Arthroscopic repair of the meniscus: Surgical management and clinical outcomes

Medial Meniscal Ramp Tears in Patients With Anterior Cruciate Ligament Tears Undergoing Reconstruction: A Surgically Relevant Classification System Based on Tear Morphology

PURPOSE

To develop an anatomically and surgically relevant classification system for medial meniscal ramp tears from prospectively collected data from a consecutive series of patients undergoing anterior cruciate ligament reconstruction (ACLR) with ramp tears.

METHODS

A series of consecutive patients undergoing ACLR with medial meniscal ramp tears treated by 2 orthopaedic surgeons between June 2021 and May 2024 were included in this study. After arthroscopic confirmation of a medial meniscal ramp tear, the tear morphology and repair technique were noted using a ramp tear diagram, operative notes, and surgical photographs and/or videos. Tears were classified as partial or complete, stable or unstable, and superior or inferior, as well as based on whether they were in the capsule or within 3 mm of the meniscal rim.

RESULTS

A total of 115 patients with a mean age of 27.0 years (range, 13-52 years) were included and grouped into 5 distinct groups based on ramp tear morphology. Tear patterns were classified into partial stable tears (type 1; n = 8, 7.0%), partial unstable femoral-sided (meniscocapsular and superior meniscus) tears (type 2; n = 8, 7.0%), partial unstable tibial-sided (meniscotibial and inferior meniscus) tears (type 3; n = 31, 27.0%), complete separation tears (type 4; n = 46, 40.0%), and complex tears (type 5; n = 22, 19.1%).

CONCLUSIONS

This study shows that it was possible to establish a medial meniscal ramp tear classification system for patients undergoing ACLR based on anatomic and arthroscopic morphologic tear documentation. In this study, tears were grouped into 5 distinct groups: partial stable ramp tears (type 1), partial unstable superior ramp tears (type 2), partial unstable inferior ramp tears (type 3), complete separation ramp tears (type 4), and complex ramp tears (type 5).

CLINICAL RELEVANCE

Previous studies have highlighted the importance of the ramp attachment for stability and the prevention of anterior cruciate ligament graft failure. Our classification system is based on a prospectively collected patient population and incorporates assessment of the tear for stability to probing, identification of the location of the tear, and a surgically relevant tear progression. With the described classification system, we hope to optimize repair techniques and improve outcomes associated with different ramp tear types.

Current advances in animal model of meniscal injury: From meniscal injury to osteoarthritis

Meniscal injury is a prevalent orthopedic practice that causes articular cartilage wear and degeneration due to tissue damage or loss, and may eventually result in the occurrence of knee osteoarthritis (KOA). Hence, investigating the structural regeneration and mechanical function restoration of the meniscus after injury is pivotal research topic for preventing KOA. Animal models are essential for investigating therapeutic strategies for meniscal injuries and their clinical translation, yet no current model can fully recapitulate the complexity of human meniscal injuries. This review aims to categorize the prevalent animal models of meniscal injury by their establishment methods, elucidate their principles and procedures, and discuss the suitability and limitations of each model. We delineate the pros and cons of different models in simulating the pathology and biomechanics of human meniscal injury. We also analyze different animal species regarding their meniscal structure, function, and repair potential, and their implications for model selection. We conclude that selecting an appropriate animal model requires a comprehensive consideration of various factors, such as research aims, anticipated outcomes, and feasibility. Furthermore, to translate novel therapeutic approaches to clinical applications more safely and effectively, future model development should emphasize aspects such as choosing animals of suitable age. The Translational Potential of this Article: This review aims to categorize and discuss current animal models of meniscal injury by establishment methods and provides a comprehensive overview of the routinely employed experimental animals in each model to facilitate the clinical translation of OA-related research.

Fibrin clot augmentation of high-risk meniscal repairs may result in clinical healing in up to 90% of cases

OBJECTIVE

While meniscal repair is preferable to meniscectomy, some cases may be at higher risk of failure if repaired. Incorporating fibrin clot (FC) into the repair has been proposed to improve healing rates. The purpose of this study was to determine the failure rates, patient reported outcome measures (PROMs) and complications of FC augmented meniscal repair for cases considered to be at higher risk of failure.

METHODS

A retrospective case series of all patients undergoing FC augmented repair of isolated meniscus tears between January 2016 and September 2021 was undertaken. All cases were thought be at higher risk of failure; they included chronic, radial, complex, horizontal cleavage, and tears not in the red-red zone. Patients were excluded if they had a concomitant anterior cruciate ligament (ACL) reconstruction or if the repair was done through an open incision. The primary outcome was clinical failure defined as further repair or debridement. Secondary outcomes were PROMs and surgical complications. PROMs collected were Lysholm score, Knee injury and Osteoarthritis Outcome Score, Oxford Knee Score and the Tegner score.

RESULTS

Fifty one inside-out meniscal repairs using FC were performed in 50 patients (62% male). The mean age was 34 years (range 14-70). The median time from injury to repair was 122 days (range 4-1565). The medial meniscus was repaired in 63% of cases. Tear types included radial (31%) and complex (39%) and 71% of cases included repair of the white-white zone. 16% of cases were revision meniscal repairs. FC was used in 43% of isolated meniscal repairs during the study period. All patients were followed up to a median of 46 months (range 22-87 months). PROMs at a median of 30 months post-operatively showed statistically significant improvements. Five patients (10%) underwent further surgery for failure after median 21 months. Two patients (4%) reported sensory disturbance around their skin wounds, no other complications were reported. 13% of medial meniscal repairs failed, whereas only 5% of lateral meniscal repairs failed (p ​= ​0.4).

CONCLUSIONS

FC augmented meniscal repair performed for tears considered to be at higher risk of failure may result in acceptably low rates of clinical failure.

LEVEL OF EVIDENCE

Level IV, case series.

Double-Needle Meniscal Suture Technique: Technical Description and Clinical Application in Dogs

Current treatments for medial meniscus lesions in association with CCL ruptures have shown disappointing long-term outcomes. Meniscal suturing may improve the outcome, but their clinical application remains limited. This study aims to assess the practicability of a minimally invasive DNT to facilitate meniscal suturing in dogs. Ten stifles of eight client-owned dogs with arthroscopically confirmed CCL disease and medial meniscal tears in the abaxial third of the meniscus were included. The described suture technique was applied under joint distraction using the Titan joint distractor. Surgical stabilization of all stifles was then accomplished via an X-Porous TTA procedure. The DNT allowed for the precise placement of meniscal sutures. Minor intraoperative complications included reduced arthroscopic visibility (n = 2) and suture breakage during its passage through the meniscus (n = 3). No complications related to the meniscal sutures were noted throughout the six-month follow-up period. The described DNT proved to be a viable and effective method for suturing lesions of the caudal horn of the medial meniscus, provided there is adequate visualization during the procedure. Appropriate stifle stabilization postoperatively is mandatory for protecting the suture and avoiding concomitant meniscal lesions due to joint instability.

Correlation of meniscus tear type with synovial inflammation and the therapeutic potential of docosapentaenoic acid

BACKGROUND

Synovitis, characterized by inflammation of the synovial membrane, is commonly induced by meniscus tears. However, significant differences in inflammatory responses and the key inflammatory mediators of synovium induced by different types of meniscal tears remain unclear.

METHODS

Magnetic resonance imaging (MRI) was employed to identify the type of meniscus tear, and the quantification of synovial inflammation was assessed through H&E staining assay. Transcription and expression levels of IL-1β and IL-6 were evaluated using bioinformatics, ELISA, RT-qPCR, and IHC of CD68 staining assays. The therapeutic potential of Docosapentaenoic Acid (DPA) was determined through network pharmacology, ELISA, and RT-qPCR assays. The safety of DPA was assessed using colony formation and EdU staining assays.

RESULTS

The results indicate that both IL-1β and IL-6 play pivotal roles in synovitis pathogenesis, with distinct expression levels across various subtypes. Among tested meniscus tears, oblique tear and bucket handle tear induced the most severe inflammation, followed by radial tear and longitudinal tear, while horizontal tear resulted in the least inflammation. Furthermore, in synovial inflammation induced by specific meniscus tears, the anterior medial tissues exhibited significantly higher local inflammation than the anterior lateral and suprapatellar regions, highlighting the clinical relevance and practical guidance of anterior medial tissues' inflammatory levels. Additionally, we identified the essential omega-3 fatty acid DPA as a potential therapeutic agent for synovitis, demonstrating efficacy in blocking the transcription and expression of IL-1β and IL-6 with minimal side effects.

CONCLUSION

These findings provide valuable insights into the nuanced nature of synovial inflammation induced by various meniscal tear classifications and contribute to the development of new adjunctive therapeutic agents in the management of synovitis.

[Application of anterior region suture of popliteal hiatus in treatment of discoid lateral meniscus injury with instability in popliteal tendon region]

Objective

To discuss the application of anterior region suture of the popliteal hiatus (PH) under arthroscopy in the treatment of discoid lateral meniscus (DLM) injury with instability in the popliteal tendon region.

Methods

The clinical data of 53 patients (56 knees) with DLM injury who met the selection criteria between March 2014 and November 2022 were retrospectively analyzed. There were 15 males and 38 females, aged 8-55 years with an average age of 36.5 years. Fourteen cases had a history of trauma, while the remaining 39 cases had no clear history of trauma. The disease duration ranged from 1 day to 6 years, with an average duration of 15.6 months. According to the Watanabe classification, there were 40 knees of complete type and 16 knees of incomplete type. The preoperative International Knee Documentation Committee (IKDC) knee joint score was 51.2±8.3, the Lysholm score was 59.6±11.2, and the visual analogue scale (VAS) score was 4.7±1.3. After the arthroscopic meniscal plasty, the instability of the popliteal tendon region meniscus was checked by probing traction. Subsequently, the Out-inside technique or a combination of Out-inside and All-inside techniques was used to suture the anterior region of the PH. The stability of the meniscus after suturing was assessed, and if necessary, further suturing using the All-inside technique at the posterior region of the PH, the posterior horn of the meniscus, and using the Out-inside technique at the anterior horn of the meniscus was performed. Postoperative complications were recorded. The effectiveness was evaluated using pre- and post-operative IKDC scores, Lysholm scores, and VAS scores.

Results

After operation, knee joint pain, crepitus, and locking disappeared, with McMurray and grinding tests turning negative. All patients were followed up 12-93 months with an average of 57.5 months. There was no complication such as common peroneal nerve injury, deep vein thrombosis of the lower limbs, joint infection, or joint stiffness. At last follow-up, the IKDC knee joint score was 76.7±5.5, the Lysholm score was 94.0±4.1, and the VAS score was 1.1±0.8. The differences compared with preoperative scores were significant ( t=-22.090, P<0.001; t=-23.704, P<0.001; t=19.767, P<0.001).

Conclusion

Suturing of the anterior region of the PH is crucial in the treatment of DLM injury with instability in the popliteal tendon region.

Modified Outside-In Plus Suture Technique for Repair of the Anterior and Middle Segments of the Meniscus: Technical Note

Traditionally, an outside-in suture technique is appropriate to repair longitudinal tears of the anterior and middle segments of the meniscus. However, it has a fundamental weakness of not creating a vertical mattress-type suture. To overcome this weakness, the modified outside-in technique was developed using a suture hook to create a vertical mattress-type suture in the inner fragment. However, it still has the disadvantage of requiring an open skin incision to prevent neurovascular damage during knot tying. Thus, we developed the modified outside-in plus technique to make a vertical mattress suture without an open skin incision in the knee joint. With this technique, the use of both vertical and horizontal mattress sutures is possible. Although this technique is similar to the modified outside-in technique, a suture knot is made inside the knee joint. Therefore, it compensates for the disadvantage of the outside-in technique. The modified outside-in plus technique is able to achieve good reduction and sufficient stability through a vertical mattress suture technique without additional skin incisions.

Arthroscopic treatment of the symptomatic discoid lateral meniscus improves the knee function in the long-term: a ten-year follow-up study

PURPOSE

Discoid lateral meniscus (DLM) is a common meniscal anatomic disorder and can cause irreversible knee consequences. The long-term clinical outcomes of DLM management remain unclear. Moreover, several potential factors would influence the long-term functional outcomes. The factors also remain unclear. This study aims to evaluate the long-term clinical outcomes of the arthroscopic management of the DLM and to identify the patients' factors affecting the long-term results.

METHODS

Medical records were retrospectively examined for patients with symptomatic unilateral DLM who underwent arthroscopic procedures between January 2004 and August 2011. The characteristics of DLM, the preoperative and the long-term postoperative visual analog scale (VAS), the International Knee Documentation Committee (IKDC) score, Lysholm, and Yulish scores were evaluated. Data were collected, processed, and analyzed using SAS software version 9.2. Univariate and multivariate analyses were performed to identify the factors influencing the long-term outcomes of the DLM arthroscopy.

RESULTS

A total of 128 patients were included, most of whom were females (68.7%). The median age of the included participants was 24 (16-31) years old. The median duration of symptoms was 23.3 (10, 31) months, and the median follow-up duration was 126.2 (113, 140) months. The functional scores significantly improved postoperatively compared to the preoperative scores; VAS (1.65 ± 1.17 vs. 6.08 ± 1.31), Lysholm (91.39 ± 5.05 vs. 77.51 ± 10.19), and IKDC (84.63 ± 7.69 vs. 67.89 ± 9.56), respectively; p<0.05. Multivariate analysis revealed that gender, the status of self-reported instability, preoperative VAS, Yulish MR cartilage grade, and Lysholm score had a significant correlation with the worsening of the final follow-up IKDC scores.

CONCLUSIONS

Arthroscopic procedure significantly improved the long-term joint function of the DLM patients, as evidenced by the sustained improvement of the VAS, Lysholm, and IKDC scores. These clinical outcomes were greatly influenced by gender, the status of self-reported instability, preoperative Yulish MR cartilage grade, VAS, and Lysholm score.

Horizontal Cleavage Tear Meniscal Repair Using All-Inside Circumferential Compression Sutures

Horizontal cleavage meniscus tears occur more frequently in older patient populations with degenerative changes within the meniscus. Traditionally, they have been managed with nonsurgical interventions or with partial meniscectomy. As increasing evidence demonstrates the link between partial meniscectomy and progressive osteoarthritis with these types of tears, as well as worse long-term outcomes and reduced cost savings, surgical repair of horizontal cleavage meniscal tears has increased in appropriate patients. This technique article highlights the evaluation, indications, and preferred repair technique for horizontal cleavage tears in appropriately selected patients.

Clinical and MRI Outcomes of Repaired Peripheral Longitudinal Tears of the Posterior Horn of the Medial Meniscus With ACL Reconstruction: Results According to Tear Size

Background

Arthroscopic repair of longitudinal tears in the medial meniscal posterior horn (MMPH) has been reported to result in high rates of meniscal healing when performed alongside anterior cruciate ligament reconstruction (ACLR). However, studies that have focused on longitudinal tears and their impact on clinical outcomes after arthroscopic repair are insufficient.

Purpose

To investigate the clinical outcome and healing status after concomitant arthroscopic ACLR and repair of MMPH peripheral longitudinal tears, with respect to the tear length.

Study Design

Cohort study; Level of evidence, 3.

Methods

A total of 263 patients who underwent concurrent arthroscopic suture repair of longitudinal tears of the MMPH and ACLR were enrolled. All patients had 2-year postoperative magnetic resonance imaging (MRI) evaluations, and 61% of patients underwent a second-look arthroscopy. The exclusion criteria were partial meniscectomies and multiligament injuries. Patients were assessed pre- and postoperatively for clinical scores, amount of anterior translation, grade of pivot shift, and presence of meniscal tear extension. According to the length of longitudinal tears, patients were classified into 2 groups: (1) patients with tears that were located in the posterior compartment and (2) patients with tears that extended to the midbody of the meniscus. Binary stepwise logistic regression analysis was used to evaluate the risk factors for unhealed menisci as identified by MRI.

Results

A total of 83 patients were included in this study-52 patients (group 1) had MMPH tears without tear extension and 31 patients (group 2) had MMPH tears with tear extension. There were no differences in outcomes between the groups, including the healing rate after meniscal repair (P > .05). Based on postoperative MRI scans, 67 patients (80.7%) were categorized as completely healed and 16 patients (19.3%) as unhealed. There were no significant differences between the completely healed and unhealed groups in outcomes or the rate of preoperative midbody tear extension. Higher body mass index and lower preoperative Lysholm scores were identified as risk factors for unhealed menisci.

Conclusion

Overall, the rate of complete healing of MMPH tears repaired concomitantly with ACLR was 80.7% (67/83), and midbody tear extension did not affect the healing rate of the repaired meniscus. Results indicate that suture repair for unstable MMPH tears should be considered regardless of tear size.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Meniscal Root Tears: An Update Focused on Preoperative and Postoperative MRI Findings

Meniscal root tears represent radial tears or avulsions of the meniscal cartilage at the tibial attachment site that profoundly affect meniscal biomechanics and kinematics. Meniscal root tears have the functional effect of a total meniscectomy and can lead to rapid degenerative change with development of early knee osteoarthritis (OA). A growing range of arthroscopic surgical techniques have been developed to repair meniscal root tears with the aim of restoring joint kinematics and contact pressures and delaying the development of OA. With increased understanding of the anatomy and biomechanics of the meniscal root, meniscal root injury repair has become the treatment of choice in knees with nonadvanced OA. This article reviews the anatomy and biomechanics of the meniscal roots, clinical and imaging diagnostic criteria of meniscal root tears, correlation between arthroscopy and MRI in the diagnosis and classification of meniscal root tears, and expected and abnormal MRI findings after meniscal root repair. Familiarity with MRI signs and classifications of meniscal root tears, as well as with root repair surgical techniques, can aid radiologists in correctly reporting preoperative and postoperative MRI findings.

Higher healing rate after meniscal repair with concomitant ACL reconstruction for tears located in vascular zone 1 compared to zone 2: a systematic review and meta-analysis

PURPOSE

The purpose of this study was to determine and compare the percentage of completely healed meniscal tears after arthroscopic repair combined with anterior cruciate ligament reconstruction (ACLR) for the different vascular zones of the meniscus.

METHODS

PubMed, Embase, Web of Science, Cochrane library and Emcare were searched on 19 May 2020 for articles reporting healing rates after arthroscopic meniscal repair with concomitant ACLR for the different meniscal vascular zones as assessed by second-look arthroscopy. Data on meniscal tears were extracted as located in zones 1, 2 or 3, according to the Cooper classification. Studies were graded in quality using a modified Newcastle-Ottawa Scale. Pooled analyses were performed utilizing a random-effects model. Meta-analyses were performed using R version 3.6.2 and SPSS statistical software version 25.0. The study was registered with PROSPERO (ID:CRD42020176175).

RESULTS

Ten observational cohort studies met the inclusion criteria, accounting for 758 meniscal tear repairs in total. The pooled overall proportion of healing was 78% (95% CI 72-84%). The mean weighted proportion of healing was 83% (95% CI 76-90%) for studies (n = 10) reporting zone 1 tears and 69% (95% CI 59-79%) for studies (n = 9) reporting zone 2 tears. No study reported healing rates for zone 3 tears. The pooled overall odds ratio was 2.5 (95% CI 1.00-6.02), indicating zone 1 tears as 2.5 times more likely to heal than zone 2 tears.

CONCLUSION

This study demonstrates that meniscal tears localized in vascular zone 1 were more likely to heal than those in zone 2.

LEVEL OF EVIDENCE

IV.

A narrative review of lateral meniscus root tears and extrusion: techniques and outcomes

Objective

In this review, we performed a literature search and described the surgical procedure for a lateral meniscus posterior root tears (LMPRT) repair using a pull-out technique and an arthroscopic centralization for lateral meniscus (LM) extrusion.

Background

The menisci play a pivotal role in the shock-absorbing and load-dispersing functions of the knee joint. They also contribute to its stability. Meniscal root tears substantially affect meniscal hoop function and accelerate cartilage degeneration. Additionally, LMPRT have been shown to affect anterolateral knee laxity and tibiofemoral contact pressure in knees with anterior cruciate ligament (ACL) injury. Therefore, appropriate management of LMPRT is essential for restoring knee function. Meniscus extrusion has attracted attention due to its association with early osteoarthritis (OA). Recently, an arthroscopic centralization technique has been proposed to reduce meniscal extrusion. During this procedure the capsule attached to the meniscus is sutured to the edge of the tibial plateau using suture anchors.

Methods

A narrative review of LMPRT repair and arthroscopic centralization of lateral meniscal extrusion was performed through a PubMed search.

Conclusions

Specific magnetic resonance imaging (MRI) signs were useful for the diagnosis of LMPRT. Pull-out techniques can restore knee stability and load distribution function and result in favorable clinical outcomes. Arthroscopic centralization of the extruded LM caused by meniscectomy and lateral discoid meniscus achieved satisfactory clinical outcomes at the 2-year follow-up. Biomechanical studies demonstrated that this procedure reduced meniscus extrusion and had beneficial effects on load distribution and joint stability. In summary, to restore knee function, LMPRT should be repaired as much as possible. The centralization technique is a promising surgical treatment for extruded lateral menisci due to meniscectomy and discoid meniscus. However, due to the lack of high-level evidence studies such as randomized control trials (RCTs) in this field, it remains necessary to accumulate evidence to confirm the efficacy of LMPRT repair and the centralization technique.

Biochemical Characteristics and Clinical Result of Bone Marrow-Derived Fibrin Clot for Repair of Isolated Meniscal Injury in the Avascular Zone

PURPOSE

To characterize bone marrow aspirate-derived fibrin clot (BMA clot) and evaluate the clinical result of meniscal repair with a BMA clot for isolated meniscal injury in the avascular zone.

METHODS

Blood counts of total leukocytes, platelets, and concentrations of basic fibroblast growth factor (bFGF), transforming growth factor β (TGF-β), and stromal cell-derived factor 1 (SDF-1) were analyzed with BMA, peripheral blood (PB), BMA clot, and PB clot from 5 patients treated for meniscal repair. In addition, a retrospective analysis of 30 patients with isolated avascular meniscal injuries who underwent repair with a BMA clot was performed to assess rate failure. Avascular meniscal injury was identified as horizontal tear, radial tear, and flap tear. Clinical failure was defined as the presence of 1 or more of Barrett's criteria. Anatomic failure was defined as the existence of equivalent signal intensity to intra-articular fluid along the repair area on follow-up magnetic resonance imaging (MRI). Patients' demographic and clinical data were compared between the overall failure group and the success group.

RESULTS

The bFGF, TGF-β, and SDF-1 levels of BMA clots were more highly concentrated compared with PB clots. The Lysholm scores and meniscal status evaluated by MRI were significantly improved from preoperatively to postoperatively (both P < .001). The Kellgren-Lawrence grading of knee radiographs did not significantly differ pre- and postoperatively (P = .140). Rates of clinical failure, anatomic failure, and retear were 10%, 6.7%, and 3.3%, respectively. The demographic characteristics and surgical and postoperative status did not significantly differ between the overall failure group and the success group.

CONCLUSIONS

BMA clots had increased levels of cytokines compared to PB clots. The retrospective analysis revealed that the rates of clinical failure and anatomic failure after meniscal repair with a BMA clot for isolated avascular meniscal injury were 10% and 6.7%, respectively.

LEVEL OF EVIDENCE

Level IV, case series.

Comparative clinical outcomes of different therapies for traumatic meniscal tears in adults: A protocol for systematic review and network meta-analysis

BACKGROUND

Meniscus tears are usually classified as degenerative or traumatic tears according to their pathogenesis. At present, traumatic meniscal tears are generally believed to have high healing potential. In recent years, multiple treatments have been described for traumatic meniscal tears, such as the inside-out technique, outside-in technique, all-inside technique, biological augmentation of meniscal repair, meniscectomy, and non-surgical treatment. However, the functional recovery of the knee joint and healing of the meniscus after treatment are quite different from the results reported in the literature, which requires more reliable evidence-based medical findings. This study will evaluate evidence from multiple types of research comparing different therapies for traumatic meniscal tears in adults.

METHODS

We will search the EMBASE, Cochrane Library (the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials [CENTRAL], Cochrane Methodology Register), PubMed, Web of Science (Science and Social Science Citation Index), China Knowledge Network, CBM, Wanfang data, and VIP electronic databases from their inception to August 10, 2021, with no language restrictions. We will also manually search Baidu and Google Scholar to identify randomized controlled studies, non-randomized controlled studies, and cohort studies on the treatment of traumatic meniscal tears. Two researchers will independently screen the literature, extract the data, and evaluate the quality of the studies. Software programs, including Microsoft Access, Excel, Stata (Version 15), WinBUGS (Version 1.4.3), and ADDIS (Version 1.16.8), were used to analyze and manipulate the data.

RESULTS

In this study, the main outcomes were physical function and healing rate, based on the Western Ontario and McMaster Universities Osteoarthritis Index, Lysholm Knee Scoring Scale, Knee Injury and Osteoarthritis Outcome Score, Functional Recovery Scale, and clinical healing rate. The secondary indexes included total cost, cost-effectiveness ratio, incremental cost-effectiveness ratio, Tegner activity scale score, visual analogue scale, numerical rating scale, and meniscal tear complications.

CONCLUSIONS

This systematic review will provide reliable evidence-based findings for the clinical application of different therapies for traumatic meniscal tears in adults.

Intra-operative assessment of the vascularisation of a cross section of the meniscus using near-infrared fluorescence imaging

PURPOSE

The purpose of this study was to assess whether the vascularisation of the meniscus could be visualised intra-operatively using near-infrared fluorescence (NIRF) imaging with indocyanine green (ICG) in patients undergoing total knee arthroplasty (TKA).

METHODS

The anterior horn (i.e., Cooper classification: zones C and D) of the meniscus that was least affected (i.e., least degenerative) was removed during TKA surgery in ten patients to obtain a cross section of the inside of the meniscus. Thereafter, 10 mg of ICG was injected intravenously, and vascularisation of the cross section of the meniscus was assessed using the Quest spectrum NIRF camera system. We calculated the percentage of patients in whom vascularisation was observed intra-operatively using NIRF imaging compared to immunohistochemistry.

RESULTS

Meniscal vascularisation using NIRF imaging was observed in six out of eight (75%) patients in whom vascularisation was demonstrated with immunohistochemistry. The median extent of vascularisation was 13% (interquartile range (IQR) 3-28%) using NIRF imaging and 15% (IQR 11-23%) using immunohistochemistry.

CONCLUSION

This study shows the potential of NIRF imaging to visualise vascularisation of the meniscus, as vascularisation was observed in six out of eight patients with histologically proven meniscal vascularisation.

LEVEL OF EVIDENCE

IV.

Effects of different surgical procedures for meniscus injury on two-year clinical and radiological outcomes after anterior cruciate ligament reconstructions. -TMDU MAKS study

BACKGROUND

The treatment of meniscus injuries combined with anterior cruciate ligament (ACL) reconstruction would be important to improve outcomes after ACL reconstruction. However, the effects of treatment methods for meniscus after ACL reconstruction have not been thoroughly investigated. The objective of this study was to investigate the effects of treatment methods for meniscus on clinical and radiological outcomes at 2 years after ACL reconstruction.

METHODS

Three-hundred and eighteen patients with primary ACL reconstruction using autologous hamstring tendon registered in our multicenter study database and who were followed up for 2 years were included. They were then divided into 3 groups, the no meniscal lesion/untreated group (n = 149), the meniscal repair group (n = 139), and the meniscal resection group (n = 30). Patient-based subjective evaluations (Lysholm score, Knee injury and Osteoarthritis Outcome score and International Knee Documentation Committee subjective score), objective evaluations (Lachman test, pivot shift test and KT measurement), and radiological measurements (medial and lateral joint space width) were compared among the 3 groups preoperatively and at 2 years follow-up.

RESULTS

All subjective scores and objective evaluations significantly improved in all groups without significant differences among the groups postoperatively. Regarding radiological findings, the medial joint space width significantly decreased only in the resection group during the 2-year period, and the medial joint space width in the resection group was significantly smaller than that of the other groups at the 2-year follow-up. Moreover, the medial joint space width significantly decreased during the 2-year period when MM was resected.

CONCLUSIONS

In radiological findings, medial meniscus resection decreased medial joint space width two years after ACL reconstruction. On the other hand, treatment methods for meniscus neither significantly affected subjective nor objective findings until the 2-year follow-up.

LEVEL OF EVIDENCE

Ⅱ, Cohort study.

Six-Month Outcomes of Clinically Relevant Meniscal Injury in a Large-Animal Model

BACKGROUND

The corrective procedures for meniscal injury are dependent on tear type, severity, and location. Vertical longitudinal tears are common in young and active individuals, but their natural progression and impact on osteoarthritis (OA) development are not known. Root tears are challenging and they often indicate poor outcomes, although the timing and mechanisms of initiation of joint dysfunction are poorly understood, particularly in large-animal and human models.

PURPOSE/HYPOTHESIS

In this study, vertical longitudinal and root tears were made in a large-animal model to determine the progression of joint-wide dysfunction. We hypothesized that OA onset and progression would depend on the extent of injury-based load disruption in the tissue, such that root tears would cause earlier and more severe changes to the joint.

STUDY DESIGN

Controlled laboratory study.

METHODS

Sham surgeries and procedures to create either vertical longitudinal or root tears were performed in juvenile Yucatan mini pigs through randomized and bilateral arthroscopic procedures. Animals were sacrificed at 1, 3, or 6 months after injury and assessed at the joint and tissue level for evidence of OA. Functional measures of joint load transfer, cartilage indentation mechanics, and meniscal tensile properties were performed, as well as histological evaluation of the cartilage, meniscus, and synovium.

RESULTS

Outcomes suggested a progressive and sustained degeneration of the knee joint and meniscus after root tear, as evidenced by histological analysis of the cartilage and meniscus. This occurred in spite of spontaneous reattachment of the root, suggesting that this reattachment did not fully restore the function of the native attachment. In contrast, the vertical longitudinal tear did not cause significant changes to the joint, with only mild differences compared with sham surgery at the 6-month time point.

CONCLUSION

Given that the root tear, which severs circumferential connectivity and load transfer, caused more intense OA compared with the circumferentially stable vertical longitudinal tear, our findings suggest that without timely and mechanically competent fixation, root tears may cause irreversible joint damage.

CLINICAL RELEVANCE

More generally, this new model can serve as a test bed for experimental surgical, scaffold-based, and small molecule-driven interventions after injury to prevent OA progression.

A review of strategies for development of tissue engineered meniscal implants

The meniscus is a key stabilizing tissue of the knee that facilitates proper tracking and movement of the knee joint and absorbs stresses related to physical activity. This review article describes the biology, structure, and functions of the human knee meniscus, common tears and repair approaches, and current research and development approaches using modern methods to fabricate a scaffold or tissue engineered meniscal replacement. Meniscal tears are quite common, often resulting from sports or physical training, though injury can result without specific contact during normal physical activity such as bending or squatting. Meniscal injuries often require surgical intervention to repair, restore basic functionality and relieve pain, and severe damage may warrant reconstruction using allograft transplants or commercial implant devices. Ongoing research is attempting to develop alternative scaffold and tissue engineered devices using modern fabrication techniques including three-dimensional (3D) printing which can fabricate a patient-specific meniscus replacement. An ideal meniscal substitute should have mechanical properties that are close to that of natural human meniscus, and also be easily adapted for surgical procedures and fixation. A better understanding of the organization and structure of the meniscus as well as its potential points of failure will lead to improved design approaches to generate a suitable and functional replacement.

Five Overlooked Injuries on Knee MRI

This article highlights five knee injuries that, in the author's experience, are commonly overlooked by readers inexperienced in knee MRI: ramp lesions, meniscocapsular tears, meniscal root ligament tears, posterior capsular ligament tears, and partial anterior cruciate ligament tear. While these injuries are readily apparent when the images are assessed for the given abnormality, the author's belief is that these may be overlooked because either the injury is not considered, or the affected area is not closely inspected. While these injuries may not alter immediate clinical management or require surgical intervention, they may, nevertheless, result in patient symptoms and may potentially increase the risk of further knee injury. Further, these injuries are difficult to recognize clinically and arthroscopically. In this review, we present these five injuries, emphasising relevant anatomy, normal MRI appearances, common injury patterns, and tips to avoid their being overlooked. Routine review of these areas when interpreting knee MRI, with additional imaging as necessary, will allow these injuries to be recognized more regularly.

Cavendish P, P. Quinn J, DiBartola AC, Flanigan DC. Repair of Radial Meniscus Tears Results in Improved Patient-Reported Outcome Scores: A Systematic Review

PURPOSE

To quantify healing rates and patient-reported outcome scores following repair of radial meniscus tears.

METHODS

PubMed, Scopus, and Embase databases were searched according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Inclusion criteria included: human subjects with meniscal tears, full-text English language, average follow-up of at 1 year, and publication after the 2000. Exclusion criteria included technical, biomechanical, and cadaveric studies. Study quality was assessed using Coleman Methodology Scores and Methodological Index for Non-Randomized Studies (MINORS) criteria.

RESULTS

Twelve studies reported on the repair of 243 radial tears in 241 patients. The mean Modified Coleman Methodology Score was 46.8, range 26-60, with a mean level of evidence of 3.5. Arthroscopic techniques were used in all studies, with 1 study using an arthroscopic-assisted 2-tunnel trans-tibial pullout technique. The mean patient age was 32 years (11-71). The mean follow-up was 35 months (12 to 75.6). The average time to surgery was 10.9 months (0.5-22.4). Eight of the 12 studies reported concomitant anterior cruciate ligament (ACL) reconstruction, with 64% having concomitant ACL injury. The most common outcome measure was the Lysholm score, which improved from 47-68.9 preoperatively to 86.4-95.6 postoperatively. Tegner Activity Scale improved from 2.5-3.1 preoperatively to 4.7-6.7 postoperatively. Healing rates were reported via magnetic resonance imaging and second-look arthroscopy. Second-look arthroscopy was performed for a variety of indications, including removal of screw, washers or plates, dissatisfaction with original procedure, partial healing found on magnetic resonance imaging, or desire of the patient to know the true healing status before return to sport. Of those assessed, 62.0% had complete healing, 30.0% partial healing, and 8.0% failure to heal.

CONCLUSIONS

Patient-reported outcomes of radial meniscus repair with and without ACL reconstruction are encouraging, with high patient-reported outcomes reported at final follow-up when compared with preoperative scores. Among all meniscus repairs assessed for healing, the majority demonstrated at least some healing with an overall low rate of failure.

LEVEL OF EVIDENCE

IV; systematic review of level III-IV studies.

All-Inside Arthroscopic Repair For Longitudinal Meniscal Tears: Clinical and Functional Results

Meniscal injuries are a common challenge in orthopaedic surgery. Depending on their location and the patient's age and functional needs, they can be treated either conservatively or surgically. A surgical approach can consist of arthroscopic meniscectomy or meniscal suture. The latter is the treatment of choice in case of lesions involving the red-red or red-white areas of the meniscus, especially for young high-demanding patients. We report here our experience with the repair of longitudinal meniscal tears using the all-inside technique with the Fast-Fix™ 360 Meniscal Repair System (Smith & Nephew Endoscopy, Andover, MA). We retrospectively evaluated 20 consecutive cases of longitudinal meniscal tears. In 4 cases, concomitant ACL rupture was diagnosed and treated alongside the meniscal repair. All patients underwent periodic clinical evaluations. At the latest check-up, their functional outcomes were rated according to the Tegner-Lysholm Knee and KOOS scoring scales. The mean Tegner-Lysholm Knee score was 84.85 (44-100) and the mean KOOS score was 88.58. No failure or major complications were observed. Furthermore, a negative statistical association was observed between age at surgery and the post-operative Tegner-Lysholm Knee score (coef. = -1.01189 [-1.942073,-0.0817063], p = 0.035). This relation, independent of gender, meniscus involved, eventual associated ACL reconstruction, and chondral injury, suggests that functional outcomes worsen with increasing patient age. Our results suggest that the arthroscopic all-inside suture is both safe and effective in cases of longitudinal meniscal tear, considering the good post-operative functionality and low rates of local complications and surgical failures.

Earlier Is Better? Timing of Adductor Canal Block for Arthroscopic Knee Surgery under General Anesthesia: A Retrospective Cohort Study

The adductor canal block (ACB) is effective for treating postoperative pain during arthroscopic knee surgery, but its impact on anesthesia course and the optimal administration timing are unknown. This retrospective study addressed these questions. The aim of this study was to compare the effects of preoperative ACB and postoperative ACB on anesthesia course and postoperative recovery. We allocated 215 adult patients who underwent arthroscopic knee surgery under sevoflurane anesthesia between January 2019 and December 2019 to three groups. Group A received general anesthesia without ACB, Group B received ACB before general anesthesia induction, and Group C received ACB in the post-anesthesia recovery unit (PACU). Group B consumed significantly less sevoflurane (0.19 mL/kg/h) and milligram morphine equivalents (0.08 MME) intraoperatively than Groups A (0.22 mL/kg/h; 0.10 MME, respectively) and C (0.22 mL/kg/h; 0.09 MME, respectively). Groups B and C had lower visual analogue scale (VAS) scores upon PACU discharge than Group A. Dynamic, but not at-rest VAS scores, were significantly higher in Group A. Opioid consumption was similar in the ward, but Group A requested more intravenous parecoxib for pain relief. Length of hospital stay was similar. Thus, preoperative ACB reduced the amount of volatile anesthetic required and maintained stable hemodynamics intraoperatively. Preoperative or postoperative ACB improved postoperative pain control. Consequently, preoperative ACB is optimal for intraoperative stress suppression and postoperative pain control.

Arthroscopic Procedure for Chronic Isolated Bucket-Handle Meniscal Tears

Arthroscopic treatment is the treatment of choice in bucket-handle meniscal tears (BHMTs). Following BHMT, however, surgery failure rates are approximately 20% in the literature. Achieving the healing of BHMT is difficult. This is worse in chronic situations because the torn meniscus is deformed, leading to nonanatomical reduction. Some authors have reported greater failure rates, especially in the early postoperative period. In isolated BHMTs, the failure rate is greater because of inadequate and incomplete repairs due to the tight medial compartment. Multiple techniques for possible reduction of failure rate have been described. We describe an arthroscopic technique for treating chronic isolated BHMT using the technique of subcutaneously releasing the posterior fibers of the medial collateral ligament to provide adequate space for arthroscopy, meniscal reduction, and repair. A combined inside-out and all-inside repair technique was used to enhance anatomic reduction, stable fixation, surface fixation (rather than the usual suture-points fixation), and biologic healing in repairable chronic BHMTs.

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.

The all-inside all-suture technique demonstrated better biomechanical behaviors in meniscus radial tear repair

PURPOSE

The purpose of this study was to evaluate the effectiveness of three constructs and techniques for repair of radial tears of the meniscus.

METHODS

Thirty fresh frozen porcine menisci were divided equally into three groups consisting of (1) inside-out repair group, (2) a commonly used all-inside suture with anchor hybrid repair construct (AISAH) (Meniscal Cinch™), and (3) an all-inside all-suture repair construct (AIAS) (Knee Scorpion™). Radial tears were created and repaired and then the menisci were secured to the materials testing machine. Both cyclic loading and load-to-failure testing were performed. The displacement, stiffness, response to cyclic loading, and mode of failure were recorded and analyzed statistically.

RESULTS

The displacement after cyclic loading (DACL) of the Cinch repair construct group was significantly higher than that of the inside-out repair construct group (p = 0.000) and AIAS repair construct (p = 0.000). There was not a statistical difference of DACL between inside-out and AIAS groups (n.s.). The inside-out construct failed at a significantly higher load than the AISAH repair construct (p = 0.000) and AIAS construct (p = 0.006). The AIAS construct failed at a significantly higher load than the AISAH repair construct (p = 0.009). The AIAS had a higher stiffness than AISAH (p = 0.047). The AIAS had a higher load at 3 mm protrusion than AISAH (p = 0.034).

CONCLUSION

The AIAS repair construct had better biomechanical behaviors than AISAH construct and inside-out repair technique. Inside-out sutures and AIAS repair construct had similar biomechanical responses to cyclic loading. The AIAS can be used for meniscus tear surgical repair with less damage to peri-meniscus tissues.

Outside-in Continuous Meniscal Suture Technique of the Knee

The meniscus is largely responsible for the health and longevity of the knee. It has diverse functions, being fundamental in load absorption and distribution and even in joint stability. To preserve meniscal functions and prevent the occurrence of osteoarthritis after meniscectomy, several meniscal repair techniques have been developed. To perform meniscal repair in anterior horn, the outside-in technique is the most used. There are few devices for performing them, with most of the surgical techniques described using needles. Our group uses a device capable of performing meniscal repair in different ways. Our objective is to describe a continuous outside-in meniscal repair technique, especially indicated for anterior horn and meniscus body tears, with the "Meniscus 4-All suture device." The continuous outside-in meniscal suture technique using this device is easy to perform, inexpensive, fast, and reproducible, minimizing the risk of soft-tissue entrapment. In addition, it allows the surgeon to perform meniscal repair in the posterior horn in extensive injuries with the same repair device, just switching to inside-out technique.

[A mid-term clinical follow-up study on repair of the meniscus tears by a modified arthroscopic outside-in puncture suture technique]

OBJECTIVE

To investigate the clinical effect of a modified arthroscopic outside-in suture technique in the treatment of meniscus tear using a spinal needle.

METHODS

From January 2015 to October 2017, 95 patients treated with this method were followed-up. Among these cases, there were 36 males and 59 females. The age of the patients ranged from 16 to 77 years, (46.79±18.07) years in average. Among them, there were 28 patieats aged 16-35, 53 patients aged 36-65, and 14 patients aged over 65 years old. 28 cases were diagnosed with medial meniscus tear, 43 cases with lateral meniscus tear and 24 cases with both medial and lateral meniscus tear. Causes of the injury included sports, sprain, etc. According to Barrett standard, the clinical healing of meniscus tear was judged. Lysholm score, knee range of motion, visual simulation score (VAS) and magnetic resonance imaging (MRI) were used to evaluate the postoperative knee function and recovery of the patients.

RESULTS

The 95 patients were followed up for 22 to 36 months, with an average of (28.32±3.98) months. According to Barrett standard, 90 patients (94.7%) obtained meniscus clinical healing. Meniscal healing rates were 96.43%, 96.23% and 85.71% in the three age groups, respectively. The meniscal healing rate was lower in the elderly group, but there was no significant difference in statistical results (P=0.262). Five patients had deep tenderness in the joint space of the injured side, and the overstretch test was positive. The preoperative and postoperative VAS scores, Lysholm scores and knee motion were compared in each group, and the differences were statistically significant (P < 0.01). At the end of the last follow-up, there were no cases of knee joint effusion, swelling and interlocking, and the joint function was effectively improved in most patients. No surgical site infection, periarticular vascular/nerve injury or knotting reaction was found during the follow-up.

CONCLUSION

This modified arthroscopic outside-in suture technique using a spinal needle has the characteristics of simple operation, small trauma and rapid recovery, and the mid-term follow-up results were satisfactory. Therefore, we consider this method to be a safe and efficient method for the treatment of meniscus anterior horn and body tear.

Clinical practice and postoperative rehabilitation after knee arthroscopy vary according to surgeons' expertise: a survey among polish arthroscopy society members

BACKGROUND

Meniscus repair is a challenging task in knee arthroscopy. Currently, there are a variety of arthroscopic methods available for meniscus repair. The purpose of this study was to determine a consensus in meniscus tear treatment in the environment of Polish orthopaedists.

METHODS

A total of 205 registered orthopaedic surgeons participated in the surveys. The survey consisted of 35 questions regarding general arthroscopy and postoperative management, including physicians' level of expertise, anaesthesia, postoperative treatment, rehabilitation and procedures performed. Comparisons were made between knee arthroscopy experts (> 100 arthroscopies performed per year) and non-experts (≤ 100 cases) on aspects of patient care.

RESULTS

The most important finding of this study was the agreement among almost all aspects of the knee arthroscopy approach. Consensus among Polish surgeons was noticed in choosing regional anaesthesia for knee arthroscopy, the lack of need for knee braces and knee medications, the of use of LMW heparin for thromboprophylaxis, 1-2 days of hospitalization, the recommendation of rehabilitation and the use of magnetic resonance as a diagnostic test for meniscus damage. Surgical expertise was significantly associated with the performance of meniscus suture procedures (p = 0.009). Experts recommended starting rehabilitation on the day of surgery (p = 0.007) and were more likely to use objective physical tests (p = 0.003). Non-expert surgeons recommended a longer period from meniscus suture to full-range knee motion (p = 0.001) and admitted that patient age does matter for meniscus repair qualification (p = 0.002).

CONCLUSIONS

There is consensus among almost all issues of meniscus tear treatment in the environment of Polish orthopaedists; however, the issues of rehabilitation and the use of advanced meniscus repair techniques are associated with surgical expertise.

Arthroscopic procedure for revision of failed isolated bucket-handle meniscal tear repair

Surgery failure rates average 20% following bucket-handle meniscal tears (BHMT) repairs in the literature. Achieving the healing of BHMT is difficult, how much more in revision cases. Some authors have reported higher failure rates especially in the early postoperative period and in younger patients. Multiple techniques and augmentations to enhance biologic healing and reduce failure rate have been described. We describe an arthroscopic technique for successfully revising a failed BHMT repair using the technique of percutaneously releasing the posterior fibers of the medial collateral ligament to provide adequate space for arthroscopy, refreshing of the torn surfaces, bed trephination before reduction and repair. We concluded that a combined double-level inside out vertical sutures with horizontal reinforcement and all-inside technique using fast fix give anatomic reduction, stable fixation, surface contact, and increased potential for biologic healing in failed BHMT repairs. Coupled with adequate rehabilitation programs, this technique has reduced the failure rate in revision cases and enhances early return to sport.

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

Background

Few studies have approached in a long-term follow-up of meniscal repair at an amateur level, specially studying variables as a quality of life and failure rate. The purpose of this review is to study medium to long-term clinical results in patients at amateur sports patients, that have required meniscal sutures at our center, with or without ACL reconstruction. We evaluate the objective function of the knee, as well as patients’ return to sports activities, quality of life, and the rate of failed repair and study of the possible reasons.

Methods

This was an observational retrospective study. Ninety-two patients who regularly perform amateur sports activities (Tegner 4 to 7) were assessed, with a minimum follow-up period of 2 years, divided into 2 groups: group 1, isolated meniscal suture (43 cases) and group 2, associated to ACL reconstruction (49 cases). Each patient made this test in 2019: Lysholm and Tegner (validated for Spanish) before a knee injury and after surgery, motivation to return to sports activity (Likert scale with 3 items: low, regular, or high), and quality of life through SD-12 test.

Results

High return to amateur sports rate (92%) was even higher in the isolated meniscal repair group in comparison to the group with associated ACL. We have not found statistically significant differences between sports return and age, gender, injured meniscus, chondral injuries, preoperative Tegner score, or motivation. No significant differences in physical or mental health fields between both groups. Meniscal repair failed in 12 patients (13%). Higher rate of failure in isolated bucket-handle tear injuries (p < 0.0062). No statistically significant association was found between the other variables studied.

Conclusions

Good results with 92% of sports return, low rate of complications, and low retear rate, even lower when is associated with ACL reconstruction and in external meniscus repair, and high values at SF-12 between 2 groups.

Pain-related risk factors after arthroscopic minimally invasive treatment of meniscus injury of knee joints

Pain-related risk factors after arthroscopic minimally invasive treatment of meniscus injury of knee joints were explored. Altogether 42 patients (conservative group), 40 patients (open group) and 46 patients (minimally invasive group) who received conservative treatment or arthroscopic knee surgery at the Quwo County People's Hospital were selected. The clinical effects of patients in the three groups at 24 weeks after treatment were observed. The knee joint activity, the knee injury and osteoarthritis outcome score (KOOS), Lysholm knee joint function score, VAS pain score and WOMAC score were recorded before treatment, at 24 weeks after treatment and at 2 years after treatment. Complications were also recorded. The related risk factors of postoperative pain were analyzed. There was no significant difference between the short-term efficacy of conservative treatment and that of surgical treatment (P>0.05); however, the long-term improvement effect of the surgical treatment on knee joint function and pain was better (P<0.05). The short-term and long-term effects of arthroscopic surgery were close to those of the open surgery. Arthroscopic surgery had a good long-term improvement effect on knee joint function and pain (P<0.05), and the incidence of postoperative pain was low (P<0.05). The results of logistic multivariate regression analysis manifested that WOMAC score, articular cartilage injury, time of postoperative weight bearing <1 week, no postoperative cold compress and open knee surgery were independent risk factors that affected postoperative pain (P<0.05). In conclusion, arthroscopic minimally invasive treatment has a good effect on patients with meniscus injury of knee joints who fail conservative treatment. Articular cartilage injury, postoperative weight bearing, cold compress and type of operation are independent risk factors that affect postoperative pain. Clinicians should bring patient attention to the prevention of meniscus injury and further improve the efficacy of treatment.

Near-Infrared Spectroscopy for Mapping of Human Meniscus Biochemical Constituents

Degenerative changes in meniscus are diagnosed during surgery by means of mechanical testing and visual evaluation. This method is qualitative and highly subjective, providing very little information on the internal state of the meniscus. Thus, there is need for novel quantitative methods that can support decision-making during arthroscopic surgery. In this study, we investigate the potential of near-infrared spectroscopy (NIRS) for mapping the biochemical constituents of human meniscus, including water, uronic acid, and hydroxyproline contents. Partial least squares regression models were developed using data from 115 measurement locations of menisci samples extracted from 7 cadavers and 11 surgery patient donors. Model performance was evaluated using an independent test set consisting of 55 measurement locations within a meniscus sample obtained from a separate cadaver. The correlation coefficient of calibration (ρ_training), test set (ρ_test), and root-mean-squared error of test set (RMSEP) were as follows: water (ρ_training = 0.61, ρ_test = 0.39, and RMSEP = 2.27 percentage points), uronic acid (ρ_training = 0.68, ρ_test = 0.69, and RMSEP = 6.09 basis points), and hydroxyproline (ρ_training = 0.84, ρ_test = 0.58, and error = 0.54 percentage points). In conclusion, the results suggest that NIRS could enable rapid arthroscopic mapping of changes in meniscus biochemical constituents, thus providing means for quantitative assessment of meniscus degeneration.

The modified cross-suture technique for unilateral pulled-out anchor during all-inside meniscal repair

Background

Meniscal repair has received increasing attention, but for inexperienced doctors, unilateral suture anchor pulling out may occur during all-inside meniscal repair, and the treatment outcome may be affected. When the errors happened intraoperatively, how to minimize the loss under guaranteeing of treatment effectiveness is a topic worth studying.

Purpose

To explore the practicability and effectiveness of the modified cross-suture method for arthroscopic remediation of unilateral suture anchor pulling out of an all-inside meniscal repair system.

Methods

From May 2014 to May 2017, 28 patients diagnosed with injuries of the meniscus and anterior cruciate ligaments (ACL) from the First Department of Orthopaedics of the Second Affiliated Hospital of Xi’an Jiaotong University were enrolled in the study as the observation group, including 18 males and 10 females with an average age of 25.5 ± 2.3 years (range 18–42 years). All patients underwent ACL reconstruction concurrently. All meniscus injuries were repaired with an all-inside meniscal repair technique, and 1–3 needles of unilateral suture anchor pulling out occurred intraoperatively. The modified cross-suture method was used to remedy the error of anchor pulling out and to eventually complete an effective repair. Another 30 patients who underwent ACL reconstruction and all-inside meniscal concurrently without unilateral suture anchor pulling out, including 20 males and 10 females with an average age of 26.3 ± 1.9 years (range 19–45 years), were enrolled as the control group. During postoperative follow-up, range of motion, Lachman test and pivot shift test were performed during the physical examination. The clinical healing of the meniscus was evaluated according to the Barrett standard. The meniscus healing status was also confirmed with magnetic resonance imaging (MRI). The function of the knee joint was evaluated according to the IKDC, Lysholm and Tegner scores.

Results

Twenty-five patients in the observation group and 28 patients in the control group completed the follow-up, with an average follow-up of 18.4 ± 5.2 months. All operations were performed by the same surgeon. At the follow-up 1 year after the operation, the average knee ROM of the two groups was 125.2 ± 4.3 degrees and 124.7 ± 3.8 degrees, the clinical healing rate of the meniscus of the two groups was 92.0% (23/25) and 92.9% (26/28), the MRI healing rate of the menniscus of the two groups was 72.0% (18/25) and 71.4% (20/28), and the IKDC, Lysholm and Tegner scores of the two groups were 90.52 ± 2.8, 89.17 ± 3.1, and 6.81 ± 1.7 and 91.42 ± 1.9, 90.32 ± 3.4, and 7.02 ± 1.4, respectively. The differences were not statistically significant (P > 0.05).

Conclusions

The modified cross-suture method is practicable and effective for arthroscopic remediation of unilateral suture anchor pulling out in an all-inside meniscal repair system.

Continuous Meniscal Suture Technique of the Knee

The menisci are fibroelastic structures interposed between the articular surfaces of the femur and tibia. They absorb impact and transmit load. Meniscal injury may compromise function and cause rapid joint degeneration, leading to the development of secondary osteoarthritis. Surgical treatment of meniscal injury is usually performed by arthroscopy, and meniscectomy or meniscal suture may be associated with such treatment. Meniscal suture should be considered when the injury compromises the proper functioning of the meniscus to recover its anatomy and function. Different meniscal suture techniques exist; the most widely used are the inside-out, outside-in, and all-inside techniques. The gold-standard repair technique is the inside-out technique. A drawback of this technique is the need to alternate between intra- and extra-articular structures for every stitch, which makes it even more laborious. We describe the continuous meniscal suture technique, also called "meniscal stitching," for a medial meniscal bucket-handle injury. This technique is performed from the inside out and allows the surgeon to perform multiple stitches with the same thread quickly and effectively. This surgical technique is performed using a single meniscal suture device that was developed by our group, called the "Meniscus 4 A-II" device.

MRI appearance of the different meniscal ramp lesion types, with clinical and arthroscopic correlation

BACKGROUND

Meniscal ramp lesions have been defined as longitudinal vertical peripheral tears of the medial meniscus involving the posterior meniscocapsular ligament, meniscotibial ligament, and/or the red-red zone of the posterior horn. They are heavily associated with anterior cruciate ligament injuries, and because of their potentially important biomechanical role in knee stabilization, injuries to this region may require surgical repair. However, due to their location and lack of general knowledge regarding their different types and associated appearances on magnetic resonance imaging, ramp lesions are routinely underreported. This is compounded by the fact that ramp lesions are also often overlooked during conventional anterior portal arthroscopy when direct visualization is not achieved.

PURPOSE

To demonstrate MRI appearances and arthroscopic findings of the different types of meniscal ramp lesions, in the hopes of improving their detection on pre-operative imaging.

Meniscal Repair Techniques

The menisci play a vital role in knee joint stability, load distribution, and lubrication, protecting the joint surfaces from degenerative change. Meniscal repair protects the joint from increased loading and when successful reduces progression of osteoarthritis. Successful repair involves accurate surgical techniques, guarded postoperative rehabilitation, and potential use of additional biologics to promote healing. An integrated approach to meniscal surgery is required as part of an overall strategy to preserve and restore knee function, preserving meniscal tissue whenever possible. This article reviews the repair techniques: procedures, indications, and rehabilitation for meniscal repair.

Evaluation of Midterm Clinical and Radiographic Outcomes of Arthroscopically Repaired Vertical Longitudinal and Bucket-Handle Lateral Meniscal Tears

Background:

Lateral meniscal tears in the stable knee are rare. There are few comparative studies evaluating functional and radiological outcomes of vertical longitudinal and bucket-handle lateral meniscal tears.

Purpose:

To evaluate the midterm clinical and radiological outcomes of arthroscopically repaired traumatic vertical longitudinal and bucket-handle lateral meniscal tears.

Study Design:

Case series; Level of evidence, 4.

Methods:

A total of 43 full-thickness lateral meniscal repairs, including 22 (51.2%) for vertical longitudinal tears and 21 (48.8%) for bucket-handle tears, were evaluated. A clinical assessment was performed according to the Barrett criteria, and patient outcomes were measured with the Lysholm knee score, Tegner activity scale, and overall satisfaction scale. Magnetic resonance imaging was used as the radiological re-examination method preoperatively and at final follow-up. A subgroup analysis examining isolated repair versus repair with concurrent anterior cruciate ligament (ACL) reconstruction was performed.

Results:

The mean follow-up period was 63.2 months (range, 24-86 months). Based on clinical and radiological outcomes, 38 of the 43 repairs (88.3%) were successful, and the remaining 5 (11.6%) cases were considered to be failures. Overall, the combined results for both groups demonstrated an improvement in the Lysholm score, Tegner score, and patient satisfaction. There was no significant difference in the postoperative Lysholm score (91.4 vs 87.0, respectively; P = .223), Tegner score (5.4 vs 5.5, respectively; P = .872), or patient satisfaction (7.2 vs 7.4, respectively; P = .624) between bucket-handle repair and vertical longitudinal repair. The subgroup analysis demonstrated no difference in outcome scores for isolated repair versus repair with concurrent ACL reconstruction. Smoking was identified as a risk factor for repair failure.

Conclusion:

Comparable clinical and radiological outcomes were obtained after vertical longitudinal and bucket-handle lateral meniscal repairs using the all-inside or hybrid suture technique with different suture configurations, regardless of whether ACL reconstruction was performed. Smoking was identified as a risk factor for failure.