The relationship between ACL reconstruction and meniscal repair: quality of life, sports return, and meniscal failure rate-2- to 12-year follow-up

Anterior Cruciate Ligament Reconstruction in French Army: Return to Prior Level of Running on Selected Military Tests

INTRODUCTION

Anterior cruciate ligament (ACL) rupture is frequently encountered in athletes as well as in military personnel. In civilian population, many studies have looked at the return to sport, but return to duty in Army is a topic that requires further research.The purpose of this study was to determine through annual military fitness tests in real conditions, the return to sport in soldiers after ACL reconstruction and factors influencing failure.

MATERIALS AND METHODS

This was a retrospective comparative study. Patients were all soldiers and had followed up in a Military Hospital. The SUCCESS group was military personnel who obtained a result of the specific aptitude test greater than or equal to this same test carried out before reconstruction of the ACL, the FAILURE group comprised the others. Results of the annual specific aerobic fitness tests were collected before and after ACL reconstruction. Preoperative epidemiological data, intraoperative information, and isokinetic test results were collected.

RESULTS

One hundred forty four soldiers were included between January 2011 and December 2017 (94.9% of men with a median age of 27.6 years); 40.3% obtained a result greater than or equal to the preoperative fitness test after ACL reconstruction. Among the soldiers who did not regain their performance, 24.3% were declared unfit or discharged. In the FAILURE group, we found patients with a higher body mass index (25.5 vs. 24.4; P = .04), less patients with isokinetic deficit < 30% on the knee flexors and extensors (26.6% vs. 62.9%; P < .01), more long sick leave (39.5% vs. 13.7%; P < .01), and late resumption of military activities (10.5 vs. 8.9 months; P < .01).

CONCLUSION

Rupture of ACL has a significant impact on the operational capacity of the French army. The proportion of return to the same level in annual specific fitness tests after ACL reconstruction is 40% among soldiers. Several variables are important to consider in the follow-up of these patients to optimize their recovery of sports performance and therefore their operational capacity.

Meniscal Repair Outcome in 3829 Patients With a Minimum Follow-up From 2 Years Up to 5 Years: A Meta-analysis on the Overall Failure Rate and Factors Influencing Failure

BACKGROUND

The importance of meniscal repair is widely accepted because of the association of loss of meniscal tissue with the development of early-onset knee arthritis. Many factors influencing the results of meniscal repair have been reported, but results remain controversial.

PURPOSE

This meta-analysis determines the pooled meniscal repair failure rate of studies with a minimum follow-up of 2 years up to 5 years, with a mean follow-up of 43 months. Moreover, selected failure-influencing factors are analyzed.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 4.

METHODS

PubMed and Scopus were searched for studies published between January 2000 and November 2021 reporting on meniscal repair outcome with a minimum follow-up of 24 months. The overall pooled failure rate and pooled failure rates for possible predictors were calculated. Random-effect models were used to pool failure rates, and effect estimates in the form of odds ratios with 95% CIs were established.

RESULTS

The initial literature search identified 6519 studies. A total of 51 studies met the inclusion criteria. In total, 3931 menisci were included with an overall failure rate of 14.8%. Subgroup analysis revealed a significantly lower failure rate for meniscal repair with concomitant anterior cruciate ligament (ACL) reconstruction compared with knees without any reported injury to the ACL (8.5% vs 14%; P = .043). The pooled failure rate for lateral meniscal repair was significantly lower than that for medial meniscal repair (6.1% vs 10.8%; P = .031). Pooled failure rates of all-inside and inside-out repair were not significantly different (11.9% vs 10.6%; P > .05).

CONCLUSION

This meta-analysis on close to 4000 patients demonstrates an overall meniscal repair failure rate of 14.8% at a minimum follow-up from 2 years up to 5 years. Meniscal repair remains a procedure with a high failure rate, especially within the first 2 postoperative years. This review and meta-analysis also identified clinically relevant factors associated with favorable outcomes such as concomitant ACL reconstruction or repair of the lateral meniscus. All-inside meniscal repair with the latest-generation devices yields failure rates of <10%. The failure mechanism and the time of failure is poorly documented; further studies are needed for a better understanding of the retear mechanism.

Alteration in ACL loading after total and partial medial meniscectomy

Anterior cruciate ligament (ACL) injuries are often caused by high impact loadings during competitive sports but may also happen during regular daily activities due to tissue degeneration or altered mechanics after a previous knee injury or surgery such as meniscectomy. Most existing research on ACL injury has focused on impact loading scenarios or the consequence of ACL injury on meniscus. The objective of the present study was to investigate the effects of varying degrees of medial meniscectomy on the mechanics of intact ACL by performing a poromechanical finite element analysis under moderate creep loadings. Four clinical scenarios with 25%, 50%, 75% and total medial meniscectomy were compared with the intact knee finite element model. Our results suggested that different medial meniscal resections may increase, at different extents, the knee laxity and peak tensile stress in the ACL, potentially leading to collagen fiber fatigue tearing and altered mechanobiology under normal joint loadings. Interestingly, the ACL stress actually increased during early knee creep (~ 3 min) before it reached an equilibrium. In addition, meniscectomy accelerated ACL stress reduction during knee creep, transferred more loading to tibial cartilage, increased contact pressure, and shifted the contact center posteriorly. This study may contribute to a better understanding of the interaction of meniscectomy and ACL integrity during daily loadings.

Significant improvements in clinical outcome measures and patient satisfaction after combined all-arthroscopic meniscal allograft transplantation and autologous chondrocyte implantation: A single-centre longitudinal study

PURPOSE

The optimal treatment approach for the complex pathology of meniscal insufficiency and coexisting full-thickness cartilage defects remains unclear. The purpose of this study was to evaluate the viability, safety, and efficacy of this combined surgical approach at medium-term follow-up.

METHODS

This is a single-centre longitudinal study with blinded outcome assessment. All consecutive patients treated with combined all-arthroscopic meniscal allograft transplantation (MAT) with bone bridge fixation and ACI using chondrospheres at our institution between 2001 and 2021 were eligible for inclusion. Twenty patients with an average follow-up of 72.6 ± 34.4 months were included in the statistical analysis. Clinical outcomes were assessed pre- and postoperatively using the IKDC Subjective Knee Form, Lysholm Score, Tegner Activity Scale, KOOS, and Visual Analog Scale (VAS) for patient satisfaction. Failure and reoperation rates were assessed, and cartilage regeneration tissue was evaluated on postoperative MRI.

RESULTS

IKDC scores significantly improved from 52.1 ± 16.9 to 68.5 ± 16.3 (p = 0.003). Lysholm scores improved from 61.5 ± 21.7 to 78.5 ± 12.9 (p = 0.004). Tegner scores improved from 3.5 (1-4) to 4.0 (2-6) (p = 0.014). KOOS scores improved significantly across all subcategories, except 'symptoms', where improvements did not reach statistical significance. VAS for overall patient satisfaction showed improvements but did not reach statistical significance. The combined procedure was successful in 17 patients (85%). Eight patients had to undergo reoperation (40%), comprising mostly small, arthroscopic procedures. Seven reoperations were directly attributable to meniscal allograft transplantation (46.7%). Postoperative Magnetic Resonance Observation of Cartilage Repair Tissue scores were 68.9 ± 16.8 (n = 14).

CONCLUSION

Combined arthroscopic MAT and autologous chondrocyte implantation (ACI) is a viable, safe, and effective treatment approach for younger patients with meniscal insufficiency and coexisting full-thickness cartilage damage, where alternative treatment options are limited. The combined surgical procedure achieved significant improvements in clinical outcome measures and patient satisfaction with acceptable failure and high arthroscopic reoperation rates. MAT is the limiting part of this combined procedure, with most failures and reoperations being attributable to MAT, as opposed to ACI.

LEVEL OF EVIDENCE

Level III.

Surgical Management of Traumatic Meniscus Injuries

The menisci increase the contact area of load bearing in the knee and thus disperse the mechanical stress via their circumferential tensile fibers. Traumatic meniscus injuries cause mechanical symptoms in the knee, and are more prevalent amongst younger, more active patients, compared to degenerative tears amongst the elderly population. Traumatic meniscus tears typically result from the load-and-shear mechanism in the knee joint. The treatment depends on the size, location, and pattern of the tear. For non-repairable tears, partial or total meniscal resection decreases its tensile stress and increases joint contact stress, thus potentiating the risk of arthritis. A longitudinal vertical tear pattern at the peripheral third red-red zone leads to higher healing potential after repair. The postoperative rehabilitation protocols after repair range from immediate weight-bearing with no range of motion restrictions to non-weight bearing and delayed mobilization for weeks. Pediatric and adolescent patients may require special considerations due to their activity levels, or distinct pathologies such as a discoid meniscus. Further biomechanical and biologic evidence is needed to guide surgical management, postoperative rehabilitation protocols, and future technology applications for traumatic meniscus injuries.

Incomplete meniscal healing in early second-look arthroscopy does not indicate failure of repair: a case series

PURPOSE

To assess if incomplete meniscal healing during second-look arthroscopy at six to eight weeks after all-inside suture hook meniscus repair results in longer-term failure of repair in patients with restored knee stability.

METHODS

From 2008 to 2013, 41 patients with post-traumatic, longitudinal, vertical, complete meniscal tears with concomitant ACL injury were treated via a two-stage surgical procedure and prospectively evaluated. In the first stage, all-inside meniscus repair was performed using suture hook passers and non-absorbable sutures. In total, there were 26 medial and 16 lateral meniscus tears. A second-stage ACL reconstruction, performed six to eight weeks later, served as an early second-look arthroscopic evaluation of meniscal healing. Clinical follow-up was performed at a minimum of 24 months.

RESULTS

Second-look arthroscopy revealed 31 cases (75.6%) of complete and ten cases (24.4%) of incomplete meniscal healing. Two patients were lost prior to follow-up, and three were excluded due to recurrent instability. Therefore, 36 patients were assessed at the final follow-up. All patients with complete meniscal healing during second-look arthroscopy achieved clinical success at follow-up. Six out of nine (66.7%) of patients with incomplete meniscal healing during second-look arthroscopy achieved clinical success at follow-up (p = 0.012). One saphenous neuropathy occurred (2.4%).

CONCLUSION

Incomplete meniscal healing during early second-look arthroscopy after all-inside meniscal repair using suture hook passers and non-absorbable sutures did not necessarily result in longer-term failure in patients with restored knee stability. The described method of meniscal repair was associated with a low rate of symptomatic re-tears and complications.

Meniscal repair failure following concurrent primary anterior cruciate ligament reconstruction: results from the New Zealand ACL Registry

PURPOSE

This study aimed to identify the risk factors for meniscal repair failure following concurrent primary anterior cruciate ligament (ACL) reconstruction.

METHODS

Prospective data recorded by the New Zealand ACL Registry and the Accident Compensation Corporation were reviewed. Meniscal repairs performed during concurrent primary ACL reconstruction were included. Repair failure was defined as a subsequent reoperation involving meniscectomy of the repaired meniscus. Multivariate survival analysis was performed to identify the risk factors for failure.

RESULTS

A total of 3,024 meniscal repairs were analysed with an overall failure rate of 6.6% (n = 201) at a mean follow-up of 2.9 years (SD 1.5). The risk of medial meniscal repair failure was higher with hamstring tendon autografts (adjusted HR [aHR] = 2.20, 95% CI 1.36-3.56, p = 0.001), patients aged 21-30 years (aHR = 1.60, 95% CI 1.30-2.48, p = 0.037) and in patients with cartilage injury in the medial compartment (aHR = 1.75, 95% CI 1.23-2.48, p = 0.002). The risk of lateral meniscal repair failure was higher in patients aged ≤ 20 years (aHR = 2.79, 95% CI 1.17-6.67, p = 0.021), when the procedure was performed by a low case volume surgeon (aHR = 1.84, 95% CI 1.08-3.13, p = 0.026) and when a transtibial technique was used to drill the femoral graft tunnel (aHR = 2.30, 95% CI 1.03-5.15, p = 0.042).

CONCLUSION

The use of a hamstring tendon autograft, younger age and the presence of medial compartment cartilage injury are risk factors for medial meniscal repair failure, whereas younger age, low surgeon volume and a transtibial drilling technique are risk factors for lateral meniscal repair failure.

LEVEL OF EVIDENCE

Level II.

Clinical, Biomechanical, and Self-reported Health Status After ACL Reconstruction With Meniscal Repair in Soccer Players: Results at Minimum 1-Year Follow-up

Background

Performing meniscal repair with anterior cruciate ligament reconstruction (ACLR) has been shown to contribute to the long-term preservation of knee health and gait biomechanics.

Purpose

To evaluate the role of meniscal repair in the performance of semiprofessional soccer players who returned to sport after ACLR.

Study Design

Case series; Level of evidence, 4.

Methods

This study included 51 male soccer players (mean ± SD age, 28.82 ± 5.33 years) who underwent ACLR at a single institution between July 2018 and July 2019. The players were divided into 3 groups according to surgery type: ACLR only (n = 30), ACLR with lateral meniscal repair (n = 9), and ACLR with medial meniscal repair (n = 12). Outcomes were evaluated through clinical examination, self-reported health questionnaires (Cincinnati Knee Rating System, Tegner activity score, Tegner Lysholm Knee Scoring Scale, Tampa Scale of Kinesiophobia, and ACL-Return to Sport After Injury), and biomechanical performance evaluations (balance, strength, coordination, and symmetry tests). Parametric and nonparametric tests were carried out for multiple comparisons.

Results

The mean ± SD follow-up time was 20.75 ± 9.38 months. Although no significant differences emerged in clinical and self-reported health status, almost all the physical parameters tested resulted in lower performance in players treated with ACLR and meniscal repair. Moreover, patients with ACLR with lateral meniscal repair reported higher pain and fear of reinjury, with lower outcomes in terms of strength, symmetry, and coordination as compared with the other 2 groups. Balance abilities were significantly affected in players who underwent meniscal repair as compared with those who underwent ACLR only.

Conclusion

The findings showed that biomechanical performance measures and fear of reinjury were significantly worse in soccer players with associated meniscal repair at a minimum 1-year follow-up, especially in those with a lateral meniscal tear.

Spanish Version of the Anterior Cruciate Ligament-Quality of Life Questionnaire: Translation, Cross-cultural Adaptation, and Validation

Background

The Anterior Cruciate Ligament-Quality of Life (ACL-QOL) questionnaire is a patient-reported outcome measure used to assess the effect of an anterior cruciate ligament (ACL) injury on the lives of patients. It was originally written in English, which may affect its use when completed by nonnative English speakers.

Purpose

To translate and adapt the ACL-QOL to Spanish and provide evidence of its psychometric properties.

Study Design

Cohort study (diagnosis); Level of evidence, 2.

Methods

A total of 183 patients with an ACL injury from 4 Catalan hospitals were included: 99 patients who had undergone ACL reconstruction (ACLR) completed the Spanish version of the ACL-QOL (ACL-QOL-Sp) twice (mean interval, 15.2 days) in 2 weeks for test-retest reliability, and 84 patients completed the ACL-QOL-Sp, the Lysholm knee scoring scale, the Knee injury and Osteoarthritis Outcome Score (KOOS), Tegner Activity Scale, and the 12-item Short Form Health Survey (SF-12) before and at 4 and 9 months after ACLR to assess responsiveness. The association between the ACL-QOL-Sp and the other outcome measures was evaluated with the Spearman correlation coefficient.

Results

The ACL-QOL-Sp showed good internal consistency (Cronbach alpha = 0.96) and test-retest reliability (intraclass correlation coefficient = 0.97). The standard error of measurement was 3.6, also suggesting the precision of measurements. The smallest detectable change was 9.98 in 94% of patients. No association was found between the ACL-QOL-Sp score and the Tegner score or SF-12 mental component summary score; however, a moderate correlation was found with the overall KOOS score (r = -0.545), Lysholm score (r = 0.509), and SF-12 physical component summary score (r = 0.607). The correlation ranged from weak for the KOOS-Symptoms subscore (r = -0.290) to moderate for the KOOS-Quality of Life subscore (r = -0.698). No ceiling or floor effects were observed. The ACL-QOL-Sp showed a moderate effect size (0.73) at 4 months but a large effect size (1.70) at 9 months.

Conclusion

The ACL-QOL-Sp showed adequate internal consistency, test-retest reliability, and responsiveness in evaluating quality of life after ACLR in Spanish-speaking patients.

Long-term quality of life, work limitation, physical activity, economic cost and disease burden following ACL and meniscal injury: a systematic review and meta-analysis for the OPTIKNEE consensus

OBJECTIVE

Determine the long-term health-related quality-of-life (HRQoL), work limitation, physical activity, health/economic cost and disease burden of traumatic ACL and/or meniscal injury. Findings will inform OPTIKNEE evidence-based consensus recommendations.

DESIGN

Random-effects meta-analysis evaluated HRQoL (SF-36/SF-12/VR-12 Physical Component Scores (PCS) and Mental Component Scores (MCS), EuroQol-5D (EQ-5D)) stratified by time postinjury, and pooled mean differences (95% CI) between ACL-injured and uninjured controls. Other outcomes were synthesised descriptively. Risk-of-bias (RoB) and certainty of evidence (Grading of Recommendations Assessment, Development and Evaluation) were assessed.

DATA SOURCES

MEDLINE, EMBASE, CENTRAL, SPORTDiscus, CINAHL searched inception: 22 November 2021.

ELIGIBILITY

Studies reporting HRQoL, work limitations, physical activity levels, health/economic costs or disease burden, ≥2 years post-ACL and/or meniscal injury.

RESULTS

Fifty studies were included (10 high-RoB, 28 susceptible-to-some-bias and 12 low-RoB). Meta-analysis (27 studies, very low certainty of evidence) estimated a pooled mean (95% CI) PCS of 52.4 (51.4 to 53.4) and MCS of 54.0 (53.0 to 55.0) 2-14 years post-ACL injury. Pooled PCS scores were worse >10 years (50.8 (48.7 to 52.9)) compared with 2-5 years (53.9 (53.1 to 54.7)) postinjury. Excluding high-RoB studies, PCS scores were worse in ACL-injured compared with uninjured controls (-1.5 (-2.9 to -0.1)). Six studies (low certainty of evidence) informed a pooled EQ-5D score of 0.83 (0.81 to 0.84). Some individuals experienced prolonged work absenteeism and modified activities ≥2 years post-ACL injury. ACL injury was associated with significant direct and indirect costs, and early ACL reconstruction may be less cost-effective than rehabilitation. Only three studies evaluated meniscal injury outcomes (all evaluated HRQoL).

CONCLUSION

There is a very-low certainty of evidence that PCS scores ≥2 years post-ACL injury are worse than uninjured controls and decline over time, whereas MCS scores remain high. ACL injury can result in prolonged work absenteeism and high health/economic costs. Further studies are needed to determine the long-term burden of traumatic meniscal injury.

Single versus double bundle in posterior cruciate ligament (PCL) reconstruction: a meta-analysis

Posterior cruciate ligament (PCL) reconstruction can be performed using single bundle (SB) and double bundle (DB) techniques. The present study investigated whether DB PCL reconstruction is superior to SB reconstruction in terms of patient reported outcome measures (PROMs) and joint stability. In December 2021 Embase, Google Scholar, Pubmed, Scopus databases were accessed. All clinical trials comparing SB versus DB reconstruction to address PCL insufficiency in skeletally mature patients were considered. Data from 483 procedures were retrieved. The mean follow-up was 31.0 (28.0 to 107.6) months, and the mean timespan between injury and surgery was 11.3 (6 to 37) months. The mean age of the patients was 29.3 ± 3.8 years. 85 of 483 patients (18%) were women. At a mean of 31.0 months post reconstruction, ROM (P = 0.03) was slightly greater in the SB group, while the Tegner score (P = 0.03) and the Telos stress (P = 0.04) were more favorable in the DB cohort. Similarity was found in instrumental laxity (P = 0.4) and Lysholm score (P = 0.3). The current evidence does not support the use of DB techniques for PCL reconstruction. Both methods could restore knee stability and motion with satisfactory short term patient reported outcome measures. Further high quality clinical trials are required to validate these results on a larger scale.

Clinical Outcomes of Meniscus Repair with or without Multiple Intra-Articular Injections of Platelet Rich Plasma after Surgery

Preservation of the meniscal volume is crucial in meniscus repair. The goal of this study was to evaluate the clinical outcome of repeated intra-articular platelet-rich plasma (PRP) injections after arthroscopic repair of a traumatic meniscal tear. We retrospectively reviewed 61 primary meniscal repairs in 61 patients (PRP group: 30; non-PRP: 31) from 2017 to 2018. Patients in the PRP group received repeated intra-articular PRP injections in week 2,4,6 after the primary meniscus repair. Subsequent meniscal repair treatment or meniscectomy, knee arthroplasty, and IKDC changes of less than 11.5 points were defined as healing failures. After following up for at least 24 months, the IKDC score was 75.1 ± 13.6, and the Lysholm score was 80.6 ± 14.9 in the PRP group and 72.6 ± 15.8 (IKDC) and 77.7 ± 17.2 (Lysholm) in the non-PRP group. Healing rates of the PRP and the non-PRP groups were 93.3% (Kaplan-Meier 91.6%) and 87.1% (Kaplan-Meier 84.7%), respectively (log rank test p = 0.874). Our study is the first to use multiple intra-articular PRP injections to facilitate meniscal healing after meniscal repair. Though selection bias may be present in this study, the PRP group had similar functional outcome and healing rate compared to non-PRP group.