Root Repair Has Superior Radiological and Clinical Outcomes Than Partial Meniscectomy and Nonoperative Treatment in the Management of Meniscus Root Tears: A Systematic Review

Editorial Commentary: Rate of Meniscal Repair Versus Meniscectomy Has Improved and Should Continue to Improve

As a result of research supporting meniscus preservation, evidence shows that internationally, there has been a rise in rates of meniscus repair, especially in younger population, and a decline in rates of partial meniscectomy. The decline in partial meniscectomy has been rather rapid and has outpaced the rise in meniscal repair, likely due to increasing evidence against routine partial meniscectomy in degenerative tears with coexistent arthritis. However, despite the rise in meniscus repair, close to 95% of meniscus surgeries are still partial meniscectomies. The partial meniscectomy to meniscus repair ratio seems to be rather high. Optimistically, this will improve because successful repair outcomes have been demonstrated in situations previously considered "high-risk," including complex patterns, central tears, radial tears, and root and ramp tears. This may be due to multiple factors, many of which may be beyond the control of surgeons, including the fact that as many as 25% of repairs fail to heal. Yet, with improved techniques and instrumentation, the success rate of repair is improving. The cost of repair may be a limiting factor, especially in low-income countries with poor health insurance penetration and unfavorable reimbursement of repair cost. Every effort must be made to repair a tear, which has potential to heal.

Suture anchor and transtibial pullout refixation of the posterior medial meniscus root tears restore tibiofemoral contact pressure and area to intact meniscus levels

PURPOSE

To compare the load distributed to the medial tibial articular cartilage after refixation of posterior medial meniscus root tears between the suture anchor and transtibial pullout techniques in posterior medial meniscus root tears.

METHODS

Twelve Thiel's embalmed human cadaveric knees are used and divided into three groups (four knees in each group): (1) intact meniscus (IM), (2) fixation with suture anchor technique (SA) and (3) fixation with transtibial pullout technique (TP). Each group applies an axial compression load up to 1500 N by Instron E 10000 at two knee flexion angles (0° and 60°). A Tekscan 4000 pressure sensor is used to record the contact pressure and the contact area for each testing condition.

RESULTS

The contact pressure and the contact area between the three conditions are not significantly different at 0° and 60° knee flexion angles. The peak contact pressure and contact area are 3734.8 ± 2642.2 kPa, 288.2 ± 115.0 mm2, 4510 ± 2930.5 kPa, 204.4 ± 36.8 mm2 and 5328.8 ± 2607.7 kPa, 219.2 ± 84.7 mm2 in IM, SA and TP, respectively.

CONCLUSION

Both suture anchor and transtibial pullout refixation of PMMRT can restore contact pressure and contact area similar to the intact meniscus. This finding suggests that either technique can be reliably used in clinical practice to preserve joint function and potentially reduce the risk of osteoarthritis progression following posterior medial meniscus root tear repairs.

LEVEL OF EVIDENCE

Level III.

The use of lateral wedge insoles delays osteoarthritis progression and improves clinical outcomes in medial meniscus posterior root repair

Purpose

The purpose of this retrospective study was to evaluate the efficacy of using a lateral wedge insole (LWI) during the first 3 months after medial meniscus posterior root (MMPR) repair.

Methods

Overall, 179 patients were categorized into LWI use (LWI group, 90 patients) and nonuse (control group, 89 patients) groups. Patients in the LWI group were instructed to wear an LWI from the initiation of load bearing up to 3 months postoperatively. Medial meniscus extrusion (MME) was evaluated preoperatively and 1 year postoperatively, Kellgren-Lawrence (KL) grade and clinical scores were evaluated preoperatively and 2 years postoperatively, and second-look arthroscopic meniscal healing scores were evaluated at 1 year postoperatively.

Results

The proportion of patients with KL grade progression at 2 years postoperatively was significantly lower in the LWI group than in the control group (23.3% vs. 39.3%; p = 0.024). Change in the MME at 1 year postoperatively was significantly smaller in the LWI group than in the control group (1.1 ± 1.2 vs. 1.6 ± 1.4 mm; p = 0.042). The Lysholm score (p = 0.003) and Knee Injury and Osteoarthritis Outcome Scores-sport and recreation function (p = 0.027) at 2 years postoperatively were significantly superior in the LWI group than in the control group. The arthroscopic meniscal healing score after 1 year was not significantly different between the LWI and control groups (total score, 7.6 ± 1.1 vs. 7.4 ± 1.3 points; p = 0.732). The anteroposterior width of the repaired posterior root at 1 year second-look evaluation was significantly broader in the LWI group than in the control group (7.7 ± 1.6 vs. 6.9 ± 1.6 mm; p = 0.001).

Conclusions

The use of LWI is an effective way to delay postoperative osteoarthritis progression and improve clinical outcomes after MMPR repair.

Level of Evidence

Level III.

Transtibial Pullout for Medial Meniscus Posterior Root Reconstruction With Split-Gracilis Autograft

Meniscal root tears are recognized as an important pathology. Failure to recognize and to treat this pathology could lead to early-onset osteoarthritis, similar to a total meniscectomy. Surgical treatment is essential to restore meniscal function and to normalize compartment contact pressures, whenever there is joint overload and not severe cartilaginous damage. Still, the biological healing property of the medial meniscus is poor, and failure of the surgical procedure may occur. This Technical Note proposes a technical procedure for revision of medial meniscus posterior root reconstruction with a split-gracilis autograft tendon anatomical transtibial pullout technique.

Meniscus Reconstruction Using Autologous Tendon Combined With Open-Wedge High Tibial Osteotomy: A Technique to Achieve Rigid Fixation and Avoid Interference Between Locking Screws and Tibial Bone Tunnel

Meniscal posterior root tears reportedly result in accelerated cartilage degeneration and spontaneous insufficiency fractures of the knee. While meniscus repair combined with open-wedge high tibial osteotomy is an optional method, the healing rate is not sufficiently high. Therefore, this Technical Note describes a technique for meniscal reconstruction combined with open-wedge high tibial osteotomy that may offer improvements in meniscal healing rates and clinical results.

Posterior Lateral Meniscal Root Repair Through Lateral Tunnel and Anterior Cruciate Ligament Revision: How to Avoid Tunnel Overlapping

Posterior lateral meniscal root (PLMR) tears are commonly observed in conjunction with anterior cruciate ligament (ACL) injuries. The presence of PLMR tears exacerbates knee instability, increasing stress on ACL grafts and accelerating joint degeneration if left untreated. Anatomical repair of PLMR tears is therefore crucial for restoring native knee kinematics and reducing tibiofemoral contact pressures, thereby safeguarding the ACL graft. However, the standard use of a single medial tunnel approach for concomitant PLMR and revision ACL reconstruction may require reconsideration to prevent the potential risks of tunnel overlapping, which could undermine graft anatomical integrity. This article, to prevent the risk of tunnel overlapping, introduces a surgical approach that employs an additional lateral tibial tunnel for PLMR repair, instead of the typically used single medial one, for PLMR repair during simultaneous revision ACL reconstruction.

More than 3 mm of preoperative medial meniscal extrusion is identified as a key risk factor for varus progression in limb alignment after arthroscopic repair of medial meniscus posterior root tear

PURPOSE

To investigate the risk factors for varus progression after arthroscopic medial meniscal posterior root tear (MMPRT) repair and to compare the clinical outcomes between two groups: one with more varus progression and the other with less varus progression.

METHODS

Patients who underwent isolated arthroscopic repair of MMPRT between 2015 and 2020 were enroled, and 2-year follow-up data were collected. Participants were categorized into two groups based on preoperative values of the weight-bearing line (WBL) ratio: group A with <5.9% increase and group B with ≥5.9% increase. Various factors, including demographic features and radiological findings, were analysed and compared between the two groups. Intra-meniscal signal intensity, meniscal healing, medial meniscal extrusion (MME), and articular cartilage grade were assessed preoperatively and 1-year postoperatively using coronal magnetic resonance imaging.

RESULTS

The final cohort consisted of 34 patients in group A and 46 in group B, with a mean age of 55.8 ± 11.2 and 59.8 ± 6.6 years, respectively. Preoperative WBL ratio and cartilage lesions in the medial compartment did not differ between the groups. Preoperative MME were significantly lower in group A than those in group B (2.6 ± 0.6 mm in group A and 3.5 ± 0.7 mm in group B, p < 0.05). Patient-reported outcomes at the 2-year follow-up did not differ between the two groups (n. s.). In a logistic analysis, the odds ratio of MME was 2.1 (p < 0.05), and the cutoff value of MME was 3.02 mm.

CONCLUSION

Preoperative MME is a risk factor for varus progression. However, no differences in patient-reported outcomes were observed at 2-year follow-up, even in the group with greater varus progression.

LEVEL OF EVIDENCE

Level IV.