Pullout Repair Research Articles

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

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

Time-Dependent Increase in Medial Meniscus Extrusion Predicts the Need for Meniscal Repair in Patients with Partial Medial Meniscus Posterior Root Tears: A Case–Control Study

PurposeThis study aimed to compare medial meniscus extrusion (MME) in patients with partial medial meniscus posterior root tears (MMPRTs) through magnetic resonance imaging (MRI) conducted at two-time points and to determine whether patient characteristics or MME measurements differ in patients who respond to nonoperative treatment compared with those who require surgical treatment.MethodsThirty-seven patients with partial MMPRTs underwent two MRI scans during nonoperative management or before pull-out repair. Among these, 17 patients received nonoperative management, and 20 underwent pull-out repair. Partial MMPRTs were diagnosed based on the MRI findings. MME measurements were performed on both MRI scans. Statistical and receiver operating curve (ROC) analyses were performed.ResultsThe duration between the two MRI scans was significantly shorter in the pull-out repair group than in the nonoperative management group. The increase in MME (ΔMME) on MRI scans was significantly greater in the pull-out repair group than in the nonoperative management group. Linear regression analysis revealed a weak correlation between the MRI interval and ΔMME in the nonoperative management group and a moderate correlation in the pull-out repair group. In the ROC construction, the cut-off value for ΔMME that requires surgical intervention was 0.41 mm, with a sensitivity and specificity of 85.0% and 52.9%, respectively.ConclusionPatients with partial MMPRTs requiring surgical treatment had greater MME progression in a shorter time and a time-dependent increase in MME. Therefore, a ΔMME of ≥ 0.41 mm may be useful in deciding surgical intervention based on MRI retests.Level of evidenceIII.

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.

Insufficient restoration of meniscal extrusion by transtibial pullout repair for medial meniscus posterior root tears.

The long-term changes in the dynamics of the medial meniscus after transtibial pullout repair for medial meniscus posterior root tears (MMPRTs) are not completely understood. Thus, the aim of this study was to investigate the effects of transtibial pullout repair on MMPRTs and whether the effects would be sustained. Nineteen knees with MMPRTs that were treated by trans-tibial pullout repair were enrolled in this study. Medial meniscus extrusion (MME) was measured by ultrasonography during knee extension (no weight-bearing with the knee at 0° extension: NW0°) and 90° flexion (no weight-bearing with the knee at 90° flexion: NW90°) with the patient in the supine position and with full weight-bearing (FW0°) preoperatively and at 3 and 12months postoperatively. The clinical outcomes were assessed using the Knee Injury and Osteoarthritis Outcome Score, Lysholm score, and International Knee Documentation Committee score. The difference in MME with NW0° was not statistically significant between the preoperative (3.4 ± 1.0mm) and 12-month postoperative (3.7 ± 0.6mm) time points. The MME with NW90° at 3 (2.1 ± 0.7mm) and 12months (2.9 ± 0.6mm) postoperatively were significantly lower than the preoperative values (3.4 ± 0.8mm) (P < 0.05). However, the value significantly increased from 3 to 12months postoperatively (P < 0.05). The MME with FW0° at 12months postoperatively (4.3 ± 0.6mm) was significantly larger than that at pre-operatively (3.6 ± 0.9mm) (P < 0.05). All the patients' clinical conditions were significantly improved at 12months postoperatively when compared to their preoperative clinical conditions. Surgery did not reduce the extrusion in the no weight-bearing and weight-bearing positions at knee extension, and these values increased in the postoperative period. In addition, while the surgery reduced the extrusion in the knee flexion position, the restoration achieved by the surgery was not sustained in the long term. Level IV.

Comparison of medial tibiofemoral joint mechanics between all-suture anchors and transtibial pullout technique for posterior medial meniscal root tears

BackgroundThe posterior medial meniscal root tear (PMMRT) seriously impacts the tibiofemoral joint biomechanics. Two available techniques for PMMRT repair include the transtibial pullout (TPO) repair and all-suture anchor (ASA) repair techniques. These techniques have not been compared biomechanically.MethodsA total of 20 fresh porcine cadaveric knee specimens were used. All 20 knees were randomly and evenly distributed into four groups (five specimens per group): (1) intact posterior meniscal root, (2) PMMRT, (3) TPO repair technique for PMMRT, and (4) ASA repair technique for PMMRT. The tibiofemoral contact mechanics were investigated using a pressure sensor. All knee specimens were tested by being loaded with 600 N axial compressive force at three different flexion angles (0°, 45°, and 90°). The contact surface area, contact pressure, peak pressure, and time-zero displacement were recorded.ResultsThe PMMRT caused a significant decrease in contact surface area, an increase in contact pressure, and peak pressure from the reference values observed in the intact meniscus group (P = 0.05, 0.016, and 0.008, respectively). After fixation, no significant difference was observed between the ASA and intact group. Meanwhile, significant differences were found between the TPO and intact group in terms of contact surface area, contact pressure, and peak pressure. In the comparison between the two techniques, the ASA group demonstrated higher contact surface area than the TPO group at the average knee flexion angle (p = 0.05).ConclusionFor most testing conditions, the ASA technique demonstrated superior biomechanical property in terms of contact surface area compared with the TPO technique under compressive loading conditions. The ASA technique could also restore the tibiofemoral contact mechanics to be comparable with those of the native intact knee. Meanwhile, a significant difference in tibiofemoral mechanics, compared with the intact knee, could be observed in the TPO technique.

Biomechanical Comparison of Two Different Sutures for the Tensile Strength of the Pullout Repair of Posterior Meniscal Root Tear.

Background Medial meniscal posterior root tear has garnered attention because it causes increased joint contact pressure and loss of load distribution function. Currently, the common treatment for posterior meniscal root tears is transtibial pullout repair, and loop suture remains the gold standard procedure. Purpose The aim of this study is to validate whether the meniscus-suture complex exhibits better structural properties after loop stitch using a suture tape versus the conventional thread. Study design and methods This is a controlled laboratory study. In total, 20 menisci harvested from castrated male pigs were prepared and randomly assigned to two suturing techniques: loop stitch using ULTRATAPE (n = 10, tape group) or loop stitch using 2-0 UltraBraid (n = 10, control group). The single-loop stitch meniscus-suture technique was used. A single suture using ULTRATAPE or 2-0 UltraBraid was placed through the meniscus 5 mm medial from the resected edge of the posterior meniscus horn. The meniscus-suture complex specimens were mounted on a tensile tester to apply tensile load on the meniscus-suture complex parallel to the long axis of the stitched suture materials. Each specimen was stretched to failure at a crosshead speed of 50 mm/minute. The structural properties of the meniscus-suture complex (maximum load, linear stiffness, and elongation at failure) were determined. Results In the tape group, all the repaired complexes were torn at the ligature; conversely, in the control group, the threads were torn in three of 10 specimens, and the repaired complexes in the remaining seven specimens were torn at the ligature. No significant between-group differences were observed in linear stiffness (9.0 ± 4.1 vs 7.1 ± 2.9 N/mm) and elongation at failure (15.8 ± 6.1 vs 19.6 ± 20.1 mm); however, the tape group exhibited a significantly higher average maximum load than the control group (104.6 ± 41.2 vs 62.6 ± 32.1 N; P = 0.020). Conclusion Suture tape can be a potential alternative to the conventional thread for Medial meniscal posterior root tear repair. Clinical relevance Medial meniscal posterior root tear repair using tape rather than the conventional thread may be beneficial in obtaining better structural properties.

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

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

Reprint of: Outcomes of Arthroscopic All-Inside Repair Are Improved Compared to Transtibial Pull-Out Repair of Medial Meniscus Posterior Root Tears

The purpose of the present study was to compare the clinical outcomes of patients who underwent an all-inside repair (with a bony trough) versus transtibial pull-out repair in medial meniscus posterior root tears (MMPRTs). We retrospectively investigated consecutive patients who underwent MMPRT repairs in nonacute tears in age over 40 from November 2015 to June 2019. All patients were divided into a transtibial pull-out repair group and an all-inside repair group. Different surgical techniques were used during different time frames. All patients were followed-up for a minimum of 2 years. The data collected included the International Knee Documentation Committee (IKDC) Subjective, Lysholm, and Tegner activity scores. Magnetic resonance imaging (MRI) was performed at the 1-year follow-up to assess meniscus extrusion, signal intensity, and healing. The final cohort consisted of 28 patients in the all-inside repair group and 16 in the transtibial pull-out repair group. In the all-inside repair group, the IKDC Subjective, Lysholm, and Tegner scores improved significantly at the 2-year follow-up. In the transtibial pull-out repair group, the IKDC Subjective, Lysholm, and Tegner scores did not improve significantly at the 2-year follow-up. Postoperative extrusion ratio increased in both groups, and patient-reported outcomes at follow-up did not differ between the two groups The change in the extrusion ratio was significantly less in the all-inside repair group (P= .009), as was the postoperative meniscus signal (P= .011). Postoperative MRI revealed significantly better healing in the all-inside group (P= .041). All-inside repair improved the functional outcome scores. Radiologically, all-inside repair was better than transtibial pull-out repair. All-inside repair may be a viable MMPRT treatment option. III, retrospective cohort study.

Posterior Horn Lateral Meniscal Root Repair Via Double-Tunnel Transtibial Pullout With Meniscocapsular Release

Background: Lateral meniscal root tears often occur in the acute setting in concert with anterior cruciate ligament (ACL) tears. Severe changes in tibiofemoral biomechanics and joint degeneration are encountered when these injuries are either unrecognized or are treated with meniscectomy; therefore, meniscal root surgical repair is now preferred for longer-term benefits. The most common repair techniques include side-to-side and transtibial pull-out repair, which may be performed via single or double transtibial tunnel techniques. Indications: The primary indication for lateral meniscal root repair with double transtibial tunnels is suspicion for a lateral meniscal root tear based upon injury mechanism, physical examination findings, magnetic resonance imaging findings, and confirmation with diagnostic arthroscopy. Technique Description: The root attachment site is decorticated. Adhesions that cause lateral meniscal root retraction are arthroscopically released. Two separate transtibial tunnels are drilled 5 mm apart from the anterolateral tibia, entering the anterolateral tibia distal to Gerdy’s tubercle and entering the joint at the decorticated lateral root attachment site. Two suture tapes are passed through the torn lateral meniscal root in a vertical mattress configuration and shuttled with a passing suture through the tibial tunnels. The suture tapes are tied over a surgical button on the anterolateral tibia with the knee flexed to approximately 90° while the repair is viewed arthroscopically. Results: Lateral meniscal root repairs are safe and have very low reoperation rates. It has been reported that the transtibial pullout repair technique of the lateral meniscus significantly decreases lateral meniscus extrusion compared with other repair techniques in patients with combined ACL reconstruction. Zhuo et al also reported significantly improved postoperative clinical outcomes compared with the preoperative state in patients who underwent pullout repair for posterior lateral meniscal root avulsion tears. Discussion/Conclusion: The biomechanical and clinical evidence supports concomitant lateral meniscal root repair in the setting of concurrent ACL injury, and no studies to date have demonstrated a clear harm associated with this procedure. In addition, failure to repair the lateral meniscal root places supraphysiologic loads on the ACL graft and may increase the risk of graft failure. 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.

Posterior Medial Meniscus Root Repair With Peripheral Stabilization Stitch

Background: Posteromedial meniscal root tears occur when the meniscal root detaches from the tibial plateau, which limits the native functionality of the meniscus, alters tibiofemoral contact forces, and can progress to meniscal extrusion. Untreated meniscal root tears with meniscal extrusion have been associated with significant articular cartilage loss and accelerated progression of osteoarthritis. Recent biomechanical evidence suggests restoring the contact area with the use of a peripheral stabilization suture at the posteromedial aspect of the tibial plateau. Indications: Meniscal root repair with a peripheral stabilization suture is indicated by clinical and radiographic evidence of complete detachment of the posteromedial meniscus root with significant meniscal extrusion outside the joint. Technique Description: This technique uses 2 tunnels for the meniscal root repair as well as a single additional transtibial tunnel for the peripheral stabilization suture. The described technique demonstrates a peripheral release along the meniscocapsular junction to allow the meniscus to be reapproximated to its anatomical attachment site. This is followed by transtibial tunnel preparation to allow suture passage for the meniscal root repair and an additional transtibial tunnel is created for the peripheral stabilization suture. After stabilization of the extruded meniscus, the suture is tied down over a cortical fixation device on the anteromedial tibia. Results: Significant improvement has been reported by clinical studies after the transtibial pullout repair method; however, structural outcomes have shown conflicting results. Kaplan et al reported patients treated with transtibial suture pullout technique with 2 locking cinch sutures had improved clinical outcomes, but increased extrusion of the medial meniscus compared with the preoperative state, whereas Kim et al reported a decrease in meniscal extrusion following pullout suture repair technique. Discussion: Posteromedial meniscus root repair using a peripheral stabilization suture is an effective surgical technique to restore the contact pressures of the knee and limit the amount of meniscal extrusion. This allows for appropriate correction of hoop stress to prevent further cartilage loss and progression of osteoarthritis. 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.

Evaluation of the bone tunnel position and state of healing on second-look arthroscopy after pullout repair of medial meniscus posterior root tear during open-wedge high tibial osteotomy

BackgroundThe aim of the present study was to evaluate the outcome of pullout repair of medial meniscus posterior root tear during open-wedge high tibial osteotomy, including the bone tunnel position and the state of healing on second-look arthroscopy. MethodsThe cohort comprised 22 patients (six men, 16 women) who underwent arthroscopic root fixation by the transtibial pullout technique for medial meniscus posterior root tear during open-wedge high tibial osteotomy. The mean patient age was 63.7 years. The location of the tibial tunnel was assessed using a percentage-dependent method, and the location of a critical point was determined by two coordinates on CT. We defined the distance between the tibial tunnel center and the medial meniscal posterior root anatomic center as the TC-AC distance. The healing state was classified as complete, partial, or failed on second-look arthroscopy. Patients were categorized into those with complete or partial healing (group H) and those with failed healing (group F). The differences in the outcomes and characteristics of groups H and F were evaluated. ResultsTwelve and 10 knees were classified into groups H and F, respectively. The bone tunnel position was significantly more posterior in group H than in group F. The TC-AC distance was significantly shorter in group H than in group F. ConclusionsIn pullout repair of medial meniscus posterior root tear during open-wedge high tibial osteotomy, it was considered important to create a bone tunnel position more posterior to increase the healing rate on second-look arthroscopy.Level of evidence: Level Ⅳ.

Accuracy of the newly developed Zimmer Biomet Root Aiming guide in tibial tunnel creation compared with that of conventional guides

Background/objectiveAccurate tibial tunnel creation is crucial for successful transtibial pullout repair of medial meniscus (MM) posterior root tears (MMPRTs). This study aimed to evaluate the accuracy of the newly developed Zimmer Biomet Root Aiming (ZeBRA) guide for transtibial pullout repair of MMPRTs. MethodsThis study included 50 patients who underwent transtibial pullout repair using the Unicorn Meniscal Root (UMR) (n = 25) and ZeBRA (n = 25) guides. The expected anatomic centre (AC) and tibial tunnel centre (TC) were assessed using three-dimensional postoperative computed tomography (CT) images. The expected AC was defined as the centre of the circle tangent to the triangular footprint of the MM posterior root. The expected AC and TC on the tibial surface were assessed using the percentage-based posterolateral location on the tibial surface. The absolute distance between the AC and TC (mm) was evaluated. ResultsThe mean AC location was 76.1% ± 3.1% posterior and 40.8% ± 2.1% lateral, whereas the mean TC location was 76.7% ± 5.3% posterior and 37.2% ± 3.6% lateral using the UMR guide and 75.8% ± 3.1% posterior and 36.5% ± 2.4% lateral using the ZeBRA guide. No significant difference was observed in the absolute distance between the UMR and ZeBRA guides (3.9 ± 1.4 and 3.8 ± 1.3 mm, respectively; p = 0.617). ConclusionsThe newly developed ZeBRA guide allows accurate tibial tunnel creation, and its accuracy is comparable to that of the conventional UMR guide. Tibial tunnels were created at optimal positions using both guides, and the choice of the guide would depend on the surgeon's preference.

Meniscus extrusion is a predisposing factor for determining arthroscopic treatments in partial medial meniscus posterior root tears

BackgroundPatients with partial medial meniscus posterior root tears (MMPRTs) sometimes require arthroscopic pullout repair because of their intolerable/repeated knee pains and continuous disturbance in gait during activities of daily living. However, the predisposing factors for future knee surgery in patients with partial MMPRTs remain unclear. We compared the findings of magnetic resonance imaging (MRI) between patients who underwent pullout repair and nonoperative management following partial MMPRTs.MethodsTwenty-five patients who required arthroscopic repair for partial MMPRTs and 23 patients who were managed nonoperatively were evaluated during a mean follow-up period of 27.1 months. Sex, age, height, body weight, body mass index, duration from onset to initial MRI, MRI findings, and medial meniscus (MM) extrusion were compared between the two groups. Linear regression analysis was used to assess the correlation between MM extrusion and duration from onset to MRI examination.ResultsNo significant differences were observed between the pullout repair and nonoperative management groups in terms of patient demographics and the positive ratio of MRI-based root tear signs. However, absolute MM extrusion in the pullout repair group (3.49 ± 0.82 mm) was larger than that in the nonoperative management group (2.48 ± 0.60 mm, P < 0.001). Extrusion of the MM (> 3 mm) was detected more frequently in the pullout repair group than in the nonoperative management group (P < 0.001). The odds ratio in the pullout repair and MM extrusion > 3 mm cases was 9.662. Linear regression analysis revealed a fair correlation between the duration from onset to MRI and MM extrusion only in the pullout repair group (0.462 mm/month increase in MM extrusion).ConclusionsThis study demonstrated that more severe MM extrusions were observed in the pullout repair group than in the nonoperative management group. Major extrusion (> 3 mm) was also observed more in the pullout repair group than in the nonoperative group. Assessing MM extrusion and its severity can help determine a valid treatment for patients with partial MMPRTs.Level of evidenceIV, Retrospective comparative study.

What's New in Sports Medicine.

What's New in Sports Medicine.

Coronal extrusion of the lateral meniscus does not increase after pullout repair of the posterior root of the lateral meniscus at short-term follow-up

PurposePosterior lateral meniscus root (PLMR) tears are injuries that commonly occur together with anterior cruciate ligament (ACL) tears. The aim of this study was to evaluate the clinical and radiological outcome of PLMR repair accompanying ACL reconstruction. Specifically, PLMR healing rates, meniscal extrusion behavior and their influence on patient-reported outcome measures (PROMs) were analyzed. It was hypothesized that PLMR repair shows satisfactory healing rates and coronal meniscal extrusion does not increase significantly following PLMR repair.MethodsPatients that underwent PLMR repair between 2014 and 2019 were evaluated at least 12 months postoperatively. At follow-up, magnetic resonance imaging (MRI) was performed in order to evaluate the PLMR healing behavior (complete vs. partial vs. no healing) as well as the coronal and sagittal meniscal extrusion in comparison with the preoperative MRI. Additionally, patient-reported outcome measures (PROMs; Lysholm score, International Knee Documentation Committee subjective knee form [IKDC]) were compiled. Pre- and postoperative meniscal extrusion were tested for statistical significance using the paired t test. The Kruskal–Wallis test was used to compare extrusion values and PROMs in relation to different healing states. A correlation analysis was conducted using the Pearson correlation coefficient between differences in meniscal extrusion and PROMs.ResultsOut of 25 patients, 18 patients (72.0%; 11 male and seven female) were available for final assessment at a mean follow-up of 40.8 ± SD 17.5 months. One revision PLMR repair was performed five months after the initial repair. In 14 cases (77.8%), healing of the lateral meniscus was observed (6 × complete, 8 × partial). Coronal extrusion of the lateral meniscus did not increase significantly following PLMR repair (2.0 ± 1.5 mm vs. 2.1 ± 1.3 mm; p = 0.645). Sagittal extrusion increased significantly (25.7 ± 2.4 mm vs. 27.0 ± 1.4 mm; p < 0.001). The healing status of the PLMR showed no significant association with meniscal extrusion or PROMs (p > 0.05). But a higher increase in coronal meniscal extrusion negatively affected PROMs (Lysholm score: p = 0.046, r = − 0.475; IKDC: p = 0.003, r = − 0.651).ConclusionHigh healing rates of the PLMR and no significant increase in coronal extrusion may be expected following combined PLMR repair and ACL reconstruction. But a greater increase in postoperative coronal meniscal extrusion correlates with less favorable clinical results. A greater increase in sagittal extrusion was observed, but this did not influence the clinical outcome.Level of evidenceRetrospective Case Series; IV.

Medial joint space narrowing progresses after pullout repair of medial meniscus posterior root tear.

The extent to which arthropathic changes progress after medial meniscus posterior root tear (MMPRT) repair remains controversial. This retrospective study assessed medial joint space (MJS) narrowing progression after pullout repair for MMPRT and identified the correlating factors. We included 56 patients who underwent pullout repair for MMPRT. The MJS of the bilateral knees was assessed with radiography using the fixed-flexion view. A second-look arthroscopy was performed one year post-operatively for all patients. The baseline characteristics, clinical scores, Kellgren-Lawrence (KL) grade, and medial meniscus extrusion (MME) were identified. Statistical comparisons and correlation analyses were conducted. The MJS narrowing width was significantly larger in MMPRT knees than in contralateral knees (0.51 ± 0.85 mm vs. 0.09 ± 0.49 mm, p < 0.001). KL grade progression was observed in 23.2% (13/56) of patients. There was a significant difference between pre- and post-operative MME values, indicating MME progression (p < 0.001). Each clinical score showed significant improvement one year post-operatively (p < 0.001). Positive correlations were found between MJS narrowing and pre-operative MJS (coefficient = 0.510, p < 0.001), rate of change in MJS (coefficient = 0.929, p < 0.001), and increase in MME (ΔMME) (coefficient = 0.506, p < 0.001). Knees that underwent pullout repair for MMPRT showed progression of MJS narrowing by 0.51 mm at one year post-operatively, although clinical scores markedly improved. Correlating factors for MJS narrowing were pre-operative MJS, rate of change in MJS, and ΔMME. Preventing MME progression is essential for preventing arthropathic changes.

Arthroscopy Revision of Medial Meniscus Posterior Root (MMPR) Reconstruction Using Gracillis Tendon Graft. A Case Report

The techniques for medial meniscal posterior roots (MMPR) repair can vary in relationship to the surgical approach, type of suture, device used, and fixation technique. Anatomic reduction, meniscal root fixation, and prevent extursion are possible by the trans-tibial pull-out repair procedure for MMPR tears. But it has been found that it has a substantially weaker than the natural root with unsactisfactory healing rates. Objective: We purposed this technique to reduce the failure of meniscus repair with a more anatomical, better healing and reproducible outcome Case Presentation: A 60-year-old female patient with Medial Meniscus Posterior Root tear LaPrade classification type 2. She had arthroscopic transtibial pull-out meniscal root repair using Ethibond No. 5 non-absorbable suture material. Six months after surgery, she had retear on MMPR and we performed the arthroscopic MMPR reconstruction with gracilis tendon graft. 3 months after surgery, patient has a good function and MRI evaluation. Conclusion: This arthroscopic medial meniscus posterior root reconstruction using gracilis graft is provide an anatomical repair, a more strong with a biological healing than previous repair techniques.

Medial meniscal posterior root attachment repair in degenerative patient to slower the progression of knee osteoarthritis

Introduction: Meniscal root tear is frequently misdiagnosed and often lead to knee osteoarthritis. Historically, such entity was often treated nonoperatively or with partial meniscectomy. We reported a case of a 78-year-female with osteoarthritis of the knee and meniscal root tear treated with transtibial double tunnel pullout technique. Case Report: A 78-year-old female presenting with left knee pain. One month ago, the patient fell in her bathroom. Physical examination demonstrated locking knee, positive McMurray test. Radiograph suggested osteoarthritis of the left knee Kellgren-Lawrence (KL) grade 2. Magnetic resonance imaging demonstrated traumatic medial posterior meniscal root tear. The patient then underwent meniscal root repair using transtibial double-tunnel pullout technique. Postoperatively, the patient’s knee was placed in a brace and she was kept non-weight-bearing for 6 weeks. At six months of follow-up, the patient no longer complained of pain and locking knee. The Knee Injury and Osteoarthritis Outcome Score (KOOS) also improved from 50 to 90 after six months of follow up. She could weightbear and perform daily activities. Discussion: Meniscal root tear is commonly underdiagnosed, and it often go unnoticed on magnetic resonance imaging and arthroscopy in large part due to the lack of anatomic understanding. Surgery is worthwhile in this case, as it may prevent osteoarthritis from getting worsen. Repairing the meniscal root with a transtibial pullout repair may restore contact pressures to those of the intact states and allow for the dispersion of hoop stresses across the meniscus. In this report, the patient had satisfactory outcome at 6 months of follow-up, where she no longer felt pain and locking knee. Conclusions: Transtibial double-tunnel pullout technique may be treatment of choice for those with meniscal root tear and may provide the greatest improvement in function and lowest risk of conversion to Total Knee Arthroplasty. Further clinical studies are required to investigate the comparative benefit of the transtibial repair technique.

Concomitant posterior anchoring further reduces posterior meniscal extrusion during pullout repair of medial meniscus posterior root tears: a retrospective study.

Transtibial pullout repair improves the clinical outcomes of medial meniscus (MM) posterior root tears (PRTs); however, reducing MM extrusion remains challenging. Thus, the purpose of this study was to examine the role of additional posterior anchoring (PA) during pullout repair in reducing the severity of MM extrusion compared to pullout repair alone. Patients who underwent pullout repair with two-cinch stitches (TCS) only or TCS combined with PA (TCS-PA)-deployment of an additional suture anchor in the posteromedial corner of MM-were included retrospectively. MM medial and posterior extrusion (MMME and MMPE), MM extrusion and remaining volume (MMEV and MMRV), and corresponding ratios were evaluated pre-operatively and threemonths post-operatively using a three-dimensional meniscal model at 10° and 90° of knee flexion and compared within and between groups. A total of 15 and 16 patients treated with TCS and TCS-PA, respectively, were enrolled. At 90° knee flexion, both techniques significantly reduced MMPE (TCS: 4.2 ± 0.7mm to 3.5 ± 0.6mm, p < 0.05; TCS-PA: 3.7 ± 0.8mm to 2.8 ± 0.7mm, p < 0.05) at threemonths post-operatively. TCS-PA reduced MMPE more significantly than TCS alone (p < 0.05). Only TCS-PA significantly improved the MMEV and MMRV ratios (39.6 ± 8.9% to 28.1 ± 6.0%, p < 0.05 and 60.4 ± 8.9% to 71.9 ± 6.0%, p < 0.05, respectively). Significance was not found in all other comparisons. Both techniques improved MMPE at knee flexion at the threemonth follow-up, with TCS-PA providing significantly superior results. Our findings support the evidence that the application of PA may be an effective surgical option for alleviating persistent MMPE.

Healing of the Torn Anterior Horn of Rabbit Medial Meniscus to Bone after Transtibial Pull‐Out Repair and Autologous Platelet‐Rich Plasma Gel Injection

The transtibial pull-out repair (TP) is a relatively new method for treating meniscal root tear; however, the clinical evaluation of its healing effect remains controversial. Due to ethical constraints and limitations of imaging techniques in humans, here we dynamically observe the healing effects of TP and TP with platelet-rich plasma gel (PRG) at the histological level using an animal model. Platelet-rich plasma (PRP) and PRG of rabbits were prepared. Platelet-derived growth factor (PDGF) and transforming growth factor-β1 (TGF-β1) levels in PRP and PRG were determined using an enzyme-linked immunosorbent assay. A rabbit model of anterior horn tear of the medial meniscus and TP surgery were created. PRG was injected between the anterior horn of the medial meniscus and the tibial tunnel. Rabbits were divided into three groups: the anterior horn tear group (Tear group), the anterior horn tear + TP group (TP group), and the anterior horn tear + TP + PRG group (TP + PRG group). The healing effect was observed dynamically using histopathological studies and biomechanical experiments. The platelet content in PRP significantly increased to approximately 4.57 times that of whole blood. PDGF and TGF-β1 concentrations in PRG increased to 2.46 and 4.15 times those in PRP, respectively. Hematoxylin and eosin (H&E) and Masson staining showed that the number of inflammatory cells in healing tissue decreased and the collagen fibers significantly increased in TP and TP + PRG groups at 4, 8, and 12 weeks postoperatively compared to those in Tear group. Neatly arranged, interlaced, and dense collagen fibers were found between the anterior horn and bone at 12 weeks. H&E and toluidine blue staining showed that the injury to the femoral condyle cartilage was alleviated. The healing performance in TP + PRG group was better and faster than that in TP group. The maximum tensile fracture strength of the meniscus progressively increased at 8 and 12 weeks postoperatively. Anterior horn injury of the medial meniscus in rabbits can be repaired using the TP technique, and the addition of autologous PRG to the bone tunnel promotes early healing of the meniscus and bone postoperatively. Meanwhile, both treatments can reduce the secondary damage to the cartilage due to osteoarthritis.