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Arthroscopy : the Journal of... Feb 2024To compile and analyze structural and clinical outcomes after meniscus root tear treatment as currently described in the literature. (Review)
Review
Root Repair Has Superior Radiological and Clinical Outcomes Than Partial Meniscectomy and Nonoperative Treatment in the Management of Meniscus Root Tears: A Systematic Review.
PURPOSE
To compile and analyze structural and clinical outcomes after meniscus root tear treatment as currently described in the literature.
METHODS
A review was conducted to identify studies published since 2011 on efficacy of repair, meniscectomy, and nonoperative management in the treatment of meniscus root tears. Patient cohorts were grouped into treatment categories, with medial and lateral root tears analyzed separately; data were collected on patient demographics, structural outcomes including joint space width, degree of medial meniscal extrusion, progression to total knee arthroplasty, and patient-reported outcome measures. Risk of bias was assessed using the MINORS (methodological index for non-randomized studies) criteria. Heterogeneity was measured using the I-statistic, and outcomes were summarized using forest plots without pooled means.
RESULTS
The 56 included studies comprised a total of 3,191 patients. Mean age among the included studies ranged from 24.6 to 65.6 years, whereas mean follow-up ranged from 12 to 125.9 months. Heterogeneity analysis identified significant differences between studies. Change in joint space width ranged from -2.4 to -0.6 mm (i.e., decreased space) after meniscectomy (n = 186) and -0.9 to -0.1 mm after root repair (n = 209); change in medial meniscal extrusion ranged from -0.6 to 6.5 mm after root repair (n = 521) and 0.2 to 4.2 mm after meniscectomy (n = 66); and event rate for total knee arthroplasty ranged from 0.00 to 0.22 after root repair (n = 205), 0.35 to 0.60 after meniscectomy (n = 53), and 0.27 to 0.35 after nonoperative treatment (n = 93). Root repair produced the greatest numerical increase in International Knee Documentation Committee and Lysholm scores of the 3 treatment arms. In addition, root repair improvements in Knee Injury and Osteoarthritis Outcome Score Pain (range: 22-32), Sports and Recreational Activities (range: 23-36), Quality of Life (range: 22-42), and Symptoms subscales (range: 10-19), in studies with low risk of bias.
CONCLUSIONS
The literature reporting on the treatment of meniscus root tears is heterogenous and largely limited to Level III and IV studies. Current evidence suggests root repair may be the most effective treatment strategy in lessening joint space narrowing of the knee and producing improvements in patient-reported outcomes.
LEVEL OF EVIDENCE
Level IV, systematic review of Level II-IV studies.
PubMed: 38401664
DOI: 10.1016/j.arthro.2024.02.017 -
Knee Surgery, Sports Traumatology,... Mar 2024To conduct a systematic review evaluating potential correlations between preoperative articular cartilage integrity on outcomes and survivorship in patients undergoing...
PURPOSE
To conduct a systematic review evaluating potential correlations between preoperative articular cartilage integrity on outcomes and survivorship in patients undergoing meniscal allograft transplantation (MAT).
METHODS
A literature search was performed by querying SCOPUS, PubMed, Medline, and the Cochrane Central Register for Controlled Trials from database inception through May 2023 according to the 2020 PRISMA statement. Inclusion criteria were limited to studies reporting on outcomes and survivorship following MAT based on preoperative cartilage status.
RESULTS
Sixteen studies, consisting of 1723 patients (n = 1758 total menisci), were identified in six level III and 10 level IV evidence studies. There was high heterogeneity in cartilage grading scales, reporting of concomitant cartilage procedures, and indications for MAT based on osteoarthritis. Patients with lower limb malalignment were either excluded or corrected with an osteotomy. MAT failure rate was reported in nine studies, with four studies reporting a greater rate of failure in knees with higher degrees of cartilage damage. Eight studies reported on clinical outcomes based on cartilage grade, with two studies reporting significant differences in clinical outcomes based on cartilage grade. Of the five studies reporting management of full-thickness chondral defects with cartilage surgery, three studies reported no significant difference in survivorship based on preoperative cartilage grade, while one study reported lower survivorship and one study reported unclear results. No studies found significant differences in survivorship and outcomes between medial and lateral MAT.
CONCLUSIONS
Conflicting results and high variability in reporting of concomitant cartilage repair and indications for MAT exist in studies evaluating the efficacy of MAT based on articular cartilage status. The degree of preoperative chondral damage did not have a strong relationship with clinical outcomes following MAT. Higher degrees of cartilage damage were associated with higher MAT failure rates, with possible improvement in survivorship when treated with an appropriate cartilage procedure.
LEVEL OF EVIDENCE
Level IV.
Topics: Humans; Cartilage, Articular; Survivorship; Menisci, Tibial; Musculoskeletal Diseases; Osteotomy; Allografts; Follow-Up Studies
PubMed: 38383989
DOI: 10.1002/ksa.12065 -
The American Journal of Sports Medicine Feb 2024While increased posterior tibial slope (PTS) is an established risk factor for anterior cruciate ligament tears, the association between tibial slope and meniscal...
BACKGROUND
While increased posterior tibial slope (PTS) is an established risk factor for anterior cruciate ligament tears, the association between tibial slope and meniscal posterior root tears is not well-defined.
PURPOSE
To summarize the available literature evaluating the association between PTS and meniscus root injuries compared with patients without root tears.
STUDY DESIGN
Systematic review; Level of evidence, 4.
METHODS
A literature search was performed using the Scopus, PubMed, and Embase databases. Human clinical studies evaluating the associations between the medial tibial slope (MTS), lateral tibial slope (LTS), lateral-to-medial (L-to-M) slope asymmetry, and the risk of meniscus root tears were included. Patients with medial meniscus posterior root tears (MMPRTs) and lateral meniscus posterior root tears (LMPRTs) were compared with a control group without root injury. Study quality was assessed using the methodological index for non-randomized studies criteria.
RESULTS
Ten studies with 1313 patients were included (884 patients with root tears; 429 controls). The LMPRT subgroup (n = 284) had a significantly greater LTS (mean ± SD, 7.3°± 1.5° vs 5.7°± 3.91°; < .001), MTS (5.26°± 1.2° vs 4.8°± 1.25°; < .001), and increased L-to-M asymmetry (2.3°± 1.3° vs 0.65°± 0.5°; < .001) compared with controls. The MMPRT group (n = 600) had significantly increased MTS relative to controls (8.1°± 2.5° vs 4.3°± 0.7°; < .001). Furthermore, there was a higher incidence of noncontact injuries (79.3%) and concomitant ramp lesions (56%) reported in patients with LMPRT.
CONCLUSION
Increased MTS, LTS, and L-to-M slope asymmetry are associated with an increased risk of LMPRTs, while increased MTS is associated with MMPRTs. Surgeons should consider how proximal tibial anatomy increases the risk of meniscus root injury.
PubMed: 38362610
DOI: 10.1177/03635465231225981 -
Arthroscopy : the Journal of... Feb 2024To compare patient-reported outcomes, failure rates, risk factors for failure, and complications in patients with bucket-handle meniscus tears (BHMTs) undergoing repair...
All-Inside and Inside-Out Repair Techniques for Bucket-Handle Meniscus Tears Both Result in Improved Patient Outcomes and a Broad Range of Failure Rates: A Systematic Review.
PURPOSE
To compare patient-reported outcomes, failure rates, risk factors for failure, and complications in patients with bucket-handle meniscus tears (BHMTs) undergoing repair with inside-out (IO) versus all-inside (AI) techniques.
METHODS
A literature search was performed using the PubMed, Embase, and Scopus databases from database inception to August 2023 according to the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. The inclusion criteria consisted of Level I to IV clinical studies published in the past 10 years with greater than 2 years of follow-up that evaluated patient-reported outcome scores and/or the incidence of failure after IO or AI repairs for BHMTs. Clinical studies not reporting outcomes or failure rates, older studies using outdated implants, animal studies, reviews, letters to the editor, case reports, cadaveric studies, and articles not written in the English language or with English-language translation were excluded. Study quality was assessed using the Methodological Index for Non-randomized Studies (MINORS) criteria. Outcomes were reported as ranges and qualitatively compared.
RESULTS
A total of 16 studies published from 2013 to 2023, consisting of 1,062 patients with BHMTs, were identified. Thirteen studies (14 cohorts, 649 patients) reported on AI repair (mean age range, 23.7-32 years) and 7 studies (7 cohorts, 413 patients) reported on IO repair (mean age range, 16.7-34.6 years). Both groups had improved postoperative Lysholm and Tegner scores. Decreased range of motion was the most commonly reported complication in the AI group (range, 2.6%-4%), whereas adhesions for arthrofibrosis were the most commonly reported complication in the IO group (n = 12; range, 6%-7.9%). The overall reported failure rate ranged from 6.9% to 20.5% within the AI group and from 0% to 20% within the IO group.
CONCLUSIONS
AI and IO repair techniques for BHMTs both result in improved Lysholm and Tegner scores. However, broad ranges of failure are reported in the literature, with overall failure rates ranging from 6.9% to 20.5% after AI repair and from 0% to 20% after IO repair. Younger age and isolated medial BHMT repair are the most frequently reported risk factors for the AI technique, whereas postoperative stiffness is the most frequently reported complication after both repair techniques.
LEVEL OF EVIDENCE
Level IV, systematic review of Level I to IV studies.
PubMed: 38311264
DOI: 10.1016/j.arthro.2024.01.021 -
The American Journal of Sports Medicine Jul 2024Fresh-frozen allografts are the current standard in meniscal allograft transplant (MAT) surgery, due to their availability, ease of preservation, and affordability....
BACKGROUND
Fresh-frozen allografts are the current standard in meniscal allograft transplant (MAT) surgery, due to their availability, ease of preservation, and affordability. However, fresh-frozen grafts are associated with several clinical challenges such as graft shrinkage and extrusion, among many others.
PURPOSE
To present the current knowledge on the use of fresh meniscal allografts, presenting whether benefits associated with fresh grafts provide sufficient evidence to support their use in clinical practice.
STUDY DESIGN
Systematic review; Level of evidence, 5.
METHODS
A comprehensive search was conducted with keywords listed below. After an initial screening on title and abstract, full-text articles were assessed with the inclusion criteria.
RESULTS
A total of 78 studies matched the inclusion criteria. Literature and preclinical studies indicated that fresh meniscal allografts are beneficial for maintaining mechanical properties, graft ultrastructure, and matrix metabolism due to the presence of viable cells. Therefore, fresh allografts may address common complications associated with fresh-frozen MAT. To overcome challenges associated with both fresh-frozen and fresh allografts, a group has studied treating fresh-frozen allografts with a cell-based injection therapy.
CONCLUSION
Fresh meniscal allografts pose several challenges including limited availability, demanding preservation procedures, and high costs. Although the role of viable cells within meniscal allografts remains controversial, these cells may be vital for maintaining tissue properties.
Topics: Humans; Menisci, Tibial; Allografts; Transplantation, Homologous; Cryopreservation; Tibial Meniscus Injuries
PubMed: 38282584
DOI: 10.1177/03635465231200236 -
The American Journal of Sports Medicine Jun 2024Various suture configurations are available for medial meniscus posterior root tear (MMPRT) repair. The modified Mason-Allen (MMA) technique has been proposed as a... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Various suture configurations are available for medial meniscus posterior root tear (MMPRT) repair. The modified Mason-Allen (MMA) technique has been proposed as a refixation technique for MMPRT instead of the conventional 2 simple stitches (TSS). This is in view of its superior biomechanical characteristics.
PURPOSE
To perform a systematic review and meta-analysis to compare MMA and TSS configuration techniques for MMPRT repair and identify any differences between the 2 techniques in terms of clinical outcomes, medial meniscal extrusion (MME), and postoperative healing.
STUDY DESIGN
Meta-analysis; Level of evidence, 4.
METHODS
The Cochrane Controlled Register of Trials, PubMed, Medline, and Embase databases were used to perform a systematic review and meta-analysis using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria with the following search terms: ("meniscus" OR "meniscal injuries") AND ("Mason-Allen" OR "simple stitch" OR "suture techniques"). Data pertaining to all patient-reported outcome measures, postoperative complications, MME, postoperative healing, cartilage degeneration, and progression of knee osteoarthritis were extracted from each study. The pooled outcome data were analyzed using random- and fixed-effects models.
RESULTS
After abstract and full-text screening, 6 clinical studies were included. In total, there were 291 patients; 160 underwent MMA fixation, and 131 underwent the TSS technique. The majority of studies had similar surgical techniques regarding repair technique, suture material, tibial fixation, and number and position of tibial tunnels. There were no differences between the groups in terms of patient-reported outcome measures at 14.2 months. Both techniques were also similar in the degree of postoperative MME and meniscal healing.
CONCLUSION
Both suture configurations were equivalent in terms of clinical outcomes, the extent of meniscal extrusion, and postoperative healing. The TSS technique may offer advantages in terms of faster learning curve and shorter operative time. However, randomized controlled trials with large sample sizes, longer follow-up and assessment of chondral degeneration, and presence of knee osteoarthritis are required to assess whether a true difference exists, as the majority of included studies were limited by their retrospective design.
Topics: Humans; Tibial Meniscus Injuries; Suture Techniques; Menisci, Tibial; Postoperative Complications
PubMed: 38258492
DOI: 10.1177/03635465231190650 -
Journal of ISAKOS : Joint Disorders &... Jun 2024The diagnosis of ramp lesions can be problematic, even with arthroscopy, due to their extreme posteromedial position. Consequently, they have been colloquially referred... (Review)
Review
IMPORTANCE
The diagnosis of ramp lesions can be problematic, even with arthroscopy, due to their extreme posteromedial position. Consequently, they have been colloquially referred to as the "hidden lesions" of the knee. Undiagnosed and untreated injuries in this knee region may be associated with ongoing dynamic rotational laxity of the knee after anterior cruciate ligament reconstruction and an increased risk of anterior cruciate ligament graft failure.
AIM
This study aimed to systematically review the literature to assess the sensitivity, specificity and accuracy of magnetic resonance imaging (MRI) for detecting ramp lesions in children and adolescents with anterior cruciate ligament (ACL)-deficient knees. It was hypothesized that MRI has poor sensitivity for identifying ramp lesions in children and adolescents.
EVIDENCE REVIEW
A systematic review was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The following search terms were used in the title, abstract and keywords fields: "ramp" or "meniscus" AND "children" or "adolescents." The outcome data extracted from the studies were incidence of ramp in concomitant with ACL lesion, MRI sensitivity, specificity, accuracy and positive and negative predictive values (PPV and NPV).
FINDINGS
Of the 387 patients with ACL injury, 90 were reported to have ramp lesions (23.3%). The mean age at the time of diagnosis was 15.3 ± 0.81 years. The mean time from injury to MRI was 116.1 ± 113.5 days, while the mean time from injury to surgery was 172.6 ± 139.1 days. The MRI taken to detect ramp lesions in the paediatric population showed a pooled sensitivity of 50%, specificity of 75%, accuracy of 70%, PPV of 41% and NPV of 79%.
CONCLUSIONS AND RELEVANCE
The prevalence of ACL-associated ramp lesions in children and adolescents is similar to that in adult populations. Magnetic resonance imaging has low sensitivity but good specificity for assessing ramp lesions. In the presence of a posteromedial tibial bone bruise or a thin fluid signal separating the posterior horn of the medial meniscus and the posteromedial capsule a ramp lesion should always be suspected.
LEVEL OF EVIDENCE
Level IV.
STUDY REGISTRATION
PROSPERO -: CRD42023453895.
Topics: Humans; Anterior Cruciate Ligament Injuries; Magnetic Resonance Imaging; Adolescent; Child; Sensitivity and Specificity; Anterior Cruciate Ligament Reconstruction; Tibial Meniscus Injuries; Female; Male; Arthroscopy; Predictive Value of Tests; Joint Instability; Knee Joint
PubMed: 38135056
DOI: 10.1016/j.jisako.2023.12.005 -
Arthroscopy : the Journal of... May 2024To identify frequently studied significant preoperative risk factors for meniscal allograft transplantation (MAT) failure. (Review)
Review
PURPOSE
To identify frequently studied significant preoperative risk factors for meniscal allograft transplantation (MAT) failure.
METHODS
Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines were used to conduct this systematic review. The database analysis was performed in May 2022 and included PubMed, Embrace, and Cochrane. Studies between January 1, 2000, and January 1, 2021, were reviewed with search terms, including "meniscal," "meniscus," "transplantation," "transplant," and "allograft." Twenty-one full-text manuscripts met inclusion criteria of studies assessing preoperative risk factors for MAT failure defined as either clinical failure (Lysholm <65) or surgical failure (revision, removal, or conversion to knee arthroplasty).
RESULTS
In total, 21 studies were included, comprising 47.6% with Level of Evidence III and 52.4% with Level of Evidence IV. The analysis involved 2,533 patients, and the mean final follow-up ranged from 2.2 to 20.0 years. The presence of high-grade cartilage defects was the only factor found predictive of MAT surgical failure in the majority of studies in which it was analyzed (5/7 studies, 71.4%). Four of the 5 studies that found high-grade cartilage defects to be a predictor of MAT surgical failure did not treat all cartilage lesions, whereas the 2 studies that found high-grade cartilage defects an insignificant predictor of MAT surgical failure treated all defects at the time of MAT. For clinical failure, no risk factors were predictive of MAT failure in the majority of studies, although smoking and concomitant ligamentous or realignment procedures were significant in 1 study.
CONCLUSIONS
The presence of untreated high-grade cartilage appears to elevate the risk of surgical MAT failure; however, concomitant treatment of defects may mitigate their detrimental effect. There is no clear risk factor that consistently predicts clinical failure. Age, sex, body mass index, knee compartment, time from prior meniscectomy, femorotibial alignment (after correction), concomitant cartilage procedure, and laterality do not routinely influence MAT failure.
LEVEL OF EVIDENCE
Level IV, systematic review of Level III and IV studies.
Topics: Humans; Allografts; Cartilage, Articular; Menisci, Tibial; Risk Factors; Tibial Meniscus Injuries; Transplantation, Homologous; Treatment Failure
PubMed: 38008388
DOI: 10.1016/j.arthro.2023.11.011 -
The Knee Dec 2023Meniscus extrusion is crucial for the diagnosis and treatment of meniscal injury, but the literature on this topic has not yet been systematized. The purpose of this... (Review)
Review
BACKGROUND
Meniscus extrusion is crucial for the diagnosis and treatment of meniscal injury, but the literature on this topic has not yet been systematized. The purpose of this systematic review was to compare diagnostic methods and summarize the data of medial and lateral meniscal extrusion in knees with and without osteoarticular pathology.
METHODS
This systematic review was conducted according to the PRISMA 2020 statement. Searches were conducted on PubMed, EMBASE and Cochrane databases to identify studies that measured meniscal extrusion using magnetic resonance imaging (MRI) or ultrasound (US). Meniscal extrusion data was summarized as weighted mean for medial and lateral meniscus, and stratified according to the method of measurement (MRI or US) and presence of knee osteoarticular pathology.
RESULTS
A total of 26 studies were included in this review. Weighted mean values of meniscal extrusion were always higher for the medial than the lateral meniscus, regardless of the method of measurement. The medial meniscus extrusion was always higher in knees with osteoarticular pathology than those without. For the lateral meniscus extrusion, the mean values were higher in those knees without osteoarticular pathology. When classifying pathological meniscal extrusion with pre-defined cut-off values, the higher the cut-off used, the lower the percentage of knees classified as pathological meniscal extrusion.
CONCLUSIONS
The medial meniscus presents on mean higher extrusion and extrusion is higher in knees with osteoarticular pathology. Based on summary data, the most suitable cut-offs for pathological meniscal extrusion for both MRI and US seem to fall within >2 and >3 mm.
Topics: Humans; Knee Joint; Menisci, Tibial; Magnetic Resonance Imaging; Lower Extremity
PubMed: 37925806
DOI: 10.1016/j.knee.2023.09.010 -
Arthroscopy : the Journal of... Apr 2024To provide comprehensive information about the anterolateral ligament (ALL) prevalence, morphometry, isometry, insertions, histology, and its relationship with the... (Meta-Analysis)
Meta-Analysis
The Anterolateral Ligament of the Knee Is a Nonisometric Thin Ligament With High Prevalence and Almost Constant Attachment to the Lateral Meniscus: A Systematic Review With Meta-analysis.
PURPOSE
To provide comprehensive information about the anterolateral ligament (ALL) prevalence, morphometry, isometry, insertions, histology, and its relationship with the lateral meniscus (LM).
METHODS
The study was performed, according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Eligible cadaveric studies investigating the frequency of the ALL presence, and anatomical features were identified through an online search of the PubMed, Scopus, and Cochrane Central databases from inception to June 2022. Statistical analysis was conducted with the open-source R programming language using the "meta" package. The Higgins I2 statistic was used for quantifying heterogeneity.
RESULTS
Thirty-three studies (1,478 cadaveric knees) were included. The ALL had a 79% prevalence. It was attached to the LM periphery in 97% of studies. Most studies reported a femoral insertion of the ALL, just proximal and posterior to the lateral epicondyle. Tibial attachment is constant at the midpoint between Gerdy's tubercle and fibular head. The mean ALL thickness at the joint line was 1.6 [1.2; 2.0] mm. The ALL length was found to significantly change across the knee flexion (P < .01). It was increased from 0° to 60° and decreased after 60° flexion. Seven histological studies demonstrated a typical ligamentous microstructure.
CONCLUSION
The ALL is a thin ligament, distinct to the knee capsule, which may be found in 79% of the knees having an almost constant attachment to the LM. The ALL is not isometric. It becomes tense during internal rotation and between 30° and 60° knee flexion. Pooled results should be interpreted with caution due to the high heterogeneity among the included studies.
CLINICAL RELEVANCE
This study sheds light on controversial issues and provides comprehensive and accurate information about the essential anatomical knowledge on ALL, which may contribute to optimizing ALL reconstruction surgical techniques and biomechanical settings.
Topics: Humans; Menisci, Tibial; Prevalence; Cadaver; Knee Joint; Tibia; Ligaments, Articular; Range of Motion, Articular; Biomechanical Phenomena
PubMed: 37832743
DOI: 10.1016/j.arthro.2023.09.031