Root Repair Research Articles

Concomitant Medial Meniscal Root Repair with Extrusion Repair (Centralization Technique).

Concomitant Medial Meniscal Root Repair with Extrusion Repair (Centralization Technique).

Poster 239: Advanced Patellofemoral Chondromalacia Does Not Affect Outcomes After Meniscal Root Repair

Objectives: Meniscal root tears have been shown to accelerate cartilage breakdown and increase the risk of total knee arthroplasty (TKA) if left unaddressed. Unfortunately, many patients with meniscal root tears already have associated chondromalacia which can impact surgical outcomes. The presence of advanced chondromalacia in the medial or lateral compartmentsof the knee is a known contraindication to performing meniscal root repair; however, the effect of advanced patellofemoral chondromalacia on meniscal root outcomes is not known. The purpose of this study was to compare the outcomes of meniscal root repair in patients with and without advanced patellofemoral chondromalacia (PFC). Methods: A retrospective review of prospectively collected data of patients undergoing meniscal root repair by a single surgeon was conducted between January 2016 and December 2019. Patients were included if they had undergone an isolated posterior medial or lateral meniscal root repair. The meniscal root repair was performed using a transtibial suture technique. Patients were placed into one of two groups depending on the amount of patellofemoral chondromalacia present at the time of surgery. Patients with Outerbridge grade 0-2 were placed in the Minimal Patellofemoral Chondromalacia (MPFC) Group. Patients with Outerbridge 3-4 changes found the time of surgery were placed in the Patellofemoral Chondromalacia (PFC) Group. Patients with Outerbridge 3-4 changes found in the medial or lateral compartment were excluded from the study. Lysholm Knee Scoring Scale and the International Knee Documentation (IKDC) Subjective Knee Form were collected preoperatively, 6,12 and 24 months after surgery. Clinical outcomes followed included recurrent meniscal tear, conversion to total knee arthroplasty, knee arthrofibrosis requiring manipulation under anesthesia/lysis of adhesions and infection. PASS and MCID were determined using data on meniscal repairs in other literature. Continuous data was compared using two-tailed student-T test while categorical data was compared utilizing chi-square testing. Results: A total of 27 patients made up the PFC group and 54 in the MPFC group. There was no difference between the groups with regards to age, sex, BMI or laterality of the procedure. The PFC group had 26 medial and 1 lateral meniscal root repairs. The MPFC group had 51 medial and 3 lateral repairs. The average Outerbridge score of the patella for the PFC group was 3.2 compared to 1.8 in the MPFC group (p<.001). The Outerbridge score for the trochlea in each group was 3.4 vs. 1.6 for the PFC and MPFC groups respectively (p<.001). No difference was identified between the Outerbridge score for the medial compartment for the PFC and MPFC groups (1.48 vs 1.46 respectively) or the lateral compartments (0.48 vs. 0.61 respectively). Lysholm and IKDC scores rose significantly over the pre- operative value at all time points in the study for both groups. No difference was seen between the two groups for the Lysholm or IKDC scores at any timepoint during study. PASS rates for IKDC between the two groups were similar with 6,12 and 24-month PASS rates being 66.7%, 87.5% and 81.4% respectively for the PFC group and 62.9%, 77.8% and 85.2% for the MPFC group. There was also no difference between the groups with regards to the percentage of patients reaching MCID for IKDC. The PFC group showed the percentage of patients reaching MCID to be 81.5%, 100% and 92.6% at the 6,12, and 24 month time points respectively while the MPFC group showed the percentage of patients reaching MCID to be 75.9%, 88.9% and 94.4% at the 6,12 and 24 month postoperative time points respectively. There was 1 (3.7%) recurrent tear in the PFC group and 3 (5.6%) in the MPFC group (p=.72). One patient (3.7%) in the PFC and none of the MPFC group were converted to TKA by the 2-year follow up (p=.15). Each group had 1 patient develop arthrofibrosis requiring MUA/LOA. There were no infections in the PFC group and one in the MPFC group which was a superficial wound infection that resolved after a course of oral antibiotics. Conclusions: In our series, the presence of advanced patellofemoral chondromalacia did not lead to inferior short-term outcomes in patients undergoing meniscal root repair compared to patients without patellofemoral chondromalacia. IKDC and Lysholm scores were similar between the PFC and MPFC group at all time points while scores for both groups were significantly higher than preoperative levels at all time points. The ability to reach MCID and PASS for IKDC was not significantly different between the two groups. In addition, there was not a significant difference between the two groups in the number of recurrent tears, conversion to total knee arthroplasty or complications identified. Our results show meniscal root repair can be performed in patients with severe patellofemoral chondromalacia with similar results as patients undergoing root repair without severe patellofemoral chondromalacia. Patellofemoral chondromalacia should not be considered a contraindication to meniscal root repair.

Paper 32: Meniscus Repair Outcomes and Reoperation Rate in Patients Over the Age of 40

Objectives: Meniscus injuries remain a common source of morbidity in patients over the age of 40. Historically, meniscus injuries in this age group have been treated non-operatively or with surgical management limited to debridement procedures. There is strong evidence for repair over meniscectomy in younger patients, however literature remains sparce regarding repair outcomes and re-operation rates for patients over the age of 40. The objectives of this study were to document patient reported outcomes, complications, and re-operation rates for meniscus repairs in patients above the age of 40 and determine what patient demographics or injury characteristics correlated with reoperation. Methods: A retrospective chart review was conducted at a single academic institution after obtaining IRB approval. An initial query of patients over the age of 40, was performed via the CPT code 29882. Inclusion criteria consisted of patient age greater than 40 at time of initial meniscal repair. Exclusion criteria consisted of prior surgery in the ipsilateral knee, meniscal root repair, septic arthritis postoperatively, and any form of knee trauma postoperatively. Patients that met inclusion criteria were chart reviewed for relevant data including demographic information, comorbidities, surgical procedure information such as type of implant used, laterality of meniscus tear, type of tear and pattern, and revision/re-operation data. Patients were then contacted to answer full 100-point KOOS (Knee Injury and Osteoarthritis Outcome Score) questionnaires. Results: 413 total patients met inclusion criteria. The average age at time of surgery was 46 years (IQR, 43-51), and 214 patients were female (51.8%). KOOS scores were reported at a median follow-up of 24-months (IQR, 3-62). Median symptom, pain, activity of daily living (ADL), sport, and quality of life (QoL) subscales were reported as 78.6 (IQR, 60.7-92.9), 87.5 (IQR, 69.4-97.2), 94.1 (IQR, 82-100), 80.0 (IQR, 55-95), and 68.8 (IQR, 40.6-81.3), respectively. A total of 74 patients underwent reoperation (17.8%). There was no significant difference in reoperation rates when stratified by age group (40-49, 50-59, 60-69) (p=0.515). Reoperation rates were not affected by type of implant used for initial meniscus repair (Fast-fix anchor, Omnispan meniscal anchor, Meniscal cinch implant, Fiberwire, MaxBraid suture, Ethibond suture, PDS suture or Bionics meniscal arrow) (p>0.7). Average number of all-inside anchors used for repair was 2 (IQR, 2-3) and did not correlate with reoperation (p=0.49). Location of initial meniscus tear (body or posterior horn) and tear pattern did not correlate with reoperation rates (p>0.36, p>0.28 respectively). A total of 47 patients complained of postoperative stiffness, of which 28 (6.7%) underwent lysis of adhesions and/or arthroscopic debridement (p=.042). Twenty-five patients sustained a meniscal re-tear or injury, of which 17 underwent reoperation with partial or total meniscectomy. Of the total patient cohort, only seven patients ultimately went on to require ipsilateral total knee arthroplasty (1.6%). Conclusions: Patients over the age of 40 who underwent meniscus repair showed favorable reported outcomes at a mean 2-year follow-up. Reoperation rates were associated with postoperative stiffness and repeat injury. Re-operation rates in patients over 40 are comparable to reported rates of younger patients who undergo meniscus repair.

Poster 264: Medial Tibia Bone Marrow Edema on Preoperative MRI Predicts Inferior Patient Outcomes Following Posterior Medial Meniscus Root Repair

Objectives: Repair of posterior medial meniscus root (PMMR) tears demonstrates favorable patient outcomes and may prevent rapid progression of knee osteoarthritis, however, there is a paucity of data in literature regarding prognostic factors affecting postoperative outcomes. The medial meniscus plays an important role in the knee biomechanically by increasing tibiofemoral contact area and decreasing peak tibiofemoral contact pressures. Few studies exist that examine preoperative knee magnetic resonance imaging (MRI) findings and patient reported outcome measures (PROMs) following PMMR repair. Semi-quantitative MRI evaluation can offer improved detection of degenerative pathology. Identifying specific factors that may predict surgical outcomes is important when considering PMMR repair, as some patients with more advanced degenerative joint disease may benefit from consideration for knee arthroplasty instead of joint preservation with meniscus repair surgery. The purpose of this study was to identify factors on preoperative MRI that may predict postoperative outcomes following PMMR repair. We hypothesize that patients with worse knee overall quality would have worse postoperative PRO scores. Methods: Between 2012 and 2020, patients who underwent posterior medial meniscus root repair at a tertiary referral academic center by fellowship trained sports medicine surgeons were retrospectively identified, recruited, and enrolled in the study. Institutional review board approval and informed consent was obtained. Inclusion criteria included patients ages 18-70, posterior medial meniscus root repair through transtibial fixation technique, minimum two years postoperative follow-up, and a preoperative knee MRI. Exclusion criteria included prior ipsilateral knee meniscus or ligamentous injury, additional ipsilateral knee injury requiring surgery, and conversion to knee arthroplasty. Visual Analog Scale (VAS) pain and PRO surveys including Patient Reported Outcome Measures Information System Physical Function (PROMIS-PF) Computer Adaptive Test, Lysholm Knee Score, Knee Osteoarthritis and Injury Outcome Score (KOOS) with 5 sub-sections, were collected at minimum 2-years postoperative. Patient Acceptable State Score (PASS) values from a prior meniscus study were utilized to identify patients that met PASS for the KOOS subsections. A fellowship-trained musculoskeletal radiologist reviewed preoperative MRIs and calculated Whole Organ Magnetic Resonance Imaging Scores (WORMS) for meniscus, cartilage, bone marrow edema pattern (BMEP) in 6 knee locations as well as effusion/synovitis and meniscal extrusion. Radiographs were scored with Kellgren-Lawrence (KL) scores to assess presence and severity of osteoarthritis. Statistical analysis was performed with Stata (StataCorp) using two sample T-tests, Mann-Whitney, and Fisher’s exact test for categorical variables. Significance was defined as p<0.05. Results: We evaluated 29 knees (22 female patients) with a mean age at surgery of 52.3±9.9 years, body mass index of 27.6±5.6 kg/m2, and at a mean follow-up of 59.6 months ± 26.5. median KL grade 2, and 44.8% with meniscal extrusion. Pain scores decreased significantly from before surgery to final follow-up (p<0.001), and the percentage of patients meeting PASS ranged from 44.8% for KOOS-Sport subscale to 72.4% for KOOS-Pain and KOOS-Quality of Life subscales (Table 1). There were 10 patients with medial tibial BMEP on pre-operative MRI and 19 with no medial tibial BMEP (Table 2). Patients with medial tibia BMEP had significantly lower Lysholm Knee Score (p=0.037), KOOS-Symptoms (p=0.028), and KOOS-QOL (p=0.029) (Figure 1). There were no significant differences in demographics between those with and without medial tibia BMEP. There was no significant difference in PRO scores when comparing those with medial femoral condyle BMEP, cartilage quality in any of the knee regions, or presence of meniscus extrusion. Conclusions: We observed that patients with medial tibia BMEP at baseline on their preoperative MRI had inferior PROMs for Lysholm Knee Score, KOOS Symptoms, and KOOS-QOL after PMMR repair compared to those without medial tibia BMEP. The presence of medial tibial BMEP could represent underlying damage that may not be evident in the cartilage itself, given most medial tibia cartilage was normal on MRI and cartilage quality was not a significant discriminant for outcomes. The presence of meniscus extrusion did not correlate with patient outcomes either. Limitations of this study include only VAS-Pain score as a pre-operative measure. Multivariate analysis was not possible due to the sample size available. A strength of this study is the mean follow up of approximately 5 years and preoperative MRI data on all patients. Posterior medial meniscus root tears are generally treated with surgical repair due to increased risk of progression to arthritis, however, some patients continue to have symptoms after repair. Our results show that patients with medial tibial BMEP on their preoperative MRI have worse PRO scores after posterior medial meniscus root repair, which can help surgeons better counsel patients towards optimal treatment options. In conclusion, the presence of medial tibia BMEP on preoperative MRI was a marker for inferior patient outcomes for Lysholm Knee Score, KOOS Symptoms, and QOL at minimum two years postoperative following posterior medial meniscus root repair. [Table: see text][Table: see text]

Poster 281: Current practice for meniscus repair rehabilitation amongst AOSSM members

Objectives: Meniscus repair has correspondingly become more popular, with promise of preservation of joint mechanics and hopes of preventing secondary arthritis. However, it is not clear the optimal rehabilitation protocol, with regards to the duration of limitation of range of motion and weight bearing, following repair of various meniscal tear types. The purpose of this study is to understand the current contextual landscape of how practitioners recommend rehabilitating patients that undergo meniscal repair. Methods: This is a cross-section observational survey study. A de-identified survey was designed using arthroscopic images from six cases of meniscal repair (Fig 1): Radial tear at popliteal hiatus, medial meniscus posterior root repair, lateral meniscus radial tear, lateral meniscus horizontal tear, medial meniscus red-white zone bucket-handle repair, and medial meniscus red-red zone longitudinal peripheral tear. This survey was distributed to American Orthopaedic Society for Sports Medicine (AOSSM) members by e-mail. Questions were designed to elicit, from the surveyed surgeons, their recommendations for duration of limitation of: 1. range of motion, and 2. weight bearing status, for each case. Additionally, use of meniscal repair adjuncts, including bracing and use of biologics, was elicited from the same cohort. Results: 451 completed surveys were obtained from 2973 AOSSM members (15.2%). A majority of AOSSM members recommend bracing after repair of tears that lost hoop integrity (83.3%) and that had intact hoop integrity (76.0%). A majority of members report routine use of synovial rasping/trephination (86.0%) and notch microfracture (66.5%), while a minority report use of more involved biologic supplementations including classic fibrin clot (4.9%), platelet-rich plasma (8.9%), and bone marrow aspirate concentrate (2.9%). Timing of return to weight-bearing and range of motion appear to depend on hoop stress integrity; tears with intact hoop integrity were, on average, permitted to return to weight bearing more quickly (1.4 weeks for partial weight bearing, 3.6 weeks for full weight bearing), versus tears that demonstrated loss of hoop integrity (3.9 weeks for partial weight bearing, 6.2 weeks for full weight bearing). Hoop integrity also appears to affect return to full range of motion, with tears that had a loss of hoop integrity demonstrating a longer period of post-operative restriction of range of motion. Full flexion was permitted at an average of 5.0 weeks for tears with intact hoop stress, versus 5.8 weeks for tears with loss of hoop stress. Out of the six cases presented, the most cautious tear types for post- repair rehabilitation were a radial tear at the popliteal hiatus, followed by a medial meniscus posterior root tear. Conclusions: Although there is no consensus on how each tear type should be rehabilitated following repair, initial tear hoop stress integrity appears to substantially affect rehabilitation decision-making, with loss of hoop stresses triggering a more conservative approach to rehabilitation, both with regards to permissive return to range of motion and weight bearing. A majority of AOSSM practitioners brace after meniscal repair. A majority of practitioners perform in situ adjuncts for biological healing, while a minority adds extrinsic biologics. [Table: see text]

Poster 145: A Biomechanical Comparison of All-Inside versus Trans-tibial Meniscal Root Repair Techniques

Objectives: To evaluate the biomechanical characteristics of an all-inside meniscal root repair procedure versus transtibial repair Methods: Nine paired cadaveric knees were prepared with pressure mapping sensors and underwent pressure testing to obtain peak pressures, average pressures, and femorotibial contact area in both the medial and lateral compartments. Testing was performed in three states: meniscus intact, meniscal root cut, and following meniscal root repair with all-inside repair technique. Additionally, testing was completed on eight pairs of cadaveric knees to compare stiffness and maximal load to failure between all-inside and transtibial meniscal root repair techniques. Results: In the medial compartment, there were significant increases in both median peak pressures (p=0.017) and median average pressures (p=0.047) in the root cut state compared to the intact state (+636 kilopascal (kPA) [246-1026 95% confidence interval (95%CI)] and +190 kPA [49-330 95%CI] respectively). All-inside meniscal root repair restored median peak pressures and median average pressures to approach that of the intact meniscus (p=0.293; +311 kPA [-79-701 95%CI] and p=0.171; +137 kPA [-3-277 95%CI] respectively). In the lateral compartment, there were also significant increases in both median peak pressures (p=0.025) and median average pressures (p=0.05) in the root cut state compared to the intact state (+718 kPA [246-1191 95%CI] and +203 kPA [51-355 95%CI]) respectively). All-inside meniscal root repair restored median peak pressures and median average pressures to be not significantly different from the intact state (p=0.399; +322 kPA [-150-795 95%CI] and p=0.97; +18 kPA [- 134-171 95%CI] respectively). There was no difference between repair techniques regarding load to failure (p=0.896). Conclusions: All-inside meniscal root repair restores median peak and average pressures that approach that of the native, intact meniscus. Compared to a transtibial meniscal root repair technique, all-inside repair demonstrated equivalent load to failure.

A Biomechanical Comparison of All-Inside Versus Transtibial Meniscus Root Repair Techniques

Background: Meniscus root tears are associated with chondral injury, early degenerative change, and a high conversion rate to total knee arthroplasty. It is well-established that meniscus root tears lead to decreased femorotibial contact area, increased peak contact pressures, and increased stress on the articular cartilage. Purpose: To evaluate the biomechanical characteristics of the all-inside meniscus root repair procedure and compare it with the previously described transtibial technique. Study Design: Controlled laboratory study. Methods: Nine paired cadaveric knees were prepared by removing skin, subcutaneous tissues, quadriceps muscles, patella, and patellar tendon, while leaving the capsule in place. Pressure-mapping sensors were inserted, and specimens underwent compressive loading to obtain peak pressures, mean pressures, and femorotibial contact area in the medial and lateral compartments. Tests were performed as static compression tests with the knee locked at 0° of flexion. Compression testing was performed in 3 states: meniscus intact, meniscus root cut, and after meniscus root repair with an all-inside repair technique. Additionally, testing was completed on 9 pairs of cadaveric knees to compare stiffness and maximal load to failure between the all-inside and transtibial meniscus root repair techniques. Results: In the medial compartment, there were significant increases in median peak pressures and median mean pressures in the root cut state as compared with the intact state (+636 kPA [95% CI, 246 to 1026] and +190 kPA [95% CI, 49 to 330], respectively). All-inside meniscus root repair restored median peak pressures and median mean pressures to approach those of the intact meniscus (+311 kPA [95% CI, –79 to 701] and +137 kPA [95% CI, –3 to 277]). In the lateral compartment, there were also significant increases in median peak pressures and median mean pressures in the root cut state as compared with the intact state (+718 kPA [95% CI, 246 to 1191] and +203 kPA [95% CI, 51 to 355]). All-inside meniscus root repair restored median peak pressures and median mean pressures such that they were not significantly different from the intact state (+322 kPA [95% CI, –150 to 795] and +18 kPA [95% CI, –134 to 171]). There was no difference between repair techniques regarding load to failure (P = .896). Transtibial meniscus root repair had significantly more stiffness (mean ± SD, 24.8 ± 9.3 N/mm) as compared with the all-inside meniscus root repair technique (13.6 ± 3.8 N/mm, P = .015). Conclusion: All-inside meniscus root repair reduced median peak and mean pressures to those of the native intact meniscus with the knee in extension in the cadaveric model. When compared with a transtibial meniscus root repair technique, all-inside repair demonstrated decreased stiffness and a similar load to failure. Clinical Relevance: All-inside meniscus root repair restored mean and peak femorotibial pressures to those of the intact meniscus. Additionally, it offers a technically easier technique for management of meniscus root tears.

Comparison of the Microleakages of Four Root-End Filling Materials: An In Vitro Study.

When a nonsurgical endodontic treatment is ineffective, surgery is necessary. This entails putting a retrofilling to seal the tooth's apex. Exposing the lesion, performing a curettage, exposing the root apex, resecting it, preparing the root end, and lastly filling the cavity with the proper material are all steps in endodontic surgery. Thus, the aim of this study is to compare the apical microleakage of four root-end filling materials in cavities prepared using ultrasonic retro tip in in vitro conditions. An in vitrostudy was conducted on 60 extracted single-rooted teeth and was cut at the cementoenamel junction (CEJ). They were biomechanically prepared and obturated. Apical 3 mm root-end resection was done using a diamond disc. Root-end cavities were made using an ultrasonic retro tip. Teeth were separated into four groups and filled with SuperEBA®️ ethoxy-benzoic acid (EBA; Keystone Industries, New Jersey), mineral trioxide aggregate (MTA), Biodentine (Septodont, France), and TotalFill Bioceramic Root Repair Material (BC RRM; FKG Dentaire Sàrl, Switzerland). The samples were kept in methylene blue dye and split longitudinally. The degree of dye penetration was observed under a stereomicroscope and scored. Finally, the results were analyzed. TotalFill BC RRM and Biodentine showed the least apical microleakage (p <0.05).Group 1 samples had the highest mean microleakage, followed by Group 2, Group 3, and Group 4 samples. All of the sample groups showed some evidence of microleakage, but not all of the samples showed leaking. SuperEBA (Group 1) demonstrated the highest microleakage when compared to the other groups.

Leave It or Repair It? Comparison of the Arthroscopic and Clinical Outcomes after High Tibial Osteotomy with or without Medial Meniscus Posterior Root Repair

Leave It or Repair It? Comparison of the Arthroscopic and Clinical Outcomes after High Tibial Osteotomy with or without Medial Meniscus Posterior Root Repair

New Considerations in ACL Surgery: When Is Anatomic Reconstruction Not Enough?

➤ Clinicians should be careful to assess for associated injuries including anterolateral complex and medial meniscal ramp lesions or lateral meniscal posterior root tears.➤ Consideration of lateral extra-articular augmentation should be given for patients with >12° of posterior tibial slope.➤ Patients with preoperative knee hyperextension (>5°) or other nonmodifiable risk factors, including high-risk osseous geometry, may benefit from a concomitant anterolateral augmentation procedure to improve rotational stability.➤ Meniscal lesions should be addressed at the time of anterior cruciate ligament reconstruction with meniscal root or ramp repair.

Augmentation of a Nonanatomical Repair of a Medial Meniscus Posterior Root Tear With Centralization Using Three Knotless Anchors May Be Associated With Less Meniscal Extrusion and Better Compressive Load Distribution in Mid-Flexion Compared With Non-Anatomical Root Repair Alone in a Porcine Knee Model

To investigate the biomechanics of the centralization augmentation using knotless soft anchors to a nonanatomicaltranstibial pull-out root repair in a porcine medial meniscus posterior root tear (MMPRT) model. Porcine knee joints (N= 10) were used to perform one of the following procedures: (1) intact; (2) MMPRT; (3) nonanatomical root repair; (4) nonanatomical root repair with centralization using 2 anchors: anchors were inserted at the posterior medial collateral ligament (MCL) border and 10 mm anterior to the posterior MCL border; and (5) nonanatomical root repair with centralization using 3 anchors: another anchor was placed 10 mm posterior to the posterior MCL border. Contact area on the medial meniscus (MM), contact pressure in the MM and tibial cartilage, and MM extrusion were evaluated at 30°, 45°, 60°, and 90° knee flexions under 200 N compressive force. MM extrusion at the posterior MCL border was significantly reduced after root repair with centralization using 3 anchors than after root repair alone at 30° (-0.063 mm vs 1.5 mm, P= .017), 45° (0.21 mm vs 1.7 mm, P= .018), and 60° (0.78 mm vs 2.3 mm, P= .019). There were no significant differences in MM extrusion between the root repair alone and root repair with centralization using 2 anchors at all flexion angles. The contact area in the middle and posterior MM was significantly greater after centralization with 3 anchors than after root repair alone at all flexion angles (except the posterior MM at 90°). The mean contact pressure in the tibial cartilage was significantly lower after centralization with 3 anchors than after root repair at all angles. Augmentation of a nonanatomical repair of a medial meniscus posterior root tear with centralization using three knotless anchors may be associated with less meniscal extrusion and better compressive load distribution between 30° and 60° flexion compared with nonanatomical root repair alone in a porcine model. This biomechanical study at time zero suggests that the addition of centralization using 3 knotless anchors may reduce MM extrusion and restore the load-distributing function of the MM.

A Systematic Review of Adverse Events and Complications After Isolated Posterior Medial Meniscus Root Repairs

Background: Medial meniscus posterior root (MMPR) tears are recognized as a substantial cause of disability and morbidity. However, meniscus root repair, regardless of technique, is not without potential complications. Purpose: To evaluate the reported incidence of complications and adverse events after isolated MMPR repair. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using Embase, PubMed, and Scopus databases with the following search terms combined with Boolean operators: “meniscus,”“root,” and “repair.” Inclusion criteria consisted of level 1 to 4 human clinical studies in English or English-language translation reporting complications and adverse events after isolated posterior medial meniscus root repairs. The overall incidence of specific complications was estimated from the pooled sample of the included studies. Results: Eleven studies with a total pooled sample of 442 patients were identified. The mean patient age was 58.1 years, while the mean final follow-up time was 37.2 months (range, 12-84.8 months). The overall incidence of complications was 9.7% (n = 43/442), with the most commonly reported complication being progressive degenerative changes within the knee (10.4%; n = 25/240; n = 5 studies). A total of 1.25% (n = 3/240) of patients who experienced degenerative changes required conversion to total knee arthroplasty. Repair failures were reported in 3.1% (n = 10/327; n = 8 studies) of patients. Conclusion: Repairing MMPR tears is critical in preventing accelerated progression of knee osteoarthritis in patients without significant knee osteoarthritis preoperatively. While this repair is still recommended and necessary in appropriate patients, this review found that the incidence of complications after isolated posterior medial meniscus root repair was 9.7%, primarily involving the presence of progressive degeneration, while repair failure was reported in 3% of patients.

Echocardiography of the aortic root: a practical approach for aortic valve-sparing surgery.

Owing to its excellent long-term results, aortic valve-sparing surgery is increasingly used in patients with aortic regurgitation and/or ascending aortic aneurysm. Moreover, in patients with a bicuspid valve who meet the criteria for replacement of the aortic sinuses or aortic regurgitation surgery, valve-sparing surgery may be considered if performed at a comprehensive valve center (Class 2b indication in both the American and European guidelines). Reconstructive valve surgery aims at restoring a normal aortic valve function and a normal aortic root shape as well. Echocardiography plays a central role in defining abnormal valve morphologies, in quantifying aortic regurgitation and mechanisms, and in appreciating tissue valve quality and surgical results. Therefore, despite the emergence of other tomographic techniques, 2D and 3D echocardiography represents the cornerstone for patient selection and prediction of the probability of a reliable repair. The present review focuses on echocardiographic evaluation to detect aortic valve and aortic root abnormalities, to quantify aortic valve regurgitation, to predict aortic valve reparability, and to assess immediate postoperative results in the operating room. Echocardiographic predictors of successful valve and root repair are presented in a practical way.

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.

Biological properties of Ceraputty as a retrograde filling material: an in vitro study on hPDLSCs

ObjectivesTo assess the cytocompatibility and bioactive potential of the new calcium silicate-based cement Ceraputty on human periodontal ligament stem cells (hPDLSCs) compared to Biodentine and Endosequence BC root repair material (ERRM).Materials and methodshPDLSCs were isolated from extracted third molars from healthy donors. Standardized sample discs and 1:1, 1:2, and 1:4 eluates of the tested materials were prepared. The following assays were performed: surface element distribution via SEM–EDX, cell attachment and morphology via SEM, cell viability via a MTT assay, osteo/cemento/odontogenic marker expression via RT-qPCR, and cell calcified nodule formation via Alizarin Red S staining. hPDLSCs cultured in unconditioned or osteogenic media were used as negative and positive control groups, respectively. Statistical analysis was performed using one-way ANOVA or two-way ANOVA and Tukey’s post hoc test. Statistical significance was established at p < 0.05.ResultsThe highest Ca2+ peak was detected from Biodentine samples, followed by ERRM and Ceraputty. hPDLSC viability was significantly reduced in Ceraputty samples (p < 0.001), while 1:2 and 1:4 Biodentine and ERRM samples similar results to that of the negative control (p > 0.05). Biodentine and ERRM exhibited an upregulation of at least one cemento/odonto/osteogenic marker compared to the negative and positive control groups. Cells cultured with Biodentine produced a significantly higher calcified nodule formation than ERRM and Ceraputty (p < 0.001), which were also higher than the control groups (p < 0.001).ConclusionCeraputty evidenced a reduced cytocompatibility towards hPDLSCs on its lowest dilutions compared to the other tested cements and the control group. Biodentine and ERRM promoted a significantly higher mineralization and osteo/cementogenic marker expression on hPDLSCs compared with Ceraputty. Further studies are necessary to verify the biological properties of this new material and its adequacy as a retrograde filling material.Clinical relevanceThis is the first study to elucidate the adequate biological properties of Ceraputty for its use as a retrograde filling material.

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.

Repair of meniscus root tear - Is there a difference between medial meniscus root repair and lateral meniscus root repair? A systematic review and meta-analysis.

Complete meniscus root tear is associated with meniscus extrusion; this causes a loss of meniscus function and accelerated osteoarthritis of the knee. Existing small-scale retrospective case-control studies suggested that the outcomes were different between medial and lateral meniscus root repair. This meta-analysis aims to study whether such discrepancies exist via a systematic review of the available evidence in the literature. Studies evaluating the outcomes of surgical repair of posterior meniscus root tears, with reassessment MRI or second-look arthroscopy, were identified through a systematic search of PubMed, Embase, and Cochrane Library. The degree of meniscus extrusion, healing status of the repaired meniscus root, and functional outcome scores after repair were the outcomes of interest. Among the 732 studies identified, 20 studies were included in this systematic review. 624 knees and 122 knees underwent MMPRT and LMPRT repair, respectively. The amount of meniscus extrusion following MMPRT repair was 3.8 ± 1.7mm, which was significantly larger than the 0.9 ± 1.2mm observed after LMPRT repair (p < 0.001). Significantly better healing outcomes were observed on reassessment MRI after LMPRT repair (p < 0.001). The postoperative Lysholm score and IKDC score was also significantly better after LMPRT than MMPRT repair (p < 0.001). LMPRT repairs resulted in significantly less meniscus extrusion, substantially better healing outcomes on MRI, and superior Lysholm/IKDC scores, when compared to MMPRT repair. This is the first meta-analysis we are aware of that systematically reviews the differences in the clinical, radiographic, and arthroscopic results of MMPRT and LMPRT repair.

Arthroscopic Transtibial Repair of Acute Traumatic Posterior Medial Meniscus Root Tear

Background: The posteromedial meniscal root is a critical structure in maintaining balanced tibiofemoral contact stresses and joint stability. Studies have shown that posterior root tears are biomechanically equivalent to total meniscectomy and can lead to the rapid development of osteoarthritis. Our presentation focuses on the less common, acute, traumatic posteromedial meniscal root avulsion, although our technique is also applicable to the more common degenerative posteromedial meniscal root tears. Indications: Surgical indications include acute tears, as well as chronic or degenerative tears in patients without advanced osteoarthritis. Absolute surgical contraindications include subchondral bone collapse, substantial concurrent meniscal pathology, malalignment of &gt;5°, and advanced knee osteoarthritis. Technique Description: Once the tear is identified, the bone at the root insertion is prepared with a meniscal rasp. Two looped sutures are passed through the meniscal root in a cinch-type fashion using a knee scorpion. A tunnel is drilled at the root insertion using a specialized meniscal root repair guide. Approximately, 10 mm of bone are drilled in a retrograde fashion with a flip cutter deployed to 7 mm to decorticate the bone and enhance healing. The drill is then removed and a rubber tube with a retrieval suture is advanced through the drill guide into the joint. The loop suture is retrieved through the anteromedial portal and the repair sutures are passed through the retrieval loop. Under arthroscopic visualization, the root is then reduced to its anatomic insertion and the sutures secured to the tibia using a knotless suture anchor placed 1 cm distal to the transtibial tunnel. Results: Several recent studies have shown that meniscal root repair decreases rapid knee degeneration as gauged by meniscal extrusion, progression of Kellgren-Lawrence grade and rate of conversion to total knee arthroplasty (TKA). Discussion/Conclusion: Posteromedial meniscal root tears are increasingly being recognized as a distinct meniscal pathology that can lead to rapid arthritis if left unrepaired. Arthroscopic repair techniques continue to improve allowing orthopedic surgeons to more readily address this significant, but treatable pathology. 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.

Opening-Wedge Distal Femoral Osteotomy With Concomitant Medial Meniscal Root Repair

Background: Valgus malalignment leads to excessive loading of the lateral compartment and has been associated with lateral compartment meniscal injuries and early-onset knee osteoarthritis. Distal femoral osteotomy (DFO) is a treatment option that allows correction of the mechanical access to offload the lateral compartment. Lateral opening-wedge distal femoral osteotomy and medial meniscal root repairs are both aimed to address the pathologic biomechanics of the tibiofemoral joint and when successful can delay or even prevent progression to end-stage osteoarthritic changes in the lateral and medial compartment, respectively. Indications: Distal femoral osteotomy is indicated for patients with normal metabolic bone health and valgus malalignment who may present with concurrent lateral meniscal injury, symptomatic lateral compartment arthritis, or a chronic medial collateral ligament tear/laxity. Technique Description: Long-leg alignment radiographs and preoperative magnetic resonance images are required to evaluate the degree of mechanical access deviation and to evaluate for soft tissue injury, as there is often concomitant lateral meniscal or cartilage pathology present. This technique demonstrates the optimal order of surgical steps for DFO with a concurrent medial meniscal root repair. The senior author’s preferred order is to first perform the open lateral approach and expose the lateral cortex for the placement of plate prior to arthroscopic work and excess fluid extravasation. Intra-articular work is then performed with a diagnostic arthroscopy followed by medial meniscal root repair. Finally, the osteotomy and subsequent internal fixation are performed. Results: The literature on opening-wedge DFO outcomes is heterogeneous, with variable rates of successful outcomes and complications. Saithna et al reported that International Knee Documentation Committee and the pain subdomain of Knee injury and Osteoarthritis Outcome Scores significantly improved postoperatively following lateral opening-wedge DFOs in patients with lateral compartment osteoarthritis. The 10-year success rate of varus-producing DFO has been reported to be 64% to 85%. Discussion: We describe a technique for correction of a valgus deformity with opening-wedge DFO and concurrent meniscal root repair. This surgical technique effectively restores the native femoral and tibial axis with appropriate load distribution and also concurrently restores the appropriate function of the medial meniscus which allows axial force dispersion via hoop stresses for the medial compartment. 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.

Prosthetic Valve Endocarditis After Transcatheter and Surgical Aortic Valve Replacement

BackgroundProsthetic valve endocarditis (PVE) is a devastating sequela of transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR). However, reoperation for post-TAVR PVE is not well described. We investigated the implications of surgically managed PVE after TAVR and SAVR. MethodsReoperations for active PVE after TAVR and SAVR from 2011 to 2021 were queried using The Society of Thoracic Surgeons (STS) database. We identified 6257 patients, consisting of 374 TAVR (6%) and 5883 SAVR recipients (94%). ResultsPost-TAVR case volume increased from 1 in 2011 to 116 in 2020. Compared with SAVR, the TAVR group was associated with older age, more frequent preexisting pacemaker, and fewer aortic root abscesses. Intraoperatively, TAVR patients received less aortic root repair (24.9% vs 34.8%; P < .001) and had shorter cardiopulmonary bypass/aortic cross-clamp times. Among all comers, the operative mortality in patients with previous was 13.6% for TAVR vs 10.8% for SAVR (P = .088). After risk adjustment, previous TAVR itself was not associated with operative mortality (odds ratio, 0.99; 95% CI, 0.72-1.38). In contrast, among 154 post-TAVR and 2232 post-SAVR patients with STS-indexed procedures (SAVR ± coronary artery bypass grafting) with available STS predicted risk of mortality, the mortality was 14.3% and 7.9% (P = .005), with corresponding observed-to-expected mortality ratio of 2.2 and 1.3, respectively. ConclusionsAortic root repair was seen less frequently after TAVR than after SAVR. Furthermore, previous TAVR was not associated with increased operative mortality. In contrast, the post-TAVR setting was associated with higher mortality regarding isolated SAVR or SAVR plus coronary artery bypass grafting.