Meniscectomy Procedures Research Articles

Outcome of Meniscus Repair vs Meniscectomy in 40 Years and Older Patient: Systematic Review and Meta Analysis of Direct Comparative Studies

Introduction and Objectives: An older age of the patient is a common reason for choosing meniscectomy instead of meniscus repair. Lately, there have been more meniscus repairs done for all ages. But not many studies have looked at how well meniscus repair works compare to meniscectomy in people who are 40-years-old and older. And there is not a lot of review of the studies about how well meniscus repair works. The goal of this research was to look at the results of a recent study on patients who were 40-years-old and older and had either meniscus repair or meniscectomy. The hypothesis was that repair the meniscus would give better results than meniscectomy procedure in patients who are 40-years-old and older. Materials and Methods: The study design was following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, including 5 comprehensive literature databases. Inclusion criteria: (1) Patient with meniscus tear who got arthroscopic meniscal repair or meniscectomy; (2) Studies were written in English, (3) Studies are direct outcome comparison between Meniscus repair to meniscectomy. Exclusion criteria: (1) Studies other than direct comparison of Meniscus repair to meniscectomy; (2) Expert opinions, case reports, case series, review articles, and meta-analyses were excluded.; (3) Studies did not analyzed outcomes evaluations. Search terms used are included the following: (menisci OR meniscus) AND (meniscus injuries OR menisci tear) AND (meniscectomy OR meniscus repair) AND (40 Years old or Elderly). Result: A total of 3 studies with sample of 220 knees were direct outcome comparison of meniscus repair and meniscectomy in 40 years old and older. The Lysholm score and IKDC score of Meniscus repair are superior and statistically significant compare to meniscectomy. The satisfactory score of meniscus repair is superior but not statistically significant compare to meniscectomy. Conclusion: This study found that meniscus repair in patients with meniscus tear in 40 years old and older has better clinical outcomes than meniscectomy. But, the study has a limitation because the lack of RCT studies. We need future RCT studies for a better result of the study.

Clinical outcomes of arthroscopic partial meniscectomy at 10 years follow up - A retrospective cohort study

Objectives: In recent times, the advent of newer meniscal repair systems and studies thereof seem to have implied that meniscectomy procedures should be abandoned or used only as a last resort procedure in most patients. This study was done to report the outcomes of partial meniscectomy done in indicated patients by a skilled arthroscopic surgeon at a long-term follow-up of 10 years. The indications and the appropriate strategy for performing this procedure are also described. Materials and Methods: One hundred consecutive patients who underwent arthroscopic partial meniscectomy (APM) over one year were evaluated 10 years later for functional and clinical outcomes. Results: A retrospective case series of 100 consecutive patients was conducted to study the clinical outcome of APM after 10 years. Their mean age was 41.23 ± 7.81 years. 70% of the selected patients were male. Medial meniscus involvement was the most common (73%). At their 10-year follow-up, the majority of cases were asymptomatic (72%), with a mean international knee documentation committee score of 86.90 ± 5.51. Mean Tegner Lysholm Knee score was 90.05 ± 10.21, the Western Ontario and McMaster Universities Arthritis Index score was 8.83 ± 6.19, and the Western Ontario meniscal evaluation tool score was 85.54 ± 10.91. The subjective assessment after surgery was “excellent” in the majority of patients (48%). Conclusion: With proper patient selection and accurate decision-making, patients operated with APM for isolated meniscus tears can return to their daily routine activities and have good clinical and functional outcomes. The technique of performing arthroscopy and the skill set of the operating surgeon may perhaps also be an important criterion influencing the outcomes.

Influence of Previous Arthroscopic Meniscectomy on Midterm to Long-term Outcomes After Medial Open-Wedge High Tibial Osteotomy

Background: Few studies have evaluated the clinical and radiological outcomes of medial open-wedge high tibial osteotomy (MOWHTO) in patients who had previously undergone arthroscopic meniscectomy. Purpose: To verify whether previous arthroscopic meniscectomy affects the clinical and radiological outcomes of MOWHTO. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 183 consecutive knees that underwent MOWHTO and had a minimum 5 years of follow-up were retrospectively reviewed. We compared the preoperative and postoperative clinical and radiological data of 32 knees with a history of meniscectomy (previous meniscectomy group) to 151 control knees without a history of meniscectomy. Cartilage status was also compared at first- and second-look arthroscopic surgery according to the International Cartilage Repair Society grading system. Failure was defined as conversion to total knee arthroplasty or revision MOWHTO. On subgroup analysis, the previous meniscectomy group was divided into 2 subgroups based on the time from meniscectomy to MOWHTO (<3 vs ≥3 years). Results: The mean age at the time of surgery was 55.9 years (range, 38-70 years), and the mean follow-up period was 86.2 months (range, 60-164 months). The mean time between meniscectomy and MOWHTO was 48.9 months (range, 5-156 months), and all meniscectomy procedures were performed on the medial side. Preoperative patient characteristics were similar between the study groups. Clinical and radiological outcomes were not significantly different between the groups at the latest follow-up, and no significant between-group differences were observed regarding postoperative cartilage status on arthroscopic examination. One knee in the control group underwent conversion to total knee arthroplasty at 7 years postoperatively for arthritic progression. Subgroup analysis of the previous meniscectomy group indicated no significant differences in clinical outcomes based on the time from meniscectomy to MOWHTO. Conclusion: Based on the results, a history of meniscectomy did not adversely affect the midterm to long-term outcomes of MOWHTO. Furthermore, the time between previous meniscectomy and MOWHTO was not associated with the clinical outcomes of MOWHTO.

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.

Strength-Based Rehabilitation on Clinical Outcomes in Patients Postpartial Meniscectomy: A Systematic Review and Meta-analysis.

The aim of the study is to determine the effect of strength-based rehabilitation programs on patients who underwent partial meniscectomy procedures. Three databases MEDLINE, PubMed, and Embase were searched from inception to May 9, 2022. Data on functional outcomes such as quadriceps and hamstring strengths, as well as patient-reported outcomes such as Knee Osteoarthritis and Outcome Score and visual analog scale were recorded. A total of nine studies comprising 417 patients were included in this review. There were no significant differences in quadriceps or hamstring strength measures between preinterventation and postintervention for both groups. Knee Osteoarthritis and Outcome Scores significantly increased from preintervention and postintervention in both control and exercise groups. Visual analog scale scores changed from 5.0 to 1.4 cm in the exercise arm and 3.1 to 1.9 cm in the control arm. Strength-based exercise programs for patients postpartial meniscectomy did not result in significantly different improvements in quadriceps or hamstring strength compared with control programs. However, strength-based exercise programs resulted in significantly higher Knee Osteoarthritis and Outcome Scores and a greater decrease in visual analog scale scores. Further studies, specifically well-designed systematic randomized controlled trials, are necessary to elucidate the specifics behind what type of exercises to use in addition to load progression and frequency of training.

Bucket-Handle Meniscus Tear Management With Meniscectomy Versus Repair Correlates With Patient, Socioeconomic, and Hospital Factors.

Bucket-handle meniscus tears are common knee injuries that are often treated surgically with meniscectomy or meniscal repair. Although clinical factors may influence the choice of one treatment approach over the other, the influence of patient, socioeconomic, and hospital factors remains poorly characterized. This study aimed to estimate the relative nationwide utilization of these two procedures and delineate a variety of factors that are associated with the selection of one treatment approach over the other. Meniscal repair and meniscectomy procedures conducted for isolated bucket-handle meniscus tears in 2016 and 2017 were identified in the Nationwide Ambulatory Surgery Sample database. Cases were weighted using nationally representative discharge weights. Univariate analyses and a multivariable logistic regression model were used to compare patient, socioeconomic, and hospital factors associated with meniscal repair versus meniscectomy. In total, 12,239 cases were identified, which represented 17,236 cases after weighting. Of these, meniscal repair was conducted for 4,138 (24.0%). Based on the logistic regression model, meniscal repair was less likely for older and sicker patients. By contrast, several factors were associated with markedly higher odds of undergoing meniscal repair compared with meniscectomy. These included urban teaching hospitals; geographic location in the midwest, south, and west; and higher median household income. Using a large nationally representative cohort, the current data revealed that only 24.0% of surgically treated bucket-handle meniscus tears were treated using repair. Identification of patient, socioeconomic, and hospital factors differentially associated with meniscal repair suggest that other factors may systematically influence surgical decision-making for this patient population. Surgeons should be conscious of these potential healthcare disparities when determining the optimal treatment for their patients. Level III.

Poster 219: Posterior Sagittal Position of the Tibial Tubercle as Measured by the Sagittal Tibial Tubercle – Trochlear Groove Distance Correlates with an Increased Risk for Surgery in Patients with Patellofemoral Chondral Lesions

Objectives:The etiology of isolated patellofemoral (PF) cartilage defects without patellar instability is currently incompletely understood. The purpose of the present study was to evaluate the variation in knee sagittal alignment in patients with and without PF cartilage wear.Methods:This was a single-center, retrospective review of patients that underwent a cartilage restoration procedure for isolated PF cartilage wear from 2014-2020. Patients were matched in a 1:2:2 ratio for age, sex, and BMI to anterior knee pain diagnosis and meniscectomy procedure cohorts as controls. Exclusion criteria included knee flexion angle >10°, elevated Caton-Deschamps index (CDI>1.3), increased sulcus angle (>145°), increased patellar tilt (>5°), elevated coronal TT-TG (>15mm), varus/valgus malalignment (>5°), or ICRS patellofemoral cartilage defects of ≥3 in either control group. The sagittal TT-TG (sTT-TG) distance was measured on preoperative axial T2 magnetic resonance imaging (MRI) and was defined as the distance between a point at the nadir of the trochlear cartilage and the most anterior point of the tibial tubercle. Comparisons between the 3 groups were made using ANOVA testing with Bonferroni corrections. Reliability was assessed with the interclass correlation coefficient (ICC). Odds ratios were calculated based on a sTT-TG measurement threshold obtained from a receiver operative characteristic curve graph.Results:Two hundred and thirty-five patients (47 cartilage restoration, 94 anterior knee pain, 94 meniscectomy) were included. Mean age, BMI, and height were 33.8 +/- 8.7 and 26.7 +/- 5.7, 170.6 +/- 24.3 respectively, with 130 males (55%) and 105 females (45%). There were no significant differences between groups for age, BMI or sex(p>0.05). Mean sTT-TG was significantly more posterior in the cartilage restoration group compared to the meniscectomy group (-2.5 mm +/-5.9 vs 1.72 mm +/- 5.3, p<0.001). The anterior knee pain group sTT-TG was between the meniscectomy and cartilage restoration groups, but was not significantly different from either (p=0.067, p=0.13). Interrater reliability was excellent (ICC=0.927, p<0.001). Patients with a posterior translation of -2.15 or greater were 2.12 times more likely to undergo a cartilage restoration procedure (OR 2.12, 95% CI 1.1 to 4.1).Conclusions:Cartilage restoration procedure patients had a significantly more posterior tibial tubercle than partial meniscectomy controls. Anterior knee pain patient sagittal TT-TG was between both groups, but was not significantly different from either. Patients with sTT-TG of <-2.15 mm were 2.12 x more likely to have a cartilage restoration procedure.

Patients With Medicaid Insurance Undergoing Anterior Cruciate Ligament Reconstruction have Lower Postoperative International Knee Documentation Committee Scores and are Less Likely to Return to Sport Than Privately Insured Patients

PurposeTo determine whether patients insured through Medicaid exhibit differences in patient-reported outcomes, return to sport rates, and reinjury and reoperation metrics after anterior cruciate ligament (ACL) reconstruction compared with patients insured with private insurance.MethodsPatients insured through Medicaid who had undergone a primary ACL reconstruction were identified and compared with a matched cohort of patients insured through private insurance with the same age and sex. Patients were contacted via telephone and emailed a questionnaire containing the International Knee Documentation Committee (IKDC) score, return to sport questions, and reinjury and reoperation metrics. Physical therapy (PT) notes were also reviewed to determine number of PT visits attended and distance from patients’ home address to PT facility.ResultsA total of 26 patients insured through Medicaid and 25 insured through private insurance were enrolled in this study. The 2 groups demonstrated no statistically significant differences in age, body mass index, or sex. There were no differences in preoperative meniscus injuries or concomitant meniscus repair or meniscectomy procedures between the 2 groups. There were no differences in preoperative IKDC scores; however, the Medicaid group demonstrated a significantly lower postoperative IKDC score (74.7 vs 90.5; P = .005). Patients insured through Medicaid also demonstrated a significantly lower rate of return to sport and attended significantly fewer PT visits following surgery. There were no significant differences in reinjury or reoperation to the index knee between the 2 groups. The threshold number of PT visits for return to sport was determined to be 31.5 visits. Within the private insurance cohort, 17 of 23 patients (73.9%) exceeded this threshold. However, in the Medicaid cohort, 5 of 18 patients (27.8%) exceeded this threshold.ConclusionsPatients with Medicaid insurance undergoing ACL reconstruction had lower postoperative IKDC scores and were less likely overall to return to sport than their private insurance counterparts at final follow-up in this study. Preoperative IKDC scores, incidence of preoperative meniscus injury, number of concomitant meniscus procedures, average distance from home to PT facility, return to same level of sport, and reinjury and reoperation rate were similar between groups. However, the number of postoperative PT sessions attended by patients insured through Medicaid was significantly lower than private insurance patients.Level of EvidenceIII, retrospective comparative study.

Analysis of the trends in arthroscopic meniscectomy and meniscus repair procedures in France from 2005 to 2017

IntroductionIn 2008, the French National Authority for Health (HAS) recommended that “conservative” treatments be adopted for meniscal lesions. This recommendation and the lack of superiority of meniscectomy over non-operative treatment for meniscus degeneration have modified the treatment pathway. However, the impact of these findings on French clinical practice is not known. The objective of this study was to evaluate the change over time in the number of alternative surgical procedures (meniscectomy and meniscus repair) and regional variation in France using data from the French agency for information on hospital care (ATIH). HypothesisWe hypothesized that the number of meniscectomy procedures will decrease, and the number of repair procedures will increase over time at various healthcare facilities. Patients and methodsBetween 2005 and 2017, the number of hospitalizations in the Medicine-Surgery-Obstetrics wards for meniscectomy (NFFC003 and NFCC004) or meniscus repair (NFEC001 and NFEC002) was evaluated overall and then based on whether the stay occurred in public or private sector hospitals in France. Data were extracted from the ATIH database and the findings were (1) related to French demographics during the period in question; (2) separated into public or private sector hospitals; (3) distributed into various regions in France and; (4) stratified by patient age. ResultsBetween 2005 and 2017, 1,564,461 meniscectomy and 63,142 meniscus repair procedures were done in France. Over this period in the entire country, the meniscectomy rate gradually decreased from 19.80/10,000 inhabitants in 2005 to 15.77/10,000 inhabitants in 2017 (21.4% reduction) (p<0.0001) while the meniscus repair rate increased from 0.42/10,000 inhabitants in 2005 to 1.36/10,000 inhabitants in 2017 (320% increase) (p<0.0001). The largest meniscectomy reduction effort occurred in private sector hospitals, going from 15.79 to 12.01/10,000 inhabitants in 12 years; the decrease was smaller in public hospitals (going from 4.01 to 3.77/10,000 inhabitants) (p<0.0001 in both cases). The change in the procedure ratio between private and public hospitals was asymmetric, with the meniscus repair/meniscectomy ratio clearly increasing more in public hospitals (4% to 12.6%) between 2005 and 2017 than in private hospitals (1.6% to 6.6%) (p<0.0001). We found large regional differences: regions in Eastern France had higher meniscectomy rates, while regions in Western France had higher meniscus repair rates. When the analysis of procedures between 2008 and 2017 was stratified by age, a similar increase in repair procedures was found in all age brackets. Conversely, the reduction in meniscectomy was most apparent before 40 years of age, and the number of meniscectomy procedures was stable after 60 years of age. ConclusionThese findings suggest there has been a significant shift in the surgical management of meniscal injuries towards more conservative treatments. But the large variations between regions in France is evidence of a continued disparity in clinical practices. Level of evidenceIV, retrospective study without control group.

Meniscus Root Repair vs Meniscectomy or Nonoperative Management to Prevent Knee Osteoarthritis After Medial Meniscus Root Tears: Clinical and Economic Effectiveness

Background: Medial meniscus root tears are a common knee injury and can lead to accelerated osteoarthritis, which might ultimately result in a total knee replacement. Purpose: To compare meniscus repair, meniscectomy, and nonoperative treatment approaches among middle-aged patients in terms of osteoarthritis development, total knee replacement rates (clinical effectiveness), and cost-effectiveness. Study Design: Meta-analysis and cost-effectiveness analysis. Methods: A systematic literature search was conducted. Progression to osteoarthritis was pooled and meta-analyzed. A Markov model projected strategy-specific costs and disutilities in a cohort of 55-year-old patients presenting with a meniscus root tear without osteoarthritis at baseline. Failure rates of repair and meniscectomy procedures and disutilities associated with osteoarthritis, total knee replacement, and revision total knee replacement were accounted for. Utilities, costs, and event rates were based on literature and public databases. Analyses considered a time frame between 5 years and lifetime and explored the effects of parameter uncertainty. Results: Over 10 years, meniscus repair, meniscectomy, and nonoperative treatment led to 53.0%, 99.3%, and 95.1% rates of osteoarthritis and 33.5%, 51.5%, and 45.5% rates of total knee replacement, respectively. Meta-analysis confirmed lower osteoarthritis and total knee replacement rates for meniscus repair versus meniscectomy and nonoperative treatment. Discounted 10-year costs were $22,590 for meniscus repair, as opposed to $31,528 and $25,006 for meniscectomy and nonoperative treatment, respectively; projected quality-adjusted life years were 6.892, 6.533, and 6.693, respectively, yielding meniscus repair to be an economically dominant strategy. Repair was either cost-effective or dominant when compared with meniscectomy and nonoperative treatment across a broad range of assumptions starting from 5 years after surgery. Conclusion: Repair of medial meniscus root tears, as compared with total meniscectomy and nonsurgical treatment, leads to less osteoarthritis and is a cost-saving intervention. While small confirmatory randomized clinical head-to-head trials are warranted, the presented evidence seems to point relatively clearly toward adopting meniscus repair as the preferred initial intervention for medial meniscus root tears.

Intra-articular Implantation of Mesenchymal Stem Cells, Part 1: A Review of the Literature for Prevention of Postmeniscectomy Osteoarthritis.

Osteoarthritis (OA) after a partial or total meniscectomy procedure is a common pathology. Because of the high incidence of meniscectomy in the general population, as well as the significant burden of knee OA, there is increasing interest in determining methods for delaying postmeniscectomy OA. Biological therapies, including mesenchymal stem cells (MSCs), induced pluripotent stem cells (iPSCs), and platelet-rich plasma (PRP), have been proposed as possible therapies that could delay OA in this and other settings. Several studies in various animal models have evaluated the effect of injecting MSCs into the knee joints of animals with OA induced either by meniscal excision with or without anterior cruciate ligament transection. When compared with control groups receiving injections without progenitor cells, short-term benefits in the experimental groups have been reported. In human subjects, there are limited data to determine the effect of biological therapies for use in delaying or preventing the onset of OA after a meniscectomy procedure. The purpose of this review is to highlight the findings in the presently available literature on the use of intra-articular implantation of MSCs postmeniscectomy and to offer suggestions for future research with the goal of delaying or treating early OA postmeniscectomy with MSCs.

Meniscus Induced Cartilaginous Damage and Non-linear Gross Anatomical Progression of Early-stage Osteoarthritis in a Canine Model

Background:The predictable outcome of the anterior cruciate ligament transection (ACLT) canine model, and the similarity to naturally occurring osteoarthritis (OA) in humans, provide a translatable method for studying OA. Still, evidence of direct meniscus-induced cartilaginous damage has not been identified, and gross-anatomical blinded scoring of early-stage OA has not been performed.Objective:A gross anatomical observation and statistical analysis of OA progression to determine meniscus induced cartilaginous damage, to measure the macroscopic progression of OA, and to address matters involving arthroscopic and surgical procedures of the knee.Method:Unblinded assessment and blinded scoring of meniscal, tibial, femoral, and patellar damage were performed for control and at four time points following unilateral ACLT: 3-week (N=4), 8-week (N=4), 12-week (N=5), and 25-week (N=4). Mixed-model statistics illustrates damage (score) progression; Wilcoxon rank-sum tests compared time-point scores; and Wilcoxon signed-rank tests compared ACLT and contralateral scores, and meniscus and tibia scores.Result:Damage was manifest first on the posterior aspect of the medial meniscus and subsequently on the tibia and femur, implying meniscal damage can precede, coincide with, and aggravate cartilage damage. Damage extent varied chronologically and was dependent upon the joint component. Meniscal damage was evident at 3 weeks and progressed through 25-weeks. Meniscal loose bodies corresponded to tibial cartilage damage location and extent through 12 weeks, followed by cartilage repair activity after complete meniscal degeneration.Conclusion:This study provides additional information for understanding OA progression, identifying OA biomarkers, and arthroscopic and meniscectomy procedures.

Board #300 - Technology Innovation Validation with Expert Surgeons of the Anatomical Adult Knee Model for Training Techniques (Submission #9690)

Introduction Several simulators have been created to improve the learning curve of residents in knee surgery. Laboratory training is fundamental for acquiring familiarity with the techniques of surgery and skill in handling instruments. Arthroscopy is a surgical procedure useful in medical practice in orthopedic knee surgery. This surgical technique is defined as a “gold standard” for treatment, mainly in meniscal tears and anterior cruciate ligament reconstruction. In fact the young orthopedic surgeon who wants to work in this area must be able to do this type of surgical approach. The aim of this study is to validate the synthetic model called “Kneetrainer 1” by expert surgeons practicing realistic surgical simulations for the knee, for example: arthroscopy, meniscectomy and anterior cruciate ligament reconstruction. We selected for this validation 17 expert surgeons in the knee procedure. All performed this procedures in the “Kneetrainer 1” model. After the procedure, all surgeons answered a questionnaire to evaluate the realistic model with the following sentences: consistency, strength, tactile identification, applicability of the model for training young surgeons, and general capability score of simulation to the procedures described above. Description Despite the consistency of the model material, 53% of surgeons reported it with minor changes compared to the normal tissue or considered similar to the normal tissue. As for the strength of the material model, 37% reported that it needs minor changes as compared to normal tissue, so as not to cause damage to the surgical simulation. Regarding the tactile and arthroscopic identification of bone and soft tissue structures, the majority (range 65-100 % ) of the participants felt the simulator was appropriate to the shape and size of the human knee. The overall procedure of meniscectomy and anterior cruciate ligament reconstruction were considered adequate by 82% and 100% of experts, respectively. Overall capability score for realistic simulation for the meniscectomy procedure was 64.7% of surgeons so they concluded that the simulator is able to increase surgical skills and handling of practical application with young surgeons. The overall capability score for realistic simulation for the arthroscopy procedure and anterior cruciate ligament reconstruction was 82.4% of surgeons have approved the model. Most of the participants (94%) considered that the “Kneetrainer 1” was able to create skills and modify activities of non expert surgeons in training. Conclusion The model for realistic simulation “Kneetrainer 1” was validated with overall capability score of the simulation for 64.7% to meniscectomy and 82.4% to arthroscopy with the anterior cruciate ligament reconstruction. The majority of expert surgeons (94%) considered the “Kneetrainer 1” to be able to generate or to modify the skills and activities of the young surgeons in training.

Short- to mid-term results of arthroscopic meniscal repair of long vertical longitudinal tears using combined cruciate and horizontal suture techniques: a retrospective study.

The purpose was to evaluate the clinical results of arthroscopic meniscal repair of long vertical longitudinal tears using combined cruciate and horizontal suture techniques. Single surgeon retrospective case series study. A total of 38 patients having long vertical longitudinal tears were operated using combined cruciate and horizontal suture techniques. Two patients had to undergo a meniscectomy procedure within the 1st year postoperative and those were considered failure cases; 32 patients were available for follow-up evaluation (average 4.6 years) and six were lost including the two failures. Objective IKDC, modified Lysholm knee score, SF-36 score, VAS for patients' satisfaction and VAS for pain were used for follow-up evaluation. Kellgren and Lawrence (K/L) classification of osteoarthritis was also used. Successful rate was 94.1% (32 patients), while failure was 5.9% (2 patients). Objective IKDC score revealed that 27 patients had grade "A" and 5 had grade "B," while no single patient had neither grade "C" nor "D." The average modified Lysholm score was 91.3. Average SF-36 score was 88.4. The average VAS for operation satisfaction was eight. Average VAS for pain was 1.5. Preoperatively, 30 patients were classified as normal K/L classification, while two patients were K/L classification grade "1." At the time of the follow-up, 24 patients were classified as normal K/L classification, six were grade "1," two were grade "2," and thus, six had osteoarthritis progression. Arthroscopic meniscal repair of long vertical longitudinal tears using combined cruciate and horizontal suture techniques is a safe surgical procedure with good clinical outcome. Level IV.

Matrix-Assisted Autologous Chondrocyte Transplantation for Cartilage Regeneration in Osteoarthritic Knees

Background: Young patients with osteoarthritic knees are a challenging population because of a combination of high functional demands and limited indication for joint replacement. Purpose: To analyze the potential of the cartilage regenerative approach by documenting the results and failures of matrix-assisted autologous chondrocyte transplantation (MACT) at midterm follow-up. Study Design: Case series; Level of evidence, 4. Methods: Forty-four patients affected by cartilage lesions in osteoarthritic knees underwent MACT as a salvage procedure. The mean age at surgery was 42 years (range, 20-58 years), and the average defect size was 4 cm2 (range, 1.5-9 cm2). Patients were prospectively evaluated with the subjective International Knee Documentation Committee (IKDC), EuroQol visual analog scale (EQ-VAS), and Tegner scores preoperatively; at 1, 2, and 5 years; and at a final assessment at 9 years’ mean follow-up. Adverse events and failures were also reported. Results: A statistically significant improvement was observed in all scores from the initial evaluation to the final follow-up. The mean ± standard deviation IKDC subjective score improved from 38.0 ± 15.8 to 67.0 ± 18.3 at 2 years (P < .0005), with a subsequent decrease to 57.8 ± 20.6 at the final follow-up (P = .012). The same trend was confirmed by the EQ-VAS score. The activity level revealed by the Tegner score improved at all follow-ups but without achieving the preinjury level. The analysis of the influencing factors showed the importance of the meniscus condition, revealing a significantly inferior outcome in knees with previous or combined partial meniscectomy procedures. During the study period, 12 patients had failed results, producing a cumulative failure rate of 27.3%. At the last evaluation, half of the patients considered their condition not better than before the treatment, and 39% would not repeat the treatment considering the results obtained. Conclusion: Despite a statistically significant improvement, the clinical outcome was poor. A higher improvement could be obtained in patients who had not undergone previous or combined meniscectomies, but this was limited over time. The failure rate was also high, regardless of the degree of osteoarthritis. Tissue-engineered cartilage implantation is questionable for this indication, and the limits of this scaffold-based procedure have to be considered if it is used as a salvage procedure for young patients affected by knee osteoarthritis.

Meniscectomy

To review the meniscus from a historical perspective especially on surgical management and general guidelines for arthroscopic meniscectomy procedures for various types of meniscal tears. We searched MEDLINE and PubMed for the years of 1980-2010 using the terms meniscus, meniscal repair, menisectomy, and arthroscopy. Orthopedic surgeons frequently encounter patients with pain or functional impairment of the knee joint and repair or resection of the injured meniscus is one of the most common orthopedic operative procedures. The object of meniscal surgery is to reduce pain, restore functional meniscus and prevent the development of degenerative osteoarthritis in the involved knee. Historically, total meniscectomy was a common procedure performed for meniscus tear symptoms. However, it has been reported that total meniscectomy has deleterious effects on the knee. In the past, the menisci were thought as a functionless remnant tissue. Currently, it is known that the meniscus is an important structure for knee joint function. Menisci provide several vital functions including mechanical support, localized pressure distribution, and lubrication to the knee joint. It is widely accepted that the function of the meniscus can be preserved through minimal excision. An arthroscopic partial meniscectomy preserving more of the meniscus is preferred over total meniscectomy. In recent decades, this shift toward arthroscopic partial meniscectomy has led to the development of new surgical techniques.

Tissue engineering with meniscus cells derived from surgical debris

Injuries to the avascular regions of the meniscus fail to heal and so are treated by resection of the damaged tissue. This alleviates symptoms but fails to restore normal load transmission in the knee. Tissue engineering functional meniscus constructs for re-implantation may improve tissue repair. While numerous studies have developed scaffolds for meniscus repair, the most appropriate autologous cell source remains to be determined. In this study, we hypothesized that the debris generated from common meniscectomy procedures would possess cells with potential for forming replacement tissue. We also hypothesized that donor age and the disease status would influence the ability of derived cells to generate functional, fibrocartilaginous matrix. Meniscus derived cells (MDCs) were isolated from waste tissue of 10 human donors (seven partial meniscectomies and three total knee arthroplasties) ranging in age from 18 to 84 years. MDCs were expanded in monolayer culture through passage 2 and seeded onto fiber-aligned biodegradable nanofibrous scaffolds and cultured in a chemically defined media. Mechanical properties, biochemical content, and histological features were evaluated over 10 weeks of culture. Results demonstrated that cells from every donor contributed to increasing biochemical content and mechanical properties of engineered constructs. Significant variability was observed in outcome parameters (cell infiltration, proteoglycan and collagen content, and mechanical properties) amongst donors, but these variations did not correlate with patient age or disease condition. Strong correlations were observed between the amount of collagen deposition within the construct and the tensile properties achieved. In scaffolds seeded with particularly robust cells, construct tensile moduli approached maxima of approximately 40 MPa over the 10-week culture period. This study demonstrates that cells derived from surgical debris are a potent cell source for engineered meniscus constructs. Results further show that robust growth is possible in MDCs from middle-aged and elderly patients, highlighting the potential for therapeutic intervention using autologous cells.

Two to nineteen years follow-up of arthroscopic meniscal repair using the outside-in technique: a retrospective study

To perform a long-term follow-up evaluation of the outside-in technique of arthroscopic meniscal repair. Retrospective study. Between the years 1986 and 2002, 93 cases of arthroscopic meniscal repair using the outside-in technique have been operated by the senior author (F.L.). Forty-one patients were available for the follow-up evaluation with a mean follow-up of 11.71 years. The International Knee Documentation Committee (IKDC), the modified Lysholm score, the SF-36 (short form 36) health survey score, a visual analogue scale (VAS) for assessment of patients' satisfaction and another VAS for assessment of patients' pain were used retrospectively to evaluate the patients. We also used the Kellgren and Lawrence (K/L) classification of osteoarthritis to evaluate the preoperative X-rays and the X-rays done at the time of the follow-up evaluation. Failure was defined as having a meniscectomy procedure post-operatively. From the 93 patients, 52 could not be retrieved for the follow-up evaluation, while 41 were available for it; 36 patients were clinically successful and 5 were considered as failure. Thirty-six patients were classified as grade "A" in the objective IKDC score, mean modified Lysholm score was 87.29 (SD 16.43), while mean SF-36 score was 85.73 (SD 14.17). The results of the VAS for operation satisfaction ranging from -10 to +10 revealed that the mean of the answers was 8.05 (SD 2.99). The results of the VAS for pain ranging from 0 to 10 revealed that the mean of the patients' pain at the time of the follow-up evaluation was 1.8 (SD 2.42). Twenty out of 24 (only 24 preoperative X-rays were available) were classified as having no osteoarthritis pre-operatively, whereas only 12 out of the 41 patients were classified as having no osteoarthritis (normal) at the time of the follow-up evaluation according to the K/L classification which indicates progression of osteoarthritis. No complications related to the outside-in arthroscopic meniscal repair procedure were reported. We conclude that arthroscopic meniscal repair using the outside-in technique is a safe surgical procedure with a good clinical outcome.

Effect of provider volume on resource utilization for surgical procedures of the knee

Operating-room time and patient disposition on discharge are important determinants of healthcare resource utilization and cost. We examined the relation between these determinants and hospital/surgeon volume for anterior cruciate ligament (ACL) reconstruction and meniscectomy procedures. Patients undergoing ACL reconstruction (18,390 cases) and meniscectomy (123,012 cases) were extracted from the State Ambulatory Surgery Databases for the years 1997-2000. Surgeon and hospital volume were divided into low-, intermediate-, and high-volume categories. Multivariate logistic regression models were used to estimate the adjusted association between surgeon and hospital volume and patient discharge status and operating-room time. Patients undergoing ACL reconstruction or meniscectomy performed by low-volume surgeons were significantly more likely to be non-routinely discharged as compared to high-volume surgeons (adjusted odds ratio 3.5, 95% confidence interval 1.7-7.2 for ACL reconstruction; adjusted odds ratio 2.0, 95% confidence interval 1.6-2.3 for meniscectomy). The mean operating-room time for performing ACL reconstruction or meniscectomy was significantly higher in low- and intermediate-volume surgeons and hospitals as compared to high-volume surgeons and hospitals (p < or = 0.001). High-volume providers utilize healthcare resources more efficiently. Our findings may help surgeons and hospitals in optimizing resource utilization and cost for routinely-performed ambulatory surgery procedures.

Ergonomic handle for an arthroscopic cutter

From an analysis of the routinely performed meniscectomy procedures, it was concluded that a punch with a side-ways steerable tip would improve the reachability of meniscal tissue. This potentially leads to a safer and more efficient meniscectomy. Furthermore, the current scissors handles of arthroscopic punches are ergonomically not sufficient. An ergonomic handle is designed with one lever that enables opening and closing of the instrument tip, and side-ways steering of the instrument tip. The design of the handle complies with ergonomic guidelines that were found in the literature. A model of the instrument tip was added to the new handle for comparison with conventional handles. Experiments were performed with a knee joint model, using objective and subjective criteria. The results show that the concept of a side-ways steerable punch is promising, since faster task times are achieved without increasing the risk of damaging healthy tissue. The current design of the ergonomic handle incorporates two degrees of freedom in an intuitive way, the handle is more comfortable to hold, and easy to control. The external memory capabilities of the new handle could be improved. Further development of this handle and the addition of a sufficient instrument tip and force transmission are recommended.