Surgical management of degenerative meniscus lesions: the 2016 ESSKA meniscus consensus

Revealing the complexity of meniscus microvasculature through 3D visualization and analysis

Three-dimensional information is essential for a proper understanding of the healing potential of the menisci and their overall role in the knee joint. However, to date, the study of meniscal vascularity has relied primarily on two-dimensional imaging techniques. Here we present a method to elucidate the intricate 3D meniscal vascular network, revealing its spatial arrangement, connectivity and density. A polymerizing contrast agent was injected into the femoral artery of human cadaver legs, and the meniscal microvasculature was examined using micro-computed tomography at different levels of detail and resolution. The 3D vascular network was quantitatively assessed in a zone-base analysis using parameters such as diameter, length, tortuosity, and branching patterns. The results of this study revealed distinct vascular patterns within the meniscus, with the highest vascular volume found in the outer perimeniscal zone. Variations in vascular parameters were found between the different circumferential and radial meniscal zones. Moreover, through state-of-the-art 3D visualization using micro-CT, this study highlighted the importance of spatial resolution in accurately characterizing the vascular network. These findings, both from this study and from future research using this technique, improve our understanding of microvascular distribution, which may lead to improved therapeutic strategies.

Improved Outcome With Knee Arthroscopy Relative to Physiotherapy for Symptomatic Unstable Meniscal Tears: 2-Year Prospective Cohort Study

BACKGROUND

Although preservation of meniscal tissue is paramount, there are occasions when repair of a torn meniscus is not possible. The surgical option may be a partial meniscectomy, the objective being to alleviate the patient's symptoms with resection of only that portion of the meniscus that is no longer functioning but is the cause of symptoms. Previous studies have questioned the need to perform such surgery and have recommended nonoperative treatment instead. Our goal was to compare the outcome of partial meniscectomy with that of physiotherapy alone for irreparable meniscal tears.

HYPOTHESIS

Clinical outcome following arthroscopic partial meniscectomy may differ from that following physiotherapy alone, for patients with symptomatic irreparable meniscal tears.

STUDY DESIGN

Nonrandomized prospective cohort study.

LEVEL OF EVIDENCE

Level 2.

METHODS

Patients satisfying the inclusion criteria chose to undergo knee arthroscopy (group A) or physiotherapy (group B). The diagnosis of a meniscal tear was made on physical assessment and magnetic resonance imaging examination. The meniscal tear was preventing them from continuing with their regular weightbearing exercise. Outcomes of interest were the following patient-reported outcomes (PROs): the Knee Osteoarthritis Outcome Score (KOOS) and Tegner Activity Score (TAS), with minimal clinically important differences being 10 and 1, respectively. PROs were completed at baseline, and at 1-year and 2-year follow-up. Changes in scores within and between groups were compared using analysis of variance and Wilcoxon tests (P <0.05). A power analysis demanded 65 patients in each group to produce a power of 80% and a P value of 5%.

RESULTS

Of 528 patients enrolled in the study, 10 were lost to follow-up and 8 were excluded. Data were complete for 269 in group A, and 228 in Group B. Group A and B were similar in terms of age (41.1 years, SD 7.8 vs 40 years, SD 13.3), body mass index (22.5 kg/m2, SD 3.1 vs 23.1 kg/m2, SD 2.3), radiographic grade of osteoarthritis (median grade 2, range 0-3 in both groups), gender (male:female = 134:135 vs 112:116), and duration of symptoms (44.4 days, SD 5.6 vs 46.6 days, SD 8.8), with P >0.05. At both 1-year and 2-year follow-up, Group A had higher scores in the mean total KOOS (88.8, SD 8.0 vs 72.4, SD 3.8), as well as in all subscales within the KOOS, and the TAS (median 7, range 5-9 vs median 5, range 3-6), with P <0.001 for each variable.

CONCLUSION

Performing a knee arthroscopy with partial meniscectomy is associated with improved KOOS and TAS, relative to treatment with physiotherapy alone, at 2-year follow-up.

CLINICAL RELEVANCE

Physically active patients with symptomatic irreparable meniscal tears may experience a better clinical outcome following knee arthroscopy, relative to to physiotherapy alone.

Conversion to knee arthroplasty is more common after meniscectomy than meniscus repair in patients older than age 40

PURPOSE

To describe rates of conversion to unicompartmental or total knee arthroplasty (KA) in patients over the age of 40 years (at initial surgery) after partial meniscectomy (ME) or meniscal repair (MR).

METHODS

Patients over the age of 40 undergoing isolated ME or MR between 2016 and 2018 were extracted from a single healthcare provider database. Data on patient characteristics, type of initial surgery, number of returns to the operating room, as well as performed procedures, including conversion to KA, were recorded. Comparative group statistics as well as a Kaplan-Meier survival rate analysis were performed.

RESULTS

A total of 3638 patients (47.8% female) were included, with 3520 (96.8%) undergoing ME and 118 (3.2%) MR. Overall, 378 (10.4%) patients returned to the OR at an average of 22.7 ± 17.3 months postoperatively. Conversion to KA was performed more frequently in patients after primary ME (n = 270, 7.7%) compared to those with MR (2.5%, n = 3, odds ratio [OR]: 3.2, p = 0.03). Compared to ME (2.3%, n = 82), two times as many patients undergoing MR returned for subsequent meniscus surgery (MR: 5.9%, n = 7, OR: 2.6, p = 0.02). Time from primary surgery to KA (ME: 22 ± 17 months, MR: 25 ± 15 months, p = 0.96) did not differ between the treatment groups. Survivorship was 95% for ME and 98.2% for MR after 24 months (p = 0.76) and 92.5% and 98.2% after 60 months (p = 0.07), respectively.

CONCLUSION

The overall reoperation rate after meniscal surgery was 10.4% in patients over the age of 40 years. Patients treated with primary ME have over three times higher odds to undergo subsequent KA compared to those treated with MR. However, patients with primary MR have a higher rate of subsequent meniscus surgery compared to those undergoing primary ME. This information is important when considering and treating a patient over the age of 40 and meniscal injury.

LEVEL OF EVIDENCE

Level III study.

The use of injectable orthobiologics for knee osteoarthritis: A European ESSKA-ORBIT consensus. Part 1-Blood-derived products (platelet-rich plasma)

PURPOSE

The aim of this European Society of Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA) consensus is to provide recommendations based on evidence and expert opinion to improve indications, decision-making and administration-related aspects when using blood-derived orthobiologics (for simplicity indicated as PRP-platelet-rich plasma-with PRP being the most common product) for the management of knee osteoarthritis (OA).

METHODS

Leading European expert clinicians and scientists were divided into a steering group, a rating group and a peer review group. The steering group prepared 28 question-statement sets divided into three sections: PRP rationale and indications, PRP preparation and characterisation and PRP protocol. The quality of the statements received grades of recommendation ranging from A (high-level scientific support) to B (scientific presumption), C (low-level scientific support) or D (expert opinion). The question-statement sets were then evaluated by the rating group, and the statements scored from 1 to 9 based on their degree of agreement with the statements produced by the steering group. Once a general consensus was reached between the steering and rating groups, the document was submitted to the peer review group who evaluated the geographic adaptability and approved the document. A final combined meeting of all the members of the consensus was held to produce the official document.

RESULTS

The literature review on the use of blood-derived products for knee OA revealed that 9 of 28 questions/statements had the support of high-level scientific literature, while the other 19 were supported by a medium-low scientific quality. Three of the 28 recommendations were grade A recommendations: (1) There is enough preclinical and clinical evidence to support the use of PRP in knee OA. This recommendation was considered appropriate with a strong agreement (mean: 8). (2) Clinical evidence has shown the effectiveness of PRP in patients for mild to moderate degrees of knee OA (KL ≤ 3). This recommendation was considered appropriate with a strong agreement (mean: 8.1). (3) PRP injections have been shown to provide a longer effect in comparison to the short-term effect of CS injections. They also seem to provide a safer use profile with less potential related complications. This recommendation was considered appropriate with a very strong agreement (mean: 8.7). Six statements were grade B recommendations, 7 were grade C and 12 were grade D. The mean rating score was 8.2 ± 0.3.

CONCLUSIONS

The consensus group reached a high level of agreement on all the questions/statements despite the lack of clear evidence for some questions. According to the results from this consensus group, given the large body of existing literature and expert opinions, PRP was regarded as a valid treatment option for knee OA and as a possible first-line injectable treatment option for nonoperative management of knee OA, mainly for KL grades 1-3.

LEVEL OF EVIDENCE

Level II.

[Meniscus update]

Meniscus tears are classified as horizontal, longitudinal, radial, and complex tears. Flap tears are a specific form in which a portion of the meniscus is displaced from a horizontal or longitudinal tear. The question of whether it is possible to preserve the meniscus by meniscus repair is of crucial therapeutic importance. It is therefore important to specify not only the configuration of the tear but also its extent and location as precisely as possible. Cooper's zonal classification should also be used for this purpose. Lesions of the meniscus roots are of high clinical relevance. On the posterior horn of the medial meniscus, root lesions are usually degenerative; on the posterior horn of the lateral meniscus, they are often traumatic. It is important to familiarize oneself with the normal appearance and anatomical location of the meniscal roots. Ramp lesions have received particular attention in recent years, especially in patients with anterior cruciate ligament tears. Therefore, particularly the integrity of the attachment of the posterior horn of the medial meniscus to the tibial plateau must be analyzed. If the meniscotibial ligament tears along its course or at the insertion to the meniscus or if it avulses with a meniscus fragment, this is a ramp lesion.

Females show worse functional outcome and quality of life compared to males 2 years after meniscus surgery: Data analysis from the German Arthroscopy Registry

PURPOSE

The purpose of this study was to investigate the impact of sex on knee function, activity and quality of life following meniscus surgery using data from the German Arthroscopy Registry.

METHODS

This is a retrospective cohort study with data collected between 2017 and 2022. Patient-reported outcome measures (PROMs), namely Knee Injury and Osteoarthritis Outcome Score (KOOS), EuroQol Visual Analogue Scale (EQ Scale), and Marx Activity Rating Scale (MARS), were collected preoperatively and at 6, 12 and 24 months postoperatively. Data were analysed to examine differences between male and female patients regarding PROMs, pre-existing conditions, meniscus lesion types and surgical treatments.

RESULTS

A total of 1106 female (36.6%) and 1945 male patients (63.7%) were included. Males were significantly younger than females and had a higher body mass index. Overall, there were four times more medial meniscus lesions (MMLs) (77.5%) than lateral meniscus lesions (LMLs) (27.9%). Degenerative LMLs were more frequent in females, while traumatic LMLs were more common in males. Frequencies of traumatic and degenerative MMLs were similar among males and females. Males had higher absolute KOOS irrespective of treatment or meniscus lesion type. Meniscus repair resulted in similar improvements in ΔKOOS for both sexes, while meniscus resection exhibited higher absolute KOOS for males at each time point. Males generally had higher EQ Scale and MARS than females.

CONCLUSION

Greater improvements in knee function, activity and quality of life were observed in males. While MMLs appear to be comparable among sexes, the nature of LML differed significantly. These results may help surgeons to refine patient selection for specific treatments to improve overall clinical outcomes.

LEVEL OF EVIDENCE

Level III.

Knee Offloading by Patients During Walking and Running After Meniscectomy

Background

Changes in knee loading have been reported after meniscectomy. Knee loading has previously been assessed during jogging and treadmill running rather than overground running, which could give altered results.

Purpose/Hypothesis

The purpose of this study was to evaluate knee function during overground running and walking after meniscectomy. It was hypothesized that the affected limb would demonstrate higher external knee adduction moment, lower knee flexion moment (KFM), and lower knee rotation moment (KRM) compared with the contralateral limb and with healthy individuals.

Study Design

Controlled laboratory study.

Methods

Kinematic and kinetic data were collected during running and walking in individuals after a meniscectomy and healthy individuals. Total knee joint moments (TKJM) were calculated from the sagittal, frontal, and transverse knee moments. Isometric quadriceps strength, perceived knee function, and kinesiophobia were also assessed. A mixed linear model compared differences between the affected leg, the contralateral leg, and the healthy leg.

Results

Data were collected on 20 healthy individuals and 30 individuals after a meniscectomy (mean ± SD, 5.7 ± 2.9 months postsurgery), with 12, 16, and 2 individuals who had medial, lateral, and both medial and lateral meniscectomy, respectively. The affected limb demonstrated lower TKJM (P < .001), KFM (P = .004), and KRM (P < .001) during late stance of walking compared with the healthy group. Lower TKJM and KFM were observed during running in the affected limb compared with the contralateral limb and healthy group. No significant differences were observed between contralateral and healthy limbs except for KRM during late stance of walking. Lower quadriceps strength was observed in the affected (P < .001) and contralateral limbs (P = .001) compared with the healthy group. Individuals after a meniscectomy also reported greater kinesiophobia (P = .006) and lower perceived knee function (31.1%; P < .001) compared with the healthy group.

Conclusion

After meniscectomy, individuals who sustained a traumatic meniscal injury showed lower TKJM in the affected limb compared with the contralateral limb and healthy individuals. This decrease in TKJM can be attributed to altered knee-loading strategies in the sagittal and transverse planes.

Clinical Relevance

Improving movement strategies, quadriceps strength, and kinesiophobia through rehabilitation approaches will allow individuals to load their knee appropriately when returning to sport.

Registration

NCT03379415 (ClinicalTrials.gov identifier).

Risk Factor for Clinical Failure of Medial Meniscal Allograft Transplant: Early vs Late Graft Tear

BACKGROUND

Graft tears are common postoperative findings in meniscal allograft transplant (MAT). Graft tear in medial MAT may be different from that of lateral MAT, considering the difference between medial meniscal tears and lateral meniscal tears. Moreover, medial MAT is frequently accompanied by ligament reconstruction, which is associated with graft tear. The effect of graft tear on the long-term survivorship of medial MAT has not been investigated.

HYPOTHESIS

Graft tear would adversely affect the survivorship of medial MAT and the effect would be different according to the timing of graft tear.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 55 patients undergoing medial MAT between June 2019 and March 2000 were retrospectively reviewed. Postoperative magnetic resonance imaging (MRI) scans were reviewed to identify graft tears, and the timing of their occurrence was investigated. Postoperative MRI was performed routinely during the first postoperative year and every 2 years thereafter. The patients were classified into a no graft tear (NT) group, early graft tear (occurring within 1 year; ET) group, and late graft tear (occurring 1 year after surgery; LT) group. The survival rate of medial MAT was estimated according to graft tear, with a failure being defined as (1) reoperations including arthroplasty, realignment osteotomy, revision MAT, and meniscectomy (>50% of the graft or to the zone of the meniscocapsular junction) or (2) Lysholm score <65. Clinical scores were compared between the groups.

RESULTS

The mean follow-up duration was 8.6 ± 5.3 years. During that period, clinical failures occurred in 6 (10.9%) patients. The overall survival rate at 5 years was 94.0% (95% CI, 90.6%-97.4%). Graft tears were seen in 18 patients: 6 patients in the ET group and 12 patients in the LT group. The median time when the graft tear was noted on MRI scans was 5.5 months (range, 1-11 months) postoperatively in the ET group and 99.5 months (range, 19-264 months) postoperatively in the LT group. Five patients in the ET group had root tears, whereas 9 patients in the LT group had complex or horizontal tears. The 5-year survival rate of the ET group was 62.5% (95% CI, 41.2%-83.8%), which was significantly lower than that of the NT group (96.8%; 95% CI, 93.6%-99.9%) and the LT group (85.7%; 95% CI, 72.5%-98.9%; P = .002). The mean postoperative Lysholm scores were 85.6 ± 17.9 in the NT group, 93.0 ± 2.8 in the ET group, and 79.3 ± 11.6 in the LT group, showing no significant difference between the groups (Kruskal-Wallis test, P = .058).

CONCLUSION

Clinical relevance of graft tear that occurred after medial MAT was dependent upon its timing. ET was a risk factor for clinical failure, whereas LT did not adversely affect graft survivorship. Lysholm scores did not differ according to graft tear.

Autologous microfragmented adipose tissue treatment of knee osteoarthritis demonstrates effectiveness in 68% of patients at 4-year follow-up

BACKGROUND

Adipose tissue-derived stem cells are an interesting therapeutic option for early knee osteoarthritis (OA) treatment due to their high plasticity, easiness of harvesting and rapidity of administration. The aim of this study was to evaluate the medium-term effectiveness and safety of Microfragmented Autologous Fat Tissue (MFAT) injection treatment at 4-year follow-up and to investigate potential correlations among patients' pre-treatment clinical condition and clinical outcomes to identify possible predicting factors for procedure success or failure.

PATIENTS AND METHODS

This is a prospective trial enrolling 46 patients with diagnosis of symptomatic knee OA and failure of previous conservative measures who underwent diagnostic arthroscopy and single autologous MFAT injection between June 2017 and July 2018. Patients were assessed with repeated clinical scoring systems at baseline, 6 months, 1 and 4 years after surgery. The evaluation included demographic characteristics, arthroscopic findings, and stem cell number from injected tissue.

RESULTS

No major complications were reported during follow-up period and there was a significant increase of Lysholm knee score from baseline value of 61.7 ± 13.8 to 79.5 ± 16.9 at 4 years (p < 0.001). The WOMAC score increased from a baseline value of 66.5 ± 14.7 to 82.8 ± 15.7 at 4 years (p < 0.001) and there was a significant decrease of VAS pain score from baseline value of 6.3 ± 1.5 to 3.5 ± 2.6 at 4-year follow-up (p < 0.001). ROM improved significantly from 118.4 ± 2.6 to 122.5 ± 2.5 at 12 months (p < 0.001), but did not improve at 4 years (p > 0.05). 15 patients (32.6%) were considered treatment failures, because they required secondary surgery, further injection therapy or experienced symptoms persistence. Patient with synovitis had 75% failure rate, although synovitis did not result as a statistically significant factor influencing clinical outcome up to 4-year follow-up (p = 0.058). Age, cartilage defects severity, BMI, concomitant procedures, and stem cell number from injected MFAT did not show any significant correlation with the results.

CONCLUSIONS

MFAT intra-articular injection is a safe procedure with positive improvements up to 4-year follow-up in patients with early knee OA. These findings suggest MFAT could be a minimally invasive treatment of early knee OA with durable benefits at mid-term evaluation.

TRIAL REGISTRATION

IRB number ID-3522.

Molecular Biology of Meniscal Healing: A Narrative Review

This review provides insights at the molecular level into the current and old methods for treating meniscal injuries. Meniscal injuries have been found to have a substantial impact on the progression of osteoarthritis. In line with the "save the meniscus" approach, meniscectomy is considered a last-resort treatment. Nevertheless, it is important to note that mechanical repair alone may not achieve the complete restoration of the meniscus. A deep understanding of the healing pathways could lead to future improvements in meniscal healing. The inclusion of cytokines and chemokines has the potential to facilitate the process of tear repair or impede the inflammatory catabolic cascade. MicroRNA (miRNA) could serve as a potential biomarker for meniscal degeneration, and RNA injections might promote collagen and growth factor production. The critical aspect of the healing process is angiogenesis within the inner zone of the meniscus. The use of collagen scaffolds and the implantation of autologous meniscus fragments have been successfully integrated into clinical settings. These findings are encouraging and underscore the need for well-designed clinical trials to explore the most effective factors that can enhance the process of meniscal repair.

Comparison of the effect of dexmedetomidine intrathecal injection and intravenous infusion on subarachnoid blockade during knee arthroscopy procedures: a randomized controlled trial

BACKGROUND

Comparison of whether intrathecal dexmedetomidine prolongs spinal anesthesia-associated sensorimotor blockade more than intravenous infusion during knee arthroscopy procedures performed under subarachnoid blockade.

METHODS

Ninety patients aged 18-75 years, ASA class I-II, who underwent knee arthroscopy between October 2022 and April 2023 were randomized into intrathecal、intravenous and control groups.Subjects received three modes of administration: an intrathecal group (2 ml of 1% ropivacaine + 1 ml of 5 μg dexmedetomidine, along with intravenous saline infusion), an intravenous group (intrathecal 2 ml of 1% ropivacaine + 1 ml of 0.9% saline, with dexmedetomidine pumped intravenously at a dose of 0.5 μg/kg/h), and a control group (intrathecal 2 ml of 1% ropivacaine + 1 ml of 0.9% saline, along with intravenous saline infusion). Total analgesic duration, duration of sensory and motor blockade, Ramsay sedation score, Visual Analogue Score (VAS) at different postoperative time points, and occurrence of adverse effects were recorded.

RESULTS

The total analgesia duration was significantly longer in the intrathecal group than in the intravenous and control groups (352.13 ± 51.70 min VS 273.47 ± 62.57 min VS 241.41 ± 59.22 min, P < 0.001).The onset of sensory block was shorter in the intrathecal group than in the intravenous and control groups (4 [3-4]min VS 5 [4-5]min VS 5 [4-5]min; P < 0.001);the onset of motor block was shorter in the intrathecal group than in the intravenous group and the control group (5 [4-5]min VS 5 [5-6]min VS 6[5.5-7]min; P < 0.001).Sedation scores were higher in the intravenous group than in the intrathecal and control groups (P < 0.001). At 5 h postoperatively, the VAS score in the intrathecal group was lower than that in the intravenous and control groups (P < 0.001). At 24 h postoperatively, the VAS score in the intrathecal group was lower than that in the control group (P < 0.001). In addition, the incidence of bradycardia was significantly higher in the intravenous group than in the intrathecal and control groups (30%, 6.5%, and 3.4%, respectively; P = 0.018, P = 0.007).

CONCLUSIONS

Intrathecal administration of dexmedetomidine did prolong the total analgesia duration, as well as accelerate the onset of sensory-motor blockade compared with intravenous infusion, and did not result in any hemodynamic instability or other adverse events at the doses studied.

TRIAL REGISTRATION

This single-center, prospective, RCT has completed the registration of the Chinese Clinical Trial Center at 26/09/2023 with the registration number ChiCTR2300076170.

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.

Comparing Surgical Techniques for Meniscal Tears: A Systematic Review of Radiographic and Functional Outcomes

Meniscal tears are a common orthopedic injury. The management approaches for meniscal tears include both surgical and non-surgical procedures; however, the majority of the surgeons opt for various surgical interventions. This systematic review aimed to compare the outcomes of different surgical techniques for meniscal tears. The systemic search was carried out in various databases including PubMed, Web of Science, CINAHL, and Scopus. Studies that investigated surgical techniques for meniscal repair and published between 2010 to 2023 were included. Out of the 7,421 potential studies identified from databases and Google Scholar search, only 17 studies were included in our systemic review. The follow-up periods ranged from 6 weeks to 123 months. Adverse effects were reported in some studies, including joint line tenderness, swelling, and loss of flexion, while others reported no significant adverse events. Pull-out repair and refixation techniques demonstrated better clinical outcomes and slower arthritic progression than partial meniscectomy. Mason-Allen stitches and simple stitches yielded comparable results, and both inside-out and all-inside techniques had similar clinical and functional outcomes. This systematic review provides valuable insights into the outcomes of different surgical techniques for meniscal tears. Further studies with longer follow-up periods may help assess the long-term effectiveness of these surgical techniques.

Short-term transplantation effect of a tissue-engineered meniscus constructed using drilled allogeneic acellular meniscus and BMSCs

During the construction of tissue-engineered meniscus, the low porosity of extracellular matrix restricts the flow of nutrient solution and the migration and proliferation of cells, thus affecting the tissue remodeling after transplantation. In this study, the canine allogeneic meniscus was drilled first and then decellularized. The drilled tissue-engineered menisci (Drilled Allogeneic Acellular Meniscus + Bone Marrow Mesenchymal Stem Cells, BMSCs) were transplanted into the knee joints of model dogs. On the basis of ensuring the mechanical properties, the number of the porosity and the cells implanted in allogeneic acellular meniscus was significantly increased. The expression levels of glycosaminoglycans and type II collagen in the drilled tissue-engineered meniscus were also improved. It was determined that the animals in the experimental group recovered well-compared with those in the control group. The graft surface was covered with new cartilage, the retraction degree was small, and the tissue remodeling was good. The surface wear of the femoral condyle and tibial plateau cartilage was light. The results of this study showed that increasing the porosity of allogeneic meniscus by drilling could not only maintain the mechanical properties of the meniscus and increase the number of implanted cells but also promote cell proliferation and differentiation. After transplantation, the drilled tissue-engineered meniscus provided a good remodeling effect in vivo and played a positive role in repairing meniscal injury, protecting articular cartilage and restoring knee joint function.

Management of anterior cruciate ligament revision in adults: the 2022 ESSKA consensus: part II-surgical strategy

PURPOSE

The aim of this ESSKA consensus is to give recommendations based on scientific evidence and expert opinion to improve the diagnosis, preoperative planning, indication and surgical strategy in Anterior Cruciate Ligament revision.

METHODS

Part 2, presented herein, followed exactly the same methodology as Part 1: the so-called ESSKA formal consensus derived from the Delphi method. Eighteen questions were ultimately asked. The quality of the answers received the following grades of recommendation: Grade A (high level scientific support), Grade B (scientific presumption), Grade C (low level scientific support) or Grade D (expert opinion). All answers were scored from 1 to 9 by the raters. Once a general consensus had been reached between the steering and rating groups, the question-answer sets were submitted to the peer-review group. A final combined meeting of all the members of the consensus was then held to ratify the document.

RESULTS

The review of the literature revealed a rather low scientific quality of studies examining the surgical strategy in cases of ACL reconstruction failure. Of the 18 questions, only 1 received a Grade A rating; 5, a Grade B rating; and 9, grades of C or D. The three remaining complex questions received further evaluations for each portion of the question and were looked at in more detail for the following grades: B and D; A, C and D; or A, B, C and D. The mean rating of all questions by the rating group was 8.0 + - 1.1. The questions and recommendations are listed in the article.

CONCLUSION

ACL revision surgery, especially the surgical strategy, is a widely debated subject with many different opinions and techniques. The literature reveals a poor level of standardization. Therefore, this international European consensus project is of great importance and clinical relevance for guiding the management of ACL revision in adults.

LEVEL OF EVIDENCE

Level II.

Management of anterior cruciate ligament revision in adults: the 2022 ESSKA consensus part I-diagnostics and preoperative planning

PURPOSE

The aim of this ESSKA consensus is to give recommendations based on evidence and expert opinion to improve diagnosis, preoperative planning, indication and surgical strategy in ACL revision.

METHODS

The European expert surgeons and scientists were divided into four groups to participate in this consensus. A "literature group" (four surgeons); "steering group" (14 surgeons and scientists); "rating group" (19 surgeons) and finally "peer review group" (51 representatives of the ESSKA-affiliated national societies from 27 countries). The steering group prepared eighteen question-answer sets. The quality of the answers received grades of recommendation ranging from A (high-level scientific support), to B (scientific presumption), C (low level scientific support) or D (expert opinion). These question-answer sets were then evaluated by the rating group. All answers were scored from 1 to 9. The comments of the rating group were incorporated by the steering group and the consensus was submitted to the rating group a second time. Once a general consensus was reached between the steering and rating groups, the question-answer sets were submitted to the peer review group. A final combined meeting of all the members of the consensus was held to ratify the document.

RESULTS

The literature review for the diagnosis and preoperative planning of ACL revision revealed a rather low scientific quality. None of the 18 questions was graded A and six received a grade B. The mean rating of all the questions by the rating group was 8.4 ± 0.3. The questions and recommendations are listed below.

CONCLUSION

ACL revision surgery is a widely debated subject with many different opinions and techniques. The literature reveals a poor level of standardisation. Therefore, this international consensus project is of great importance.

LEVEL OF EVIDENCE

II.

Evaluation and Treatment of Knee Pain: A Review

Importance

Approximately 5% of all primary care visits in adults are related to knee pain. Osteoarthritis (OA), patellofemoral pain, and meniscal tears are among the most common causes of knee pain.

Observations

Knee OA, affecting an estimated 654 million people worldwide, is the most likely diagnosis of knee pain in patients aged 45 years or older who present with activity-related knee joint pain with no or less than 30 minutes of morning stiffness (95% sensitivity; 69% specificity). Patellofemoral pain typically affects people younger than 40 years who are physically active and has a lifetime prevalence of approximately 25%. The presence of anterior knee pain during a squat is approximately 91% sensitive and 50% specific for patellofemoral pain. Meniscal tears affect an estimated 12% of the adult population and can occur following acute trauma (eg, twisting injury) in people younger than 40 years. Alternatively, a meniscal tear may be a degenerative condition present in patients with knee OA who are aged 40 years or older. The McMurray test, consisting of concurrent knee rotation (internal or external to test lateral or medial meniscus, respectively) and extension (61% sensitivity; 84% specificity), and joint line tenderness (83% sensitivity; 83% specificity) assist diagnosis of meniscal tears. Radiographic imaging of all patients with possible knee OA is not recommended. First-line management of OA comprises exercise therapy, weight loss (if overweight), education, and self-management programs to empower patients to better manage their condition. Surgical referral for knee joint replacement can be considered for patients with end-stage OA (ie, no or minimal joint space with inability to cope with pain) after using all appropriate conservative options. For patellofemoral pain, hip and knee strengthening exercises in combination with foot orthoses or patellar taping are recommended, with no indication for surgery. Conservative management (exercise therapy for 4-6 weeks) is also appropriate for most meniscal tears. For severe traumatic (eg, bucket-handle) tears, consisting of displaced meniscal tissue, surgery is likely required. For degenerative meniscal tears, exercise therapy is first-line treatment; surgery is not indicated even in the presence of mechanical symptoms (eg, locking, catching).

Conclusions and Relevance

Knee OA, patellofemoral pain, and meniscal tears are common causes of knee pain, can be diagnosed clinically, and can be associated with significant disability. First-line treatment for each condition consists of conservative management, with a focus on exercise, education, and self-management.

ESSKA consensus initiative: why, when and how?

The goal of a Consensus in clinical practice is to provide daily practitioners with evidence- based recommendations on data from the literature, clinical expertise and expectations of professionals and patients. In this context, a consensus aligns with the principles of evidence-based medicine in clinical practice and is consequently regarded as a scientific work of a certain level of evidence (LOE). It is expected that such a project may contribute to filling the gap observed between scientific evidence and reality of the daily practice.A Clinical Consensus is particularly needed for those topics that are of interest to daily practice but controversial due to lack of evidence, and for which expert agreement can provide valuable support in reaching conclusions.A Consensus requires a strict methodology, based on two principles: an iterative process with independence of the involved groups and pluralism (geographical and professional representation). These processes guarantee the scientific quality of the recommendations.Among the various consensus modalities, ESSKA has adopted the Formal Consensus derived from the Delphi method, and the RAND/UCLA appropriateness method. These two methods are complementary. The first one, based on questions-answers sets, is particularly suitable for questions of terminology, diagnosis, planning, strategy. The second one is based on the concept of scenarios, particularly adapted to treatment indications. These two methods can also be used within the same consensus.The aim of this article is to define what is a consensus initiative, to detail the methodology ESSKA has chosen, and to point out the key role of the dissemination.

The Proportion of Meniscus Tears Considered Repairable, and Thus Repaired, Increased During a Single Surgeon's Practice of 20 Years

PURPOSE

The purpose of this study was to evaluate practice patterns of a single surgeon with respect to meniscectomy and meniscal repair over a 20-year period at a single institution.

METHODS

A cross-sectional descriptive study was carried out by reviewing the surgical data from the past 20 years (2002-2021) of patients who underwent arthroscopic primary meniscal surgery. Age, sex, knee and meniscus affected, morphology of the meniscal tear, meniscal radial location, location on the axial plane, tissue quality, and associated injuries were recorded. An analysis of the evolution of the characteristics of the meniscal lesions was performed according to the presence of degenerative tissue, the repairability of the lesion, and the treatment performed. Categorical data were represented in contingency tables and compared using the χ2 test for significance of differences, which was set at P < .05.

RESULTS

In total, 1,892 cases were included. A decrease in degenerative meniscal tears was found, from 63.2 in 2002 to 2006 to 9.7% in 2017 to 2021 (P < .001), while repairable tears increased from 1.6% to 82.3% P < .001); in the same periods, arthroscopic partial meniscectomy procedures declined from 75.7% to 17.7% (P < .001) while meniscal repair increased from 0.4% to 81.3% (P < .001). All types of tears increased significantly their repairability, although longitudinal tears, root tears, and ramp lesions showed the highest possibilities for repair.

CONCLUSIONS

In the present study, a drastic change in the attitude toward meniscal preservation in the past 20 years was observed, with a large increase in the proportion of tears considered repairable found in primary arthroscopic surgery (to 80% of cases) and a decrease in degenerative meniscus tears (to less than 10%).

CLINICAL RELEVANCE

In the past 2 decades, arthroscopic knee surgery has evolved such that more meniscus tears are deemed repairable, and fewer tears considered degenerative are indicated for arthroscopy.

Could a three-dimensional contralateral meniscus segmentation for allograft or scaffold sizing be possible? A prospective study

PURPOSE

Meniscal allografts and biodegradable meniscal implants are attractive surgical options for painful subtotal or total meniscectomies. In order to get the best results, these should be as similar as possible to the original meniscus in terms of shape, structure, and volume. Three-dimensional meniscus sizing could be an approach to improve the accuracy of meniscus matching. Therefore, the aims of this study were to perform a comparative morphological and volumetric analysis of the healthy meniscus based on manual tri-planar segmentation and to demonstrate that the menisci from the contralateral knee could be used as a reference in the sizing of a meniscal graft or a scaffold.

METHODS

Three-dimensional meniscal models were created based on 120 MRIs in 60 healthy subjects (bilateral knees). The differences between the pairs of menisci concerning the widths, thicknesses, lateromedial distances, anteroposterior distances, angles of coverage, and meniscal volumes were evaluated. T-Student tests were used to compare the quantitative numerical variables of the different groups. Pearson's linear regression was used to determine if correlations existed between demographic variables (age, gender, height, weight) and anatomical parameters. Statistical significance was set at p < 0.05.

RESULTS

Comparing the 120 pairs of menisci of each subject, there was no statistically significant difference for all parameters studied for both the medial and lateral meniscus. When the measurements were stratified by gender, statistically significant differences were observed for all parameters except meniscal coverage angles. We observed that anteroposterior and lateromedial distances were positively correlated with height and body mass index both at the level of the medial meniscus (r = 0.68; r = 0.66; r = 0.65; and r = 0.63) and lateral (r = 0.68; r = 0.69; r = 0.61; and r = 0.60).

CONCLUSION

Our study demonstrated that the intra-individual 3D shapes of the left and right menisci are very similar. Therefore, the contralateral side could be used as a template for the 3D sizing of meniscal allografts or meniscal implants.

Introduction of an easy-to-operate arthroscopic test in detecting and treatment of meniscal instability: "suction drift" test

OBJECTIVE

To explore the surgical guidance value of "suction drift" in osteoarticular meniscal instability.

METHODS

The clinical data of 104 patients with significant knee symptoms following surgery were retrospectively analyzed. "Suction drift" was diagnosed in both groups. Depending on the treatment, patients treated with conventional debridement were assigned to group A, and those treated by meniscus suture until the disappearance of the "suction drift" phenomenon were included in group B. All patients were followed up for a minimum of 6 months after surgery. The postoperative Visual Analogue Scale (VAS) score, Lysholm knee score and the occurrence of meniscus-related symptoms were compared between the two groups.

RESULTS

After puncture, 78 patients (75.0%) had excessive displacement of the meniscus, with 53 (67.9%) of them being followed-up for at least 6 months. Twenty-five patients in group A and twenty-eight in group B were included in the final analysis (The number of patients with "suction drift" in two groups was tested to be comparable, P>0.05). VAS score was significantly decreased and Lysholm knee score was markedly increased in both groups after treatment, with lower VAS score and higher Lysholm knee score in group B compared with group A. In addition, group A had a significantly higher incidence of meniscus-related symptoms (joint space tenderness, joint clicks, and noose sensation) than group B.

CONCLUSIONS

"Suction drift" is a quick and easy-to-operate arthroscopic test, which can not only diagnose meniscus instability due to knee osteoarthrosis-induced meniscus degeneration, but also help determine the recovery of meniscus stability after suture, and significantly relieve symptoms.

Age and synovitis affect the results of the treatment of knee osteoarthritis with Microfragmented Autologous Fat Tissue

PURPOSE

This study aims to assess the effectiveness of Microfragmented Autologous Fat Tissue (MFAT) treatment for knee osteoarthritis and to investigate whether patients' pre-treatment clinical condition, such as synovitis, correlates with clinical outcomes, to identify potential predicting factors for the success or failure of the treatment.

METHODS

In this prospective Cohort Study Level II multicentric trial, consecutive patients with a diagnosis of early/mild osteoarthritis and failure of previous conservative measures were enrolled to undergo diagnostic arthroscopy and a single MFAT injection. Patients were assessed with repeated scoring systems at baseline, 6 months, and 12 months after surgery. The demographic features, the arthroscopic findings, the immunophenotype of injected tissue and the histologic examination of synovia of failed patients were analyzed.

RESULTS

Data from 91 patients showed a significant improvement in Lysholm, WOMAC scores at 1-year follow-up (p < 0.001). A significant decrease in VAS score was observed, while a significant improvement of measured flexion angle was registered at 1 year (p < 0.001). No major complications were reported. Age and synovitis were identified as significant factors influencing the clinical outcome (p < 0.05). Body mass index, previous or concomitant procedures, and specific cartilage defects had no influence. The mean number of injected adipose tissue-derived mesenchymal stem cells seem not to correlate with the clinical outcome.

CONCLUSION

MFAT is effective in reducing pain when used with a single dose injection in early/mild OA of the knee, without major complications. Age over 60 and synovitis may be predictive for persistent pain at one year and should be considered before indications.

Health-economic evaluation of meniscus tear treatments: a systematic review

PURPOSE

To evaluate the overall evidence of published health-economic evaluation studies on meniscus tear treatment.

METHODS

Our systematic review focuses on health-economic evaluation studies of meniscus tear treatment interventions found in PubMed and Embase databases. A qualitative, descriptive approach was used to analyze the studies' results and systematically report them following PRISMA guidelines. The health-economic evaluation method for each included study was categorized following one of the four approaches: partial economic evaluation (PEE), cost-effectiveness analysis (CEA), cost-benefit analysis (CBA), or cost-utility analysis (CUA). The quality of each included study was assessed using the Consensus on Health Economic Criteria (CHEC) list. Comparisons of input variables and outcomes were made, if applicable.

RESULTS

Sixteen studies were included; of these, six studies performed PEE, seven studies CUA, two studies CEA, and one study combined CBA, CUA, and CEA. The following economic comparisons were analyzed and showed the respective comparative outcomes: (1) meniscus repair was more cost-effective than arthroscopic partial meniscectomy (meniscectomy) for reparable meniscus tear; (2) non-operative treatment or physical therapy was less costly than meniscectomy for degenerative meniscus tear; (3) physical therapy with delayed meniscectomy was more cost-effective than early meniscectomy for meniscus tear with knee osteoarthritis; (4) meniscectomy without physical therapy was less costly than meniscectomy with physical therapy; (5) meniscectomy was more cost-effective than either meniscus allograft transplantation or meniscus scaffold procedure; (6) the conventional arthroscopic instrument cost was lower than laser-assisted arthroscopy in meniscectomy procedures.

CONCLUSION

Results from this review suggest that meniscus repair is the most cost-effective intervention for reparable meniscus tears. Physical therapy followed by delayed meniscectomy is the most cost-effective intervention for degenerative meniscus tears. Meniscus scaffold should be avoided, especially when implemented on a large scale.

LEVEL OF EVIDENCE

Systematic review of level IV studies.

Three-Dimensional Imaging and Quantitative Analysis of Blood Vessel Distribution in The Meniscus of Transgenic Mouse after Tissue Clearing

OBJECTIVE

Blood supply to the meniscus determines its recovery and is a reference for treatment planning. This study aimed to apply tissue clearing and three-dimensional (3D) imaging in exploring the quantitative distribution of blood vessels in the mouse meniscus.

MATERIALS AND METHODS

In this experimental study, tissue clearing was performed to treat the bilateral knee joints of transgenic mice with fluorescent vascular endothelial cells. Images were acquired using a light sheet microscope and the vascular endothelial cells in the meniscus was analysed using 3D imaging. Quantitative methods were employed to further analyse the blood vessel distribution in the mouse meniscus.

RESULTS

The traditional three-equal-width division of the meniscus is as follows: the outer one-third is the red-red zone (RR), the inner one-third is the white-white zone (WW), and the transition area is the red-white zone (RW). The division revealed significant signal differences between the RW and WW (P<0.05) zones, but no significant differences between the RR and RW zones, which indicated that the division might not accurately reflect the blood supply of the meniscus. According to the modified division (4:2:1) in which significant differences were ensured between the adjacent zones, we observed that the width ratio of each zone was 38 ± 1% (RR), 24 ± 1% (RW), and 38 ± 2% (WW). Furthermore, the blood supply to each region was verified. The anterior region had the most abundant blood supply. The fluorescence count in the anterior region was significantly higher than in the central and posterior regions (P<0.05). The blood supply of the medial meniscus was superior to the lateral meniscus (P<0.05).

CONCLUSION

Analysis of the blood supply to the mouse meniscus under tissue clearing and 3D imaging reflect quantitative blood vessel distribution, which would facilitate future evaluations of the human meniscus and provide more anatomical references for clinicians.

Medial Meniscus Posterior Root Tear: How Far Have We Come and What Remains?

Medial meniscus posterior root tears (MMRTs), defined as tears or avulsions that occur within 1 cm of the tibial attachment of the medial meniscus posterior root, lead to biomechanically detrimental knee conditions by creating a functionally meniscal-deficient status. Given their biomechanical significance, MMRTs have recently been gaining increasing interest. Accordingly, numerous studies have been conducted on the anatomy, biomechanics, clinical features, diagnosis, and treatment of MMRTs, and extensive knowledge has been accumulated. Although a consensus has not yet been reached on several issues, such as surgical indications, surgical techniques, and rehabilitation protocols, this article aimed to comprehensively review the current knowledge on MMRTs and to introduce the author's treatment strategies.

Meniscus tears treatment: The good, the bad and the ugly-patterns classification and practical guide

Over the years, several studies demonstrated the crucial role of knee menisci in joint biomechanics. As a result, save the meniscus has become the new imperative nowadays, and more and more studies addressed this topic. The huge amount of data on this topic may create confusion in those who want to approach this surgery. The aim of this review is to provide a practical guide for treatment of meniscus tears, including an overview of technical aspects, outcomes in the literature and personal tips. Taking inspiration from a famous movie directed by Sergio Leone in 1966, the authors classified meniscus tears in three categories: The good, the bad and the ugly lesions. The inclusion in each group was determined by the lesion pattern, its biomechanical effects on knee joint, the technical challenge, and prognosis. This classification is not intended to substitute the currently proposed classifications on meniscus tears but aims at offering a reader-friendly narrative review of an otherwise difficult topic. Furthermore, the authors provide a concise premise to deal with some aspects of menisci phylogeny, anatomy and biomechanics.

Moving orthopaedic procedures out of the operating theatre:Outpatient needle arthroscopy can reduce cost & waste, and increase inpatient capacity compared to conventional knee arthroscopy

BACKGROUND

Needle arthroscopy (NA) is an emerging technique that could streamline pathways, facilitate timely care, and reduce service burden. The primary aim was to assess the practical and economic viability of an outpatient NA service. Secondary aims were to assess the relative costs and benefits compared to a conventional arthroscopy (CA) service.

METHODS

This service feasibility study was conducted between 2021-2022 in a high-volume national treatment centre. A NA pathway was established for patients with chronic soft tissue pathology or early degenerative knee disease. The pathway was evaluated in terms of: i) cost; ii) efficiency, and iii) waste production, and an assessment was conducted of the patient-related and service-related effects.

RESULTS

The cost of the NA pathway was £1555.20 per patient, compared to £2,351.53 for CA. Time to management was 45 days for NA versus 180 days for CA. The NA pathway involved two hospital attendances, whereas CA required a minimum of three. NA cases produced 1.4 kg of non-recyclable waste compared to 5.0 kg produced by CA. For every two cases managed by NA instead of CA, capacity for one additional obligate-inpatient procedure was created.

CONCLUSIONS

The NA pathway offers a technically and economically viable approach for the management of refractory knee symptoms in the context of chronic soft tissue or early degenerative disease. NA placed less demand on hospital resources, produced two-thirds less non-recyclable waste, and is amenable to a one-stop clinic approach. Clinical studies focused on objective and patient-reported outcome measures are required to assess clinical efficacy.

Aquatic vs. land-based exercise after arthroscopic partial meniscectomy in middle-aged active patients with a degenerative meniscal tear: A randomized, controlled study

BACKGROUND

Awareness of the value of aquatic exercise (AE) in the postoperative rehabilitation has increased, and several inherent advantages of AE, such as adjustment of both resistance and muscle strengthening parameters makes good rationale for its inclusion in postoperative rehabilitation. This study aimed to determine and compare the benefits of AE and land-based exercise (LBE) on pain, functionality, and quality of life after arthroscopic partial meniscectomy (APM).

METHODS

This randomized controlled study included 30 middle-aged (35-50), physically active patients who were randomized into LBE (n = 15) and AE (n = 15) groups after APM for a degenerative meniscal tear. Visual analogue scale (VAS), Short Form-36 (SF-36), single-leg hop test and Lysholm questionnaire scores in addition to isokinetic muscle strength values were evaluated at baseline, at fourth week immediately after cessation of exercise program and at eighth week follow-up visits. The exercise sessions were conducted in 1-h sessions per day, three days a week for a total of four weeks.

RESULTS

Significant improvement was observed in the VAS, single-leg hop test, Lysholm questionnaire, and most of SF-36 subscale scores in both groups at both fourth and eighth follow-ups. Isokinetic dynamometer revealed significant improvement in the peak torque values for extension at angular velocities of 60° and 180° at both follow-ups in the AE group. LBE group showed significant improvement in the peak torque value for extension only at an angular velocity of 60° only at fourth week follow-up. There was no significant difference between groups for any of these parameters at any of the follow-ups.

CONCLUSION

Both AE and LBE programs had significantly improved pain, function, isokinetic muscle strength, and quality of life in patients after APM. Either type of exercise is essential as part of the rehabilitation protocol for good clinical outcomes after APM and should not be neglected (level II).

CLINICALTRIALS REGISTRATION NUMBER

NCT04925726.

Effectiveness of Rehabilitation for Knee Osteoarthritis Associated With Isolated Meniscus Injury: A Scoping Review

Meniscus tear is the most common type of injury to the meniscus and occurs more frequently on the medial compartments than the lateral compartments. Further, it is often caused by trauma or degenerative processes and can occur anywhere on either the meniscus, anterior horn, posterior horn, or midbody. Treatment of meniscus injuries is likely to greatly impact the evolution of osteoarthritis (OA) as meniscus injuries can gradually progress to knee OA. Hence, treatment of these injuries is important for managing the progression of OA. While the types of meniscus injuries and symptoms have been reported previously, the effectiveness of rehabilitation according to the degree of meniscus injury (e.g., vertical, longitudinal, radial, and posterior horn tears) remains unknown. In this review, we aimed to investigate whether rehabilitation for knee OA associated with isolated meniscus injuries varies with the degree of injury and determine the effects of rehabilitation on outcomes. We searched PubMed, Cumulative Index to Nursing and Allied Health Literature, Web of Science, and Physiotherapy Evidence Database for studies published before September 2021. Studies on ≥40-year-old patients with knee OA and isolated meniscus injury were included for analysis. The types of meniscus injury were classified as longitudinal, radial, transverse, flap, combined, or avulsion of the anterior and posterior roots of the medial meniscus, and assigned knee arthropathy grades of 0-4 according to the Kellgren-Lawrence classification. The exclusion criteria were meniscus injury, combined meniscus and ligament injury, and knee OA associated with combined injury in patients <40 years of age. There were no restrictions on the region, race, or gender of participants, or language or research format of the studies. The outcome measures were the Knee Osteoarthritis Outcome Score, Western Ontario and McMaster Universities Osteoarthritis Index Score, Visual Analog Scale or Numeric Rating Scale, Western Ontario Meniscal Evaluation Tool, International Knee Documentation Committee Score, Lysholm Score, 36-Item Short-Form Health Survey, one-leg hop test, timed up and go test, and re-injury and muscle strength. A total of 16 reports met these criteria. In studies that did not classify or distinguish degrees of meniscus injury, the effects of rehabilitation were generally favorable in the medium-to-long term. In cases where the intervention was not sufficiently effective, patients were recommended either arthroscopic partial meniscectomy or total knee replacement. Studies on medial meniscus posterior root tear did not confirm the effectiveness of rehabilitation due to the short intervention period. Further, Knee Osteoarthritis Outcome Score cut-offs, clinically important differences in Western Ontario and McMaster Universities Osteoarthritis Index, and minimum important changes in patient-specific functional scales were reported. Of the 16 studies reported in this review, nine met the definition. This scoping review has a few limitations such as the effect of rehabilitation alone could not be examined, and the intervention effectiveness differed at short-term follow-up. In conclusion, there was a gap in evidence regarding the rehabilitation of knee OA after isolated meniscus injury due to differences in intervention duration and methods. In addition, on short-term follow-up, intervention effects varied across studies.

Age alone does not affect the joint survivorship after arthroscopic partial meniscectomy for degenerative medial meniscus tears: a propensity-score matched survival analysis

PURPOSE

To evaluate the effect of age itself on the joint survivorship after arthroscopic partial meniscectomy (APM) for degenerative medial meniscus tears (DMTs).

METHODS

Patients undergoing APM for DMTs during 1999-2010 were retrospectively reviewed. The inclusion criteria were as follows: (1) DMTs identified on preoperative MRI scans, (2) no definite history of trauma, and (3) follow-up duration more than 5 years. In evaluation of the joint survivorship, the endpoint was defined as conversion to arthroplasty (or realignment osteotomy) or progression to Kellgren-Lawrence grade 4. The study population was divided into older and younger groups by a cutoff age at which the difference in the joint survival rates was maximized, using a time-dependent receiver operating characteristic (ROC) curve. The two groups were then matched based on propensity scores. The joint survival rates were compared between the groups using Kaplan-Meier analysis, before and after propensity score matching (PSM).

RESULTS

A total of 633 knees were included. The cutoff age was calculated as 60 years. Before PSM, 239 knees were allocated to the older group (≥ 60 years) and 394 knees to the younger group (< 60 years). A significant difference in the joint survival rates was noted between the groups (log-rank test, p < 0.001). After PSM, 183 knees remained in each group. The difference in the survival rates was no more statistically significant (n.s.). The latest Lysholm scores of the older and the younger groups before PSM were 72.2 ± 20.8 and 79.9 ± 19.6, respectively (p < 0.001); however, the scores after PSM were 73.2 ± 20.3 and 77.4 ± 20.5, respectively (n.s.).

CONCLUSIONS

Joint survivorship after APM was affected by other factors associated with the aging process, such as cartilage status and meniscal tear pattern, rather than age itself. Advanced age should not be the only reason for precluding APM in treatment of DMTs. APM is a viable option when treating DMTs in elderly patients if adopted with caution. According to this study, a surgeon should assess the age-related factors when he considers APM in elderly patients.

LEVEL OF EVIDENCE

III.

Comparison of Various Modalities in the Treatment of Early Knee Osteoarthritis: An Unsolved Controversy

Introduction Osteoarthritis (OA) of the knee is a common degenerative disease, relatively more prevalent among middle-aged people. It is one of the major reasons for walking-related disability. Recently, early knee OA has been seen as an imperative concern in many younger patients who struggle with the disabling effect of pain and management is extremely speckled. Degenerative changes such as loss of cartilage, subchondral bone changes, synovial inflammation, and meniscal degeneration are seen in OA. Symptoms are relieved by therapeutic strategies such as lifestyle behaviour changes, exercise, and oral and injectable medications. Intra-articular delivery of drugs acts as a direct effect on the target tissue, which grossly reduces side effects and is commonly preferred nowadays. The current study is a comparative assessment of the functional outcomes associated with various treatment modalities in osteoarthritis of the knee, i.e., arthroscopic debridement, arthroscopic debridement with microfracture, platelet-rich plasma (PRP) injection, and hyaluronic acid. Methods A retrospective observational hospital-based study was conducted among 139 cases of osteoarthritis. Patients aged between 40-60 years with diagnosed Kellgren- Lawrence grade 1 and 2 OA knee, who underwent arthroscopic debridement, arthroscopic debridement with microfracture, PRP injection, or hyaluronic acid in our institute were included. Results The mean age was 52.83 + 6.8 years. The mean BMI was 27.45 + 1.6 kg/m². At the time of diagnosis of OA, the mean visual analogue scale for pain (VAS) and Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores were 7.26 +0.7 and 55.30 + 2.21 respectively. Out of the total, 88 (63.3%) were females and 51 (36.7%) were males. Right-sided OA knee was seen in the majority of study participants. Of the total, 93 (66.9%) patients had grade 2 and only 46 (33.1%) had grade 1 OA. A statistically significant difference was found between the mean VAS and WOMAC score at the time of diagnosis, three weeks, three months, as well as at six months of therapy. In the hyaluronic acid treatment, no significant difference was found in mean VAS and WOMAC scores. Conclusion Various treatments are available for early-diagnosed OA. According to the findings of this study, overall improvement was seen in VAS and WOMAC scores at the follow-up after six months of specific treatment. In a period over six months, arthroscopic debridement with micro-fracture was more effective and safe when compared with other modalities of treatment for early OA knee. Also, injection of PRP was superior to other methods for VAS pain reduction, and WOMAC-pain and WOMAC-stiffness scores improved at one month.

Has Arthroscopic Meniscectomy Use Changed in Response to the Evidence? A Large-database Study From Spain

BACKGROUND

Several randomized clinical trials on the treatment of meniscal tears have shown that surgery is not superior to nonoperative treatment in middle-aged and older adults. However, clinical practice has not changed consistently worldwide in response to this evidence, and arthroscopic meniscectomy remains one of the most frequently performed operations.

QUESTIONS/PURPOSES

(1) How has the use of arthroscopic meniscectomy changed in Spain between 2003 and 2018, particularly in middle-aged (35 to 59 years) and older patients (over 60 years) relative to younger patients? (2) How have surgical volumes changed across different healthcare areas in the same health system? (3) How has the proportion of outpatient versus inpatient arthroscopic procedures changed over time?

METHODS

Data on all 420,228 arthroscopic meniscectomies performed in Spain between 2003 and 2018 were obtained through the Atlas of Variations in Medical Practice project (these years were chosen because data in that atlas for 2002 and 2019 were incomplete). This database has been promoted by the Spanish Health Ministry since 2002, and it collects basic information on all admissions to public and public-private partnership hospitals. The Spanish population of 2003 was used to calculate age- and sex-standardized rates of interventions per 10,000 inhabitants and year. To assess the change in standardized rates among the age groups over the study period, a linear regression analysis was used. Standard small-area variation statistics were used to analyze variation among healthcare areas. Data on outpatient surgery and length of stay for inpatient procedures were also included.

RESULTS

The standardized rate of arthroscopic meniscectomy in Spain in 2003 was 4.8 procedures per 10,000 population (95% CI 3.9 to 5.6), while in 2018, there were 6.3 procedures per 10,000 population (95% CI 5.4 to 7.3), which represents an increase of 33%. Standardized rates increased slightly in the age group < 35 years (0.06 interventions per 10,000 inhabitants per year [95% CI 0.05 to 0.08]), whereas they increased more markedly in the age groups of 35 to 59 years (0.14 interventions per 10,000 inhabitants per year [95% CI 0.11 to 0.17]) and in those 60 years and older (0.13 interventions per 10,000 inhabitants per year [95% CI 0.09 to 0.17]). The variability among healthcare areas in the meniscectomy rate progressively decreased from 2003 to 2018. In 2003, 32% (6544 of 20,384) of knee arthroscopies were performed on an outpatient basis, while in 2018, these accounted for 67% (19,573 of 29,430).

CONCLUSION

We observed a progressive increase in arthroscopic meniscectomies in Spain; this procedure was more prevalent in older patients presumed to have degenerative pathologic findings. This increase occurred despite increasing high-level evidence of a lack of the additional benefit of meniscectomy over other less-invasive treatments in middle-aged and older people. Our study highlights the need for action in health systems with the use of financial, regulatory, or incentive strategies to reduce the use of low-value procedures, as well as interventions to disseminate the available evidence to clinicians and patients. Research is needed to identify the barriers that are preventing the reversal of interventions that high-quality evidence shows are ineffective.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Biomechanical assessment of disease outcome in surgical interventions for medial meniscal posterior root tears: a finite element analysis

BACKGROUND

The adverse consequences of medial meniscus posterior root tears have become increasingly familiar to surgeons, and treatment strategies have become increasingly abundant. In this paper, the finite element gait analysis method was used to explore the differences in the biomechanical characteristics of the knee joint under different conditions.

METHODS

Based on CT computed tomography and MR images, (I) an intact knee (IK) model with bone, cartilage, meniscus and main ligaments was established. Based on this model, the posterior root of the medial meniscus was resected, and (ii) the partial tear (PT) model, (iii) the entire radial tear (ERT) model, and (iv) the entire oblique tear (EOT) model were established according to the scope and degree of resection. Then, the (v) meniscus repair (MR) model and (vi) partial meniscectomy (PM) model were developed according to the operation method. The differences in stress, displacement and contact area among different models were evaluated under ISO gait loading conditions.

RESULTS

Under gait loading, there was no significant difference in the maximum stress of the medial and lateral tibiofemoral joints among the six models. Compared with the medial tibiofemoral joint stress of the IK model, the stress of the PM model increased by 8.3%, while that of the MR model decreased by 18.9%; at the same time, the contact stress of the medial tibiofemoral joint of the ERT and EOT models increased by 17.9 and 25.3%, respectively. The displacement of the medial meniscus in the ERT and EOT models was significantly larger than that in the IK model (P < 0.05), and the tibial and femoral contact areas of these two models were lower than those of the IK model (P < 0.05).

CONCLUSIONS

The integrity of the posterior root of the medial meniscus plays an important role in maintaining normal tibial-femoral joint contact mechanics. Partial meniscectomy is not beneficial for improving the tibial-thigh contact situation. Meniscal repair has a positive effect on restoring the normal biomechanical properties of the medial meniscus.

Comparison of adhesion of thawed and cultured synovial mesenchymal stem cells to the porcine meniscus and the relevance of cell surface microspikes

BACKGROUND

Placement of a cultured synovial mesenchymal stem cell (MSC) suspension on a repaired meniscus for 10 min accelerated meniscus repair. Upon placement of the MSC suspension on the meniscus, microspikes projecting from the MSC surface trap meniscus fibers and promote MSC adhesion. Thawed cryopreserved MSCs are preferred materials for meniscus repair, as they can be transplanted without additional culture. However, the adhesion ability of thawed cryopreserved MSCs is unknown. Here, we compared the proportion of cultured versus thawed MSCs adhering to a porcine meniscus immediately and 10 min after placement. We also investigated the relationship between adhesion and the number of microspikes on the synovial MSCs.

METHODS

Synovial MSCs were prepared from the knees of four donors with osteoarthritis. The "cultured MSCs" were thawed MSCs that were re-cultured and suspended in PBS for transplantation. A similarly prepared suspension was cryopreserved, thawed again, suspended in PBS, and used without further culture as the "thawed MSCs." MSCs with at least three microspikes in SEM images were defined as microspike-positive MSCs. Porcine meniscus surfaces were abraded, cut into a cylindrical shape, and treated with MSC suspension. Non-adherent cells were counted immediately and again 10 min after placement to calculate the adhesion proportion.

RESULTS

The proportion of microspike-positive MSCs was significantly higher in thawed (53 ± 3%) than in cultured (28 ± 5%) MSC suspensions. MSC adhesion to the meniscus was significantly better for the thawed than for the cultured MSC suspensions immediately after placement on the meniscus, but no differences were detected after 10 min. The proportion of MSCs with microspikes in the cell suspension was significantly correlated with the proportion of adhered MSCs immediately after the placement, but not 10 min later. Addition of FBS to the cryopreservation medium promoted a concentration-dependent increase in the proportion of microspike-positive cells.

CONCLUSIONS

Thawed MSCs adhered better than cultured MSCs immediately after placement, but adhesion was similar for both MSC preparations after 10 min. Immediately after placement, the presence of microspikes was associated with better adhesion of synovial MSCs to the meniscus.

Hidden Unstable Flap Should Be Suspected in Treating Intractable Pain from Medial Meniscus Horizontal Tear

(1) Background: The medial meniscus horizontal tear (MMHT) is known as a lesion that can be treated nonoperatively. However, some patients show persistent pain despite conservative treatments. In arthroscopic surgery for MMHT, surgeons often encounter unexpected unstable flaps, which can explain the intractable pain. This study aimed to determine whether preoperative factors could predict the hidden unstable flaps in MMHT. (2) Materials and Methods: Medical records of 65 patients who underwent arthroscopic partial meniscectomy (APM) for isolated MMHT during 2016–2020 were retrospectively reviewed. APM was indicated when there was no severe chondral degeneration and intractable localized knee pain in the medial compartment did not resolve despite conservative treatments. Unstable flap was confirmed based on arthroscopic images and operation notes. Each of the following preoperative factors were investigated using logistic regression analyses to determine whether they can predict an unstable flap: age, sex, body mass index, lower limb alignment, trauma history, mechanical symptoms, symptom duration, visual analogue scale (VAS), Lysholm score, cartilage wear of the medial compartment, and subchondral bone marrow lesion (BML). (3) Results: Hidden unstable flaps were noted in 45 (69.2%) patients. Based on univariate analyses for each preoperative factor, age, symptom duration, cartilage wear (of the femoral condyle and the tibial plateau), and subchondral BML were included in the multivariate logistic regression analysis. The results showed that symptom duration (p = 0.026, odds ratio = 0.99) and high-grade cartilage wear of the medial femoral condyle (p = 0.017, odds ratio = 0.06) were negatively associated with unstable flaps. A receiver operating characteristic curve was used to calculate the symptom duration at which the prediction of unstable flaps was maximized, and the cutoff point was 14.0 months. (4) Conclusions: More than two thirds of patients suffering intractable pain from MMHT had hidden unstable flaps. However, APM should not be considered when the symptom duration is more than 14 months or high-grade cartilage wear of the medial femoral condyle is noted.

The role of patient characteristics and the effects of angiogenic therapies on the microvasculature of the meniscus: A systematic review

BACKGROUND

Considerable interindividual variation in meniscal microvascularization has been reported. The purpose of this review was to identify which patient characteristics affect meniscal microvascularization and provide a structured overview of angiogenic therapies that influence meniscal neovascularization.

METHODS

A systematic literature search was undertaken using PubMed, Embase, Web of Science, Cochrane library and Emcare from inception to November 2021. Studies reporting on (1) Patient characteristics that affect meniscal microvascularization, or (2) Therapies that induce neovascularization in meniscal tissue were included. Studies were graded in quality using the Anatomical Quality Assessment (AQUA) tool. The study was registered with PROSPERO(ID:CRD42021242479).

RESULTS

Thirteen studies reported on patient characteristics and eleven on angiogenic therapies. The influence of Age, Degenerative knee, Gender, and Race was reported. Age is the most studied factor. The entire meniscus is vascularized around birth. With increasing age, vascularization decreases from the inner to the peripheral margin. Around 11 years, blood vessels are primarily located in the peripheral third of the menisci. There seems to be a further decrease in vascularization with increasing age in adults, yet conflicting literature exists. Degenerative changes of the knee also seem to influence meniscal vascularization, but evidence is limited. Angiogenic therapies to improve meniscal vascularization have only been studied in preclinical setting. The use of synovial flap transplantation, stem cell therapy, vascular endothelial growth factor, and angiogenin has shown promising results.

CONCLUSION

To decrease failure rates of meniscal repair, a better understanding of patient-specific vascular anatomy is essential. Translational clinical research is needed to investigate the clinical value of angiogenic therapies.

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.

Natural biopolymer scaffold for meniscus tissue engineering

Meniscal injuries caused by trauma, degeneration, osteoarthritis, or other diseases always result in severe joint pain and motor dysfunction. Due to the unique anatomy of the human meniscus, the damaged meniscus lacks the ability to repair itself. Moreover, current clinical treatments for meniscal injuries, including meniscal suturing or resection, have significant limitations and drawbacks. With developments in tissue engineering, biopolymer scaffolds have shown promise in meniscal injury repair. They act as templates for tissue repair and regeneration, interacting with surrounding cells and providing structural support for newly formed meniscal tissue. Biomaterials offer tremendous advantages in terms of biocompatibility, bioactivity, and modifiable mechanical and degradation kinetics. In this study, the preparation and composition of meniscal biopolymer scaffolds, as well as their properties, are summarized. The current status of research and future research prospects for meniscal biopolymer scaffolds are reviewed in terms of collagen, silk, hyaluronic acid, chitosan, and extracellular matrix (ECM) materials. Overall, such a comprehensive summary provides constructive suggestions for the development of meniscal biopolymer scaffolds in tissue engineering.

Declining trends in arthroscopic meniscus surgery and other arthroscopic knee procedures in Denmark: a nationwide register-based study

BACKGROUND AND PURPOSE

A doubling of arthroscopic meniscal procedures was observed in Denmark from 2000 to 2011, but arthroscopic meniscal procedures for degenerative meniscal tears are no longer recommended. We performed an updated investigation of Danish meniscal procedure trends in the private and public healthcare sectors in Denmark from 2006 to 2018, including trends for other arthroscopic knee procedures.

PATIENTS AND METHODS

We extracted data on the 5 most commonly registered arthroscopic knee procedures (diagnostic arthroscopy, meniscal surgery, anterior cruciate ligament reconstruction, synovectomy, and cartilage resection) from the Danish National Patient Register from January 1, 2006 to December 31, 2018, linked with the Danish Population Statistic Register, to obtain data on age and sex.

RESULTS

414,253 arthroscopic knee procedures were registered during 315,290 surgeries on 244,113 individual patients in the study period. For meniscal procedures, the highest incidence was observed in 2010 (319 per 105 persons/year, 95% CI 314-323) and the lowest in 2018 (173 per 105 persons/year, CI 169-176), corresponding to relative decrease of 46% from 2010 to 2018. Remaining arthroscopic procedures also showed declining trends, with lowest incidence for all procedures in 2018.

INTERPRETATION

A large decrease in the incidence for arthroscopic meniscal procedures was observed from 2010 to 2018, possibly in response to mounting evidence of limited benefit of this procedure for degenerative knee disease. All other investigated arthroscopic knee procedures also declined in the same period.

Arthroscopic repair of degenerative medial meniscus tears in patients aged over 45 years resulted in favorable clinical outcomes and low clinical failure rates at a minimum 2-year follow-up

PURPOSE

This study aimed to investigate clinical and radiological results of arthroscopic repair for isolated medial degenerative meniscus tears (DMTs) in patients over 45 years old at a minimum 2-year follow-up.

METHODS

From 2013 to 2017, patients aged over 45 years with isolated medial DMT refractory to conservative management or with true mechanical symptoms who had undergone arthroscopic repair were retrospectively reviewed. Arthroscopic meniscus repair was performed using all-inside or all-inside and inside-out technique in combination with bone marrow venting procedure. Tear patterns were classified according to arthroscopic findings. Magnetic resonance imaging (MRI) and outcome evaluations, including Lysholm score, Tegner activity score, and International Knee Documentation Committee (IKDC) score, were evaluated preoperatively and at the final follow-up. International Cartilage Repair Society grades of the medial compartments and MRI signal at tear sites were assessed preoperatively and at the final follow-up. A grade 0 to 2 signal at the repair site suggested a healed meniscus, whereas a grade 3 signal suggested an unhealed meniscus. Clinical failure was determined according to Barrett criteria.

RESULTS

Twenty-seven patients (mean age, 57.7 ± 7.4 years) were enrolled. The mean follow-up was 52.0 ± 15.6 months. Among tear patterns, 48% were complex tears, 30% were horizontal tears, and 22% were other patterns. The mean Lysholm score and IKDC score significantly improved from 53 ± 25 to 89 ± 15 (p < 0.001) and 34 ± 24 to 72 ± 15 (p < 0.001) at the final follow-up, respectively. The median Tegner activity score significantly improved from 1 (range 1-4) to 4 (range 2-7, p < 0.001). Three (11%) patients were considered clinical failures, and five patients (19%) had cartilage lesion progression. At the final follow-up, MRI showed grade 0 in one (4%) patient, grade 1 in nine (33%) patients, grade 2 in six (22%) patients, and grade 3 in eleven (41%) patients.

CONCLUSION

Arthroscopic repair of isolated medial DMT refractory to conservative management or with true mechanical symptoms in patients aged over 45 years had good to excellent clinical outcomes with low clinical failure rates, despite unhealed menisci being observed on MRI in 41% of patients at a mean 4.3-year follow-up. Arthroscopic repair could be a treatment option for these patients.

LEVEL OF EVIDENCE

IV.

Arthroscopic surgery or exercise therapy for degenerative meniscal lesions: a systematic review of systematic reviews

BACKGROUND

Arthroscopic partial meniscectomy (APM) is widely applied for the treatment of degenerative meniscal lesions in middle-aged patients; however, such injury is often associated with mild or moderate osteoarthritis and has been reported by MRI in asymptomatic knees. Previous studies suggested, in most patients, a lack of benefit of surgical approach over conservative treatment, yet many controversies remain in clinical practice. Our aims were to assess the functional and pain scores between exercise therapy and arthroscopic surgery for degenerative meniscal lesions and to evaluate the methodological quality of the most recent systematic reviews (SRs).

METHODS

Two authors independently searched PubMed and Google Scholar for SRs comparing the outcome (in knee pain and functionality) of arthroscopic treatment and exercise therapy or placebo for degenerative meniscal lesions. The timeframe set was from 2009 to 2019 included.

RESULTS

A total of 13 SRs were selected. Two reviewers independently assessed the methodological quality of each paper using the AMSTAR 2 tool: seven scored as "moderate," four obtained a "low" grade while the remaining two were evaluated as "critically low." SRs agreed that in middle-aged patients with degenerative meniscal lesions arthroscopic surgery appears to grant no long-term improvement in pain and function over exercise therapy or placebo.

CONCLUSIONS

Conservative treatment based on physical therapy should be the first-line management. However, most SRs revealed subgroups of patients that fail to improve after conservative treatment and find relief when undergoing surgery. In the future, randomized controlled trials, evidence should be looked for that APM can be successful in case of the unsatisfactory results after physical therapy.

Variation in Patient-Reported Outcomes in Young and Old Patients Up to 4 to 6 Years After Arthroscopic Partial Meniscectomy

OBJECTIVE

To assess the variation in changes in patient-reported outcomes 4 to 6 years after arthroscopic partial meniscectomy (APM).

DESIGN

Prospective cohort study.

SETTING

Orthopedic departments at public hospitals.

PATIENTS

Patients (n = 447) from the Knee Arthroscopy Cohort Southern Denmark undergoing APM.

INTERVENTIONS

All patients underwent APM.

MAIN OUTCOME MEASURES

Change in KOOS4 scores from baseline before surgery to ∼5 years (range 4-6 years) after surgery. KOOS4 is the average aggregated score of 4 of 5 of the Knee injury and Osteoarthritis Outcome Score (KOOS) excluding the activities of daily living subscale (minimal clinical important improvement ∼10 points). A mixed linear model adjusted for sex and body mass index was used to assess change from baseline to ∼5-year follow-up. Change in KOOS4 was divided into 5 categories based on change from baseline to ∼5-year follow-up: <0 points, 0 to 9 points, 10 to 19 points, 20 to 29 points, and ≥30 points.

RESULTS

On average, patient-reported outcomes continued to improve from baseline to ∼5-year follow-up (mean KOOS4 change: 26, 95% CI, 24-28). Proportions in the different response groups were <0 points (12%), 0 to 9 points (13%), 10 to 19 points (16%), 20 to 29 points (19%), and ≥30 points (40%), with no difference between younger (≤40 years, n = 75) and older (>40 years, n = 337) patients (P = 0.898).

CONCLUSIONS

Patient-reported outcomes on average improved up to ∼5 years after APM; however, large variability was observed. The similar variability in younger and older patients questions the assumption that younger patients with traumatic injuries experience larger benefits from APM.

Patient’s subjective knee function 3-5 years following partial meniscectomy or meniscus repair compared to a normal population: a retrospective cohort study

Purpose

Evaluate patient-reported knee function after arthroscopic partial meniscectomy (APM) and meniscus suture repair in two different age cohorts compared with a normal population.

Method

Arthroscopic meniscus surgery was performed on 421 patients at Skåne University Hospital from 2010 to 2014, with a mean (SD) follow-up of 4.2 (1.4) years. Patients and controls were divided into two age cohorts; 18–34 years (younger) and 35–54 years (middle-aged) as well as according to surgery performed; either solely meniscus surgery or with concurrent anterior cruciate ligament reconstruction (ACLR). The outcome is measured with the five subscales of the Knee and Osteoarthritis Outcome Score (KOOS).

Results

No significant difference in outcome after all studied types of meniscus surgeries between younger-aged and middle-aged patients.

Younger patients with APM or meniscus suture repair, with or without, ACLR score lower than the normal population in all subscales of KOOS (p<0.001), except in Activities of Daily Living (ADL) for meniscus suture patients.

Middle-aged patients with APM score lower in all subscales than the normal population (p≤0.009). Those with meniscus suture repair score lower than the normal population only for the subscales Sport/Rec and quality of life (p<0.001).

Both younger-aged and middle-aged patients achieve better KOOS values after meniscus suture repair and ACLR than after all other combinations of surgery.

Conclusion

Patients with meniscus injuries do not reach the same KOOS score as the normal population, irrespective of age or type of meniscus surgery performed. However, combined with ACLR in younger-aged and middle-aged patients, meniscus suture gives a better subjective outcome than isolated meniscus surgery.

Clinical significance and management of meniscal extrusion in different knee pathologies: a comprehensive review of the literature and treatment algorithm

The menisci are crescent-shaped, fibrocartilaginous structures that play a crucial role in the load transition and distribution of the contact forces along the tibiofemoral articulation. Meniscal extrusion (ME) is a radiological finding, especially in magnetic resonance imaging (MRI) scans, for which there has been growing interest in recent years. ME, in the coronary plane, is defined as the maximum distance of the most distal end of the meniscus from the border of the tibial plateau, where the tibial eminences are the most prominent, without taking into account the osteophytes. Although there is still controversy in the literature in respect of the optimal cutoff value, a threshold of 3 mm is considered significant. ME has no specific clinical finding or sign and it is encountered in many knee pathologies. It is associated with either rapidly progressive knee osteoarthritis or early onset of knee osteoarthritis and increased morbidity. In this review, we delineate the clinical significance of ME in various knee pathologies, as well as when, why and how it should be managed. To the best of our knowledge, this is the first study to elaborate on these topics.

Second-look arthroscopy after meniscus repair and synovial mesenchymal stem cell transplantation to treat degenerative flaps and radial tears of the medial meniscus: A case report

BACKGROUND

The purpose of this study was to compare arthroscopic findings of a degenerative flap and radial tear of the medial meniscus (MM) before and one year after treatment by meniscus repair and synovial mesenchymal stem cell (MSC) transplantation.

METHODS

Patients with a degenerative flap and radial MM tear that would generally be treated by meniscectomy were included. The patients ranged in age from 45 to 62 years and all underwent meniscus repair and synovium harvest at time 0. The digested synovium was cultured with autologous serum for 12 days, and an average of 4 × 10⁷ MSCs were transplanted at two weeks. A second-look arthroscopy was performed at 52 weeks (n = 6). The average duration of symptoms was 24 months. For flap tears, arthroscopic findings were quantified in terms of the presence, stability, and smoothness of the meniscus at each zone and area. The Lysholm score was evaluated throughout the 52 week follow-up.

RESULTS

Four patients with MM flap tears showed deficiencies in the central area at the posterior junctional zone before treatment, but this zone was completely restored to a stable and smooth condition in two patients and partially restored in the other two patients. The arthroscopy score for a flap tear at the central area of the posterior junctional zone was 0.3 ± 0.5 before treatment and 4.3 ± 2.1 after treatment. The score was significantly higher after treatment (p < 0.05, n = 4). The original radial MM tears in two patients were healed one year after treatment. Lysholm scores were significantly higher at 4 and 52 weeks after treatment than before treatment (n = 6).

CONCLUSIONS

Arthroscopic findings for a degenerative flap and radial tear of the MM were improved at the central area of the posterior junctional zone one year after meniscus repair and MSC transplantation.

Effect of Physical Therapy vs Arthroscopic Partial Meniscectomy in People With Degenerative Meniscal Tears: Five-Year Follow-up of the ESCAPE Randomized Clinical Trial

IMPORTANCE

There is a paucity of high-quality evidence about the long-term effects (ie, 3-5 years and beyond) of arthroscopic partial meniscectomy vs exercise-based physical therapy for patients with degenerative meniscal tears.

OBJECTIVES

To compare the 5-year effectiveness of arthroscopic partial meniscectomy and exercise-based physical therapy on patient-reported knee function and progression of knee osteoarthritis in patients with a degenerative meniscal tear.

DESIGN, SETTING, AND PARTICIPANTS

A noninferiority, multicenter randomized clinical trial was conducted in the orthopedic departments of 9 hospitals in the Netherlands. A total of 321 patients aged 45 to 70 years with a degenerative meniscal tear participated. Data collection took place between July 12, 2013, and December 4, 2020.

INTERVENTIONS

Patients were randomly allocated to arthroscopic partial meniscectomy or 16 sessions of exercise-based physical therapy.

MAIN OUTCOMES AND MEASURES

The primary outcome was patient-reported knee function (International Knee Documentation Committee Subjective Knee Form (range, 0 [worst] to 100 [best]) during 5 years of follow-up based on the intention-to-treat principle, with a noninferiority threshold of 11 points. The secondary outcome was progression in knee osteoarthritis shown on radiographic images in both treatment groups.

RESULTS

Of 321 patients (mean [SD] age, 58 [6.6] years; 161 women [50.2%]), 278 patients (87.1%) completed the 5-year follow-up with a mean follow-up time of 61.8 months (range, 58.8-69.5 months). From baseline to 5-year follow-up, the mean (SD) improvement was 29.6 (18.7) points in the surgery group and 25.1 (17.8) points in the physical therapy group. The crude between-group difference was 3.5 points (95% CI, 0.7-6.3 points; P < .001 for noninferiority). The 95% CI did not exceed the noninferiority threshold of 11 points. Comparable rates of progression of radiographic-demonstrated knee osteoarthritis were noted between both treatments.

CONCLUSIONS AND RELEVANCE

In this noninferiority randomized clinical trial after 5 years, exercise-based physical therapy remained noninferior to arthroscopic partial meniscectomy for patient-reported knee function. Physical therapy should therefore be the preferred treatment over surgery for degenerative meniscal tears. These results can assist in the development and updating of current guideline recommendations about treatment for patients with a degenerative meniscal tear.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01850719.

Identification and diagnosis of meniscus tear by magnetic resonance imaging using a deep learning model

Objective

Meniscus tear is a common problem in sports trauma, and its imaging diagnosis mainly relies on MRI. To improve the diagnostic accuracy and efficiency, a deep learning model was employed in this study and the identification efficiency was evaluated.

Methods

Standard knee MRI images from 924 individual patients were used to complete the training, validation and testing processes. Mask regional convolutional neural network (R–CNN) was used to build the deep learning network structure, and ResNet50 was adopted to develop the backbone network. The deep learning model was trained and validated with a dataset containing 504 and 220 patients, respectively. Internal testing was performed based on a dataset of 200 patients, and 180 patients from 8 hospitals were regarded as an external dataset for model validation. Additionally, 40 patients who were diagnosed by the arthroscopic surgery were enrolled as the final test dataset.

Results

After training and validation, the deep learning model effectively recognized healthy and injured menisci. Average precision for the three types of menisci (healthy, torn and degenerated menisci) ranged from 68% to 80%. Diagnostic accuracy for healthy, torn and degenerated menisci was 87.50%, 86.96%, and 84.78%, respectively. Validation results from external dataset demonstrated that the accuracy of diagnosing torn and intact meniscus tear through 3.0T MRI images was higher than 80%, while the accuracy verified by arthroscopic surgery was 87.50%.

Conclusion

Mask R–CNN effectively identified and diagnosed meniscal injuries, especially for tears that occurred in different parts of the meniscus. The recognition ability was admirable, and the diagnostic accuracy could be further improved with increased training sample size. Therefore, this deep learning model showed great potential in diagnosing meniscus injuries.

Translational potential of this article

Deep learning model exerted unique effect in terms of reducing doctors’ workload and improving diagnostic accuracy. Injured and healthy menisci could be more accurately identified and classified based on training and learning datasets. This model could also distinguish torn from degenerated menisci, making it an effective tool for MRI-assisted diagnosis of meniscus injuries in clinical practice.

Patient beliefs and perceptions play a crucial role in the decision-making process when managing a meniscal tear. A qualitative systematic review of the literature

INTRODUCTION

There has been an increase in research on the effectiveness of treatment options for the management of meniscal tears. However, there is very little evidence about the patient experiences of meniscal tears.

AIM

To summarise the available qualitative evidence on patients' experiences and expectations of meniscal tears.

METHOD

A search of EMBASE, Medline, Sociofile and Web of Science up to November 2020 was performed to identify studies reporting patient experiences of meniscal tears. Studies were critically appraised using the CASP (Critical Appraisal Skills Program) checklist, and a meta-synthesis was performed to generate third-order constructs (new themes).

RESULTS

Two studies reporting semi-structured interviews from 34 participants (24 male; 10 female) were included. The mean interview length ranged from 16 to 45 min. Five themes were generated: (1) the imaging (MRI) results are a key driver in the decision-making process, (2) surgery is perceived to be the definitive and quicker approach, (3) physiotherapy and exercise is a slower approach which brought success over time, (4) patient perceptions and preferences are important in the clinical decision-making process and, (5) the impact on patient lives is a huge driver in seeking care and treatment decisions.

CONCLUSION

This is the first study to summarise the qualitative evidence on patient experiences with meniscal tears. The themes generated demonstrate the importance of patient perceptions of MRI findings and timing of treatment success as important factors in the decision-making process. This study demonstrates the need to strengthen our understanding of patients' experiences of meniscal tears.