences were found for AP30 and AP90 between SBLP Isolated ACL and SBLP + MM groups, while a significantly higher AP90 translation was found for the SB + MM group compared to the SB Isolated ACL group. Moreover, the AP90 translation in the SB ACL + MM group was significantly higher than the one of the other three groups, i.e., SBLP ACL + MM, SB, and SBLP Isolated ACL group.

CONCLUSION

The ACL reconstruction with lateral plasty reduced the AP knee laxity caused by the medial meniscectomy in the context of an ACL surgery.

LEVEL OF EVIDENCE

Level II.

Radial T2* mapping reveals early meniscal abnormalities in patients with knee osteoarthritis

OBJECTIVE

We aimed to validate a 2D radial T2* mapping method and its ability to reveal subtle alterations in the menisci of patients with knee osteoarthritis (OA).

METHODS

Of 40 enrolled participants, 20 were diagnosed with OA, and 20 were age- and sex-matched asymptomatic controls. Data from the right knee of each participant were collected using a 1.5-T MRI equipped with a single-channel knee coil. T2* values were acquired using a conventional T2* mapping protocol and a radial T2* mapping method. Mean T2* values in the meniscal white zones, meniscal red zones, and total menisci were calculated. Numerical simulation was performed for validation.

RESULTS

Both simulation and clinical data confirmed that 2D radial T2* mapping provided better discrimination than the conventional method. Compared to controls, the OA group showed significantly greater mean (standard deviation) T2* values in the white zones (9.33 [2.29] ms vs. 6.04 [1.05] ms), red zones (9.18 [2.03] ms vs. 6.81 [1.28] ms), and total menisci (9.26 [2.06] ms vs. 6.34 [1.14] ms). Correlations were found between the Lequesne index and the meniscal T2* values in all three regions (r = 0.528, p = 0.017; r = 0.635, p = 0.003; and r = 0.556, p = 0.011, respectively).

CONCLUSION

These findings indicate that in early OA, radial T2* mapping is an alternative means of assessing meniscal degeneration and can be used to monitor its progression.

KEY POINTS

• Radial T2* mapping outperforms Cartesian T2* mapping. • Radial T2* measurements are useful in assessing meniscal degeneration. • Meniscal T2* values correlate well with disease severity.

Nineteen percent of meniscus repairs are being revised and failures frequently occur after the second postoperative year: a systematic review and meta-analysis with a minimum follow-up of 5 years

PURPOSE

Meniscus repair has gained increasing interest over the last two decades as loss of meniscus tissue predisposes to early onset knee arthritis. Although there are many reports of meniscus repair outcome in short-term studies, data on the long-term outcome of meniscus repair are still scarce. The purpose of this meta-analysis was to evaluate the overall failure rate of meniscus repair with a minimum follow-up of 5 years. Additionally, possible factors influencing meniscus repair outcome were assessed.

METHODS

PubMed and Scopus were searched for studies of the last 20 years reporting on meniscus repair outcome with a minimum follow-up of 5 years. The study was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The search terms used for this study were ([meniscus OR meniscal] AND repair). Titles and abstracts were evaluated by two authors independently. Using meta package of R (version 3.6.2), random-effect models were performed to pool failure rates. Subgroup analyses were performed and effect estimates in form of an odds ratio with 95% CIs were established.

RESULTS

In total, 12 studies with 864 patients were included. Degenerative tears were excluded in two studies and one study only included traumatic meniscus tears. Other studies did not state whether the cause of meniscus tear was degenerative or traumatic. Studies reporting meniscus repair outcome on root repairs, revision anterior cruciate ligament reconstruction, discoid menisci or ramp lesions were excluded. Revision surgery was used as failure definition in all included studies. The overall failure rate of meniscal repair at a mean follow-up of 86 months was 19.1%. There was no significant difference in meniscus repair outcome when performed in combination with anterior cruciate ligament reconstruction compared to isolated meniscus repair (18.7% vs. 28%; n.s.) or when performed on the lateral meniscus compared to the medial meniscus (19.5% vs. 24.4%; n.s.). There was no significant difference of meniscus repair outcome between vertical/longitudinal tears and bucket-handle tears (n.s.). Thirty-six percent of meniscus repair failures occur after the second postoperative year. The only significant finding was that inside-out repair results in a lower failure rate compared to all-inside repair (5.6% vs. 22.3%; p = 0.009) at 5 years.

CONCLUSION

The overall meniscus repair failure rate remains nineteen percent in long-term studies. The cause of failure is poorly documented, and it remains unclear whether failure of the meniscus repair itself or additional adjacent tears lead to revision surgery. Despite the given technical advantages of all-inside repair devices, this meta-analysis cannot demonstrate superior outcomes compared to inside-out or outside-in repair at 5 years.

LEVEL OF EVIDENCE

IV.

Meniscal Repair Using Fibrin Clots Made From Bone Marrow Blood Wrapped in a Polyglycolic Acid Sheet

Meniscal repair is one of the most common procedures for meniscal tears; however, a previous systematic review showed meniscal repairs have a greater reoperation rate compared with partial meniscectomies. Therefore, an improvement of existing meniscal repair techniques is warranted. Clinical results of polyglycolic acid (PGA) sheets have been reported for rotator cuff repairs. In recent years, we have performed meniscal repairs using wrapped fibrin clots in PGA sheet. We considered the use of wrapped fibrin clots with a PGA sheet to treat meniscus tears. The purpose of this paper is to introduce a step-by-step guide to our new delivery technique using fibrin clots.

Cardiovascular Drugs and Osteoarthritis: Effects of Targeting Ion Channels

Osteoarthritis (OA) and cardiovascular diseases (CVD) share many similar features, including similar risk factors and molecular mechanisms. A great number of cardiovascular drugs act via different ion channels and change ion balance, thus modulating cell metabolism, osmotic responses, turnover of cartilage extracellular matrix and inflammation. These drugs are consumed by patients with CVD for many years; however, information about their effects on the joint tissues has not been fully clarified. Nevertheless, it is becoming increasingly likely that different cardiovascular drugs may have an impact on articular tissues in OA. Here, we discuss the potential effects of direct and indirect ion channel modulating drugs, including inhibitors of voltage gated calcium and sodium channels, hyperpolarization-activated cyclic nucleotide-gated channels, β-adrenoreceptor inhibitors and angiotensin-aldosterone system affecting drugs. The aim of this review was to summarize the information about activities of cardiovascular drugs on cartilage and subchondral bone and to discuss their possible consequences on the progression of OA, focusing on the modulation of ion channels in chondrocytes and other joint cells, pain control and regulation of inflammation. The implication of cardiovascular drug consumption in aetiopathogenesis of OA should be considered when prescribing ion channel modulators, particularly in long-term therapy protocols.

Meniscus Repair Techniques

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

All-inside repair of bucket handle meniscus tears - Mid-term outcomes with postoperative magnetic resonance imaging

PURPOSE

The purpose of this study was to evaluate our results of bucket handle meniscus tear (BHMT) repairs with an all-inside repair technique using postoperative radiological imaging to evaluate meniscus reduction and healing and use them as criteria for evaluation of repair success.

METHODS

Prospective recruitment of 20 patients with 21 BHMT repairs performed with an all-inside techniqueover a period from 2013 to 2015. All patients had an International Knee Documentation Committee (IKDC) Subjective Knee Form (SKF), Lysholm Score, Knee Injury and Osteoarthritis Outcome Score (KOOS) and Tegner Activity Level Scale obtained pre-operatively and at a minimum of 24 months after surgery. All patients had postoperative knee magnetic resonance imaging (MRI) performed between 18 and 24 months after surgery to assess the stability or failure of their repairs.At 5 years after surgery, the patients were assessed with regard to whether they had undergone repeat surgery or not.

RESULTS

At 2 years, the mean postoperative SKF, Lysholm and KOOS grand scores were 78.9, 88.5 and 86.8, respectively. The mean pre-injury Tegner Activity Scale was 7.6 and postoperatively it was 6.0. There was a significant difference in all pre- and postoperative outcome scores (P < 0.01). The postoperative MRIs showed that 19 of the 21 BHMT repairs had stable reduction of the tear fragment and two patients had displacement of the torn bucket handle fragment. At 5 years, one patient had undergone revision surgery.

CONCLUSION

BHMTs can be repaired with all-inside techniques with good results and successful outcomes.

Association between tears of the posterior root of the medial meniscus and far posterior femoral condyle osteoarthritis

PURPOSE

We aimed to evaluate whether tears of the posterior horn of the medial meniscus root ligament (PHMM RL) are associated with osteoarthritis of the far posterior femoral condyles (FPFC).

METHODS

Retrospective review of 1158 patients who underwent arthroscopy identified 49 patients with confirmed tears of the medial meniscus posterior root ligament attachment. Preoperative magnetic resonance imaging (MRI) studies were reviewed to identify advanced osteoarthritis involving the medial and lateral FPFC. Control patients (n=48) had no meniscal tears confirmed by arthroscopy. Cases and controls were age- and sex-matched exactly 1:1. One case patient was excluded since there was no age- and sex-matched control available. The International Cartilage Research Society (ICRS) MRI cartilage grade was recorded for the medial and lateral FPFC. Associations were evaluated using univariate and multivariable conditional logistic regression analyses.

RESULTS

There were 48 case and 48 control patients (10 men in each group, 20.8%) with median age 53 years (range, 21-67). Medial FPFC ICRS Grade 2 or higher lesions were present in 34 (70.8%) of case patients and 16 (33.3%) of control patients. Lateral FPFC ICRS Grade 2 or higher lesions were present in 24 (50%) of case patients and 14 (28.2%) of control patients. Increased body mass index (BMI) was associated with PHMM RL tears (OR=1.11, 95% CI [1.01, 1.22], P = 0.020). MRI was 81.2% (39/48) sensitive and 91.2% (44/48) specific for detection of PHMM RL tears. PHMM RL tears were associated with Grade 2 or higher medial FPFC osteoarthritis (OR=10.00, 95% CI (2.34, 42.78), P < 0.001). This association remained after adjusting for BMI (OR=11.79, 95% CI [2.46, 56.53], P = 0.002). There was also an association between PHMM RL tears and lateral FPFC osteoarthritis, which persisted after adjusting for BMI (OR =3.00, 95% CI [1.07, 8.37], P = 0.036).

CONCLUSION

PHMM RL tears are associated with advanced osteoarthritis of the FPFC. Radiologists identifying FPFC osteoarthritis should look carefully for PHMM RL tears.

Exosomal transfer of osteoclast-derived miRNAs to chondrocytes contributes to osteoarthritis progression

Osteoarthritis (OA) is a prevalent aging-related joint disease lacking disease-modifying therapies. Here, we identified an upregulation of circulating exosomal osteoclast (OC)-derived microRNAs (OC-miRNAs) during the progression of surgery-induced OA in mice. We found that reducing OC-miRNAs by Cre-mediated excision of the key miRNA-processing enzyme Dicer or blocking the secretion of OC-originated exosomes by short interfering RNA-mediated silencing of Rab27a substantially delayed the progression of surgery-induced OA in mice. Mechanistically, the exosomal transfer of OC-miRNAs to chondrocytes reduced the resistance of cartilage to matrix degeneration, osteochondral angiogenesis and sensory innervation during OA progression by suppressing tissue inhibitor of metalloproteinase-2 (TIMP-2) and TIMP-3. Furthermore, systemic administration of a new OC-targeted exosome inhibitor (OCExoInhib) blunted the progression of surgery-induced OA in mice. We suggest that targeting the exosomal transfer of OC-miRNAs to chondrocytes represents a potential therapeutic avenue to tackle OA progression.

Delayed or neglected meniscus tear repair and meniscectomy in addition to ACL reconstruction have similar clinical outcome

PURPOSE

To compare the clinical outcomes of meniscus repair and meniscus resection with concurrent anterior cruciate ligament (ACL) reconstruction in patients with ACL rupture and neglected or delayed medial meniscus tears.

METHODS

Thirty patients with ACL ruptures and unstable vertical longitudinal medial meniscus tears were included. Patients were divided into two groups. Group I included 15 patients who underwent meniscal repair and Group II included 15 patients who underwent meniscectomy. The knee range of motion, McMurray test, Lachman test, pivot shift test, Lysholm Knee Scoring Scale, International Knee Documentation Committee (IKDC) Questionnaire, Hospital for Special Surgery (HSS) Knee score, and Tegner activity (TA) scale were used to assess all patients.

RESULTS

The median follow-up time was 3.6 (0.5-6.5) years. Median age was 28 (16-36) years. Fourteen patients (93.3%) in Group I and six patients (40%) in Group II returned to their preinjury sport activity level (P = .007). Median maximum knee flexion was 132° (121°-140°) in Group I and 134° (121°-139°) in Group II (n.s.). All patients had full knee extension and negative McMurray test results. Lachman and pivot shift test results were similar between groups. The median IKDC Questionnaire score was 99 (86-100) in Group I and 93 (70-100) in Group II (P = .016). The difference in Lysholm Knee Scoring Scale, HSS knee, and TA scale score between groups were not significant.

CONCLUSION

Clinical outcomes of patients that underwent meniscus repair were better than those that underwent meniscus resection with concurrent ACL reconstruction. The technically complicated and costly meniscus repair may achieve better clinical outcomes than meniscectomy when treating a neglected or delayed meniscal tear with a concurrent ACL tear.

LEVEL OF EVIDENCE

III.

Risk of Subsequent Knee Arthroplasty After Sports Medicine Procedures

INTRODUCTION

Approximately 10% of men and 13% of women older than the age of 60 are affected by symptomatic osteoarthritis of the knee. Anatomic repair or reconstruction after knee injury has been a central tenet of surgical treatment to reduce the risk of osteoarthritis. The purpose of this study was to examine common sports medicine procedures of the knee and determine the proportion of patients who subsequently undergo total knee arthroplasty (TKA).

METHODS

The MarketScan database was queried from the period of January 2007 through December 2016. Patients were identified, who underwent a procedure of the knee, as defined by Current Procedural Terminology codes relating to nonarthroplasty procedures of the knee. Patients in whom laterality could not be confirmed or underwent another ipsilateral knee procedure before TKA were excluded from this study. The primary outcome of this study was the overall rate of TKA after index knee surgery. Time from index procedure to TKA was a secondary outcome. A multivariate regression analysis was used to control for covariates such as age, sex, and comorbidity status.

RESULTS

A total of 843,749 patients underwent one of the 13 common sports medicine procedures of the knee. The procedure with the highest unadjusted rate of subsequent TKA was arthroscopic osteochondral allograft (5.81%), whereas anterior cruciate ligament (ACL) reconstruction with meniscus repair demonstrated the lowest rate of subsequent TKA (0.01%). When adjusting for confounding factors, the regression analysis identified meniscal transplantation (odds ratio [OR] = 3.06, P < 0.0001) as having the highest risk of subsequent TKA, followed by osteochondral autograft (OR = 1.74, P = 0.0424) and arthroscopic osteochondral allograft (OR = 1.49, P < 0.0001). ACL reconstruction with meniscus repair (OR = 0.02, P < 0.0001), ACL reconstruction alone (OR = 0.17, P < 0.0001), ACL with meniscectomy (OR = 0.20, P < 0.0001), and meniscal repair (OR = 0.65, P < 0.0001) had the lowest rate of subsequent TKA. ACL reconstruction with meniscus repair had the longest period from index procedure to TKA at 2827 days.

CONCLUSION

ACL reconstruction and meniscus preservation demonstrated an extremely low rate of conversion to TKA when compared with patients who needed salvage interventions such as meniscus and cartilage transplantation. None of the salvage interventions delayed the need for a TKA. Meniscal transplantation had the highest risk of all procedures of going on to a TKA.

Incidence and risk factors of joint stiffness after Anterior Cruciate Ligament reconstruction

Background

Joint stiffness is a common complication after anterior cruciate ligament (ACL) reconstruction, which seriously affects the efficacy of the operation and patient satisfaction. After ACL reconstruction, the identification of joint stiffness’ risk factors can help its prevention. This meta-analysis was conducted to evaluate joint stiffness’ risk factors and incidence after ACL reconstruction and provide guidance on its prevention.

Methods

PubMed, Embase, and Cochrane Library were searched to obtain relevant studies. The odds ratios (ORs) with 95% confidence intervals (CIs) for all potential risk factors were analyzed using fixed or random-effects meta-analysis in RevMan 5.2.

Results

In total, there were 37 studies and 113,740 patients that were included in this study. After ACL reconstruction, joint stiffness’ incidence negatively correlated with the studies publication time (R = −0.62, P = 0.0094). After ACL reconstruction, the joint stiffness overall pooled incidence was 3% (95% CI, 3-4%). Gender (OR, 0.51; 95% CI, 0.38-0.68; P < 0.00001) was identified as a risk factor. Potential risk factors, such as trauma to surgery time interval, graft type, and concomitant surgery with meniscus injury, have no significant correlation with joint stiffness after ACL reconstruction.

Conclusion

This study indicated that joint stiffness’ incidence after ACL reconstruction is 3% and that gender is a risk factor for joint stiffness after ACL reconstruction.

Mechanical alterations in the avascular region of the meniscus following partial meniscectomy: A cadaveric porcine longitudinal meniscal tear model

BACKGROUND

Although partial meniscectomy is a common treatment for the tears in the avascular region of the meniscus, mechanical alterations following meniscectomy are known to initiate mechanically-induced osteoarthritis. We aimed to measure the articular cartilage contact pressure distributions in the knees with surgically repaired and partially resected menisci in the avascular region.

METHODS

A pneumatic loading device was developed to apply a 1000 N compressive load on the cadaveric porcine knee samples at the flexion angles of 20, 35, 50, and 65°. We simulated longitudinal meniscal tears in the avascular inner 1/3 portion and the well-vascularized middle 1/3 portion of the meniscus. Articular cartilage contact pressures for the knees with intact, torn, repaired, and resected menisci were compared.

FINDINGS

For the tears in well-vascularized regions, meniscal repairs restored articular cartilage contact pressures to the levels in intact joints. However, partial meniscectomy significantly increases the maximum contact pressures and the average contact pressures in highly compressed areas. However, partial meniscectomy in the avascular region did not alter the maximum articular cartilage contact pressures and the average contact pressures in highly compressed areas. Stabilities in knee samples were not significantly altered following partial meniscectomy in both inner and middle regions.

INTERPRETATION

Although repair surgeries are beneficial for the tears in well-vascularized areas because the articular cartilage contact mechanics are reconstructed, partial meniscectomy may be a viable alternative treatment for the tears in avascular regions without introducing significant mechanical alterations.

Early Functional Rehabilitation after Meniscus Surgery: Are Currently Used Orthopedic Rehabilitation Standards Up to Date?

Meniscus therapy is a challenging process. Besides the respective surgical procedure such as partial meniscectomy, meniscus repair, or meniscus replacement, early postoperative rehabilitation is important for meniscus regeneration and return to sport and work as well as long-term outcome. Various recommendations are available. However, the current literature lacks information concerning the actual early rehabilitation in daily routine recommended by orthopedic surgeons. Thus, the purpose of this study was to investigate currently used standard early rehabilitation protocols in the daily routine of orthopedic surgeons. This study investigated the recommendations and concepts for early rehabilitation after meniscus therapy given by German, Austrian, and Swiss orthopedic institutions. Standardized criteria such as weight bearing, range of motion, use of an orthosis, and rehabilitation training were analyzed according to the conducted surgical procedure: partial meniscectomy, meniscus repair, or meniscus replacement. The analysis of standard rehabilitation concepts for partial meniscectomy (n = 15), meniscus repair (n = 54), and meniscus replacement (n = 7) showed significantly earlier functional rehabilitation in all criteria after partial meniscectomy in contrast to meniscus repair techniques (p < 0.001). In addition, significant restrictions were found in full weight bearing, full range of motion, and the use of braces. In summary, a wide range of recommendations for weight bearing, ROM, brace therapy, and mobilization is available, particularly after meniscus repair and meniscus replacement. Most concepts are in accordance with those described in the current literature. Further research is necessary to enhance the scientific evidence on currently used early rehabilitation concepts after meniscus therapy.

Every second retired elite female football player has MRI evidence of knee osteoarthritis before age 50 years: a cross-sectional study of clinical and MRI outcomes

PURPOSE

To assess knee health in retired female football players, using magnetic resonance imaging (MRI) and self-report. The focus of analysis were degenerative changes of the tibiofemoral joint, and their relationship to osteoarthritis symptoms and previous knee injury.

METHODS

Forty-nine retired elite, female football players (98 knees) aged 37 years on average participated. Tibiofemoral cartilage and meniscus status of both knees were evaluated using MRI and graded according to modified Outerbridge and Stoller classifications, respectively. Symptoms were assessed through a standardised questionnaire (Knee Osteoarthritis Outcome Score: KOOS). Knee injury history was recorded via a semi-structured interview. To investigate how injury variables relate to outcomes, binary logistic regression models were used and reported with odds ratios (OR).

RESULTS

Fifty-one per cent of players (n = 25) fulfilled the MRI criterion for knee osteoarthritis, 69.4% (n = 34) had substantial meniscal loss and 59.6% (n = 28) reported substantial clinical symptoms. Chondral- and meniscal loss were associated with significantly lower scores on three of five KOOS subscales (p < .05). Both chondral and meniscal loss were significantly predicted by previous traumatic knee injury (OR = 4.6, OR = 2.6), the injury affecting the non-striking leg (OR = 8.6, OR = 10.6) and type of injury; participants with combined ACL/meniscus injuries had the highest risk for substantial chondral and meniscal loss (OR = 14.8, OR = 9.5). Chondral loss was significantly predicted by isolated meniscus injury treated with partial meniscectomy (OR = 5.4), but not by isolated reconstructed ACL injury. Clinical symptoms were only significantly predicted by previous traumatic knee injury (OR = 5.1).

CONCLUSIONS

Serious degenerative changes were found in a high number of retired female football players' knees 10 years after their career. Meniscal integrity is key for knee osteoarthritis outcomes in young adults, and thus, its preservation should be a priority.

Management of traumatic meniscus tears: the 2019 ESSKA meniscus consensus

PURPOSE

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

METHODS

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

RESULTS

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

DISCUSSION

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

Three-dimensional finite-element analysis of aggravating medial meniscus tears on knee osteoarthritis

BACKGROUND

The biomechanical change during the medial meniscus damage in the process of knee osteoarthritis has not been explored. The purpose of this study was to determine the effect of aggravating medial meniscus degenerative tear on the progress of knee osteoarthritis through the finite-element simulation method.

METHODS

The three-dimensional digital model of a total-knee joint was obtained using a combination of magnetic resonance imaging and computed tomography images. Four types of medial meniscus tears were created to represent the aggravating degenerative meniscus lesions. Meniscectomy of each meniscal tear was also utilized in the simulation. The compression and shear stress of bony tissue, cartilage, and meniscus were evaluated, and meniscus extrusion of the healthy knee, postinjured knee, and postmeniscectomy knee were investigated under the posture of balanced standing.

RESULTS

Based on the results of finite-element simulation, the peak shear principal stress, peak compression principal stress, and meniscus extrusion increased gradually as the meniscus tears' region enlarged progressively (from 7.333 MPa to 15.14 MPa on medial femur and from 6 MPa to 20.94 MPa on medial tibia). The higher stress and larger meniscus extrusion displacement in all tests were observed in the flap and complex tears. The oblique tears also had a biomechanical variation of stress and meniscus extrusion in the knee joint, but their level was milder. Both the peak value of the stress and meniscus displacement increased after the meniscectomy.

CONCLUSION

In contrast to the damaged hemijoint, the stress applied on the healthy lateral hemijoint increased. The change of biomechanics was more obvious with the aggravation of meniscus injury. The advanced degenerative damage resulted in increasing stress that was more likely to cause symptomatic clinical manifestation in the knee joint and accelerate the progress of osteoarthritis. Moreover, we found that the meniscus injury caused higher stress concentration on the contralateral side of the joint. We also discovered that the meniscectomy can lead to more serious biomechanical changes, and although this technique can relieve pain over a period of time, it increased the risk of osteoarthritis (OA) occurrence.

THE TRANSLATIONAL POTENTIAL OF THIS ARTICLE

It is clear that the meniscal lesions can cause osteoarthritic knee, but the biomechanical change during the meniscus damage period has not been explored. We have evaluated the variation of stress during the aggravating medial degenerative meniscus tears and the relationship in the process of knee OA through finite-element simulation. This study does favour to obtain a better understanding on the symptoms and pathological changes of OA. It also may provide some potential directions for the prophylaxis and treatment of OA.

Anterior cruciate ligament reconstruction with concomitant meniscal surgery: a systematic review and meta-analysis of outcomes

PURPOSE

The aim of this review was to compare the clinical outcomes of anterior cruciate ligament reconstruction (ACLR) with either meniscal repair or meniscectomy for concomitant meniscal injury. The primary hypothesis was that short-term clinical outcomes (≤ 2-year follow-up) for ACLR concomitant with either meniscal repair or resection would be similar. The secondary hypothesis was that ACLR with meniscal repair would result in better longer term outcomes compared with meniscal resection.

METHODS

The authors searched two online databases (EMBASE and MEDLINE) from inception until March 2018 for the literature on ACLR and concurrent meniscal surgery. Two reviewers systematically screened studies in duplicate, independently, and based on a priori criteria. Quality assessment was also performed in duplicate. The Knee injury and Osteoarthritis Outcome Score (KOOS) sub-scale scores at 2 years post-operatively were combined in a meta-analysis of proportions using a random-effects model.

RESULTS

Of 2566 initial studies, 25 studies satisfied full-text inclusion criteria. Mean follow-up was 2.09 years, with a total sample of 37,087 subjects including controls. The meta-analysis demonstrated equivocal results at 2 years, except for KOOS symptom scores which favoured meniscal resection over repair. Mean KT-1000 side-to-side difference (SSD) scores were 1.51 ± 0.60 mm for meniscal repair, 1.96 ± 0.36 mm for meniscal resection, and 1.58 ± 0.20 for control patients (isolated ACLR). Medial meniscal repair showed decreased anterior knee joint laxity compared to medial meniscal resection (P < 0.001). Patients with meniscal repair had higher rates of re-operation (13.3% vs 0.8% for meniscal resection, P < 0.001).

CONCLUSION

Patients with ACLR combined with meniscal resection demonstrate better symptoms at 2-year follow-up compared to patients with ACLR combined with meniscal repair. ACLR combined with meniscal repair results in decreased anterior knee joint laxity with evidence of improved patient-reported outcomes in the long term, but also higher re-operation rates.

LEVEL OF EVIDENCE

III.

Biomechanical Stimulus Based Strategies for Meniscus Tissue Engineering and Regeneration

Meniscus injuries are very common in the knee joint. Treating a damaged meniscus continues to be a scientific challenge in sport medicine because of its poor self-healing potential and few clinical therapeutic options. Tissue engineering strategies are very promising solutions for repairing and regenerating a damaged meniscus. Meniscus is exposed to a complex biomechanical microenvironment, and it plays a crucial role in meniscal development, growth, and repairing. Over the past decades, increasing attention has been focused on the use of biomechanical stimulus to enhance biomechanical properties of the engineered meniscus. Further understanding the influence of mechanical stimulation on cell proliferation and differentiation, metabolism, relevant gene expression, and pro/anti-inflammatory responses may be beneficial to enhance meniscal repair and regeneration. On the one hand, this review describes some basic information about meniscus; on the other hand, we sum up the various biomechanical stimulus based strategies applied in meniscus tissue engineering and how these factors affect meniscal regeneration. We hope this review will provide researchers with inspiration on tissue engineering strategies for meniscus regeneration in the future.