Meniscal Lesions Research Articles

The Diagnostic Accuracy of Different MRI Sequences for Different Meniscus Lesions: A Meta-analysis.

It is still uncertain to determine the exact diagnostic accuracy of MRI for medial meniscus (MM) tear, lateral meniscus (LM) tear and MM posterior root tear (MMPRT) at different magnetic field intensities (MFIs), different sequences and different publication dates. This study aimed to identify the diagnostic performance of MRI for different meniscus lesions at different MFIs, different sequences and different publication dates, and also to compare it with physical examination. PubMed, Embase, Ovid database, Biosis Previews, Cochrane library, Web of Sciences and manual searching were performed from 1 January 2000 to 31 December 2021. Prospective studies of meniscus injuries examined by physical examination, MRI and arthroscopy were included. Thirteen studies with 1583 meniscal tears were included. The pooled sensitivity, specificity, positive likelihood ratio (LR+), negative likelihood ratio (LR-), diagnostic odds ratio (DOR) and area under curve (AUC) were 87% (95% confidence interval (CI), 86-89%), 82% (80-83%), 7.44 (5.11- 10.75), 0.18 (0.14-0.23), 45.95 (26,68-79.15) and 0.93, respectively. The pooled specificity between MM and LM (p = 0.015), the pooled sensitivity and LR- between MM and MMPR (p = 0.031), different MRI sequences (p = 0.035, p = 0.027), and the accuracy of less than 1.5T and 3.0T (p = 0.04), 1.5T and 3.0T (p = 0.035) were statistically different. There was no publication bias (p = 0.54). MRI performed well in the diagnosis of MM tear, LM tear and MMPRT, and the diagnostic performance of physical examination is similar to MRI. The diagnostic accuracy of 3.0T is the highest, and the -weighted imaging (SWI) sequence may be beneficial for diagnosing meniscus tear. However, there are not enough evidence to prove that recent studies are significantly better than previous ones.

The meniscal extrusion index is a reliable indirect sign of different meniscal lesion patterns: a classification based on percentage of meniscal extrusion

PurposeThis study's goal is to propose a straightforward classification system based on the MEI (Meniscal Extrusion Index), a measure of meniscal extrusion, that relates to various meniscal lesion patterns and has clinical and biomechanical significance. The study's secondary goal is to determine whether the standard 3 mm meniscal extrusion parameter still has value by correlating the MEI with it.Methods1350 knee MRIs that were performed over the course of 2 years made up the study cohort. Following the application of inclusion and exclusion criteria, 200 of those patients were qualified to participate in the study. All the measurements examined for this study underwent an interobserver reliability test.ResultsIn the 1350 MRIs that were examined for this study, meniscal extrusion of any grade was present 18.9% of the time. The use of the MEI revealed three groups of patients: those with a MEI < 20%, who are likely para-physiological; those with a MEY between 20% and 40%, who are in a grey area; and those with a MEY > 40%, who have lesions that are impairing the proper meniscal function. According to the authors' findings, the percentage of meniscal extrusion did not correlate with the finite number (3 mm), making the 3 mm parameter an unreliable evaluation method.ConclusionsThis study is clinically relevant, because it proposes a simple and reproducible classification of meniscal extrusion that may aid in evaluating the severity of an extrusion and help in the diagnosis of lesions that might be difficult to identify on MRI.Level of evidenceLevel IV.

High Prevalence of Persistent Measurable Postoperative Knee Joint Laxity in Patients with Tibial Plateau Fractures Treated by Open Reduction and Internal Fixation (ORIF).

The development of post-traumatic osteoarthrosis after tibial plateau fracture (TPF) is multifactorial and can only be partially influenced by surgical treatment. There is no standardized method for assessing pre- and postoperative knee joint laxity. Data on the incidence of postoperative laxity after TPF are limited. The purpose of this study was to quantify postoperative laxity of the knee joint after TPF. Fifty-four patients (mean age 51 ± 11.9 years) were included in this study. There was a significant increase in anterior-posterior translation in 78.0% and internal rotation in 78.9% in the injured knee when compared to the healthy knee. Simple fractures showed no significant difference in laxity compared to complex fractures. When preoperative ligament damage and/or meniscal lesions were present and surgically treated by refixation and/or bracing, patients showed higher instability when compared to patients without preoperative ligament and/or meniscal damage. Patients with surgically treated TPF demonstrate measurable knee joint laxity at a minimum of 1 year postoperatively. Fracture types have no influence on postoperative laxity. This emphasizes the importance of recognizing TPF as a multifaceted injury involving both complex fractures and damage to multiple ligaments and soft tissue structures, which may require further surgical intervention after osteosynthesis.

Concurrent Repair of Medial Meniscal Ramp Lesions and Lateral Meniscus Root Tears in Patients Undergoing Anterior Cruciate Ligament Reconstruction: The “New Terrible Triad”

Recent studies have suggested that up to 8% of patients with anterior cruciate ligament (ACL) tears can present with a combined medial meniscal ramp lesion (MMRL) and lateral meniscus root tear (LMRT). MMRLs and LMRTs often are missed preoperatively and can increase the risk of ACL graft failure if left untreated. Given the potential synergistic biomechanical consequences and challenging repair techniques used for treatment, our group commonly refers to this presentation (MMRL-LMRT-ACL) as the “new terrible triad” of ACL pathology. This Technical Note aims to describe a systematic approach for arthroscopic assessment and our preferred inside-out and transtibial pull-out repair techniques to efficiently diagnose and treat a combined MMRL and LMRT at the time of ACL reconstruction surgery.

Treatment of acute injury of the anterior cruciate ligament : Always only reconstruction?

The aim of treatment of a ruptured anterior cruciate ligament (ACL) is the return of the patient to an acceptable level of activity without giving way phenomena as well as adequate treatment of prognostically relevant concomitant lesions. The treatment of acute ACL ruptures can be either early reconstruction or a primary physiotherapy with optional later reconstruction. Which path is taken depends on possible concomitant injuries that require early surgical intervention (e.g., repairable meniscal injury or distal rupture of the medial collateral ligament) and on patient-specific factors (age, level of activity). Isolated ruptures of the ACL can also be primarily treated without surgery. Then the injured knee joint should first be so far conditioned by rehabilitative measures that pain, swelling and posttraumatic restriction of movement are improved and neuromuscular training can be started. A screening test consisting of jumping tests, patient-reported outcome measures and the testing for giving way phenomena can be suitable to differentiate compensators (copers) from noncompensators (non-copers). Surgical reconstruction of the ACL should be recommended to non-compensators in the sense of participatory decision-making. Activity modification (adapter) can also be considered as atreatment strategy. If instability events (giving way) or secondary meniscal lesions occur during nonsurgical therapy, cruciate ligament reconstruction should be considered.

Failure rate, return-to-sports and magnetic resonance imaging after meniscal repair: 119 patients with 7 years mean follow up.

One of the most important factors to consider in relation to meniscal repair is the high failure rate reported in the existing literature. To evaluate failure rates, return to sports (RTS) rate, clinical outcomes and magnetic resonance image (MRI) evaluation after meniscus suture repair for longitudinal tears at a minimum 2-year-follow-up. We conducted a retrospective review of meniscal repairs between January 2004 and December 2018. All patients treated for longitudinal tears associated or not with an anterior cruciate ligament reconstruction (ACL-R) were included. Meniscal ramp lesions, radial and root tears, associated with multiligament injuries, tibial fracture and meniscal allograft transplants were excluded. Surgical details and failure rate, defined as symptomatic patients who underwent a revision surgery, were analyzed. As isolated bucket handle tears (BHTs) were usually associated with higher failure rates, we compared BHTs and not BHTs associated or not with an ACL-R. Since 2014, the inside-out technique using cannulas and suture needles with 2-0 Tycron began to predominate. In addition, the number of stitches per repair was increased. In view of differences in surgical technique, we compared two different cohorts: before and after 2014. We recorded the RTS according to the level achieved and the time to RTS. Lysholm and IKDC scores were recorded. Patients were studied with x-rays and MRI as standard postoperative control. One hundred and nineteen patients were included with a mean follow up of 7 years (SD: 4.08). Overall failure rate was 20.3% at a mean 20.1 mo. No statistically significant differences were found when comparing failure for medial and lateral meniscal repair (22.7% and 15.3%, P = 0.36), BHTs and not BHTs (26% and 17.6%, P = 0.27), isolated or associated with an ACL-R (22.9% and 18%, P = 0.47), or when comparing only BHTs associated with an ACL-R (23% and 27.7%, P = 0.9) or not. When comparing cohorts before and after 2014, we found a significant decrease in the overall failure rate from 26% to 11% (P < 0.03). Isolated lesions presented a decrease from 28% to 6.6% (P = 0.02), BHTs from 34% to 8% (P = 0.09) and those associated with an ACL-R from 25% to 10% (P = 0.09). Mean RTS time was 6.5 mo in isolated lesions and 8.64 mo when associated with an ACL-R. Overall, 56% of patients returned to the same sport activity level. Mean pre and postoperative Lysholm scores were 64 and 85 (P = 0.02), and IKDC 58 and 70 (P = 0.03). Out of 84 asymptomatic patients evaluated with MRI, 39% were classified as "not healed" and 61% as "healed". Even though the overall failure rate of our series was 20.3%, we found a statistically significant decrease from 26% to 11%, not only for isolated lesions, but also for BHT's and those associated with an ACL-R when comparing our series in two different cohorts, most probably due to improvements in surgical technique.

Influence of Meniscal Repair vs. Meniscectomy on Anterior Cruciate Ligament Reconstruction in Terms of Knee Stability and Radiological Imaging.

The menisci are essential components in the pathophysiology of knee osteoarthritis. Patients with meniscal lesions and an intact anterior cruciate ligament (ACL) undergoing meniscectomy exhibit a significantly increased prevalence of radiographic osteoarthritis. ACL reconstruction surgery enhances knee stability and mitigates the advancement of minor meniscal tears. The purpose of this study was to show the influence of meniscal repair as compared to meniscectomy on anterior cruciate ligament reconstruction in terms of knee stability and radiological imaging. This was a retrospective study performed in Dr. D.Y. Patil Hospital, Pimpri, Pune, on a sample size of 30 patients between December 2021 and January 2023. Patients were followed up clinically and radiologically post-operatively at six months and one year. ACL reconstruction with meniscectomy was performed on 16 patients (group 2), while ACL reconstruction with meniscus repair was performed on 14 patients (group 1). At the end of six months in group 1, one patient out of 14 had a grade 2 Lachman test positive, while seven patients out of 16 had a grade 2 Lachman test positive in group 2. It was a statistically insignificant value (p>0.05). Further, at the end of 12 months, X-ray evaluation of the femoral tunnel shows an average increment of 0.5 mm in Group 1, while an average femoral tunnel widening of 3 mm was observed in Group 2. It was statistically insignificant (p>0.05). The study concluded that meniscus repair significantly increases anteromedial knee stability. It has been shown that meniscectomy, when done along with ACL reconstruction, increases the chances of femoral tunnel widening, resulting in less graft bone integration.

THE MANAGEMENT OF ISOLATED MENISCAL TEARS IN SKELETALLY IMMATURE CHILDREN: AN INTERNATIONAL EXPERT CONSENSUS

AbstractIntroductionThere is currently very little evidence which can be used to guide surgeons treating skeletally immature patients with suspected meniscal injury. The aim of our modified Delphi study was to develop comprehensive recommendations for the management of isolated meniscal tears in skeletally immature children.MethodologyAn international, two round, modified Delphi consensus was completed. Included ‘experts’ were identified as having an established adult and/or paediatric knee practice and either: 1) Faculty at the international kid's knee meeting, 2) Active member of the complex national paediatric MDT group, or 3) faculty on recognised national course aimed at teaching knee surgeons regarding the management of meniscal lesions. A threshold of 70% was used to identify consensus.ResultsA total of 43 experts (Round 1) and 41 experts (Round 2) took part in the Delphi study. Surgeons from the UK, Europe, USA and South America took part. 34 statements were identified exploring 4 main domains – clinical diagnosis, investigation, management and specialist tears. Following round 1 consensus was reached on 17 (50%) statements, subsequently after completion of round 2 consensus was reached on 28 (82%) statements, leaving 6 (18%) with no consensus.ConclusionsThis is the first modified delphi consensus which provides evidence for surgeons treating skeletally immature children with isolated meniscal tears. Further studies are required to provide evidence for the areas where no consensus was reached.

Diagnosing knee osteoarthritis in patients, differences between general practitioners and orthopedic surgeons: a retrospective cohort study

Backgroundknee complaints are one of the most common reasons to consult the general practitioners in the Netherlands and contribute to the increasing burden on general practitioners. A proportion of patients that are referred to orthopedic outpatient clinics are potentially referred unnecessarily. We believe osteoarthritis is not always considered by general practitioners as the cause of atraumatic knee complaints. This may impede early recognition and timely care of osteoarthritis complaints and lead to unnecessary referrals.Methodsthe aim of this study was to compare the frequency of (differential) diagnosis of osteoarthritis mentioned in referral letters of general practitioners with the frequency of osteoarthritis mentioned as orthopedic diagnosis at the outpatient clinic. Therefore we conducted a retrospective cohort study based on data collected from referral letters and the corresponding outpatient clinic reports of patients with atraumatic knee complaints of 45 years or older referred to a regional hospital in Nijmegen, The Netherlands in the period from 1-6-2019 until 1-01-2020.Resultsa total of 292 referral letters were included. In the younger aged patients (45–54 years) osteoarthritis was mentioned less frequent and meniscal lesions were mentioned more frequent in referral letters when compared to diagnoses made at the outpatient clinic. Differences in differential diagnosis of osteoarthritis as well as meniscal lesions between orthopedic surgeon and general practitioners were found (both p < 0.001, McNemar). Matching diagnoses were present in 58.2% when all referral letters were analyzed (n = 292) and 75.2% when only referrals containing a differential diagnosis were analyzed (n = 226). Matching diagnoses were present in 31.6% in the younger age categories (45–54 years). A linear trend showing fewer matching diagnoses in younger patient categories was observed (p < 0.001).ConclusionsOsteoarthritis was less frequently mentioned in general practitioner referral letters among the differential diagnosis then it was diagnosed at the outpatient clinic, especially in younger patients (45–54 years). Also matching diagnoses in younger patients were evidently lower than in older patients, partly explained by underdiagnosing of osteoarthritis in younger patients in this cohort. Better recognition of osteoarthritis in younger patients and changing the diagnostic approach of general practitioners might improve efficacy in knee care. Future research should focus on the effectiveness of musculoskeletal triage, the need for multidisciplinary educational programs for patients and promotion of conservative treatment modalities among general practitioners.

Concomitant Injuries Associated With ACL Rupture in Elite Professional Alpine Ski Racers and Soccer Players: A Comparative Study With Propensity Score Matching Analysis.

For elite professional soccer players and alpine skiers, injuries associated with anterior cruciate ligament (ACL) rupture, such as meniscal, cartilage, or collateral ligament lesions, could result in a delayed return to sport compared with isolated ACL injury. The purpose of the study was to provide a detailed description of associated injuries at the time of primary ACL reconstruction in elite soccer players and alpine skiers. It was hypothesized that soccer players and skiers would present different typical injury patterns due to different injury mechanisms. Cohort study; Level of evidence, 3. Surgical reports and arthroscopic images of elite professional soccer players and alpine skiers who underwent primary ACL reconstruction at a single institution between January 2010 and June 2022 were analyzed retrospectively. The presence and location of multiligamentous injury, meniscal tears, and chondral lesions were compared between the athlete groups. A propensity score matching analysis with 1:1 ratio was performed between skiers and soccer players to limit the effect of selection bias. Included were ACL reconstruction data representative of 37 soccer players and 44 alpine skiers. Meniscal pathology was found in 32 (86%) soccer players and 30 (68%) skiers. Chondral injuries were reported in 11 (30%) soccer players and 15 (34%) skiers. Results of the propensity score matching analysis in 15 pairs of soccer players and skiers indicated that soccer players had a significantly higher rate of medial meniscal injuries (73% vs 27%; P = .03) and lateral posterior root tears (33% vs 0%; P = .04) compared with skiers. A higher prevalence of combined chondral and meniscal injuries versus isolated ACL injuries was observed in both groups of athletes. Professional soccer players were characterized by higher prevalence of medial meniscal tears and lateral posterior root lesions compared with professional alpine skiers.

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.

Lateral meniscus with tears or with histologic calcification does not increase the risk of lateral osteoarthritis after medial unicompartmental arthroplasty.

Meniscal tears or histological meniscal calcifications (in the absence of radiological chondrocalcinosis) are frequent in osteoarthritis. Whether lateral meniscal lesions influence clinical outcomes after medial unicompartmental knee arthroplasty (UKA) is unknown. We analyzed 130 patients (130 knees) with medial unicompartmental knee arthroplasties between 2005 and 2015. These 130 knees had full articular cartilage thickness in the lateral compartment and no radiological chondrocalcinosis on preoperative radiographs. The lateral meniscus was analyzed with preoperative MRI and a biopsy of the anterior horn at the time of surgery. Synovial fluid was collected and analyzed for calcium pyrophosphate dihydrate crystal deposition (CPPD crystals). Lateral meniscal tears were untreated when detected on MRI or during surgery, with the hypothesis that these tears on the opposite compartment would remain asymptomatic in medial UKA. At average 10-year follow-up, patients were evaluated with clinical and radiographic outcome, with a focus on the risk of joint space narrowing of the lateral femorotibial compartment. CPPD crystals were present in the synovial fluid of 70 knees. Lateral meniscal tears were seen on MRI in 34 (49%) normal meniscuses of the 60 knees without CPPD crystals and in six other knees without histological meniscal calcification despite CPPD crystals. Histological calcification was present on 61 lateral meniscuses with 53 meniscal tears. The results showed no significant differences in the clinical outcomes between knees with lateral meniscal tears or lateral meniscal histological chondrocalcinosis or both lesions and those without these conditions. Additionally, radiographic progression of osteoarthritis in the opposite femorotibial compartment of the knee was not more frequent in patients with these meniscal issues. The tenyear cumulative survival rates, measured by the need for total knee arthroplasty, were 91% for knees without meniscal lesions and 92% for knees with these lesions. On this basis, treatment of meniscal tears of the lateral compartment and routine aspiration of the knee to assess for birefringent crystals in the planning of medial UKA do not appear necessary.

Concentric Isokinetic Strengthening Program's Impact on Knee Biomechanical Parameters, Physical Performance and Quality of Life in Overweight/Obese Women with Chronic Meniscal Lesions.

Meniscal injuries are one of the most common intra-articular knee injuries. Different treatments are presented depending on the symptoms and duration of meniscus tears, such as arthroscopic partial meniscectomy, physiotherapy, or even pharmacological treatment. The purpose was to investigate the effect of a concentric isokinetic knee muscle strengthening program on strength, joint range of motion, physical performance, quality of life and pain tolerance in overweight/obese women with chronic meniscal lesions. Twenty-four overweight/obese women were randomized into two groups. A control group (CG) performed a usual rehabilitation program plus isokinetic muscle strengthening (IMS) in the continuous passive motion mode and measured with an isokinetic dynamometer. An experimental group (EG) performed the same program in combination with IMS in the isokinetic active mode. The peak torque of the knee extensors (PTE) and flexors (PTF), sit-to-stand test, stair climb test, joint amplitude, heel-to-buttock distance, Thessaly test, KOOS questionnaire of pain and quality of life were measured pre- and post-protocol. After the intervention, the sit-stand number for both groups was significantly higher (p < 0.001) and the time to climb stairs was significantly reduced for the EG (p < 0.001). A significant improvement in joint range of motion, life quality (p < 0.001), relief in knee pain (p < 0.001) and in the post-program evaluation at the EG (p < 0.05) was noted. There was no significant difference in PTE and PTF between groups at 60°/s and 180°/s. The IMS in the active mode could be an effective therapeutic modality in managing middle-aged patients suffering from a degenerative meniscal tear.

Searching for the Best Treatment for Ramp Lesions: A Systematic Review and Network Meta-Analysis.

Ramp lesions are a common occurrence in patients with anterior cruciate ligament (ACL) tears. These lesions can be difficult to diagnose due to their concealed nature, and their treatment is crucial due to the stabilizing function of the medial meniscocapsular region. The optimal treatment option for ramp lesions varies depending on the size and stability of the lesion. The purpose of this study was to evaluate the best treatment option for ramp lesions based on the stability of the lesion, including no treatment, biological treatment, and arthroscopic repair. We hypothesize that stable lesions have a favorable prognosis with techniques that do not require the use of meniscal sutures. In contrast, unstable lesions require appropriate fixation, either through an anterior or posteromedial portal. This study is a systematic review and meta-analysis with a level of evidence IV. The study used Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for a systematic review of clinical studies reporting outcomes of ramp lesion treatment. The PubMed/MEDLINE database was searched using Mesh and non-Mesh terms related to ramp lesions, medial meniscus ramp lesions, and meniscocapsular injuries. The inclusion criteria encompassed clinical studies in English or Spanish that reported the treatment of ramp meniscal lesions, with a follow-up of at least six months and inclusion of functional results, clinical stability tests, radiological evaluation, or arthroscopic second look. The analysis included 13 studies with 1614 patients. Five studies distinguished between stable and unstable ramp lesions using different criteria (displacement or size) for assessment. Of the stable lesions, 90 cases received no treatment, 64 cases were treated biologically (debridement, edge-curettage, or trephination), and 728 lesions were repaired. There were 221 repaired unstable lesions. All different methods of repair were registered. In stable lesions, three studies were included in a network meta-analysis. The best-estimated treatment for stable lesions was biological (SUCRA 0.9), followed by repair (SUCRA 0.6), and no treatment (SUCRA 0). In unstable lesions, seven studies using International Knee Documentation Committee Subjective Knee Form (IKDC) and 10 studies using Lysholm for functional outcomes showed significant improvement from preoperative to postoperative scores after repair, with no differences between repairing methods. We recommend simplifying the classification of ramp lesions as stable or unstable to determine treatment. Biological treatment is preferred for stable lesions rather than leaving them in situ. Unstable lesions, on the other hand, require repair, which has been associated with excellent functional outcomes and healing rates.

Poster 252: BMAC Augmentation of Allograft Anterior Cruciate Ligament Reconstruction Improves Patient Reported Outcomes in the Presence of Intra-articular Pathology

Objectives: A randomized control trial demonstrated evidence of earlier graft remodeling and improved 9-month International Knee Documentation Committee (IKDC) scores when anterior cruciate ligament reconstruction (ACLR) with bone-tendon-bone allograft was augmented with an intra-graft injection of bone marrow aspirate concentrate (BMAC). While these results are promising, the mechanism by which BMAC may affect patient reported outcome measures (PROMs) following ACLR is unclear. Methods: This was a sub-analysis of patients enrolled to date in an IRB-approved, double-blinded, randomized control trial comparing patients undergoing ACLR with BTB allograft ± BMAC. Only patients who had completed at least 9 months follow-up were included. Patients were stratified by 1) treatment arm (BMAC versus control) and 2) presence of concurrent meniscus or cartilage pathology, as noted on diagnostic arthroscopy). The primary outcome was the Tegner activity scale and International Knee Documentation Committee (IKDC) at 9 months. A secondary sub-analysis assessed differences in MRI characteristics (signal intensity ratio [SIR], graft volume) by group. Results: The final study cohort included 44 BMAC patients – 19 (43%) without and 25 (57%) with concurrent cartilage or meniscus pathology – and 39 control group patients - 16 (41%) without and 23 (59%) with concurrent cartilage or meniscus pathology. 24 patients in the BMAC group had a meniscus lesion, 13 of which were treated via meniscectomy (54%) and 11 by meniscus repair (46%). By comparison, 21 patients in the control group had a meniscus lesion (P=0.57), 11 who were treated with meniscectomy (52%, P=0.88) and 11 who had a meniscus repair (P=1.00). 5 patients with BMAC (20%) and 6 control patients (25%) had a cartilage injury noted intraoperatively (P=0.94); chondroplasty was performed in 2 patients in the BMAC group (8.0%) and 4 patients in the control group (16.7%). Tegner score at 9 months did not differ by BMAC treatment or presence of concurrent meniscus/cartilage pathology (P=0.816). If a patient had a concurrent meniscus and/or cartilage lesion, the group treated with BMAC had a greater mean IKDC at 9 months (81.7 [SD=10.2] vs. 74.3 [SD=14.6], P=0.039). If a patient had no concurrent pathology, there was no difference in IKDC scores by treatment group (P=0.80). Change in Tegner (P=0.99) and IKDC (P=0.31) did not differ by groups. At 3 months, patients with BMAC and concurrent pathology had the highest mean SIR in the inferior 1/3 of the graft (3.00), followed by patients with BMAC but no concurrent pathology (2.60), controls without concurrent pathology (1.95), and controls with concurrent pathology (1.83, P=0.041). There were no significant differences in SIR at 9 months or graft volume, in this comparative cohort study. Conclusions: Amongst patients with concurrent meniscus and/or cartilage lesions, patients with BMAC had an 8-point higher mean IKDC score than controls at 9 months postoperatively. However, there was no difference in mean IKDC score between BMAC and control groups if no concurrent pathology was present. Thus, improved IKDC amongst patients with BMAC may be mediated by improved healing of repaired tissue or through an undefined anti-inflammatory or nociceptive pathway. Further investigation will be required to delineate a physiologic mechanism of action associated with BMAC during the recovery process when utilized at the time of ACL allograft reconstruction. [Table: see text][Table: see text][Table: see text]

Poster 306: Examining Preoperative Magnetic Resonance Imaging for Medial Meniscal Ramp Lesions in Patients Surgically Treated for Acute Grade III Combined Posterolateral Corner Knee Injuries

Objectives: While medial meniscocapsular tears ( ramp lesions) are commonly associated with isolated anterior cruciate ligament (ACL) injuries, there are limited descriptions of these meniscal injuries in multi-ligament knee injuries (MLKIs). The purposes of this study were: (1) To retrospectively evaluate preoperative MRIs for the presence of ramp lesions in patients surgically treated for acute grade III combined posterolateral corner knee injuries and (2) To determine if a preoperative posteromedial tibia plateau (PMTP) bone bruise is associated with the presence of preoperative ramp lesions on MRI in these same patients. Methods: Data on consecutive patients at a Level I trauma center with MLKIs between 2001 and 2021 were retrospectively reviewed. Only patients with acute grade III combined PLC injuries who received a magnetic resonance imaging (MRI) scan within 30 days of injury were assessed. Two musculoskeletal radiologists retrospectively reviewed each patient’s preoperative MRI for evidence of ramp lesions and bone bruises (Figure 1). Intra-class correlation coefficients (ICCs) were used to calculate reliability among the reviewers. Multivariate analysis was used to evaluate the relationship between bone bruising patterns and the presence of a ramp lesion on MRI. Results: Sixty-eight patients (79.4% male; mean age, 36.2 ± 13.7 years) with an acute grade III combined PLC injury were included in the study (Table 1). On MRI, the ICC for detection of ramp lesions and PMTP bone bruising were 0.921 and 0.938, respectively. Medial meniscal ramp lesions were diagnosed in 18/68 (26.5%). 11/18 (61.1%) patients with ramp lesions also showed evidence of PMTP bruising, while 13/50 (26.0%) patients without ramp lesions had PMTP bruising (P=0.008) (Table 2). When controlling for age and sex, PTMP bruising was significantly associated with the presence of a ramp lesion in combined PLC injuries (OR, 4.62; P=0.012) (Table 3). Conclusions: Preoperative medial meniscal ramp lesions were diagnosed on MRI in 26.5% of patients with acute grade III combined PLC injuries. In addition, PMTP bone bruising was significantly associated with the presence of a ramp lesion in patients with a grade III combined PLC injury. These findings demonstrate the need to assess for potential ramp lesions at the time of multi-ligament reconstruction. [Table: see text][Table: see text][Table: see text]

Paper 29: Untreated Type 4 Ramp Injuries at Index Anterior Cruciate Ligament Reconstruction Surgery Result in Higher Rates of Revision ACL-R within the First 2 Years

Objectives: Ramp lesions are commonly associated with ACL tears and recent studies have identified these lesions in 17-42% of patients undergoing treatment with ACL reconstruction. In addition to its association with ACL tears, there is increasing recognition that ramp lesions lead to significant biomechanical changes in the knee. Our study seeks to investigate whether patients with type 4 ramp lesions at the time of initial ACL reconstruction have higher rates of reoperation, specifically revision ACL-R, compared to those that undergo ACL-R without a ramp lesion. Methods: Retrospective chart review was conducted on all patients surgically treated with ACL reconstruction at level I academic center from January 2015 to December 2019. Type 4 ramp lesions were diagnosed on preoperative MRIs by two MSK-trained radiologists blinded to clinical information. Demographic, associated injuries, intra-operative, clinical data, and re-operations were extracted from our ACL-R database. Statistical analysis using Students T-test and chi x2 for comparing cohorts. Cox Regression with covariates for re-operation surgery was used. Risk factors evaluated for revision surgery included patient age, sex, BMI, treatment of ramp, timing to surgery. Inter-reliability coefficient correlation was used for MRI reliability. Results: A total of 255 patients ACL-R were identified that met inclusion. There were 170 patients with ACL-R without a ramp present and 85 patients with ACL-R + type 4 ramp lesion. Revision ACL-R occurred in 10.5% in ramp group compared to 2.4% without ramp (P&lt;0.005). Around 75% of the revision ACL-R for the ramp group occurred within the first 2 and half years after surgery. Risk factor associated with revision ACL-R included untreated ramp (HR 10.46 (CI: 2.13-109.70) p=0.01). Conclusions: Meniscal ramp lesions with ACL-R result in higher revision ACL-R when compared to no ramp ACL-R. Most significantly untreated type 4 ramp lesions with concomitant ACL-R were associated with increased risk of ACL-R revision surgery . Standard portals are not sufficient in diagnosing and assessing stability of ramp lesions intra-operatively. [Table: see text]

Poster 237: Menisco-Tibial Ligament Complex Anatomy and Biomechanics – Implications for Meniscus Repairs, Ramp Lesions and Transplants

Poster 237: Menisco-Tibial Ligament Complex Anatomy and Biomechanics – Implications for Meniscus Repairs, Ramp Lesions and Transplants

Poster 321: MENISCAL RAMP LESIONS IN ADOLESCENT PATIENTS UNDERGOING PRIMARY ACL RECONSTRUCTION

Objectives: Meniscal ramp lesions describe a specific injury to the meniscocapsular junction at the posterior horn of the medial meniscus. The lesions are strongly associated with anterior cruciate ligament (ACL) injuries and may affect the biomechanical stability of the knee if left untreated. Despite the increasing rates of ACL reconstructions performed in adolescents each year, the prevalence and risk factors for ramp lesions in this patient population is poorly understood. The purpose of this study was to determine the prevalence and risk factors for ramp lesions in children and adolescent patients undergoing primary ACL reconstruction. Methods: All patients ≤19 who underwent primary ACL reconstruction at a single institutional between 2019 and 2021 were included. All surgeries were performed by three fellowship trained orthopedic surgeons. Patients were considered to have a ramp lesion if one was identified arthroscopically at the time of ACL reconstruction. Basic demographic data, preoperative imaging, and other arthroscopic findings at the time of ACL reconstruction were reviewed. Results: 247 consecutive patients who underwent ACL reconstruction were reviewed. Patients were excluded if they had had prior ACL injury, prior knee surgery, fibular hemimelia, or incomplete documentation. A total of 230 patients met inclusion criteria. Average age at time of injury was 15.7 years (range 4.0-18.2 years). A ramp lesion was identified in 12% of patients. Posteromedial tibial bone bruise on preoperative MRI and medial femoral chondromalacia at time of ACL reconstruction were associated with the presence of a ramp lesion, Figure 1A (OR = 2.6, 95% CI [1.15, 5.93]). A striation pattern of medial femoral chondromalacia was highly specific for the presence of a ramp lesion, Figure 1B (OR = 424.3, 95% CI [50.99, 3531.3]). Sensitivity and specificity for detecting a ramp lesion was 68% and 76% with preoperative MRI and 68% and 99.5% with medial condyle striations, respectively. Conclusions: The prevalence of a ramp lesion in our cohort was 12%, mirroring historical reports in adult patients. Posteromedial bone bruising and medial femoral chondromalacia, especially in a striation pattern, should increase suspicion for the presence of a ramp lesion in patients undergoing ACL reconstruction.

Medial Meniscal Posterior Horn Suturing Influences Tibial Internal-External Rotation in ACL-Reconstructed Knees.

The role of meniscal lesions and repair in combination with anterior cruciate ligament (ACL) injury and reconstruction has not been extensively investigated in vivo and under weightbearing conditions. The purposes of this study were to (1) compare the in vivo knee kinematics between patients with ACL tear and those with combined ACL and medial meniscal tears and (2) investigate kinematic differences between isolated ACL reconstruction and ACL reconstruction plus medial meniscal repair (MR). It was hypothesized that concomitant posterior horn medial meniscal tear and ACL deficiency would affect knee internal-external rotation and anterior-posterior translation but MR would restore these parameters. Controlled laboratory study. Nineteen patients who underwent ACL reconstruction were included: 10 had intact menisci (IM group) and 9 had a medial meniscal injury that was repaired during ACL reconstruction using an all-inside technique (MR group). Preoperatively and 18 months postoperatively, active knee kinematics under weightbearing conditions was evaluated during a single-leg squat using a dynamic biplane x-ray imaging system. The general linear model was used to investigate the differences between group (IM vs MR) and time (preoperative vs follow-up) and their interactions. Tibial internal rotation was higher in the MR group than the IM group both before and after surgery (P = .007). Knee valgus rotation was higher in the MR group preoperatively (P < .001), while no differences were found postoperatively because of an increase of valgus rotation in the IM group, which was significant in the descendant phase (P < .001). Preoperatively, the IM group showed a more medial tibial translation compared with the MR group in the descendant phase (P = .006). When performing a single-leg squat, patients with ACL-deficient knees and a medial meniscal tear demonstrated a more valgus rotation, tibial internal rotation, and lateral tibial translation versus those with intact menisci. After ACL reconstruction and MR, these patients demonstrated significantly higher tibial internal rotation when compared with patients who underwent isolated ACL reconstruction. Surgeons should be aware that MR does not fully restore knee kinematics in vivo and under weightbearing conditions in the context of ACL reconstruction.