Meniscal Preservation Research Articles

Lower Surgical Volume Reduces the Odds of Performing Meniscus Repair for Tears During Primary ACL Reconstruction

PurposeTo investigate the influence of surgical volume, and various patient-, injury-, and surgery-related factors, on meniscal treatment strategies in primary anterior cruciate ligament reconstruction (ACLR). MethodsThis retrospective cohort study analyzed patients with concomitant meniscal injuries undergoing primary ACLR, 2008–2022, using data from the Swedish National Knee Ligament Registry. Surgeons and clinics were stratified by total caseload (cutoff: 50 ACLRs/surgeon, 500 ACLRs/clinic) and annual volume (cutoff: 29 ACLRs/year/surgeon, 56 ACLRs/year/clinic). To assess factors influencing medial meniscus (MM) or lateral meniscus (LM) repair, adjusted multivariable logistic regression was conducted, with results presented as odds ratios (OR) and 95% confidence intervals (CI). Results20,699 patients undergoing primary ACLR with concomitant meniscal injuries were included. Lower percentages of meniscus repair were seen among surgeons with low caseload and annual volume (LCLV) (13.3-20.8%) compared to high caseload and annual volume (HCHV) surgeons (19.0-29.8%), and at LCLV clinics (11.1-18.3%) compared to HCHV clinics (21.5-33.8%), all P<0.001. Significantly decreased odds of MM repair were seen for patients operated on by LCLV surgeons (OR 0.82, 95% CI 0.70-0.96; P=0.015) or at LCLV clinics (OR 0.56, 95% CI 0.50-0.64; P<0.001. Similar results were seen for LM repair with LCLV surgeons (OR 0.83, 95% CI 0.69-1.01; P=0.067) and LCLV clinics (OR 0.62, 95% CI 0.53-0.72; P<0.001). Additionally, younger age, female sex, shorter time from injury to surgery, and ACLRs performed more recently were associated with increased odds of repair. ConclusionsLower surgical volume significantly decreased the rates and odds of performing meniscal repair during primary ACLR. In contrast, ACLRs performed during more recent years in younger age, female sex, shorter time from injury to surgery, in absence of chondral injuries, and injuries sustained during nonpivoting activities, positively influenced meniscal preservation. Level of EvidenceLevel III. Retrospective cohort study.

Decreasing Incidence of Partial Meniscectomy, and Increasing Incidence of Meniscus Preservation Surgery from 2010-2020 in the United States

The aim of the present study was to characterize the incidence of meniscus surgery from 2010 to 2020 in the United States, using the metrics of age, sex, type of meniscus surgery, and Charlson Comorbidity Index (CCI). A retrospective analysis was performed using the PearlDiver national insurance claims database from 2010-2020. Meniscus surgeries were identified using Current Procedural Terminology codes. Patients were stratified by procedure type, age, biological sex, and Charlson Comorbidity Index (CCI) scores. Compound annual growth rate (CAGR) analysis and analysis of variance (ANOVA) were performed to analyze the trends and demographic variables between cohorts. Of 2,053,884 meniscus surgeries, 94.7% were meniscectomies, 0.3% were open repairs, 4.9% were arthroscopic repairs, and 0.1% were meniscal transplantations. CAGR analysis displayed a 4.0% decrease per year in total meniscus surgery. For individual procedure types, the largest decrease was in meniscectomy, and the largest increase was in open repair. Patients undergoing meniscal transplantation were youngest, with the lowest CCI. Meniscectomy patients were oldest, and open repair patients had the highest average CCI. Most procedures were performed on female patients (52.4%), and patients in the 50-59-year age group (30.4%). There was a sustained decrease in the incidence of total meniscus surgeries from 2010-2020. Meniscectomy was the procedure with the highest incidence, however, it showed the most significant decline in usage over the study period. Conversely, meniscal repair and transplantation procedures increased during the study period.

Pediatric meniscal surgery in Italy: A 10-year epidemiological nationwide registry study

PurposeOver the last two decades the incidence of meniscal injuries has grown amongst the pediatric population predominantly due to greater involvement in sporting activities. The treatment and the natural history represent a socioeconomic burden for healthcare systems. This study demonstrates the epidemiology of meniscal tears treated surgically in Italy from 2010 to 2019 in a population up to 18 years. MethodsData was collected from the National Archive of Hospital Discharges. ICD9-CM classification was used to select surgically treated meniscal injuries. Concomitant treatment of associated lesions were excluded. Data on the national population was retrieved from the Italian National Institute for Statistics (ISTAT). Statistical analyses were performed. Results17,449 isolated meniscal tears were surgically treated with a mean incidence of 20.6 per 100.000 in the Italian population aged up to 18 from 2010 to 2019. The mean age of patients was 15.85 with 89 % aged 14 or older. 30 % of the population was female. The incidence of medial meniscal surgery was higher than for the lateral meniscus. A declining trend in surgical incidence was observed. The mean hospitalization time was 1.53 days. ConclusionsOur study reveals a reduction in the total number of surgeries performed over the time frame and a significant rise in the incidence of meniscal lesions in pediatric patient above at the age of 13, especially in males. Despite a worldwide shift towards meniscal preservation, this trend is not evident in Italy as the current ICD9-CM classification does not differentiate between meniscectomy and meniscal repair, although an overall reduction in surgery may imply better management. Study designCohort study; Level of evidence III.

Poster 307: Meniscal Repair in the Setting of Revision Anterior Cruciate Ligament Reconstruction: 6-Year Follow up Results from the MARS Cohort

Objectives: Meniscal preservation has been demonstrated to contribute to long term knee health and has been a successful intervention in the isolated and ACL reconstructed patient. The long-term results of meniscus repair in the setting of revision ACL reconstruction have yet to be documented. The purpose of this study is to report the incidence of meniscal repair failures at 6-year follow-up in a cohort of patients who underwent concurrent revision ACL reconstruction and meniscal repair. Methods: All revision ACL reconstructions with concomitant meniscal repair cases from a multicenter group between 2006 and 2011 were selected. Six-year follow-up was obtained by both phone and email to determine whether any subsequent surgery had occurred to either knee since their initial revision ACL reconstruction. If so, operative reports were obtained, whenever possible, to verify pathologic condition and treatment. Results: In total, 221 patients from 1234 revision ACL reconstructions underwent concurrent meniscal repairs (18% of the cohort). There were 238 repairs performed: 173 medial and 65 lateral. The vast majority of these repairs (n=181; 76%) were performed with an all-inside technique. Baseline patient and surgical characteristics of this group are reported (Tables 1, 2). Six-year surgical follow-up was obtained on 77% (171/221) of the cohort. Overall, the meniscal repair failure rate defined as reoperation was 13% (31/235) at 6 years. Of the 31 failures, 28 were medial (24 all-inside, 4 inside-out; 16% failure rate) and 3 were lateral (2 all-inside, 1 inside-out; 4.6% failure rate; Table 2). Three medial failures were treated in conjunction with a subsequent repeat revision reconstruction. The mean (SD) time to failure for the medial repairs was 2.6 (1.7) years, while the time to failure for the lateral repairs was 1.6 (1.8) years. Medial tears underwent reoperation for failure at a statistically significant higher rate than lateral tears (16% versus 4.6%; p&lt;0.001). Conclusions: Meniscus repair in the revision ACL setting is a successful treatment option when clinically indicated with low failure rates. At 6-year follow-up, overall meniscal failure rate as defined by reoperation was 13% in this revision cohort. Failure rates for medial tears (16%) were higher than for lateral tears (4.6%), which aligns with previous studies both in the revision and primary setting.

Poster 228: A Novel Description of Medial Meniscus Vascularization: A Multicenter Study Introducing the Medial Meniscal Artery

Objectives: The microvasculature of the human meniscus has been previously described by Arnoczky and Warren. However, to date the qualitative and quantitative extra-articular vascular anatomy of the medial meniscus has not yet been characterized. Therefore, the purpose of our study was to perform a qualitative and quantitative anatomic study of the extra-articular medial meniscal vasculature and to introduce the novel “medial meniscal artery” (MMA), potentially providing future guidelines for the treatment of meniscal pathology. Methods: Thirty-three unpaired frozen human cadaveric knees were dissected. The popliteal artery was identified and cannulated with an angiocatheter. The arteries were perfused with a red acrylic paint solution allowing for improved visualization. Artery dimensions and distances were measured using a digital caliper. Perfused specimens were imaged with Computed Tomography scanning and segmented using software to identify vessels and repeat artery measurements. Results: The MMA was consistently identified in all specimens. In 26 of 33 (82%) specimens, the MMA branched directly from the popliteal artery, while in 6, the MMA shared a common trunk with the inferior medial genicular artery (IMGA). The MMA was easily distinguishable from the superior MGA, inferior MGA, and MGA, given its direct course to the medial joint line with terminal branches to the posterior horn of the medial meniscus and deep to the semimembranosus tendon. The MMA exhibited a consistently smaller vessel diameter relative to the genicular arteries. Conclusions: This is the first study identifying and quantitively describing the MMA in the human knee. The MMA can be identified consistently on gross anatomic dissection in patients of varying demographics. The findings of this study will provide future avenues of study toward understanding the medial meniscus vascularization and the genesis of potential degenerative changes when vascularization is poor. This will help to further refine diagnostic and treatment options for meniscus revascularization and compartment preservation. Additionally, this study may help define safe zones in the knee during posterior approaches, as well as furthering the base of knowledge for emerging vascular procedures such as genicular artery embolization. Further research is needed to identify and characterize the artery in vivo and to determine the MMA’s role in meniscus preservation.

Poster 304: Isolating The Medial Meniscal Artery with Ultrasonography: Anatomical Characterization of the Novel Vascular Structure and a Technical Note on Imaging Technique

Objectives: The vascularity of the human meniscus was first famously described by Arnoczky and Warren, who used histological analysis to map out vessel contributions to the medial and lateral menisci. This study determined that the medial and lateral superior and inferior genicular arteries branches give rise to a perimeniscal capillary plexus within the capsular and synovial tissues of the knee. However, since this study, there have been limited investigations into the macro- and microvascularity of the menisci. This includes anatomical, biomechanical, and imaging studies. Doppler ultrasound is an easily accessible, safe, and non-invasive modality that gives clinicians real-time visualization of vascular anatomy. To date, there have been no ultrasound studies that have highlighted vascular deviations from the popliteal artery to the medical meniscus, including the newly discovered medial meniscal artery (MMA), as described in Part 1 of this study (Figure 1, from Part 1 of this investigation). The purpose of this study was to use find a reproducible ultrasound technique to identify the MMA and provide a detailed characterization of the vessel’s precise anatomy. We hypothesized that the MMA would be consistently identifiable in vivo using ultrasound imaging and that multiple anatomic variants of the MMA would exist. Methods: Fifty-six patients underwent ultrasound examination of the left knee. Patient demographics were collected. The MMA was isolated by one of two techniques. In the first approach, the inferior medial genicular artery (IMGA) was isolated and followed back to the popliteal artery, where the examiner then coursed the artery proximally to find medial-sided vasculature branching to the medial meniscus. In the second approach, the probe was started on the medial meniscus and once an arterial supply was found, it was traced back to the popliteal artery. Once the MMA was isolated by either technique, the following variables were measured: presence or absence of MMA, artery diameter, presence of arterial calcifications or atheromatous plaques, and any vascular variations. Once the MMA was found and isolated in the left knee, its presence was investigated in the right knee. Results: The MMA was identified in 50/56 patients (89.2%). The average vessel diameter was 0.89 mm (SD ± 0.39). All 50 patients with a MMA present on the left knee also had the presence of the artery on the right knee. None of the MMA isolated in this study were noted to have any plaques or calcifications. 45 patients were noted to have a Type 1 MMA, whereas five patients were noted to have a Type 2 MMA where the vessel shares an origin with the IMGA (Figure 2). Conclusions: This is the first study to utilize ultrasound to isolate and characterize the MMA in a in vivo human model. The MMA can be consistently seen on ultrasonography in the majority of patients and ultrasound examination demonstrated that the artery perforates into the meniscal tissue to contribute to the meniscal microplexus. The key methods to ensure reproducible identification of the artery and patient characteristics that produce lesser quality images are discussed in detail. Ultrasound identification in clinic may serve as a point-of-care diagnostic modality to determine the likelihood of success of procedures such as medial meniscal repair, given the artery provides a direct blood supply to the meniscus. The MMA may play a pivotal role in meniscal injury, repair, healing, and preservation. Future studies are necessary to determine the extent to which this vessel contributes to said mechanisms.

Meniscus Tears in Elite Athletes: Treatment Considerations, Clinical Outcomes, and Return to Play.

Management of meniscal injuries in the elite athlete is a difficult problem secondary to the high demands of athletic competition, the need for a timely return to sport, and the desire to maximize performance over time. The purpose of this review is to provide an up-to-date summary on the current literature and trends regarding the management of meniscus injuries with a special consideration for elite athletes. Historically, partial meniscectomy has been the primary treatment option for meniscus injuries. However, in recent years there has been an increased emphasis on meniscus preservation due to the increased risk of cartilage degeneration over time. Moreover, while partial meniscectomy still provides a quicker return to sport (RTS), recent literature has demonstrated similar rates of RTS and return to pre-injury levels between partial meniscectomy and meniscus repair. In the setting of symptomatic meniscal deficiency, meniscus allograft transplantation has become an increasingly utilized salvage procedure with promising yet variable outcomes on the ability to withstand elite competition. Currently, there is no uniform approach to treating meniscal injuries in elite athletes. Therefore, an individualized approach is required with consideration of the meniscus tear type, location, concomitant injuries, athlete expectations, rehabilitation timeline, and desire to prevent or delay knee osteoarthritis. In athletes with anatomically repairable tears, meniscus repair should be performed given the ability to restore native anatomy, provide high rates of RTS, and mitigate long-term chondral damage. However, partial meniscectomy can be indicated for unrepairable tears.

High-resolution magnetic resonance imaging can predict osteoarthritic progression after medial meniscus posterior root injury: randomized in vivo experimental study in a rabbit model

ImportanceThe field of meniscal root preservation has undergone significant advancement over the past decades; however, the challenge remains to fully understand whether meniscal root repair can ultimately arrest or delay osteoarthritic changes. ObjectiveTo assess longitudinal changes in articular cartilage, subchondral bone, and progression to meniscal extrusion (ME) using high-resolution magnetic resonance imaging (MRI). MethodsMedial meniscus posterior root tear was surgically induced in 39 New Zealand white rabbits. Animals were randomly assigned into three experimental groups: partial meniscectomy after root tear (PM, n ​= ​13); root tear left in situ (CT, n ​= ​13); and transtibial root repair (RR, n ​= ​13). Contralateral limbs were used as healthy controls. High resolution 4.7 Tesla MRI of the knee joint was performed at baseline, after 2-, and 4-months of post-surgery. Cartilage thickness was calculated in medial and lateral compartments. In addition, the evaluation of ME, subchondral bone edema and healing potential after root repair were assessed too. ResultsProgressive cartilage thinning, ME, and subchondral bone edema were evident in all 3 study groups after 4-months of follow-up. The mean cartilage thickness in the PM group was 0.53 ​mm (±0.050), 0.57 ​mm (±0.05) in the CT group, and 0.60 ​mm (±0.08) in the RR group. The PM group exhibited significantly higher cartilage loss when compared to the CT and RR groups (p ​< ​0.001). Moreover, progressive ME and subchondral bone edema were associated with a more severe cartilage loss at the final follow-up. ConclusionMeniscal root repair did not halt but rather reduced the progression of osteoarthritis (OA). Degenerative changes worsened at a rapid rate in the PM group compared to the RR and CT groups. Early cartilage swelling, persistent subchondral edema, and progressive ME predicted a more severe progression to knee OA in the CT and RR groups. Level of evidenceII.

Osteoarthritis Development Following Meniscectomy vs. Meniscal Repair for Posterior Medial Meniscus Injuries: A Systematic Review.

This systematic review aims to evaluate critically and synthesize the existing literature on the outcomes of meniscectomy versus meniscal repair for posterior medial meniscus injuries, with a focus on osteoarthritis (OA) development. We sought to assess the incidence of OA following both treatment modalities, compare functional outcomes post-treatment, and identify factors influencing treatment choice, providing evidence-based recommendations for clinical decision-making. A comprehensive search strategy was employed across PubMed, Scopus, and Embase up until December 2023, adhering to PRISMA guidelines. The primary outcomes included OA development, functional knee outcomes, and quality of life measures. Six studies met the inclusion criteria, encompassing 298 patients. The systematic review revealed a significant association between meniscal repair and decreased progression of OA compared to meniscectomy. Meniscectomy patients demonstrated a 51.42% progression rate towards OA, significantly higher than the 21.28% observed in meniscal repair patients. Functional outcomes, as measured by the International Knee Documentation Committee (IKDC) and Lysholm scores, were notably better in the repair group, with average scores of 74.68 (IKDC) and 83.78 (Lysholm) compared to 67.55 (IKDC) and 74.56 (Lysholm) in the meniscectomy group. Furthermore, the rate of complete healing in the repair group was reported at 71.4%, as one study reported, indicating a favorable prognosis for meniscal preservation. However, these pooled data should be interpreted with consideration to the heterogeneity of the analyzed studies. Meniscal repair for posterior medial meniscus injuries is superior to meniscectomy in preventing OA development and achieving better functional outcomes and quality of life post-treatment. These findings strongly suggest the adoption of meniscal repair as the preferred treatment modality for such injuries, emphasizing the need for a paradigm shift in clinical practice towards preserving meniscal integrity to optimize patient outcomes.

Meniscal Repair in the Setting of Revision Anterior Cruciate Ligament Reconstruction: 6-Year Follow-up Results from the MARS Cohort

Objectives: Meniscal preservation has been demonstrated to contribute to long term knee health and has been a successful intervention in the isolated and ACL reconstructed patient. The long-term results of meniscus repair in the setting of revision ACL reconstruction have yet to be documented. The purpose of this study is to report the incidence of meniscal repair failures at 6-year follow-up in a cohort of patients who underwent concurrent revision ACL reconstruction and meniscal repair. Methods: All revision ACL reconstructions with concomitant meniscal repair cases from a multicenter group between 2006 and 2011 were selected. Six-year follow-up was obtained by both phone and email to determine whether any subsequent surgery had occurred to either knee since their initial revision ACL reconstruction. If so, operative reports were obtained, whenever possible, to verify pathologic condition and treatment. Results: In total, 221 patients from 1234 revision ACL reconstructions underwent concurrent meniscal repairs (18% of the cohort). There were 238 repairs performed: 173 medial and 65 lateral. The vast majority of these repairs (n=181; 76%) were performed with an all-inside technique. Baseline patient and surgical characteristics of this group are reported (Tables 1, 2). Six-year surgical follow-up was obtained on 77% (171/221) of the cohort. Overall, the meniscal repair failure rate defined as reoperation was 13% (31/235) at 6 years. Of the 31 failures, 28 were medial (24 all-inside, 4 inside-out; 16% failure rate) and 3 were lateral (2 all-inside, 1 inside-out; 4.6% failure rate; Table 2). Three medial failures were treated in conjunction with a subsequent repeat revision reconstruction. The mean (SD) time to failure for the medial repairs was 2.6 (1.7) years, while the time to failure for the lateral repairs was 1.6 (1.8) years. Medial tears underwent reoperation for failure at a statistically significant higher rate than lateral tears (16% versus 4.6%; p&lt;0.001). Conclusions: Meniscus repair in the revision ACL setting is a successful treatment option when clinically indicated with low failure rates. At 6-year follow-up, overall meniscal failure rate as defined by reoperation was 13% in this revision cohort. Failure rates for medial tears (16%) were higher than for lateral tears (4.6%), which aligns with previous studies both in the revision and primary setting.

The frequency of medial meniscal repairs in stable knees during one year of arthroscopic activity (2021–2022) – comparison with a retrospective study (prior to 2017)

IntroductionThere has been a significant increase in the use of conservative treatment for meniscal lesions due to raised awareness around the need for meniscal preservation. However, sutures of the medial meniscus (MM) in stable knees remain less frequently used. The objective of this study was to, firstly, identify the MM suture rate over one year of activity; secondly, to identify and compare the distribution of MM sutures in stable, and stabilized, knees on this prospective series; and thirdly, to compare the evolution of practices with a retrospective series of more than 5 years follow-up. HypothesisThe number of MM sutures in stable knees represents a small percentage of annual arthroscopic activity. Material and methodsThis multicenter study was carried out in 10 reference centers participating in the 2022 symposium of the Francophone Society of Arthroscopy (Bordeaux, Caen, Lille, Lille Louvière, Lyon, Marseille, Toulouse, Saint-Étienne, Strasbourg, Versailles). This study included a prospective series on interventions performed under arthroscopy during one year of activity. The inclusion criteria were patients operated on via an arthroscopic technique and aged over 18 at the time of the operation. Demographic data, as well as the circumstances leading to the injury, were collected. A register of the lesions found was established in order to list the lesions of the MM, the lateral meniscus (LM), the anterior cruciate ligament (ACL), the associated chondral lesions; as well as the treatment performed: meniscal suture of the MM and/or LM, meniscectomy of the MM and/or LM and ligamentoplasty of the ACL. This study also included a retrospective series comprised of only MM sutures in stable knees at more than 5 years of follow-up. ResultsOf the 4154 patients included, 1919 patients (46.2%) underwent surgery for ACL reconstruction and 2235 for arthroscopy without associated ligament surgery. MM sutures (in stable knees and in knees with ACL reconstruction) represented 14% of the overall arthroscopic activity (583 MM sutures) versus 8.6% for LM (360 sutures). In cases of ACL surgery, there were 895 associated meniscal lesions (337 LM and 558 MM) and 66% of MM tears (371 MM sutures) were sutured. In stable knees, MM tears were weaker (212 MM sutures out of 1359 lesions, i.e. 15%). Of all the arthroscopic procedures performed over the course of a year, MM suturing in stable knees represented 5.1% of the activity. Compared to the retrospective series (n=367), the patients were older (37 years versus 28 years) and the management of ramp lesions or root tears was noted. In both series, these tears were related to sports trauma in more than 70% of cases. ConclusionMM suturing in stable knees represents a small part of annual arthroscopic activity and it occurs less frequently than during ACL reconstruction surgery. Level of evidenceIV.

The Proportion of Meniscus Tears Considered Repairable, and Thus Repaired, Increased During a Single Surgeon’s Practice of 20 Years

The purpose of this study was to evaluate practice patterns of a single surgeon with respect to meniscectomy and meniscal repair over a 20-year period at a single institution. A cross-sectional descriptive study was carried out by reviewing the surgical data from the past 20 years (2002-2021) of patients who underwent arthroscopic primary meniscal surgery. Age, sex, knee and meniscus affected, morphology of the meniscal tear, meniscal radial location, location on the axial plane, tissue quality, and associated injuries were recorded. An analysis of the evolution of the characteristics of the meniscal lesions was performed according to the presence of degenerative tissue, the repairability of the lesion, and the treatment performed. Categorical data were represented in contingency tables and compared using the χ2 test for significance of differences, which was set at P < .05. In total, 1,892 cases were included. A decrease in degenerative meniscal tears was found, from 63.2 in 2002 to 2006 to 9.7% in 2017 to 2021 (P < .001), while repairable tears increased from 1.6% to 82.3% P < .001); in the same periods, arthroscopic partial meniscectomy procedures declined from 75.7% to 17.7% (P < .001) while meniscal repair increased from 0.4% to 81.3% (P < .001). All types of tears increased significantly their repairability, although longitudinal tears, root tears, and ramp lesions showed the highest possibilities for repair. In the present study, a drastic change in the attitude toward meniscal preservation in the past 20 years was observed, with a large increase in the proportion of tears considered repairable found in primary arthroscopic surgery (to 80% of cases) and a decrease in degenerative meniscus tears (to less than 10%). In the past 2 decades, arthroscopic knee surgery has evolved such that more meniscus tears are deemed repairable, and fewer tears considered degenerative are indicated for arthroscopy.

Poster 256: Pediatric Meniscus Repair: Safety Profile based on &gt; 2000 Arthroscopic Meniscus Repairs

Objectives: Pediatric meniscus tear prevalence is increasing, and meniscus preservation methods are essential for long term knee function in this at risk group. In this patient population meniscus anatomy and vascularity may support higher rates of healing after repair, but safety of meniscus repair has not been studied in a large prospective cohort group. The purpose of this study is to establish the incidence of complications associated with pediatric meniscus repairs in a multi-center prospective quality improvement registry, and to identify the characteristics of meniscus repair that are associated with complications. Methods: A prospective multi-center quality improvement registry (16 institutions, 26 surgeons) monitoring the safety of meniscus repairs was reviewed. Audit processes using CPT codes were designed to ensure that all consecutive cases were prospectively entered on patients &lt;19 years old into a HIPAA- compliant electronic platform. Each meniscus repair case with a complication form was secondarily reviewed to ensure consistency of identification and grading according to the modified Clavien Dindo classification. Demographics, tear type, repair technique, and implant type, when applicable, were included, and a common cause analysis was performed to evaluate risk factors for early repair failures. Results: 2375 meniscus repair cases were identified, with a mean age of 15.1 years (2-19) and 44.1% females. These consisted of (25%) isolated repair, (5.4%) discoid meniscus repair, and (66.9%) concomitant ACL and meniscus repair. Overall complication rate was 12.64%, with 5.67% grade III complications. The most common complications were motion loss/stiffness (3.96%), failed repair (2.3%) and continued pain/mechanical symptoms (2.09%). Failed repair was identified in all repair groups but had the highest prevalence in isolated meniscus repair (6.38%), in which grade III complications were more common overall. Stiffness was more common when a meniscus repair was performed during an ACL reconstruction (2.1% Grade II and 1.27% Grade III). There was no statistical difference in complications associated with age, gender, or technique, medial or lateral meniscus, displacement, or zone of repair. However, posterior horn and posterior horn + body repairs of the medial meniscus sustained more complications (p=0.003) as did longitudinal/complex tears of the lateral meniscus (p=0.02). Conclusions: Pediatric meniscus repairs performed arthroscopically have a complication rate of 12.64%, with 1 and 20 meniscus repairs leading to a grade III complication. Although there is no difference in complications based on technique, posterior horn medial meniscus and longitudinal tears of lateral meniscus may be at higher risk of complications.

High tibial osteotomy is equally effective for varus malaligned knees with either virgin or wrecked medial meniscus: An age and gender-matched secondary analysis of a Francophone Arthroscopy Society Symposium

IntroductionDespite the growing concept of meniscal preservation, partial meniscectomy could be the definitive procedure in specific scenarios. And total meniscectomy was once before a frequent procedure, with current sequelae of degenerate knees. High tibial osteotomy (HTO) is an effective treatment for patients suffering from unicompartmental degenerative changes, and substantial deformities. However, it is yet to be answered, whether HTO is similarly effective in both post-meniscectomy knees and knees with not previously operated meniscus. HypothesisOutcomes of HTO is similar with or without previous history of total or subtotal meniscectomy. MethodsThis study compared the clinical and radiological outcomes of 41 patients who received HTO and had no previous history of surgery in the ipsilateral knee (group I), and 41 age, and gender-matched patients who had meniscectomy surgery in the ipsilateral knee (group II). Preoperatively and postoperatively, all patients were clinically evaluated; the visual analogue scale scores, Tegner activity score, and the Western Ontario and Macmaster University scores were reported. Radiographically, osteoarthritis grade and pre- and postoperative parameters were reported, including hip-knee-ankle angle, femoral mechanical angle, medial proximal tibial angle, joint line convergence angle, proximal posterior tibial angle, and limb length discrepancy. Perioperative details and complications were reported. ResultsA total of 82 patients were included; group I (n=41) and group II (n=41). The mean age was 51.18±8.64 (27–68) and 90.24% were male. The duration since the onset of symptoms was longer in group II vs. group I, 43.34±41.03 versus 38.07±36.11months respectively. No significant differences in the clinical evaluation between the two groups with a greater proportion of patients demonstrating moderate degenerative changes. Similar preoperative and postoperative radiographic parameters were reported, in group I, Δ HKA was 7.19±4.14 versus 7.65±3.16 in group II. Preoperative pain VAS scores were slightly higher in group II vs. group I, 79.23±26.35 vs. 76.31±24.45, respectively. However, postoperatively, the pain scores significantly improved in group I vs. group II, 22.84±3.65 vs. 41.69±17.33, respectively. Tegner activity scores and WOMAC scores were comparable between both groups preoperatively and postoperatively. Only the WOMAC function scores were better in group I when compared to group II, 26.13±25.84 versus 20.01±17.98. All patients returned to work at an average of 0.82±0.38months. ConclusionKnee preservation with high tibial osteotomy is equally effective in managing unicompartmental degenerative changes in varus malaligned knees with either no previous history of meniscal surgeries or where a meniscal sacrifice was inevitable, either with subtotal or total meniscectomy. Level of evidenceIII, retrospective case-control study.

A Single-Centre, Retrospective, Observational Study to Assess Safety and Functional Outcomes of Arthroscopic Meniscal Repair Using Surestitch All Inside Implant.

Introduction The meniscus plays a vital role in maintaining knee stability. It acts as a shock absorber and knee filler. The incidence of meniscal tears is estimated to be 60 per 100,000 people. Due to lack of awareness among patients, only 10% of the meniscus tears were treated through partial or total meniscectomy. Recently, the concept of meniscus preservation surgery has emerged to preserve early degeneration of the knee joint. In the current retrospective study, safety and functional outcomes of arthroscopic meniscal repair surgery using SurestitchAll inside implants (Sironix Arthroscopy Solutions, Healthium Medtech Limited, Bengalaru, India) were assessed. Methods Fifty-two patients who underwent arthroscopic meniscal repair surgery between January 2019 to July 2022 at Epic Hospital in Gujarat, India, were enrolled in the study. Retrospective data including demographics, injury details, surgery details, and post-surgery complications were collected from the medical records of the patients. Then, the patients were followed up telephonically to document safety and functional outcomes using patient-reported instruments such as International Knee Documentation Committee (IKDC) score, Single Assessment Numeric Evaluation (SANE) score, Tegner activity level, and Lysholm knee score. Results The recruited patients had the mean age, height, and weight of 37.56 ± 12.52 years, 167.61 ± 7.28 cm, and 75.87 ± 10.7 kgs, respectively. Seventy-one percent of patients were male and 29% were female. Majority of the patients had the routine of doing mild exercise. During pre-surgery representations, medial meniscal tear was observed in majority of patients. The mean length of the tear was 1.32 ± 0.84 cm. In addition, patients were also diagnosed with anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL) tears, and osteochondral defects. Surgeries for meniscal repair were performed using Surestitch All inside implant. In patient-reported outcomes, the mean IKDC, SANE, and Lysholm scores were 81.72 ± 14.23, 94.02 ± 13.79, and 93.32 ± 14.63, respectively. When the mean Tegner scores of pre-injury and post-surgery periods were compared, this resulted in no significant difference (p>0.05) in the activity levels of the patients. Conclusion Based on our findings, arthroscopic meniscal repair with Surestitch All inside meniscal repair implant provides satisfactory and favorable functional outcomes with no remarkable adverse events.

Meniscus repair via collagen matrix wrapping and bone marrow injection: clinical and biomolecular study

PurposeThe functional outcomes of arthroscopic matrix-based meniscus repair (AMMR) in patients two and five years after the treatment clearly show that the use of the collagen matrix and bone marrow aspirate creates favorable biological conditions for meniscus healing. This study not only provides ten follow-up results but also investigates biomolecular mechanisms governing the regenerative process.MethodsCase series was based on data collected from patients who underwent AMMR procedure, starting with preoperatively through two-year and five-year till ten-year follow-up. The outcomes are presented as IKDC and the Lysholm subjective scores as well as the imaging results. Biomolecular investigation of the membranes utilized in the AMMR procedure include DNA content analysis, cell viability and proliferation study of bone marrow and bone marrow concentrate-derived cells, and cytokine array performed on monocytes cultured on the membranes.ConclusionData collected from patients who underwent AMMR procedure, starting with pre-operatively through two year and five year till ten year follow-up, indicate the possibility for long-term, stable meniscus preservation. Outcomes are manifested with a visible improvement of the IKDC and the Lysholm subjective scores as well as in the imaging results. The type of the meniscal tear or complexity of the knee injury (isolated AMMR vs. AMMR + ACL) did not affect the clinical outcomes. The study highlighted the role of the membrane in facilitating cell adhesion and proliferation. Additionally, several cytokines were selected as potentially crucial products of the membrane vs. monocyte interactions, driving the tissue regeneration and remodeling. Interestingly, thresholds of what constitutes a safe and well-decellularized membrane according to relevant literature have been significantly breached, but ultimately did not elicit detrimental side effects.

Arthroscopic Intrameniscal Decompression for the Treatment of Lateral Meniscal Cysts

The meniscal cyst is a common complication associated with complex degenerative meniscal tears such as degenerative flaps and horizontal cleavage tears. The current gold standard treatment for this condition is arthroscopic decompression with partial meniscectomy; however, there are three concerns regarding this treatment. First, cases of meniscal cysts commonly involve an intrameniscal location of the degenerative lesion. Second, when there is difficulty in finding the lesion, a so-called “check-valve” is required, and a large-scale meniscectomy is necessary. Thus, postoperative osteoarthritis is a well-known sequela. Third, treatment of a meniscal cyst from the inner edge of the meniscus is indirect and inadequate for reaching the pathological region, as most meniscal cysts are located at the peripheral portion of the meniscus. Therefore, this report describes direct decompression of a large lateral meniscal cyst and repair of the meniscus using decompression with an intrameniscal approach. This technique is simple and reasonable for the purpose of meniscal preservation.

Segmental meniscal replacement

Meniscal damage results in higher peak stress on the articular cartilage and leads to cartilage degeneration and osteoarthritis. Thus, in recent years there has been an increasing tendency to “save the meniscus” and to repair meniscal defects. However, this is not always possible and restoring meniscal function using scaffolds fulfills this gap. This approach requires the physical presence of an artificial meniscus to allow successful migration and colonization with precursor cells and vessels that lead to the development of organized meniscal tissue. Two meniscal scaffolds are currently available; 1 composed of aliphatic polyurethane named Actifit (Orteq Sports Medicine, Ltd.), and one based on collagen type I fibers called Collagen Meniscus Implant (Stryker Kalamazoo). Both provide an effective and safe solution to treat symptomatic patients with segmental meniscus mid-substance defects. Indeed, recent studies have demonstrated their ability to significantly improve patient satisfaction and clinical evaluation in the mid- to long-term. As such, these approaches hold great promise as a meniscus preservation option to facilitate long-term knee health.

The Current Role of Biologics for Meniscus Injury and Treatment.

There is little doubt that the consensus has changed to favor preservation of meniscal function where possible. Accordingly, the indications for meniscal repair strategies have been refocused on the long-term interest of knee joint health. The development and refinements in surgical technique have been complemented by biological augmentation strategies to address intrinsic challenges in healing capacity of meniscal tissue, with variable effects. A contemporary approach to meniscal healing includes adequate surgical fixation, meniscal and synovial tissue stimulation, and management of the intraarticular milieu. Overall, evidence supporting the use of autogenous or allogeneic cell sources remains limited. The use of FDA-approved medications to effect biologically favorable mechanisms during meniscal healing holds promise. Development and characterization of biologics continue to advance with translational research focused on specific growth factors, cell and tissue behaviors in meniscal healing, and joint homeostasis. Although significant strides have been made in laboratory and pre-clinical studies, translation to clinical application remains challenging. Finally, expert consensus and standardization of nomenclature related to orthobiologics for meniscal preservation will be important for the advancement of this field.

Poster 224: Tear Features and Surgical Techniques in 1230 Child and Adolescent Meniscus Repairs: Results from a Prospective, Multicenter Registry

Objectives:Recent literature has suggested a marked shift towards increased meniscus repair relative to meniscectomy over the last decade in younger populations. Children and adolescents are more profoundly impacted by the outcomes of meniscus preservation, in terms of long-term joint health, given the subsequent decades of high activity levels, risk of meniscus re-injury, and progression towards degenerative joint disease in the setting of meniscus deficiency. The purpose of this study was to provide a comprehensive assessment of meniscus tear patterns and repair techniques utilized in children and adolescents to better elucidate features of this common injury and national trends in treatment.Methods:A prospective, multi-center registry of 4 different arthroscopic surgeries—discoid meniscus surgery, non-discoid meniscus repair [medial meniscus repair (MMR) or lateral meniscus tear (LMR)], anterior cruciate ligament reconstruction (ACLR), and tibial spine repair (TSR)—performed by 32 surgeon-investigators at 20 different academic centers over 30 months, was queried for all cases of non-discoid meniscus repair, which were further categorized according to whether they were performed in isolation (I-MR), or in conjunction with ACLR or TSR. Variables collected included patient demographic features (age, sex, BMI), compartment (lateral, LMT; medial, MMT), zone (white-white, red-white, red-red), pattern (longitudinal/vertical, complex/degenerative, radial, oblique/parrot’s beak, horizontal/cleavage), displacement (yes/no), location (anterior, body, posterior, root), repair technique (all-inside, inside-out, outside-in, other), repair implant/construct (menisco-capsular implants/sutures, meniscal-based sutures), and number of implants/sutures. Descriptive statistics and comparative analysis were performed for I-MR vs. ACLR-MR vs. TSR-MR and MMR vs. LMR.Results:Of 1374 meniscus repairs (mean 15.1 years old, range 5-19, 44% Female), 763 (55.5%) were performed for LMT and 611 (44.5%) for MMT, with 184 of all cases (15%) representing bicompartmental meniscus repair (LMR+MMR). ACLR-MR (n=817, 66.9%) was significantly more common than I-MR (n=373, 30.6%), which was significantly more common than TSR-MR (n=31, 2.5%, p=0.001). I-MR had a higher incidence of anterior horn, meniscal body tears, inside out repairs, and outside in repairs (all p<0.001). Of MMTs that underwent repair 81.2% were vertical/longitudinal, while LMTs that underwent repair were comprised of 49.6% vertical/longitudinal, 24.2% complex/degenerative, and 13.9% radial (Table 1). While the most common tear zone for repaired menisci was the red-white zone, 18% of LMR and 13.4% of MMR were in the white-white zone. The posterior horn was one of the most common locations of a repairable lesion (45.1% LMT and 43.9% MMT) with 12.8% of LMT repairs and 6.2% of MMT repairs performed on the posterior root. 70% of repairs were performed with all-inside technique, which was the predominant technique for all tear patterns in both MMT and LMT. Only 14.1% of repairs were performed with inside-out technique, but 70% of these cases were for displaced tears. The average number of implants/sutures for non-displaced tears was 4.0, compared with 5.9 for displaced tears. While a majority of repairs used meniscocapsular repair techniques, 11.1% of meniscus repairs were based on meniscal-based sutures including 20.8% of radial tear repairs. 14 different implants were used by study surgeons (Figures 1 and 2).Conclusions:Amongst tears selected for repair in children and adolescents, LMT is more common than MMT, and the majority of cases arise in conjunction with ACLR, compared to isolated tears. The predominant tear pattern is vertical in MMTs (80%). By percentage, radial tears are seven times more common and posterior root tears are twice as common in lateral meniscus tears. Given the high and increasing frequency of this injury and procedure, nationally, the variation detected in repair techniques and implants utilized represent potential opportunities for optimization of care and reduction in health care costs.Table 1.Medial and lateral mensicus tear types and fixation techniques used. () indicated percentage of repair technique type for each tear type