Recent advances in ligamentous, meniscal and joint-preserving knee surgery: Pushing the limits

Survivorship and outcomes of intra- and perimeniscal corticosteroids injections with structured physiotherapy for degenerative medial meniscus tears

BACKGROUND

Degenerative medial meniscus tears are a common pathology in the general population. Recent randomized trials demonstrated non-superiority of arthroscopic partial meniscectomy over conservative management. However, there is a paucity of information regarding the outcomes of combined conservative treatments.

HYPOTHESIS

It was hypothesized that combined intra- and perimeniscal corticosteroid injections with structured physiotherapy, for degenerative medial meniscus tears, would result in high surgery-free and second injection-free survivorship.

METHODS

A retrospective review of 671 patients with symptomatic degenerative medial meniscus tears, who received intra- and perimeniscal corticosteroids injection combined with structured physiotherapy, was conducted. An ultrasound-guided injection of Triamcinolone Hexacetonide 20 mg/ml comprised; 1.5 ml intra-meniscal,1.5 ml in the meniscal wall, and 2 ml in the peri-meniscal space, was performed. Surgery free- and a second injection free-survivorship were analysed. Western Ontario and Macmaster University scores (WOMAC), Tegner activity scores, patient satisfaction, return-to-work status and average time to return to work were recorded.

RESULTS

A total of 481 patients who met the inclusion criteria were included. The mean age was 51.1 ± 7.9 years. At five years post-procedure, surgery-free, and second injection-free survivorship of the ipsilateral knee was 83%, and 52%, respectively. A multivariate analysis adjusting survival on parametric risk factors identified that only effusion before steroid injection was an independent risk factor of treatment failure. At a mean follow-up of 4 ± 2 years, there was an improvement in WOMAC scores by 5.2 ± 4.9 for pain, by 2 ± 2 for stiffness, by 7.3 ± 7.4 for function, and by 12.4 ± 12.7 for the global scores. Additionally, there was significant improvement in the Tegner activity scores (All p < 0.001). Knee effusion and advanced osteoarthritis (Kellgren-Lawrence > III) were significantly associated with poorer outcomes; p < 0.003 and p < 0.0004, respectively.

CONCLUSION

A combination of intra- and perimeniscal corticosteroid injections and structured physiotherapy for degenerative medial meniscus tears, results in high surgery-free (83%) and second injection-free (52%) survivorship, as well as, effective clinical outcomes and satisfaction at 5 years.

LEVEL OF EVIDENCE

IV; Retrospective Case Series.

Editorial Commentary: Meniscal Allograft Transplantation Is Effective for Adolescents With Meniscal Insufficiency, Although Outcomes May Decline Over Time

Over the last several years, there has been a shift from arthroscopic partial meniscectomy to meniscal repair, especially in the younger patient. In case of a necessary partial meniscectomy, some patients have unremittent symptoms of pain and effusion corresponding to the postmeniscectomy syndrome. In these patients without large coronal malalignment, meniscal allograft transplantation is a valuable option to restore contact pressures, promote a chondroprotective microenvironment, and potentially delay secondary surgical interventions symptoms. In the adolescent population, meniscal allograft transplantation has been shown to effectively improve patient-reported outcomes with a low conversion to arthroplasty. However, these treatments are far from ideal, and prevention is certainly better than the cure: timely diagnosis of meniscus injuries, appropriate treatment with meniscus repair rather than partial meniscectomy, even in the complex tear patterns, and consideration of corrective osteotomy for milder cases of malalignment.

Extrusion and meniscal mobility evaluation in case of ramp lesion injury: a biomechanical feasibility study by 7T magnetic resonance imaging and digital volume correlation

Introduction: The existing body of literature on the biomechanical implications of ramp lesions is limited, leaving a significant gap in our understanding of how these lesions impact joint kinematics and loading in the medial compartment. This cadaveric biomechanical study aims to address this gap by employing an innovative Digital Volume Correlation (DVC) method, utilizing 7 Tesla Magnetic Resonance Imaging (MRI) images under various loading conditions. The primary objective is to conduct a comprehensive comparison of medial meniscal mobility between native knees and knees affected by grade 4 ramp lesions. By focusing on the intricate dynamics of meniscal mobility and extrusion, this work seeks to contribute valuable insights into the biomechanical consequences of medial meniscus ramp lesions. Materials and methods: An initial set of 7T MRI imaging sessions was conducted on two intact native knees, applying load values up to 1500N. Subsequently, a second series of images was captured on these identical knees, with the same loads applied, following the creation through arthroscopy of medial meniscus ramp lesions. The application of DVC enabled the precise determination of the three components of displacement and spatial variations in the medial menisci, both with and without ramp lesions. Results: The measured directional displacements between native knees and injured knees indicate that, following the application of axial compression load, menisci exhibit increased extrusion and posterior mobility as observed through DVC. Discussion: Injuries associated with Subtype 4 medial meniscus ramp lesions appear to elevate meniscal extrusion and posterior mobility during axial compression in the anterior cruciate ligament of intact knees. Following these preliminary results, we plan to expand our experimental approach to encompass individuals undergoing weight-bearing MRI. This expansion aims to identify meniscocapsular and/or meniscotibial insufficiency or rupture in patients, enabling us to proactively reduce the risk of osteoarthritic progression.

The frequency of medial meniscal repairs in stable knees during one year of arthroscopic activity (2021-2022) - comparison with a retrospective study (prior to 2017)

INTRODUCTION

There has been a significant increase in the use of conservative treatment for meniscal lesions due to raised awareness around the need for meniscal preservation. However, sutures of the medial meniscus (MM) in stable knees remain less frequently used. The objective of this study was to, firstly, identify the MM suture rate over one year of activity; secondly, to identify and compare the distribution of MM sutures in stable, and stabilized, knees on this prospective series; and thirdly, to compare the evolution of practices with a retrospective series of more than 5 years follow-up.

HYPOTHESIS

The number of MM sutures in stable knees represents a small percentage of annual arthroscopic activity.

MATERIAL AND METHODS

This multicenter study was carried out in 10 reference centers participating in the 2022 symposium of the Francophone Society of Arthroscopy (Bordeaux, Caen, Lille, Lille Louvière, Lyon, Marseille, Toulouse, Saint-Étienne, Strasbourg, Versailles). This study included a prospective series on interventions performed under arthroscopy during one year of activity. The inclusion criteria were patients operated on via an arthroscopic technique and aged over 18 at the time of the operation. Demographic data, as well as the circumstances leading to the injury, were collected. A register of the lesions found was established in order to list the lesions of the MM, the lateral meniscus (LM), the anterior cruciate ligament (ACL), the associated chondral lesions; as well as the treatment performed: meniscal suture of the MM and/or LM, meniscectomy of the MM and/or LM and ligamentoplasty of the ACL. This study also included a retrospective series comprised of only MM sutures in stable knees at more than 5 years of follow-up.

RESULTS

Of the 4154 patients included, 1919 patients (46.2%) underwent surgery for ACL reconstruction and 2235 for arthroscopy without associated ligament surgery. MM sutures (in stable knees and in knees with ACL reconstruction) represented 14% of the overall arthroscopic activity (583 MM sutures) versus 8.6% for LM (360 sutures). In cases of ACL surgery, there were 895 associated meniscal lesions (337 LM and 558 MM) and 66% of MM tears (371 MM sutures) were sutured. In stable knees, MM tears were weaker (212 MM sutures out of 1359 lesions, i.e. 15%). Of all the arthroscopic procedures performed over the course of a year, MM suturing in stable knees represented 5.1% of the activity. Compared to the retrospective series (n=367), the patients were older (37 years versus 28 years) and the management of ramp lesions or root tears was noted. In both series, these tears were related to sports trauma in more than 70% of cases.

CONCLUSION

MM suturing in stable knees represents a small part of annual arthroscopic activity and it occurs less frequently than during ACL reconstruction surgery.

LEVEL OF EVIDENCE

IV.