Concomitant Anterior Cruciate Ligament Research Articles

Save the meniscus - Clinical outcomes of meniscectomy versus meniscal repair.

This study was designed to compare the clinical outcomes of meniscectomy versus repair and to study the effects of (1) duration of follow-up and (2) concomitant anterior cruciate ligament (ACL) reconstruction on clinical outcomes. A retrospective study was conducted, involving 112 knees of 106 patients who underwent meniscus surgery, either partial meniscectomy or meniscal repair between 2008 and 2016. There were 42 meniscectomies and 70 meniscal repairs. Patients were graded pre- and post-operatively using the International Knee Documentation Committee (IKDC) score and Tegner Activity Level Scale through case notes review. Statistical analysis was done using the paired Student's t-test (two-tailed) or Wilcoxon signed-rank test for paired scores. The two-sample Student's t-test (two-tailed) or Mann-Whitney U test was used for independent scores. Multiple variable linear regression analysis was used to assess the importance of the variables on outcomes. A statistical significance is taken as p < 0.05. Meniscectomy and repair had good outcomes. IKDC scores improved from 46.6 to 81.7 after meniscectomy and from 45.9 to 84.4 after repair ( p < 0.001). Meniscectomy fared worse in late follow-up (>18 months), decreasing from 88.2 in early follow-up (≤18 months) to 72.1 ( p < 0.05). The post-operative scores in meniscal repair were maintained in the late follow-up group (82.9 compared to 87.1, p > 0.05). Concomitant ACL reconstruction improved the outcomes of meniscectomy (IKDC and Tegner: p < 0.05) and repair (IKDC and Tegner: p < 0.05). Both meniscectomy and meniscal repair are viable surgical techniques for meniscal injury and have good outcomes. Meniscal repair has a better prognosis in the long run.

Meniscal Repair in Pediatric Populations: A Systematic Review of Outcomes.

Background:Loss of meniscal tissue in the pediatric population can have long-term consequences on joint health, highlighting the importance of meniscal preservation in this group.Purpose:To systematically review reported knee outcome measures and complication rates after repair of meniscal tears in children and adolescents.Study Design:Systematic review; Level of evidence, 4.Methods:A review of the literature regarding the existing evidence for pediatric meniscal tear outcomes was performed through use of the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed (1980-present), and MEDLINE (1980-present). Included were articles in English that reported the outcomes of meniscal tears in the pediatric population (<18 years old) with a follow-up of more than 12 months. Clinical outcome scores were reviewed.Results:A total of 1003 total studies were initially retrieved, with 8 meeting the inclusion criteria. The review included 287 patients (165 male, 122 female), mean age 15.1 years (range, 4-18 years), with 301 meniscal tears (reported: 134 medial, 127 lateral, and 32 both medial and lateral, 8 location unspecified). Concomitant anterior cruciate ligament reconstruction was performed in 52% (158/301) of meniscal repairs. The average reported postoperative Lysholm scores ranged from 85.4 to 96.3, and the average reported postoperative Tegner activity scores ranged from 6.2 to 8.Conclusion:Arthroscopic repair of a meniscal tear in the pediatric and adolescent population is an effective treatment option that has a low failure rate, enhances postoperative clinical outcomes, and preserves meniscal tissues.

Prevalence, development, and factors associated with cyst formation after meniscal repair with the all-inside suture device.

To investigate the prevalence of cyst formation after using all-inside meniscal repair device and analysed the risk factors associated with it. Between August 2008 and September 2013, 51 menisci of 46 patients were included in the study, 46 menisci of which had concomitant anterior cruciate ligament (ACL) ruptures and had an ACL reconstruction. Magnetic resonance imaging (MRI) of the knee was performed at 3, 6, 12 and 24 months after meniscal surgery. The MRIs were assessed to detect the development of cysts encasing the suture anchors and to evaluate meniscal healing. Statistical analysis was performed using multiple regression analysis. Out of the 51 menisci examined, MRI revealed cysts in 15 menisci. Cysts were detected in 3 menisci at 6 months, in 9 menisci at 12 months, and in 3 menisci at 24 months after surgery. Only 3 patients (6.5%) were symptomatic, and cystectomy was performed in 2 of these patients and arthroscopic debridement in the other. Compared with using both the suture device and an inside-out suture repair, using the suture device alone was more likely to be associated with cyst development [odds ratio (OR), 12.04]. The medial meniscus was also significantly more likely to develop a cyst compared with the lateral meniscus (OR, 12.48). There was an increased outcome for the number of device use (P = 0.033). Though it was not statistically significant, the patients with anterior knee laxity (side-to-side difference > 3mm using a knee arthrometer) were more likely to develop cysts than those without anterior knee laxity (P = 0.06). There were no significant differences between the remaining variables. The prevalence of cyst formation around the suture implant was 29%, but most cases were not symptomatic. Significant risk factors for cyst formation included the use of a suture device alone, and a location in the medial meniscus. III.

Improved diagnostic accuracy of combined anterior cruciate ligament/fibular collateral ligament injuries utilizing a simple physical exam measure

Diagnosing injuries to the posterolateral corner are often challenging for the clinician, especially in the acute setting (1). Physical examination and imaging such as magnetic resonance imaging (MRI) has led to improved diagnostic strategies and treatments for anterior cruciate ligament (ACL) injuries. However, in the event of concomitant ACL and fibular collateral ligament (FCL) injuries, FCL injuries may be missed or go undiagnosed due to lack of diagnostic sensitivity with MRI and potential for patient guarding during the clinical exam. This is particularly important in combined ACL and FCL injured patients, because unaddressed FCL tears have been shown to increase force on the ACL reconstruction graft (2). Therefore, identifying common injury patterns that may help increase the diagnostic accuracy of such combined injuries is warranted.

Incidence and Risk Factors for Meniscal Cyst After Meniscal Repair

To investigate the incidence of magnetic resonance imaging-confirmed cyst formation after meniscal repair and to analyze associated risk factors. This retrospective study included cases repaired arthroscopically with the all-inside (AI) technique (using suture anchors) and/or the inside-out (IO) technique between October 2008 and December 2014. A meniscal cyst was detected on T2 fat-suppressed magnetic resonance images. All cases were divided into 3 groups according to the repair method (AI, IO, and combined technique). The incidence of radiographically confirmed meniscal cyst formation in each group and the associated risk factors (age, sex, AI device, medial meniscus, Tegner activity scale preinjury) were analyzed. A total of 102 menisci in 96 knees were evaluated. The mean follow-up period was 3.8 (range, 2-8) years. The mean patient age was 21.0 (range, 6-53) years. Thirty cases were in the AI group, 60 in the IO group, and 12 in the combined group. Demographically, there were significant differences among groups regarding the number of medial, lateral, and discoid tears; concomitant anterior cruciate ligament tears; Tegner scale; and suture number. Meniscal cysts developed in 14 of 102 cases. Two of the 14 cysts were symptomatic, requiring open cystectomy. The incidence of meniscal cyst was significantly higher in the AI group (12 of 30, 40%) than in the IO group (1 of 60, 1.7%) or the combined-technique group (1 of 12, 8.3%) (P < .001). Both symptomatic cysts were in the AI group and were in continuity with the anchors. Medial meniscus tear (odds ratio= 6.92) and the use of AI suture anchors (odds ratio= 15.03) significantly increased the risk of cyst formation. The incidence of meniscal cysts after arthroscopic meniscal repair was 1.7% to 40.0%, depending on the surgical method. Medial meniscus tears and use of an AI device are suggested as risk factors for cyst formation in this retrospective study. Level Ⅲ, retrospective comparative study.

CONCOMITANT POSTEROLATERAL CORNER INJURIES IN SKELETALLY IMMATURE PATIENTS WITH ACUTE ANTERIOR CRUCIATE LIGAMENT INJURIES

Background: Missed and/or untreated posterolateral corner (PLC) injuries are a known cause of anterior cruciate ligament (ACL) reconstruction failure in the adult population. Failed ACL reconstruction causes significant morbidity in the skeletally immature pediatric population. There is little literature on the character and potential significance of posterolateral corner injuries in skeletally immature patients. Methods: Magnetic resonance imaging (MRI) studies of the knee performed at a single tertiary care pediatric hospital between 01/01/2010 and 12/31/2015 for patients who underwent an ACL reconstruction were retrospectively reviewed. Demographic variables were obtained via medical record review, and MRI studies were evaluated for PLC (popliteus, fibular collateral ligament (FCL), popliteofibular ligament (PFL), arcuate ligament) injury, as well as ACL, medial collateral ligament (MCL), bone bruise, fracture, and meniscal pathology by an experienced pediatric musculoskeletal radiologist. Results: Fifty-two patients, 65% of whom were male, with a mean age of 13.8 years at injury were analyzed. PLC injuries were found in 28 patients (54%), with 7 patients (14%) having a complete tear of a component of the PLC. MCL injuries were found in 13 patients (25%). Meniscus tears were found in 25 patients (48%); 17 were of the medial meniscus (33%), and 10 were of the lateral meniscus (19%). A Segond fracture was seen in four patients (8%). The most common injury pattern involved the PFL only (9, 32% of patients with PLC injuries). There was no association between sex (p=0.29), Segond fracture (p=0.09), meniscus injury (p=0.93), or MCL injury (p=0.32) with the risk of PLC injury. There was an association between patient age and PLC injury (p=0.02). For each additional year of age, the odds of PLC injury increased by 1.7 times (OR=1.7 (1.1, 2.8)). Patients were an average age of 14.0 years at ACL reconstruction, and 9 patients went on to re-tear. There was no association between PLC injury and ACL graft failure (p=0.72). Conclusions: This study demonstrates the prevalence of PLC injuries in the setting of concomitant ACL injuries in the skeletally immature patient population. Age was found to predict the odds of PLC injury, which was significantly higher in older skeletally immature patients. No other concomitant injury predicted likelihood of PLC injury.

Long-term Results After Repair of Isolated Meniscal Tears Among Patients Aged 18 Years and Younger: An 18-Year Follow-up Study

Background: Meniscal repair is desirable over resection to prevent postmeniscectomy arthritis, especially among young and active patients. However, long-term data are currently lacking following isolated meniscal repair, particularly in the pediatric population. Purpose/Hypothesis: To report long-term follow-up of isolated meniscal tears treated by meniscal repair in a pediatric and adolescent population and to compare those results with previous midterm follow-up data reported. The authors hypothesized that these patients would have satisfactory function and reoperation rates at long-term follow-up. Study Design: Case series; Level of evidence, 4. Methods: Forty-four patients aged ≤18 years undergoing repair of an isolated meniscal tear (without concomitant anterior cruciate ligament injury) between 1990 and 2005 were included. At the time of final follow-up, recurrent tear, reoperations, and International Knee Documentation Committee (IKDC) and Tegner scores were determined. With logistic regression, the overall failure among tear types was calculated. Wilcoxon rank sum analysis were performed to calculate the differences in clinical outcome for different time points, and Spearman coefficients were calculated for Tegner and IKDC with different variables. Results: At a mean follow-up of 17.6 years (range, 13.1-25.9 years), 32 patients with 33 isolated meniscal repairs (29 male, 3 female) with a mean age of 16.1 years (range, 9.9-18.7 years) at surgery were included in this study. At early follow-up, the overall failure rate was 14 of 33 (42%); complex tears (80%) and bucket-handle tears (47%) had higher overall failure rates when compared with simple tears (18.2%), although only complex tears had a significantly higher failure rate. However, no further failures occurred since midterm follow-up with any tear type. At final follow-up, the mean IKDC score was 92.3, which was significantly increased when compared with preoperative (65.3, P < .0001) and midterm (90.2, P = .01) scores. The mean Tegner score (6.5) was significantly lower than both preoperative (8.3, P < .0001) and midterm (8.4, P < .0001) scores. There was no difference in Tegner or IKDC score for patients with successful versus failed repair. Conclusion: In conclusion, while there was a high early failure rate, this study demonstrated overall good to excellent long-term clinical outcomes after isolated meniscal repair in an adolescent population, even for those requiring reoperation. Early failure and reoperation rates were variable, depending on tear type, with complex multiplanar tears having more failures at short-term follow-up. However, at long-term follow-up, IKDC and Tegner scores were not significantly different for those with complex tears as compared with other tear types.

The posterolateral corner of the knee

The posterolateral corner (PLC) of the knee refers to a complex of structures that play a key role in knee stability. The main three structures in the PLC of the knee are the lateral collateral ligament, the popliteus and the popliteofibular ligament. These are primarily restraints to varus and external rotation forces. As such, mechanisms of injury include varus and hyperextension, and are typically high energy. These injuries are rarely isolated and are commonly associated with other injuries such as cruciate ligament injury or tibiofemoral knee dislocation. If undetected or untreated, PLC injuries can cause severe long-term disability due to instability and cartilage degeneration. Failure to recognize these injuries can also jeopardize the results of concomitant anterior or posterior cruciate ligament reconstruction. Immediate management in acute injuries involves assessment and treatment of any associated neurovascular injury, especially to the popliteal artery or peroneal nerve, and reduction of knee dislocation. Acute repairs of the damaged structures can be undertaken, but ligament reconstruction is often required, using either autograft or allograft. Graft reconstruction procedures can be fibula-based or anatomic, each having their own merits. The timing of surgery can be acute, chronic or staged, depending on the exact nature of the injury and on timing.

Long-term deterioration after one-stage unicompartmental knee arthroplasty and anterior cruciate ligament reconstruction.

Treatment for unicompartmental knee osteoarthritis (OA) is controversial in young patients with concomitant anterior cruciate ligament (ACL) deficiency. The aim of the current study is to report long-term results after the combination of unicompartmental knee arthroplasty (UKA) and ACL reconstruction. Retrospective study of one-stage medial UKA and ACL reconstruction was performed on eight patients at a mean age of 52years (42-60). Clinical and radiological results were assessed and analyzed after a mean follow-up of 14.6years. Patients were satisfied and mean personal satisfaction rate was 8.8 (4-10). At the last follow-up, mean WOMAC score was 26 (1-52) and mean global KSS was 154 (102-200). One revision surgery to total knee arthroplasty was performed 9years after the combined procedure due to aseptic loosening. One more case of clinical deterioration was observed 13years after index surgery. Combined UKA and ACL reconstruction can be a therapeutic option for young and active patients with concomitant knee instability and unicompartmental OA. The procedure is highly demanding and reliable only in hands of experienced surgeons. Overall, satisfactory outcome can be achieved at a minimum follow-up of 10years. However, clinical deterioration can be observed in the long term.

Seventeen-Year Follow-up After Meniscal Repair With Concomitant Anterior Cruciate Ligament Reconstruction in a Pediatric and Adolescent Population

Background: Studies have shown good and excellent clinical and radiographic results after meniscal repair. Limited published information exists on the long-term outcomes, however, especially in a pediatric and adolescent population. Purpose: To determine long-term results of meniscal repair and concomitant anterior cruciate ligament (ACL) reconstruction in a pediatric and adolescent population. Specifically, the aims were to determine the clinical success rate of meniscal repair with concomitant ACL reconstruction, compare results with midterm outcomes, and analyze risk factors for failure. Study Design: Case series; Level of evidence, 4. Methods: Cases of meniscal repair with concomitant ACL reconstruction between 1990 and 2005 were reviewed among patients aged ≤18 years. Patient demographics, injury history, and surgical details were recorded, and risk factors for failure were analyzed. Physical examination findings and clinical outcomes at latest available follow-up were collected. Subjective knee outcomes were compared with midterm results. Descriptive statistics and univariate analysis were used to evaluate the available data. Results: Forty-seven patients (30 females, 17 males) with a mean age of 16 years (SD, 1.37) and a mean follow-up of 16.6 years (SD, 3.57) were included in this study. Overall, 13 patients (28%) failed meniscal repair and required repeat surgery at the time of final follow-up. Of the 13 failures, 9 underwent a subsequent meniscectomy; 2, meniscectomy and revision ACL reconstruction; 1, meniscal repair and revision ACL reconstruction; and 1, meniscal repair and subsequent meniscectomy. Mean International Knee Documentation Committee scores improved from 47.9 preoperatively to 87.7 postoperatively (P < .01), and the mean score at long-term follow-up (87.7) did not significantly differ from that at the midterm follow-up (88.5) at a mean 7.4 years (P = .97). Mean Tegner Activity Scale scores improved from 1.9 preoperatively to 6.3 postoperatively (P < .01) and decreased from 8.3 at preinjury to 6.3 at final long-term follow-up (P < .01). Conclusion: In conclusion, the long-term overall clinical success rate (failure-free survival) was 72% for repair of pediatric and adolescent meniscal tears in the setting of concomitant ACL reconstruction. Patients reported excellent knee subjective outcome scores that remained favorable when compared with midterm follow-up.

Combined anterior cruciate ligament and posterolateral corner injuries: diagnosis and treatment

Combined multiligament knee injuries are more frequent than previously reported when objective diagnostic tools are utilized. Timely diagnosis of concurrent lateral sided ligamentous injuries is of vital importance because unaddressed posterolateral corner (PLC) tears are known to increase the stress on an anterior cruciate ligament (ACL) reconstruction graft and potentially increase the risks of graft failure. Additionally, improved surgical outcomes can be expected if all injured structures are addressed concurrently in the acute setting. Therefore, the purpose of this article was to review the relevant literature on the diagnosis and treatment of concomitant ACL and PLC injuries.

Bicompartmental locked bucket-handle tears of menisci concealing the concomitant anterior cruciate ligament injury for 2 years – case report

Bicompartmental locked bucket-handle tears of menisci concealing the concomitant anterior cruciate ligament injury for 2 years – case report

Arthroscopic transtibial pullout repair for posterior meniscus root tears

Anatomic repair of the torn meniscal root using transosseous sutures through the proximal tibia. Nontraumatic meniscal root tears without severe degenerative changes (Kellgren-Lawrence grade ≤ 2), good quality meniscal tissue, traumatic root tears with or without concomitant anterior cruciate ligament tears or multiligament injuries. Uncorrected varus or valgus malalignment (>3°), osteoarthritis Kellgren-Lawrence grades III and IV, and diffuse articular cartilage changes International Cartilage Regeneration and Joint Preservation Society (ICRS) grades III and IV of the effected compartment, noncompliance. Root tear confirmed by probing; location for the planned root refixation on the tibial plateau is identified. Atibial socket or full transtibial tunnel created with an aiming drill guide. Using aself-retrieving suture passing device or acurved suture passer, the torn meniscus root sutured with no.0 non-absorbable braided suture. Meniscal sutures passed through the tibial tunnel and the meniscus root reduced into the socket or tunnel by tensioning the free ends of the sutures, followed by fixation on the tibial cortex. Toe touch weight-bearing for 6weeks, restricted range of motion (0-60° of flexion) for 6weeks, no axial loading at flexion angles >90° until 6months postoperatively. For medial root tears, pullout repair significantly improves functional outcome scores and seems to prevent the progression of osteoarthritis in theshort-term. Complete healing observed in only 60% of patients. Negative prognostic factors: varus malalignment > 5°, cartilage degeneration Outerbridge grade III and IV, and older age. Outcomes after lateral root repair are encouraging with apparent prevention of progression of osteoarthritis.

Using only MRI is moderately reliable in the prediction of meniscal tear reparability.

The purpose of this study was to evaluate the role of surgeons' experience with meniscal repairs and meniscectomy decisions, and to determine the factors affecting the disagreement between meniscal repairs and meniscectomy decisions. In total, 223 patients with meniscal tears, 106 meniscal repairs, and 117 meniscectomies were included. Six orthopedic surgeons (3: > 5years; 3: < 5years' arthroscopy experience) were blinded, and they independently reviewed all preoperative MR images for over a month. Their reviews were compared with arthroscopic interventions performed by a surgeon with > 10years' arthroscopy experience. Reparability-associated factors were also evaluated using multivariate logistic regression. The first and second evaluation results did not differ significantly between groups (n.s.). There was good agreement between MRI predictions and arthroscopic interventions for both groups (< 5years' experience: k = 0.248, agreement 62.3%; > 5years' experience: k = 0.351, agreement 67.3%). Sex, side, and distance of tear from the meniscocapsular junction were not significantly different between agreements and disagreements. Disagreement regarding meniscectomy was significantly higher than those regarding meniscus repair (p = 0.002). Concomitant anterior cruciate ligament (ACL) injury, osteochondral lesions, and medial meniscal tear increased the likelihood of meniscal repair (p = 0.0063, p = 0.0010, and p = 0.0369, respectively). An increased risk of disagreement between MRI and surgical procedure was found in the presence of bucket-handle, horizontal or complex tear, chronic tear, high sports activity and expectation level. Surgeon's experience level may influence the prediction of meniscus reparability. Concomitant ACL injury, osteochondral lesions, and presence of medial meniscal tear increase the likelihood of meniscal repair. Tear type, tear chronicity, patient's activity and expectation level may influence the surgeon's operative decision in addition to MRI. III.

Comparative Outcomes of Radial and Bucket-Handle Meniscal Tear Repair: A Propensity-Matched Analysis

Background: Full-thickness radial meniscal tears render the meniscus nonfunctional and have historically been treated with partial meniscectomy. As preservative techniques evolve for radial repair, comparisons with other tear patterns are necessary to evaluate repair efficacy and prognosis. Purpose: To assess clinical outcomes and reoperation rates of radial meniscal repair and to compare them to bucket-handle meniscal repair. Study Design: Cohort study; Level of evidence, 3. Methods: Radial and bucket-handle meniscal tears without concurrent root injuries undergoing surgical repair at a single institution between 2007 and 2015 were analyzed, including both all-inside and inside-out suturing techniques. Propensity matching was performed on the basis of age at surgery, sex, meniscus laterality, body mass index (BMI), and concomitant anterior cruciate ligament reconstruction (ACLR) using a comparison pool of 70 bucket-handle repairs. Reoperation-free survival rates and Tegner, visual analog scale (VAS) for pain, and International Knee Documentation Committee (IKDC) scores were analyzed. Results: Twenty-four patients (18 male, 6 female; mean age, 22.8 ± 11.9 years) who underwent repair of a radial meniscal tear were followed for a mean of 3.5 years (range, 2.0-6.3 years). Significant postoperative improvements in VAS scores at rest and with use and IKDC scores were noted postoperatively (P < .001). Five patients (20.8%) required a reoperation. Subsequently, 18 patients with radial tears (mean age, 19.1 ± 9.1 years; 12 male; mean BMI, 27.0 ± 6.2 kg/m2; 3 medial; 11 ACLR) were propensity matched to 18 patients with bucket-handle tears (mean age, 20.8 ± 5.1 years; 13 male; mean BMI, 25.0 ± 3.5 kg/m2; 3 medial; 11 ACLR). The matched radial and bucket-handle groups demonstrated similar (P = .17) reoperation-free survival rates at 2 years (88.9% and 94.4%, respectively) and 5 years (77.8% and 87.7%, respectively). VAS and IKDC scores improved significantly after surgery (P < .001), with no difference noted between the groups (P ≥ .17). Patients with radial and bucket-handle meniscal repairs achieved mean postoperative Tegner scores (6.6 and 6.6, respectively) not significantly different from their preinjury levels (6.9 and 6.7, respectively) (P ≥ .32). Conclusion: Satisfactory clinical outcomes are achievable for radial meniscal tear repair at short-term follow-up. In a robustly matched comparison, radial and bucket-handle meniscal tears demonstrate similar improvements in VAS and IKDC scores, restoration of preoperative Tegner scores, and acceptable reoperation rates. Full-thickness radial meniscal tears should be considered for repair.

Management of Simultaneous Patellar Tendon and Anterior Cruciate Ligament Ruptures-A Systematic Review of Available Literature.

Combined rupture of the anterior cruciate ligament (ACL) and patellar tendon (PT) is a rare injury pattern. Currently, little evidence exists to help guide management decisions for these patients. A systematic literature search was conducted using PubMed (MEDLINE) and Scopus (EMBASE and MEDLINE) for all articles reporting on combined rupture of the ACL and PT. The characteristic injury mechanisms, common presentation findings, and outcomes of simultaneous and staged treatment strategies were determined to provide guidance for the management of this uncommon injury pattern. An additional case report from our institution is also reported. Overall, 17 studies met the inclusion criteria and were included in our qualitative review. The mean age at injury was 30 years (range, 15-50 years). A high-energy injury with a rapid deceleration event through a flexed knee on a fixed foot is commonly described as the mechanism of injury. Anterior cruciate ligament rupture was missed on initial clinical examination in 24.1% compared with 17.2% for PT rupture. Injuries to the medial collateral ligament and menisci occured in 65.5% of cases. Outcome scores were reported in 41.4% (12/22) of patients undergoing staged or simultaneous repair. The Lysholm score postoperatively was 96 ± 3.3 for the staged group compared with 85.3 ± 18.6 for simultaneous repair. There were no clear differences between range of motion, time to return to sport, and complication rates between the groups. A high index of suspicion is required to detect concomitant ACL injuries when assessing high-energy PT ruptures. Simultaneous or staged protocols to address both injuries are safe and effective management strategies for this rare combined injury pattern. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Which Factors Increase the Risk of Re-Operation after Meniscus Surgery in the Skeletally Immature?

Objectives:The purpose of this study is to determine which factors heighten the risk for subsequent operations in skeletally immature patients undergoing meniscus surgery.Methods:A retrospective institutional database of 1,063 meniscus surgeries performed between 2000 and 2015 was reviewed. All procedures were performed in skeletally immature patients. Demographic and intra-operative information was recorded, as were concurrent injuries or operations and subsequent surgeries. Univariate analysis consisted of chi-square and independent-samples t-tests. Multivariate logistic regression was then performed to control for confounding factors.Results:The mean age at initial surgery was 13.4 years (standard deviation, SD, 2.2 years) and the average follow-up duration was 47 months (SD 54 months). Overall, 314 patients (29.5%) required repeat surgical intervention. 36% of all females required subsequent surgery compared to 26% of males (p<0.01). Discoid menisci underwent repeat operation more frequently than non-discoid menisci (35% vs. 27%, p=0.01). After accounting for confounders in a multivariate model, females had 2.2 times the odds of repeat surgery than males (95% CI 1.4-3.3, p<0.01) and each year of increasing age resulted in 1.3 times higher odds (95% CI 1.1 -1.4, p<0.01). The odds of subsequent surgeries were 4.2 times higher in those with flap tears (95% CI 1.8-9.7, p<0.01) and 2.9 times higher for discoid menisci (95% CI 1.4-6.0, p<0.01). Concomitant anterior cruciate ligament rupture or tibial spine fracture decreased the risk of needing additional surgeries in univariate analysis, but lost statistical significance in the multivariate model.Conclusion:Even when accounting for other factors in a multivariate model, female sex, increasing age, flap tears, and discoid meniscus were risk factors for subsequent procedures after meniscus surgery in skeletally immature patients. The re-operation rate in this population may be higher than previously reported. This study describes, for the first time, risk factors for repeat operations in skeletally immature patients undergoing meniscus surgery. These results can be used to counsel and monitor patients accordingly.

What are the factors to affect outcome and healing of meniscus bucket handle tears?

The purpose of this study is to identify patient, meniscus rupture and surgical characteristics that influence the outcome and clinical healing following operative repair of bucket handle tears. Between 02/2006 and 10/2012, a total of 38 patients (14 women, 24 men) with bucket handle tears underwent surgical meniscus repair. There were 27 isolated repairs and 11 with concomitant anterior cruciate ligament (ACL) replacement. Patients were analyzed on an average of 44.4months (range 15-96months) after surgery by the use of standardized subjective scoring instruments [Lysholm, International Knee Documentation Committee (IKDC), Knee Injury and Osteoarthritis Outcome Score (KOOS) and Tegner Activity Scale (TAS)]. To identify factors affecting the outcome and suture survival, patient-specific, trauma-specific as well as meniscus- and surgery-specific factors were collected. Patients were divided in two groups with healed menisci (group 1) and re-rupture subjects (group 2). Meniscus re-rupture was defined as a clinical failure. There were 25 patients with healed menisci and 13 (34.2%) that sustained re-rupture and underwent either partial meniscectomy (n = 8) or re-suture (n = 5). Group 1 achieved slightly higher outcome compared to group 2 [Lysholm: 87.8 vs. 84.3 (p = 0.35), IKDC: 86.9 vs. 85.7 (p = 0.67), KOOS: 91.3 vs. 90.5 (p = 0.74)]. TAS was better for group 2 [5.9 vs. 6.8 (p = 0.36)]. Strong impact to result in a significantly increased outcome was identified for higher age, subjective knee joint stability, high preoperative Lysholm Score, short trauma-to-repair time, previous ACL reconstruction and a smaller number of sutures to fulfill meniscus repair. Lower patient age, male gender and higher activity level had the strongest impact to provoke re-rupture. Clinical outcome after meniscus bucket handle suture is satisfying. Re-rupture rate among this collective was 34.2%. Clear risk factors were identified for diminished clinical healing and outcome.

Comparative Outcomes of All-Inside Versus Inside-Out Repair of Bucket-Handle Meniscal Tears: A Propensity-Matched Analysis.

Background:There are limited data comparing the outcomes of all-inside versus inside-out meniscal repair techniques.Purpose:To assess failure rates and clinical outcomes after the surgical repair of bucket-handle meniscal tears utilizing either an all-inside or inside-out technique.Study Design:Cohort study; Level of evidence, 3.Methods:Patients with bucket-handle meniscal tears undergoing all-inside or inside-out repair at a single institution between 2003 and 2013 were analyzed. A total of 28 mensici repaired utilizing second-generation all-inside suturing devices and 42 menisci repaired using an inside-out technique were eligible for inclusion. Rigorous propensity matching was performed on the basis of age, sex, tear laterality, rim width, and concomitant anterior cruciate ligament reconstruction (ACLR), resulting in a total of 40 patients equally distributed between the 2 repair techniques for comparison. Retear-free survival as well as preoperative and postoperative International Knee Documentation Committee (IKDC) and Tegner scores and physical examination findings were subsequently analyzed.Results:Twenty patients who underwent all-inside repair (14 male; mean age, 23.7 ± 6.7 years) were successfully propensity matched to 20 patients who underwent inside-out meniscal repair (15 male; mean age, 22.5 ± 7.6 years), with a mean retear-free follow-up of 4.4 years (range, 2.5-7.4 years). Four (20%) all-inside repairs and 4 (20%) inside-out repairs failed over the course of follow-up (P > .999), with a mean time to failure of 2.7 years (range, 1.3-4.4 years) and 5.0 years (range, 0.8-7.5 years), respectively (P = .25). Increasing patient age trended toward a decreased clinical retear rate, independent of the repair technique (hazard ratio, 0.86; P = .056). There were no significant differences in the Tegner scores, IKDC scores, or range of motion between the groups as a whole or when subcategorizing by age, sex, body mass index, tear complexity, rim width, isolated versus concomitant ACLR, or medial- versus lateral-sided repair. There were no complications in the all-inside group, while there was a 10% rate of minor complications in the inside-out group (P = .49).Conclusion:Overall, satisfactory clinical outcomes are achievable at short-term to midterm follow-up with both inside-out and all-inside repair techniques of bucket-handle meniscal tears in rigorously matched patients with similar meniscal tear patterns.

Predictors of Knee Arthrofibrosis and Outcomes after Arthroscopic Lysis of Adhesions following Ligamentous Reconstruction: A Retrospective Case-Control Study with Over Two Years' Average Follow-Up.

Arthrofibrosis can be a devastating complication after ligamentous knee reconstruction. Beyond early range of motion (ROM), manipulation under anesthesia (MUA) and arthroscopic lysis of adhesions (LOAs) are the most frequently employed interventions for the condition. There is a paucity of data regarding predictive factors of arthrofibrosis requiring MUA and LOA, and even less data regarding changes in validated patient-reported outcome measures following the procedure. A retrospective case-control study was performed at an academic, urban Level I trauma center of patients that developed arthrofibrosis requiring MUA and LOA following ligamentous reconstruction. The indication for LOA was failure to achieve a 90° arc of ROM by 6 weeks. Seventeen cases and 141 controls were identified. Follow-up for cases was 26.9 ± 17.1 months (mean ± standard deviation). Time from initial reconstruction to LOA was 75.2 ± 27.9 days. Cases had higher body mass indices by a mean of 2.9 (p = 0.024). The most significant risk factors for stiffness were concomitant anterior cruciate ligament, posterior cruciate ligament, and posterolateral corner/lateral collateral ligament injury (odds ratio [OR], 17.08), knee dislocation (OR, 12.84), and use of an external fixator (OR, 12.81, 95% confidence interval [CI], 3.03-54.20) (all p < 0.0026). Mean Knee Injury and Osteoarthritis Outcome Scores, Western Ontario and McMaster Universities Osteoarthritis Indices, and International Knee Documentation Committee scores improved by 47.5, 50.5, and 47.3% (all p < 0.0038), respectively. All patients reported improvement in pain, with maximum daily pain scores improving by a mean of 4.1 points on the Numeric Pain Rating Scale (p < 0.001). Mean ROM arc improved by 38.8° (p < 0.001). All 17 cases were satisfied with the procedure. Twelve cases (70.59%) reported a full return to preinjury level of activity. No factors were identified that predicted success from the procedure, likely due to inadequate sample size. Arthrofibrosis following knee injury and ligamentous reconstruction can be predicted by the severity of injury and early intervention with MUA and arthroscopic LOA can lead to a satisfactory outcome for the patient.