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Rotini M, Papalia G, Setaro N, Luciani P, Marinelli M, Specchia N, Gigante A. Arthroscopic surgery or exercise therapy for degenerative meniscal lesions: a systematic review of systematic reviews. Musculoskelet Surg 2023; 107:127-141. [PMID: 36057031 PMCID: PMC10192166 DOI: 10.1007/s12306-022-00760-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 07/30/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Arthroscopic partial meniscectomy (APM) is widely applied for the treatment of degenerative meniscal lesions in middle-aged patients; however, such injury is often associated with mild or moderate osteoarthritis and has been reported by MRI in asymptomatic knees. Previous studies suggested, in most patients, a lack of benefit of surgical approach over conservative treatment, yet many controversies remain in clinical practice. Our aims were to assess the functional and pain scores between exercise therapy and arthroscopic surgery for degenerative meniscal lesions and to evaluate the methodological quality of the most recent systematic reviews (SRs). METHODS Two authors independently searched PubMed and Google Scholar for SRs comparing the outcome (in knee pain and functionality) of arthroscopic treatment and exercise therapy or placebo for degenerative meniscal lesions. The timeframe set was from 2009 to 2019 included. RESULTS A total of 13 SRs were selected. Two reviewers independently assessed the methodological quality of each paper using the AMSTAR 2 tool: seven scored as "moderate," four obtained a "low" grade while the remaining two were evaluated as "critically low." SRs agreed that in middle-aged patients with degenerative meniscal lesions arthroscopic surgery appears to grant no long-term improvement in pain and function over exercise therapy or placebo. CONCLUSIONS Conservative treatment based on physical therapy should be the first-line management. However, most SRs revealed subgroups of patients that fail to improve after conservative treatment and find relief when undergoing surgery. In the future, randomized controlled trials, evidence should be looked for that APM can be successful in case of the unsatisfactory results after physical therapy.
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Affiliation(s)
- M Rotini
- Department of Clinical and Molecular Science, School of Medicine, Università Politecnica Delle Marche, Via Tronto, 10/A, 60126, Ancona, Italy
| | - G Papalia
- Department of Clinical and Molecular Science, School of Medicine, Università Politecnica Delle Marche, Via Tronto, 10/A, 60126, Ancona, Italy
| | - N Setaro
- Department of Clinical and Molecular Science, School of Medicine, Università Politecnica Delle Marche, Via Tronto, 10/A, 60126, Ancona, Italy
| | - P Luciani
- Department of Clinical and Molecular Science, School of Medicine, Università Politecnica Delle Marche, Via Tronto, 10/A, 60126, Ancona, Italy
| | - M Marinelli
- Clinic of Adult and Paediatric Orthopaedic, Azienda Ospedaliero-Universitaria, Ospedali Riuniti Di Ancona, Via Tronto 10/ 60126, Ancona, Italy
| | - N Specchia
- Clinic of Adult and Paediatric Orthopaedic, Azienda Ospedaliero-Universitaria, Ospedali Riuniti Di Ancona, Via Tronto 10/ 60126, Ancona, Italy
| | - A Gigante
- Department of Clinical and Molecular Science, School of Medicine, Università Politecnica Delle Marche, Via Tronto, 10/A, 60126, Ancona, Italy.
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Franovic S, Kuhlmann NA, Pietroski A, Schlosser CT, Page B, Okoroha KR, Moutzouros V, Makhni EC. Preoperative Patient-Centric Predictors of Postoperative Outcomes in Patients Undergoing Arthroscopic Meniscectomy. Arthroscopy 2021; 37:964-971. [PMID: 33144235 DOI: 10.1016/j.arthro.2020.10.042] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 10/12/2020] [Accepted: 10/16/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine the minimal clinically important difference (MCID) using Patient-Reported Outcome Measurement Information System (PROMIS) computer-adaptive testing assessments in patients undergoing arthroscopic partial meniscectomy. The secondary purpose was to identify which preoperative patient factors are associated with MCID achievement. METHODS Three PROMIS computer-adaptive testing assessments (Physical Function [PF], Pain Interference [PI], and Depression [D]) were administered to all patients presenting to 1 of 2 board-certified, sports medicine orthopaedic surgeons. Patients with Current Procedural Terminology codes of 29880 or 29881 were chart reviewed for a host clinical and demographic factors. PROMIS scores were assessed for improvement and patient characteristics were assessed for influence on any improvement. MCID was calculated according to the distribution methodology and receiver operating characteristics were used to assess preoperative scores predictive ability. RESULTS In total, 166 patients met inclusion criteria (58 exclusions). Postoperative PROMIS-PF (45.6), PROMIS-PI (54.6), and PROMIS-D (44.1) significantly improved at least 3 months after surgery when compared with baseline (P = .002). MCID values for PROMIS-PF, PROMIS-PI, and PROMIS-D were 3.5, 3.3, and 4.4, respectively. Individuals with PROMIS-PF scores below 34.9 yielded an 82% probability of achieving MCID, while PROMIS-PI scores above 67.5 yielded an 86% probability of achieving MCID and a cutoff of 58.9 for PROMIS-D yielded a 60% probability of achieving MCID, with 90% specificity. CONCLUSIONS PROMIS scores, obtained preoperatively, were shown to be valid predictors of postoperative clinical improvement in patients undergoing meniscectomy. Our findings suggest that patients with physical function scores of 34.9 or less have an increased probability of reaching a minimal clinically important difference. Similarly, patients with pain interference scores of 67.5 and above have increased probability of reaching MCID for pain interference. These cutoffs may be used by physicians to aid in the counseling of patients considering arthroscopic meniscectomy. LEVEL OF EVIDENCE IV, Case Series.
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Affiliation(s)
| | | | | | | | - Brendan Page
- Henry Ford Health System, Detroit, Michigan, U.S.A
| | | | | | - Eric C Makhni
- Henry Ford Health System, Detroit, Michigan, U.S.A..
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McKeon BP, Zaslav KR, Alfred RH, Alley RM, Edelson RH, Gersoff WK, Greenleaf JE, Kaeding CC. Preliminary Results From a US Clinical Trial of a Novel Synthetic Polymer Meniscal Implant. Orthop J Sports Med 2020; 8:2325967120952414. [PMID: 33062765 PMCID: PMC7536377 DOI: 10.1177/2325967120952414] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 04/09/2020] [Indexed: 01/03/2023] Open
Abstract
Background: At least 760,000 outpatient meniscectomies are performed in the United States
each year, making this the most common musculoskeletal procedure. However,
meniscal resection can alter the joint biomechanics and overload the
articular cartilage, which may contribute to degenerative changes and the
need for knee replacement. Avoiding or delaying knee replacement is
particularly important in younger or more active patients. Synthetic
meniscal implants have been developed in an attempt to restore the natural
joint biomechanics, alleviate pain and disability, and potentially minimize
degenerative changes in patients who require meniscectomy. Purpose To evaluate the preliminary results from 2 ongoing trials that are evaluating
the safety and effectiveness of a synthetic polymer meniscal implant
(NUsurface; Active Implants, LLC). Study Design: Cohort study; Level of evidence, 2. Methods: This was a preliminary analysis of the first 100 patients enrolled across 2
studies for 12 months: a single-arm, intervention-only study and a
randomized controlled trial comparing the investigational meniscal implant
with nonsurgical therapy. There were 65 patients in the implant group (30
randomized) and 35 in the control group. Outcomes included Knee injury and
Osteoarthritis Outcome Score (KOOS) and adverse events (AEs) collected at
baseline and follow-up visits of 6 weeks, 6 months, and 12 months. Results: No statistically significant differences were found in baseline
characteristics between the implant and control groups. At 12 months,
follow-up KOOS data were available for 87% of the 100 included patients.
Significantly greater improvements from baseline were observed in the
implant group compared with controls in all KOOS subcomponents, except for
symptoms (119%-177% greater improvement at 12 months). AEs were reported at
similar rates between the 2 groups, with 12 AEs among 11 patients in the
implant group (16.9%) versus 5 AEs among 5 patients (14.3%) in the control
group (P = .99). Conclusion: These preliminary results suggest significant improvements in pain and
function scores with the implant over nonsurgical therapy and a similar
adverse event rate.
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Affiliation(s)
- Brian P McKeon
- Boston Sports & Shoulder Center, Waltham, Massachusetts, USA
| | - Kenneth R Zaslav
- Ortho Virginia, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Richard H Alfred
- The Bone & Joint Center and Albany Medical College, Albany, New York, USA
| | - R Maxwell Alley
- The Bone & Joint Center and Albany Medical College, Albany, New York, USA
| | | | - Wayne K Gersoff
- Advanced Orthopedic and Sports Medicine Specialists, Denver, Colorado, USA
| | | | - Christopher C Kaeding
- Sports Medicine Institute and Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Neumann J, Kern K, Sun D, Foreman SC, Joseph GB, Gersing AS, Nevitt MC, McCulloch CE, Quitzke A, Link TM. Cartilage degeneration post-meniscectomy performed for degenerative disease versus trauma: data from the Osteoarthritis Initiative. Skeletal Radiol 2020; 49:231-240. [PMID: 31289901 PMCID: PMC8172084 DOI: 10.1007/s00256-019-03267-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 06/10/2019] [Accepted: 06/20/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To compare the extent of cartilage deterioration in knees with prior meniscal resection related to trauma versus knees with resection related to degenerative disease, and to compare cartilage deterioration in knees with meniscal surgery to knees without meniscal surgery, controlling for prior knee trauma. MATERIALS AND METHODS In this cross-sectional study, we assessed cartilage deterioration in right knees of Osteoarthritis Initiative participants: (i) with meniscal surgery due to injury (n = 79); (ii) matched control knees with a prior injury but without meniscal surgery (n = 79); (iii) with meniscal surgery but without preceding injury (n = 36); and (iv) matched control knees without meniscal surgery or prior knee injury (n = 36). Cartilage composition was measured using T2 measurements derived using semi-automatic cartilage segmentation of the right. Linear regression analysis was used to compare compartmental values of T2 between groups. RESULTS Comparing the mean T2 values in surgical cases with and without injury our results did not show significant differences (group i vs. iii, p > 0.05). However, knees with previous meniscal surgery showed significantly (p < 0.001) higher mean T2 values across all compartments (i.e., global T2) when compared to those without meniscal surgery for both knees with a history of trauma (group i vs. ii) and knees without prior trauma (group iii vs. iv). Similar results were obtained when analyzing the compartments separately. CONCLUSIONS Cartilage deterioration, assessed by T2, is similar in knees undergoing meniscal surgery after trauma and for degenerative conditions. Both groups demonstrated greater cartilage deterioration than nonsurgical knees, controlling for prior knee injury.
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Affiliation(s)
- Jan Neumann
- Musculoskeletal Quantitative Imaging Research Group, Department of Radiology & Biomedical Imaging, University of California San Francisco, 185 Berry St, Suite 350, San Francisco, CA, 94107, USA.
- Department of Diagnostic and Interventional Radiology, Technical University of Munich, Munich, Germany.
| | - Kai Kern
- Musculoskeletal Quantitative Imaging Research Group, Department of Radiology & Biomedical Imaging, University of California San Francisco, 185 Berry St, Suite 350, San Francisco, CA, 94107, USA
| | - Dong Sun
- Musculoskeletal Quantitative Imaging Research Group, Department of Radiology & Biomedical Imaging, University of California San Francisco, 185 Berry St, Suite 350, San Francisco, CA, 94107, USA
| | - Sarah C Foreman
- Musculoskeletal Quantitative Imaging Research Group, Department of Radiology & Biomedical Imaging, University of California San Francisco, 185 Berry St, Suite 350, San Francisco, CA, 94107, USA
| | - Gabby B Joseph
- Musculoskeletal Quantitative Imaging Research Group, Department of Radiology & Biomedical Imaging, University of California San Francisco, 185 Berry St, Suite 350, San Francisco, CA, 94107, USA
| | - Alexandra S Gersing
- Musculoskeletal Quantitative Imaging Research Group, Department of Radiology & Biomedical Imaging, University of California San Francisco, 185 Berry St, Suite 350, San Francisco, CA, 94107, USA
- Department of Diagnostic and Interventional Radiology, Technical University of Munich, Munich, Germany
| | - Michael C Nevitt
- Department of Epidemiology and Biostatistics, University of California San Francisco, 185 Berry St, Suite 350, San Francisco, CA, 94107, USA
| | - Charles E McCulloch
- Department of Epidemiology and Biostatistics, University of California San Francisco, 185 Berry St, Suite 350, San Francisco, CA, 94107, USA
| | - Azien Quitzke
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas M Link
- Musculoskeletal Quantitative Imaging Research Group, Department of Radiology & Biomedical Imaging, University of California San Francisco, 185 Berry St, Suite 350, San Francisco, CA, 94107, USA
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Sonesson S, Kvist J, Yakob J, Hedevik H, Gauffin H. Knee Arthroscopic Surgery in Middle-Aged Patients With Meniscal Symptoms: A 5-Year Follow-up of a Prospective, Randomized Study. Orthop J Sports Med 2020; 8:2325967119893920. [PMID: 32047825 PMCID: PMC6985975 DOI: 10.1177/2325967119893920] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 11/11/2020] [Indexed: 12/11/2022] Open
Abstract
Background: Arthroscopic meniscal surgery is a common orthopaedic procedure in middle-aged patients, but the efficacy of this procedure has been questioned. In this study, we followed up the only randomized controlled trial that has shown a 1-year benefit from knee arthroscopic surgery with an exercise program compared with an exercise program alone. Purpose: To (1) evaluate whether knee arthroscopic surgery combined with an exercise program provided an additional 5-year benefit compared with an exercise program alone in middle-aged patients with meniscal symptoms, (2) determine whether baseline mechanical symptoms affected the outcome, and (3) compare radiographic changes between treatment groups. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: Of 179 eligible patients aged 45 to 64 years, 150 were randomized to either a 3-month exercise program (nonsurgery group) or to the same exercise program plus knee arthroscopic surgery (surgery group) within 4 weeks. Radiographs were assessed, according to the Kellgren-Lawrence grade, at baseline and at the 5-year follow-up. The primary outcome was the change in Knee injury and Osteoarthritis Outcome Score (KOOS)–Pain (KOOSPAIN) subscore from baseline to the 5-year follow-up. We performed an as-treated analysis. Results: A total of 102 patients completed the 5-year questionnaire. At the 5-year follow-up, both groups had significant improvement in KOOSPAIN subscores, although there was no significant change from the 3-year scores. There was no between-group difference in the change in the KOOSPAIN subscore from baseline to 5 years (3.2 points [95% CI, –6.1 to 12.4]; adjusted P = .403). In the surgery group, improvement was greater in patients without mechanical symptoms than in those with mechanical symptoms (mean difference, 18.4 points [95% CI, 8.7 to 28.1]; P < .001). Radiographic deterioration occurred in 60% of patients in the surgery group and 37% of those in the nonsurgery group (P = .060). Conclusion: Knee arthroscopic surgery combined with an exercise program provided no additional long-term benefit after 5 years compared with the exercise program alone in middle-aged patients with meniscal symptoms. Surgical outcomes were better in patients without mechanical symptoms than in patients with mechanical symptoms during the preoperative period. Radiographic changes did not differ between treatment groups. Registration: NCT01288768 (ClinicalTrials.gov identifier).
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Affiliation(s)
- Sofi Sonesson
- Unit of Physiotherapy, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Joanna Kvist
- Unit of Physiotherapy, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.,Division of Physiotherapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Solna, Sweden
| | - Jafar Yakob
- Division of Radiological Sciences, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Henrik Hedevik
- Unit of Physiotherapy, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Håkan Gauffin
- Division of Surgery, Orthopedics and Oncology, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
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Stahel PF, Wang P, Hutfless S, McCarty E, Mehler PS, Osgood GM, Makary MA. Surgeon Practice Patterns of Arthroscopic Partial Meniscectomy for Degenerative Disease in the United States: A Measure of Low-Value Care. JAMA Surg 2019; 153:494-496. [PMID: 29490362 DOI: 10.1001/jamasurg.2017.6235] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Philip F Stahel
- Department of Orthopaedics, Rocky Vista University, College of Osteopathic Medicine, Parker, Colorado.,Department of Orthopaedics, University of Colorado School of Medicine, Aurora
| | - Peiqi Wang
- Gastrointestinal Epidemiology Research Center, Division of Gastroenterology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Susan Hutfless
- Gastrointestinal Epidemiology Research Center, Division of Gastroenterology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Eric McCarty
- Department of Orthopaedics, University of Colorado School of Medicine, Aurora
| | - Philip S Mehler
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Greg Michael Osgood
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Martin A Makary
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland.,Department of Health Policy & Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Second-Order Peer Reviews of Clinically Relevant Articles for the Physiatrist: Early Surgery or Physical Therapy for Nonobstructive Meniscal Tears. Am J Phys Med Rehabil 2019; 99:e50-e52. [PMID: 31335346 DOI: 10.1097/phm.0000000000001270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Application of Native Plasma to the Treatment of Knee Joint Injury. Fam Med 2018. [DOI: 10.30841/2307-5112.6.2018.170464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Tibiofemoral Contact Mechanics With Horizontal Cleavage Tears and Treatment of the Lateral Meniscus in the Human Knee: An In Vitro Cadaver Study. Clin Orthop Relat Res 2018; 476:2262-2270. [PMID: 30188343 PMCID: PMC6259975 DOI: 10.1097/corr.0000000000000464] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Partial meniscectomy is one of the most commonly performed orthopaedic procedures for a meniscus tear. Decreased contact area and increased contact pressure have been seen in partial meniscectomies from treatment of various types of meniscal tears; however, the biomechanical effect of a horizontal cleavage tear in the lateral meniscus and subsequent treatment are unknown. QUESTIONS/PURPOSES This study asked whether a horizontal cleavage tear of the lateral meniscus, resecting the inferior leaf, and further resecting the superior leaf would (1) decrease contact area and (2) increase peak contact pressure. METHODS Eleven fresh-frozen human cadaveric knees were evaluated under five conditions of intact meniscus, horizontal cleavage tear, inferior leaf resection, and resection of the inferior and superior leaves of the lateral meniscus. Tibiofemoral contact area and pressure were measured at 0° and 60° knee flexion under an 800-N load, normalized to that at the intact condition of the corresponding knee flexion, and compared across the five previously described conditions. RESULTS At 0° knee flexion, normalized contact area with inferior leaf resection (65.4% ± 14.1%) was smaller than that at the intact condition (100% ± 0.0%, p < 0.001); smaller than horizontal cleavage tear (94.1% ± 5.8%, p = 0.001) contact area; and smaller than repaired horizontal tear (92.8% ± 8.2%, p = 0.001) contact area. Normalized contact area with further superior leaf resection (50.5% ± 7.3%) was smaller than that at the intact condition (100% ± 0.0%, p < 0.001); smaller than horizontal cleavage tear (94.1% ± 5.8%, p < 0.001) contact area; and smaller than repaired horizontal tear (92.8% ± 8.2%, p < 0.001) contact area. At 60° flexion, normalized contact area with inferior leaf resection (76.1% ± 14.8%) was smaller than that at the intact condition (100% ± 0.0%, p = 0.004); smaller than horizontal cleavage tear (101.8% ± 7.2%, p = 0.006) contact area; and smaller than repaired horizontal tear (104.0% ± 13.3%, p < 0.001) contact area. Normalized contact area with further superior leaf resection (52.1% ± 16.7%) was smaller than that at the intact condition (100% ± 0.0%, p < 0.001); smaller than horizontal cleavage tear (101.8% ± 7.2%, p < 0.001) contact area; and smaller than repaired horizontal tear (104.0% ± 13.3%, p < 0.001) contact area. At 60° flexion, contact area with both leaf resection (52.1% ± 16.7%) was smaller than that with inferior leaf resection (76.1% ± 14.8%, p = 0.039). At 0° knee flexion, peak pressure increased to 127.0% ± 22.1% with inferior leaf resection (p = 0.026) and to 138.6% ± 24.3% with further superior leaf resection (p = 0.002) compared with that at the intact condition (100% ± 0.0%). At 60° flexion, compared with that at the intact condition (100% ± 0.0%), peak pressure increased to 139% ± 33.6% with inferior leaf resection (p = 0.035) and to 155.5% ± 34.7% (p = 0.004) with further superior leaf resection. CONCLUSIONS Resection of the inferior leaf or both leaves of the lateral meniscus after a horizontal cleavage tear resulted in decreased contact area and increased peak contact pressure at 0° and 60° knee flexion. CLINICAL RELEVANCE In vitro resection of one or both leaves of a horizontal cleavage tear of the lateral meniscus causes increases in peak pressure, consistent with other types of partial meniscectomies associated in a clinical setting with excessive loading and damage to knee cartilage. Clinical outcomes in patients undergoing partial leaf meniscectomy could confirm this theory. Avoidance of resection may be relatively beneficial for long-term function. The findings of this in vitro study lend biomechanical support for nonoperative management.
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