Medial Meniscal Lesions Research Articles

Surgical Treatment of Meniscal RAMP Lesion.

RAMP lesion, defined as peripheral detachment lesion of posterior horn of medial meniscus, has been shown to accompany anterior cruciate ligament (ACL) ruptures and is thought to play an important role in the knee joint stability. In this study, we aimed to present results of postoperative knee function scores and patient satisfaction after surgical repair of RAMP lesion. We included 15 patients who had undergone knee arthroscopy due to RAMP lesion in 2017. We recorded demographic data, diagnosis, pre- and postoperative International Knee Documentation Committee and Tegner-Lysholm scores of all patients. In this study, we included 15 patients: the number of male and female patients was eight and seven, respectively. The mean age of patients was 26.8 (18-35). Associated injuries included ACL rupture in 12 patients, additional medial meniscus lesion in 3 patients, lateral meniscus lesion in 3 patients, and superomedial patellar plicae syndrome in 2 patients. All patients had the same postoperative rehabilitation protocol. Mean preoperative Tegner-Lysholm knee score was 64.4 (53-75), while it was 82.5 (75-89) postoperatively, and mean preoperative and postoperative Visual Analogue Scale score at last postoperative follow-up were 5.26 (2-8) and 1.06 (0-2), respectively. All differences were found to be statistically significant. Meniscal RAMP lesions are commonly associated with ACL ruptures. RAMP repair significantly increases postoperative knee function scores and patient satisfaction following ACL reconstruction.

Double bundle anterior cruciate ligament reconstruction: Failure rate and patients-reported outcomes at 4–11 years of follow up

BackgroundBiomechanical studies have demonstrated that single bundle (SB) anterior cruciate ligament (ACL) reconstruction (SB-ACLr), which represents the gold standard for the management of ACL lesions, is not sufficient to completely restore the rotational stability and resistance to valgus stress of the knee. PurposeTo evaluate the failure rate and patients reported outcomes at a long-term follow-up of double bundle anterior cruciate ligament reconstruction (DB-ACLr). Study designRetrospective cohort study. Materials and methodsThe database of arthroscopic DB-ACLr procedures performed from 2006 to 2015 at our Institution was retrospectively reviewed. Patients were screened for eligibility according to the following inclusion criteria: magnetic resonance imaging (MRI) evidence of anterior cruciate ligament (ACL) lesion, positive anterior drawer test and/or Lachman test; age ≤ 45 years at the time of surgery; DB-ACLr with autologous hamstrings, minimum follow up of 24 months. Patients were excluded if they presented associated lesions of the knee preoperatively or at the time of surgery, expect for meniscal lesions, or in case of inability to complete clinical questionnaires. Clinical outcomes were assessed at a mean follow up of 95.4 ± 21.9 months (range 51–129 months; median 98 months) using the Tegner-Lysholm score and the IKDC subjective score. Failures were defined as Tegner-Lysholm score ≤65 points, and were confirmed with MRI. Results58 (81.7%) male and 13 (18.3%) female patients (mean age 29.7 ± 7.8 years) were included in the study. 2 (2.8%, 95% CI 0.3–9.8%) patients had a failure of DB-ACLr both occurred after a sports trauma. The IKDC subjective score was statically better in patients younger than 30 years. Tegner-Lysholm and IKDC subjective score were statistically better in professional athletes and in patients with isolated medial or lateral meniscus lesion instead of combined medial and lateral meniscus lesion. ConclusionDB-ACLr technique provides excellent clinical results at a long term follow-up. Low failure rate and high percentage of return to sports participation at the same pre-injury level was found in our cohort of patients.

Current Trends Among US Surgeons in the Identification, Treatment, and Time of Repair for Medial Meniscal Ramp Lesions at the Time of ACL Surgery.

Background:Given the potential hidden nature of medial meniscal ramp lesions and the controversy regarding treatment, it is important to understand the current trends regarding the identification and treatment strategies of meniscal ramp lesions by the leading surgeons and educators in the field of sports medicine.Purpose:To better understand the current trends in orthopaedic surgery regarding arthroscopic identification and treatment of medial meniscal ramp lesions at the time of anterior cruciate ligament (ACL) surgery.Study Design:Cross-sectional study.Methods:An electronic questionnaire was sent in a blinded fashion to 91 directors of orthopaedic sports medicine fellowship training programs in the United States. Participants’ email addresses were obtained through the American Orthopaedic Society for Sports Medicine directory of current fellowship program directors. Inclusion criteria were only those surgeons who currently performed ACL reconstruction surgery. Exclusion criteria were those surgeons who did not perform ACL reconstruction or who chose to opt out of the survey.Results:Overall, 19 surgeons opted out of the survey; 36 responded from the remaining 72 surveys (50%). The majority (n = 31, 86%) reported routinely checking for a medial meniscal ramp lesion via inspection of the posteromedial meniscocapsular junction during an ACL reconstruction. The most common repair technique cited was all-inside (n = 24, 66.7%), followed by inside-out (n = 8, 22.2%). Three (8%) surgeons indicated that they did not repair meniscal ramp lesions. Regarding surgical treatment (repair vs no treatment), the majority reported using the extent of the tear (89%; partial vs full thickness) and the stability of the tear upon probing (81%) as the main criteria for intraoperative decision making. Nineteen (52.8%) surgeons required a mean time of <15 minutes for meniscal ramp repair; 16 surgeons (44.4%), 15 to 30 minutes; and 1 surgeon (2.8%), 30 to 45 minutes.Conclusion:This study provides insight regarding meniscal ramp tear identification, treatment, and repair strategies from the fellowship directors of sports medicine orthopaedic surgery in the United States. Such information may be useful for current orthopaedic surgeons to advance their practice according to the current trends surrounding ACL reconstruction and medial meniscal ramp repair.

High Posterior Tibial Slope Influence Medial Meniscus Injuries in ACL Deficient Knees

The purpose of the current study was to evaluate the correlation between the tibial slope and medial meniscus injury in anterior cruciate ligament deficient knees. A total of 223 patients with primary ACL injury admitted to Foisor Orthopedic Hospital between 2015-2016 were included in this study. The posterior tibial slope was evaluated on a lateral x-ray view of the knee and was defined as the angle between the line joining the tibial plateau and the line perpendicular to the longitudinal axis (the proximal tibial anatomical axis). Patients were divided into two groups depending on the posterior tibial slope ([9.9 and �10), and a Chi square test was used to evaluate if there is any correlation between this and internal meniscus injuries, and Fisher�s exact test was used to verify this. Overall medial meniscus lesions were found in 43.5% of the patients. The mean value of the posterior tibial slope was 11.19+/-2,685. After grouping patients in low and high group ([9.9 and �10), there were 66.8% in the high tibial slope group and 33.2% in the low group. In the high PTS group there were 93 patients with medial meniscus lesion (62.4%), and 56 (37.6%) without medial meniscus lesion. The mean posterior tibial slope was higher in the medial meniscus tear group (11.78 degrees), than mean PTS in the group without medial meniscus lesion (10.42 degrees). There was a strong correlation between high tibial slope and medial meniscus lesions (p=0.015). The main finding of the current study is that there is a statistically significant correlation between posterior tibial slope higher than 10 degrees and internal meniscus tears.

Is Edema at the Posterior Medial Tibial Plateau Indicative of Ramp Lesion? An Examination of 852 Patients with Anterior Cruciate Ligament Reconstruction

Objectives:Meniscal injuries are commonly observed with anterior cruciate ligament (ACL) deficiency. A subset of these injuries includes tears of the medial meniscus at the posterior meniscocapsular junction, or ramp lesions. Biomechanical studies have indicated that ramp injuries may compromise anterior stability of the knee, even after ACL reconstruction (ACLR). These lesions are not consistently diagnosed with magnetic resonance imaging (MRI). One criterion that shows promise is the presence of posterior medial tibial plateau (PMTP) edema. A correlation of PMTP edema and peripheral posterior horn medial meniscal injuries has been observed in the literature. We evaluated a consecutive series of patients who underwent ACLR for incidence of ramp tears. These patients were then compared to patients with non-ramp (meniscal body) medial meniscal tears. The utility of PMTP edema on preoperative MRI for ramp tear diagnosis was then determined.Methods:A retrospective chart review via an institutional database search identified 892 patients who underwent ACLR by one of two senior authors (R.A.A., C.E.) between January 2006 and June 2016. Operative notes identified patients diagnosed arthroscopically with medial meniscal lesions, including ramp lesions. Arthroscopic identification was the gold standard for diagnosis of both ramp and non-ramp (meniscal body) tears. Demographic information such as age, sex, laterality, mechanism of injury (contact/noncontact), sport, revision procedure, multi-ligament procedure, time to MRI, and time to surgery were recorded. Patients without available operative records were excluded. Preoperative MRIs were obtained for all patients and reviewed by an orthopaedic sports medicine fellow for PMTP edema. Axial, coronal, and sagittal T2 and proton-density sequences were utilized. A MRI was considered positive if edema was detected in 2 different planes of sequences. Differences between groups were analyzed with two-sample t test or Chi square test Univariate and multivariate logistic regression models analyzed the relationships among patient factors, MRI findings, and ramp lesions.Results:852 patients met the inclusion criteria for analysis. 307 patients were diagnosed with medial meniscal tear at the time of ACLR, 127 of which were ramp lesions. The overall incidence of ramp tear was 14.9% and consisted of 41.4% of all medial meniscal tears. Patients with ramp tears were mean 7.5 years younger than patients with meniscal body tears (p<0.01). There was no difference between the groups in regard to mechanism of injury, revision surgery, or multi-ligamentous injury. Patients with delayed ACLR were at 3.3x greater odds (p<0.01) of having meniscal body tear compared to ramp lesion. MRI was available for review in 178 patients, 97 of whom had positive MRI for PMTP edema. Sensitivity and specificity of PMTP edema for ramp tear was 66.3% and 55.1%, respectively. Of patients with PMTP edema, 54.6% had ramp lesions and 45.4% had non-ramp tears (p<0.01). Patients with preoperative MRI positive for PMTP edema were at 2.1 times greater odds (p<0.01) of having sustained a ramp tear compared to a meniscal body tear.Conclusion:The incidence of ramp tear was 14.9% and was more prevalent in younger patients. Delayed ACLR resulted in 3.3x greater odds of meniscal body tears compared to ramp tears. Patients with PMTP edema on preoperative MRI were at 2.1x greater odds to have ramp lesions compared to a meniscal body tears at the time of ACL reconstruction.

Does medial collateral ligament pie-crusting induce residual laxity in arthroscopic management of medial meniscus tears? A prospective study of 40 cases

Arthroscopic meniscectomy and medial meniscal repair are frequent procedures, liable to be complicated by iatrogenic cartilage lesions, especially in tight knee. Medial collateral ligament pie-crusting was developed to counter this, but, although the technique is employed, its impact on medial laxity has not been precisely determined. We therefore conducted a prospective observational study to compare radiographic laxity preoperatively versus 6 weeks following pie-crusting. Medial collateral ligament pie-crusting alters radiographic laxity at 6 weeks. Between December 2015 and February 2017, 40 patients (33 male, 7 female) underwent surgery with pie-crusting for isolated medial meniscal lesion. Mean age was 39 years (range, 20-54 years). Meniscectomy was performed in 33 cases (82.5%) and repair in 7 (17.5%). Pie-crusting used an intramuscular needle under arthroscopic control, adjacent to the medial meniscus at the posterior two-thirds junction of the compartment, until opening was deemed satisfactory. Laxity was compared on preoperative versus 6 weeks stress valgus views (Telos ™), by 2 independent observers, on 2 measurements: opening angle, and medial tibiofemoral joint space height. Each measurement was taken twice at a 2-week interval by each observer. Inter- and intra-observer concordance was excellent on both measurements: intraclass correlation coefficient was 0.82 (95% CI, 0.73-0.89) and 0.91 (95% CI, 0.86-0.94) pre- and post-operatively for opening angle, and 0.87 (95% CI, 0.79-0.92) and 0.88 (95% CI, 0.82-0.92) for joint space height. Tibiofemoral joint space opening was significantly greater at 6 weeks on both measurements: 0.9±1° [range, -1° to 4°] (p<0.0001) and 1.1±1mm [range, -0.6 to 3.2mm] (p<0.0001). Medial collateral ligament pie-crusting led to a moderate but significant increase in medial laxity at 6 weeks. A longer-term study is needed to assess progression. IV, prospective study without control group.

Surgical timing of anterior cruciate ligament reconstruction to prevent associated meniscal and cartilage lesions.

The purpose of this study was to analyze the association between the prevalence of meniscal and chondral lesions and the timing of surgery in patients undergoing primary anterior cruciate ligament (ACL) reconstruction to determine a safe time for surgery. This retrospective study involved 226 patients (91 females and 135 males; median age, 29 years) undergoing primary ACL reconstruction. Time interval from ACL injury to surgery (median, 4 months; range, 1-420 months) and concomitant meniscal and cartilage lesions in ACL reconstruction were reviewed. Receiver operating characteristic (ROC) curve analysis was used to determine the precise threshold interval to surgery to prevent meniscal or cartilage lesions. The risk of lesion occurrence after each cutoff period was determined using odds ratio (OR). The incidences of medial meniscus (MM), lateral meniscus (LM), and cartilage lesions were 43.8%, 32.7%, and 27.4%, respectively. ROC analysis revealed that patients who waited for more than 6, 4, and 5 months for ACL reconstruction had a significantly greater risk of associated MM, LM, and chondral lesions, respectively. Patients who underwent ACL reconstruction ≥7 months after injury had OR of 4.1 (p<0.001) for the presence of MM lesion as compared with those who underwent reconstruction within 6 months. Similarly, patients who underwent ACL reconstruction ≥5 months after injury had OR of 1.9 (p=0.023) for the presence of LM lesion as compared with those who underwent reconstruction within 4 months, and patients who underwent ACL reconstruction ≥6 months after injury had OR of 2.9 (p<0.001) for chondral lesion as compared with those who underwent reconstruction within 6 months. ACL reconstruction should be performed within approximately 6 months after the injury to prevent associated meniscal or chondral lesions.

Clinical and Radiological Results with Second-Look Arthroscopic Findings after Open Wedge High Tibial Osteotomy without Arthroscopic Procedures for Medial Meniscal Root Tears.

PurposeTo identify the structural integrity of the healing site after medial open wedge high tibial osteotomy (MOWHTO) in patients with a posterior root tear of the medial meniscus (PRTMM) and chondral lesion by second-look arthroscopy and to determine the clinical and radiological findings.Materials and MethodsFrom August 2010 to June 2016, 52 consecutive patients underwent MOWHTO and arthroscopic examination without a chondral resurfacing procedure and meniscal treatment for PRTMM. Twenty-four patients were available for second-look arthroscopic evaluation. The mean follow-up period was 19.5 months (range, 5 to 46 months). Clinical evaluation was based on the Lysholm knee scores and Hospital for Special Surgery (HSS) scores.ResultsThere were 5 lax healing, 6 scar tissue, 13 failed healing of PRTMM. Definite change of chondral lesion was not observed. The Kellgren-Lawrence grade did not improve according to the follow-up plain radiograph. The mean Lysholm score improved from 34.7 preoperatively to 77.1 at the last follow-up, and the mean HSS score significantly increased from 36.5 to 82.4.ConclusionsThis study revealed a low rate of healing potency of PRTMM and chondral lesion after MOWHTO without any attempt for meniscal treatment or chondral resurfacing. The cartilage and healing status of PRTMM was not associated with improved clinical outcomes and radiological findings.

Magnetic Resonance Imaging Diagnosis of Medial Meniscal Ramp Lesions in Patients With Anterior Cruciate Ligament Injuries

To prospectively evaluate the sensitivity and specificity of magnetic resonance imaging (MRI) for diagnosing ramp lesions, to compare them between 1.5- and 3-T MRI, and to evaluate whether bone contusion of the posterior lip of the medial tibial plateau was associated with ramp lesions. For 155 knees that underwent primary ACL reconstruction, we prospectively examined for ramp lesions and medial meniscal body tears on MRI. MRI diagnosis of ramp lesions required high signal irregularity of the capsular margin or separation in the meniscocapsular junction of the medial meniscus posterior horn on sagittal images. Bone contusion of the posterior lip of the medial tibial plateau was verified in 105 knees with MRI performed within 6weeks after injury. All ramp lesions were identified by transcondylar observation during surgery. The sensitivity and specificity of MRI for ramp lesions and body tears were measured. Furthermore, we evaluated whether bone contusion of the medial tibial plateau was associated with ramp lesions. The χ-square test was used for statistical analysis. During surgery, ramp lesions were observed in 46 knees and medial meniscal body tears were seen in 35 knees. The sensitivity of MRI for ramp lesions was 71.7% and specificity was 90.5%. The sensitivity for ramp lesions was significantly lower than that for meniscal body tears (94.3%) (P= .01). The sensitivity of 3-T MRI (83.3%) was superior to that of 1.5-T MRI (67.6%), but not significantly different. The incidence of bone contusions was not significantly different among ramp lesions (38.5%), body tears (40.0%), or no tears (30.5%). The sensitivity of MRI for diagnosing ramp lesions was significantly lower than that for medial meniscal body tears. Bone contusion of the posterior lip of the medial tibial plateau on MRI was not associated with ramp lesions. Level III, comparative trial.

Better outcome from arthroscopic partial meniscectomy than skin incisions only? A sham-controlled randomised trial in patients aged 35–55 years with knee pain and an MRI-verified meniscal tear

ObjectiveCompare arthroscopic partial meniscectomy to a true sham intervention.MethodsSham-controlled superiority trial performed in three county hospitals in Denmark comparing arthroscopic partial meniscectomy to skin incisions only in patients aged 35–55...

Complications associated with the techniques for anterior cruciate ligament reconstruction in patients under 18 years old: A systematic review

ObjectiveDetermine the complications related to the different techniques for anterior cruciate ligament reconstruction in patients under 18 years old. MethodologySystematic review using the databases Medline, Cochrane Database of Systematic Reviews and Embase (until July 2016), additional studies were included conducting a search of the references of previous studies. The terms included in the search were: “cruciate”, “ligament”, “anterior”, “immature”, “complications”, “outcome”, “acl reconstruction”, “cruciate ligament anterior reconstruction”, “children”, “child”, “infants”, “adolescent”, “open physis”, “growth plate” and “skeletally immature”. ResultsA number of 73 studies were included; 1300 patients in total, average age 13 years, 70% were male, medial and lateral meniscal lesions in 26% and 30% respectively. Eleven cases of length discrepancy (0.8%): 4 cases were presented with physeal-sparing techniques (1.4%), 3 cases with partial physeal-sparing techniques (2.2%) and 4 cases were presented with transphyseal techniques (0.4%). There were 22 cases of axis deviation: 6 cases with physeal-sparing techniques (2%), 3 cases with partial physeal-sparing techniques and 13 cases with transphyseal techniques (1.4%). The use of allograft Achilles tendon allograft and fascia lata was associated with increased length discrepancy and axis deviation (25%). There was no difference according to Tanner. ConclusionsThe different anterior cruciate ligament reconstruction techniques in patients under 18 years old had low complications related to lower limb growth, arthrofibrosis and review. There was a higher percentage of cases of length discrepancy and axis deviation with physeal-sparing techniques than with the other surgical techniques. The evidence level studies cannot determine causality.

Prospective study correlating accuracy of clinical examination,0912 519 25 27magnetic resonance imaging and arthroscopy in meniscal and anterior cruciate ligament injuries of the knee

Background and objectives: The objectives of this study were to assess the accuracy of clinical tests for diagnosing meniscal (Thessaly, joint line tenderness and Mcmurray test) and anterior cruciate ligament (Lachman, Anterior Drawer and Pivot Shift test) injuries. Compare and correlate clinical and magnetic resonance imaging finding with arthroscopic confirmation, arthroscopy is regarded as gold standard for diagnosis. Methods: A prospective study conducted from October 2014 to October 2016. Participants included 79 patients who underwent knee arthroscopy for different indications in Erbil teaching hospital. Clinical diagnosis was established by orthopedic surgeons using clinical tests for meniscal and anterior cruciate ligament injuries. Magnetic resonance imaging was requested for confirmation. This was followed by arthroscopy for making the final diagnosis. Results: The Lachman test showed high accuracy (92.4%) to determine anterior cruciate ligament rupture. The accuracy of anterior drawer test was 70.8% and for pivot shift test was 68.3%. The Thessaly test showed high accuracy for medial (91.1%) and lateral (89.5%) meniscus tear.The joint line tenderness showed accuracy for medial (84.8%) and lateral (89.7%) meniscus tear and the McMurray test showed accuracy for medial (72.1) and for lateral (81%) meniscus tear. Validity of the clinical tests was compared to the results got from magnetic resonance imaging and arthroscopy. Accuracy of clinical diagnosis versus magnetic resonance imaging diagnosis for medial (91% vs. 89%) and lateral (89% vs. 86%) meniscal lesions was almost identical. Accuracy of clinical diagnosis compared with the accuracy of magnetic resonance imaging diagnosis for anterior cruciate ligament injuries was slightly higher (92.4% vs. 87.3%). Conclusions: The most accurate test for assessing anterior cruciate ligament rapture is Lachman test and for meniscal tear is Thessaly test with Joint line tenderness. Proper clinical examination is as accurate as magnetic resonance imaging in diagnosing meniscal injuries but for anterior cruciate ligament injuries; proper clinical examination has a better diagnostic accuracy in comparison to magnetic resonance imaging diagnosis.

Complicaciones asociadas a las diferentes técnicas de reconstrucción del ligamento cruzado anterior en menores de 18 años: Revisión sistemática

ObjectiveDetermine the complications related to the different techniques for anterior cruciate ligament reconstruction in patients under 18 years old. MethodologySystematic review using the databases Medline, Cochrane Database of Systematic Reviews and Embase (until July 2016), additional studies were included conducting a search of the references of previous studies. The terms included in the search were: «cruciate», «ligament», «anterior», «immature», «complications», «outcome», «acl reconstruction»,« cruciate ligament anterior reconstruction», «children», «child», «infants», «adolescent», «open physis», «growth plate» and «skeletally immature». ResultsA number of 73 studies were included; 1300 patients in total, average age 13 years, 70% were male, medial and lateral meniscal lesions in 26% and 30% respectively. Eleven cases of length discrepancy (0,8%): 4 cases were presented with physeal-sparing techniques (1,4%), 3 cases with partial physeal-sparing techniques (2.2%) and 4 cases were presented with transphyseal techniques (0.4%). There were 22 cases of axis deviation: 6 cases with physeal-sparing techniques (2%), 3 cases with partial physeal-sparing techniques and 13 cases with transphyseal techniques (1.4%). The use of allograft achilles tendon allograft and fascia lata was associated with increased length discrepancy and axis deviation (25%). There was no difference according to Tanner. ConclusionsThe different anterior cruciate ligament reconstruction techniques in patients under 18 years old had low complications related to lower limb growth, arthrofibrosis and review. There was a higher percentage of cases of length discrepancy and axis deviation with physeal-sparing techniques than with the other surgical techniques. The evidence level studies cannot determine causality.

Reoperation Rates After Combined Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction: A Series of 548 Patients From the SANTI Study Group With a Minimum Follow-up of 2 Years

Background: Early clinical results of anterolateral ligament (ALL) reconstruction are promising, but concerns exist due to high rates of complications after other types of lateral extra-articular tenodesis. The rate of surgery after combined anterior cruciate ligament (ACL) and ALL reconstruction is not known. Purpose: To determine the rate of reoperation after combined ACL and ALL reconstruction. Study Design: Case series; Level of evidence, 4. Methods: A retrospective analysis of prospectively collected data from the Scientific ACL Network International (SANTI) Study Group database was performed to include all patients who had undergone combined ACL and ALL reconstruction between January 2012 and June 2014. At the end of the study period, all patients were contacted by telephone, and the operative notes of those who stated that they had undergone reoperation were reviewed to determine the type and rates of the subsequent procedures performed. Descriptive data were analyzed for the entire patient cohort. Results: The study population comprised 548 quadruple hamstring graft (4HT)+ALL reconstructions. The mean age (±SD) was 24.3 ± 7.9 years (range, 11.9-55.7 years), and 70.3% of subjects were male. The mean duration of follow-up was 35.5 ± 8.0 months (range, 24-54 months). Seventy-two patients (13.1%) underwent ipsilateral reoperation. This comprised a total of 77 procedures. Graft revision occurred in 14 knees (2.6%) at a mean of 18.3 months (±7.4 months) after the index procedure. There were 63 reoperations for ipsilateral, non–graft rupture–related indications (meniscus, n = 30; arthrofibrosis, n = 22; removal of hardware, n = 4; deep infection, n = 3; arthroscopic lavage without infection, n = 4). The only specific complications related to the ALL procedure (n = 3) were all related to femoral hardware that required removal. In both univariate and multivariate analyses, only the presence of a medial meniscal lesion at the index procedure was significantly associated with ipsilateral reoperation (odds ratio, 2.58; 95% CI, 1.43-4.76; P = .002). Conclusion: The reoperation rate after combined ACL and ALL reconstruction in this series is broadly comparable to the reoperation rate after isolated ACL reconstruction as reported in previous studies. In addition, the high rates of knee stiffness and reoperation reported in historical series of nonanatomic, lateral extra-articular tenodesis were not observed in the current series.

Incidence and Detection of Meniscal Ramp Lesions on Magnetic Resonance Imaging in Patients With Anterior Cruciate Ligament Reconstruction

Background: Meniscal ramp lesions have been reported to be present in 9% to 17% of patients undergoing anterior cruciate ligament (ACL) reconstruction. Detection at the time of arthroscopy can be accomplished based on clinical suspicion and careful evaluation. Preoperative assessment via magnetic resonance imaging (MRI) has been reported to have a low sensitivity in identifying meniscal ramp lesions. Purpose: To investigate the incidence of meniscal ramp lesions in patients with ACL tears and the sensitivity of preoperative MRI for the detection of ramp lesions. Study Design: Case series; Level of evidence, 4. Methods: All patients who underwent ACL reconstruction by a single surgeon between 2010 and 2016 were included in this study, and patients with medial meniscal ramp lesions found at the time of arthroscopy were identified. The sensitivity of MRI compared with the gold standard of arthroscopic evaluation was determined by review of the preoperative MRI musculoskeletal radiologist report, mimicking the clinical scenario. The incidence was calculated based on arthroscopic findings, and the potential secondary signs of meniscal ramp tears were evaluated on MRI. Results: In a consecutive series of 301 ACL reconstructions, 50 patients (33 male, 17 female) with a mean age of 29.6 years (range, 14-61 years) were diagnosed with a medial meniscal ramp lesion at arthroscopic evaluation (16.6% incidence). The sensitivity of MRI for ramp lesions was 48% based on the preoperative MRI report. A secondary finding of a posteromedial tibial bone bruise was identified on preoperative MRI in 36 of the 50 patients with ramp lesions in a retrospective MRI review by 2 orthopaedic surgeons. Conclusion: Medial meniscal ramp lesions were present in approximately 17% of 301 patients undergoing ACL reconstruction, and less than one-half were diagnosed on the preoperative MRI. A posteromedial tibial bone bruise was found to be a secondary sign of a ramp lesion in 72% of patients. Increased awareness of this potentially combined injury pattern is necessary, and careful intraoperative evaluation is required to identify all meniscal ramp tears.

The frequency of cartilage lesions in non-injured knees with symptomatic meniscus tears: results from an arthroscopic and NIR- (near-infrared) spectroscopic investigation.

Are symptomatic tear injuries to the menisci of the knee frequently or always associated with cartilage damage to the corresponding articular surfaces and other joint surfaces, respectively? A total of 137 patients (medial n = 127; lateral n = 10) underwent a meniscus resection. These patients showed no signs of a clear radiographic arthrosis and no MRI-detectable cartilage lesions >grade II. Traumatic injury was ruled out with a thorough medical history. The indication for operation was made exclusively on the basis of distinct, clinically apparent meniscus signs. In addition to the ICRS classification, all articular surfaces were examined spectroscopically (NIRS, near-infrared spectroscopy). In 76.6% (n = 105) of all knees examined, clear cartilage damage (ICRS-grade III/IV) was found. For 43.8%, these were in the area of the patella, while for 34.3% they were in the area of the medial femur, and for 17.5%, in the area of the medial tibial plateau. More rarely, this damage was localized to the area of the trochlea (8.8%) or the lateral joint compartment (femoral 2.2%, tibial 15.3%). There were no significant differences between patients with medial or lateral meniscus lesions with respect to the distribution pattern of the joint injuries. During spectroscopic examination, pathological values were demonstrated (objective evidence of cartilage degeneration) in at least one of the examined articular surfaces (media n = 6, range 1-6). Through our investigations, a high, if not complete, concomitance of degenerative cartilage lesions and degenerative meniscus damage was demonstrated. From this it can be concluded that the entity of "isolated degenerative meniscus damage" clearly does not exist in practice. It is therefore highly probable that degenerative meniscus lesions, as a part of general joint degeneration, are to be interpreted in the context of the development of arthrosis. The practical consequences still are unclear. Patients after partial meniscectomy need a longer follow-up to detect potential cartilage lesions as well as an OA progression.

A modified tibial compression test for the detection of meniscal injury in dogs.

To assess diagnostic efficacy of a modified tibial compression test in predicting medial meniscal injury in dogs with cranial cruciate ligament failure. Dogs admitted for surgical stabilisation of stifles with cranial cruciate ligament failure were examined by five preoperative physical tests to assess medial meniscal injury. Results of each physical test were compared with findings at arthrotomy and used to calculate sensitivities, specificities, positive and negative predictive values. None of the physical tests were accurate in reflecting meniscal integrity for dogs with cranial cruciate failure. Out of the five tests, the modified tibial compression test exhibited the highest concordance and sensitivity for the detection of medial meniscal tears. A palpable click during the modified tibial compression test had a sensitivity and specificity up to 63 and 77%, respectively, for the detection of medial meniscal lesions. Concordance values were up to 40% for the modified tibial compression test, followed by the range of motion test (up to 25%), while all other physical tests had concordance values below 10%. Physical tests are highly available, affordable and can be easily performed, but their efficacy in diagnosing medical meniscal injury is low. Meniscal clicks associated with meniscal tears were more frequently elicited during the modified tibial compression test when compared with other traditional tests.

Association Between Meniscal and Chondral Lesions and Timing of Anterior Cruciate Ligament Reconstruction.

Background:Rupture of the anterior cruciate ligament (ACL) is a common sports injury and is known to be associated with an increased risk of knee osteoarthritis. Several studies have indicated that the risk of additional injuries to the menisci and articular cartilage increases with delays in the treatment of ACL tears. However, no consensus has been reached regarding the ideal timing for ACL reconstruction in terms of preventing secondary lesions.Purpose:To determine how the time elapsed between an ACL lesion and its reconstruction affects the incidence of meniscal and chondral lesions.Study Design:Case series; Level of evidence, 4.Methods:Medical records of 764 patients who underwent primary ACL reconstruction were reviewed. Data from arthroscopic findings that included information about meniscal lesions and full-thickness articular cartilage lesions at the time of surgery were collected. The association between time elapsed between ACL lesion and reconstruction surgery and incidence of articular cartilage and meniscal lesions was analyzed by chi-square or Fisher exact test. The risk of secondary lesion was calculated by odds ratios (ORs) obtained from simple logistic regression analysis.Results:A positive correlation was observed between time after injury and the presence of any articular lesions (P = .003), cartilage lesions (P = .01), and medial meniscus lesions (P < .001). When analyzing the risk of secondary lesion relative to the reference period (<2 months), it was observed that the odds of finding any articular injury at the time of ACL reconstruction increased when the time from ACL injury to surgery was between 12 and 24 months (OR = 2.62) and >24 months (OR = 5.88). Furthermore, the odds of lesions on the medial meniscus increased when the timing between injury and surgery was 6 to 12 months (OR = 2.71) and continued to increase when the timing was 12 to 24 months (OR = 3.78) and >24 months (OR = 9.07).Conclusion:Associated articular lesions are more common if ACL reconstruction is delayed by ≥6 months (medial meniscus lesion) and ≥1 year (chondral or any meniscal lesion).

Posterior Root Meniscal Tears: Preoperative, Intraoperative, and Postoperative Imaging for Transtibial Pullout Repair.

The menisci play an important biomechanical role in axial load distribution of the knees by means of hoop strength, which is contingent on intact circumferentially oriented collagen fibers and meniscal root attachments. Disruption of the meniscal root attachments leads to altered biomechanics, resulting in progressive cartilage loss, osteoarthritis, and subchondral edema, with the potential for development of a subchondral insufficiency fracture. Identification of meniscal root tears at magnetic resonance (MR) imaging is crucial because new arthroscopic surgical techniques (transtibial pullout repair) have been developed to repair meniscal root tears and preserve the tibiofemoral cartilage of the knee. An MR imaging classification of posterior medial meniscal root ligament lesions has been recently described that is dedicated to the posterior root of the medial meniscus. An arthroscopic classification of meniscal root tears has been described that can be applied to the anterior and posterior roots of both the medial meniscus and the lateral meniscus. This arthroscopic classification includes type 1, partial stable root tears; type 2, complete radial root tears; type 3, vertical longitudinal bucket-handle tears; type 4, complex oblique tears; and type 5, bone avulsion fractures of the root attachments. Knowledge of these classifications and the potential contraindications to meniscal root repair can aid the radiologist in the preoperative reporting of meniscal root tear types and the evaluation of the tibiofemoral cartilage. As more patients undergo arthroscopic repair of meniscal root tears, familiarity with the surgical technique and the postoperative radiographic and MR imaging appearance is important to adequately report the imaging findings. ©RSNA, 2016.

Complications in posteromedial arthroscopic suture of the medial meniscus

IntroductionAll-inside posteromedial suture for lesions of the posterior horn of the medial meniscus in anterior cruciate ligament (ACL) repair provides effective freshening and good healing. HypothesisThe posteromedial portal provides satisfactory healing rates without increasing morbidity or complications rates. Material and methodsIntra- and postoperative complications were collected for a consecutive single-center series of 132 patients undergoing posteromedial hook suture of the medial meniscus in ACL repair. Meniscal healing was assessed as the rate of recurrence of symptomatic medial meniscus lesions (Barret criteria) and on revision surgery, if any, in terms of the aspect and extent of the iterative lesion. The severity of any sensory disorder was assessed by questionnaire. ResultsThe intraoperative complications rate was 1.5% (2 saphenous vein punctures). At a mean 31months (range, 28–35months), there was no loss to follow-up. Twelve patients (9%) showed symptomatic recurrence of the medial meniscus lesion, requiring 10 repeat surgeries. In 6 cases (4.5%), the iterative lesion involved a smaller, more central part of the meniscus anterior to the sutures, of “postage-stamp” effect, possibly implicating the suture hook and/or non-absorbable sutures. There were no cases of infection or fistula. Postoperative hematoma occurred in 7% of patients. In total, 1.8% reported dysesthesia areas equal to or greater than the size of a credit card (45cm2). DiscussionSome retears, or “partial failures”, may implicate a new lesion caused by the suture hook and possibly prolonged by non-resorbable sutures. Hematoma and sensory disorder rates were comparable to those reported in isolated ACL repair without posteromedial portal. ConclusionThe present results show that posteromedial arthroscopic hook suture in posterior medial meniscus tear provides good healing rates without increased morbidity due to the supplementary portal. Level of evidenceIV.