Medial Meniscus Posterior Root Repair Research Articles

Research progress on pathological mechanism and clinical correlation between medial meniscus posterior root tear and tibial rotation

To summarize the current research progress on the concept, clinical presentation, diagnosis, biomechanical changes, and pathological mechanisms of the medial meniscus posterior root tear (MMPRT), and its clinical correlations with tibial rotation. The research literature on MMPRT and its relationship with tibial rotation at home and abroad in recent years was extensively consulted and summarized. MMPRT is a specific and common type of medial meniscus injury of the knee joint. The occurrence of posterior medial pumping pain events following low-energy trauma in patients provides important clues for the diagnosis of this injury, with MRI being the preferred imaging modality. The biomechanical effects generated by MMPRT are similar to those caused by total removal of the medial meniscus. And this injury is usually associated with tibial rotation. MMPRT induces pathological external rotation of the tibia, which can be restored by timely medial meniscus posterior root repair. Furthermore, changes in tibial rotation are related to the healing status after medial meniscus posterior root repair. MMPRT is closely related to tibial rotation. Understanding the biomechanics, pathological mechanisms, and clinical correlations between the two is of great significance for improving the diagnosis and treatment strategies.

Initial tension at suture fixation affects the suture breakage following medial meniscus posterior root repair: A retrospective cohort study

ObjectivesThis study aimed to investigate whether the initial suture tension when pullout sutures are fixed affects postoperative clinical outcomes following medial meniscus posterior root repair. MethodsThe data of 48 patients who underwent transtibial pullout repair using two simple stitches (outer and inner sutures) with an additional all-inside posteromedial pullout were retrospectively investigated. The patients were sequentially divided into two groups to compare the clinical efficacy of the initial pullout tension (N) when pullout sutures were fixed: the 30 N Group (April 2019 to September 2019, 24 patients) and the 15 N group (October 2019 to February 2020, 24 patients). The rate of suture breakage (suture cutout or rupture) at the second-look arthroscopy at 1 year postoperatively and clinical outcomes at 2 years postoperatively were compared between the two groups. ResultsIn both groups, each clinical score significantly improved at 2 years postoperatively. At the second-look arthroscopy, the rate of posteromedial suture breakage was significantly higher in the 30 N group (19 patients, 79 ​%) than in the 15 N group (10 patients, 42 ​%); the rate of outer suture breakage was also higher in the 30 N group (five patients, 21 ​%) than in the 15 N group (no patients). On comparing 2 years of preoperative clinical scores between the groups categorized according to posteromedial suture breakage, the pain score was significantly higher in the suture breakage group. ConclusionsThe initial tension of pullout repair of the medial meniscus posterior root tear is related to suture breakages. To prevent suture breakage, 15 N is a more initially suitable condition than 30 N. Level of evidenceLevel III.

Increased quadriceps muscle strength after medial meniscus posterior root repair is associated with decreased medial meniscus extrusion progression

BackgroundThis study aimed to assess quadriceps muscle strength after medial meniscus (MM) posterior root repair and determine its relationship with clinical scores and MM extrusion (MME).MethodsThirty patients who underwent pullout repair for MM posterior root tear and were evaluated for quadriceps muscle strength preoperatively and at 1 year postoperatively were included in this study. Quadriceps muscle strength was measured using the Locomo Scan-II instrument (ALCARE, Tokyo, Japan). MME and clinical scores (i.e., Knee Injury and Osteoarthritis Outcome Score [KOOS], International Knee Documentation Committee score, Lysholm score, Tegner score, and visual analog scale pain score) were evaluated preoperatively and at 1 year postoperatively, and second-look arthroscopy was performed at 1 year postoperatively. Wilcoxon's signed-rank test was used to compare each measure pre- and postoperatively. Pearson's correlation coefficient was used to assess the correlation with quadriceps muscle strength values. Multiple regression analysis was performed to identify factors associated with the change in MME (ΔMME).ResultsSecond-look arthroscopy confirmed continuity of the posterior root in all patients. The quadriceps muscle strength measured at 1 year postoperatively (355.1 ± 116.2 N) indicated significant improvement relative to the quadriceps muscle strength measured preoperatively (271.9 ± 97.4 N, p < 0.001). The MME at 1 year postoperatively (4.59 ± 1.24 mm) had progressed significantly relative to the MME preoperatively (3.63 ± 1.01 mm, p < 0.001). The clinical scores at 1 year postoperatively were improved significantly relative to the scores preoperatively (p < 0.001). The postoperative quadriceps muscle strength was correlated with ΔMME (correlation coefficient = -0.398, p = 0.030), and the change in quadriceps muscle strength was correlated with the KOOS-Quality of Life (correlation coefficient = 0.430, p = 0.018). Multiple regression analysis showed that the postoperative quadriceps muscle strength had a significant effect on ΔMME even when the body mass index and time from injury to surgery were included.ConclusionsAfter MM posterior root repair, patients with greater quadriceps muscle strength showed less MME progression. In addition, patients with greater improvement in quadriceps muscle strength had better clinical scores; therefore, continued rehabilitation aimed at improving quadriceps muscle strength after MM posterior root repair is recommended.Level of evidenceIV

Medial Meniscus Posterior Root Repair Reduces but Does Not Avoid Histologic Progression of Osteoarthritis: Randomized In Vivo Experimental Study in a Rabbit Model

Background: The optimal treatment option for meniscus root tears is still challenging, and whether the meniscus root repair ultimately can arrest or delay osteoarthritic changes is still a concern. Purpose/Hypothesis: The purpose of this study was 2-fold: (1) to describe and compare histopathologic findings of 3 different therapeutic options for medial meniscus posterior root tear: nonoperative management, partial meniscectomy, and meniscus root repair; and (2) to test the hypothesis that meniscus root tears treated nonoperatively predispose to a lower risk of osteoarthritic progression compared with partial meniscectomy. Study Design: Controlled laboratory study. Methods: Posteromedial meniscus root tears were carried out in 39 New Zealand White rabbits. Animals were randomly assigned into 3 experimental groups: partial meniscectomy after root tear (PM; n = 13), root tears treated conservatively (CT; n = 13), and transtibial root repair (RR; n = 13). Contralateral limbs were used as healthy controls. The animals were euthanized at 16 weeks postoperatively; tissue samples of femoral and tibial articular cartilage were collected and processed for macro- and microscopic assessment to detect signs of early osteoarthritis (OA). Each sample was histopathologically assessed using the Osteoarthritis Research Society International grading and staging system. Results: Osteoarthritic changes were the hallmark in all 3 experimental groups. The RR group had the lowest scores for cartilage damage (mean, 2.5; range, 2-3), and the PM group exhibited higher and more severe signs of OA (mean, 16; range, 9-16) compared with the CT group (mean, 5; range, 4-6). The between-group comparison revealed significant differences, as the PM group showed a significantly higher rate of macro- and microscopic osteoarthritic changes compared with the RR (P < .001) and CT (P < .001) groups. The weightbearing area of the medial femoral condyle was the most severely affected, and tidemark disruption was evident in all tissue samples. Conclusion: Meniscus root repair cannot completely arrest the histopathologic progression of knee OA but leads to significantly less severe degenerative changes than partial meniscectomy and nonoperative treatment. Partial meniscectomy leads to the most severe osteoarthritic progression, while stable radial tears left in situ have lower progression compared with partial meniscectomy. Clinical Relevance: Histologic assessment is an essential tool and metric for guiding and understanding osteoarthritic features, providing insight into the disease development and progression. This study provides histopathologic evidence on osteoarthritic progression after medial meniscus posterior root repair. This knowledge can help to set more realistic expectations and can lead to the future development of augmented techniques.

Poster 281: Current practice for meniscus repair rehabilitation amongst AOSSM members

Objectives: Meniscus repair has correspondingly become more popular, with promise of preservation of joint mechanics and hopes of preventing secondary arthritis. However, it is not clear the optimal rehabilitation protocol, with regards to the duration of limitation of range of motion and weight bearing, following repair of various meniscal tear types. The purpose of this study is to understand the current contextual landscape of how practitioners recommend rehabilitating patients that undergo meniscal repair. Methods: This is a cross-section observational survey study. A de-identified survey was designed using arthroscopic images from six cases of meniscal repair (Fig 1): Radial tear at popliteal hiatus, medial meniscus posterior root repair, lateral meniscus radial tear, lateral meniscus horizontal tear, medial meniscus red-white zone bucket-handle repair, and medial meniscus red-red zone longitudinal peripheral tear. This survey was distributed to American Orthopaedic Society for Sports Medicine (AOSSM) members by e-mail. Questions were designed to elicit, from the surveyed surgeons, their recommendations for duration of limitation of: 1. range of motion, and 2. weight bearing status, for each case. Additionally, use of meniscal repair adjuncts, including bracing and use of biologics, was elicited from the same cohort. Results: 451 completed surveys were obtained from 2973 AOSSM members (15.2%). A majority of AOSSM members recommend bracing after repair of tears that lost hoop integrity (83.3%) and that had intact hoop integrity (76.0%). A majority of members report routine use of synovial rasping/trephination (86.0%) and notch microfracture (66.5%), while a minority report use of more involved biologic supplementations including classic fibrin clot (4.9%), platelet-rich plasma (8.9%), and bone marrow aspirate concentrate (2.9%). Timing of return to weight-bearing and range of motion appear to depend on hoop stress integrity; tears with intact hoop integrity were, on average, permitted to return to weight bearing more quickly (1.4 weeks for partial weight bearing, 3.6 weeks for full weight bearing), versus tears that demonstrated loss of hoop integrity (3.9 weeks for partial weight bearing, 6.2 weeks for full weight bearing). Hoop integrity also appears to affect return to full range of motion, with tears that had a loss of hoop integrity demonstrating a longer period of post-operative restriction of range of motion. Full flexion was permitted at an average of 5.0 weeks for tears with intact hoop stress, versus 5.8 weeks for tears with loss of hoop stress. Out of the six cases presented, the most cautious tear types for post- repair rehabilitation were a radial tear at the popliteal hiatus, followed by a medial meniscus posterior root tear. Conclusions: Although there is no consensus on how each tear type should be rehabilitated following repair, initial tear hoop stress integrity appears to substantially affect rehabilitation decision-making, with loss of hoop stresses triggering a more conservative approach to rehabilitation, both with regards to permissive return to range of motion and weight bearing. A majority of AOSSM practitioners brace after meniscal repair. A majority of practitioners perform in situ adjuncts for biological healing, while a minority adds extrinsic biologics. [Table: see text]

Top Ten Pearls for a Successful Transtibial Pull-Out Repair of Medial Meniscal Posterior Root Tears With a Concomitant Centralization Stitch

Although historically overlooked, medial meniscus posterior root (MMPR) tears are now increasingly recognized as a substantial cause of biomechanical impairment and morbidity. MMPR tears, when left untreated, are strongly correlated to meniscal extrusion and ultimately lead to altered kinematics and loading functionally equivalent to a total meniscectomy. To prevent progressive joint degeneration and alleviate pain while re-establishing native joint kinematics, MMPR repair is generally recommended in appropriately selected patients. In this Technical Note, the authors describe a detailed checklist with 10 crucial points of emphasis when performing the gold-standard transtibial pull-out repair of the MMPR, with an additional centralization stitch, providing technical pearls backed up by previous literature and ample experience treating this condition.

Leave It or Repair It? Comparison of the Arthroscopic and Clinical Outcomes after High Tibial Osteotomy with or without Medial Meniscus Posterior Root Repair

Leave It or Repair It? Comparison of the Arthroscopic and Clinical Outcomes after High Tibial Osteotomy with or without Medial Meniscus Posterior Root Repair

Medial Meniscus Posterior Root Repair Restores Contact Pressure and Contact Area to Its Native State Even After Opening-Wedge High Tibial Osteotomy: A Cadaveric Biomechanical Study

To elucidate the effect of medial meniscus posterior root (MMPR) repair during opening-wedge high tibial osteotomy (OWHTO) in terms of contact pressure (CP) and contact area (CA). Nine fresh-frozen human cadaveric knee specimens were included. Each specimen was tested under 9 conditions comprising 3 different degrees of correction during OWHTO (neutral, 5° of valgus, and 10° of valgus) and 3 different types of MMPR conditions (intact, torn, and repaired). The prepared specimens were attached to a customized tibiofemoral jig in a fully extended state. The CP and CA generated by a tibiofemoral axial load of 650 N was recorded using the Tekscan sensor's pressure mapping software. Statistical analysis was performed using a repeated measures analysis of variance. The increased CP and decreased CA in torn MMPR was decreased and increased, respectively, to the intact MMPR after repairing, irrespective of whether OWHTO was performed. The mean CP at a correction angle of 5° of valgus was 0.4067 ± 0.0768 MPa for intact MMPR, which increased to 0.7340 ± 0.1593 MPa for the torn MMPR and decreased to 0.3614 ± 0.0639 MPa for the repaired MMPR. In addition, the proportion of decrease in CP and increase in CA after MMPR repair was constant, compared with the torn MMPR, irrespective of the degree of correction during OWHTO. MMPR repair decreases CP and increases CA, irrespective of whether OWHTO is performed. The biomechanical advantage of repairing torn MMPR is maintained, regardless of the degree of correction during OWHTO. Both OWHTO and MMPR repair are known to protect the medial compartment of the knee. However, there are concerns in performing 2 procedures simultaneously. Results of our study showed that concurrent repair of the MMPR during OWHTO is useful for protecting the medial compartment of the knee with respect to tibiofemoral contact biomechanics.

Early outcome of medial meniscus posterior root repair in elderly- a clinical and radiological study

Meniscus functions as a load distribution, shock absorption, proprioception, lubrication, and stabilization. Meniscal roots anchor the medial and lateral menisci to the tibial plateau, allowing the meniscus to disperse axial loads into hoop stresses. Currently, repair of meniscus root is the treatment of choice for meniscus root tears. The aim of this study is to evaluate the clinical and radiological outcome of medial meniscus posterior root repair in elderly patients. Material and Methods: It is a prospective clinical and radiological study in 10 consecutive patients, who met the inclusion criteria and operated between June 2017 to June 2018 by a single surgeon. Patients were followed up for clinical and radiological evaluation by MRI. Duration of follow up ranges from 24 to 36 months. Results: Of the 10 patients (2 male and 8 female) with the mean age of 64 years. Mean follow-up period is 30 months. Mean BMI of the patients is 26.14 + 1.95 kg/m2. The difference in pre-operative and post-operative patient’s IKDC and Lysholm scores are significant (p value &lt; 0.05). 2 patient showed complete healing of meniscus root, 8 patients showed partial healing and there was no repeat tear. Meniscus extrusion decreased from 5.2 + 0.8 mm preoperatively to 4.13 + 0.55 mm postoperatively. Conclusion: In this study, the outcomes after posterior medial meniscus root repair in elderly results in significant improvements in function, symptoms of pain, and activity level in spite of partial root healing in MRI in this short term follow up.

The functional impact of home-based self-rehabilitation following arthroscopic meniscus root repair

BackgroundCorona virus infectious pandemic makes outdoors rehabilitation a potential hazard. Patient education to perform simple home-based exercises seems to be an interesting and sometimes a mandatory option. This study provides a comparison between the conventional and home-based virtual rehabilitation after surgical repair of medial meniscus root tears.MethodsIn this prospective study, all patients who underwent medial meniscus posterior root repair with a modified trans-tibial pull-out technique from March 2019 to March 2021 were evaluated. Those who underwent surgery after December 2019 were trained to perform self-rehabilitation. The rest had undergone outdoors specialized rehabilitation according to a unified protocol and these were used as a historical control group. All patients were followed up for a minimum of 2 year after surgery. Final Lysholm scores were utilized to compare functional outcomes after considering the effect of age, body mass index and time from surgery by multivariate linear regression analysis.ResultsForty-three consecutive patients with medial meniscal root tears were studied. Thirty-nine (90.7%) were women and 4 (9.3%) were men. The mean age of participants was 53.2 ± 8.1 years. The total Lysholm knee score, and all its items were significantly improved in both groups at a two-year follow-up (p < 0.05), except the “Using cane or crutches” item (p = 0.065). Nevertheless, the final Lysholm knee score improvement was higher in patients who performed outdoors specialized rehabilitation and in patients with shorter time-to-surgery.ConclusionRegardless of age and gender, home-based rehabilitation after meniscal root repair with the modified trans-tibial pull-out technique improved the patients’ function at a two-year follow-up. Nonetheless, this effect was still significantly lower than that of the outdoors specialized rehabilitation. Future work is required to clarify basic protocols for home-based tele-rehabilitation programs and determine clinical, radiological and functional results.Level of evidenceLevel IV, therapeutic, historically controlled study.

Arthroscopic Meniscal Healing following Medial Meniscus Posterior Root Repair: A Comparison between Two Suture Materials.

Recently, transtibial pullout repair of the medial meniscus (MM) posterior root tear (PRT) has become widely accepted and provides satisfactory clinical outcomes. Widening after cyclic loading or ultimate failure load using different suture materials and configurations has been studied. However, no study has compared the clinical outcomes using different suture materials. This study aimed to evaluate the clinical outcomes after performing MMPRT pullout repair using different suture materials. We hypothesized that better clinical outcomes would be achieved using ultra-high molecular weight polyethylene (UHMWPE) tape compared with a normal polyester suture. Thirty-seven patients who underwent MM posterior root repair between November 2019 and May 2020 were retrospectively investigated. Pullout repair was performed using a hollow no. 0 polyester suture (n = 14) and UHMWPE tape (n = 23). Clinical outcomes were assessed preoperatively and at 1 year postoperatively, using the Lysholm knee score, Knee Injury and Osteoarthritis Outcome Score, and visual analogue scale (VAS) pain score. The meniscal healing status was assessed using an arthroscopic scoring system (range: 0-10). All clinical scores were improved significantly in both groups. However, significantly higher meniscal healing scores and decreased VAS pain scores were observed in the UHMWPE group (7.3 ± 0.9 and 7.7 ± 11.3, respectively) than in the polyester group (5.6 ± 2.1 and 18.4 ± 18.6, respectively; p < 0.01). Suture cut-out and loss of the root continuity were observed in some cases (three cases [21.4%] in the polyester suture group and one case [4.3%] in the UHMWPE tape group). Both suture materials led to satisfactory clinical outcomes at 1 year postoperatively, whereas the UHMWPE tape was useful for obtaining good meniscal healing and decreasing the VAS pain score.

Medial meniscus posterior root repair influences sagittal length and coronal inclination of the anterior cruciate ligament: a retrospective study.

Medial meniscus (MM) posterior root tears (PRTs) lead to abnormal kinematic changes in the knee and may induce pathological external rotation of the tibia during knee flexion. This study aimed to investigate changes in the length and inclination of the anterior cruciate ligament (ACL) after MM posterior root repair using magnetic resonance imaging (MRI). This retrospective study included 44 patients who underwent MM posterior root repair between 2016 and 2019. Clinical outcomes were evaluated before and after surgery. MRI examinations were performed at 10°/90° of knee flexion preoperatively and 3months postoperatively. The ACL length, proximal angle, and distal angle were determined using the sagittal view. MM extrusion and ACL inclination angle were determined using the coronal view. Clinical outcomes significantly improved 1year after surgery. The postoperative ACL length (29.7 ± 2.4mm) and proximal angle (47.0 ± 7.4°) at 90° of knee flexion decreased relative to the preoperative values (31.5 ± 2.3mm and 51.8 ± 8.7°, P < 0.01). The postoperative ACL inclination (64.9 ± 5.6°) at 10° of knee flexion decreased relative to the preoperative value (69.7 ± 5.6°, P < 0.01). Pathologically-stretched linear ACL at 90° of knee flexion and a steep ACL inclination at 10° of knee flexion could be reduced after MM posterior root repair. This suggests that pullout repair could restore MM function as a secondary stabilizer, thereby preventing meniscal and cartilage degeneration.

Examining the Efficacy of Medial Meniscus Posterior Root Repair: A Meta-analysis and Systematic Review of Biomechanical and Clinical Outcomes

Background: Medial meniscus posterior root (MMPR) injuries accelerate the progression of osteoarthritis. While partial meniscectomy was once considered the gold standard for treatment, meniscus root repair has become increasingly utilized with reported improvements in clinical and biomechanical outcomes. Purpose: To perform a systematic review of biomechanical outcomes and a meta–analysis of clinical and radiographic outcomes after MMPR repair. Study Design: Meta-analysis and systematic review; Level of evidence, 4. Methods: The PubMed, Embase, and Cochrane databases were queried in August 2021 for studies reporting biomechanical, clinical, and radiographic outcomes after MMPR repair. Biomechanical studies were assessed for main results and conclusions. Data including study characteristics, cohort demographics, and outcomes were extracted. Included clinical studies were analyzed with a random–effects meta-analysis of proportions for binary outcomes or continuous outcomes for mean differences between preoperative and postoperative time points. Subgroup analysis for studies reporting repair outcomes with concomitant high tibial osteotomy (HTO) was performed where appropriate. Results: A total of 13 biomechanical studies were identified and reported an overall improvement in mean and peak contact pressures after MMPR repair. There were 24 clinical studies, consisting of 876 patients (877 knees), identified, with 3 studies (106 knees) reporting outcomes with concomitant HTO. The mean patient age was 57.1 years (range, 23-74 years), with a mean follow–up of 27.7 months (range, 2-64 months). Overall, clinical outcomes (Lysholm, Hospital for Special Surgery, International Knee Documentation Committee, visual analog scale for pain, Tegner, and Knee injury and Osteoarthritis Outcome Score scores) were noted to improve postoperatively compared with preoperatively, with improved Lysholm scores in patients undergoing concomitant HTO versus MMPR repair alone. Meniscal extrusion was not significantly improved after MMPR repair compared with preoperative measurements. The progression in Kellgren-Lawrence grades from grade 0 to grades 1 to 3 occurred in 5.9% (21/354) of patients after repair, with no patients progressing from grades 1 to 3 to grade 4. Conclusion: MMPR repair generally improved biomechanical outcomes and led to improved patient–reported outcomes with greater improvements noted in patients undergoing concomitant HTO. Repair did not significantly improve meniscal extrusion, while only 5.9% of patients were noted to progress to low–grade osteoarthritis. The high level of heterogeneity in the included biomechanical and clinical investigations emphasizes the need for more well–designed studies that evaluate outcomes after MMPR repair.

Risk of interference between the tibial tunnel and locking screws in medial meniscus posterior root repair and open wedge high tibial osteotomy

PurposeTo evaluate whether the frequency of interference between locking screws for the plate fixation and tibial tunnels differs depending on the tibial tunnel positions in a surgical simulation of the transtibial pull-out repair of medial meniscus posterior root tears (MMPRTs) in patients undergoing biplanar open wedge high tibial osteotomy (OWHTO).MethodsSixty-five patients (75 knees) who underwent OWHTO with TomoFix small plate (Depuy Synthes, PA, USA) for medial knee osteoarthritis with varus malalignment were enrolled in this study. Surgical simulation of transtibial pull-out repair of MMPRTs was performed using postoperative computed tomography images. The tibial tunnel was created in the anatomical attachment area of the medial meniscus posterior root. Another aperture of the tibial tunnel was created on the anteromedial (AM) tibial cortex, the posteromedial (PM) tibial cortex, and the anterolateral (AL) tibial cortex in the proximal tibial fragment. The frequency of interference between the tibial tunnel and A–D locking screws was compared in the 3 tibial tunnel positions. In each tibial tunnel position, the locking plate position with and without interference between the tibial tunnel and at least one locking screw was compared.ResultsFor screw A, the frequency of interference with the tibial tunnel in the AL position was higher than that in the AM (P = 0.048) and PM positions (P < 0.001). For screws B and C, the frequency of interference with the tibial tunnel in the AM position was higher than that in the PM (P < 0.001, P = 0.007) and AL positions (P < 0.001, P = 0.001), respectively. For screw D, there was no difference in the frequency of interference with the tibial tunnel among the three positions. The frequency of interference between the tibial tunnel and at least one screw in the AM position was 100%, which was higher than that in the PM (P < 0.001) and AL positions (P < 0.001). In the PM position, the locking plate was placed more posteriorly in the group where the locking screw interfered with the tibial tunnel. In the AL position, the locking plate was placed more parallel to the medial/lateral axis of the tibial plateau in the interference group.ConclusionMaking the tibial tunnel in the AM position should be avoided because interference with locking screws was inevitable. When the tibial tunnel is created in the PM position, interference between the tibial tunnel and screw C should be paid attention. Anterior placement of the locking plate could be useful to prevent interference between locking screws and the tibial tunnel in the PM position. In addition, when the tibial tunnel is created in the AL position, interference between the tibial tunnel and especially screw A among screws A–C should be paid attention. Placing the locking plate in an anteromedial direction could be useful to prevent interference between locking screws and the tibial tunnel in the AL position.Level of evidenceIV

A posterior anchoring method decreases pullout suture translation of the medial meniscus posterior root repair during knee flexion

BackgroundThe medial meniscus (MM) translates posteriorly and extrudes severely from the medial tibial plateau (MTP) during knee flexion in the MM posterior root tear (PRT) knee. Transtibial pullout repair of the MMPRT has been performed to regulate MM extrusion. This study aimed to evaluate pullout suture translation during knee flexion before and after posterior anchoring during pullout repair. We hypothesized that suture translation after posterior anchoring would be significantly decreased relative to that before posterior anchoring. MethodsThirty-five patients who underwent MM posterior root repair were prospectively investigated. Pullout repair was performed using two cinch sutures (outer and inner sutures) and posterior anchoring through the MM posterior horn and an additional bone tunnel on the MTP. The translation of the outer suture from 0° to 90° of knee flexion was measured and compared before and after posterior anchoring intraoperatively. The MM morphologic features were measured using preoperative magnetic resonance imaging, and the correlation between these values and outer suture translation was evaluated. ResultsThe average outer suture translation after posterior anchoring (1.6 ± 1.5 mm) was significantly decreased relative to that before posterior anchoring (2.5 ± 1.7 mm, P < 0.01). No significant correlations were observed between the MM morphological features and outer suture translation. ConclusionsThe posterior anchoring method with an MM posterior root repair is useful in decreasing posterior translation of the pullout suture during knee flexion, which might have an advantage in preventing suture pullout from the repaired MM, leading to good clinical outcomes.

Technique for Arthroscopic Transtibial Medial Meniscus Posterior Root Repair

Background: Medial meniscus posterior root tears (MMPRT) can lead to significant pain, functional limitations, and osteoarthritis (OA). Biomechanically, MMPRT has been shown to be equivalent to total meniscectomy in terms of peak contact pressure in the medial compartment. Transtibial repair of a meniscus root tear has also been shown to restore hoop stresses and reduced peak contact pressure to the normal intact state. Clinically, root repair was shown to reduce rates of OA progression and need for total knee arthroplasty when compared with nonoperative treatment or partial meniscectomy for MMPRT. Indications: Medial meniscus posterior root repair is indicated in patients with a symptomatic MMPRT who are appropriate surgical candidates: age ≤65 years, body mass index ≤40 kg/m2, &lt;5° varus alignment, no more than Kellgren-Lawrence grade 2 changes, and willing and able to undergo the demanding postoperative rehabilitation program. Technique Description: This surgical technique video demonstrates our preferred technique for arthroscopic transtibial medial meniscus posterior root repair using a case example in a commonly encountered patient. The repair is completed using a 3 simple suture triangle configuration with 2 tibial tunnels to create a broad footprint for healing. Results: There are a number of case series and comparative studies published with good clinical outcomes using similar transtibial medial meniscus posterior root repair techniques. In short-term follow-up of 18 patients at a mean of 10.5 months post-operatively, we have demonstrated improvements in pain and functional status with a 16.7% clinical failure rate and 11% rate of conversion to arthroplasty. Discussion: In this surgical technique video, we review the anatomy of the native medial meniscus posterior root and the biomechanical and clinical consequences of a MMPRT. We highlight important technique pearls and pitfalls to avoid failures and complications during the surgical demonstration. Finally, we review postoperative rehabilitation guidelines and clinical outcomes within the existing literature. In patients with MMPRT, transtibial repair provides a safe and reliable technique to achieve healing of the medial meniscus posterior root and return patients to full activities with reduced risk of OA progression.

Meniscal Root Repair in Pediatric Patients: Minimum 2-Year Outcomes (196)

Objectives:The medial and lateral menisci function to optimize force transmission across the knee by increasing contact area between the femur and tibia, absorbing shock, and transmitting loads. The anterior and posterior meniscus roots anchor the meniscus to bone. Injuries to the meniscus root attachments result in extrusion of the meniscus, impaired distribution of hoop stresses, and progressive degenerative articular wear. As a result of these deleterious effects, there has been increasing emphasis on repair of meniscus root injuries to restore structure and function. The purpose of this study is to describe meniscus root tears, associated injuries, and minimum 2-year treatment outcomes in a series of pediatric patients.Methods:A single-institution, IRB approved, retrospective review was performed of consecutive pediatric patients less than 19 years of age with a meniscus root tear treated with transosseous root repair over a 4-year period. All patients had minimum 24-month clinical follow-up. Partial root tears treated with partial meniscectomy or irreparable root tears were excluded. All meniscus root tears were classified arthroscopically based on the tear types described by LaPradeADDIN EN.CITE 9. The primary outcomes were revision meniscus surgery and patient reported outcome scores (PROs) (Lysholm, Patient Satisfaction, and Tegner activity).Results:Twenty-one patients, 11 males and 10 females with a mean age of 15 years (range 7 – 18 years), met inclusion criteria. There were 15 lateral meniscus root tears and 6 medial meniscus root tears. The tears occurred in the posterior root in 20 patients (95%). The most common injury pattern was a lateral meniscus posterior root tear (14 patients, 67%). 18 patients (86%) had an associated ligament tear: 13 ACL tears and 5 PCL tears. Two root tears occurred in isolation, and both were the posterior root of the medial meniscus. The majority of meniscus root tears (15 patients, 71%) were root avulsions (type 5). Mean follow-up was 42 months (range 25 – 71 months). Three patients had a second surgery on the affected knee. In two patients, one with revision ACL reconstruction and one treated with chondroplasty of the patella, the meniscus root repair was noted to be well healed. A third patient sustained a new injury to the knee 4 years following medial meniscus posterior root repair and underwent partial medial meniscectomy. At final follow-up, PROs were obtained for 17 patients (81%). Mean Lysholm score was 91 (range 51 – 100). Mean patient satisfaction score was 8.7 (range 5 – 10). Fourteen of 16 patients (88%) reported returning to the same or higher level of activity following surgery.Conclusions:Meniscus root tears occur in pediatric patients, most commonly as root avulsions of the posterior root of the lateral meniscus and in association with ACL tears. This is unique as compared to the adult population, in which the medial meniscus posterior root is often injured in isolation and radial tears adjacent the root are the most commonly described injury pattern. In our case series, transosseous root repair resulted in successful outcomes in the majority of patients with durable results at midterm follow-up.

Semi-quantitative arthroscopic scoring system is related to clinical outcomes in patients after medial meniscus posterior root repair

BackgroundDifferent methods are available to assess the healing status of repaired root for medial meniscus posterior root tears (MMPRT) using second-look arthroscopy. However, few studies are comparing them or validating their usefulness. Therefore, it was hypothesized that the semi-quantitative arthroscopic score might correlate more with 1-year clinical outcomes in patients with MMPRT than the qualitative evaluation. MethodsData of 61 patients who underwent MMPRT pullout repair and second-look arthroscopy were retrospectively evaluated. The semi-quantitative arthroscopic scoring system was divided into three evaluation criteria: scores from 0 to 10 points include the width of the bridging tissue, stability of the repaired root, and synovial coverage. The qualitative evaluation was classified into 4 status; complete healing, lax healing, scar tissue healing, and failed healing according to the stability and mobility of the repaired root. Multivariate linear regression analyses were used to identify predictors of 1-year postoperative clinical outcomes, including Knee Injury and Osteoarthritis Outcome, Lysholm, or International Knee Documentation Committee scores. Spearman's correlation analysis was used to analyze the correlation between second-look arthroscopic score/qualitative evaluation and 1-year postoperative clinical outcomes. In addition, the optimal cutoff point of semi-quantitative arthroscopic score was determined by receiver operating characteristic (ROC) curve. The Mann–Whitney U test was used to compare clinical outcomes between patients with semi-quantitative arthroscopic scores ≥8 and scores <8. ResultsAll clinical scores significantly improved at 1 year postoperatively. A good correlation was observed between the semi-quantitative score and clinical scores, but none between qualitative evaluation and clinical scores. The optimal cutoff point of semi-quantitative second-look arthroscopic score was 8 points. Significantly, better clinical outcomes were observed in patients with semi-quantitative scores ≥8 points. ConclusionsAll 1-year postoperative clinical scores were significantly improved. The semi-quantitative arthroscopic scores correlate more with 1-year clinical outcomes in patients with MMPRT than the qualitative evaluation. Level of evidenceIV case series study.

Comparison of Long-term Radiographic Outcomes and Rate and Time for Conversion to Total Knee Arthroplasty Between Repair and Meniscectomy for Medial Meniscus Posterior Root Tears: A Systematic Review and Meta-analysis

Background: Previous meta-analyses have demonstrated superior outcomes in patients undergoing arthroscopic repair of medial meniscus posterior root tears (MMPRTs) compared with meniscectomy. However, these analyses have considered only short- or midterm outcomes and low-quality evidence. Purpose: To compare the mid- to long-term rates of radiographic osteoarthritis (OA) between repair and meniscectomy for MMPRT. Study Design: Systematic review and meta-analysis; Level of evidence, 4. Methods: PubMed, EMBASE, Ovid/MEDLINE, and Cochrane Central Register of Controlled Trials databases were queried for articles evaluating repair and meniscectomy for MMPRT. Articles were eligible if they had a minimum mean 4-year follow-up for radiographic OA or conversion to total knee arthroplasty (TKA) and were at least level 3 evidence. Radiographic OA was assessed using Kellgren-Lawrence (KL) progression. Rates of conversion to TKA and International Knee Documentation Committee (IKDC) scores were also extracted. DerSimonian-Laird binary random-effects models were created to evaluate differences in radiographic OA and TKA conversion rates, with odds ratios (ORs) representing pooled estimates. Continuous random-effects models with standardized mean differences (SMDs) were used to compare postoperative IKDC scores. Results: Repair and meniscectomy cohorts were followed for a mean of 64.8 months and 62.5 months, respectively, for KL progression; and 82.8 months and 73.8 months, respectively, for TKA rates and IKDC scores. Overall, 59 of 144 (41%) patients undergoing surgical intervention for MMPRT demonstrated OA progression; 18 of 82 (22%) who underwent repair for MMPRT exhibited OA progression compared with 41 of 62 (66%) who underwent meniscectomy (OR, 0.17; 95% CI, 0.03-0.83; P = .029). Overall, 30 of 143 (21%) patients converted to TKA; 9.8% (8/82) of patients who underwent repair converted to TKA (range, 47-131 months), while 36% (22/61) who underwent meniscectomy converted to TKA (range, 17.8-101 months) (OR, 0.15; 95% CI, 0.05-0.44; P < .001). No significant differences between postoperative IKDC scores were observed (SMD, 0.51; 95% CI, -0.02 to 1.05; P = .06). Conclusion: Medial meniscus posterior root repair results in significantly lower rates of radiographic OA progression and conversion to TKA at >60-month follow-up. On the basis of these findings, we recommend consideration of repair of MMPRTs when degenerative changes are not severe, as it can yield improved outcomes.

Knee Flexion-induced Translation of Pullout Sutures Used in the Repair of Medial Meniscus Posterior Root Tears.

Medial meniscus posterior root tears (MMPRTs) have recently attracted considerable interest in orthopedics. To date, no in vivo human study has investigated suture translation changes in repaired MMPRTs with different degrees of knee flexion. This study examined suture translation at various degrees of knee flexion in 30 patients undergoing medial meniscus posterior root repair using the modified Mason-Allen suture technique between August 2016 and September 2017. Intraoperatively, sutures were provisionally fixed to an isometric positioner at the tibial site of the desired meniscal attachment, and the suture translation was measured at 0°, 30°, 60°, and 90° of knee flexion. The results showed significant increases in mean suture translation at the knee flexion positions from 0° to 30°, 30° to 60°, and 60° to 90° (p<0.01 for all). Our findings indicate that surgeons should carefully assess the degree of knee flexion at the moment when the meniscus is refixed by surgical sutures.