Hypermobile lateral meniscus: A systematic review of current treatment options

PURPOSE

The reliable data on the incidence of hypermobile lateral meniscus (HLM) and its clinical manifestations, diagnostic methods and therapeutic approaches are limited. This systematic study aimed to review available treatment options for HLM and the outcomes of each approach.

METHODS

A systematic search was performed in four electronic databases (PubMed, EMBASE, Scopus, Web of Science) to identify studies in which arthroscopically confirmed cases of HLM were treated surgically or nonsurgically, and the required data comprising study characteristics, patient data, treatment approaches and outcome measures were extracted from eligible studies.

RESULTS

Twenty studies with a total of 212 patients (138 males and 74 females) and 219 knees were included. The most frequently reported symptoms were locking sensations, knee pain, giving way and snapping. Treatments used by the studies were: radiofrequency energy in two studies; arthroscopic partial meniscectomy in one study; open surgery in two studies; and arthroscopic meniscal repair in 17 studies. Eleven studies used an all-inside repair method and an inside-out meniscal repair was reported in eight studies. Three studies reported the usage of posterior arthroscopy for therapeutic or diagnostic approaches. Evaluation of symptom resolution was the main outcome measurement for which almost all of the studies stated relief of symptoms after intervention.

CONCLUSION

Despite the lack of definite consensus about the most appropriate intervention for HLM, therapeutic preference was directed towards arthroscopic all-inside and inside-out repair techniques. Although the surgeon's decision remains the key factor in choosing the most suitable treatment option for each individual, posterior arthroscopic meniscal repair may be considered as a better option for HLM treatment according to the findings of this review.

LEVEL OF EVIDENCE

Level IV.

Kinematic Alignment Technique Outperforms Mechanical Alignment in Simultaneous Bilateral Total Knee Arthroplasty: A Randomized Controlled Trial

BACKGROUND

The aim of this study was to compare the clinical results of kinematic alignment (KA) with those of mechanical alignment (MA) in single-stage bilateral total knee arthroplasty.

METHODS

In this double-blinded randomized controlled trial, 65 patients who had bilateral knee osteoarthritis underwent simultaneous bilateral total knee arthroplasty. One knee was randomly selected to be operated on with the calipered-KA technique and the other with MA. The participants were assessed via the Oxford Knee Score, Western Ontario and McMaster Universities Osteoarthritis Index questionnaire, and visual analog scale before the surgery and the same plus the Forgotten Joint Score at their last follow-up visit, 2 years postoperatively. Maximum knee flexion and the time reaching maximum knee flexion, named the recovery time, were also recorded. Hip-knee-ankle angle, medial proximal tibial angle, and lateral distal femoral angle were measured before and after the surgery using 3-joint-view radiographs.

RESULTS

At 2 years, there were significant differences between the KA and MA techniques in terms of duration of surgery, recovery time, and final Western Ontario and McMaster Universities Osteoarthritis Index, Forgotten Joint Score, and maximum flexion range in favor of KA (P < .05), but no significant difference in visual analog scale score or Oxford Knee Score. In patients who have a preferred knee, the KA knee was preferred over the MA knee by most patients. No prosthetic failure or revision was reported in either group.

CONCLUSIONS

The KA technique yields acceptable functional outcomes compared to the MA technique. The KA technique was associated with a shorter surgery time, a faster recovery time, and higher patient satisfaction in 2-year follow-ups. Larger multicenter studies with longer follow-ups are warranted to confirm these findings.

LEVEL OF EVIDENCE

I.

A New Concept of Using Femoral Condyles Surface for Femoral Component Alignment During Total Knee Arthroplasty: A Technical Note

Background

Orthopedic surgeons favor an intramedullary guiding system on the femoral component during total knee arthroplasty (TKA); nevertheless, improper positioning of the entry point affects the final alignment. We have designed a new femoral cutting system for TKA that uses the distal and posterior femoral condyles as reference points for the setting of the cutting system regardless of the femoral canal. This study aims to evaluate the outcomes of this new guiding system.

Methods

We enrolled a series of 75 consecutive knees undergoing TKA. The alpha, gamma, and hip-knee-ankle (HKA) angles were assessed three months postoperatively. Also, surgical time and intraoperative blood loss were recorded for all patients.

Results

Fifteen patients underwent TKA using the mechanical alignment (MA) strategy, and 60 underwent kinematically aligned (KA) TKA. Both groups showed normal coronal and sagittal alignment 3 months postoperatively. The mean intraoperative blood loss was 213.11 ± 52.73 ml, which was not different between the two groups (n.s.). The mean surgical time was 43.12 ± 11.62 min, which was significantly shorter in the KA-TKA (41.11 ± 3.77 min) than in the MA-TKA (49.34 ± 4.56 min) (P < 0.001).

Conclusion

Using the new guiding system with good femoral alignment, we introduced the easily palpable and available condylar surface as a new landmark for cutting the distal femur in TKA.

Level of Evidence

IV.

Is Posterior Cruciate Ligament Needle Pie-Crusting Safe and Effective in Balancing Cruciate-Retained Total Knee Arthroplasty? A Comparative Study

Background

There is still debate over whether to sacrifice the posterior cruciate ligament (PCL) during total knee arthroplasty (TKA). Several studies reported the costs and benefits of each approach regarding technical difficulties in PCL balancing and postoperation complications. In this study, we aimed to evaluate PCL needling as a safe method for balancing the cruciate-retained TKA (CR-TKA).

Methods

In this comparative study, 120 patients underwent CR-TKA and were divided into 2 groups. Fifty-four patients with an acceptable PCL tightness were included in group A, and 66 cases with a tight PCL were included in group B. In group B, needle pie-crusting of the PCL was performed instead of releasing the PCL from its insertions as the standard procedure. The participants' functional outcomes, pain severity, knee range of motion, and PCL laxity were evaluated during multiple follow-ups in 3 years postoperatively.

Results

The participants' age, weight, and body mass index did not differ between the 2 groups. The mean age of the patients was 69 ± 5.9 years. The functional outcomes and range of motion of the patients in the 2 groups significantly improved after the operation compared to the preoperative status, but the postoperative score was not significantly different between groups (P > .05). Clinical examinations were normal in all patients in both groups in all follow-up stages.

Conclusions

PCL balancing is a time-consuming yet essential step for the outcome of CR-TKA and patient satisfaction. PCL needling technique shows promising results and a few complications for PCL balancing in CR-TKA.

Is posterior knee arthroscopy using posterior portals necessary for orthopedic surgeons? The latest evidence on applications and techniques

Various uses of posterior knee arthroscopy have been shown, including all-inside repair of posterior meniscal lesions, posterior cruciate ligament (PCL) reconstruction or PCL avulsion fixation, extensile posterior knee synovectomy for pigmented villonodular synovitis or synovial chondromatosis, posterior capsular release in the setting of knee flexion contractures, and loose bodies removal. Posterior arthroscopy provides direct access to the posterior meniscal borders for adequate abrasion and fibrous tissue removal. This direct view of the knee posterior structures enables the surgeon to create a stronger biomechanical repair using vertical mattress sutures. During PCL reconstruction, posterior arthroscopy gives the surgeon proper double access to the tibial insertion site, which can result in less acute curve angles and the creation of a more anatomic tibial tunnel. Moreover, it gives the best opportunity to preserve the PCL remnant. Arthroscopic PCL avulsion fixation is more time-consuming with a larger cost burden compared to open approaches, but in the case of other concomitant intra-articular injuries, it may lead to a better chance of a return to pre-injury activities. The high learning curve and overcaution of neuromuscular injury have discouraged surgeons from practicing posterior knee arthroscopy using posterior portals. Evidence for using posterior portals by experienced surgeons suggests fewer complications. The evidence suggests toward learning posterior knee arthroscopy, and this technique must be part of the education about arthroscopy. In today's professional sports world, where the quick and complete return of athletes to their professional activities is irreplaceable, the use of posterior knee arthroscopy is necessary.

Long-term clinical results of using a posteromedial all-inside and anteromedial inside-out approach to repair unstable or irreducible bucket-handle medial meniscal tears

BACKGROUND

In irreducible bucket-handle medial meniscal tears (BHMMTs), the displaced central fragment is rotated 180° or more, meaning reduction is impossible without derotation of the tear. In chronic cases, the rotated meniscus is deformed and degenerated; thus, the issue of reproducibility and repairability arises. This study presents the clinical outcomes of chronic irreducible and unstable locked BHMMTs. Radiological outcomes were also evaluated using magnetic resonance imaging (MRI).

METHODS

This is a retrospective study of 37 patients with 11 cases of irreducible BHMMT and 26 cases of reducible but unstable chronic BHMMT who underwent operations between 2011 and 2016. Posterior arthroscopy was performed after temporary meniscus fixation using a provisional needle fixation technique. After the posterior repair with vertical mattress sutures was completed using an all-inside technique, the classic outside-in technique was performed for the anterior third of the meniscus. The Lysholm, International Knee Documentation Committee (IKDC), and Tegner activity scores were obtained from all patients before surgery and at the latest follow-up. Radiological evaluations were performed using MRI before surgery and at 6 months postoperatively.

RESULTS

Between 2011 and 2016, a total of 37 consecutive patients with irreducible and chronic BHMMTs underwent surgery. The average postoperative follow-up was 7.2 ± 1.4 years (mean ± SD). Postoperative Lysholm (89.57 ± 2.7) and IKDC (87.22 ± 3.2) scores improved significantly at the last follow-up when compared with the pre-operative scores (38.44 ± 4.5 and 23.52 ± 7.8, respectively). According to the Tegner activity scale, patients' postoperative activity levels remained unchanged compared to preoperative levels at the last follow-up.

CONCLUSION

Posterior knee arthroscopy with the all-inside posterior suture and inside-out anteromedial suture technique presented in this study yielded excellent clinical outcomes when used to repair chronic irreducible or unstable BHMMTs.

LEVEL OF EVIDENCE

Level IV.

Clinical Outcomes of Fixation of Depressed Posterolateral Tibial Plateau Fractures Using a Direct Lateral Approach

Introduction

Fixation of plateau posterolateral fracture (PLF) is challenging because the fracture site is mostly covered by vital neurovascular structures. We operated on 15 cases of PLF using a direct lateral approach. This study aims to report on clinical results.

Material and methods

Between 2017 and 2019, 15 cases of PLFs were fixed with a direct lateral approach and a tricortical autologous bone graft from the iliac crest. A depression of more than 2 mm was indicated for the surgical treatment. Clinical evaluation included Lysholm score, International Knee Documentation Committee Score (IKDC) score, and Tegner activity scale after two years follow-up.

Results

The last follow-up was at 24 months after the operation. The mean postoperative Tegner activity scale did not change significantly compared to before the injury (6.5 (6-7) vs. 7 (6-8, p = 0.5)). The postoperative IKDC and Lysholm scores improved significantly compared to before the operation (p < 0.001). The full range of motion was seen in all patients except one who was manipulated after three months.

Conclusions

Surgical treatment using a direct lateral approach is a safe procedure for PLFs that results in good, short-term clinical and radiologic outcomes without fibular osteotomy or compromising the important neurovascular structures.

Level of evidence

IV.

Comparison of fine-needle aspiration with fine-needle capillary cytology in thyroid nodules

INTRODUCTION

High false-negative results have been reported for fine-needle aspiration (FNA) cytology in thyroid nodules. Fine-needle capillary (FNC) cytology is an alternative technique that prevents aspiration, reducing tissue damage. This study aimed to compare FNA and FNC in assessing thyroid nodules and in terms of their predictive role in the appropriate diagnosis of malignancy.

METHODS

This is a comparative prospective study conducted on 486 patients. FNA was performed in 235 patients during 2016 and 2017 and FNC in 251 patients during 2018 and 2019. The quality of cytological specimens was compared and then correlated with the final histopathological findings of 39 patients who underwent thyroidectomy.

RESULTS

Both groups were statistically similar regarding age and sex distribution. The FNA technique yielded significantly higher adequate specimens compared with FNC (p<0.001). Abundant blood in the background was found more frequently in the FNA technique (p<0.001). The sensitivity and specificity of FNA for malignancy diagnosis were both 100%, compared with 83.3% and 57.7% for FNC, respectively.

CONCLUSIONS

The two methods, FNA and FNC, did not differ in terms of overall quality. FNA was superior regarding consistency with the histopathological results and the ability to diagnose malignancy.

Prediction of hamstring tendon autograft diameter using preoperative measurements with different cut-offs between genders

PURPOSE

Studies have suggested some predictors for hamstring tendon (HT) autograft diameter based on anthropometric factors and preoperative magnetic resonance imaging (MRI) with variable results. Some authors have attributed the variability to gender differences. This prospective cohort reports the sensitivity and specificity of anthropometric and MRI predictors in males and females separately to determine the difference.

METHODS

Forty-two eligible patients who underwent anterior cruciate ligament reconstruction (ACLR) and MRI in our center were included. ACLR was performed by the senior surgeon using a 4-stranded HT autograft for all patients. A blinded musculoskeletal radiologist measured the cross-sectional area (CSA) of gracilis and semitendinosus tendons using the free-hand region of interest tool for all patients. An orthopaedic resident (PGY4) collected anthropometric factors and measured intraoperative autograft diameter.

RESULTS

Mean intraoperative autograft diameter was 8.0 mm. Females had a significantly lower autograft diameter (7.4 vs. 8.2, P < 0.001), smaller gracilis (6.9 vs. 7.9, P = 0.003) and semitendinosus CSA (11.5 vs. 12.8, P = 0.014) compared to males. ROC curve analysis resulted different cut-off values with high sensitivity and specificity for semitendinosus and combined CSA regarding gender.

CONCLUSION

Based on the results of this study, CSA of either isolated or combined HTs on preoperative axial MRI, height, and weight are the strongest predictors of intraoperative autograft diameter. It is suggested to consider different cut-offs for males and females to have a better clinical guide for surgeons.

LEVEL OF EVIDENCE

Level II.

Evaluation of the Validity and Reliability of a Persian Version of the Forgotten Joint Score in Patients Undergoing Total Hip Arthroplasty

Objectives

The increasing number of total hip arthroplasties (THA) has led to increased patient demands and expectations, making it crucial to assess patients' ability to "forget" their implants in daily life. This study aimed to determine the reliability and validity of a Persian version of the Forgotten Joint Score (P-FJS) in THA patients.

Methods

The questionnaire was translated bidirectionally with the permission of the questionnaire designer. Data were collected from 2018 to 2020 and included 142 patients who had undergone THA by the same surgeon at least one year ago. Participants completed the FJS questionnaire twice within a one-week interval, and the validity, reliability, and feasibility of the questionnaires were assessed using statistical tests on the HHS and OHS forms completed by all participants.

Results

In 142 patients (52.1% male) with a mean age of 65 ± 0.5 years who answered the questionnaires, P-FJS correlated strongly with OHS and HHS. The internal consistency (α = 0.91) and reproducibility of the questionnaire were excellent. None of the floor and ceiling effects were detected.

Conclusion

The P-FJS questionnaire in the THA is considered a legitimate, repeatable, and self-administered survey that can be compared to its English-language counterpart. In addition, it is noteworthy that this version does not show any floor or ceiling effects.

Posterior knee arthroscopy facilitates the safe and effective all-inside repair of locked bucket-handle medial meniscal tear using a suture hook technique

PURPOSE

This study reported the outcomes of locked bucket-handle medial meniscal tear (BHMMT) repairs using an arthroscopic posterior approach during anterior cruciate ligament (ACL) reconstruction.

METHODS

Between 2011 and 2014, 48 patients with BHMMTs and ACL tears who met the eligibility criteria were enrolled in the present study. BHMMTs were assessed using a posterolateral transseptal portal and repaired using a posteromedial portal. Transportal ACL reconstruction was performed using hamstrings autograft. Patients were assessed based on their IKDC and Lysholm scores and Tegner activity level. Meniscal healing was clinically evaluated based on the absence of swelling, joint line tenderness, locking, and catching; McMurray test results; and the need for meniscectomy.

RESULTS

According to follow-up assessments, the average IKDC and Lysholm scores improved significantly after 3-5 years (P < 0.001) CONCLUSION:  Excellent clinical outcomes were obtained when locked BHMMTs were repaired using an all-inside suture technique that employed posteromedial and posterolateral transseptal portals.

LEVEL OF EVIDENCE

IV.

Repair of popliteomeniscal fascicles tear using a posterior transseptal portal fixes hypermobile lateral meniscus

PURPOSE

This study investigates the effects of the all-inside repair of posterosuperior popliteomeniscal fascicle (PMF) on lateral meniscus stabilization using a posterior arthroscopic approach.

METHODS

Between 2015 and 2018, 17 patients with hypermobile lateral meniscus (HLM) underwent posterior knee arthroscopy for PMF repair. The all-inside repair was performed through posteromedial transseptal and posterolateral portals using a suture hook technique. Patients were clinically assessed based on IKDC and Lysholm scores.

RESULTS

Both IKDC and Lysholm scores improved significantly after an average follow-up of 3.5 years (P < 0.001). No patients underwent reoperation, and no complications associated with posterior knee arthroscopy were reported.

CONCLUSION

The all-inside suture hook technique using posterolateral and posteromedial transseptal portals fixes HLM with excellent IKDC and Lysholm scores.

LEVEL OF EVIDENCE

Level IV.

Influence of topical iodine-containing antiseptics used during delivery on recall rate of congenital hypothyroidism screening program

BACKGROUND

The proportion of newborns recalled during neonatal screening programs for congenital hypothyroidism (CH) varies substantially by country and may be higher in settings where povodine iodine (PVP-I) is used during delivery. We assessed this hypothesis by substituting PVP-I for chlorhexidine (CHL) and evaluated the reduction in the recall rate of the Irainian newborn screening program.

METHODS

This study investigated 2282 neonates of mothers admitted to a local hospital for delivery between December 2012 and October 2013. We measured thyorid stimulating hormone (TSH) levels in heel-prick blood specimens of infants, aged between 3 and 5 days, born to mothers who received PVP-I (phase I) and those who received CHL after withdrawal of PVP-I from obstetric procedures (phase II). Then we compared the median TSH levels and the recall rate based on a TSH level ≥5 mU/L.

RESULTS

Of 2282 cases, 1094 infants were born to mothers exposed to PVP-I during phase I (PVP-I group) and 1188 ones were born to mothers exposed to chlorhexidine in phase II (CHL group); 6.56% of the PVP-I group and 1.91% of the CHL group were recalled later during screening (p<0.001). The median TSH level was significantly higher in the PVP-I group compared to the CHL group (1.35 vs. 1.00, p<0.001).

CONCLUSIONS

Replacement of iodine-containing antiseptics by iodine-free ones, during delivery resulted in a significant reduction in the recall rate of the Iranian screening program for CH.