Partial Lateral Meniscectomy Research Articles

Load Distribution After Serial Resection of the Posterior Horn of the Lateral Meniscus and Subsequent Meniscal Allograft Transplant: A Biomechanical Study

Background: Data are lacking as to when a meniscal allograft transplant (MAT) may be biomechanically superior to a partially resected lateral meniscus. Hypothesis: Lateral MAT using a bone bridge technique would restore load distribution and contact pressures in the tibiofemoral joint to levels superior to those of a partial lateral meniscectomy. Study Design: Controlled laboratory study. Methods: Eleven fresh-frozen human cadaveric knees were evaluated in 5 lateral meniscal testing conditions (native, one-third posterior horn meniscectomy, two-thirds posterior horn meniscectomy, total meniscectomy, MAT) at 3 flexion angles (0°, 30°, and 60°) under a 1600-N axial load. Pressure sensors were used to acquire contact pressure, contact area, and peak contact pressure within the tibiofemoral joint. Results: Limited (one-third and two-thirds) partial lateral posterior horn meniscectomy showed no significant increase in mean and peak contact pressures as well as no significant decrease in contact area compared with the intact state. Total meniscectomy significantly increased mean contact pressure at 0° and 30° (P = .008 and P < .001, respectively), increased peak contact pressure at 30° (P = .04), and decreased mean contact area in all flexion angles compared with the native condition (P < .01). Lateral MAT significantly improved mean contact pressure compared with total meniscectomy at 0° and 30° (P = .002 and P = .003, respectively) and increased contact area at 30° and 60° (P = .003 and P = .009, respectively), although contact area was still significantly smaller (24.1%) after MAT relative to the native meniscus (P = 0.015). However, allograft transplant did not result in better tibiofemoral contact biomechanics compared with limited partial meniscectomy (P > .05). Conclusion: The peripheral portion of the lateral meniscus provided the most important contribution to the distribution of contact pressure across the tibiofemoral joint in the cadaveric model. Total meniscectomy significantly increased mean and peak contact pressure in the cadaveric model and decreased contact area. Lateral MAT restored contact biomechanics close to normal but was not superior to the partially meniscectomized status. Clinical Relevance: Surgeons should attempt to preserve a peripheral rim of the posterior lateral meniscus. Meniscal allograft transplant appears to improve but not normalize mean contact pressure and contact area relative to total lateral meniscectomy.

Concomitant Anatomic PCL and FCL Reconstructions With Partial Lateral Meniscectomy

Background: Fibular collateral ligament (FCL) injuries commonly present in a multiligament knee injury pattern. These injuries are associated with significant instability leading to altered tibiofemoral biomechanics and therefore require surgical intervention. Similarly, grade 3 posterior cruciate ligament (PCL) injuries may disrupt normal tibiofemoral and patellofemoral biomechanics and increase the risk of secondary osteoarthritis. Therefore, concomitant reconstruction of the FCL and PCL should be performed to decrease knee laxity and optimize functional outcomes. Indications: Early operative treatment is indicated for patients with combined grade 3 FCL injuries and complete PCL tears. Contraindications to this procedure include patients who have significant osteoarthritis, open knee dislocations, or medical comorbidities making them unfit for surgery. Technique Description: The fundamental idea behind this technique is a stepwise treatment starting with open aspects of the procedure and followed by arthroscopic work. The technique is initiated with a lateral approach, common peroneal neurolysis, fibular and femoral FCL reconstruction tunnel preparation, and a gracilis or semitendinosus tendon autograft harvest. After that, focus shifts to intra-articular work such as associated meniscal assessment and treatment, PCL femoral and tibial tunnel preparation, graft passage, and PCL femoral tunnel fixation. Final graft fixation order is as follows: anterolateral bundle of PCL, posteromedial bundle of PCL, and finally FCL. Results: Multiple studies have reported that an anatomic FCL reconstruction in the setting of multiligament injury results in improved patient outcomes. In a prospective study of 20 patients, LaPrade et al reported −0.4 mm difference in side-to-side lateral compartment gapping and significant postoperative improvement of symptom and functional scores at a minimum 2 year postoperative follow-up after anatomic reconstruction of the FCL. Similarly, Moulton et al reported significant improvement in the average Western Ontario and Lysholm scores at 2.7 years follow-up. LaPrade et al also reported significant improvement in function and objective outcome scores at 3 years’ follow-up from anatomic double-bundle PCL reconstruction. Discussion: Anatomic FCL and PCL reconstructions successfully restore near native knee objective stability and provide superior clinical outcomes when compared to nonanatomic-based FCL reconstructions that continue to be performed. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Anterior Cruciate Ligament Reconstruction Using Bone–Patellar Tendon–Bone Autograft With Lateral Compartment Meniscectomy or Chondroplasty Does Not Lead to Decreased Return to Sport and Activity Compared With No Lateral Pathology

PurposeTo investigate the influence of lateral meniscal and cartilage pathology on the outcome after ACL reconstruction in patients who participate in pivoting sports. MethodsUsing a single surgeon patient registry, patients undergoing an ACL reconstruction (ACLR) using BTB autograft were evaluated with minimum 2-year patient reported outcomes evaluated using Marx, Tegner, Lysholm, and International Knee Documentation Committee (IKDC) scales. Patients were divided into three groups: isolated ACL surgery, ACLR with a partial lateral meniscectomy, or a ACLR with partial lateral meniscectomy and lateral compartment chondroplasty. ResultsA total of 98 patients met inclusion criteria. Using the isolated ACL reconstruction group as a control, Marx scores were higher in patients who additionally underwent a partial lateral meniscectomy at 1-year (p=0.016). There were no significant differences between the ACL only group and the ACL with partial lateral meniscectomy and chondroplasty group. Within the partial meniscectomy cohort comparing the red-white zone tears to the white-white zone tear patients, there were no significant differences when compared with the ACL only control. There were no significant differences appreciated between groups using the IKDC, Lysholm, andTegner scales. ConclusionACL reconstruction using BTB autograft with anteromedial portal drilling technique does not have any significant short-term (2-year outcome) differences in return to activity and patient reported outcomes compared to if patients additionally have a partial lateral meniscectomy and/or lateral compartment chondroplasty. Additional partial lateral meniscectomy showed significantly higher Marx scores at 1 and 2 years post-operatively. Level of Evidence3, Retrospective Cohort Study

Clinical and Radiological Outcomes After Combined ACL and MPFL Reconstruction Versus Isolated ACL Reconstruction for ACL Injury With Patellar Instability

Background: An anterior cruciate ligament (ACL) injury accompanied by patellar instability (PI) is a topic that has gained orthopaedic surgeons’ attention recently. Untreated PI is reportedly associated with worse clinical outcomes after isolated ACL reconstruction (ACLR) in patients after an ACL injury with PI. Nevertheless, the appropriate surgical approach and its long-term therapeutic effects in these patients remain unclear. Purpose: (1) To compare the clinical and radiological outcomes between isolated ACLR (iACLR) and combined ACLR and medial patellofemoral ligament reconstruction (cAMR) in patients after an ACL injury with PI and (2) to explore the correlations between these 2 procedures and clinical and radiological outcomes. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 106 patients diagnosed with an ACL injury accompanied by PI between January 2016 and April 2021 were analyzed in this study. There were 34 patients excluded because of missing postoperative radiological data. Among the remaining 72 patients, 34 patients underwent iACLR, while 38 patients underwent cAMR. Demographic characteristics, intraoperative findings, and patient-reported outcomes (Lysholm score, subjective International Knee Documentation Committee score, and Tegner activity score) were prospectively collected. Patellar alignment parameters and worsening patellofemoral osteoarthritis (PFOA) features (evaluated with the modified Whole-Organ Magnetic Resonance Imaging Score) were analyzed longitudinally on magnetic resonance imaging. The Kujala score was used to evaluate the functional recovery of the patellofemoral joint, and redislocations of the patella were prospectively recorded. Finally, multivariate logistic regression analysis was used to explore the correlations between these 2 procedures and clinical (not achieving the minimal detectable change [MDC] for the Lysholm score) and radiological (worsening PFOA features) outcomes. Results: The mean follow-up duration was 28.9 ± 6.2 and 27.1 ± 6.8 months for the iACLR and cAMR groups, respectively (P = .231). Significantly higher Lysholm scores (88.3 ± 9.9 vs 82.1 ± 11.1, respectively; P = .016) and subjective International Knee Documentation Committee scores (83.6 ± 11.9 vs 78.3 ± 10.2, respectively; P = .046) were detected in the cAMR group compared with the iACLR group postoperatively. The rates of return to preinjury sports were 20.6% and 44.7% in the iACLR and cAMR groups, respectively (difference, 24.1% [95% CI, 3.3%-45.0%]; P = .030). Moreover, the rates of worsening PFOA features were 44.1% and 18.4% in the iACLR and cAMR groups, respectively (difference, 25.7% [95% CI, 4.9%-46.4%]; P = .018). In addition, significantly higher Kujala scores (87.9 ± 11.3 vs 80.1 ± 12.0, respectively; P = .006), lower redislocation rates (0.0% vs 11.8%, respectively; difference, 11.8% [95% CI, 0.9%-22.6%]; P = .045), and significantly better patellar alignment were detected in the cAMR group compared with the iACLR group postoperatively. Furthermore, multivariate logistic regression analysis determined that iACLR and partial lateral meniscectomy were significantly correlated with not achieving the MDC for the Lysholm score and worsening PFOA features in our study population. Conclusion: In patients after an ACL injury with PI, cAMR yielded better clinical and radiological outcomes compared with iACLR, with better patellar stability and a lower proportion of worsening PFOA features. Furthermore, not achieving the MDC for the Lysholm score and worsening PFOA features were significantly correlated with iACLR and partial lateral meniscectomy. Our study suggests that cAMR may be a more appropriate procedure for patients after an ACL injury with PI, which warrants further high-level clinical evidence.

Poster 331: ACL Graft Tear or Contralateral ACL Tear: Which is Worse???

Objectives: Anterior cruciate ligament (ACL) graft tears and contralateral ACL tears are both relatively common following primary ACL reconstruction (ACLR). While some prior studies have combined these injuries as an outcome variable (“subsequent cruciate injury”), there is little prior work comparing the outcomes of these injuries. We hypothesize that patient reported outcome measures (PROMs) and activity level are lower following revision ACLR than following contralateral ACLR. Methods: From a prospective cohort study of 2333 patients who underwent primary, unilateral ACLR, 298 patients were identified who underwent revision ACLR or contralateral ACLR within 5 years of primary ACLR. Following exclusion of 11 patients who had both injuries, 256 patients were eligible for study inclusion, including 124 patients who underwent revision ACLR and 132 patients who underwent contralateral ACLR. Patients were contacted for follow-up at 6 years after the primary ACL reconstruction and PROMs were collected including subjective International Knee Documentation Committee (IKDC) score, Knee Osteoarthritis pain (KOOS-Pain) and knee-related quality of life (KOOS- QOL) subscales, and Marx activity level. Patient demographic and initial injury factors, surgical factors, and PROMs were compared between groups. Multiple regression models were used to determine whether side of subsequent surgery (revision versus contralateral ACLR) was a significant predictor of outcome. Results: Two hundred trenty-three of 256 patients (87%) were contacted and completed PROMs at 6 years following primary ACLR. The median time from primary ACLR to second ACL surgery was lower in the revision group (1.3 years) than the contralateral group (2.0 years, p &lt; 0.001). The revision group also demonstrated a lower incidence of partial lateral meniscectomy and was more likely to have received an allograft for the primary ACLR. There were no significant differences in age, sex, smoking status, pre- operative knee laxity, articular cartilage status at primary ACLR, medial meniscus status at primary ACLR, sport, or pre-operative PROMs between the two groups. At follow-up, the revision ACLR group demonstrated lower Marx activity level and PROMs than the contralateral injury group (Table 1). When controlling for the above factors, the revision ACL group demonstrated a 7.8 point lower IKDC (p&lt;0.001), a 3.2 point lower KOOS-pain (p=0.012), a 10.4 point lower KOOS-QOL (p&lt;0.001), and 2.0 point lower Marx score (p=0.002) than the contralateral ACLR group. Conclusions: Patients who undergo revision ACL R demonstrate with poorer PROMs and lower activity level than those who undergo subsequent revision ACLR. [Table: see text]

Risk factors of reoperative post anterior cruciate ligament reconstruction

Background: ACL reconstruction (ACLR) is a surgical procedure to graft the ACL using tendon tissue to restore joint fixation and stabilization functions. Rehabilitation management is performed by physiotherapy in ACLR phase III patients to increase strength, balance, and functional motion control of patients with rehabilitation and exercise adaptation interventions. Case Description: On June 09, 2022, the patient was playing basketball, when the patient heard his leg "pop" due to sudden stopping and turning movements while playing basketball. The patient took the initiative to go to the hospital because his leg was painful and was advised to do an MRI, the results of the MRI examination stated that the patient had an ACL and Meniscus rupture. The patient has undergone ACL reconstruction surgery and partial lateral meniscectomy on July 20, 2022, the patient has been doing physiotherapy since the first postoperative day until now entering the 10th week, the patient still feels something is stuck in the knee, and feels that left leg is stiff and weak when moved. Conclusion: There is an increase in ROM measurement results, muscle strength, segment circumference, hamstring and trunk flexibility, functional knee, and decreased pain scale. It is hoped that this case can be used as a reference for providing exercise interventions in patients with ACL postoperative conditions, especially phase III with other comorbidities.

Physiotherapy rehabilitation management on phase III of post-operative anterior cruciate ligament reconstruction with partial lateral meniscectomy: a case report

BACKGROUND/LATAR BELAKANG:&#x0D; Angka kejadian cedera pada lower esxtremity saat aktivitas olahraga menacapai 40-60% diseluruh dunia dan 16%nya menyebabkan cedera pada ligament ACL, dimana ligament ACL mengalami peregangan hingga rupture, cedera ACL dapat terjadi karena adanya mekanisme trauma, dimana posisi lutut rotasi, dan hiperekstensi atau disebabkan adanya kontraksi tiba-tiba dari otot quadricep femoris1. Cedera pada ACL dan juga disertai dengan meniscus tear dapat menimbulkan gangguan fungsi gerak tubuh sehingga dapat menganggu aktivitas sehari-hari 2.&#x0D; Rekonstruksi ACL adalah prosedur bedah untuk mencangkok ACL dengan menggunakan jaringan tendon untuk mengembalikan fungsi fiksasi dan stabilisasi sendi. Tendon yang diambil untuk cangkok ACL berasal dari tendon hamstring, quadriceps, pattelar, maupun tendon otot ekstremitas bawah lainnya yang dinilai kuat dan panjang, Pada kondisi meniskus yang mengalami kerobekan dapat dilakukan Tindakan menisektomi. Menisektomi parsial melibatkan mengeluarkan bagian yang robek dari meniscus dan biasanya dilakukan untuk robekan yang memiliki kemungkinan penyembuhan sangat rendah setelah perbaikan. Prosedur ini akan mengangkat sepotong meniskus yang robek sehingga lutut dapat berfungsi secara normal kembali 3.&#x0D; Penatalaksanaan rehabilitasi yang dilakukan oleh fisioterapi pada pasien ACL-R fase III untuk meningkatkan strength, balance dan kontrol gerak fungsional pasien dengan intervensi adaptasi rehabilitasi dan latihan dengan tujuan untuk mencegah cedera, mengembalikan fungsi optimal serta berkontribusi dalam meningkatkan performa olahraga atlet atau pemain dari segala usia dan kemampuan dengan menjamin standar profesionalitas yang tinggi.&#x0D; &#x0D; &#x0D; &#x0D; &#x0D; CASE DESCRIPTION/DESKRIPSI KASUS :&#x0D; Pada tanggal 09 Juni 2022 pasien bermain basket, lalu pasien mendengar kakinya berbunyi “pop” akibat gerakan berhenti dan berputar secara mendadak pada saat bermain basket. Pasien berinisiatif pergi kerumah sakit karena kakinya terasa nyeri dan disarankan untuk melakukan MRI, hasil pemeriksaan MRI menyatakan pasien mengalami rupture ACL dan Meniscus. Pasien telah menjalani operasi rekonstruksi ACL dan partial lateral menisectomy pada 20 Juli 2022, pasien telah melakukan fisioterapi sejak hari pertama pasca operasi hingaa saat ini memasuki minggu ke 10, pasien masih merasa ada yang mengganjal di bagian lutut, dan merasa kaki kirinya kaku dan lemah pada saat digerakkan.&#x0D; CONCLUSION/KESIMPULAN :&#x0D; Pemberian asuhan fisioterapi pada kasus ini bertujuan untuk mengurangi nyeri pada knee sinistra, rasa menganjal pada lutut, meningkatkan ROM khususnya pada flexi knee, meningkatkan kekuatan, endurance dan massa otot quadriceps &amp; hamstring agar kemampuan fungsional knee sinistra pasien bisa kembali ke kondisi optinal sehingga pasien bisa menjalani kehidupan sehari-harinya tanpa gangguan kemudian return to sport.

Discoid Lateral Meniscus

Discoid lateral meniscus (DLM) is a well-known meniscus variant, and comprises excess and thickened meniscal tissue, altered collagen ultrastructure, and peripheral instability. This article presents a comprehensive review on current knowledge of DLM, focusing on pathology in parallel with surgical techniques and outcomes. A paradigm shift in surgical management of DLM is taking place as knee surgeons are seeing more patients with long-term sequelae of partial lateral meniscectomy, the standard treatment for DLM for many years. Surgical treatment has evolved alongside the understanding of DLM pathology. A new classification system has been proposed and optimal surgical techniques described in recent years. This article highlights up-to-date evidence and techniques in management of both acute DLM tears and joint restoration following subtotal meniscectomy for DLM. Surgical management of DLM must be tailored to individual pathology, which is variable within the diagnosis of DLM. We present an algorithm for management of DLM and discuss future directions for the understanding and treatment of this debilitating condition.

Real-time stereo reconstruction of intraoperative scene and registration to preoperative 3D models for augmenting surgeons' view during RAMIS.

During minimally invansive surgery (MIS) procedures, there exists an ever-growing/apparent need for providing computer generated visual feedback to the surgeon(s), through a visualization device. While multiple solutions have been proposed in the literature, there is limited evidence of such a system performing reliably in practice, and when it does, it is often tailored to a specific operation type. Another important aspect is regarding the usability of such systems, which typically include complicated and time-consuming steps, and often require the assistance of specialized personnel. In this study, we propose an auxiliary visualization system for surgeons, which includes streamlined process to use preoperative data of the patient, and apply it to two different MIS cases, namely, robot-assisted partial nephrectomy and robot-assisted partial lateral meniscectomy. The visualization and processing pipeline consists of an intraoperative 3D reconstruction of the surgical area, using an optimized version of the quasi-dense method, aimed to perform with good accuracy while maintaining real-time speed. A set of preprocessing and postprocessing techniques further contribute to the result by providing a smoother and more dense point cloud. DynamicFusion is used for the registration of the preoperative model to the intraoperative scene. Two silicon kidney phantoms and an ex-vivo porcine meniscus are used for evaluation, representing subjects for the examined surgicalcases. Performance is evaluated qualitatively using the two datasets. The preoperative model of the subject is projected on top of the actual 2D image and also in 3D space. The model is superimposed on top of the actual physical structure it represents, and remains in the correct position throughout the experiments, even when abrupt camera movements are taking place. Finally, when deformation is introduced, the model is deformed as well, resembling the real subject's structure. Results demonstrate and validate the use of the presented algorithms for each separate task of the pipeline. A complete methodology to provide surgeon(s) with visual information during surgery is presented. Its operation is evaluated over two different surgical scenarios, paving the way for a single visualization methodology that can adapt and perform robustly for multiple cases, with minimaleffort.

Effect of Anterolateral Structure Augmentation on Graft Maturity After Anterior Cruciate Ligament Reconstruction: A Clinical and MRI Follow-up of 2 Years

Background: Anterolateral structure augmentation (ALSA) has been applied to prevent residual rotatory instability and lower clinical failure rates after anterior cruciate ligament (ACL) reconstruction (ACLR); however, the effect of combined ALSA on the maturity of ACL grafts remains unknown. Purpose: To evaluate the graft maturity and patient–reported outcomes in patients who underwent double–bundle ACLR with or without ALSA. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 92 patients who underwent double–bundle ACLR between January 2016 and July 2019 were included in the present study—44 patients with isolated ACLR (ACLR group) and 48 patients with combined ACLR and ALSA (ALSA group). Demographic characteristics, intraoperative findings, and patient–reported outcomes were prospectively collected. On postoperative magnetic resonance imaging at the 2–year follow–up, the signal–to–noise quotient (SNQ) values were separately calculated for 6 sections of the ACL graft, including the femoral intratunnel graft (FTG), intra–articular graft (IAG), and tibial intratunnel graft (TTG) of the anteromedial bundle (AMB) and the posterolateral bundle (PLB). Superior graft maturity was usually indicated by lower SNQ values. Results: The rates of return to preinjury sports were 47.9% and 27.3% in the ALSA and ACLR groups, respectively (difference, 20.6% [95% CI, 1.3%-40%]; P = .042). The AMB demonstrated significantly lower SNQ values in the ALSA group than in the ACLR group (FTG, 7.04 ± 3.65 vs 9.44 ± 4.51 [P = .006]; IAG, 6.62 ± 4.19 vs 8.77 ± 5.92 [P = .046]; TTG, 6.93 ± 3.82 vs 8.75 ± 4.55 [P = .040]). The SNQ values were significantly lower in the ALSA group for 2 of the 3 sections of the PLB (IAG, 7.73 ± 4.61 vs 9.88 ± 5.61 [P = .047]; TTG, 5.88 ± 3.10 vs 8.57 ± 4.32 [P = .001]). Partial lateral meniscectomy was correlated with higher SNQ values of the TTG in the AMB (β = 0.27; P = .009) and the PLB (β = 0.25; P = .008), with both groups pooled. Higher body mass index, smaller ACL graft–Blumensaat line angles, larger AMB graft diameters, and lower postoperative Tegner scores were also associated with inferior maturity in specific regions of the ACL graft. Conclusion: A combination of ACLR and ALSA is a desirable option to improve the maturity of ACL grafts for patients who are young or expected to return to pivoting sports. Meanwhile, further investigations with higher levels of evidence and longer periods of follow–up are warranted.

Paper 18: Treatment of Lateral Meniscus Tears Influences OA Rate following ACL Reconstruction at 9-year Follow-Up

Objectives:Recent studies have described an increased risk of osteoarthritis (OA) following ACL reconstruction (ACLR). Systematic reviews have suggested that meniscal pathology, which occurs in up to 60% of patients with ACL injury, increases this risk. The purpose of this study was to determine the influence of lateral meniscus tears and repair versus partial lateral meniscectomy on the risk of OA in patients following ACLR.Methods:All patients who underwent primary autograft or allograft bone-patellar tendon-bone (BPTB) transtibial ACLR by a single surgeon between 1999-2019, were identified. Revision ACLR, multi-ligamentous reconstructions, and patients with less than 2-year imaging follow-up were excluded. Patients with lateral meniscus pathology at the time of ACLR were identified and treatment (e.g. lateral meniscectomy or lateral meniscus tear) was extracted. OA was defined at follow-up as Kellgren-Lawrence (KL) grade III-IV on plain radiographs. Chi-square tests assessed differences in incidence rates (p<0.05).Results:A consecutive series of 113 patients (57 males, 56 females; age 35.7±11.9 years) with BPTB ACLR were included. The mean follow-up was 9±5 years. The prevalence of lateral meniscus tears was 60.2% (68/113) and the prevalence of lateral compartment OA at follow-up was 14% (16/113) Patients with a lateral meniscus tear were 4.7 times more likely to develop OA compared to patients with no lateral meniscus tear. 20.6% of patients (14/68) with lateral meniscus tear developed lateral OA compared to 4.4% of patients (2/45) without lateral meniscus tear (p=0.0158). Patients who underwent lateral meniscal repair (n=16) had significantly lower prevalence of OA (0/16) compared to patients who underwent lateral meniscectomy (14/52) (p=0.0196).Conclusions:At nine-year follow-up, patients with a lateral meniscus tear at time of ACLR were more likely to develop OA compared to patients with no lateral meniscus tear and patients treated with partial meniscectomy had higher prevalence of OA compared to those treated with meniscus repair. In patients who require ACLR, care should be taken in evaluating and treating the lateral meniscus to decrease the likelihood of the development of OA. We believe lateral meniscal repair is essential for lateral meniscus tears at the time ACL reconstruction to help avoid development of OA.Figure 1.

Treatment of Malalignment and Cartilage Injury: High Tibial Osteotomy With a Concomitant Osteochondral Allograft to the Medial Femoral Condyle and Lateral and Medial Partial Meniscectomy

In patients with full-thickness focal cartilage defects, osteochondral allograft is a technique for restoration of hyaline cartilage; however, in patients with genu varum, the diseased compartment of the knee is generally offloaded as well. A high tibial osteotomy presents a biomechanical solution to malalignment of the knee and offloading of the diseased compartment of the knee. The purpose of this Technical Note is to present our preferred technique to treat focal cartilage damage in a varus misaligned knee coupling a high tibial osteotomy with an osteochondral allograft to the medial femoral condyle, along with partial medial and lateral meniscectomy.

Performance and Return to Sports After Meniscectomy in Professional Baseball Players

Background: Meniscal injuries are common in athletes across many sports. How professional baseball players respond to partial meniscectomy is not well documented. Purpose/Hypothesis: The purpose was to determine the performance and return-to-sports (RTS) rate in professional baseball players after arthroscopic partial knee meniscectomy and compare the results of partial medial meniscectomy versus partial lateral meniscectomy. The hypothesis was that there would be a high RTS rate in professional baseball players after partial meniscectomy with no difference in the RTS rate or timing of RTS between players who underwent partial medial meniscectomy versus partial lateral meniscectomy. Study Design: Cohort study; Level of evidence, 3. Methods: All professional baseball players who underwent arthroscopic partial meniscectomy between 2010 and 2017 were identified using the Major League Baseball Health and Injury Tracking System database. Demographic and performance data (before and after injury) for each player were recorded. The RTS rate and timing of RTS were then compared between players who underwent partial medial meniscectomy versus partial lateral meniscectomy. Results: A total of 168 knees (168 players) underwent arthroscopic partial meniscectomy (mean age, 25 ± 5 years; 46% medial meniscectomy, 45% lateral meniscectomy, and 9% both medial and lateral meniscectomy). The most common mechanism of injury was fielding in the infield on natural grass. Injuries were spread evenly across positions: 18% catchers, 24% infielders, 20% outfielders, and 38% pitchers. The overall RTS rate was 80% (76% returned to the same or a higher level, and 4% returned to a lower level). For performance, pitchers saw significant decreases in usage but significant improvements in performance using the advanced statistics of fielding independent pitching (P < .001) and wins above replacement (P = .011). Hitters saw significant decreases in usage but increases in efficiency as seen by improvements in wins above replacement (P = .003). Of the 79 athletes who returned during the same season, the median time to return to play was 42 days. Conclusion: The RTS rate after meniscectomy in professional baseball players was 80%. Player efficiency improved after surgery in pitchers and position players. No difference in the RTS rate or timing of RTS existed between players who underwent partial medial meniscectomy versus partial lateral meniscectomy.

ACL Reconstruction Combined With the Arnold-Coker Modification of the MacIntosh Lateral Extra-articular Tenodesis: Long-term Clinical and Radiological Outcomes

Background: Interest in the role of lateral extra-articular tenodesis (LET) in preventing rotatory instability and the pivot-shift phenomenon after anterior cruciate ligament reconstruction (ACLR) has been recently renewed. Nevertheless, there is still concern about overconstraint of the lateral compartment of the knee and the risk of subsequent osteoarthritis (OA). Purpose: The purpose of this retrospective study was to compare long-term subjective and objective outcomes and the rate of OA development between patients undergoing isolated ACLR (iACLR) with a hamstring tendon autograft and those with a combined Arnold-Coker modification of the McIntosh extra-articular procedure. Risk factors for long-term OA were evaluated. Study Design: Cohort study; Level of evidence, 3. Methods: The study included 165 consecutive patients treated at a single center by ACLR. A total of 86 patients underwent iACLR (iACLR group) and 79 received combined intra- and extra-articular reconstruction (ACLR+LET). The International Knee Documentation Committee (IKDC), Lysholm, and Tegner activity scores were administered. Knee stability was tested through the Lachman test, the pivot-shift test, and the KT-1000 knee arthrometer test. A positive pivot-shift test (++/+++), laxity on the KT-1000, and referred giving-way episodes or revision ACLR were considered failures. Radiographic results were assessed according to the Fairbank, IKDC, and Kellgren-Lawrence scales. Radiographic evaluation included both the overall tibiofemoral joint and the medial and lateral compartment separately. A univariate and a multivariate logistic regression with penalized maximum likelihood was used to identify risks factors associated with long-term OA. Results: The mean follow-up was 15.7 years. There were no statistically significant differences in subjective scores between the 2 groups. A side-to-side difference >5 mm on the KT-1000 arthrometer evaluation was found in 8 patients in the iACLR group and in 1 patient in the ACLR+LET group (P = .01). Nine cases of failure were found in the iACLR group and only 1 case was found in the ACLR+LET group (P = .0093). Patients in the iACLR group had a significantly higher OA grades than those in the ACLR+LET group for the overall tibiofemoral joint and the lateral compartment of the knee. No differences were found in the medial compartment. A higher level of lateral compartment OA was found in patients who received partial lateral meniscectomy in the iACLR group compared with those in the ACLR+LET group. Univariate and multivariate analysis results demonstrated that meniscectomy was the most significant factor for long-term OA development. Conclusion: A significantly higher risk of long-term OA was found with iACLR than with ACLR combined with the Arnold-Coker modification of the McIntosh extra-articular procedure. Knees with combined ACLR also had a significantly lower OA grade after partial lateral meniscectomy. Additionally, those undergoing combined ACLR had better knee stability and lower graft rupture rates at the long-term follow-up. Partial meniscectomy was the main risk factor negatively associated with OA changes.

Aseptic Revision and Reoperation Risks After Meniscectomy at the Time of Anterior Cruciate Ligament Reconstruction

Background: An intact meniscus is considered a secondary stabilizer of the knee after anterior cruciate ligament reconstruction (ACLR). While loss of the meniscus can increase forces on the anterior cruciate ligament graft after reconstruction, it is unclear whether this increased loading affects the success of the graft after ACLR. Purpose: To identify the risk of subsequent knee surgery when meniscectomy, either partial or total, is performed at the time of index ACLR. Study Design: Cohort study; Level of evidence, 3. Methods: We conducted a matched cohort study using data from the Kaiser Permanente Anterior Cruciate Ligament Reconstruction Registry. Patients were identified who had a primary ACLR performed between January 1, 2005 and December 31, 2016, with up to 12 years of follow-up. The study sample comprised patients with ACLR who had a lateral meniscectomy (n = 2581), medial meniscectomy (n = 1802), or lateral and medial meniscectomies (n = 666). For each meniscectomy subgroup, patients with ACLR alone were matched to patients with a meniscectomy on a number of patient and procedure characteristics. After the application of matching, Cox proportional hazards regression was used to evaluate the risk of aseptic revision, while competing risks regression was used to evaluate the risk of cause-specific ipsilateral reoperation between meniscectomy and ACLR alone. Analysis was performed for each meniscectomy subgroup. Results: After the application of matching, we failed to observe a difference in aseptic revision risk for patients with ACLR and a meniscectomy—lateral (hazard ratio [HR], 0.80; 95% CI, 0.63-1.02), medial (HR, 0.95; 95% CI, 0.70-1.29), or both (HR, 1.25; 95% CI, 0.77-2.04)—as compared with ACLR alone. When compared with patients who had ACLR alone, patients with a lateral meniscectomy had a higher risk for subsequent lateral meniscectomy (HR, 1.89; 95% CI, 1.18-3.02; P = .008), and those with a medial meniscectomy had a lower risk for manipulation under anesthesia (HR, 0.13; 95% CI, 0.02-0.92; P = .041). Conclusion: No difference in aseptic revision risk was observed for patients undergoing primary ACLR between groups with and without meniscectomy at the time of index surgery. Partial lateral meniscectomy at the time of index ACLR did associate with a higher risk of subsequent lateral meniscectomy.

Risk Factors for Rapid Chondrolysis After Partial Lateral Meniscectomy: A Scoping Review of the Literature

Background:The occurrence of rapid chondrolysis after partial lateral meniscectomy is rare. The pathophysiology, risk factors, and outcomes of treatment have not been established.Purpose:The primary aim of this study was to perform a scoping review of the literature to determine the potential risk factors and pathogenesis of rapid chondrolysis. The secondary objective was to report outcomes of treatment.Study Design:Systematic (scoping) review.Methods:A scoping review of the literature was conducted in accordance with the framework of Arksey and O’Malley. A search strategy based on the terms “chondrolysis” AND “knee,” “chondrolysis” AND “meniscus,” and “chondral damage” AND “lateral meniscus” was applied to the PubMed database on March 31, 2020. All relevant studies were included. Patient demographics and clinical data were extracted from these studies and analyzed in order to investigate the potential risk factors, pathogenesis, and outcomes of treatment for rapid chondrolysis.Results:Five articles (22 cases) featuring rapid chondrolysis in the lateral compartment after partial lateral meniscectomy were identified and included. The condition occurred most frequently in patients who were young (mean age, 25.6 years), male (20/22 cases; 91%), and participating in high-intensity sports (19/22 cases; 86.4%) within 1 year of the index procedure. Half of the included study population underwent surgery for a radial tear. All professional athletes (13/13) returned to the preinjury level of sport. All authors of included studies suggested that the main causal risk factor was mechanical focal cartilage overload in the lateral compartment of the knee.Conclusion:Rapid chondrolysis after partial lateral meniscectomy is a rare condition that typically occurs within 12 months of the index procedure. Younger age, male sex, high-intensity sports participation, and some meniscal tear patterns (eg, radial tear) are potentially important risk factors. Return-to-sport rates at short-term follow up are high, but no long-term studies were identified. The pathogenesis of rapid chondrolysis seems to relate to mechanical focal cartilage overload.

Development of OA Following ACL Reconstruction: Unexpected Finding in Medial Versus Lateral Meniscus Pathology

Objectives:Recent studies have described increased risk of OA following ACL reconstruction (ACLR). Systematic reviews have suggested that meniscal pathology, which occurs in up to 60% of patients with ACL injury, increases this risk. The literature reports a 50% incidence of OA following medial meniscectomy, two times the risk compared to lateral meniscectomy. The purpose of this study was to determine the influence of meniscal pathology on the incidence of OA following ACLR.Methods:All patients who underwent primary autograft or allograft BPTB transtibial ACLR by a single surgeon between 1999-2015 were identified. Revision ACLR, multi-ligamentous reconstructions, and patients with less than 2-year imaging follow-up were excluded. Meniscus pathology and treatment were recorded. OA was defined at follow-up as Kellgren-Lawrence grade III-IV on plain radiographs. Chi-square tests assessed differences in incidence rates (p<0.05).Results:A consecutive series of 103 patients (56 males, 47 females; age 36.1±11.4 years) with BPTB ACLR with an average follow-up of 8.81±4.96 (range 2-20 years) were included. The prevalence of medial meniscus tears at the time of ACL injury was 47.6% (49/103) and prevalence of lateral meniscus tears was 56.3% (58/103) (p=0.166). Medial compartment OA was seen in 9.7% (10/103) of patients. Prevalence of medial compartment OA was greater in patients with medial meniscus tear (14.3%; 7/49) compared to those without a medial meniscus tear (5.6%; 3/54); however, this was not significant (p=0.135). Of the 7 patients with medial meniscal tear and medial compartment OA, 5 underwent partial medial meniscectomy and 2 underwent repair. Lateral compartment OA was seen in 14.6% (15/103). The prevalence of lateral compartment OA was greater in patients with a lateral meniscus tear (22.4%; 13/58) compared to patients without lateral meniscus tears (4.4%; 2/45) (p=0.01). Patients with lateral meniscus tear were 5.04 [95%CI: 1.2 to 21.2] times more likely to develop OA. Thirteen of the 47 (28%) patients that underwent partial lateral meniscectomy developed lateral OA compared to 0% of patients (0/10) that underwent lateral meniscal repair (p=0.068).Conclusion:While studies with multiple surgeons and rehabilitation protocols have shown the development of OA following ACLR is increased with medial meniscal pathology, we found that the prevalence of medial OA was not significantly higher in these patients with medial meniscal tear at an average of 8.81 years follow-up. Whereas, lateral meniscal repair dramatically reduced the development of knee OA compared to partial meniscectomy in this cohort of patients with ACLR. These findings can inform clinical practice as despite prior literature indicating a relationship between medial meniscal tear and osteoarthritis, we did not see a greater prevalence of OA amongst patients undergoing ACLR with a medial meniscal tear. Further, a lateral meniscal repair offers superior protection against OA when compared to partial lateral meniscectomy in treating lateral meniscal tears and is essential in the treatment of these complex patients.

Thrombolysis of Postoperative Acute Pulmonary Embolism with a Thrombus in Transit

Right heart thrombus in transit clot (RHTT) associated with a pulmonary thromboembolism (PTE) is a rare but potentially fatal diagnosis. Early diagnosis and immediate intervention are crucial. This report describes the case of a healthy, physically active 32-year-old female who presented 19 days postoperatively, following an anterior cruciate ligament reconstruction and partial lateral meniscectomy with a saddle PE, RHTT, and right ventricular (RV) strain. The patient received half of the standard dose of intravenous tissue plasminogen activator (TPA) in combination with anticoagulation and survived. Case reports of RHTT will inform future studies designed to evaluate whether and when thrombolysis should be administered.

A Randomized Controlled Trial of Bone–Patellar Tendon–Bone Anterior Cruciate Ligament Reconstruction With and Without Lateral Extra-articular Tenodesis: 19-Year Clinical and Radiological Follow-up

Background: Arthroscopic anterior cruciate ligament (ACL) reconstruction (ACLR) with a bone–patellar tendon–bone graft (BTB) is a reliable surgical option for the control of anterior knee laxity after ACL injury. The addition of a lateral extra-articular tenodesis (LET) may improve control of rotation knee laxity and improve short-term graft survival in high-risk patients. Purpose: The aims of this study were to compare long-term patient-reported outcomes, graft survival, and risk of osteoarthritis between ACLR with and without LET. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: This study included 121 consecutive knees (120 patients) presenting to a single center with an ACL rupture between 1998 and 1999. In total, 61 knees were randomized to an isolated BTB ACLR, and 60 knees were randomized to a BTB ACLR with an extra-articular lateral tenodesis with gracilis tendon (modified Lemaire). Results: Eighty knees in 79 patients (66%) were available for follow-up at a postoperative mean of 19.4 years (range, 19-20.2). Of those patients, 43 had a clinical examination and completed patient-reported outcome questionnaires, and the other 37 patients were evaluated through the questionnaires alone. Standard radiographs were available for 45 patients and laximetry (TELOS) for 42 patients. Mean subjective International Knee Documentation Committee score at last follow-up was 81.8, and no differences were noted between the BTB and BTB-LET groups (P = .7). Two-thirds of patients were still participating in pivoting sports. A total of 17 knees (21%) experienced a graft failure, 5 of which (6%) underwent revision ACLR. There was no significant difference in graft failure risk between the BTB group (29%) and the BTB-LET group (13%; P = .1). Lateral tibiofemoral osteoarthritis was significantly more frequent in the BTB-LET group (59%) as compared with the BTB group (22%; P = .02). Lateral compartment osteoarthritis was correlated with partial lateral meniscectomy. Conclusion: There were no significant differences in long-term patient-reported outcomes after ACLR with or without an LET. LET may increase the risk of lateral compartment osteoarthritis at long-term follow-up. There was a trend toward decreased graft failure risk with the addition of LET but this study was underpowered to assess this outcome.

Partial Lateral Meniscectomy Affects Knee Stability Even in Anterior Cruciate Ligament-Intact Knees.

The effects of a partial lateral meniscectomy on knee kinematics and forces in the lateral meniscus are critical to understand. The purpose of this study was to quantify the effects of varying sizes of partial lateral meniscectomies of the posterior horn and a total lateral meniscectomy on knee kinematics and resultant forces in the lateral meniscus. Using a robotic testing system, loads (134-N anterior tibial load + 200-N axial compression, 5-Nm internal tibial torque + 5-Nm valgus torque, and 5-Nm external tibial torque + 5-Nm valgus torque) were applied to 10 fresh-frozen cadaveric knees. The resulting joint motion and resultant forces in the lateral meniscus were determined for 4 knee states: intact, one-third and two-thirds partial lateral meniscectomies of the posterior horn, and total lateral meniscectomy. A decrease in lateral translation of the tibia (up to 166.7%) was observed after one-third partial lateral meniscectomies of the posterior horn compared with the intact knee, in response to an anterior load at all knee flexion angles tested (p < 0.05). One-third partial lateral meniscectomies of the posterior horn decreased the resultant forces in the lateral meniscus compared with the intact knee at all knee flexion angles tested in response to an anterior load (p < 0.05) and to an internal tibial torque (p < 0.05). The results of two-thirds partial lateral meniscectomies of the posterior horn were similar to those of one-third partial meniscectomies (p > 0.05). Total lateral meniscectomies further decreased the lateral translation of the tibia (up to 316.6%) compared with the intact knee in response to an anterior load (p < 0.05). The changes in joint motion and meniscal forces observed in this study after even small partial lateral meniscectomies may predispose knees to further injury. Surgeons should always consider repairing and minimizing the resection of even small lateral meniscal tears to prevent the potential deleterious effects of partial meniscectomy reported in this cadaveric study.