Modern treatment of meniscal tears

[Short-term effectiveness of transtibial pull-out technique for complete radial tear of lateral meniscus body]

Objective

To investigate the short-term effectiveness of transtibial pull-out technique combined with side-to-side suture technique in treatment of complete radial tear of lateral meniscus body.

Methods

Between May 2020 and August 2023, 15 patients with complete radial tear of lateral meniscus body were repaired by arthroscopic transtibial pull-out technique combined with side-to-side suture technique. There were 11 males and 4 females, with an average age of 25.2 years (range, 15-43 years). Twelve cases were acute injuries and 3 were chronic injuries. All patients had tenderness in the lateral compartment of the knee. No abnormal alignment was observed on the X-ray films of the knee. MRI showed the complete radial tear of lateral meniscus body without associated injuries such as anterior cruciate ligament or cartilage. Preoperative Lysholm score was 44.5±6.4, International Knee Documentation Committee (IKDC) subjective score was 40.2±8.4, Tegner score was 1.3±1.1, and visual analogue scale (VAS) score for pain was 5.1±1.1. The operation time, incision healing, and complications such as vascular/nerve injury were recorded. During follow-up, the range of motion of the knee and tenderness in the lateral compartment of the knee were observed. The knee function and pain were evaluated using Lysholm score, Tegner score, IKDC subjective score, and VAS score. X-ray films and MRI of the knee were reexamined to assess knee degeneration.

Results

The operation time was 60-145 minutes (mean, 89.6 minutes). All incisions healed by first intention, and no complication such as vascular/nerve injury occurred. All patients were followed up 17-56 months (mean, 38.4 months). All patients had no knee extension limitation and 3 cases had tenderness in the lateral compartment of the knee. At last follow-up, the Lysholm score, IKDC subjective score, Tegner score, and VAS score for pain were 85.3±7.8, 82.1±15.7, 4.7±1.2, and 1.5±1.0, respectively, which were superior to those before operation ( P<0.05). Imaging reexamination showed that the meniscus was reset at 1 day after operation, and there was no sign of knee degeneration at last follow-up.

Conclusion

Transtibial pull-out technique combined with side-to-side suture technique can effectively treat the complete radial tear of lateral meniscus body and obtain good short-term effectiveness.

Evaluation of radiographic knee OA progression after arthroscopic meniscectomy compared with IACI for degenerative meniscus tear

The intra-articular corticosteroid injection (IACI) and arthroscopic partial meniscectomy (APM) are crucial treatment options for meniscus tears and are widely used in clinical practice. To determine whether there are differences in the progression of osteoarthritis (OA) after APM and IACI treatments for degenerative meniscal tears, and to identify the influencing factors. We finally collected the minimum joint space width (JSW), WOMAC score, and KOOS score of 189 patients after 4 years of follow-up. The mixed effects model and general estimating equation were used to analyze the differences in the progression of knee osteoarthritis and the factors affecting the progression of knee osteoarthritis in patients with degenerative meniscus tears who received different treatments. Over a 48-month follow-up period, all three groups showed a decreasing trend in knee JSW, with the IACI group having the fastest JSW decline rate at -0.020 mm/month (95% CI: -0.027 to -0.013, p < 0.01). There was no statistically significant difference in the JSW decline rate among the three groups. The WOMAC total scores for both the IACI and APM groups showed an improving trend, at -0.123/month (95% CI: -0.211 to -0.036, p < 0.01) and - 0.115/month (95% CI: -0.201 to -0.028, p < 0.01) respectively, with no statistical difference between the two groups. BMI was also a significant factor affecting postoperative JSW (regression coefficients: -0.012, 95% CI: -0.022 to 0.001, p = 0.03) and WOMAC total scores (regression coefficients: 0.189, 95% CI: 0.008 to 0.370, p = 0.04). Compared to single IACI, multiple IACI treatments resulted in faster JSW decline (B: 0.430, 95% CI: 1.012 to 2.336, p = 0.04). Patients with degenerative meniscal tears who undergo either IACI or APM treatment exhibit more pronounced progression of knee osteoarthritis compared to those in the non-treatment group. This form of deterioration is mainly driven by BMI.

The impact of smoking on meniscus surgery: a systematic review

Purpose

To provide a comprehensive, systematic review on the relationship and effects of smoking on clinical outcomes after meniscus surgery.

Methods

The following combination of keywords was entered into the electronic search engines: meniscus, meniscus repairs, meniscectomy, meniscal tear, meniscus excision AND (smoke OR smoking OR nicotine OR tobacco). The year of the study, country, type of study, number of subjects, medial/lateral/both menisci, body mass index, smoking status, mean age, gender, follow-up, type/pattern of injury, surgical implications and clinical outcomes were recorded.

Results

A total of 23 studies published in 2013-2024 were included in the analysis. In ten studies, the meniscus injury was associated with an anterior cruciate ligament (ACL) tear. In four studies, the effect of smoking on meniscal allograft transplantation (MAT) was investigated. The neutral effect of smoking on meniscus surgery was revealed in nine studies, and only one of them focused on isolated meniscus pathology and surgery. The negative effect of smoking on meniscus surgery was shown in ten papers, with four papers focused on isolated meniscus tears and six papers presenting data with concurrent ACL reconstructions.

Conclusions

This systematic review found that the results regarding the impact of smoking on meniscus repair outcomes were conflicting. Nevertheless, MAT and meniscus repair performed in the presence of concurrent ligamentous injury, both being demanding surgical procedures, require reduction of factors that may contribute to failure. Therefore, cessation of smoking in patients undergoing these procedures is highly advised.

The Meniscus: Basic Science and Therapeutic Approaches

The proper function and longevity of the knee joint are ensured by the knee menisci. Their susceptibility to damage and injury is one of the main risk factors for rapid cartilage loss and the development of osteoarthritis. The vascularization pattern and nutritional status of a torn meniscus determine its potential for healing and the success of meniscus surgery. Blood supply is a crucial factor in assessing healing potential. Knee cartilage volume loss and its modification often result from meniscal damage or excision, leading to osteoarthritis. Modern methods for preserving meniscal tissue are currently the treatment of choice. Magnetic resonance imaging (MRI) is the gold standard for assessing meniscus lesions. It provides a comprehensive evaluation of tear stability and progression risk. Additionally, it offers high sensitivity and specificity. Arthrography combined with computed tomography (CT) can be used for patients who are unable to undergo MRI. Other methods, such as X-ray and ultrasound, are not useful for the typical diagnosis of meniscal lesions. Minimally invasive surgery has become the gold standard for both treatment and diagnosis. Modern techniques, such as all-inside compression sutures and other suturing techniques, are also considered. In contrast, in the past, open total meniscectomy was routinely performed as the gold standard, based on the mistaken belief that the menisci were functionless. Currently, new treatment methods for meniscal lesions are being explored, including mesenchymal stem cells, synthetic implants, and platelet-rich plasma (PRP). The crucial role of the menisci in knee biomechanics drives the development of modern solutions focused on preserving meniscal tissue.

Impact of time between meniscal injury and isolated meniscus repair on post-operative outcomes: A systematic review

BACKGROUND

Meniscal tears are one of the most common knee injuries. After the diagnosis of a meniscal tear has been made, there are several factors physicians use to guide clinical decision-making. The influence of time between injury and isolated meniscus repair on patient outcomes is not well described. Assessing this relationship is important as it may influence clinical decision-making and can add to the preoperative patient education process. We hypothesized that increasing the time from injury to meniscus surgery would worsen postoperative outcomes.

AIM

To investigate the current literature for data on the relationship between time between meniscus injury and repair on patient outcomes.

METHODSPubMed, Academic Search Complete, MEDLINE, CINAHL, and SPORTDiscus were searched for studies published between January 1, 1995 and July 13, 2023 on isolated meniscus repair. Exclusion criteria included concomitant ligament surgery, incomplete outcomes or time to surgery data, and meniscectomies. Patient demographics, time to injury, and postoperative outcomes from each study were abstracted and analyzed.

RESULTS

Five studies met all inclusion and exclusion criteria. There were 204 (121 male, 83 female) patients included. Three of five (60%) studies determined that time between injury and surgery was not statistically significant for postoperative Lysholm scores (P = 0.62), Tegner scores (P = 0.46), failure rate (P = 0.45, P = 0.86), and International Knee Documentation Committee scores (P = 0.65). Two of five (40%) studies found a statistically significant increase in Lysholm scores with shorter time to surgery (P = 0.03) and a statistically significant association between progression of medial meniscus extrusion ratio (P = 0.01) and increasing time to surgery.

CONCLUSION

Our results do not support the hypothesis that increased time from injury to isolated meniscus surgery worsens postoperative outcomes. Decision-making primarily based on injury interval is thus not recommended.

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.

Robust tetra-armed poly (ethylene glycol)-based hydrogel as tissue bioadhesive for the efficient repair of meniscus tears

Repair and preservation of the injured meniscus has become paramount in clinical practice. However, the complexities of various clinic stitching techniques for meniscus repair pose challenges for grassroots doctors. Hence, there is a compelling interest in innovative therapeutic strategies such as bioadhesives. An ideal bioadhesive must cure quickly in aqueous and blood environments, bind strongly, endure arthroscopic washing pressures, and degrade appropriately for tissue regeneration. Here, we present a tetra-poly (ethylene glycol) (PEG)-based hydrogel bioadhesive, boasting high biocompatibility, ultrafast gelation, facile injectable operation, and favorable mechanical strength. In view of the synergistic effects of chemical anchor and physical chain entanglement to tightly bind the meniscus, a seamless interface was formed between the surrounding meniscal tissues and hydrogels, enabling the longitudinal tear of the meniscus fused in situ to withstand large tensile force with the adhesive strength of 541.5 ± 31.4 kPa and arthroscopic washout resistance of 29.4 kPa. Superior to existing commercial adhesives, ours allows sutureless application and arthroscopic assistance, without requiring specialized clinical skills. This research is expected to significantly impact our understanding of meniscal healing and ultimately promote a simpler process for achieving functional and structural recovery in torn menisci.

Longer time between anterior cruciate ligament injury and reconstruction is associated with a greater risk of medial meniscus injury

Purpose

To evaluate the impact of delaying reconstruction following anterior cruciate ligament (ACL) injury on the risk of meniscal injury and subsequent meniscectomy, the study was carried out. This constitutes the first study of its kind to be conducted in China.

Methods

This study collected data on patients who had undergone ACL reconstruction surgery at Peking University First Hospital between 2010 and 2022. Patient's injury details, including the time and cause of ACL injury, surgery date and meniscal injury details, were recorded. Patients were stratified into distinct cohorts based on the duration between injury and reconstruction. Logistic regression analysis was used to evaluate the impact of a delayed reconstruction time on the risk of meniscal injury and meniscectomy.

Results

The study involved patients with an average age of 34.1 ± 11.3 years. Nearly half of the patients (49.74%) had meniscal injuries. Univariate logistic regression analysis showed that gender and the time from ACL trauma to surgery were significantly associated with meniscus injury (p < 0.01). Men have a higher risk of meniscus damage than women (p < 0.01, odds ratio: 1.94, 95% confidence interval: 1.23-3.05). Patients who had surgery 12 months after injury had a significantly increased risk of meniscus injury compared to those who had surgery within 3 months after injury (p < 0.01). The time from ACL injury to operation was significantly correlated with medial meniscus injury (p < 0.001). There was no significant correlation between time to ACL reconstruction and lateral meniscus injury (p > 0.05). Age was significantly associated with the risk of medial meniscectomy (p > 0.05). Time from injury to surgery was not significantly associated with the risk of lateral meniscectomy (p > 0.05).

Conclusions

Delayed reconstruction beyond 12 months after ACL rupture increases the risk of medial meniscus injury. The risk of meniscus injury after ACL injury is higher in men than in women, and the risk of medial meniscectomy increases with age.

Level of Evidence

Level III.

Approaching ramp lesions from the different world of posterior knee compartment: A review of evidence with a proposal of a new classification and treatment

Ramp lesions (RLs) are peripheral lesions that occur in the posterior part of the medial meniscus or where it attaches to the joint capsule. The classification of the medial meniscus RLs has been the focus of numerous studies and publications. This review provides an overview of RL's current classification and treatment options in anterior cruciate ligament deficient knees. The study also aims to present a more practical classification system for RLs to assist in treatment decision-making. For the first time, we also presented a new surgical treatment for incomplete inferior and double-complete RL based on the posterior knee arthroscopy that provides direct access to the posterior meniscal borders, enabling effective treatment and stronger biomechanical repair.

Level of Evidence

Level V.

Learning co-plane attention across MRI sequences for diagnosing twelve types of knee abnormalities

Multi-sequence magnetic resonance imaging is crucial in accurately identifying knee abnormalities but requires substantial expertise from radiologists to interpret. Here, we introduce a deep learning model incorporating co-plane attention across image sequences to classify knee abnormalities. To assess the effectiveness of our model, we collected the largest multi-sequence knee magnetic resonance imaging dataset involving the most comprehensive range of abnormalities, comprising 1748 subjects and 12 types of abnormalities. Our model achieved an overall area under the receiver operating characteristic curve score of 0.812. It achieved an average accuracy of 0.78, outperforming junior radiologists (accuracy 0.65) and remains competitive with senior radiologists (accuracy 0.80). Notably, with the assistance of model output, the diagnosis accuracy of all radiologists was improved significantly (p < 0.001), elevating from 0.73 to 0.79 on average. The interpretability analysis demonstrated that the model decision-making process is consistent with the clinical knowledge, enhancing its credibility and reliability in clinical practice.

Factors associated with medial meniscal extrusion in non-osteoarthritic knees with medial meniscus tears: A cross-sectional study

BACKGROUND

Medial meniscal extrusion (MME) plays an important role in the progression of knee osteoarthritis. Exploring the factors associated with MME in non-osteoarthritic knees may assist in the prevention of osteoarthritis.

OBJECTIVE

To identify the factors associated with pathologic MME in non-osteoarthritic knees with medial meniscus tears (MMTs).

DESIGN

A cross-sectional study.

PARTICIPANTS

One hundred fifty patients with non-osteoarthritic knees who underwent arthroscopic surgery for MMT. Patients were divided into a pathologic MME group (n = 54) and a control group (n = 96) based on whether a pathologic MME was present on magnetic resonance (MR) images.

SETTING

Tertiary medical institution.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The MME distance was measured on a coronal MR image obtained at the midpoint of the medial femoral condyle. An MME distance ≥3 mm was considered to indicate pathologic MME. Demographic and clinical data were collected as variables. Multivariable logistic regression analysis was performed to identify factors associated with pathologic MME.

RESULTS

After multivariable adjustment, body mass index (BMI) and the type of MMT were associated significantly with pathologic MME in the multivariable logistic regression model. Each unit higher in BMI was associated with a 13% higher risk of pathologic MME (odds ratio [OR] 1.13, 95% confidence interval [CI] 1.01-1.28, p = .04). The odds of pathologic MME were approximately four times and three times higher for radial tears (OR 4.34, 95% CI 1.25-15.03, p = .02) and complex tears (OR 3.07, 95% CI 1.17-8.05, p = .02) than for horizontal and longitudinal tears.

CONCLUSIONS

BMI and the type of MMT were independent factors associated with pathologic MME in non-osteoarthritic knees with MMT. A higher BMI, radial tears, and complex tears were predisposed to pathologic MME.

Animal models used in meniscal repair research from ex vivo to in vivo: A systematic review

This systematic review, registered with Prospero, aims to identify an optimal animal model for meniscus repair research, moving from ex vivo experimentation to in vivo studies. Data sources included PubMed, Medline, all Evidence-Based Medicine Reviews, Web of Science, and Embase searched in March 2023. Studies were screened using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Extracted data including animal model, type of experiment, type of tear, surgical techniques, and measured outcomes, were recorded, reviewed, and analyzed by four independent reviewers. The SYstematic Review Centre for Laboratory animal Experimentation (SYRCLE) Rob tool was used for critical appraisal and risk of bias assessment. Out of 11,719 studies, 72 manuscripts were included for data extraction and analysis; 41 ex vivo extra-articular studies, 20 ex vivo intra-articular studies, and only 11 in vivo studies. Six animal models were employed: porcine, bovine, lapine, caprine, canine, and ovine. Longitudinal lesions were the most frequently studied tear pattern and sutures the most common repair technique. Studied outcomes focused mainly on biomechanical assessments and gross observations. This systematic review can guide researchers in their choice of animal model for meniscus repair research; it highlighted the strengths of the porcine, caprine, and bovine models for ex vivo cadaveric studies, while the porcine and caprine models were found to be more suited to in vivo studies due to their similarities with human anatomy. Research teams should familiarize themselves with the advantages and disadvantages of various animal models before initiating protocols to improve standardization in the field.

Decreasing Incidence of Partial Meniscectomy and Increasing Incidence of Meniscus Preservation Surgery From 2010 to 2020 in the United States

PURPOSE

To characterize the incidence of meniscus surgery from 2010 to 2020 in the United States, using the metrics of age, sex, type of meniscus surgery, and Charlson Comorbidity Index (CCI).

METHODS

A retrospective analysis was performed using the PearlDiver national insurance claims database from 2010 to 2020. Meniscus surgeries were identified using Current Procedural Terminology codes. Patients were stratified by procedure type, age, biological sex, and CCI scores. Compound annual growth rate analysis and analysis of variance were performed to analyze the trends and demographic variables between cohorts.

RESULTS

Of 2,053,884 meniscus surgeries, 94.7% were meniscectomies, 0.3% were open repairs, 4.9% were arthroscopic repairs, and 0.1% were meniscal transplantations. Compound annual growth rate analysis displayed a 4.0% decrease per year in total meniscus surgery. For individual procedure types, the largest decrease was in meniscectomy, and the largest increase was in open repair. Patients undergoing meniscal transplantation were youngest, with the lowest CCI. Meniscectomy patients were oldest, and open repair patients had the highest average CCI. Most procedures were performed on female patients (52.4%) and patients in the 50- to 59-year age group (30.4%).

CONCLUSIONS

There was a sustained decrease in the incidence of total meniscus surgeries from 2010 to 2020. Meniscectomy was the procedure with the highest incidence, but it showed the most significant decline in usage over the study period. Conversely, meniscal repair and transplantation procedures increased during the study period.

LEVEL OF EVIDENCE

Level IV, epidemiologic study.

Pulsed radiofrequency of iPACK (interspace between the popliteal artery and the posterior knee capsule) for pain control following meniscus repair - A case report

Adequate postoperative pain control is an essential factor for the success of rehabilitation programs after meniscus repair (MR). The pulsed radiofrequency of the interspace between the popliteal artery and the posterior knee capsule (PRF-iPACK) is a recently developed method. This study aimed to evaluate the use of PRF-iPACK in patients who underwent MR. We performed PRF-iPACK guided by ultrasonography for patients who underwent MR with aggravated pain. PRF-iPACK was performed following MR four weeks after surgery. The pain was evaluated using the visual analogue scale (VAS), Lysholm score, and the Euroqol-5 Dimension (EQ-5D). In this study, two patients participated. For the results, a week and three months after treatment, the mean VAS score, Lysholm score, and EQ5D improved from 7 to 1 and 0 respectively, and 42 to 86 and 90 respectively, and 0.48 to 0.82 and 0.92 respectively. We concluded that PRF-iPACK is an adequate and safe procedure for managing postoperative pain after MR. It may enhance the postoperative rehabilitation program.

The Use of Platelet-Rich Plasma Augmentation in Meniscus Repair Results in a Lower Failure Rate than in the Control Group: A Systematic Review From Meta-analysis

Purpose

To investigate the efficacy of platelet-rich plasma (PRP) as an augmentation in meniscus repair.

Methods

A comprehensive search of PubMed, Medline (via EBSCO), ProQuest, and ScienceDirect from January to February 2023 was conducted using the terms "meniscus repair," "PRP," and "meniscus tear." Meta-analyses that investigated the rate of failure after meniscus repair were included. Studies before 2003, not in English, associated procedures during surgery, and animal studies were excluded. The included studies underwent quality appraisal and risk of bias assessment. Data were extracted from each study's text, figures, tables, and associated supplementary files and then analyzed qualitatively.

Results

The failure rate is lower in the PRP augmentation group compared with the group without augmentation, with a mean difference of 0.42, 0.50, and 0.43. Visual analog scale score was also found to be significantly lower in the treatment group, with a mean difference of 0.40, 0.76, and 6.69. However, only mean differences in Lysholm score in one of the included studies were found significant regarding functional outcomes, which can be found in the Xie et al. study with a mean difference of 3.06.

Conclusions

In this study, we found that meniscal repairs augmented with PRP have a lower failure rate.

Level of Evidence

Level IV, systematic review of Level III-IV studies.

Repair of bucket handle meniscus tears improves patient outcomes versus partial meniscectomy at the time of ACL reconstruction

Purpose

The aim of this study was to examine demographic and surgical factors that influence patient-reported knee function in patients who undergo anterior crucial ligament reconstruction (ACLR) with concurrent bucket-handle meniscal tear (BHMT) procedures. We hypothesized that repair of BHMT in the setting of concomitant ACLR and shorter time from injury to surgery would lead to improved patient-reported outcomes.

Methods

Forty-one patients (mean age: 28.0 ± 9.8 years, 72% male) with BHMT at the time of ACLR completed the International Knee Documentation Committee Subjective Knee Form (IKDC-SKF) via online survey at an average of 15.2 months postop. Patient demographics and surgical characteristics, including time from injury to surgery, were compared between repair (n = 22) and meniscectomy (n = 19) groups using one-way analysis of variances; distributions of sex, graft source, BHMT compartment and zone were compared between groups using χ 2 tests. The association between IKDC-SKF score, demographics and surgical characteristics was evaluated using multivariable linear regression. A priori alpha level was p < 0.05.

Results

Meniscal repair and meniscectomy groups differed based on graft source and BHMT zone but not IKDC-SKF score (p = 0.085). Patients undergoing ACLR with autograft (p = 0.003) and with red-red zone BHMT (p < 0.001) more often underwent meniscal repair. The regression model demonstrated longer time from injury to surgery (p = 0.049), red-red tear zone (p = 0.04) and meniscectomy (p = 0.008); these were predictive of poorer IKDC-SKF scores.

Conclusion

BHMT repair was more likely performed in ACL autograft and on red-red zone tears. Longer time from injury to surgery is an indicator of poorer IKDC-SKF score, as this may increase the risk of concomitant pathologies. White-white zone BHMTs are associated with better IKDC-SKF scores than red-red zone BHMTs, which may be due to the smaller volume of tissue removed during meniscectomy of white-white zone tears and the avoidance of iatrogenic complications of meniscal repair.

Level of Evidence

Level III, therapeutic study.

Increased Age, Operative Time, American Society of Anesthesiologists Classification, Functional Dependency, and Comorbidity Burden Are Risk Factors for Adverse Events After Meniscectomy and Meniscus Repair: 10-Year Analysis of 64,223 Patients

PURPOSE

To use the National Surgical Quality Improvement Program (NSQIP) database to identify risk factors for 30-day adverse events and hospital readmission following isolated and unilateral meniscectomy or meniscus repair.

METHODS

A retrospective review of the NSQIP database from the years 2012 to 2021 identified all patients undergoing isolated, unilateral meniscectomy or meniscus repair. Multivariable analyses were performed for each procedure to identify patient characteristics associated with any adverse event (AAE) or unplanned hospital readmission within 30 days of surgery.

RESULTS

From 2012 to 2021, 59,450 (93%) patients underwent meniscectomy, and 4,773 (7%) patients underwent meniscus repair. Overall adverse event rate was 0.95% after meniscectomy and 1.40% after repair. Risk factors for AAE after meniscectomy included increased age (odds ratio [OR] = 1.010; P = .009), increased operative time (OR = 1.003; P = 0.011), American Society of Anesthesiologists (ASA) class IV (OR = 2.048; P = .045), functional dependency (OR = 3.527; P = .001), and current smoking (OR = 1.308; P = .018). Risk factors for AAE after meniscus repair included age (OR = 1.024; P = .016), operative time (OR = 1.004; P = .038), and bleeding disorders (OR = 7.000; P = .014). ASA class III increased risk of hospital readmission after both procedures (OR = 1.906; P = .008; OR = 4.101; P = .038), and medical comorbidities of heart failure (OR = 3.924; P = .016), hypertension (OR = 1.412; P = .011), and chronic obstructive pulmonary disease (OR = 2.350; P < .001) increased readmission risk after meniscectomy only.

CONCLUSIONS

Per analysis of the American College of Surgeons (ACS)-NSQIP database, surgical treatment of meniscal tears in the knee has been performed frequently over the past 10 years, with meniscectomies comprising over 90% of cases. Increased age and operative time were associated with a modest risk of adverse events after both meniscectomy and meniscus repair. Increased comorbidity burden, evidenced by ASA class, dependent functional status, current smoking, and systemic medical conditions, such as heart failure, hypertension, chronic obstructive pulmonary disease, and bleeding disorders, greatly increased rates of unfavorable outcomes within 30 days of meniscus surgery.

LEVEL OF EVIDENCE

Level III, retrospective prognostic comparative investigation.

Perspective on Clinical and Functional Outcomes of Arthroscopic All-Inside Meniscal Repair: Insights From a Lower Middle-Income Country

Background Meniscal tears are a common injury in the adult population. With the advent of newer devices, the adoption of the all-inside repair technique has been expanding substantially because of its feasibility and reduced risk to surrounding neurovascular structures. This study was conducted in a lower middle-income country to assess the functional outcome of the arthroscopic all-inside technique and to identify the potential factors that may affect the functional outcome that will eventually influence the future management of these patients. Method This study is a retrospective case series conducted at the Department of Orthopedic Surgery, Aga Khan University Hospital, Karachi, Pakistan. Patients presenting to the outpatient clinics with meniscal tears who underwent arthroscopic all-inside repair from January 2015 to December 2021 were included in this study. The exclusion criteria included patients who had associated fractures and patients with meniscal tears greater than six months ago. Results A total of 29 patients underwent all-inside meniscal repair for meniscus tears. The mean age of our patients was 26.31 years (SD = 7.11 years), ranging from 17 years to 48 years. Of these patients, 26 were males and three were females, accounting for 89.7% and 10.3%, respectively. The most frequent mechanism of injury was twisting while playing sports, accounting for 51.7%, followed by falling while playing sports and road traffic accidents (RTAs), accounting for 13.8% and 20.7%, respectively. Of the 29 patients, 16 (55.2%) had lateral meniscal injuries, 10 (34.5%) were diagnosed with medial meniscus injuries, and three (10.3%) had injuries to both menisci. The most common type of tear that was observed in our sample size was bucket handle tears, which were found in 14 patients, accounting for a total of 48.3%, followed by complex tears in seven patients (24.1%). The majority of the patients, i.e., 19 out of 29 patients (65.5%), had an acute course of injury, i.e., less than six weeks. For the functional outcome, the Lysholm score was calculated at 12 months and was found to be excellent in 17 patients, good in six patients, and fair in six patients, accounting for 58.6%, 20.7%, and 20.7%, respectively. The mean Lysholm score was 90.03 ± 8.85 points. Of the 29 patients, 27 (93.2%) had no complaints at the regular 12-month follow-up, whereas one patient (3.4%) experienced rotatory instability and one patient (3.4%) experienced stiffness at the knee joint. None of the patients had to undergo a reoperation. The mean Lysholm score in the 25 patients who had an associated anterior cruciate ligament tear was 89.64 ± 9.442 points, whereas the four patients who had an isolated meniscal tear had a mean score of 92.50 ± 2.887 points, which was not significantly different (p-value = 0.831). Conclusion All-inside meniscal repair for treating meniscal tears has become the new treatment paradigm as it not only renders excellent functional outcomes with minimal complications but also prevents damage to the surrounding neurovasculature and the soft tissue envelope as it is a minimally invasive technique.

Physical Therapist Interventions Versus or Combined With Surgical Treatment in Nontraumatic Degenerative Meniscal Pathology: A Systematic Review and Network Meta-Analysis

OBJECTIVE

This study aimed to synthesize the evidence from randomized clinical trials in people with nontraumatic degenerative meniscal pathology by comparing physical therapist interventions versus or combined with arthroscopic partial meniscectomy (APM).

METHODS

Seven electronic databases were searched. Methodological quality was evaluated using the Physiotherapy Evidence Database scale. Data synthesis was performed with random-effects network meta-analysis, and results were summarized using the standardized mean differences.

RESULTS

From 2103 studies, 10 randomized clinical trials comprising 1411 individuals were included. Ninety percent of the selected randomized clinical trials were classified as good quality according to the Physiotherapy Evidence Database scale. All interventions (physical therapist interventions, APM, and APM plus physical therapist interventions) showed reduced pain and physical impairments at 3-month follow-up. However, when a physical therapist intervention was included, greater reductions in pain at rest (APM vs physical therapist interventions: 0.73 [95% CI = 0.20 to 1.26]; APM vs APM plus physical therapist interventions: 0.59 [95% CI = 0.15 to 1.03]) and greater increases in the strength of knee extensor muscles (APM vs physical therapist interventions: 0.44 [95% CI = 0.07 to 0.80]; APM vs APM plus physical therapist interventions: 0.73 [95% CI = 0.29 to 1.16]) were observed at 3 months. By contrast, no differences were found between treatments beyond 3 months.

CONCLUSION

Physical therapist interventions based on exercise programs demonstrate superior short-term outcomes in pain reduction and knee extensor strength compared to surgical treatment.

IMPACT

For nontraumatic degenerative meniscal pathology, conservative treatment utilizing a physical therapist intervention approach should be prioritized as the first choice over surgical treatment. It offers comparable or superior short-term pain reduction and strength improvements, with a lower risk of side effects. In cases where surgery is deemed necessary, including postsurgical, physical therapist interventions are highly recommended to enhance muscle strength and alleviate pain.

The Impact of Bone Marrow Venting Augmentation on Knee Functions in the Repair of Vertical/Longitudinal Meniscus Tears: A Triple Comparison

Objective

Preserving and restoring meniscus function is crucial for maintaining knee biomechanics and overall functionality. To enhance the healing process after meniscus repair, various biological techniques have been introduced. In this study, three treatment approaches examined were bone marrow venting with stem cells (BMVP), anterior cruciate ligament reconstruction (ACLR) with meniscus repair, and isolated meniscus repair.

Materials and Methods

From 2015 to 2019, we retrospectively analyzed data from 83 patients who presented with complaints of knee pain or pain in addition to instability, were diagnosed with vertical/longitudinal meniscus tears, and underwent arthroscopic repair (30 with isolated repair, 28 with ACLR repair, and 25 with BMVP) at our University Hospital. Among the 28 patients with anterior cruciate ligament rupture, pain and instability were the predominant complaints, whereas 55 patients with meniscus tear primarily complained pain. Clinical and functional conditions were assessed using Lysholm, WOMAC, IKDC, and VAS scores before and 18 months after surgery. Surgical success was evaluated based on Barrett's criteria. Causes of failure were analyzed considering demographic data, smoking status, injury time, tear location, shape, zone, and suture type and number.

Results

Of the participants, 58 were male, 25 were female, 61 had medial meniscus lesions, and 22 had lateral meniscus lesions. The tear types included 51 simple longitudinal tears, 18 bucket handle tears, and 14 complex tears. A significant improvement was observed in the postoperative 18 month Lysholm, WOMAC, and IKDC values in all three groups (p: 0.001). At the 18 month mark, clinical and functional outcomes were comparable between BMVP and ACLR repair groups (Lysholm p: 0.951, WOMAC p: 0.241, IKDC p: 0.984). Both of these procedures yielded better results compared to isolated meniscus repair (Lysholm p: 0.001, WOMAC p: 0.027, IKDC p: 0.001).

Conclusion

The superior clinical and functional outcomes observed after meniscus repair with BMVP and ACLR, compared to isolated meniscus repair, indicate positive effects of bone marrow stem cells, blood components, and tissue healing factors on meniscus repair and knee function.

[Research progress of magnesium and magnesium alloy implants in sports medicine]

Objective

To review the research progress of magnesium and magnesium alloy implants in the repair and reconstruction of sports injury.

Methods

Relevant literature of magnesium and magnesium alloys for sports injury repair and reconstruction was extensively reviewed. The characteristics of magnesium and its alloys and their applications in the repair and reconstruction of sports injuries across various anatomical sites were thoroughly discussed and summarized.

Results

Magnesium and magnesium alloys have advantages in mechanical properties, biosafety, and promoting tendon-bone interface healing. Many preclinical studies on magnesium and magnesium alloy implants for repairing and reconstructing sports injuries have yielded promising results. However, successful clinical translation still requires addressing issues related to mechanical strength and degradation behavior, where alloying and surface treatments offer feasible solutions.

Conclusion

The clinical translation of magnesium and magnesium alloy implants for repairing and reconstructing sports injuries holds promise. Subsequent efforts should focus on optimizing the mechanical strength and degradation behavior of magnesium and magnesium alloy implants. Conducting larger-scale biocompatibility testing and developing novel magnesium-containing implants represent new directions for future research.

Comparison of Partial Meniscectomy With Meniscal Repair With Respect to Functional Outcome

Introduction Meniscus tear is a commonly encountered sports-related injury requiring surgical intervention due to knee mobility dysfunction and discomfort. Previously, it has been thought that these are non-functional vestigial structures and they used to be excised commonly. Recent studies have shown that meniscal repair gives superior results when compared with partial meniscectomy. Methods This quasi-experimental study was conducted at the Orthopedics Department, Khyber Teaching Hospital, Peshawar, Pakistan. A total of 92 patients of both genders with meniscal injuries were included. Forty-six of them underwent meniscal repair (Group A), and 46 underwent partial meniscectomy (Group B). Functional outcome was noted after 12 weeks and recorded. Results The age range was from 18 to 50 years with a mean of 28.630±6.64 years in Group A and 29.630±8.12 years in Group B. Functional outcome was excellent in 44 (95.7%) patients who underwent meniscal repair as compared to 23 (50%) patients who underwent partial meniscectomy (P= 0.000). Conclusion It is concluded that meniscal repair should be pursued over partial meniscectomy when surgically treating meniscal tears.

The Association between the Extent of the Osteoarthritic Meniscus Degeneration and Cigarette Smoking-A Pilot Study

Background and Objectives: The negative effects of smoking on the musculoskeletal system were presented by many authors, although the relationship between smoking and osteoarthritis remains unclear. The aim of this paper was to investigate the negative effects of smoking on meniscal tissue in osteoarthritic knees by microscopic examination, by adapting the Bonar scoring system and its modifications. Materials and Methods: The study involved 34 patients with varus knees, from whom 65 samples of knee menisci were obtained. The mean age in the studied group was 65.385 years. The smoking status of the patients concluded that there were 13 smokers and 21 nonsmokers. Results: Among smokers, the mean classical Bonar score was 8.42 and the mean modified Bonar score was 6.65, while nonsmokers were characterized by scores of 8.51 and 7.35, respectively. There was a statistically significant negative correlation between the number of cigarettes and the collagen in the medial meniscus (p = 0.0197). Moreover, in the medial meniscus, the modified Bonar score correlated negatively with the number of cigarettes (p = 0.0180). Similarly, such a correlation was observed between the number of cigarettes and the modified Bonar score in the lateral meniscus (p = 0.04571). Furthermore, no correlation was identified between the number of cigarettes and the classical Bonar score in the lateral meniscus. There was a statistically significant difference in the collagen variable value between the smokers and nonsmokers groups (p = 0.04525). Conclusions: The microscopic investigation showed no differences in the menisci of smokers and nonsmokers, except for the collagen, which was more organized in smokers. Moreover, the modified Bonar score was correlated negatively with the number of cigarettes, which supports the role of neovascularization in meniscus pathology under the influence of tobacco smoking.

Long-term follow-up of inpatients with meniscus tears who received integrative Korean medicine treatment: A retrospective analysis and follow-up survey

Evidence regarding the use of Korean medicine (KM) for the conservative treatment of meniscus tears remains lacking. We aimed to evaluate clinical effectiveness and long-term follow-up outcomes in patients undergoing integrative KM treatment for meniscus tears. We analyzed the electronic medical records (EMRs) of 86 patients with meniscus tears and administered a follow-up survey. Patients treated at 1 of 4 KM hospitals between June 1, 2015, and June 30, 2020, were reviewed. KM treatment comprised herbal medicine, acupuncture, pharmacopuncture, bee venom pharmacopuncture, Chuna therapy, and KM physiotherapy. The primary outcome was the numeric rating scale (NRS) score for knee pain; secondary outcomes were the Western Ontario and McMaster Universities Arthritis Index (WOMAC), EuroQol 5-dimension (EQ-5D) score, range of motion, and patient global impression of change. The NRS for knee pain was reduced by an average of 2.49 (95% confidence interval [CI]: 2.03-2.95) at discharge and 1.97 (95% CI: 2.03-2.95) at follow-up. The WOMAC decreased by an average of 15.52 (95% CI: 10.14-20.89) during hospital stay and 30.72 (95% CI: 24.58-36.87) at follow-up. The EQ-5D score increased by an average of 0.06 (95% CI: -0.14 to 0.02) at discharge and 0.19 (95% CI: -0.29 to -0.09) at follow up. KM treatment effectively reduced knee pain, improved knee joint function, and enhanced the quality of life in patients with a meniscus tear for a relatively long period after treatment.

Comparative, Controlled, Retrospective Study of Patient-Reported Outcomes After Meniscectomy With Adjunctive Use of Platelet-Rich Plasma or Amniotic Umbilical Cord Tissue

Background: Meniscal tears are one of the most frequent injuries to the knee, with an estimated incidence of 222 per 100,000 individuals aged 18 to 55 years based on magnetic resonance imaging. Poor outcomes following meniscal surgical interventions are common and have led many surgeons to use biologic augmentation strategies to enhance the healing. Methods: We conducted a single-center, retrospective, observational study of patients who underwent arthroscopic meniscectomy with and without adjunctive platelet-rich plasma (PRP) or the particulate form of amniotic umbilical cord (AMUC) tissue. We evaluated patient-reported outcomes on the visual analog scale for pain, International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, Lysholm Knee Scoring Scale, 12-Item Short Form Survey, and Knee Injury and Osteoarthritis Outcome Score (KOOS) during a 1-year postoperative period. Complications and follow-up procedures were also evaluated. Results: We evaluated 113 patients who underwent meniscectomies from November 2010 to March 2017. Pain severity was significantly decreased only in the AMUC group at 6 months (P=0.0143). Patients in the AMUC group demonstrated significant improvement in functional recovery based on the IKDC and the KOOS subscales of pain, symptoms, activities of daily living, and sport and recreation function at 6 months. Patients in the PRP group had a significant benefit in the KOOS subscales of pain, symptoms, sport and recreation function, and knee-related quality of life at 3 months. Improvement in the control group was less substantial. Patients in the PRP group had more complications and follow-up procedures (30.0%) than patients in the AMUC group (8.3%). Conclusion: In our study population, arthroscopic meniscectomy with adjunctive use of AMUC tissue improved patient-reported outcomes and reduced the reoperation rate compared to conventional technique or adjunctive use of PRP.

Meniscectomy is associated with a higher rate of osteoarthritis compared to meniscal repair following acute tears: a meta-analysis

PURPOSE

Meniscal tears are common and may impair knee function and biomechanics. This meta-analysis compared meniscal repair versus resection in patients with symptomatic meniscal tears in terms of patient-reported outcomes measures (PROMs), joint width, surgical failure, and rate of progression to osteoarthritis (OA) at conventional radiography.

METHODS

This study was conducted according to the 2020 PRISMA statement. In August 2023, the following databases were accessed: PubMed, Web of Science, Google Scholar, and Embase. Two reviewers independently performed the analysis and a methodological quality assessment of the included studies. All the clinical investigations which compared repair versus resection of meniscal tears were accessed.

RESULTS

Data from 20 studies (31,783 patients) were collected. The mean BMI was 28.28 ± 3.2 kg/m2, and the mean age was 37.6 ± 14.0 years. The mean time elapsed from injury to surgery was 12.1 ± 10.2 months and the mean medial joint width was 4.9 ± 0.8 mm. Between studies comparability at baseline was found in age, women, BMI, time from injury to surgery and length of the follow-up, PROMs, medial joint width, and stage of OA. The resection group demonstrated a greater Lysholm score (P = 0.02). No difference was found in the International Knee Documentation Committee (P = 0.2). Nine studies reported data on the rate of failures at a mean of 63.00 ± 24.7 months. No difference was found between the two groups in terms of persistent meniscal symptoms (P = 0.8). Six studies reported data on the rate of progression to total knee arthroplasty at a mean of 48.0 ± 14.7 months follow-up. The repair group evidenced a lower rate of progression to knee arthroplasty (P = 0.0001). Six studies reported data on the rate of advanced knee OA at a mean of 48.0 ± 14.7 months of follow-up. The repair group evidenced a lower rate of advanced knee OA (P = 0.0001). No difference was found in the mean joint space width (P = 0.09).

CONCLUSION

Meniscal repair is associated with a lower progression to knee osteoarthritis at approximately six years of follow-up compared to partial meniscectomy. No difference in PROMs, medial joint width, and failures were evidenced.

LEVEL OF EVIDENCE

Level III, meta-analysis.

In-Office Needle Arthroscopy with Meniscal Repair for Meniscal Lesions of the Knee

Meniscal injuries are a common cause of knee pain and are often an indication for knee arthroscopy, the most common orthopedic surgical procedure in the United States. In-office needle arthroscopy (IONA) is a described technique with the ability to diagnose and treat meniscal injuries in the office. IONA allows for diagnosis and treatment at a significantly deceased cost, with both quicker patient recovery, and improved patient satisfaction. The purpose of this technical report is to describe the technique for performing in-office needle arthroscopy for meniscal injuries of the knee, including the technique for obtaining adequate local anesthesia, proper indications, adequate visualization, and the advantages of performing these procedures in the office rather than the operating room.

Health-economic evaluation of meniscus tear treatments: a systematic review

PURPOSE

To evaluate the overall evidence of published health-economic evaluation studies on meniscus tear treatment.

METHODS

Our systematic review focuses on health-economic evaluation studies of meniscus tear treatment interventions found in PubMed and Embase databases. A qualitative, descriptive approach was used to analyze the studies' results and systematically report them following PRISMA guidelines. The health-economic evaluation method for each included study was categorized following one of the four approaches: partial economic evaluation (PEE), cost-effectiveness analysis (CEA), cost-benefit analysis (CBA), or cost-utility analysis (CUA). The quality of each included study was assessed using the Consensus on Health Economic Criteria (CHEC) list. Comparisons of input variables and outcomes were made, if applicable.

RESULTS

Sixteen studies were included; of these, six studies performed PEE, seven studies CUA, two studies CEA, and one study combined CBA, CUA, and CEA. The following economic comparisons were analyzed and showed the respective comparative outcomes: (1) meniscus repair was more cost-effective than arthroscopic partial meniscectomy (meniscectomy) for reparable meniscus tear; (2) non-operative treatment or physical therapy was less costly than meniscectomy for degenerative meniscus tear; (3) physical therapy with delayed meniscectomy was more cost-effective than early meniscectomy for meniscus tear with knee osteoarthritis; (4) meniscectomy without physical therapy was less costly than meniscectomy with physical therapy; (5) meniscectomy was more cost-effective than either meniscus allograft transplantation or meniscus scaffold procedure; (6) the conventional arthroscopic instrument cost was lower than laser-assisted arthroscopy in meniscectomy procedures.

CONCLUSION

Results from this review suggest that meniscus repair is the most cost-effective intervention for reparable meniscus tears. Physical therapy followed by delayed meniscectomy is the most cost-effective intervention for degenerative meniscus tears. Meniscus scaffold should be avoided, especially when implemented on a large scale.

LEVEL OF EVIDENCE

Systematic review of level IV studies.

Strength-Based Rehabilitation on Clinical Outcomes in Patients Postpartial Meniscectomy: A Systematic Review and Meta-analysis

OBJECTIVE

The aim of the study is to determine the effect of strength-based rehabilitation programs on patients who underwent partial meniscectomy procedures.

DESIGN

Three databases MEDLINE, PubMed, and Embase were searched from inception to May 9, 2022. Data on functional outcomes such as quadriceps and hamstring strengths, as well as patient-reported outcomes such as Knee Osteoarthritis and Outcome Score and visual analog scale were recorded.

RESULTS

A total of nine studies comprising 417 patients were included in this review. There were no significant differences in quadriceps or hamstring strength measures between preinterventation and postintervention for both groups. Knee Osteoarthritis and Outcome Scores significantly increased from preintervention and postintervention in both control and exercise groups. Visual analog scale scores changed from 5.0 to 1.4 cm in the exercise arm and 3.1 to 1.9 cm in the control arm.

CONCLUSIONS

Strength-based exercise programs for patients postpartial meniscectomy did not result in significantly different improvements in quadriceps or hamstring strength compared with control programs. However, strength-based exercise programs resulted in significantly higher Knee Osteoarthritis and Outcome Scores and a greater decrease in visual analog scale scores. Further studies, specifically well-designed systematic randomized controlled trials, are necessary to elucidate the specifics behind what type of exercises to use in addition to load progression and frequency of training.

INFLUENCE OF CRYOTHERAPY WITH PULSE COMPRESSION ON THE FUNCTIONAL CONDITION OF THE KNEE JOINT AFTER PARTIAL MENISCECTOMY

OBJECTIVE

The aim: To study the effect of cryotherapy with adjustable pulse compression in patients after arthroscopic partial meniscectomy on the functional state of the knee joint in the early period of rehabilitation.

PATIENTS AND METHODS

Materials and methods: A total of 63 patients took part in the research: the experimental group included 32 patients (23 men and 9 women), and the control group - 31 patients (21 men and 10 women). In order to determine the effect on the functional state of the knee joint after arthroscopic partial meniscectomy in the experimental group, cryotherapy with adjustable pulse compression was used with the help of «GIOCO CRYO - 2» system; ice bags were used in the control group. In the research process, the following methods were used: visual analogue point scale, sonography, goniometry and myotonometry.

RESULTS

Results: It was found that in the experimental group, under the influence of cryotherapy with adjustable pulse compression, there was a progressive decrease in the intensity of the pain syndrome, the accumulation of reactive synovial fluid, a dynamic increase in the amplitude of movements of the operated joint, and an improvement in the muscle tone of the quadriceps femoris (p<0,05-0,001).

CONCLUSION

Conclusions: Thus, cryotherapy with adjustable pulse compression has shown a positive effect on the functional state of the knee joint in the early period of patients' rehabilitation, after partial meniscectomy and can be recommended for use in clinical practice.

Smoking Has No Influence on Outcomes after Repair of the Medial Meniscus in the Hypo and Avascular Zones-A Pilot Study

Complete loss of the meniscus inevitably leads to knee joint degeneration. Smoking is an important factor predicting poor outcome in orthopedics; however, data about its role in meniscus surgery are inconclusive. Smoking could be an important negative factor in isolated meniscus repair. The aim of this paper was to determine the influence of smoking on functional outcomes after isolated all-inside medial meniscus repair. This study included 50 consecutive patients with isolated, traumatic tear of the medial meniscus who underwent knee joint arthroscopy between 2016 and 2019. All-inside arthroscopic repair of the medial meniscus was performed in each case. All patients followed a uniform, postoperative rehabilitation protocol for 8 weeks. The follow-up examination was based on the functional scores at 3 and 6 months postoperatively. According to smoking status there were 17 smokers and 33 non-smokers. The mean number of cigarettes smoked per day was 11, for a mean of 7.4 years, and the mean pack-years index value was 4.9. There was no correlation between smoking years, number of cigarettes smoked per day, pack-years index, and functional outcomes. The arthroscopic inspection of the knee joints revealed cartilage lesions (≤IIº) in eight subjects, suggesting the secondary pathology to the meniscus tear. In this study, we found no evidence of an association between smoking indices and functional outcomes after all-inside repair of chronic medial meniscus tear. The nature of the chronic meniscal tear could be smoking-resistant owing to the poor blood supply to the sites in which these specific lesions occur.

The Efficacy of the Mulligan Concept to Treat Meniscal Pathology: A Systematic Review

Background

Meniscal pathologies are common knee injuries and arthroscopic surgery is the current accepted gold standard for treatment. However, there is evidence to support the use of the Mulligan Concept (MC) Mobilization with Movement (MWM) for meniscal pathologies including the 'Squeeze' technique, tibial internal rotation (IR), and tibial external rotation (ER).

Hypothesis/Purpose

The purpose of this systematic review was to critically appraise the literature to investigate the effectiveness of MC MWMs for meniscal lesions on patient reported pain, function, and multi-dimensional health status in patients with clinically diagnosed meniscal pathologies.

Study Design

Systematic Review.

Methods

A literature search was completed across multiple databases using combinations of the words "knee, function, mobilization with movement, MWM, mulligan concept, MC, meniscal pathology, meniscal derangement, and meniscal tear." Studies written within the prior 10 years that examined MC MWM techniques to treat knee meniscal injury were included. Articles that met the inclusion criteria (used MC MWM 'Squeeze' technique, tibial IR, or tibial ER for treatment of clinically diagnosed meniscal pathologies; Patient reported outcome [PRO] measures had to be used in the assessment of knee pain or function) were analyzed for quality. Randomized control trials were analyzed using the PEDro scale and the Downs & Black (D&B) checklist, case series were analyzed using the Joanna Briggs Institute (JBI) checklist, and case reports were analyzed using the CARES checklist.

Results

Six articles met the inclusion criteria and were included in this review, two randomized controlled studies, two case series, and two case reports consisting of 72 subjects. All six papers included reports of improvements in pain and function that were either statistically significant or met the minimal clinically important difference (MCID). Five studies reported the Disablement in the Physically Active (DPA) scale that also demonstrated statistically significant differences or met the MCID. The MC MWM 'Squeeze' technique, tibial IR, or tibial ER demonstrated the ability to reduce pain, improve function, and improve patient perceived disability following treatment of a clinically diagnosed meniscal pathology. These studies demonstrated short term results lasting from one week to 21 weeks.

Conclusion

Treatment interventions incorporating MC MWM techniques demonstrated reduction of pain and improvement in function in the short term in patients with clinically diagnosed meniscal pathologies.

Level of Evidence

2a.

Selective Unique Signs of Meniscus Tears as Visualized by Magnetic Resonance Imaging

The meniscus is an organized collection of fibrocartilaginous tissue that is located between the femoral condyles and the tibial plateau of the knee which primarily assists with load transmission. The complex composition of articulating soft-tissue structures in the knee causes the menisci to become a common source of injury, especially in the realm of athletic trauma. Magnetic resonance imaging (MRI) has become the imaging modality of choice for evaluating patients with suspected meniscal pathology because of its numerous advantages over plain radiographs. Most forms of meniscal tears have classic MRI findings and are used in correlation with physical examination findings to confirm or rule out a diagnosis. These imaging findings are referred to as signs and have been well studied, and the associated eponyms for each sign are well published throughout the literature. This article will review and describe a unique selection of meniscal pathology as visualized by MRI that is more commonly published in musculoskeletal radiology literature when compared with orthopedics and sports medicine literature.

Formulation and evaluation of a bioink composed of alginate, gelatin, and nanocellulose for meniscal tissue engineering

1The necessity to preserve meniscal function prompts the research and development of novel treatment options, like three-dimensional (3D) bioprinting. However, bioinks for meniscal 3D bioprinting have not been extensively explored. Therefore, in this study, a bioink composed of alginate, gelatin, and carboxymethylated cellulose nanocrystal (CCNC) was formulated and evaluated. Firstly, bioinks with varying concentrations of the aforementioned components were subjected to rheological analysis (amplitude sweep test, temperature sweep test, and rotation). The optimal bioink formulation of 4.0% gelatin, 0.75% alginate, and 1.4% CCNC dissolved in 4.6% D-mannitol was further used for printing accuracy analysis, followed by 3D bioprinting with normal human knee articular chondrocytes (NHAC-kn). The encapsulated cells' viability was > 98%, and collagen II expression was stimulated by the bioink. The formulated bioink is printable, stable under cell culture conditions, biocompatible, and able to maintain the native phenotype of chondrocytes. Aside from meniscal tissue bioprinting, it is believed that this bioink could serve as a basis for the development of bioinks for various tissues.

Sensitivity Enhancement Using Chirp Transmission for an Ultrasound Arthroscopic Probe

Meniscal tear in the knee joint is a highly common injury that can require an ablation. However, the success rate of meniscectomy is highly impacted by difficulties in estimating the thin vascularization of the meniscus, which determines the healing capacities of the patient. Indeed, vascularization is estimated using arthroscopic cameras that lack of high sensitivity to blood flow. Here, we propose an ultrasound method for estimating the density of vascularization in the meniscus during surgery. This approach uses an arthroscopic probe driven by ultrafast sequences. To enhance the sensitivity of the method, we propose to use a chirp-coded excitation combined with a mismatched compression filter robust to the attenuation. This chirp approach was compared to a standard ultrafast emission and a Hadamard-coded emission using a flow phantom. The mismatched filter was also compared to a matched filter. Results show that, for a velocity of a few millimeters per second, the mismatched filter gives a 4.4-10.4-dB increase of the signal-to-noise ratio (SNR) compared to the Hadamard emission and a 3.1-6.6-dB increase compared to the matched filter. Such increases are obtained for a loss of axial resolution of 13% when comparing the point spread functions (PSFs) of the mismatched and matched filters. Hence, the mismatched filter allows increasing significantly the probe capacity to detect slow flows at the cost of a small loss in axial resolution. This preliminary study is the first step toward an ultrasensitive ultrasound arthroscopic probe able to assist the surgeon during meniscectomy.

The triply periodic minimal surface-based 3D printed engineering scaffold for meniscus function reconstruction

Background

The meniscus injury is a common disease in the area of sports medicine. The main treatment for this disease is the pain relief, rather than the meniscal function recovery. It may lead to a poor prognosis and accelerate the progression of osteoarthritis. In this study, we designed a meniscal scaffold to achieve the purposes of meniscal function recovery and cartilage protection.

Methods

The meniscal scaffold was designed using the triply periodic minimal surface (TPMS) method. The scaffold was simulated as a three-dimensional (3D) intact knee model using a finite element analysis software to obtain the results of different mechanical tests. The mechanical properties were gained through the universal machine. Finally, an in vivo model was established to evaluate the effects of the TPMS-based meniscal scaffold on the cartilage protection. The radiography and histological examinations were performed to assess the cartilage and bony structures. Different regions of the regenerated meniscus were tested using the universal machine to assess the biomechanical functions.

Results

The TPMS-based meniscal scaffold with a larger volume fraction and a longer functional periodicity demonstrated a better mechanical performance, and the load transmission and stress distribution were closer to the native biomechanical environment. The radiographic images and histological results of the TPMS group exhibited a better performance in terms of cartilage protection than the grid group. The regenerated meniscus in the TPMS group also had similar mechanical properties to the native meniscus.

Conclusion

The TPMS method can affect the mechanical properties by adjusting the volume fraction and functional periodicity. The TPMS-based meniscal scaffold showed appropriate features for meniscal regeneration and cartilage protection.

Cost-Effectiveness Analysis of a Medial Meniscus Replacement Prosthesis for the Treatment of Patients with Medial Compartment Pain in the United Kingdom

BACKGROUND

The most common intra-articular knee injury is a meniscal tear, which commonly occurs secondary to trauma following twisting or hyperflexion. Treatment options for meniscal tears can either be surgical or non-surgical, and range from rest, exercise, bracing and physical therapy to surgical intervention, including meniscal repair and partial meniscectomy. In patients with persistent pain following loss of meniscus tissue, treatment can include partial replacement or meniscal allograft transplantation. The NUsurface^® prosthesis has been developed as a treatment option for patients experiencing persistent knee pain post medial meniscus (MM) surgery.

OBJECTIVE

The aim of this study was to assess the cost effectiveness of MM replacement using NUsurface for the treatment of patients with medial compartment pain following previous partial medial meniscectomy, from a UK health service perspective.

METHODS

An economic decision-analytic model was developed to assess the cost per quality-adjusted life-year (QALY) gained associated with the introduction of MM replacement using NUsurface compared with non-surgical standard of care, over a lifetime time horizon. The model structure was primarily informed by a previous clinical trial (VENUS) and was developed based on the clinical pathways typically followed by patients with this condition, with treatment pathways and probabilities of clinical progression adjusted depending on whether patients were receiving the intervention or undergoing current practice. A hypothetical cohort of adult patients (mean age of 50 years) was modelled, with clinical data sourced from the VENUS study as well as relevant UK literature. Both deterministic and probabilistic sensitivity analyses were carried out to explore uncertainty in the model results.

RESULTS

The base-case probabilistic results indicate that MM replacement using NUsurface is likely to be cost effective across a range of willingness-to-pay (WTP) thresholds (95% probability of being cost effective at the National Institute for Health and Care Excellence (NICE)-recommended £20,000 WTP threshold). Although per-patient costs increase, QALYs are also gained, with the incremental cost per QALY (probabilistic value = £5011) being below £20,000. Deterministic sensitivity analyses indicate that the parameters that have the greatest impact on results are the failure rate in the control group (current practice), utility scores, and the cost of undergoing MM replacement using NUsurface.

CONCLUSIONS

Based on the analysis presented, MM replacement with the NUsurface prosthetic implant is likely to be a cost-effective use of UK health care service resources compared with current standard care.

Arthroscopic Meniscal Repair With Second-Generation Platelet-Rich Fibrin Clot Augmentation

Meniscal tears are among the most common injuries in the knee, and partial as well as total meniscectomy has been advocated as the treatment for meniscal injury. Over the years, the role of the meniscus as a shock absorber, load transmitter, and secondary anterior stabilizer, along with its proprioceptive and lubrication role, has been well established, and meniscal repair is recommended, especially in younger individuals. Factors such as tear location, pattern, chronicity, size, and extent; repair technique; and patient age and habits can influence meniscal repair, and to enhance meniscal healing, a variety of augmentation techniques have been introduced. These include needling, trephination, synovial abrasion, and the use of adjuvants such as platelet-rich plasma, platelet clots, fibrin clots, bone marrow clots, and stem cells. A second-generation platelet derivative called "platelet-rich fibrin" (PRF) has predictable platelet, growth factor, and cell mediator concentrations without using any anticoagulants. We describe a reproducible and simple way to harvest PRF and create and use a PRF clot, along with detailed instructions on how to integrate the clot with a meniscal repair arthroscopically.

Arthroscopic meniscus repair and augmentation with autologous fibrin clot in Indian population: A 2-year prospective study

INTRODUCTION

This study was proposed to evaluate the efficacy of fibrin clot augmentation in meniscal tear using inside-out meniscal repair.

METHODS

A total of 35 patients with meniscus tears were operated on with inside-out meniscus repair and fibrin clot augmentation. Patients were evaluated preoperatively and postoperatively with clinical criteria, Lysholm knee scoring system, and MRI.

RESULTS

Out of the total 35 cases, 5 cases were lost to follow-up. Clinical improvement was observed in 29 out of 30 patients (96.6%). The mean Lysholm score improved significantly from 67.63 ± 6.55 points preoperatively to 92.0 ± 2.9 points postoperatively (P < 0.05) in 3 years follow-up. Follow-up MRI in all patients revealed complete healing except in 1 case where the patient presented with recurrence of symptoms such as pain and locking which resolved with partial meniscectomy. Paraesthesia in the anterior part of the knee was observed in 2 cases. (6.6%).

CONCLUSION

We conclude that fibrin clot augmentation is a good cost-effective modality of treatment for repairable meniscus tears to preserve the meniscus and decrease the point contact pressure on the condyles which may prevent the early occurrence of osteoarthritis.

Return to sport rate following sports trauma-related delayed bucket-handle meniscus repair with concomitant ACL reconstruction

BACKGROUND

Return to sports rate of chronic meniscus repair concurrent with Anterior Cruciate Ligament (ACL) reconstruction remains unclear, especially there is no well-defined return to sports criteria for evaluation. The purpose of this retrospective study was to determine the success rate of chronic locked bucket-handle meniscal tear (BHMT) repair with concomitant ACL reconstruction.

METHODS

This study includes 51 chronic ACL injury patients with a locked meniscal tear of at least 6 weeks who underwent surgery. All cases were treated with arthroscopic BHMT repair and ACL reconstruction between 2017 and 2020. Patient demograph-ics, chronicity, pre-operative, and intraoperative surgical variables which associated with return to sports were defined. BHMT was repaired with an all-in-side meniscus repair and/or combined repair procedure first, then an anatomic outside-in ACL reconstruction using a suspension device for femoral fixation was performed. Patients underwent same rehabilitation program with the goal of return-ing to sport at approximately 4-8 months. A modified return-to-sport criterion was performed in this study.

RESULTS

Fifty-one patients with an average age of 27.4 (range 18-48) years were included in the study. The average time elapsed from the occurrence of locked knee symptoms to surgery was 10.5±4.4 weeks. The mean follow-up time was 25.3±4.5 months. Sig-nificant improvement was observed in all patient-reported outcomes from baseline to the final follow-up. The mean modified Lysholm knee score increased from 45.5 points to 91.5 at the final follow-up (p<0.001). The 43 out of 51 patients (84.3%) were return to their recreational activities (amateur sports). The mean time to return to sport was 5.9±0.8 (5-8) months.

CONCLUSION

Majority of the patients who underwent ACL reconstruction with BHMT repair return to their pre-operative activity levels in 8 months. All neglected BHMTs with concomitant chronic ACL rupture should be repaired in a single-stage surgery if the half plane-concave shape of the menisci has been preserved regardless of the delay in time to surgery.

Biomechanical Comparison of Meniscal Allograft Root Fixation Techniques: Anterograde Interference Bone Plug Fixation Yields Favorable Results Compared to Transosseous Suture Fixation Alone

Purpose

To compare the biomechanical properties of 2 different fixation techniques (interference bone plug fixation vs transosseous suture fixation) of the posterior horn of the medial meniscus using a porcine model.

Methods

Twenty-six matched pairs of fresh-frozen juvenile domestic porcine knees were used in this study. Specimens were randomly distributed among 3 groups: (1) native meniscus groups, (2) interference fixation, and (3) transosseous suture fixation. In each group, the posterior segments of the tested medial menisci were gripped with the freeze clamps and fixed to the tensile testing machine. Samples were preconditioned, followed by cyclic tension-relaxation for 1000 cycles between 10 and 30 N at 0.5 Hz and finally pulled to failure at a rate of 0.55 mm/s. The cyclic elongation, stiffness to failure, mode, and ultimate load to failure were recorded.

Results

There was no significant difference in ultimate load to failure between the interference fixation (169.71 ± 71.98 N) and transosseous suture fixation (222.73 ± 72.40 N) groups (P = .118), both were significantly less than that of the native meniscus (405.46 ± 95.62) (P < .001). Interference fixation displayed cyclic elongation (1.04 ± 0.71 mm) and stiffness (69.10 ± 25.8 N/mm) that were not significantly different from the native meniscus tissue (0.78 ± 0.53 mm and 83.1 ±26.28 N/mm) (P = .359 and P = .224), in comparison to transosseous suture fixation, which did show increased cyclic elongation (1.85 ± 1.44 mm) (P = .047) and decreased stiffness (34.72 ± 10.2 N/mm) (P < .001).

Conclusion

Interference fixation of the posterior horn of the medial meniscus has superior cyclic elongation and stiffness when compared to transosseous suture fixation. Interference fixation and the native meniscus model have a similar stiffness and cyclic elongation.

Clinical Relevance

The significance of our study is that using interference fixation for meniscal allograft transplantation has the potential to reduce short term surgical failures as well as long term complication rates.

Meniscus Tear: Pathology, Incidence, and Management

Meniscus tears are a common orthopedic pathology and planning a single, effective treatment is challenging. The diagnosis of meniscal tears requires detailed history-taking, physical examinations, special diagnostic tests, and most likely magnetic resonance imaging (MRI) to confirm the lesion. A good understanding of the meniscal structure including vascularity, zones, function, and affected movements with associated symptoms plays a crucial role in establishing an optimal management plan. A careful assessment of the patient's characteristics, comorbidities, post-repair rehabilitation, and patient’s overall function and satisfaction are also important for ideal management. While conservative management is commonly implemented and the only option for certain patients, partial meniscectomy remains to be the most performed treatment procedure. However, partial meniscectomy is no longer the first-line therapy due to the limitation of certain patient characteristics and side effects in the long run. Instead, meniscal repair has been shown to have better long-term outcomes and is therefore recommended for all tears, especially for young patients with acute traumatic lesions. Tissue engineering has been of high interest in the current research with promising therapeutic results. This review critically evaluates and compares the management of meniscal tears with surgical versus comprehensive management using the current literature.

Meniscus regeneration by 3D printing technologies: Current advances and future perspectives

Meniscal tears are a frequent orthopedic injury commonly managed by conservative strategies to avoid osteoarthritis development descending from altered biomechanics. Among cutting-edge approaches in tissue engineering, 3D printing technologies are extremely promising guaranteeing for complex biomimetic architectures mimicking native tissues. Considering the anisotropic characteristics of the menisci, and the ability of printing over structural control, it descends the intriguing potential of such vanguard techniques to meet individual joints’ requirements within personalized medicine. This literature review provides a state-of-the-art on 3D printing for meniscus reconstruction. Experiences in printing materials/technologies, scaffold types, augmentation strategies, cellular conditioning have been compared/discussed; outcomes of pre-clinical studies allowed for further considerations. To date, translation to clinic of 3D printed meniscal devices is still a challenge: meniscus reconstruction is once again clear expression of how the integration of different expertise (e.g., anatomy, engineering, biomaterials science, cell biology, and medicine) is required to successfully address native tissues complexities.

Medial Meniscal Allograft Transplantation With Bone Plugs Using a 3-Tunnel Technique

Meniscal allograft transplantation is an area of active research, given that the importance of the meniscus in native knee joint longevity has been increasingly recognized. This article describes a modified meniscal allograft transplantation technique using 3 bone tunnels with allograft fixation through the use of bone plugs. The addition of a third tunnel increases the strength of fixation, avoiding meniscal extrusion and improving load distribution.

Three-Dimensional-Printed Scaffolds for Meniscus Tissue Engineering: Opportunity for the Future in the Orthopaedic World

The meniscus is a critical component of a healthy knee joint. It is a complex and vital fibrocartilaginous tissue that maintains appropriate biomechanics. Injuries of the meniscus, particularly in the inner region, rarely heal and usually progress into structural breakdown, followed by meniscus deterioration and initiation of osteoarthritis. Conventional therapies range from conservative treatment, to partial meniscectomy and even meniscus transplantation. All the above have high long-term failure rates, with recurrence of symptoms. This communication presents a brief account of in vitro and in vivo studies and describes recent developments in the field of 3D-printed scaffolds for meniscus tissue engineering. Current research in meniscal tissue engineering tries to combine polymeric biomaterials, cell-based therapy, growth factors, and 3D-printed scaffolds to promote the healing of meniscal defects. Today, 3D-printing technology represents a big opportunity in the orthopaedic world to create more specific implants, enabling the rapid production of meniscal scaffolds and changing the way that orthopaedic surgeons plan procedures. In the future, 3D-printed meniscal scaffolds are likely to be available and will also be suitable substitutes in clinical applications, in an attempt to imitate the complexity of the native meniscus.