The role of meniscal tissue in joint protection in early osteoarthritis

Proteomic profiling of human menisci from mild joint degeneration and end-stage osteoarthritis versus healthy controls

Objective

To gain new insight into the molecular changes of the meniscus by comparing the proteome profiles of healthy controls with mild degeneration and end-stage osteoarthritis (OA).

Method

We obtained tissue plugs from lateral and medial menisci of 37 individuals (central part of the posterior horn) classified as healthy (n ​= ​12), mild signs of joint damage (n ​= ​13) and end-stage OA (n ​= ​12). The protein profile was analysed by nano-liquid chromatography-mass spectrometry using data-independent acquisition and quantified by Spectronaut. Linear-mixed effects modelling was applied to extract the between-group comparisons.

Results

A similar protein profile was observed for the mild group as compared to healthy controls while the most different group was end-stage OA mainly for the medial compartment. When a pattern of gradual change in protein levels from healthy to end-stage OA was required, a 42-proteins panel was identified, suggesting a potential role in OA development. The levels of QSOX1 were lower and G6PD higher in the mild group following the proposed protein abundance pattern. Qualitative protein changes suggest lower levels of CYTL1 as a potential biomarker of early joint degradation.

Conclusion

For future targeted proteomic approaches, we propose a candidate panel of 42 proteins based on gradually altered meniscal posterior horn protein abundance patterns associated with joint degradation.

MRI Criteria for Healing at 1 Year After Repair of a Traumatic Meniscal Tear

BACKGROUND

Meniscal repair for a traumatic meniscal tear is increasingly used to preserve the meniscus. Interpreting postoperative magnetic resonance imaging (MRI) scans remains challenging, especially in symptomatic patients. There is a lack of reliable MRI criteria to affirm the healed character of a traumatic meniscal injury repair.

PURPOSE

To identify relevant MRI criteria for meniscal healing after meniscal repair.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

We prospectively included all patients with a traumatic meniscal injury who underwent either an isolated meniscal repair or a repair during a concomitant anterior cruciate ligament reconstruction. A standardized preoperative and postoperative clinical evaluation was performed, along with collection of functional scores-Knee injury and Osteoarthritis Outcome Score, International Knee Documentation Committee, Lysholm Score, and 36-Item Short Form Health Survey. An MRI scan was performed 1 year postoperatively and compared with the preoperative MRI scan. The following MRI aspects were analyzed: variation of morphology and fat-saturated (FS) T2 intensity signal and pre- and postoperative tear diastasis measurement.

RESULTS

Fifty patients (age, mean ± SD, 28.7 ± 8.5 years [range, 16-45 years]) who were 1 year postoperative were included. All patients were considered clinically healed had the same MRI characteristics. A signal change (FS T2) was observed from a high signal intensity fluid to a nonfluid moderate signal intensity. The morphology of the lesion was more complex: from the initial lesion, line ramifications appeared, creating the appearance of tree branches. The tear diastasis decreased (from 2.3 ± 0.5 mm [range, 1.3-3.5] to 1.1 ± 0.28 mm [range, 0.5-1.5]).

CONCLUSION

MRI criteria confirming meniscal healing after traumatic meniscal repair at 1 year were identified: a change in the intrameniscal signal becoming nonfluid and moderate in intensity; a reduction in tear diastasis to <1.5 mm; and a change in the signal morphology of the repaired meniscus.

Subchondral bone remodeling patterns in larger animal models of meniscal injuries inducing knee osteoarthritis - a systematic review

PURPOSE

Elucidating subchondral bone remodeling in preclinical models of traumatic meniscus injury may address clinically relevant questions about determinants of knee osteoarthritis (OA).

METHODS

Studies on subchondral bone remodeling in larger animal models applying meniscal injuries as standardizing entity were systematically analyzed. Of the identified 5367 papers reporting total or partial meniscectomy, meniscal transection or destabilization, 0.4% (in guinea pigs, rabbits, dogs, minipigs, sheep) remained eligible.

RESULTS

Only early or mid-term time points were available. Larger joint sizes allow reporting higher topographical details. The most frequently reported parameters were BV/TV (61%), BMD (41%), osteophytes (41%) and subchondral bone plate thickness (39%). Subchondral bone plate microstructure is not comprehensively, subarticular spongiosa microstructure is well characterized. The subarticular spongiosa is altered shortly before the subchondral bone plate. These early changes involve degradation of subarticular trabecular elements, reduction of their number, loss of bone volume and reduced mineralization. Soon thereafter, the previously normal subchondral bone plate becomes thicker. Its porosity first increases, then decreases.

CONCLUSION

The specific human topographical pattern of a thinner subchondral bone plate in the region below both menisci is present solely in the larger species (partly in rabbits), but absent in rodents, an important fact to consider when designing animal studies examining subchondral consequences of meniscus damage. Large animal models are capable of providing high topographical detail, suggesting that they may represent suitable study systems reflecting the clinical complexities. For advanced OA, significant gaps of knowledge exist. Future investigations assessing the subchondral bone in a standardized fashion are warranted.

Return-to-sport criteria after isolated meniscus suture: Scoping review of the literature

BACKGROUND

Follow-up care including rehabilitation therapy after isolated meniscal repair remains to be standardized. Thus, no standard criteria are available for the return-to-running (RTR) or return-to-sport (RTS). The objective of this study was to identify criteria for RTR and RTS after isolated meniscal repair, based on a review of the literature.

HYPOTHESIS

Return-to-sport criteria after isolated meniscal repair have been published.

METHODS

We performed a scoping review of the literature using the methodology developed by Arksey and O'Malley. The terms "menisc*" and "repair" and "return-to-sport" or "return to play" or "return to run" or "rehabilitation" were used to search the PubMed database on 1st March 2021. All relevant studies were included. All RTR and RTS criteria were identified, analyzed, and classified.

RESULTS

We included 20 studies. Mean RTR and RTS times were 12.9 and 20 weeks, respectively. Clinical, strength, and performance criteria were identified. The clinical criteria included full range-of-motion recovery with no pain, quadriceps wasting, or joint effusion. Strength criteria were a quadriceps and hamstring deficit, no greater than 30% and 15% for RTR and RTS, respectively, compared to the normal side. Performance criteria were successful completion of proprioception, balance, and neuromuscular tests. RTS rates ranged from 80.4% to 100%.

CONCLUSION

Patients must meet clinical, strength, and performance criteria before resuming running and sports. The level of evidence is low, due to the heterogeneity and generally arbitrary choice of criteria. Further large-scale studies are therefore needed to validate and standardize RTR and RTS criteria.

LEVEL OF EVIDENCE

IV.

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.

Signatures of disease progression in knee osteoarthritis: insights from an integrated multi-scale modeling approach, a proof of concept

Introduction: Knee osteoarthritis (KOA) is characterized by articular cartilage degeneration. It has been widely accepted that the mechanical joint environment plays a significant role in the onset and progression of this disease. In silico models have been used to study the interplay between mechanical loading and cartilage degeneration, hereby relying mainly on two key mechanoregulatory factors indicative of collagen degradation and proteoglycans depletion. These factors are the strain in collagen fibril direction (SFD) and maximum shear strain (MSS) respectively. Methods: In this study, a multi-scale in silico modeling approach was used based on a synergy between musculoskeletal and finite element modeling to evaluate the SFD and MSS. These strains were evaluated during gait based on subject-specific gait analysis data collected at baseline (before a 2-year follow-up) for a healthy and progressive early-stage KOA subject with similar demographics. Results: The results show that both SFD and MSS factors allowed distinguishing between a healthy subject and a KOA subject, showing progression at 2 years follow-up, at the instance of peak contact force as well as during the stance phase of the gait cycle. At the peak of the stance phase, the SFD were found to be more elevated in the KOA patient with the median being 0.82% higher in the lateral and 0.4% higher in the medial compartment of the tibial cartilage compared to the healthy subject. Similarly, for the MSS, the median strains were found to be 3.6% higher in the lateral and 0.7% higher in the medial tibial compartment of the KOA patient compared to the healthy subject. Based on these intersubject SFD and MSS differences, we were additionally able to identify that the tibial compartment of the KOA subject at risk of progression. Conclusion/discussion: We confirmed the mechanoregulatory factors as potential biomarkers to discriminate patients at risk of disease progression. Future studies should evaluate the sensitivity of the mechanoregulatory factors calculated based on this multi-scale modeling workflow in larger patient and control cohorts.

Chondroitinase ABC Treatment Improves the Organization and Mechanics of 3D Bioprinted Meniscal Tissue

The meniscus is a fibrocartilage tissue that is integral to the correct functioning of the knee joint. The tissue possesses a unique collagen fiber architecture that is integral to its biomechanical functionality. In particular, a network of circumferentially aligned collagen fibers function to bear the high tensile forces generated in the tissue during normal daily activities. The limited regenerative capacity of the meniscus has motivated increased interest in meniscus tissue engineering; however, the in vitro generation of structurally organized meniscal grafts with a collagen architecture mimetic of the native meniscus remains a significant challenge. Here we used melt electrowriting (MEW) to produce scaffolds with defined pore architectures to impose physical boundaries upon cell growth and extracellular matrix production. This enabled the bioprinting of anisotropic tissues with collagen fibers preferentially oriented parallel to the long axis of the scaffold pores. Furthermore, temporally removing glycosaminoglycans (sGAGs) during the early stages of in vitro tissue development using chondroitinase ABC (cABC) was found to positively impact collagen network maturation. Specially we found that temporal depletion of sGAGs is associated with an increase in collagen fiber diameter without any detrimental effect on the development of a meniscal tissue phenotype or subsequent extracellular matrix production. Moreover, temporal cABC treatment supported the development of engineered tissues with superior tensile mechanical properties compared to empty MEW scaffolds. These findings demonstrate the benefit of temporal enzymatic treatments when engineering structurally anisotropic tissues using emerging biofabrication technologies such as MEW and inkjet bioprinting.

3D printing of mechanically functional meniscal tissue equivalents using high concentration extracellular matrix inks

Decellularized extracellular matrix (dECM) has emerged as a promising biomaterial in the fields of tissue engineering and regenerative medicine due to its ability to provide specific biochemical and biophysical cues supportive of the regeneration of diverse tissue types. Such biomaterials have also been used to produce tissue-specific inks and bioinks for 3D printing applications. However, a major limitation associated with the use of such dECM materials is their poor mechanical properties, which limits their use in load-bearing applications such as meniscus regeneration. In this study, native porcine menisci were solubilized and decellularized using different methods to produce highly concentrated dECM inks of differing biochemical content and printability. All dECM inks displayed shear thinning and thixotropic properties, with increased viscosity and improved printability observed at higher pH levels, enabling the 3D printing of anatomically defined meniscal implants. With additional crosslinking of the dECM inks following thermal gelation at pH 11, it was possible to fabricate highly elastic meniscal tissue equivalents with compressive mechanical properties similar to the native tissue. These improved mechanical properties at higher pH correlated with the development of a denser network of smaller diameter collagen fibers. These constructs also displayed repeatable loading and unloading curves when subjected to long-term cyclic compression tests. Moreover, the printing of dECM inks at the appropriate pH promoted a preferential alignment of the collagen fibers. Altogether, these findings demonstrate the potential of 3D printing of highly concentrated meniscus dECM inks to produce mechanically functional and biocompatible implants for meniscal tissue regeneration. This approach could be applied to a wide variety of different biological tissues, enabling the 3D printing of tissue mimics with diverse applications from tissue engineering to surgical planning.

Linguistic Analysis Identifies Emergent Biomaterial Fabrication Trends for Orthopaedic Applications

The expanse of publications in tissue engineering (TE) and orthopedic TE (OTE) over the past 20 years presents an opportunity to probe emergent trends in the field to better guide future technologies that can make an impact on musculoskeletal therapies. Leveraging this trove of knowledge, a hierarchical systematic search method and trend analysis using connected network mapping of key terms is developed. Within discrete time intervals, an accelerated publication rate for anatomic orthopedic tissue engineering (AOTE) of osteochondral defects, tendons, menisci, and entheses is identified. Within these growing fields, the top-listed key terms are extracted and stratified into evident categories, such as biomaterials, delivery method, or 3D printing and biofabrication. It is then identified which categories decreased, remained constant, increased, or emerged over time, identifying the specific emergent categories currently driving innovation in orthopedic repair technologies. Together, these data demonstrate a significant convergence of material types and descriptors used across tissue types. From this convergence, design criteria to support future research of anatomic constructs that mimic both the form and function of native tissues are formulated. In summary, this review identifies large-scale trends and predicts new directions in orthopedics that will define future materials and technologies.

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.

Bioprinting of structurally organized meniscal tissue within anisotropic melt electrowritten scaffolds

The meniscus is characterised by an anisotropic collagen fibre network which is integral to its biomechanical functionality. The engineering of structurally organized meniscal grafts that mimic the anisotropy of the native tissue remains a significant challenge. In this study, inkjet bioprinting was used to deposit a cell-laden bioink into additively manufactured scaffolds of differing architectures to engineer fibrocartilage grafts with user defined collagen architectures. Polymeric scaffolds consisting of guiding fibre networks with varying aspect ratios (1:1; 1:4; 1:16) were produced using either fused deposition modelling (FDM) or melt electrowriting (MEW), resulting in scaffolds with different internal architectures and fibre diameters. Scaffold architecture was found to influence the spatial organization of the collagen network laid down by the jetted cells, with higher aspect ratios (1:4 and 1:16) supporting the formation of structurally anisotropic tissues. The MEW scaffolds supported the development of a fibrocartilaginous tissue with compressive mechanical properties similar to that of native meniscus, while the anisotropic tensile properties of these constructs could be tuned by altering the fibre network aspect ratio. This MEW framework was then used to generate scaffolds with spatially distinct fibre patterns, which in turn supported the development of heterogenous tissues consisting of isotropic and anisotropic collagen networks. Such bioprinted tissues could potentially form the basis of new treatment options for damaged and diseased meniscal tissue. STATEMENT OF SIGNIFICANCE: This study describes a multiple tool biofabrication strategy which enables the engineering of spatially organized fibrocartilage tissues. The architecture of MEW scaffolds can be tailored to not only modulate the directionality of the collagen fibres laid down by cells, but also to tune the anisotropic tensile mechanical properties of the resulting constructs, thereby enabling the engineering of biomimetic meniscal-like tissues. Furthermore, the inherent flexibility of MEW enables the development of zonally defined and potentially patient-specific implants.

Incidence and type of meniscal tears in multilligament injured knees

PURPOSE

Meniscal injuries occurring during multi-ligament knee injuries (MLKI) are underreported. The purpose of this study was to compare the incidence and type of meniscal tears seen at the time of multi-ligament reconstruction surgery compared to those occurring during isolated anterior cruciate ligament (ACL) surgery.

METHODS

Patients undergoing surgical treatment for MLKI and ACL-only injuries between 2010 and 2020 were reviewed. Two-hundred and thirty-five patients were included in the MLKI group. There were 131 chronic injuries and 104 acute injuries. Two-hundred and twenty-two ACL-only chronic injuries were used as a control group for comparison with the chronic MLKI group. Demographic data, type of meniscal tears, ligament injury patterns (Schenck classification) and time from injury to surgery were recorded. A delayed procedure was defined by a 4-week interval after the knee injury.

RESULTS

A meniscus was torn in 69 knees (29.4%): 36 knees (15.3%) with an isolated medial meniscus tear, 33 knees (17.9%) with an isolated lateral meniscus tear,.Nine knees (3.8%) had both menisci torn. MLKI with medial or lateral-sided bicruciate ligament injuries (KDIIIM-KDIIIL) were significantly associated with a lower rate of meniscal tears than knee injuries involving the ACL-only and medial/lateral-sided ligament injuries (KDI) (medial-sided injuries p = 0.025; lateral-sided injuries p = 0.049). Lateral-sided injuries had significantly less meniscal damage than medial-sided injuries: 22/124 (17.7%) vs. 41/100 (41%); (p < 0.001). No significant differences were found for frequency, type and distribution of meniscal tears between acute and chronic MLKI surgery. ACL-only chronic injuries were associated with a higher rate of meniscal tears: 123/222 knees (55.4%) vs. 35/131 (26.9%) chronic MLKI; (p < 0.001), mainly involving the medial meniscus: 102/222 (46%) vs. 18/131 (13.7%); (p < 0.001).

CONCLUSIONS

Meniscal tears were less common in the MLKI group than in the isolated ACL injury group. The degree of ligament injury patterns and the side of the injured collateral ligament influenced the type and incidence of meniscal damage. Contrary to isolated ACL injuries, a delayed procedure was not associated with a higher rate of meniscal lesions but did influence the type of treatment. Understanding of meniscal tears patterns in MLKI helps to improve the treatment management of these complex injuries.

The anterior cruciate ligament injury severity scale (ACLISS) is an effective tool to document and categorize the magnitude of associated tissue damage in knees after primary ACL injury and reconstruction

PURPOSE

To develop a tool allowing to classify the magnitude of structural tissue damage occurring in ACL injured knees. The proposed ACL Injury Severity Scale (ACLISS) would provide an easy description and categorization of the wide spectrum of injuries in patients undergoing primary ACL reconstruction, reaching from isolated ACL tears to ACL injuries with a complex association of combined structural damage.

METHODS

A stepwise approach was used to develop the ACLISS. The eligibility of each item was based on a literature search and a consensus between the authors after considering the diagnostic modalities and clinical importance of associated injuries to the menisci, subchondral bone, articular cartilage or collateral ligaments. Then, a retrospective analysis of associated injuries was performed in 100 patients who underwent a primary ACL reconstruction (ACLR) by a single surgeon. This was based on acute preoperative MRI (within 8 weeks after injury) as well as intraoperative arthroscopic findings. Depending on their prevalence, the number of selected items was reduced. Finally, an analysis of the overall scale distribution was performed to classify the patients according to different injury profiles.

RESULTS

A final scoring system of 12 points was developed (12 = highest severity). Six points were attributed to the medial and lateral tibiofemoral compartment respectively. The amount of associated injuries increased with ACLISS grading. The median scale value was 4.5 (lower quartile 3.0; higher quartile 7.0). Based on these quartiles, a score < 4 was considered to be an injury of mild severity (grade I), a score between ≥ 4 and ≤ 7 was defined as moderately severe (grade II) and a score > 7 displayed the most severe cases of ACL injuries (grade III). The knees were graded ACLISS I in 35%, ACLISS II in 49% and ACLISS III in 16% of patients. Overall, damage to the lateral tibiofemoral compartment was predominant (p < 0.01), but a proportional increase of tissue damage could be observed in the medial tibiofemoral compartment with the severity of ACLISS grading (p < 0.01).

CONCLUSIONS

The ACLISS allowed to easily and rapidly identify different injury severity profiles in patients who underwent primary ACLR. Injury severity was associated with an increased involvement of the medial tibiofemoral compartment. The ACLISS is convenient to use in daily clinical practice and represents a feasible grading and documentation tool for a reproducible comparison of clinical data in ACL injured patients.

LEVEL OF EVIDENCE

Level III.

TGFB1, FOXO1, and COMP Genes Expression in Blood of Patients with Osteoarthritis after SARS-CoV2 Infection

Abstract—Nowadays the possible influence of the coronavirus infection on cartilage degeneration and synovial membrane inflammation during chronic joint pathology—osteoarthritis—remains largely unelucidated. The aim of the presented work is to analyze the TGFB1, FOXO1, and COMP gene expression and free radical generation intensity in blood of patients suffering from osteoarthritis after beating the SARS-CoV2 infection. The work was carried out using molecular genetics and biochemistry methods. The decrease of the TGFB1 and FOXO1 expression level was shown to be more evident in the osteoarthritis patients after COVID-19 if compared to the group with knee osteoarthritis during simultaneous and more prominent diminishing of both superoxide dismutase and catalase activity (possibly indicating cell redox state disruption and TGF- P1-FOXO1 signaling attenuation) in patients with osteoarthritis after SARS-CoV2 disease. At the same time, the more prominent decrease of COMP gene expression level was demonstrated in patients with osteoarthritis after COVID-19 compared to the group with knee osteoarthritis and more intense increase of the COMP concentration in patients with osteoarthritis after the SARS-CoV2 infection was revealed. These data indicate more significant activation of cell destructive processes after the infection as well as further pathology progression.

Current practice of concomitant surgeries in cartilage repair of the femorotibial compartment of the knee: baseline data of 4968 consecutive patients from the German cartilage registry (KnorpelRegister DGOU)

INTRODUCTION

The treatment of underlying comorbidities is a field of rising interest in cartilage repair surgery. The aim of this study was to analyze the current practice of concomitant surgeries in cartilage repair of the knee especially in the medial or lateral femorotibial compartment. Type, frequency and distribution of additional surgeries for correction of malalignment, knee instability and meniscus deficiency should be evaluated.

METHODS

Baseline data of 4968 patients of the German Cartilage Registry (KnorpelRegister DGOU) were analyzed regarding the distribution of concomitant surgeries in addition to regenerative cartilage treatment.

RESULTS

Beyond 4968 patients 2445 patients with cartilage defects in the femorotibial compartment of the knee could be identified. Of these patients 1230 (50.3%) received additional surgeries for correction of malalignment, instability and meniscus deficiency. Predominant procedures were leg axis corrections (31.3%), partial meniscectomy (20.9%) and ACL reconstruction (13.4%). The distribution of the concomitant surgeries varied between cartilage defects according to the different defect genesis. Patients with traumatic defects were younger (36y) and received predominantly ACL reconstructions (29.2%) (degenerative: 6.7%), whereas patients with degenerative defects were older (43y) and underwent predominantly leg axis corrections (38.0%; traumatic: 11.0%).

CONCLUSIONS

This study shows the high frequency and distinct distribution of the concomitant surgeries in addition to regenerative cartilage treatment procedures. Understanding of the underlying cause of the cartilage defect and addressing the comorbidities as a whole joint therapy are of utmost importance for a successful regenerative cartilage treatment. These data provide a baseline for further follow up evaluations and long-term outcome analysis.

LEVEL OF EVIDENCE

II.

Volume index as a new measure of cartilage loss: a retrospective MRI-based study of chondral injury patterns in adult patients with knee pain

BACKGROUND

Knee pain is one of the commonest symptoms in patients who attend the Orthopaedic outpatient clinics. Chondral defects result in a painful knee. Incidence of chondral defect is reported to be between 5 and 10% over the age of 40. It is well documented that chondral defects can lead to osteoarthritis. Early detection of these lesions and cartilage repair surgery can delay the onset of osteoarthritis. The purpose of this study is to highlight the incidence, associations and correlations between opposing cartilage defects in patients who present to the knee clinic with pain.

METHODS

A retrospective analysis was carried out on patients who had Magnetic Resonance Imaging scans for painful knees between June 2017 and May 2019. About 227 consecutive knees were studied for the incidence of chondral defects, number of lesions, grade and size of lesion, geographical location and associated pathology in the knee.

RESULTS

All the 227 patients had chondral lesions. Most patients had 2-3 lesions (66.1%) with patellar lesions (76.6%) being the commonest followed by medial femoral condyle (59.9%). Significant correlation was found in grade and size between opposing surface lesions in patella-trochlea, Medial Femoral Condyle-Medial Tibial Plateau and Lateral Femoral Condyle-Lateral Tibial Plateau. Females were more predisposed to patella lesions. Significance between age and lesions were established.

CONCLUSION

Incidence of cartilage defects in the knee is very high. Kissing lesions must be considered when treating cartilage lesions. Volume index could be a promising method to quantify lesions.

A decellularized and sterilized human meniscus allograft for off-the-shelf meniscus replacement

PURPOSE

Meniscus tears are one of the most frequent orthopedic knee injuries, which are currently often treated performing meniscectomy. Clinical concerns comprise progressive degeneration of the meniscus tissue, a change in knee biomechanics, and an early onset of osteoarthritis. To overcome these problems, meniscal transplant surgery can be performed. However, adequate meniscal replacements remain to be a great challenge. In this research, we propose the use of a decellularized and sterilized human meniscus allograft as meniscal replacement.

METHODS

Human menisci were subjected to a decellularization protocol combined with sterilization using supercritical carbon dioxide (scCO₂). The decellularization efficiency of human meniscus tissue was evaluated via DNA quantification and Hematoxylin & Eosin (H&E) and DAPI staining. The mechanical properties of native, decellularized, and decellularized + sterilized meniscus tissue were evaluated, and its composition was determined via collagen and glycosaminoglycan (GAG) quantification, and a collagen and GAG stain. Additionally, cytocompatibility was determined in vitro.

RESULTS

Human menisci were decellularized to DNA levels of ~ 20 ng/mg of tissue dry weight. The mechanical properties and composition of human meniscus were not significantly affected by decellularization and sterilization. Histologically, the decellularized and sterilized meniscus tissue had maintained its collagen and glycosaminoglycan structure and distribution. Besides, the processed tissues were not cytotoxic to seeded human dermal fibroblasts in vitro.

CONCLUSIONS

Human meniscus tissue was successfully decellularized, while maintaining biomechanical, structural, and compositional properties, without signs of in vitro cytotoxicity. The ease at which human meniscus tissue can be efficiently decellularized, while maintaining its native properties, paves the way towards clinical use.

Platelet-rich plasma use in meniscus repair treatment: a systematic review and meta-analysis of clinical studies

Background

There is conflicting clinical evidence whether platelet-rich plasma (PRP) therapies could translate to an increased meniscus healing rate and improved functional outcomes. The objective of this systematic review and meta-analysis was to compare the failure rate and patient-reported functional outcomes in meniscus repair augmented with and without PRP.

Methods

We comprehensively searched the PubMed, Web of Science, Medline, Embase, and Cochrane Library databases to identify studies that compared the clinical efficacy of meniscus repair performed with PRP versus without PRP. The primary outcome was the meniscus repair failure rate, while the secondary outcomes were knee-specific patient-reported outcomes, including the International Knee Documentation Committee (IKDC) score, Lysholm knee scale, visual analog scale, Tegner activity level score, Western Ontario and McMaster Universities Osteoarthritis Index score, Single Assessment Numeric Evaluation score, and Knee injury and Osteoarthritis Outcome Score. Furthermore, subgroup analyses were performed by stratifying the studies according to the PRP preparation technique to investigate the potential sources of heterogeneity among studies.

Results

Our meta-analysis included nine studies (two RCTs and seven non-RCTs) with 1164 participants. The failure rate in the PRP group was significantly lower than that in the non-PRP group [odds ratio: 0.64, 95% confidence interval (CI) (0.42, 0.96), P = 0.03]. Furthermore, the PRP group was associated with a statistically significant improvement in the visual analog scale for pain [Mean difference (MD): − 0.76, 95% CI (− 1.32, − 0.21), P = 0.007] and Knee injury and Osteoarthritis Outcome Score-symptom [MD: 8.02, 95% CI (2.99, 13.05), P = 0.002] compared with the non-PRP group. However, neither the IKDC score nor the Lysholm knee scale showed any differences between the two groups. In addition, the results of subgroup analyses favored PRP over platelet-rich fibrin matrix (PRFM) regarding the IKDC score.

Conclusions

Although meniscus repairs augmented with PRP led to significantly lower failure rates and better postoperative pain control compared with those of the non-PRP group, there is insufficient RCT evidence to support PRP augmentation of meniscus repair improving functional outcomes. Moreover, PRP could be recommended in meniscus repair augmentation compared with PRFM. PRFM was shown to have no benefit in improving functional outcomes.

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.

Human meniscus allograft augmentation by allogeneic mesenchymal stromal/stem cell injections

Meniscus allograft transplantations (MATs) represent established surgical procedures with proven outcomes. Yet, storage as frozen specimens and limited cellular repopulation may impair graft viability. This proof-of-concept study tests the feasibility of injecting allogeneic mesenchymal stromal/stem cells (MSCs) in meniscus allograft tissue. We investigated the injectable cell quantity, survival rate, migration, and proliferation ability of MSCs up to 28 days of incubation. In this controlled laboratory study, seven fresh-frozen human allografts were injected with human allogeneic MSCs. Cells were labeled and histological characteristics were microscopically imaged up to 28 days. Mock-injected menisci were included as negative controls in each experiment. Toluidine blue staining demonstrated that a 100-µl volume can be injected while retracting and rotating the inserted needle. Immediately after injection, labeled MSCs were distributed throughout the injection channel and eventually migrated into the surrounding tissues. Histological assessment revealed that MSCs cluster in disc-like shapes, parallel to the intrinsic lamination of the meniscus and around the vascular network. Quantification showed that more than 60% of cells were present in horizontally injected grafts and more than 30% were observed in vertically injected samples. On Day 14, cells adopted a spindle-shaped morphology and exhibited proliferative and migratory behaviors. On Day 28, live/dead ratio assessment revealed an approximately 80% cell survival. The study demonstrated the feasibility of injecting doses of MSCs (>0.1 million) in meniscus allograft tissue with active cell proliferation, migration, and robust cell survival.

Fibronectin Adherent Cell Populations Derived From Avascular and Vascular Regions of the Meniscus Have Enhanced Clonogenicity and Differentiation Potential Under Physioxia

The meniscus is composed of an avascular inner region and vascular outer region. The vascular region has been shown to contain a progenitor population with multilineage differentiation capacity. Strategies facilitating the isolation and propagation of these progenitors can be used to develop cell-based meniscal therapies. Differential adhesion to fibronectin has been used to isolate progenitor populations from cartilage, while low oxygen or physioxia (2% oxygen) enhances the meniscal phenotype. This study aimed to isolate progenitor populations from the avascular and vascular meniscus using differential fibronectin adherence and examine their clonogenicity and differentiation potential under hyperoxia (20% oxygen) and physioxia (2% oxygen). Human vascular and avascular meniscus cells were seeded onto fibronectin-coated dishes for a short period and monitored for colony formation under either hyperoxia or physioxia. Non-fibronectin adherent meniscus cells were also expanded under both oxygen tension. Individual fibronectin adherent colonies were isolated and further expanded, until approximately ten population doublings (passage 3), whereby they underwent chondrogenic, osteogenic, and adipogenic differentiation. Physioxia enhances clonogenicity of vascular and avascular meniscus cells on plastic or fibronectin-coated plates. Combined differential fibronectin adhesion and physioxia isolated a progenitor population from both meniscus regions with trilineage differentiation potential compared to equivalent hyperoxia progenitors. Physioxia isolated progenitors had a significantly enhanced meniscus matrix content without the presence of collagen X. These results demonstrate that combined physioxia and fibronectin adherence can isolate and propagate a meniscus progenitor population that can potentially be used to treat meniscal tears or defects.

Meniscus repair with simultaneous anterior cruciate ligament reconstruction: Clinical outcomes, failure rates and subsequent processing

PURPOSE

To retrospectively analyze the clinical outcomes of meniscus repair with simultaneous anterior cruciate ligament (ACL) reconstruction and explore the causes of failure of meniscus repair.

METHODS

From May 2013 to July 2018, the clinical data of 165 patients who were treated with meniscus surgery and simultaneous ACL reconstruction, including 69 cases of meniscus repair (repair group) and 96 cases of partial meniscectomy (partial meniscectomy group) were retrospectively analyzed. The exclusion criteria were as follows: (1) ACL rupture associated with fracture, collateral ligament injury, or complex ligament injury; (2) a history of knee surgery; or (3) a significant degree of osteoarthritis. The 69 patients in the repair group were divided into the non-failure group (62 cases) and the failure group (7 cases) depending on the repair effect. Postoperative outcomes of the repair group and the partial meniscectomy group were compared. General conditions and postoperative outcomes of the failure group and the non-failure group were compared. During the median follow-up period of 28 months (range, 4 - 65 months) after the second arthroscopy, postoperative outcomes of seven patients in the failure group were summarized. SPSS 25.0 statistical software was used for statistical analysis. A p value less than 0.05 was considered statistically significant.

RESULTS

Seven patients in the failure group who underwent the second arthroscopy were followed up for (30 ± 17.4) months and their postoperative outcomes were summarized. Compared with the partial meniscectomy group, the International Knee Documentation Committee scores of patients in the repair group improved significantly (p = 0.031). Compared with the non-failure group, more patients in the failure group were younger than 24 years (p = 0.030). The median follow-up period was 39.5 months. All patients recovered well after subsequent partial meniscectomy and relieved clinical symptoms. Visual analog scale scores decreased significantly (p = 0.026), and the International Knee Documentation Committee and Lysholm scores improved significantly (p = 0.046 for both).

CONCLUSION

The failure rate of meniscus repair in this study was 10.1% (7/69), all of which were medial meniscus tears. However, the surgical outcomes of ACL reconstruction were not affected, and there might be a role for graft protection. Therefore, meniscus retears can be successful treated by performing subsequent partial meniscectomy in patients with repair failure.

Histological Analysis of the Wrapping Treatment for Meniscal Horizontal Tears in Rabbits

OBJECTIVE

To investigate meniscal regeneration and prevent cartilage degeneration using wrapping treatment for meniscal horizontal tears that have been difficult to repair in rabbits.

DESIGN

Thirty knees from 15 Japanese white rabbits were divided into the horizontal (horizontal tears) or wrapping (horizontal tears with wrapping treatment) groups. Horizontal tears were created and wrapped with a sheet scaffold containing polyglycolic acid, polylactic acid, and polycaprolactone. The meniscus was stained with Safranin-O/Fast Green and evaluated with modified Pauli scores at 8, 12, and 16 weeks after implantation (n = 5). Cell morphology was determined with hematoxylin and eosin staining. Mature collagen was confirmed with Picrosirius Red staining. Furthermore, immunohistochemical analysis of inducible nitric oxide synthase (iNOS) for inflammation, Ki-67 for proliferation, and type II collagen for regeneration was performed. Medial femoral cartilage was stained with Safranin-O/Fast Green and evaluated with the Osteoarthritis Research Society International score at 8 and 16 weeks.

RESULTS

The wrapping group had significantly better regeneration than the horizontal group, especially at 16 weeks (P < 0.05). Wrapping treatment induced fibrochondrocyte-like cells at 16 weeks. After wrapping treatment, iNOS was overexpressed at 8 weeks, Ki-67 at 8 and 12 weeks, and type II collagen at 16 weeks. Cartilage degeneration in the wrapping group did not progress significantly compared with that in the horizontal group at 16 weeks (P < 0.05).

CONCLUSIONS

Wrapping treatment for meniscal horizontal tears induced meniscal regeneration as the sheet scaffold might induce intrinsic and extrinsic repair. Regaining the meniscal function by the wrapping treatment prevented cartilage degeneration.

Return to Work Following Arthroscopic Meniscal Allograft Transplantation

PURPOSE

Evaluate the ability of patients to return to work (RTW) following arthroscopic meniscal allograft transplantation (MAT) for meniscal deficiency.

METHODS

Consecutive patients undergoing MAT were retrospectively reviewed at a minimum of 2 years postoperatively. Patients completed a subjective work questionnaire, Visual Analogue Scale for pain, Single Assessment Numerical Evaluation, and satisfaction.

RESULTS

Forty-seven patients who were employed within 3 years prior to surgery (average age: 30.2 ± 6.9 years) were contacted at an average of 3.5 ± 0.9 years postoperatively. Forty-six patients (97.8%) returned to work by 2.7 ± 2.6 months postoperatively, and 44 patients (93.6%) returned to the same level of occupational intensity. Patients who held sedentary, light, medium, or high intensity occupations were able to RTW at a rate of 100.0%, 100.0%, 88.9%, and 85.7% (P = 0.4) by 1.1 ± 1.0 months, 2.5 ± 2.5 months, 3.5 ± 3.2 months, and 4.3 ± 2.8 months (P = 0.3) postoperatively. Thirty-eight patients (80.9%) were at least somewhat satisfied, and 43 patients (91.5%) would still have the operation if presented the opportunity. No patient underwent revision MAT or conversion to arthroplasty.

CONCLUSION

In patients with painful meniscal deficiency, MAT provides a high rate of RTW (97.8%) by 2.7 ± 2.6 months postoperatively. However, some patients may be unable to return to their previous level of occupational intensity. Although statistically insignificant, patients with higher intensity occupations may have a lower rate and longer duration until RTW than those with less physically demanding occupations. Information regarding RTW is imperative for appropriately managing postoperative expectations.

Development of a decellularized meniscus matrix-based nanofibrous scaffold for meniscus tissue engineering

The meniscus plays a critical role in knee mechanical function but is commonly injured given its central load bearing role. In the adult, meniscus repair is limited, given the low number of endogenous cells, the density of the matrix, and the limited vascularity. Menisci are fibrocartilaginous tissues composed of a micro-/nano- fibrous extracellular matrix (ECM) and a mixture of chondrocyte-like and fibroblast-like cells. Here, we developed a fibrous scaffold system that consists of bioactive components (decellularized meniscus ECM (dME) within a poly(e-caprolactone) material) fashioned into a biomimetic morphology (via electrospinning) to support and enhance meniscus cell function and matrix production. This work supports that the incorporation of dME into synthetic nanofibers increased hydrophilicity of the scaffold, leading to enhanced meniscus cell spreading, proliferation, and fibrochondrogenic gene expression. This work identifies a new biomimetic scaffold for therapeutic strategies to substitute or replace injured meniscus tissue. STATEMENT OF SIGNIFICANCE: In this study, we show that a scaffold electrospun from a combination of synthetic materials and bovine decellularized meniscus ECM provides appropriate signals and a suitable template for meniscus fibrochondrocyte spreading, proliferation, and secretion of collagen and proteoglycans. Material characterization and in vitro cell studies support that this new bioactive material is susceptible to enzymatic digestion and supports meniscus-like tissue formation.

The future of basic science in orthopaedics and traumatology: Cassandra or Prometheus?

Orthopaedic and trauma research is a gateway to better health and mobility, reflecting the ever-increasing and complex burden of musculoskeletal diseases and injuries in Germany, Europe and worldwide. Basic science in orthopaedics and traumatology addresses the complete organism down to the molecule among an entire life of musculoskeletal mobility. Reflecting the complex and intertwined underlying mechanisms, cooperative research in this field has discovered important mechanisms on the molecular, cellular and organ levels, which subsequently led to innovative diagnostic and therapeutic strategies that reduced individual suffering as well as the burden on the society. However, research efforts are considerably threatened by economical pressures on clinicians and scientists, growing obstacles for urgently needed translational animal research, and insufficient funding. Although sophisticated science is feasible and realized in ever more individual research groups, a main goal of the multidisciplinary members of the Basic Science Section of the German Society for Orthopaedics and Trauma Surgery is to generate overarching structures and networks to answer to the growing clinical needs. The future of basic science in orthopaedics and traumatology can only be managed by an even more intensified exchange between basic scientists and clinicians while fuelling enthusiasm of talented junior scientists and clinicians. Prioritized future projects will master a broad range of opportunities from artificial intelligence, gene- and nano-technologies to large-scale, multi-centre clinical studies. Like Prometheus in the ancient Greek myth, transferring the elucidating knowledge from basic science to the real (clinical) world will reduce the individual suffering from orthopaedic diseases and trauma as well as their socio-economic impact.

Total Meniscus Reconstruction Using a Polymeric Hybrid-Scaffold: Combined with 3D-Printed Biomimetic Framework and Micro-Particle

The meniscus has poor intrinsic regenerative capability, and its injury inevitably leads to articular cartilage degeneration. Although there are commercialized off-the-shelf alternatives to achieve total meniscus regeneration, each has its own shortcomings such as individualized size matching issues and inappropriate mechanical properties. We manufactured a polycaprolactone-based patient-specific designed framework via a Computed Tomography scan images and 3D-printing technique. Then, we completed the hybrid-scaffold by combining the 3D-printed framework and mixture micro-size composite which consists of polycaprolactone and sodium chloride to create a cell-friendly microenvironment. Based on this hybrid-scaffold with an autograft cell source (fibrochondrocyte), we assessed mechanical and histological results using the rabbit total meniscectomy model. At postoperative 12-week, hybrid-scaffold achieved neo-meniscus tissue formation, and its shape was maintained without rupture or break away from the knee joint. Histological and immunohistochemical analysis results showed obvious ingrowth of the fibroblast-like cells and chondrocyte cells as well as mature lacunae that were embedded in the extracellular matrix. Hybrid-scaffolding resulted in superior shape matching as compared to original meniscus tissue. Histological analysis showed evidence of extensive neo-meniscus cell ingrowth. Additionally, the hybrid-scaffold did not induce osteoarthritis on the femoral condyle surface. The 3D-printed hybrid-scaffold may provide a promising approach that can be applied to those who received total meniscal resection, using patient-specific design and autogenous cell source.

The regenerative effect of different growth factors and platelet lysate on meniscus cells and mesenchymal stromal cells and proof of concept with a functionalized meniscus implant

Meniscus regeneration could be enhanced by targeting meniscus cells and mesenchymal stromal cells (MSCs) with the right growth factors. Combining these growth factors with the Collagen Meniscus Implant (CMI®) could accelerate cell ingrowth and tissue formation in the implant and thereby improve clinical outcomes. Using a transwell migration assay and a micro-wound assay, the effect of insulin-like growth factor-1, platelet-derived growth factor (PDGF), vascular endothelial growth factor (VEGF), transforming growth factor beta 1 (TGF-β1), fibroblast growth factor, and platelet lysate (PL) on migration and proliferation of meniscus cells and MSCs was assessed. The formation of extracellular matrix under influence of the above-mentioned growth factors was assessed after 28 days of culture of both MSCs and meniscus cells. As a proof of concept, the CMI® was functionalized with a VEGF binding peptide and coated with platelet-rich plasma (PRP) for clinical application. Our results demonstrate that PDGF, TGF-β1, and PL stimulate migration, proliferation, and/or extracellular matrix production of meniscus cells and MSCs. Additionally, the CMI® was successfully functionalized with a VEGF binding peptide and PRP which increased migration of meniscus cell and MSC into the implant. This study demonstrates proof of concept of functionalizing the CMI® with growth factor binding peptides. A CMI® functionalized with the right growth factors holds great potential for meniscus replacement after partial meniscectomy.

Biosynthetic scaffolds for partial meniscal loss: A systematic review from animal models to clinical practice

Acute or degenerative meniscus tears are the most common knee lesions. Meniscectomy provides symptomatic relief and functional recovery only in the short- to mid-term follow-up but significantly increases the risk of osteoarthritis. For this reason, preserving the meniscus is key, although it remains a challenge. Allograft transplants present many disadvantages, so during the last 20 years preclinical and clinical research focused on developing and investigating meniscal scaffolds. The aim of this systematic review was to collect and evaluate all the available evidence on biosynthetic scaffolds for meniscus regeneration both in vivo and in clinical studies. Three databases were searched: 46 in vivo preclinical studies and 30 clinical ones were found. Sixteen natural, 15 synthetic, and 15 hybrid scaffolds were studied in vivo. Among them, only 2 were translated into clinic: the Collagen Meniscus Implant, used in 11 studies, and the polyurethane-based scaffold Actifit®, applied in 19 studies. Although positive outcomes were described in the short- to mid-term, the number of concurrent procedures and the lack of randomized trials are the major limitations of the available clinical literature. Few in vivo studies also combined the use of cells or growth factors, but these augmentation strategies have not been applied in the clinical practice yet. Current solutions offer a significant but incomplete clinical improvement, and the regeneration potential is still unsatisfactory. Building upon the overall positive results of these “old” technologies to address partial meniscal loss, further innovation is urgently needed in this field to provide patients better joint sparing treatment options.

•

Animal studies employed natural, synthetic and hybrid natural/synthetic scaffolds.

•

Only in a few animal studies scaffold augmentation with cells or GFs was tested.

•

Only two meniscal scaffolds have reached clinical application: CMI and Actifit.

•

Clinical results are promising, but complete meniscus regeneration has not been achieved.

•

There is urgent need for technological innovation in the field of meniscal regeneration.

Which factors are associated with the prevalence of meniscal repair?

Abstract

Purpose To investigate the potential factors associated with the prevalence of meniscal repair

Methods Patients who received partial meniscectomy or meniscal repair in our institution from Jan 2015 to Dec 2019 were included in current study. The inclusion criteria were (1) meniscus tear treated using meniscectomy or repair, (2) with or without concomitant anterior cruciate ligament reconstruction, (3) not multiligamentous injury. Demographic data, including sex, age, body mass index (BMI), injury-to-surgery interval and intra-articular factors such as the location of injury, medial or lateral, ACL rupture or not and the option of procedure (partial meniscectomy or repair) were documented from medical records. Univariate analysis consisted of chi-square. Multivariate logistic regression was then performed to adjust for confounding factors.

Results 592 patients including 399 males and 193 females with a mean age of 28.7 years (range from 10 to 75 years) were included in current study. In the univariate analysis, male (p = 0.002), patients aged 40 years or younger (p < 0.001), increased weight (p = 0.010), Posterior meniscus torn (0.011), concurrent ACL ruputure (p < 0.001), lateral meniscus (p = 0.039) and early surgery (p < 0.001) were all associated with the prevalence of meniscal repair. However, After adjusting for confounding factors, we found that age (OR, 0.35; 95% CI, 0.17 - 0.68, p = 0.002), ACL injury (OR, 3.76; 95% CI, 1.97 – 7.21, p < 0.001), side of menisci (OR, 3.29; 95% CI, 1.43 – 7.55, p = 0.005), site of tear (OR, 0.15; 95% CI, 0.07 – 0.32, p < 0.001), and duration of injury (OR, 0.46; 95% CI, 0.28 – 0.82, p = 0.008) were associated with the prevalence of meniscus repair.

Conclusions Meniscal tear in aged patients especially those with concomitant ACL injury is likely to be repaired. Additionally, in order to increase the prevalence of repair and slow down progression of OA, the surgical procedure should be performed within two weeks after meniscus tear especially when the tear is located at lateral meniscal posterior.

Study design

Case-control study; level of evidence, 3.

Association between quantitative lower limb arterial calcification and bilateral severe knee osteoarthritis

OBJECTIVES

To investigate whether lower limb arterial calcification (LLAC) quantified using computed tomography (CT) was a risk factor for bilateral severe knee osteoarthritis (OA).

METHODS

This cross-sectional study included patients who were scheduled for surgical treatment of primary varus knee OA. Knee OA was evaluated using the Kellgren-Lawrence (KL) classification, KL grades 3 and 4 were defined as severe OA. The LLAC score in the bilateral whole leg CT was quantitatively measured and categorized into low or high groups based on the median value. A modified Poisson regression model was used to examine the relationship between the categorized LLAC score and the presence of bilateral severe knee OA with adjustment for possible confounders.

RESULTS

Of a total of 252 patients examined, multivariable modified Poisson regression analysis showed a significant association between higher LLAC score and the presence of bilateral severe knee OA (adjusted risk ratio = 1.28; 95% confidence interval [CI], 1.12-1.48; p < .001). A substantial interaction was observed between male sex and high LLAC (p for interaction = .03).

CONCLUSION

LLAC was associated with bilateral severe knee OA, and the LLAC score may be a useful measurement to identify patients at risk of bilateral severe knee OA.

The predictive factors that are associated with the number of sutures used during meniscal repair

Purpose

To investigate factors associated with the consumption of a large number of sutures during arthroscopic meniscus repair procedures.

Methods

All patients who received meniscal repair, with or without concomitant anterior cruciate ligament (ACL) reconstruction, in our hospital from January 2015 to December 2019 were included in the current study. Demographic data (sex, age, body mass index (BMI), and injury-to-surgery interval) and surgical data (the site of the tear, side of the meniscus, presence of an ACL rupture or not and the number of sutures) were retrospectively collected from our medical records. The number of sutures was divided into two groups (1–2 sutures versus > 2 sutures). The stitching process was implemented through an all-inside technique using a meniscal repair device (Fast-Fix; Smith & Nephew). According to the length and stability of the meniscal tear, one to seven sutures were used. Univariate analysis consisted of chi-square tests. Multivariate logistic regression was then performed to adjust for confounding factors.

Results

A total of 242 patients, including 168 males and 57 females, was finally included. In the univariate analysis, we found that those patients who underwent meniscus repair within one month after meniscus tear were more likely to need fewer sutures than those who underwent surgery more than one month after injury (70/110 versus 59/115, p=0.062). In total, 75/109 (68.8%) lateral meniscal tears were repaired with fewer sutures than medial (34/72, 47.2%) and bilateral meniscus injuries (20/44, 45.4%; p=0.003). In the multivariate analysis, we found that the duration of injury (OR, 2.06; 95% CI, 1.16–3.64, p=0.013), presence of an ACL injury (OR, 3.76; 95% CI, 1.97–7.21, p< 0.001) and the side of the meniscus (OR, 0.31; 95% CI, 0.14–0.65, p=0.002) were associated with the number of sutures used during meniscal repair procedures.

Conclusions

Patients who underwent meniscal repair within one month after meniscus tear, especially lateral menisci tears, were more likely to need fewer sutures.

Study design

Case-control study; level of evidence, 3.

Meniscal substitution, a developing and long-awaited demand

The menisci represent indispensable intraarticular components of a well-functioning knee joint. Sports activities, traumatic incidents, or simply degenerative conditions can cause meniscal injuries, which often require surgical intervention. Efforts in biomechanical and clinical research have led to the recommendation of a meniscus-preserving rather than a meniscus-resecting treatment approach. Nevertheless, partial or even total meniscal resection is sometimes inevitable. In such circumstances, techniques of meniscal substitution are required. Autologous, allogenic, and artificial meniscal substitutes are available which have evolved in recent years. Basic anatomical and biomechanical knowledge, clinical application, radiological and clinical outcomes as well as future perspectives of meniscal substitutes are presented in this article. A comprehensive knowledge of the different approaches to meniscal substitution is required in order to integrate these evolving techniques in daily clinical practice to prevent the devastating effects of lost meniscal tissue.

Technique for Treatment of Subchondral Compression Fracture of the Lateral Femoral Condyle Associated With ACL Tear

Excessive knee pivoting that causes a complete anterior cruciate ligament (ACL) tear may result in a subchondral compression fracture on the lateral femoral condyle after impacting the lateral tibial condyle. Because this mechanism is similar to the humeral head that has an impact on the glenoid during an anterior shoulder dislocation, such an osteochondral fracture can be considered equivalent to a "Hill-Sachs lesion of the knee." Restoring the native anatomy of the lateral femoral condyle articular surface is crucial, because its depression alters knee biomechanics, leading to bony knee instability, potentially greatly elevating the risk of ACL reconstruction failure and meniscal tears. In addition, bony knee instability increases the forces acting on the cartilage, which may impair one's quality of life and lead to the development of osteoarthritis. The fact that many patients with complete ACL tears are relatively young emphasizes the key role of osteoarthritis prevention. The aim of this report is to present a minimally invasive procedure to treat the "Hill-Sachs-like" knee lesion, a tricky enemy of knee stability.

Descriptive study of knee lesions using magnetic resonance imaging and correlation between medical imaging diagnosis and suspected clinical diagnosis

Objective:

This study aimed to assess the meniscus and cruciate ligament lesions of the knee using magnetic resonance imaging (MRI) and to investigate the correlation between clinical and MRI diagnoses.

Patients and Methods:

Herein, we reviewed the electronic medical records of 240 patients who underwent knee MRI. The images were evaluated and then the clinical and MRI diagnoses were compared.

Results:

Of the 240 patients, 66% were male and the mean age was 40.6 ± 15.5 years (range, 2-79 years). Knee pain alone was the most common presenting symptom (50.64%) followed by pain after trauma (47.92%). Majority of the knee lesions were medial meniscus (MM) lesions (63%) followed by osteoarthritis (48%) and ACL lesions (35%). The majority of the MM and ACL lesions were tears (54.6% and 69.41%, respectively) followed by degeneration (33.55% and 17.65%, respectively). However, the MM lesions were predominantly observed in the posterior horn (Odds ratio [OR], 152; 95% confidence interval (CI), 21.550–1072.113; P < 0.001). The ACL lesions were significantly more common in men than in women (OR, 0.355; 95% CI, 0.191-0.661; P = 0.001), and altered signal intensity on T2- and proton density–weighted images was the most common sign (P < 0.001). A strong compatibility was observed between the clinical and MRI diagnoses (Kappa = 0.141; P < 0.001).

Conclusion:

MM and ACL lesions are the most common injuries of the knee, which can be diagnosed by physical examination in most cases. Further confirmation by MRI should be reserved for doubtful cases only.

The implications of non-anatomical positioning of a meniscus prosthesis on predicted human knee joint biomechanics

Despite all the efforts to optimize the meniscus prosthesis system (geometry, material, and fixation type), the success of the prosthesis in clinical practice will depend on surgical factors such as intra-operative positioning of the prosthesis. In this study, the aim was therefore to assess the implications of positional changes of the medial meniscus prosthesis for knee biomechanics. A detailed validated finite element (FE) model of human intact and meniscal implanted knees was developed based on a series of in vitro experiments. Different non-anatomical prosthesis positions were applied in the FE model, and the biomechanical response during the gait stance phase compared with an anatomically positioned prosthesis, as well as meniscectomized and also the intact knee model. The results showed that an anatomical positioning of the medial meniscus prosthesis could better recover the intact knee biomechanics, while a non-anatomical positioning of the prosthesis to a limited extent alters the knee kinematics and articular contact pressure and increases the implantation failure risk. The outcomes indicate that a medial or anterior positioning of the meniscus prosthesis may be more forgiving than a posteriorly or laterally positioned prosthesis. The outcome of this study may provide a better insight into the possible consequences of meniscus prosthesis positioning errors for the patient and the prosthesis functionality.

Medium-Term Results of Arthroscopic Partial Meniscectomy from a Single High-Volume Center

AIM

Clinical practice is moving away from treating meniscal tears in patients with osteoarthritis unless there are mechanical symptoms. This study assessed the risk of needing further surgery for osteoarthritis in the 5 years following partial meniscectomy in different age groups and different grades of knee osteoarthritis.

METHODS

All partial meniscectomies were performed by the senior author during a 31-month period. Data were collected and analyzed retrospectively using electronic patients' records and imaging database. Patients who had previous arthroscopy, anterior cruciate ligament pathology, discoid meniscus or were less than 34 years old were excluded from the study. Range of follow-up was 3 to 5 years. Osteoarthritis was classified intra-operatively using the Outerbridge classification. Knees that needed further surgical treatment in the form of joint replacement or osteotomy were considered as failures. The population was split into three groups according to their age (35-54, 55-64 and 65+). Survival analysis was calculated using the life table method.

RESULTS

207 knees were included. In the 35-54 age group, patients with no/mild OA had a survival rate of 97.59% and the severe OA group had a survival rate of 73.5%. In the 55-64 age group, these figures were 100% and 73.6%, respectively. In the >65 age group, the survival rates were 100% and 65%, respectively.

CONCLUSION

Our study shows that patients with no/mild OA should be considered for APM. Patient's with meniscal tears and severe OA should be counseled on the outcomes and risks of further surgery after an APM.

FOXO1 and FOXO3 transcription factors have unique functions in meniscus development and homeostasis during aging and osteoarthritis

The objective of this study was to examine FoxO expression and FoxO function in meniscus. In menisci from human knee joints with osteoarthritis (OA), FoxO1 and 3 expression were significantly reduced compared with normal menisci from young and old normal donors. The expression of FoxO1 and 3 was also significantly reduced in mouse menisci during aging and OA induced by surgical meniscus destabilization or mechanical overuse. Deletion of FoxO1 and combined FoxO1, 3, and 4 deletions induced abnormal postnatal meniscus development in mice and these mutant mice spontaneously displayed meniscus pathology at 6 mo. Mice with Col2Cre-mediated deletion of FoxO3 or FoxO4 had normal meniscus development but had more severe aging-related damage. In mature AcanCreERT2 mice, the deletion of FoxO1, 3, and 4 aggravated meniscus lesions in all experimental OA models. FoxO deletion suppressed autophagy and antioxidant defense genes and altered several meniscus-specific genes. Expression of these genes was modulated by adenoviral FoxO1 in cultured human meniscus cells. These results suggest that FoxO1 plays a key role in meniscus development and maturation, and both FoxO1 and 3 support homeostasis and protect against meniscus damage in response to mechanical overuse and during aging and OA.

FOXO1 and FOXO3 transcription factors have unique functions in meniscus development and homeostasis during aging and osteoarthritis

The objective of this study was to examine FoxO expression and FoxO function in meniscus. In menisci from human knee joints with osteoarthritis (OA), FoxO1 and 3 expression were significantly reduced compared with normal menisci from young and old normal donors. The expression of FoxO1 and 3 was also significantly reduced in mouse menisci during aging and OA induced by surgical meniscus destabilization or mechanical overuse. Deletion of FoxO1 and combined FoxO1, 3, and 4 deletions induced abnormal postnatal meniscus development in mice and these mutant mice spontaneously displayed meniscus pathology at 6 mo. Mice with Col2Cre-mediated deletion of FoxO3 or FoxO4 had normal meniscus development but had more severe aging-related damage. In mature AcanCreERT2 mice, the deletion of FoxO1, 3, and 4 aggravated meniscus lesions in all experimental OA models. FoxO deletion suppressed autophagy and antioxidant defense genes and altered several meniscus-specific genes. Expression of these genes was modulated by adenoviral FoxO1 in cultured human meniscus cells. These results suggest that FoxO1 plays a key role in meniscus development and maturation, and both FoxO1 and 3 support homeostasis and protect against meniscus damage in response to mechanical overuse and during aging and OA.

Meniscectomy-induced osteoarthritis in the sheep model for the investigation of therapeutic strategies: a systematic review

PURPOSE

One of the major risk factors for OA is meniscectomy (Mx) that causes a rapid and progressive OA. Mx has been employed in various animal models, especially in large ones, to study preclinical safety and strategy effectiveness to counteract OA. The aim of the present study is to review in vivo studies, performed in sheep and published in the last ten years.

METHODS

The search strategy was performed in three websites: www.scopus.com, www.pubmed.com, and www.webofknowledge.com, using "Meniscectomy and osteoarthritis in sheep" keywords.

RESULTS

The 25 included studies performed unilateral total medial Mx (MMx), unilateral partial MMx, bilateral MMx, unilateral total lateral Mx (LMx), unilateral partial LMx, and bilateral LMx and MMx combined with anterior cruciate ligament transaction. The most frequently performed is the unilateral total MMx that increases changes in cartilage and subchondral bone more than the other techniques. Gross evaluations, histology, radiography, and biochemical tests are used to assess the degree of OA. The most widely tested treatments are related to scaffolds with or without mesenchymal stem cells.

CONCLUSION

OA therapeutic strategies require the use of large animal models due to similarities with human joint anatomy. A protocol for future in vivo studies on post-traumatic OA is clarified.

Biomechanical study of medial meniscus after posterior horn injury: a finite element analysis

We established an effective finite element model of knee joint for observation of stress and displacement of meniscus related changes after medial meniscus injury. Different types of medial meniscus injury can lead to varied meniscus stress and displacement changes. Stress and displacement concentration were found in fissure tip of meniscus tear compared to normal meniscus. The posterior horn injury of medial meniscus may initiate combined injury of medial meniscus posterior horn (MMPH) and that of medial meniscus body, and combined injury of MMPH and that of lateral meniscus anterior horn; fissure expansions regarding horizontal fissure, longitudinal fissure and grip-shaped fissure of MMPH were spotted.

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.

Point-of-Care Procedure for Enhancement of Meniscal Healing in a Goat Model Utilizing Infrapatellar Fat Pad-Derived Stromal Vascular Fraction Cells Seeded in Photocrosslinkable Hydrogel

BACKGROUND

Large radial tears of the meniscus involving the avascular region can compromise meniscal function and result in poor healing and subsequent osteochondral degeneration. Augmentation of surgical repairs with adipose-derived stromal vascular fraction (SVF), which contains mesenchymal stromal cells, may improve meniscal healing and preserve function (ie, chondroprotection).

PURPOSES

(1) To develop a goat model of a radial meniscal tear with resulting osteoarthritis and (2) to explore the efficacy of a 1-step procedure utilizing infrapatellar fat pad-derived SVF cells seeded in a photocrosslinkable hydrogel to enhance meniscal healing and mitigate osteochondral degeneration.

STUDY DESIGN

Controlled laboratory study.

METHODS

A full-thickness radial tear spanning 90% of the medial meniscal width was made at the junction of the anterior and middle bodies of the goat stifle joint. Tears received 1 of 3 interventions (n = 4 per group): untreated, repair, or repair augmented with photocrosslinkable methacrylated gelatin hydrogel containing 2.0 × 10⁶ SVF cells/mL and 2.0 µg/mL of transforming growth factor β3. The contralateral (left) joint served as a healthy control. At 6 months, meniscal healing and joint health were evaluated by magnetic resonance imaging (MRI) and assessed by histological and macroscopic scoring. The Whole-Organ Magnetic Resonance Imaging Score and the presence of a residual tear, as evaluated with T2 MRI sequences, were determined by a single blinded orthopaedic surgeon.

RESULTS

When compared with tears left untreated or repaired with suture alone, augmented repairs demonstrated increased tissue formation in the meniscal tear site, as seen on MRI and macroscopically. Likewise, the neotissue of augmented repairs possessed a histological appearance more similar, although still inferior, to healthy meniscus. Osteochondral degeneration in the medial compartment, as evaluated by the Whole-Organ Magnetic Resonance Imaging Score and Inoue (macroscopic) scale, revealed increased degeneration in the untreated and repair groups, which was mitigated in the augmented repair group. Histological evaluation with a modified Mankin score showed a similar trend. In all measures of osteochondral degeneration, the augmented repair group did not differ significantly from the uninjured control.

CONCLUSION

A radial tear spanning 90% of the medial meniscal width in a goat stifle joint showed poor healing potential and resulted in osteochondral degeneration by 6 months, even if suture repair was performed. Augmentation of the repair with a photocrosslinkable hydrogel containing transforming growth factor β3 and SVF cells, isolated intraoperatively by rapid enzymatic digestion, improved meniscal healing and mitigated osteoarthritic changes.

CLINICAL RELEVANCE

Repair augmentation with an SVF cell-seeded hydrogel may support successful repair of meniscal tears previously considered irreparable.

Alignment factors affecting the medial meniscus extrusion increases the risk of osteoarthritis development

PURPOSE

Varus alignment is known as one of the major causes of medial compartment osteoarthritis (OA). Medial meniscus extrusion also plays a critical role in the in the development of OA. However, studies on the exact relationship between alignment parameters and medial meniscus extrusion are limited. Therefore, this study aimed to investigate this relationship in patients with knee OA.

METHODS

Based on a retrospective analysis of the outpatient magnetic resonance imaging (MRI) database, 190 knees were identified to be examined using weight-bearing, whole-leg radiographs and MRIs within 3 months from the first consultation. Subsequently, various parameters of lower leg alignment were measured, which affected the knee varus in radiographs. Finally, a statistical analysis was performed to assess the relationships between the OA grade, distance of medial meniscus extrusion (MME), and alignment parameters; hip-knee-ankle angle (HKAA), percentage of mechanical axis (% MA), medial proximal tibial angle (MPTA), and joint line convergence angle (JLCA). The subjects were divided according to the presence or absence of MME (Group A: MME distance below 3 mm, Group B: MME distance 3 mm and above) to assess the differences in each alignment parameter correlated with MME distance between the groups.

RESULTS

MME distance significantly increased with OA grade progression. HKAA, % MA, MPTA, and JLCA significantly correlated with medial meniscus extrusion distance (r = - 0.21, - 0.23, - 0.16, 0.3, respectively). Multiple regression analysis of each significant alignment combined with age, sex, and body mass index revealed that HKAA, % MA, MPTA, and JLCA were significant independent factors of MME distance (P = 0.008, 0.0026, 0.011, 0.0001, respectively). These significant findings were reinforced in group B. In contrast, the correlation between alignment parameters and medial meniscus extrusion distance was not significant in group A.

CONCLUSION

Varus alignment factors are related to MME distance especially in extruded meniscus knees, as the OA grade progressed. Therefore, the coexistence of varus alignment and MME can be the risk factors for OA progression. As the low MPTA was an independent alignment factor for generating varus alignment, patients with osteoarthritis of the knee with both, low MPTA and MME could be the appropriate candidates for early intervention by high tibial osteotomy.

LEVEL OF EVIDENCE

III.

Secondary Meniscal Tears in Patients With Anterior Cruciate Ligament Injury: Relationship Among Operative Management, Osteoarthritis, and Arthroplasty at 18-Year Mean Follow-up

BACKGROUND

Anterior cruciate ligament (ACL) injury is one of the most frequent orthopaedic injuries and reasons for time loss in sports and carries significant implications, including posttraumatic osteoarthritis (OA). Instability associated with ACL injury has been linked to the development of secondary meniscal tears (defined as tears that develop after the initial ACL injury). To date, no study has examined secondary meniscal tears after ACL injury and their effect on OA and arthroplasty risk.

PURPOSE

To describe the rates and natural history of secondary meniscal tears after ACL injury and to determine the effect of meniscal tear treatment on the development of OA and conversion to total knee arthroplasty (TKA).

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A geographic database of >500,000 patients was reviewed to identify patients with primary ACL injuries between January 1, 1990, and December 31, 2005. Information was collected with regard to ACL injury treatment, rates/characteristics of the secondary meniscal tears, and outcomes, including development of OA and conversion to TKA. Kaplan-Meier and adjusted multivariate survival analyses were performed to test for the effect of meniscal treatment on survivorship free of OA and TKA.

RESULTS

Of 1398 primary ACL injuries, the overall rate of secondary meniscal tears was 16%. Significantly lower rates of secondary meniscal tears were noted among patients undergoing acute ACL reconstruction within 6 months (7%) as compared with patients with delayed ACL reconstruction (33%, P < .01) and nonoperative ACL management (19%, P < .01). Of the 235 secondary meniscal tears identified (196 patients), 11.5% underwent repair, 73% partial meniscectomy, and 16% were treated nonoperatively. Tears were most often medial in location (77%) and complex in morphology (56% of medial tears, 54% of lateral tears). At the time of final follow-up, no patient undergoing repair of a secondary meniscal tear (0%) underwent TKA, as opposed to 10.9% undergoing meniscectomy and 6.1% receiving nonoperative treatment ( P = .28).

CONCLUSION

Secondary meniscal tears after ACL injury are most common among patients undergoing delayed surgical or nonoperative treatment of their primary ACL injuries. Secondary tears often present as complex tears of the medial meniscus and result in high rates of partial meniscectomy.

Repair Augmentation of Unstable, Complete Vertical Meniscal Tears With Bone Marrow Venting Procedure: A Prospective, Randomized, Double-Blind, Parallel-Group, Placebo-Controlled Study

PURPOSE

To compare the effectiveness and safety of meniscal repair in 2 groups of patients: meniscal repair with biological augmentation using a bone marrow venting procedure (BMVP) of the intercondylar notch versus meniscal repair only.

METHODS

This single-center, prospective, randomized, double-blind, placebo-controlled, parallel-arm study included 40 patients (21 menisci in control, 23 in BMVP group) with complete vertical meniscus tears. Patients underwent all-inside and outside-in meniscal repair and a concomitant BMVP of the intercondylar notch or meniscal repair alone during an index arthroscopy. The primary endpoint was the rate of meniscus healing in the 2 groups assessed during a second-look arthroscopy (at week 35). The secondary endpoints were changes in the International Knee Documentation Committee score, Knee Injury and Osteoarthritis Outcome Score, Western Ontario and McMaster Universities Osteoarthritis Index, and visual analog scale in the 2 groups at 30 months.

RESULTS

After 36 weeks, the meniscus healing rate was significantly higher in the BMVP-treated group than in the control group (100% vs. 76%, P = .0035). Functional outcomes were significantly better 30 months after treatment than at baseline in both groups. The International Knee Documentation Committee, Knee Injury and Osteoarthritis Outcome Score, Western Ontario and McMaster Universities Osteoarthritis Index, and visual analog scale scores were significantly better in the BMVP-treated group than in the control group. No adverse events were reported during the study period.

CONCLUSIONS

Our blinded, prospective, randomized, controlled trial on the role of BMVP augmentation in meniscus repair, indicates that BMVP augmentation results in a significant improvement in the rate of meniscus healing (100% vs. 76%, P = .0035). The risk of adverse events related to augmentation with BMVP of the arthroscopic meniscal repair is very low.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

Long-term Results After Repair of Isolated Meniscal Tears Among Patients Aged 18 Years and Younger: An 18-Year Follow-up Study

BACKGROUND

Meniscal repair is desirable over resection to prevent postmeniscectomy arthritis, especially among young and active patients. However, long-term data are currently lacking following isolated meniscal repair, particularly in the pediatric population.

PURPOSE/HYPOTHESIS

To report long-term follow-up of isolated meniscal tears treated by meniscal repair in a pediatric and adolescent population and to compare those results with previous midterm follow-up data reported. The authors hypothesized that these patients would have satisfactory function and reoperation rates at long-term follow-up.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Forty-four patients aged ≤18 years undergoing repair of an isolated meniscal tear (without concomitant anterior cruciate ligament injury) between 1990 and 2005 were included. At the time of final follow-up, recurrent tear, reoperations, and International Knee Documentation Committee (IKDC) and Tegner scores were determined. With logistic regression, the overall failure among tear types was calculated. Wilcoxon rank sum analysis were performed to calculate the differences in clinical outcome for different time points, and Spearman coefficients were calculated for Tegner and IKDC with different variables.

RESULTS

At a mean follow-up of 17.6 years (range, 13.1-25.9 years), 32 patients with 33 isolated meniscal repairs (29 male, 3 female) with a mean age of 16.1 years (range, 9.9-18.7 years) at surgery were included in this study. At early follow-up, the overall failure rate was 14 of 33 (42%); complex tears (80%) and bucket-handle tears (47%) had higher overall failure rates when compared with simple tears (18.2%), although only complex tears had a significantly higher failure rate. However, no further failures occurred since midterm follow-up with any tear type. At final follow-up, the mean IKDC score was 92.3, which was significantly increased when compared with preoperative (65.3, P < .0001) and midterm (90.2, P = .01) scores. The mean Tegner score (6.5) was significantly lower than both preoperative (8.3, P < .0001) and midterm (8.4, P < .0001) scores. There was no difference in Tegner or IKDC score for patients with successful versus failed repair.

CONCLUSION

In conclusion, while there was a high early failure rate, this study demonstrated overall good to excellent long-term clinical outcomes after isolated meniscal repair in an adolescent population, even for those requiring reoperation. Early failure and reoperation rates were variable, depending on tear type, with complex multiplanar tears having more failures at short-term follow-up. However, at long-term follow-up, IKDC and Tegner scores were not significantly different for those with complex tears as compared with other tear types.