Arthroscopic scoring system of meniscal healing following medial meniscus posterior root repair

Modified Mason-Allen vs Two Simple Stitch Fixation for Medial Meniscus Posterior Root Tears: A Systematic Review and Meta-analysis

BACKGROUND

Various suture configurations are available for medial meniscus posterior root tear (MMPRT) repair. The modified Mason-Allen (MMA) technique has been proposed as a refixation technique for MMPRT instead of the conventional 2 simple stitches (TSS). This is in view of its superior biomechanical characteristics.

PURPOSE

To perform a systematic review and meta-analysis to compare MMA and TSS configuration techniques for MMPRT repair and identify any differences between the 2 techniques in terms of clinical outcomes, medial meniscal extrusion (MME), and postoperative healing.

STUDY DESIGN

Meta-analysis; Level of evidence, 4.

METHODS

The Cochrane Controlled Register of Trials, PubMed, Medline, and Embase databases were used to perform a systematic review and meta-analysis using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria with the following search terms: ("meniscus" OR "meniscal injuries") AND ("Mason-Allen" OR "simple stitch" OR "suture techniques"). Data pertaining to all patient-reported outcome measures, postoperative complications, MME, postoperative healing, cartilage degeneration, and progression of knee osteoarthritis were extracted from each study. The pooled outcome data were analyzed using random- and fixed-effects models.

RESULTS

After abstract and full-text screening, 6 clinical studies were included. In total, there were 291 patients; 160 underwent MMA fixation, and 131 underwent the TSS technique. The majority of studies had similar surgical techniques regarding repair technique, suture material, tibial fixation, and number and position of tibial tunnels. There were no differences between the groups in terms of patient-reported outcome measures at 14.2 months. Both techniques were also similar in the degree of postoperative MME and meniscal healing.

CONCLUSION

Both suture configurations were equivalent in terms of clinical outcomes, the extent of meniscal extrusion, and postoperative healing. The TSS technique may offer advantages in terms of faster learning curve and shorter operative time. However, randomized controlled trials with large sample sizes, longer follow-up and assessment of chondral degeneration, and presence of knee osteoarthritis are required to assess whether a true difference exists, as the majority of included studies were limited by their retrospective design.

Meniscal healing status after medial meniscus posterior root repair negatively correlates with a midterm increase in medial meniscus extrusion

PURPOSE

The second-look arthroscopic score of pullout repair for medial meniscus posterior root tears (MMPRTs) is associated with contemporaneous clinical scores and progression of cartilage damage. However, the relationship among these scores, midterm clinical scores and magnetic resonance imaging (MRI) evaluations is unknown. The relationship between the second-look arthroscopic score at 1 year and the clinical scores or MRI at 3 years was evaluated.

METHODS

Sixty-three patients were included. Medial meniscus extrusion (MME) was evaluated preoperatively and at 3 years postoperatively. Clinical scores were evaluated preoperatively, and 1 and 3 years postoperatively. Meniscal healing status was assessed using the semiquantitative second-look arthroscopic score at 1 year postoperatively. Correlation coefficients between patient characteristics, postoperative clinical scores or second-look arthroscopic score and the change in MME (ΔMME) were evaluated. Multiple regression analysis was performed on the ΔMME to evaluate the effects of patient characteristics and second-look arthroscopic scores.

RESULTS

No significant correlation was observed between patient characteristics and ΔMME. In contrast, a significant correlation was found between the second-look arthroscopic score and ΔMME (p < 0.001) and visual analogue scale pain score (p = 0.016) at 3 years postoperatively. In the subitems of the second-look arthroscopic score, width (p < 0.001) and stability (p = 0.009) scores also showed significant correlations with ΔMME. Multiple regression analysis showed a significant association between the second-look arthroscopic score and ΔMME (p = 0.001).

CONCLUSIONS

The second-look arthroscopic score at 1 year postoperatively correlated with the ΔMME and clinical score at 3 years postoperatively. Second-look arthroscopic scores predict midterm meniscal function after pullout repair of MMPRTs.

LEVEL OF EVIDENCE

Level IV.

Superior outcomes of pullout repairs for medial meniscus posterior root tears in partial tear compared to complete radial tear

PURPOSE

To reveal the outcomes of partial medial meniscus posterior root tears following transtibial pullout repair compared with the outcomes of complete radial meniscus posterior root tears.

MATERIALS AND METHODS

We retrospectively evaluated 15 consecutive patients (male/female, 5/10; average age, 64.4 years) who underwent transtibial pullout repair for partial medial meniscus posterior root tears and compared their results with those of 86 consecutive patients who underwent the same surgery for complete medial meniscus posterior root tears. All patients underwent second-look arthroscopy on average 1 year postoperatively, and a semi-quantitative meniscal healing score (anteroposterior width, stability, and synovial coverage, total 10 points) was evaluated. Medial meniscus extrusion was evaluated preoperatively and at second-look arthroscopy.

RESULTS

Postoperative clinical scores were not significantly different in the short term. However, second-look arthroscopy revealed a significant difference in repaired meniscal stability (partial tear; 3.3 points, complete tear; 2.3 points, p < 0.001) and total meniscal healing scores (partial tear; 8.3 points, complete tear; 7.1 points, p < 0.001). Medial meniscus extrusion progression was significantly different (partial tear; 0.4 mm, complete tear; 1.0 mm, p < 0.001).

CONCLUSION

Partial medial meniscus posterior root tears showed better meniscal healing and less medial meniscus extrusion progression following pullout repair than complete medial meniscus posterior root tears.

Mid-Term Clinical and Radiological Outcomes of Lateral Meniscal Allograft Transplantation with Suture-Only Fixation Plus Capsulodesis

Meniscal allograft transplantation (MAT) is an effective reconstructive procedure for treating a symptomatic postmeniscectomy syndrome. It consists of replacing the lost meniscal tissue aiming to improve the clinical outcomes and prevent progressive deterioration of the joint. The aim of this study was to evaluate meniscal graft survivorship and report on the radiographic (in terms of graft extrusion and joint space width and alignment) and the functional results through a midterm follow-up of lateral MAT performed with a soft tissue fixation technique after capsulodesis. In total, 23 patients who underwent lateral MAT as a single procedure were included. The Knee injury and Osteoarthritis Outcome Score, Lysholm, Tegner, and visual analog scale scales were used for patient assessment. Magnetic resonance imaging and a complete radiographic protocol were conducted to determine the degree of meniscal extrusion and the changes in the degree of osteoarthritis and coronal alignment. Assessments were performed after 2 and 7 years of follow-up. A significant improvement in all the scores, relative to preoperative values, was found after 7 years of follow-up. This improvement remained consistent throughout the first and second follow-up periods. A mean absolute extrusion of 2.2 mm ± 1.6 and an extrusion percentage of 28.0% ± 11.43 were found, with no significant differences throughout the follow-up periods. There was no statistically significant difference in terms of the frontal mechanical axis and joint space narrowing between the preoperative value and at the first and second follow-up periods. A survival rate of 85.7% was found after 7 years of follow-up. Capsulodesis results in a low degree of meniscal extrusion in isolated lateral MAT fixed with a suture-only technique, which is maintained after 7 years of follow-up, with a high graft survival index (>85%) and satisfactory results on the functional scales.

Intercondylar notch width and osteophyte width impact meniscal healing and clinical outcomes following transtibial pullout repair of medial meniscus posterior root tears

PURPOSE

This retrospective study aimed to investigate the relationship between intercondylar notch width (ICNW), osteophyte width (OW), and the healing of medial meniscus posterior root tears (MMPRTs) following arthroscopic pullout repair.

METHODS

The study included 155 patients diagnosed with MMPRTs who underwent transtibial pullout repair. Meniscal healing status was evaluated on second-look arthroscopy using a previously reported meniscus healing score. Patients were divided into two groups based on this score: the high healing score (group HH, healing score ≥ 8 points) and suboptimal healing score (group SO, healing score ≤ 6 points) groups. Computed tomography scans were performed on patients 1 week postsurgery. ICNW and OW widths were measured and relatively evaluated based on their ratio to the intercondylar distance (ICD), represented as the ICNW/ICD ratio (%) and OW/ICD ratio (%), respectively. Patient-reported outcomes were assessed preoperatively and on second-look arthroscopy using the Knee injury and Osteoarthritis Outcome Score (KOOS) and visual analogue scale (VAS).

RESULTS

There were no significant demographic differences between the SO and HH group (n = 35 and 120 patients, respectively). Regarding radiographic measurements, significant differences were observed in the ICNW/ICD ratio (group SO, 24.2%; group HH, 25.2%; p = 0.024), OW (group SO, 2.6 mm; group HH, 2.0 mm; p < 0.001), and OW/ICD ratio (group SO, 3.5%; group HH, 2.7%; p < 0.001). Both groups had similar preoperative clinical scores, but postoperative clinical scores, including KOOS-activities of daily living (group SO, 83.4; group HH, 88.7; p = 0.035) and VAS (group SO, 19.1; group HH, 11.3; p = 0.005), were significantly better in group HH.

CONCLUSION

The study suggests that ICNW and OW may play a crucial role in MMPRT healing following arthroscopic pullout repair, as evidenced by the worse clinical outcomes associated with a narrower ICNW and wider OW. These findings highlight the potential significance of ICNW and OW assessments when evaluating meniscal repair indications.

LEVEL OF EVIDENCE

Level III.

Weight loss enhances meniscal healing following transtibial pullout repair for medial meniscus posterior root tears

PURPOSE

This study investigated the impact of weight change on the success of transtibial pullout repair for medial meniscus (MM) posterior root tears (MMPRTs).

METHODS

The study included 129 patients diagnosed with MMPRTs who had undergone transtibial pullout repair. The patients were screened between July 2018 and November 2021. Patient-reported outcomes were assessed preoperatively and at 12 months postoperatively using the Knee injury and Osteoarthritis Outcome Score (KOOS). MM extrusion (MME) and ΔMME (postoperative MME - preoperative MME) were calculated preoperatively and at 12 months postoperatively using magnetic resonance imaging.

RESULTS

Patients were divided into weight loss (body mass index [BMI] decrease of at least 0.5 kg/m2 after primary repair; n = 63) and weight gain (BMI increase of at least 0.5 kg/m2 ; n = 66) groups. Both groups had similar demographic variables and preoperative clinical scores; patient-reported outcomes significantly improved postoperatively. The weight loss group had significantly greater improvement in KOOS-quality of life (weight loss, 29.4 ± 23.7; weight gain, 23.9 ± 27.6; p = 0.034), lower postoperative MME (weight loss, 3.9 ± 1.7 mm; weight gain, 4.2 ± 1.2 mm; p = 0.043) and lower ΔMME (weight loss, 0.8 ± 0.8 mm; weight gain, 1.2 ± 0.9 mm; p = 0.002) than the weight gain group. Total arthroscopic healing scores (weight loss, 7.6 ± 1.0; weight gain, 7.2 ± 1.5; p = 0.048) and associated subscales, including anteroposterior bridging tissue width (weight loss, 4.0 ± 0.0; weight gain, 3.8 ± 0.7; p = 0.004) and MM posterior root stability (weight loss, 2.6 ± 0.7; weight gain, 2.4 ± 0.7; p = 0.041), significantly differed between the groups.

CONCLUSIONS

Weight loss was associated with better meniscal healing and less MME progression after MMPRT repair, highlighting the significance of weight management in individuals undergoing meniscal surgery. These findings provide valuable insights into the clinical significance of weight loss in the success of transtibial pullout repair for MMPRTs.

LEVEL OF EVIDENCE

Level III.

Insufficient restoration of meniscal extrusion by transtibial pullout repair for medial meniscus posterior root tears

PURPOSE

The long-term changes in the dynamics of the medial meniscus after transtibial pullout repair for medial meniscus posterior root tears (MMPRTs) are not completely understood. Thus, the aim of this study was to investigate the effects of transtibial pullout repair on MMPRTs and whether the effects would be sustained.

METHODS

Nineteen knees with MMPRTs that were treated by trans-tibial pullout repair were enrolled in this study. Medial meniscus extrusion (MME) was measured by ultrasonography during knee extension (no weight-bearing with the knee at 0° extension: NW0°) and 90° flexion (no weight-bearing with the knee at 90° flexion: NW90°) with the patient in the supine position and with full weight-bearing (FW0°) preoperatively and at 3 and 12 months postoperatively. The clinical outcomes were assessed using the Knee Injury and Osteoarthritis Outcome Score, Lysholm score, and International Knee Documentation Committee score.

RESULTS

The difference in MME with NW0° was not statistically significant between the preoperative (3.4 ± 1.0 mm) and 12-month postoperative (3.7 ± 0.6 mm) time points. The MME with NW90° at 3 (2.1 ± 0.7 mm) and 12 months (2.9 ± 0.6 mm) postoperatively were significantly lower than the preoperative values (3.4 ± 0.8 mm) (P < 0.05). However, the value significantly increased from 3 to 12 months postoperatively (P < 0.05). The MME with FW0° at 12 months postoperatively (4.3 ± 0.6 mm) was significantly larger than that at pre-operatively (3.6 ± 0.9 mm) (P < 0.05). All the patients' clinical conditions were significantly improved at 12 months postoperatively when compared to their preoperative clinical conditions.

CONCLUSION

Surgery did not reduce the extrusion in the no weight-bearing and weight-bearing positions at knee extension, and these values increased in the postoperative period. In addition, while the surgery reduced the extrusion in the knee flexion position, the restoration achieved by the surgery was not sustained in the long term.

LEVEL OF EVIDENCE

Level IV.

Rehabilitation after Repair of Medial Meniscus Posterior Root Tears: A Systematic Review of the Literature

Background

There is no consensus established on postoperative rehabilitation after medial meniscus posterior root tear (MMPRT) repair, including when and how physicians can apply range of motion (ROM) exercise, weight-bearing (WB), brace use, and return to sports (RTS). The purpose of this study was to systematically review the literature on postoperative rehabilitation characteristics of MMPRT repair regarding ROM, WB, brace use, and RTS.

Methods

A literature search was performed using the Medline/PubMed, Cochrane Central Register of Controlled Trials, and Embase databases. The inclusion criteria were English language, human clinical studies, and studies describing rehabilitation protocols after MMPRT repair such as ROM, WB, brace use, and RTS. Abstracts, case reports, cohort studies, controlled laboratory studies, human cadaveric or animal studies, systematic reviews, and meta-analyses were excluded.

Results

Thirteen studies were included. Of the 12 ROM studies, ROM was started immediately within 1 or 2 days after operation in 6 studies and after 2 to 3 weeks of knee immobilization in the rest. Of the 13 WB studies, partial weight-bearing was initiated 1 to 4 weeks after operation in 8 studies and 6 weeks in the rest. Of the 9 brace studies, patients were immobilized by a splint for 2 weeks in 3 studies, and in the rest, a brace with full extension was applied for 3 to 6 weeks after several days of splint application. Of the 7 RTS studies, RTS was allowed at 6 months in 6 studies and 5 to 7 months in 1 study.

Conclusions

This systematic review revealed conservative rehabilitation protocols were more widely adapted as ROM and WB were restricted at certain degrees during postoperative periods in most protocols analyzed. However, it is impossible to identify a consensus on rehabilitation protocols as the protocols analyzed in this review were distinct each other and heterogeneous. In the future, a well-designed comparative study among different rehabilitation protocols is essential to establish a consensus.

Medial joint space narrowing progresses after pullout repair of medial meniscus posterior root tear

PURPOSE

The extent to which arthropathic changes progress after medial meniscus posterior root tear (MMPRT) repair remains controversial. This retrospective study assessed medial joint space (MJS) narrowing progression after pullout repair for MMPRT and identified the correlating factors.

METHODS

We included 56 patients who underwent pullout repair for MMPRT. The MJS of the bilateral knees was assessed with radiography using the fixed-flexion view. A second-look arthroscopy was performed one year post-operatively for all patients. The baseline characteristics, clinical scores, Kellgren-Lawrence (KL) grade, and medial meniscus extrusion (MME) were identified. Statistical comparisons and correlation analyses were conducted.

RESULTS

The MJS narrowing width was significantly larger in MMPRT knees than in contralateral knees (0.51 ± 0.85 mm vs. 0.09 ± 0.49 mm, p < 0.001). KL grade progression was observed in 23.2% (13/56) of patients. There was a significant difference between pre- and post-operative MME values, indicating MME progression (p < 0.001). Each clinical score showed significant improvement one year post-operatively (p < 0.001). Positive correlations were found between MJS narrowing and pre-operative MJS (coefficient = 0.510, p < 0.001), rate of change in MJS (coefficient = 0.929, p < 0.001), and increase in MME (ΔMME) (coefficient = 0.506, p < 0.001).

CONCLUSION

Knees that underwent pullout repair for MMPRT showed progression of MJS narrowing by 0.51 mm at one year post-operatively, although clinical scores markedly improved. Correlating factors for MJS narrowing were pre-operative MJS, rate of change in MJS, and ΔMME. Preventing MME progression is essential for preventing arthropathic changes.

The stability of repaired meniscal root can affect postoperative cartilage status following medial meniscus posterior root repair

BACKGROUND

Transtibial pullout repair yields beneficial clinical outcomes in patients with medial meniscus (MM) posterior root tear. However, the relationship between repaired meniscal root healing status and postoperative clinical outcomes remains unclear. We aimed to evaluate changes in articular cartilage damage and clinical scores after pullout repair using two simple stitches (TSS).

METHODS

Thirty-three patients who underwent pullout repair using TSS were assessed. Healing status was assessed by a semi-quantitative second-look arthroscopic scoring system comprising three evaluation criteria (width of bridging tissues, stability of the repaired root, and synovial coverage), 1 year postoperatively. MM medial extrusion (MMME) and cartilage damage were assessed preoperatively and 1 year postoperatively. The medial compartment was divided into 8 zones (A-H) for comparison of preoperative and 1-year postoperative cartilage damage. Clinical outcomes were evaluated using the Knee Injury and Osteoarthritis Outcome score, Lysholm score, International Knee Documentation Committee scores, and visual analogue scale pain score.

RESULTS

Although cartilage damage did not aggravate significantly in most medial compartment areas, MMME progressed at 1 year postoperatively. No statistical differences were observed in cartilage damage between the central-to-medial area of the medial femoral condyle and the medial tibial plateau area at 1 year postoperatively. Regarding semi-quantitative healing scores, the stability score was significantly correlated with the International Cartilage Repair Society grade at 1 year postoperatively. All 1-year and 2-year clinical scores significantly improved compared with the preoperative scores.

CONCLUSION

Regarding TSS repair, stability of repaired meniscal root negatively correlated with cartilage damage in the medial compartment loading area. All 1-year and 2-year clinical scores significantly improved than those of the preoperative scores. Achieving MM stability is crucial for suppressing cartilage degeneration.

LEVEL OF EVIDENCE

IV case series study.

The clinical and radiographic outcomes of type 2 medial meniscus posterior root tears following transtibial pullout repair

PURPOSE

The aim of this study was to compare the clinical outcomes of different subtypes of type 2 medial meniscus posterior root tears following transtibial pullout repair.

METHODS

In total, 147 patients (mean age: 66.2 ± 8.3 years) who were diagnosed with type 2 medial meniscus posterior root tears and underwent transtibial pullout repair were included. Patients were divided into 2A (n = 31), 2B (n = 90), and 2C (n = 26) groups according to tear type. Clinical outcomes were assessed pre-operatively and at second-look arthroscopy using the Knee injury and Osteoarthritis Outcome Score. The meniscal healing status was evaluated at second-look arthroscopy. Medial meniscus extrusion was calculated using magnetic resonance imaging pre-operatively and at second-look arthroscopy.

RESULTS

No significant differences in pre-operative or post-operative clinical scores were observed between each subtype, although clinical scores improved post-operatively for each subtype. Significant differences were noted in the anteroposterior width of the bridging tissues at second-look arthroscopy (2A, 7.1 ± 1.2; 2B, 6.2 ± 1.7; and 2C, 6.2 ± 1.7 mm; p = 0.045); type 2A tears were the widest. There was a significant difference in post-operative medial meniscus extrusion (2A, 3.2 ± 0.9; 2B, 4.0 ± 1.2; and 2C, 4.0 ± 1.4 mm; p = 0.004) and its progression (2A, 0.7 ± 0.6; 2B, 1.2 ± 0.8; and 2C, 1.2 ± 0.8 mm; p = 0.008), and type 2A tears were the shortest.

CONCLUSION

Although there was no significant difference in the post-operative clinical scores among different type 2 tears in the short term, type 2A tears showed better healing and medial meniscus extrusion progression prevention, thus indicating the usefulness of classifying tear type in estimating post-operative outcomes.

LEVEL OF EVIDENCE

III.

Semi-quantitative arthroscopic scoring system is related to clinical outcomes in patients after medial meniscus posterior root repair

BACKGROUND

Different methods are available to assess the healing status of repaired root for medial meniscus posterior root tears (MMPRT) using second-look arthroscopy. However, few studies are comparing them or validating their usefulness. Therefore, it was hypothesized that the semi-quantitative arthroscopic score might correlate more with 1-year clinical outcomes in patients with MMPRT than the qualitative evaluation.

METHODS

Data of 61 patients who underwent MMPRT pullout repair and second-look arthroscopy were retrospectively evaluated. The semi-quantitative arthroscopic scoring system was divided into three evaluation criteria: scores from 0 to 10 points include the width of the bridging tissue, stability of the repaired root, and synovial coverage. The qualitative evaluation was classified into 4 status; complete healing, lax healing, scar tissue healing, and failed healing according to the stability and mobility of the repaired root. Multivariate linear regression analyses were used to identify predictors of 1-year postoperative clinical outcomes, including Knee Injury and Osteoarthritis Outcome, Lysholm, or International Knee Documentation Committee scores. Spearman's correlation analysis was used to analyze the correlation between second-look arthroscopic score/qualitative evaluation and 1-year postoperative clinical outcomes. In addition, the optimal cutoff point of semi-quantitative arthroscopic score was determined by receiver operating characteristic (ROC) curve. The Mann-Whitney U test was used to compare clinical outcomes between patients with semi-quantitative arthroscopic scores ≥8 and scores <8.

RESULTS

All clinical scores significantly improved at 1 year postoperatively. A good correlation was observed between the semi-quantitative score and clinical scores, but none between qualitative evaluation and clinical scores. The optimal cutoff point of semi-quantitative second-look arthroscopic score was 8 points. Significantly, better clinical outcomes were observed in patients with semi-quantitative scores ≥8 points.

CONCLUSIONS

All 1-year postoperative clinical scores were significantly improved. The semi-quantitative arthroscopic scores correlate more with 1-year clinical outcomes in patients with MMPRT than the qualitative evaluation.

LEVEL OF EVIDENCE

IV case series study.

Clinical evaluation of suture materials for transtibial pullout repair of medial meniscus posterior root tear

BACKGROUND

There are no recommendations for specific suture materials in transtibial pullout repair of medial meniscus posterior root tears. This study aimed to evaluate the clinical outcomes of transtibial pullout repair of medial meniscus posterior root tears using ultrahigh-molecular-weight polyethylene sutures and suture tape.

METHODS

We retrospectively reviewed the data of 36 patients (27 women and 9 men, mean age 64.1 years) who had undergone transtibial pullout repair of medial meniscus posterior root tears between November 2018 and December 2019. Two groups of 18 patients each received either two different cord-like sutures or suture tape. Clinical parameters were assessed preoperatively and on second-look arthroscopy (mean postoperative period 12 months). The meniscal healing status was assessed using a previously published scoring system (ranging from 0 to 10), and the incidence rate of suture cut-out was assessed on second-look arthroscopy.

RESULTS

All clinical scores significantly improved in both groups, with no significant between-group differences on second-look arthroscopy. The arthroscopic meniscal healing scores significantly differed between sutures (mean 6.7 points) and suture tape (mean 7.4 points; p = 0.044). No significant between-group difference in the suture cut-out rate was observed.

CONCLUSIONS

This study found no significant differences in the clinical outcomes between ultrahigh-molecular-weight polyethylene sutures and suture tape. Favorable clinical outcomes were obtained using both types of suture; however, the usefulness of suture tape appears to be limited.

Clinical outcomes of medial meniscus posterior root repair: A midterm follow-up study

BACKGROUND

Transtibial pullout repair of medial meniscus posterior root tears (MMPRTs) cannot prevent the progression of knee osteoarthritis. Conversions of knee arthroplasties are occasionally required following MMPRT repair. However, other knee-related surgical treatments following MMPRT repair are unclear. This study was aimed at investigating the midterm clinical outcomes and knee-related surgical events following MMPRT repair.

METHODS

Patients with MMPRT underwent pullout repair using FasT-Fix modified Mason-Allen (F-MMA) suturing with an all-inside meniscal repair device. Thirty-two patients with follow-up duration >2 years were enrolled. We assessed the clinical outcomes and postoperative surgical treatment of both knees.

RESULTS

F-MMA pullout repair improved all clinical evaluation scores in patients with MMPRT at a mean follow-up of 36.1 months. Postoperative arthroscopic debridement was required for one patient. An additional MMPRT repair was performed in one patient on second-look arthroscopy. None of the patients required ipsilateral knee arthroplasty. In the contralateral knees, one pullout repair of a newly developed MMPRT and two knee arthroplasties were performed.

CONCLUSIONS

This study demonstrated that F-MMA pullout repair yielded satisfactory clinical outcomes. However, subsequent knee-related surgeries were observed in 6.3% of the pullout-repaired knees and 9.4% of the contralateral knees. Our results suggest that surgeons should be aware of the worsening and/or occurrence of contralateral knee joint disease, even when the postoperative clinical outcomes are satisfactory following MMPRT repair.

LEVEL OF EVIDENCE

IV.

Arthroscopic Meniscal Healing following Medial Meniscus Posterior Root Repair: A Comparison between Two Suture Materials

Recently, transtibial pullout repair of the medial meniscus (MM) posterior root tear (PRT) has become widely accepted and provides satisfactory clinical outcomes. Widening after cyclic loading or ultimate failure load using different suture materials and configurations has been studied. However, no study has compared the clinical outcomes using different suture materials. This study aimed to evaluate the clinical outcomes after performing MMPRT pullout repair using different suture materials. We hypothesized that better clinical outcomes would be achieved using ultra-high molecular weight polyethylene (UHMWPE) tape compared with a normal polyester suture. Thirty-seven patients who underwent MM posterior root repair between November 2019 and May 2020 were retrospectively investigated. Pullout repair was performed using a hollow no. 0 polyester suture (n = 14) and UHMWPE tape (n = 23). Clinical outcomes were assessed preoperatively and at 1 year postoperatively, using the Lysholm knee score, Knee Injury and Osteoarthritis Outcome Score, and visual analogue scale (VAS) pain score. The meniscal healing status was assessed using an arthroscopic scoring system (range: 0-10). All clinical scores were improved significantly in both groups. However, significantly higher meniscal healing scores and decreased VAS pain scores were observed in the UHMWPE group (7.3 ± 0.9 and 7.7 ± 11.3, respectively) than in the polyester group (5.6 ± 2.1 and 18.4 ± 18.6, respectively; p < 0.01). Suture cut-out and loss of the root continuity were observed in some cases (three cases [21.4%] in the polyester suture group and one case [4.3%] in the UHMWPE tape group). Both suture materials led to satisfactory clinical outcomes at 1 year postoperatively, whereas the UHMWPE tape was useful for obtaining good meniscal healing and decreasing the VAS pain score.

Examining the Efficacy of Medial Meniscus Posterior Root Repair: A Meta-analysis and Systematic Review of Biomechanical and Clinical Outcomes

BACKGROUND

Medial meniscus posterior root (MMPR) injuries accelerate the progression of osteoarthritis. While partial meniscectomy was once considered the gold standard for treatment, meniscus root repair has become increasingly utilized with reported improvements in clinical and biomechanical outcomes.

PURPOSE

To perform a systematic review of biomechanical outcomes and a meta-analysis of clinical and radiographic outcomes after MMPR repair.

STUDY DESIGN

Meta-analysis and systematic review; Level of evidence, 4.

METHODS

The PubMed, Embase, and Cochrane databases were queried in August 2021 for studies reporting biomechanical, clinical, and radiographic outcomes after MMPR repair. Biomechanical studies were assessed for main results and conclusions. Data including study characteristics, cohort demographics, and outcomes were extracted. Included clinical studies were analyzed with a random-effects meta-analysis of proportions for binary outcomes or continuous outcomes for mean differences between preoperative and postoperative time points. Subgroup analysis for studies reporting repair outcomes with concomitant high tibial osteotomy (HTO) was performed where appropriate.

RESULTS

A total of 13 biomechanical studies were identified and reported an overall improvement in mean and peak contact pressures after MMPR repair. There were 24 clinical studies, consisting of 876 patients (877 knees), identified, with 3 studies (106 knees) reporting outcomes with concomitant HTO. The mean patient age was 57.1 years (range, 23-74 years), with a mean follow-up of 27.7 months (range, 2-64 months). Overall, clinical outcomes (Lysholm, Hospital for Special Surgery, International Knee Documentation Committee, visual analog scale for pain, Tegner, and Knee injury and Osteoarthritis Outcome Score scores) were noted to improve postoperatively compared with preoperatively, with improved Lysholm scores in patients undergoing concomitant HTO versus MMPR repair alone. Meniscal extrusion was not significantly improved after MMPR repair compared with preoperative measurements. The progression in Kellgren-Lawrence grades from grade 0 to grades 1 to 3 occurred in 5.9% (21/354) of patients after repair, with no patients progressing from grades 1 to 3 to grade 4.

CONCLUSION

MMPR repair generally improved biomechanical outcomes and led to improved patient-reported outcomes with greater improvements noted in patients undergoing concomitant HTO. Repair did not significantly improve meniscal extrusion, while only 5.9% of patients were noted to progress to low-grade osteoarthritis. The high level of heterogeneity in the included biomechanical and clinical investigations emphasizes the need for more well-designed studies that evaluate outcomes after MMPR repair.

Postoperative external tibial rotation is correlated with inferior meniscal healing following pullout repair of a medial meniscus posterior root tear

PURPOSE

The purpose of this study was to evaluate the influence of tibial rotation on the postoperative healing status of the medial meniscus (MM) following pullout repair of the MM posterior root tear (MMPRT).

METHODS

Ninety-one patients (68 women and 23 men; mean age 63.3 ± 8.8 years) who had undergone transtibial pullout repair of MMPRT were enrolled in the study. The tibial external rotation angle (ERA) in each patient was measured postoperatively using computed tomography in the extended knee position. The meniscal healing status following transtibial pullout repair was assessed by second-look arthroscopy (mean postoperative period 12 months) using a previously published scoring system (range 0-10). The association between the ERA and the meniscal healing score was investigated using univariate linear regression models. The ERA cut-off for improved meniscal healing score (≥ 7) was determined using receiver-operating characteristic analysis.

RESULTS

The ERA and the meniscal healing score were significantly associated, confirming that increased ERAs were correlated with worse meniscal healing status (R =  - 0.28; P < 0.001). The optimum ERA cut-off value was 0.5°, with a sensitivity of 68% and a specificity of 63%. The mean meniscal healing scores were 7.3 and 6.2 among patients with ERAs < 0.5° and those with ERAs ≥ 0.5°, respectively (P < 0.001).

CONCLUSION

This study demonstrated that the ERA was significantly correlated with the postoperative meniscal healing status. Postoperative tibial rotation could be one of the factors affecting postoperative outcomes of pullout repair of MMPRT. Controlling the tibial rotation may possibly improve meniscal healing.

LEVEL OF EVIDENCE

III.

A posterior anchoring method decreases pullout suture translation of the medial meniscus posterior root repair during knee flexion

BACKGROUND

The medial meniscus (MM) translates posteriorly and extrudes severely from the medial tibial plateau (MTP) during knee flexion in the MM posterior root tear (PRT) knee. Transtibial pullout repair of the MMPRT has been performed to regulate MM extrusion. This study aimed to evaluate pullout suture translation during knee flexion before and after posterior anchoring during pullout repair. We hypothesized that suture translation after posterior anchoring would be significantly decreased relative to that before posterior anchoring.

METHODS

Thirty-five patients who underwent MM posterior root repair were prospectively investigated. Pullout repair was performed using two cinch sutures (outer and inner sutures) and posterior anchoring through the MM posterior horn and an additional bone tunnel on the MTP. The translation of the outer suture from 0° to 90° of knee flexion was measured and compared before and after posterior anchoring intraoperatively. The MM morphologic features were measured using preoperative magnetic resonance imaging, and the correlation between these values and outer suture translation was evaluated.

RESULTS

The average outer suture translation after posterior anchoring (1.6 ± 1.5 mm) was significantly decreased relative to that before posterior anchoring (2.5 ± 1.7 mm, P < 0.01). No significant correlations were observed between the MM morphological features and outer suture translation.

CONCLUSIONS

The posterior anchoring method with an MM posterior root repair is useful in decreasing posterior translation of the pullout suture during knee flexion, which might have an advantage in preventing suture pullout from the repaired MM, leading to good clinical outcomes.

Midterm Outcomes of Posterior Medial Meniscus Root Tear Repair: A Systematic Review

BACKGROUND

Whereas there has been growing interest in surgical repair of posterior medial meniscus root tears (PMMRTs), our understanding of the medium- and long-term results of this procedure is still evolving.

PURPOSE

To report midterm clinical outcomes from PMMRT repairs.

STUDY DESIGN

Systematic review.

METHODS

A literature review for this systematic analysis was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We identified studies that reported the results of arthroscopic repair of PMMRTs. Functional and imaging outcomes were reviewed and summarized.

RESULTS

In total, 28 studies with a total of 994 patients (83% female) with an overall mean age of 57.1 were included in this review. Clinical outcomes (Lysholm, International Knee Documentation Committee, Hospital for Special Surgery, and Tegner scores) were improved at final follow-up in all studies. Of patients, 49% had radiographic progression of at least 1 grade in the Kellgren-Lawrence scale at a mean follow-up of 4.0 years in 11 studies. Cartilage degeneration had progressed at least 1 grade on magnetic resonance imaging scans in 23% of patients at a mean follow-up of 31.6 months in 4 studies.

CONCLUSION

PMMRT repairs provide a functional benefit with consistent improvements in clinical outcome scores. There is some evidence that PMMRT repair slows the progression of osteoarthritis but does not prevent it at midterm follow-up.

Medial meniscus posterior root repairs: A comparison among three surgical techniques in short-term clinical outcomes and arthroscopic meniscal healing scores

BACKGROUND

Medial meniscus (MM) posterior root repairs lead to favorable clinical outcomes in patients with MM posterior root tears (MMPRTs). However, there are few comparative studies in evaluating the superiority among several pullout repair techniques such as modified Mason-Allen suture, simple stitch, and concomitant posteromedial pullout repair. We hypothesized that an additional pullout suture at the MM posteromedial part would have clinical advantages in transtibial pullout repairs of the MMPRTs. The aim of this study was to compare the clinical usefulness among several types of pullout repair techniques in patients with MMPRTs.

METHODS

Eighty-three patients who underwent arthroscopic pullout repairs of the MMPRTs were investigated. Patients were divided into three groups using different pullout repair techniques: a modified Mason-Allen suture using FasT-Fix all-inside meniscal repair device (F-MMA, n = 28), two simple stitches (TSS, n = 30), and TSS concomitant with posteromedial pullout repair using all-inside meniscal repair device (TSS-PM, n = 25). Postoperative clinical outcomes and semi-quantitative arthroscopic meniscal healing scores (0-10 points) were evaluated at second-look arthroscopies.

RESULTS

No significant differences among the three groups were observed in patient demographics and preoperative clinical scores, except for preoperative Lysholm scores. At second-look arthroscopies, there were no significant differences among the three techniques in postoperative clinical outcomes and meniscal healing scores.

CONCLUSIONS

This study demonstrated that the TSS-PM pullout repair technique did not show better scores in postoperative clinical outcomes and meniscal healings compared with the F-MMA and TSS techniques. Our results suggest that the concomitant posteromedial pullout suture may have no clinical advantage in the conventional pullout repairs for the patients with MMPRTs.

In-Office Needle Arthroscopy Can Evaluate Meniscus Tear Repair Healing as an Alternative to Magnetic Resonance Imaging

PURPOSE

To assess the healing of horizontal cleavage tears of the meniscus 1 year after surgical repair and to determine what modality is best to determine healing.

METHODS

Patients were prospectively followed for 12 months after surgical meniscus repair using a circumferential compression stitch. Inclusion criteria were preoperative magnetic resonance imaging (MRI) evidence of horizontal cleavage tear, age between 18 and 50 years, and no concomitant anterior cruciate ligament reconstruction. Patients were excluded if they were >50 years old, had a meniscus tear pattern other than horizontal cleavage tear, and underwent concomitant ligament reconstruction. MRIs were performed 1-year postoperatively for evaluation of repair healing. Preoperative and postoperative MRIs of tears were evaluated blindly by a musculoskeletal radiologist. In-office needle arthroscopy was performed at 6 months post-operatively.

RESULTS

Eight patients were included and had surgery between March 2016 and November 2017. There were 4 medial and 4 lateral meniscus tears. No patients had recurrence of preoperative symptoms or evidence of retear. Six repairs evaluated by in-office needle (at 5.9 months postsurgery) arthroscopy demonstrated complete healing. Seven of the 8 patients had grade III changes on preoperative MRI, and 1 patient had grade IIc changes. On postoperative MRI, 5 of 7 patients had grade III changes, 1 patient had IIc changes, and 1 had IIb changes. There was no significant difference in the proportion of patients with grade III changes preoperatively compared with postoperatively (P = .57). One of 8 patients with preoperative MRIs demonstrated extrusion where no patients demonstrate postoperative MRI evidence of extrusion (P = .47).

CONCLUSIONS

Horizontal cleavage meniscal tears repaired with a circumferential compression stitch demonstrate healing on in-office needle arthroscopy 6 months after surgery. No evidence of incomplete or failed healing was found. MRI at 1 year after surgery demonstrated residual tear evidence for all patients.

LEVEL OF EVIDENCE

IV, therapeutic case series.

Accurate placement of a tibial tunnel significantly improves meniscal healing and clinical outcomes at 1 year after medial meniscus posterior root repair

PURPOSE

A medial meniscus posterior root tear results in the loss of meniscal circumferential hoop stress and causes a pathological posteromedial extrusion of the medial meniscus. Although creating a tibial tunnel in the anatomic place improves postoperative medial meniscus posterior extrusion, no studies have evaluated the relationship between tibial tunnel position and clinical outcomes. This study aimed to evaluate how tibial tunnel positioning of medial meniscus posterior root pullout repair affects meniscal healing status and clinical outcomes.

METHODS

Sixty-two patients with 64 medial meniscus posterior root tears (mean age 62.8 ± 7.9 years) who had undergone pullout repairs and second-look arthroscopies were included. All 62 patients were Lachman test negative. Three-dimensional computed tomography images of the tibial surface were evaluated using a rectangular measurement grid to assess the tibial tunnel centre and medial meniscus posterior root attachment centre. Spearman's rank correlation analysis was undertaken to determine displacement distance from the medial meniscus posterior root attachment centre to the tibial tunnel centre and a meniscal healing score, as well as clinical outcomes at 1 year post-repair.

RESULTS

Tibial tunnel centres were located more anteriorly and medially than the medial meniscus posterior root attachment centre (mean distance 5.0 ± 2.2 mm). The mean meniscal healing score was 6.7 ± 1.8 of 10 possible points. The 1-year postoperative clinical scores showed significant improvement compared with preoperative scores for all the items. There was a significant negative correlation in the absolute distance between the medial meniscus posterior root attachment centre and the tibial tunnel centre with the meniscal healing score (ρ =  - 0.39, p = 0.002). Furthermore, there were significant positive correlations between the distance between the medial meniscus posterior root attachment centre and the tibial tunnel centre in the mediolateral direction and patient-based clinical outcomes (ρ = 0.25-0.43, p < 0.05).

CONCLUSION

Accurate placement of a tibial tunnel, especially in the mediolateral direction, significantly improved meniscal healing and clinical outcomes at 1 year following medial meniscus posterior root repair. Surgeons should create a medial meniscus posterior root tibial tunnel at the anatomic attachment with particular attention to the mediolateral position.

LEVEL OF EVIDENCE

Level IV.

Transtibial pullout repair of medial meniscus posterior root tears: effects on the meniscus healing score and ICRS grade among patients with mild osteoarthritis of the knee

PURPOSE

To assess the effects of transtibial pullout repair for medial meniscus posterior root tears (MMPRTs) among patients with early osteoarthritis of the knee as measured by the meniscus healing score and to determine whether the meniscus healing score correlates with the International Cartilage Repair Society (ICRS) grade progression.

METHODS

Forty-seven patients with mild osteoarthritic knees (Kellgren-Lawrence grade ≤ 2 and varus alignment < 5°) who underwent transtibial pullout repair less than 3 months after MMPRT onset were assessed. The association between meniscus healing scores at 1 year postoperatively and cartilage damage of the medial compartment (medial femoral condyle [MFC] and medial tibial plateau [MTP]) were evaluated. The MFC was divided into six zones (A to F) and the MTP into two zones (G and H). The mean ICRS grade for each zone was compared between the primary surgery and second-look arthroscopy. The correlation between cartilage damage and meniscus healing status at the time of second-look arthroscopy in each zone was analysed.

RESULTS

The mean time interval from injury to surgery was 63 days, and all clinical scores showed significant improvement. There were no significant differences in the extent of cartilage damage in areas B, C, E, or F (n.s.) for MFC or in areas G and H (n.s.) for MTP. The meniscus healing score and cartilage damage were correlated in the loading areas (B, C, E, and H; - 0.53, - 0.45, - 0.33, and - 0.38, respectively; p < 0.05).

CONCLUSION

Transtibial pullout repair of MMPRTs among patients with mild osteoarthritic knees improved the clinical outcomes and showed a negative correlation between high meniscus healing scores and ICRS grades in the medial compartment loading area. This study suggests that early surgery should be undertaken for patients with mild osteoarthritic knee who develop MMPRTs.

LEVEL OF EVIDENCE

Level IV.

Transtibial pullout repair techniques using two simple stitches for medial meniscus posterior root tear can prevent the progression of medial meniscus extrusion and obtain successful outcomes

PURPOSE

Transtibial pullout repairs using two simple stitches (TSS) and a combination of TSS with posteromedial pullout repair (TSS + PMP) using an all-inside meniscal repair device have been reported previously for the treatment of medial meniscus (MM) posterior root tears. This study aimed to investigate the postoperative clinical outcomes of these techniques including MM extrusion (MME).

METHODS

Fifty-two patients who underwent transtibial pullout repair were investigated and divided into TSS (n = 27) and TSS + PMP (n = 25) groups. The clinical outcomes were assessed using the Lysholm knee score and Knee Injury and Osteoarthritis Outcome Score 1 year postoperatively and compared between two groups. MME was measured using magnetic resonance imaging at 1 year postoperatively and compared between two groups.

RESULTS

A significant improvement in each clinical score was observed in both groups, and no significant difference was seen in clinical outcomes. Moreover, no significant difference in postoperative MME was observed in both groups (TSS and TSS + PMP: 3.5 mm and 3.8 mm, respectively). Though no significant progression of MME was observed in TSS group, a significant progression of it was observed in TSS + PMP group postoperatively.

CONCLUSIONS

This study demonstrated that both techniques improved clinical outcomes in the short-term postoperative period. However, MME was progressed significantly in TSS + PMP group 1 year postoperatively, which indicated that PMP might not be a useful additional procedure for reducing the postoperative MME.

An MRI-based suspension bridge sign can predict an arthroscopically favorable meniscal healing following the medial meniscus posterior root repair

BACKGROUND

Medial meniscus (MM) posterior root repairs show favorable clinical outcomes in patients with MM posterior root tears (MMPRTs). However, there is no useful magnetic resonance imaging (MRI) finding to determine a functionally good meniscal healing following MM posterior root repairs. We hypothesized that a characteristic postoperative MRI finding can predict a good meniscal healing following pullout repairs. The aim of this study was to investigate a clinical usefulness of several MRI findings for estimating an actual meniscal healing following MMPRT repairs.

METHODS

Fifty eight patients who had a posteromedial painful popping of the injured knee and underwent an arthroscopic pullout repair for the MMPRT were included. Arthroscopic meniscal healing was assessed according to the Furumatsu scoring system at 1 year postoperatively. We evaluated postoperative MRI-based meniscal healing using signal intensity, continuity, suspension bridge-like sign of the MM posterior root, and MM medial extrusion on coronal images. Postoperative clinical outcome evaluations were performed at second-look arthroscopy.

RESULTS

Twenty three patients showed good arthroscopic healing scores (≥7 points). Thirty five patients had moderate/poor arthroscopic healing scores (<7 points). At 1-year follow-up period, clinical outcome scores were significantly higher in the good healing group than in the moderate/poor healing group. A characteristic meniscal shape, termed "suspension bridge sign", was highly observed in the good meniscal healing group (83%) compared with in the moderate/poor healing group (26%, P < 0.001). High signal intensity and continuity of the MM posterior root and MM medial extrusion showed no differences between both groups.

CONCLUSIONS

Our study demonstrated that the MRI-based suspension bridge sign can predict an arthroscopically favorable meniscal healing following the MM posterior root repair. The suspension bridge-like MRI finding of the MM would be a useful indicator to evaluate the actual meniscal healing in patients who underwent pullout repairs for MMPRTs.

Arthroscopic Medial Meniscal Posterior Root Repair With Transtibial Luggage-Tag and Horizontal Mattress Sutures

Medial meniscal posterior root repair techniques have shown positive yet varied results in the literature. The decision to perform repair has improved clinical outcomes in many situations, although the healing rate is approximately 64% and the repair strength is roughly one-third of the native root strength, with meniscal extrusion being common. We present a technique based on biomechanical evidence to obtain a strong anatomic posterior root repair to restore nearly normal knee mechanics, combining an increased size of footprint under the lateral aspect of the medial meniscal horn for healing and a luggage-tag suture with a posteriorly placed horizontal mattress suture. The horizontal mattress suture is passed to capture the circumferential fibers of the meniscus and the luggage-tag suture is passed to capture the radial fibers of the meniscal body, through a single transtibial tunnel. The aim of this repair is to restore the normal meniscal function.

Two simple stitches for medial meniscus posterior root repair prevents the progression of meniscal extrusion and reduces intrameniscal signal intensity better than modified Mason-Allen sutures

PURPOSE

Medial meniscus posterior root tears (MMPRTs) can cause severe medial extrusion of the medial meniscus (MMME) and the progression of knee degenerative changes, inducing a high signal intensity of the meniscus on magnetic resonance imaging (MRI). Although MMME and intrameniscal signal intensity (IMSI) reportedly decreased within 3 months after MMPRT repair, no previous studies have reported these changes after a 1-year follow-up. This study aimed to investigate the 1-year postoperative changes in MMME and IMSI on MRI after using different suture techniques.

METHODS

Overall, 33 patients with MMPRT were evaluated, 22 underwent FasT-Fix-dependent modified Mason-Allen suture (F-MMA) repair, and 11 underwent two simple stitches (TSS) repair. MRI examinations were performed preoperatively and 1 year postoperatively. MMME and IMSI were determined using MRI.

RESULTS

A significant decrease in postoperative MMME was observed in the TSS group (4.1 ± 1.0) relative to that in the F-MMA group (5.1 ± 1.4, P = 0.03). A significant decrease in postoperative IMSI (0.75 ± 0.14) was observed relative to preoperative IMSI in the TSS group (P < 0.01), whereas postoperative IMSI (0.94 ± 0.25) was similar to preoperative IMSI in the F-MMA group (P = 0.06). Furthermore, a significant decrease in postoperative IMSI was observed in the TSS group relative to that in the F-MMA group (P < 0.01).

CONCLUSIONS

The most important finding of this study is that TSS repair yielded a greater decrease in MMME and IMSI than F-MMA repair in patients with MMPRT. These results suggest that TSS repair is more useful for restoring loading stress to the posterior horn of the medial meniscus.

Comparison of the clinical outcomes of transtibial pull-out repair for medial meniscus posterior root tear: Two simple stitches versus modified Mason-Allen suture

BACKGROUND

Transtibial pullout repair of a medial meniscus posterior root tear (MMPRT) is a commonly used procedure, and several techniques have been reported. We hypothesised that pull-out repairs using two simple stitches (TSS) would have similar postoperative outcomes as those using the modified Mason-Allen suture with FasT-Fix (F-MMA). We aimed to investigate the clinical outcomes of these techniques, including the meniscal healing status and osteoarthritic change.

METHODS

The data of 68 patients who underwent transtibial pull-out repair were retrospectively investigated. The patients were divided into two groups of 41 and 27 patients using F-MMA and TSS, respectively. The clinical outcomes were assessed preoperatively and at second-look arthroscopy (the mean period from surgery was one year) using the Knee injury and Osteoarthritis Outcome Score. The meniscal healing status, evaluated at second-look arthroscopy, was compared between the two groups. The cartilage damage was graded as per the classification of the International Cartilage Repair Society and compared at the primary surgery and second-look arthroscopy.

RESULTS

Both groups showed significant improvement in each clinical score. No significant difference was seen in the clinical outcome scores and the meniscal healing status between the two groups at second-look arthroscopy. Moreover, no significant progression of cartilage damage was observed in both groups. Fourteen patients in the F-MMA group developed a complication of suture bar failures postoperatively; however, there were no complications in the TSS group.

CONCLUSIONS

The TSS and F-MMA techniques showed favourable clinical outcomes and would be established as clinically useful techniques for the MMPRT treatment.

The distance between the tibial tunnel aperture and meniscal root attachment is correlated with meniscal healing status following transtibial pullout repair for medial meniscus posterior root tear

BACKGROUND

To investigate the relationship between tibial tunnel aperture location and postoperative meniscal healing.

METHODS

We enrolled 25 patients (20 women and five men, mean age: 62.5 years) who underwent transtibial pullout repair for medial meniscus (MM) posterior root repair. The expected MM posterior root attachment center (AC) and tibial tunnel center (TC) were identified using three-dimensional computed tomography, and the minimum AC-TC distance was calculated. The meniscal healing status following transtibial pullout repair was assessed by second-look arthroscopy (mean postoperative period: 15 months) using a previously reported scoring system (meniscal healing score; range: 0-10). The association between AC-TC distance and meniscal healing score was investigated using univariate linear regression models. The optimal AC-TC distance cut-off for improved MM healing score (≥7) was determined using receiver operating characteristic analysis.

RESULTS

The AC-TC distance and meniscal healing score were significantly associated (y = -0.42x + 9.48, R² = 0.342; P = 0.002), with the optimum AC-TC distance being 5.8 mm. This cut-off had a sensitivity of 100% and specificity of 53%.

CONCLUSIONS

This study demonstrates that AC-TC distance is significantly correlated with postoperative meniscal healing. Anatomical repair within 5.8 mm of the AC may result in improved meniscal healing.

The accuracy of a newly developed guide system in medial meniscus posterior root repair: a comparison between two aiming guides

Purpose

Posterior root repair of the medial meniscus (MM) can prevent rapid progression of knee osteoarthritis in patients with a MM posterior root tear (MMPRT). The anatomic reattachment of the MM posterior root is considered to be critical in a transtibial pullout repair. However, tibial tunnel creation at the anatomic attachment is technically difficult. We hypothesized that a newly developed point-contact aiming guide [Unicorn Meniscal Root (UMR) guide] can create the tibial tunnel at a better position rather than a previously designed MMPRT guide. The aim of this study was to compare the position of the created tibial tunnel between the two meniscal root repair guides.

Materials and methods

Thirty-eight patients underwent transtibial pullout repairs. Tibial tunnel creation was performed using the UMR guide (19 cases) or MMPRT guide (19 cases). Three-dimensional computed tomography images of the tibial surface were evaluated using the Tsukada’s measurement method postoperatively. The expected anatomic center of the MM posterior root attachment was defined as the center of three tangential lines referring to three anatomic bony landmarks (anterior border of the posterior cruciate ligament, lateral margin of the medial tibial plateau, and retro-eminence ridge). The expected anatomic center and tibial tunnel center were evaluated using the percentage-based posterolateral location on the tibial surface. The distance between the anatomic center and tunnel center was calculated.

Results

The anatomic center of the MM posterior root footprint was located at a position of 79.2% posterior and 39.5% lateral. The mean of the tunnel center in the UMR guide was similar to that in the MMPRT guide (posterior direction, P = 0.096; lateral direction, P = 0.280). The mean distances between the tunnel center and the anatomic center were 4.06 and 3.99 mm in the UMR and MMPRT guide group, respectively (P = 0.455).

Conclusions

The UMR guide, as well as the MMPRT guide, is a useful device to create favorable tibial tunnels at the MM posterior root attachment for pullout repairs in patients with MMPRTs.

Level of evidence

IV

A novel suture technique to reduce the meniscus extrusion in the pullout repair for medial meniscus posterior root tears

The medial meniscus (MM) posterior root has important functions in preventing an excessive loading stress during knee motion and degeneration of the articular cartilage. Although the transtibial pullout repair has become the gold standard for MM posterior root tears (MMPRTs), MM extrusion remains. In addition, during knee extension to deep flexion, the MM posterior segment in the MMPRT knee has been shown to translate toward the posteromedial direction, causing a notable MM posterior extrusion. Thus, the reduction in the MM posteromedial extrusion is one of the important postoperative outcomes to restore the meniscal function and eventually prevent the progression of knee osteoarthritis. The present technical note describes an arthroscopic technique addition to the pullout repair, in which an all-inside suture is inserted into the posteromedial part of the MM to reduce the MM posteromedial extrusion.

Description of a surgical technique of medial meniscus root repair: a fixation technique with two simple stiches under an expected initial tension

The medial meniscus (MM) posterior root has an important role in the maintenance of knee kinematics and articular cartilage. Although transtibial pullout repair of the MM posterior root tear (MMPRT) has become the gold standard, it is associated with several suturing difficulties. The present technical note describes a simple fixation technique using two simple stiches under an expected initial tension. After the degree of knee flexion (20°) and an expected tension (30 N) are checked, tibial fixation is performed using a bioabsorbable interference screw with a spring tensioner. After that, a suture knot is made just below the screw in case the sutures are pulled toward the joint direction. Furthermore, a cancellous screw is inserted at a position 1-cm distal from the tibial tunnel for augmentation and is tightened. MMPRT usually occurs in middle-aged females who often have decreased bone quality. However, there is no risk of tibial fracture with our new technique because the bone does not need to be hit. Adopting the advances of fixation with a spring tensioner and Biosure RG instead of Double Spike Plate, we can determine an expected tension easily and safely. The present fixation technique allows reproducibility for many operators to determine an initial tension and might be a good candidate for arthroscopic repair of the MMPRT. Further follow-up studies including second-look arthroscopy and scoring will be necessary to show the clinical benefits of this technique.