Type Of Tear Research Articles

THE UTILITY OF STABILITY AND TEAR LOCATION IN A CLASSIFICATION SYSTEM FOR DISCOID MENISCUS SURGICAL PLANNING

Background Discoid meniscus (DM) is a congenital variant that typically affects the lateral meniscus of the knee. Despite the presence of multiple classification systems for DM, no system has demonstrated utility in treatment planning. We performed a retrospective review of discoid menisci that underwent surgical intervention at our institution to assess for discoid meniscus characteristics associated with surgical treatment with or without repair. Next, we propose a new method of classifying lateral discoid meniscus and demonstrate its efficacy in predicting surgical treatment. Methods We searched the orthopedic database at our institution for patients who underwent surgical treatment for lateral discoid meniscus between 1991 and 2017. Clinical records were reviewed to determine the type of DM surgery performed (surgery with or without repair) as well as DM morphology, stability, tear presence, tear location, and tear type. Univariate associations between DM characteristics and surgery type were calculated and multivariable logistic regression models of surgery type were created. Based on the univariate analysis and logistic regression models, we propose a new classification system for discoid meniscus. Results There were 434 knees with discoid lateral menisci that received surgical treatment at our institution between 1991 and 2017. In univariate analysis, unstable menisci (93%, p<0.001) and menisci with a tear including the periphery (75%, p<0.001) were more likely to receive surgery with repair. By itself, instability demonstrated 89% sensitivity and 94% specificity in predicting surgery with repair. The main effects logistic regression model including stability and tear showed that that the odds of unstable lateral discoid menisci receiving surgery with repair was 133.1 times higher than stable menisci (p<0.001) while lateral discoid menisci that had a tear including the periphery had 6.54 times higher odds of receiving repair than those that had a tear in the central portion only (p<0.001). Conclusions/Significance Lateral discoid menisci stability and tear location were associated with surgical treatment type in both univariate analysis and logistic regression models (Table 1). Based on our results and clinical relevance, we propose a classification system for DM with utility in surgical treatment planning. Menisci are classified by stability (Stable (S0), Unstable (S1)), morphology (Incomplete (M0), Complete (M1)), and Tear (No tear (T0), Central tear (T1), or Peripheral tear (T2)) (Figure 1). Tables and Figures [Table: see text][Figure: see text]

A Novel Arthroscopic Classification of Degenerative Medial Meniscus Posterior Root Tears Based on the Tear Gap.

Background:Degenerative medial meniscus posterior root tears (MMPRTs) are reportedly associated with medial compartment osteoarthritis and meniscal extrusion with a displaced gap from the root insertion. However, degenerative MMPRTs have not yet been clearly classified according to arthroscopic findings.Purpose:To classify degenerative MMPRTs according to the tear gap and to investigate how the classification could reflect the joint condition properly.Study Design:Cohort study; Level of evidence, 3.Methods:Patients who underwent arthroscopic surgery, performed by a single orthopaedic surgeon, for degenerative MMPRTs between August 2006 and February 2017 were included. MMPRTs were classified according to tear patterns observed during arthroscopic surgery (type 1, incomplete root tear; types 2-5, complete root tears), with each type further divided by the size of the tear gap, defined as the degree of tear displacement from the root (type 2, no gap or overlapped; type 3, gap of 1-3 mm; type 4, gap of 4-6 mm; type 5, gap of ≥7 mm). We compared preoperative factors, including the Kellgren-Lawrence (K-L) grade, absolute extrusion, relative percentage of extrusion (RPE), tear gap on magnetic resonance imaging (MRI), and mechanical alignment, as well as intraoperative factors, including chondral wear at surgery, between each MMPRT type.Results:A total of 116 root tears were categorized according to this classification: type 1, 16.4% (19 knees); type 2, 9.5% (11 knees); type 3, 40.5% (47 knees); type 4, 25.0% (29 knees); and type 5, 8.6% (10 knees). Chondral wear of the medial femoral condyle (MFC) (P = .001), K-L grade (P = .001), meniscal extrusion (P = .001), and tear gap on MRI (P = .001) showed a tendency to increase with a higher tear type. Chondral wear (ρ for MFC = 0.388; ρ for MTP = 0.311), K-L grade (ρ = 0.390), and meniscal extrusion (ρ for absolute extrusion = 0.500; ρ for RPE = 0.451) showed a moderate correlation with tear type, whereas tear gap on MRI (ρ = 0.907) showed a strong correlation with tear type.Conclusion:Our study introduces a new classification based on the tear gap that can concisely describe a degenerative MMPRT. The classification system demonstrated that a higher tear type (increasing displacement of the tear gap in arthroscopic surgery) is associated with higher meniscal extrusion, severe chondral wear, and greater severity of arthritis.

MAGNETIC RESONANCE IMAGING FINDINGS ASSOCIATED WITH ULNAR COLLATERAL LIGAMENT TEARS IN ADOLESCENT BASEBALL PITCHERS

BACKGROUND: The number of ulnar collateral ligament (UCL) injuries in adolescent baseball pitchers has risen over the past 2 decades with the incidence of UCL reconstructions also increasing dramatically over that time period. The Joyner-Andrews magnetic resonance imaging (MRI) classification of UCL tears has previously been described to describe the grade and location of tears, which can aid in surgical decision-making. However, the classification of UCL tears in the at-risk adolescent population has yet to fully investigated. Improving our knowledge of these injuries is crucial to help drive targeted evidence-based treatment strategies. The purpose of this study was to examine the grade and location UCL tears using the Joyner-Andrews MRI classification in a large group of adolescent baseball pitchers. METHODS: We reviewed 225 symptomatic adolescent (aged =19 years) male baseball pitchers with UCL injuries treated by the senior author from 2007-2016. All patients had failed conservative treatment prior to evaluation. Pitchers with a prior history of elbow surgery were excluded. Plain radiographs and MRI arthrograms were evaluated for each patient to categorize the UCL injury and associated pathology. The images were reviewed by a sports medicine-trained orthopedic surgeon. UCL tear grade and location were classified using the Joyner-Andrews classification. RESULTS: The mean age at the time of evaluation was 17.2 ± 1.5 years. 56% of the patients were high school athletes. The majority (59.1%) of UCL tears were high-grade partial tears (Type II). Of those 53.4% were on the humeral side (Type II H). The least common tear types were low-grade partial tears (I) and tears in more than one location (Type IV) in 1.3% and 0.9% of patients, respectively. Plain radiographs revealed 31.4% of patients had abnormal findings; calcifications and olecranon osteophytes were present in 10% and 13% of patients, respectively and more commonly occurred in patients with Type II tears. CONCLUSIONS: The results of this study showed that the majority of adolescent baseball pitchers (59%) sustain high-grade partial tears of the UCL. These findings suggest that effective non-reconstruction options such as platelet-rich plasma and UCL repair with internal brace augmentation could be ideal alternatives to UCL reconstruction for these young patients. The high percentage of radiographic abnormalities in these patients highlights the adaptive changes about the elbow in response to the repetitive stresses experienced by the young elbow during throwing.

Tibial slope and medial meniscectomy significantly influence short-term knee laxity following ACL reconstruction.

To determine demographic, anatomic, and surgical factors associated withstatic and dynamic Anterior Tibial Translation (ATT) following ACL reconstruction. The hypothesis was that both static and dynamic ATT would be greater in knees with high tibial slope or that required meniscectomy. The authors prospectively enrolled 280 consecutive patients that had primary ACL reconstruction using hamstring autografts at one center for which preoperative tear type, meniscal tears, and medial tibial slope were documented. A total of 137 were excluded due to concomitant extra-articular tenodesis or surgical antecedents on either knee, and 18 were lost to follow-up, leaving 125 that were evaluated at a minimum of 6 months including: static ATT on monopodal weight-bearing radiographs, and dynamic ATT on differential stress radiographs using the Telos™ device. Both postoperative static and dynamic ATT were strongly associated with preoperative static and dynamic ATT (respectively, β = 0.068 and β = 0.50, p < 0.001). Multivariable regression confirmed that postoperative static ATT increased with tibial slope (β = 0.24; CI 0.01-0.47; p = 0.042) and in knees that had partial medial meniscectomy (β = 2.05; CI 0.25-3.84; p = 0.025), while dynamic ATT decreased with age (β = -0.11; CI -0.16 to -0.05; p < 0.001), and increased with tibial slope (β = 0.27; CI 0.04-0.49; p = 0.019) and in knees that had partial medial meniscectomy (β = 2.20; CI 0.35-4.05; p = 0.019). Both static and dynamic ATT following ACL reconstruction increased with tibial slope and in knees that had partial medial meniscectomy. These findings could help surgeons tailor their techniques and 'à la carte' rehabilitation protocols, by preserving the menisci and sometimes delaying full weight-bearing and return to sport in patients atrisk, and hence improve outcomes and prevent graft failures. Cohort study. V.

Long-term Results After Repair of Isolated Meniscal Tears Among Patients Aged 18 Years and Younger: An 18-Year Follow-up Study

Background: Meniscal repair is desirable over resection to prevent postmeniscectomy arthritis, especially among young and active patients. However, long-term data are currently lacking following isolated meniscal repair, particularly in the pediatric population. Purpose/Hypothesis: To report long-term follow-up of isolated meniscal tears treated by meniscal repair in a pediatric and adolescent population and to compare those results with previous midterm follow-up data reported. The authors hypothesized that these patients would have satisfactory function and reoperation rates at long-term follow-up. Study Design: Case series; Level of evidence, 4. Methods: Forty-four patients aged ≤18 years undergoing repair of an isolated meniscal tear (without concomitant anterior cruciate ligament injury) between 1990 and 2005 were included. At the time of final follow-up, recurrent tear, reoperations, and International Knee Documentation Committee (IKDC) and Tegner scores were determined. With logistic regression, the overall failure among tear types was calculated. Wilcoxon rank sum analysis were performed to calculate the differences in clinical outcome for different time points, and Spearman coefficients were calculated for Tegner and IKDC with different variables. Results: At a mean follow-up of 17.6 years (range, 13.1-25.9 years), 32 patients with 33 isolated meniscal repairs (29 male, 3 female) with a mean age of 16.1 years (range, 9.9-18.7 years) at surgery were included in this study. At early follow-up, the overall failure rate was 14 of 33 (42%); complex tears (80%) and bucket-handle tears (47%) had higher overall failure rates when compared with simple tears (18.2%), although only complex tears had a significantly higher failure rate. However, no further failures occurred since midterm follow-up with any tear type. At final follow-up, the mean IKDC score was 92.3, which was significantly increased when compared with preoperative (65.3, P < .0001) and midterm (90.2, P = .01) scores. The mean Tegner score (6.5) was significantly lower than both preoperative (8.3, P < .0001) and midterm (8.4, P < .0001) scores. There was no difference in Tegner or IKDC score for patients with successful versus failed repair. Conclusion: In conclusion, while there was a high early failure rate, this study demonstrated overall good to excellent long-term clinical outcomes after isolated meniscal repair in an adolescent population, even for those requiring reoperation. Early failure and reoperation rates were variable, depending on tear type, with complex multiplanar tears having more failures at short-term follow-up. However, at long-term follow-up, IKDC and Tegner scores were not significantly different for those with complex tears as compared with other tear types.

Location and Correlation of Acetabular Labral Tears and Paralabral Cysts Using Magnetic Resonance Imaging or Magnetic Resonance Arthrography in Patients With Femoroacetabular Impingement

To evaluate the prevalence and location of paralabral cysts and the correlation between the type of femoroacetabular impingement (FAI) and acetabular labral tears, as well as the location of the paralabral cysts. Patients who received a diagnosis of FAI syndrome using plain radiography, magnetic resonance imaging or magnetic resonance arthrography, or computed tomographic arthrography from 2010 to 2015 were included in this study. The exclusion criteria were patients with arthritis (Tönnis grade 2 or greater) or dysplasia. We identified paralabral cysts and their location, size, configuration. Correlations between the type of FAI and labral tears and paralabral cysts were analyzed using the χ-square test. Among 506 patients with FAI, paralabral cysts were found in 51 patients (55 hips) and were located anterosuperiorly in 40% of cases, posterosuperiorly in 36%, anteroinferiorly in 17%, and posteroinferiorly in 8%. We identified multilocular cysts in 60% of hips and unilocular cysts in 40%. Labral tears were radiographically found in 44 of 55 hips with paralabral cysts (80%); they were located anterosuperiorly in 59% and posterosuperiorly in 41%. Although paralabral cysts were found in the anteroinferior and posteroinferior areas, acetabular labral tears were not identified in the anteroinferior and posteroinferior areas. Classification of the type of FAI showed cam type in 14 of 55 hips (25.5%), pincer type in 16 (29%), mixed type in 7 (13%), labral tears in 15 (27%), and normal findings in 3 (5.5%). No correlation was found between the type of FAI and labral tears (P= .739) or the location of paralabral cysts (P= .228). Paralabral cysts in patients with FAI most commonly are found in the anterosuperior area and are of the multilocular type. Although paralabral cysts in the anterosuperior and posterosuperior portions are related to labral tears, those in the anteroinferior and posteroinferior portions are not. LevelIV, diagnostic case series.

Meniscal and Chondral Pathology Associated With Anterior Cruciate Ligament Injuries.

Anterior cruciate ligament (ACL) ruptures are commonly associated with meniscal and articular cartilage injuries, and the presence of these defects influences both short- and long-term outcomes. Multiple variables are predictive of this pathology including time from injury, age, and sex. Revision ACL reconstructions demonstrate higher rates of chondral injury than primary reconstructions. Menisci are important secondary stabilizers of the knee in the setting of ACL deficiency, and specific tear types are more consistently associated with ACL injury. Successful outcomes with multiple treatment options for meniscal tears in conjunction with ACL reconstruction have been reported. Maintaining meniscal integrity may be protective of both joint surfaces and graft stability in the long term; however, clear treatment recommendations for tear subtypes remain ill defined. High-grade chondral defects have the most consistent and potentially largest negative effect on long-term patient-reported outcomes; however, optimal treatment is also controversial with successful results demonstrated with several modalities including benign neglect.

Risk Factors for Postoperative Opioid Use in Arthroscopic Meniscal Surgery

(1) To evaluate the influence of preoperative opioid use on postoperative consumption after arthroscopic meniscal surgery and (2) to determine preoperative patient factors associated with increased opioid use after meniscal surgery. We performed a retrospective review of all patients with a primary diagnosis of a meniscal tear at a single institution between August 2013 and February 2017. Patients were classified as opioid nonusers if they had not received any opioid medications in the 3months before meniscal surgery, as acute users if they received at least 1 opioid prescription within 1month preceding meniscal surgery, or as chronic users if they received at least 1 opioid prescription within 3months preceding meniscal surgery. Clinical records were reviewed for postoperative opioid use within a year after surgery. We also recorded patient demographic characteristics and the degree of knee osteoarthritis at the time of surgery using the Outerbridge classification. A total of 735 patients were included. The average age was 46.7years (range, 12-79years), and the average body mass index was 30.2 ± 6.2 (range, 13.3-55.4). Patients who were acute or chronic opioid users preoperatively were more likely to continue to use opioids beyond 1month postoperatively (P < .001). A higher percentage of patients with advanced osteoarthritis (Outerbridge grade 3 or 4) were found to continue to use opioids at all time points beyond the first postoperative month (P < .05). Pair-wise comparisons showed that the number of total opioid prescriptions filled was significantly higher in the group with Outerbridge grade 1 or 2 and the group with Outerbridge grade 3 or 4 than the group with Outerbridge grade 0 (P= .023 and P= .014, respectively). No significant difference in postoperative opioid use was noted when we compared meniscal repair versus resection, primary procedure versus revision, different tear types, or concomitant procedures. In patients undergoing arthroscopic meniscal surgery, the chronicity of preoperative opioid intake and degree of knee osteoarthritis were found to have a significant effect on postoperative opioid use. Level III, retrospective comparative study.

Approach to Meniscal Tear by Clinical Examination and Its Management: A Review

It’s quite difficult to diagnose the meniscus tear by clinical examination even the experienced orthopaedic surgeon, so this review has shortly focused on clinical examination and its treatment. How to overcome missed diagnosis of meniscus tear in clinical setting? This review article highlighted the importance of early diagnosis and treatment; fortunately, these processes have been vastly improved by advances in Magnetic resonance imaging (MRI) and Arthroscopy. Although partial, subtotal and total meniscectomy is the choice for different types of meniscal tears, there are certain criteria to be meet for undergoing surgical treatment. The most common criteria for meniscal repair include: 1) A vertical longitudinal tear more than 1 cm in length located within vascular zone, 2) A tear which is unstable and displaceable into the joint, 3) An active informed and cooperative patient but younger than 40 years old, 4) A stable knee or wound stabilized with a ligamentous reconstruction. Chronically deformed or degenerative menisci are bottom-out candidates for repair. Most investigators report that only 10% to 15% of meniscal tears can be repaired and that most such repairs are done in association with an anterior cruciate ligament reconstruction. However, this article presents a review of the clinical relevant anatomic, function, repair and healing mechanism, description of the meniscus attachment as well as current strategies for accurate diagnosis and treatment of common injuries to these meniscus attachments.

MRI Versus Ultrasound In Diagnosis Of Meniscal Tear In Knee Joint

Background: the menisci of the knee are complex structures with various important functions within the knee. Loss of the menisci leads to a significantly increased risk of developing degenerative changes in the long term. Purpose: this study aimed to investigate the role of Ultrasound (US) in diagnosis of meniscus tears as compared to Magnetic Resonance Imaging (MRI) Patients and Methods: this study included 50 patients, presented by pain, swelling, stiffness/limitation of movement or a history of acute/chronic knee trauma, in the duration between November 2017 and July 2018. The research was carried on the Radiology Department, Al Azhar General Hospital, Zagazig, Sharkia Governorate, Ministry of Health. All patients underwent musculoskeletal ultrasound in different position then underwent magnetic resonance imaging included different pulse sequences and scanning planes. Results: this study included 50 patients, 31 (62%) males and 19 (38%) females. The patient’s age ranged between 10 and 67 years with a mean of 37.65 ± 10.24 SD. Male patient’s age ranged between 10 and 67 years with a mean of 36.35 ± 11.03 SD, while female patient’s age ranged between 29 and 55 years with a mean of 40 ± 8.34 SD. Conclusion: high resolution ultrasonography had high accuracy in detecting presence of tears in both the medial and lateral menisci. MRI is more sensitive in detection and determines types of tears than US.

EVALUATION OF SURGICAL TREATMENT OF ROTATOR CUFF ANTEROSUPERIOR TEARS ARTHROSCOPICALLY.

ABSTRACTObjective:To evaluate the functional result of arthroscopic treatment in anterosuperior rotator cuff tears.Methods:Fifty-six patients submitted to arthroscopic repair of anterosuperior rotator cuff tears were evaluated. The follow-up time was five year and five months. All the tears were diagnosed by detailed physical and imaging examination. Statistical analysis was used to compare the preoperative and postoperative results of range of motion and the UCLA score, with Wilcoxon signed-rank test, 5% significance level (p≤0.05), the relationship between the subscapularis tear and postoperative results using the Mann-Whitney test, and between the pain length and the UCLA scale using Spearman's correlation.Results:A statistically significant improvement (p<0.001) was found, comparing the range of motion and the UCLA preoperatively and postoperatively. 39% of the cases were classified as excellent, 33.9% as good, 23.7% as regular and 3.4% as bad results. A statistically significant relationship was found between the subscapularis tear type and the functional state, the pain length and the postoperative UCLA scale. Five complications, four reruptures and one adhesive capsulitis were found.Conclusions:The arthroscopic treatment for anterosuperior tears presented satisfactory results, with 8.5% of complications. Level of Evidence IV, Case series.

Posterior Horn Repair Augmented With the Central Portion of Thickened Meniscus for Large Posterolateral Corner Loss Type of Discoid Lateral Meniscus

Large posterolateral corner loss type of discoid lateral meniscus tear is unsalvageable. Therefore, subtotal meniscectomy has been the only treatment option in this case. However, long-term results of subtotal or total meniscectomy have shown a high prevalence of early degenerative changes. Persistent symptoms, such as increased pain, snapping, giving way, locking, and limited extension, can be attributed to progressive loss of posterior tibial meniscal attachment and meniscal degeneration, especially in the posterior horn. The purpose of this technique-based article is to describe a partial repair, posterior horn repair augmented with the central portion of the discoid lateral meniscus that would have been removed if a subtotal meniscectomy were performed and bone marrow stimulation in the intercondylar notch to improve meniscal healing.

Effect of meniscus repair on pivot-shift during anterior cruciate ligament reconstruction: Objective evaluation using triaxial accelerometer

BackgroundSome types of meniscus tear, especially lateral meniscus tear, have been reported to be associated with rotatory knee laxity. However, precise information regarding the effect of meniscus repair on rotatory laxity is limited. The purpose of this study was to investigate the effects of lateral and medial meniscus repair on rotatory laxity in anterior cruciate ligament (ACL) injured knees. MethodsForty-one patients who underwent ACL reconstruction were included in the study. The tibial acceleration during the pivot shift test was measured using a triaxial accelerometer preoperatively under anesthesia and intraoperatively before and after medial and lateral meniscus repair and ACL reconstruction during surgery. Effects of meniscus tear and its repair on rotatory laxity were analyzed. ResultsPreoperative measurements revealed that patients with lateral meniscus tear showed significantly higher tibial acceleration compared to the patients without meniscus tear (P = 0.006). Intraoperative measurements revealed that medial and lateral meniscus repair significantly reduced tibial acceleration by 1.46 m/s2 (P = 0.002) and 1.91 m/s2 (P < 0.001), respectively. ConclusionIn ACL injured knees, knees with lateral meniscus tear showed greater rotatory laxity compared to the knees without meniscus tear. In addition, lateral meniscus repair, and to a lesser degree medial meniscus repair, reduced rotatory laxity during ACL reconstruction surgery. Therefore, the meniscus should be repaired as much as possible for its role as a secondary stabilizer of rotatory laxity. Besides, the effect of meniscus repair on rotatory laxity should be considered when the indication of anterolateral augmentation is determined.

An efficient and fast computer-aided method for fully automated diagnosis of meniscal tears from magnetic resonance images.

Menisci are structures that directly affect movement, so early detection of meniscus tears also helps to prevent progressive knee disorders such as osteoarthritis. Manual segmentation of the menisci and diagnosis of the meniscal tear is a costly process in terms of time and effort for a radiologist. The aim of this study is to automatically determine the location and the type of meniscal tears that are important in the diagnosis and effective treatment of this problem. For this purpose, 29 different MR images, which were provided by Osteoarthritis Initiative (OAI), were used in the study. This study proposes a novel three-stage (preprocessing, segmentation and classification) method for fully automated classification from MR images, and shows the performance of each stage separately. At the preprocessing step, the most compact rectangular windows for the menisci were obtained from MR slices. At the segmentation step, the menisci were segmented using fuzzy clustering methods. In order to classify the segmented images and to determine meniscus tears, three different classifiers were used. The method first decides whether there are tears on menisci; if this is the case then, determines the place and type of the tears. There are no studies that classify the meniscus tears according to their types up to now in the literature. The experimental results indicate that the automated process can be completed within a time range of 3 to 4 min with a high classification performance. Hence, the suggested computer-aided diagnosis (CAD) system can be used as a decision support system for the diagnosis of meniscal tears by radiologists.

Correlation of Meniscal Tear with Timing of Anterior Cruciate Ligament Reconstruction in Patients without Initially Concurrent Meniscal Tear.

The incidence of meniscal tear was reported to increase with the delay of anterior cruciate ligament reconstruction (ACLR). The tear may occur concurrently with the ACL injury or after the ACL injury. Few studies had focused on the patients whose meniscus is intact during ACL injury. We determined the correlation between timing of surgery and incidence of meniscal tears in ACL-deficient knees with initially intact meniscus. We retrospectively reviewed 387 patients who had undergone primary ACLR. Time of initial ACL injury, magnetic resonance imaging (MRI) examination, and surgery was recorded. The MRI was reviewed by experienced radiologic and orthopaedic doctors. Intraoperative arthroscopic images were also obtained and reviewed. The type of tear noted during surgery was classified according to the modification of International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine classification of meniscal tears. Patients were divided into early (surgery within 12 months from injury) and late surgery group (surgery at more than 12 months from injury). There were 216 patients with intact medial meniscus and 257 patients with intact lateral meniscus on the postinjury MRI study. The incidence of medial meniscus tear (MMT) was significantly higher than lateral meniscus tear (LMT) during the ACLR (33.8 vs. 19.8%, p < 0.001). The incidence of MMT is higher in late group than in early group (53.7 vs. 29.1%, p = 0.004, odds ratio= 2.815). The incidence of LMT is mildly higher in late group but without statistics significance (23.8 vs. 18.6%, p = 0.364). In both MMT and LMT, the most common injury pattern observed was a longitudinal tear. The incidence of each type is not different between early and late group. For patients without concurrent meniscal injuries with the ACL tear, the incidence of MMT significantly increased if ACLR was performed more than 12 months after injury. The medial meniscus was more prone to injury than the lateral meniscus in chronic ACL-deficient knee. ACLR should be performed earlier to reduce the risk of meniscal tears for patients without initially concurrent meniscal tear.

Long-term Outcomes of Primary Repair of the Anterior Cruciate Ligament Combined With Biologic Healing Augmentation to Treat Incomplete Tears

Background: Surgical treatment to repair partial anterior cruciate ligament (ACL) injury without reconstruction has demonstrated inconsistent clinical success. Purpose: To examine the long-term clinical outcomes of primary ACL repair combined with biologic healing augmentation in patients with symptomatic partial ACL tears. Study Design: Case series; Level of evidence, 4. Methods: 50 patients (mean age, 29.5 years) with a partial ACL tear and symptomatic knee instability were treated with primary ligament repair in conjunction with marrow stimulation and followed prospectively for a mean duration of 10.2 years (range, 5.3-14.3 years). Comparative analysis of preinjury, preoperative, and postoperative scores using patient-reported assessment instruments was performed to examine clinical outcomes. Correlation of final outcome scores with patient age, type of ACL tear, side-to-side difference in ligamentous laxity, and body mass index (BMI) was performed through use of Spearman rank analysis. Results: 44 patients were available for assessment at final follow-up. The median Tegner Activity Scale score of 7 at final follow-up was the same as the preinjury median score of 7 (P = .128). The mean Marx Activity Scale, International Knee Documentation Committee (IKDC) Subjective, and Lysholm Knee Questionnaire scores were 10.8, 90.4, and 96.2, respectively, at final follow-up. Mean final Knee injury and Osteoarthritis Outcome Score (KOOS) subset assessments of Pain, Symptoms, Activities of Daily Living, Sports, and Quality of Life were 98.6, 97.5, 99.7, 94.3, and 95.6, respectively. Secondary ACL insufficiency occurred in 27% of patients. Clinical outcome scores were similar for all scoring instruments between patients treated for an associated diagnosis of meniscal or articular cartilage injury. No significant correlations of age, BMI, ACL tear type, or laxity and final IKDC Subjective, Lysholm, or KOOS scores were found. Analysis revealed a negative correlation of patient age and Tegner score at preinjury (rs = −0.333, P = .022) and at final follow-up (rs = −0.376, P = .013). The mean side-to-side difference in ligamentous laxity of 3.4 mm at short-term follow-up in those patients who developed secondary ACL insufficiency over the duration of follow-up was significantly greater than the mean of 0.9 mm in those who did not (P = .010). Conclusion: Primary ACL repair combined with biologic healing augmentation to treat select cases of knee instability secondary to incomplete ACL rupture demonstrated good to excellent long-term outcomes in this cohort for those patients who did not experience secondary ACL insufficiency, with high rates of restoration of knee stability and return to preinjury athletic activities. The rate of secondary treatment for recurrent ACL insufficiency over the course of long-term follow-up was greater than would be expected for primary ACL reconstruction. Greater side-to-side differences in objective findings of ligamentous laxity were identified at shorter term follow-up in the patients who later went on to experience symptomatic secondary ACL insufficiency, compared with those who maintained stability long term.

Meniscal tear morphology independently affects pain relief following arthroscopic partial meniscectomy in middle-aged patients.

To analyze the influence of meniscal tear pattern on clinical outcomes following arthroscopic partial meniscectomy in middle-aged patients with medial meniscal tears. A total of 123 patients (130 knees) aged ≥ 50years who underwent arthroscopic partial meniscectomy for medial meniscal tears were evaluated. Inclusion criteria were none to moderate medial knee osteoarthritis [Kellgren-Lawrence (KL) grade ≤ 3] and a minimum of 2-year follow-up (median 4.6 years; range 2.1-8.0years). Meniscal tears observed during arthroscopic examination were classified into six types: radial tear of the middle segment, posterior root tear, horizontal tear of the posterior segment, flap tear, minor tear, and complex tear. Postoperative outcomes were classified into effective (group 1) and non-effective (group 2) according to the pain relief administered 1month postoperatively and at the final follow-up. Demographic variables, KL grade, type of meniscal tear, and postoperative follow-up period were evaluated. Forty knees (38%) were classified into group 1. Of the six types of tears, radial tear of the middle segment [odds ratio (OR) 4.1, 95% confidence interval (CI) 1.1-20.9] and flap tear (OR 12.9, 95% CI 1.8-140.7) were significant predictors of good outcome on multivariate logistic regression analysis. In middle-aged patients with medial meniscal tears, radial tear of the middle segment was independently associated with less pain following arthroscopic meniscectomy. Arthroscopic partial meniscectomy may be indicated in patients with radial tear if conservative treatment fails. Case-control study, Level III.

The Classification of Knee Meniscal Cartilage Tears

Meniscal cartilage tears are among the most common orthopaedic pathologic conditions. The incidence of meniscal cartilage tears increases with age and as such will present a growing problem in the United States and other developed countries experiencing aging populations. To properly diagnose and assess treatment of cartilage tears classification systems are necessary to categorize and compare outcomes. There are several traditional methods of classifying tears based on their morphologic characteristics, vascular anatomy, and location. Recently there has been an interest in tear types that may have been known but were not widely recognized. Advances in arthroscopic techniques have facilitated both the diagnosis and treatment of cartilage tears. A solid knowledge of the classification of meniscal tears is essential to their proper treatment.

Tear characteristics and surgeon influence repair technique and suture anchor use in repair of superior-posterior rotator cuff tendon tears

The factors that associate with surgical decisions about repair technique and the number of suture anchors used in rotator cuff repair have not been previously investigated. This study investigated the extent to which patient, surgeon, and surgical factors associate with performing single-row vs. double-row repair technique and ultimately with the number of suture anchors used. Our institution's prospective surgical cohort was queried for patients undergoing suture anchor repair of superior-posterior rotator cuff tendon tears between February 2015 and August 2017. Exclusion criteria were patients with isolated subscapularis tears, tears that were not repaired, repairs without suture anchors, repairs involving graft augmentation, and repairs by surgeons with fewer than 10 cases. Multivariable statistical modeling was used to investigate associations between patient and surgical factors and the choice of repair technique and number of suture anchors used. A total of 925 cases performed by 13 surgeons met inclusion criteria. Tear type (full thickness), tear size (medium, large, and massive), a greater number of torn tendons, repair type (arthroscopic), and surgeon were significantly associated with performing a double-row over a single-row repair. Tear size, a greater number of torn tendons, double-row repair technique, and surgeon were significantly associated with a greater number of anchors used for repair. Our findings suggest that in the absence of data to conclusively support a clinical benefit of one repair technique over another, surgeons' training, experience, and inherent practice patterns become the primary factors that define their surgical methods.

Using only MRI is moderately reliable in the prediction of meniscal tear reparability.

The purpose of this study was to evaluate the role of surgeons' experience with meniscal repairs and meniscectomy decisions, and to determine the factors affecting the disagreement between meniscal repairs and meniscectomy decisions. In total, 223 patients with meniscal tears, 106 meniscal repairs, and 117 meniscectomies were included. Six orthopedic surgeons (3: > 5years; 3: < 5years' arthroscopy experience) were blinded, and they independently reviewed all preoperative MR images for over a month. Their reviews were compared with arthroscopic interventions performed by a surgeon with > 10years' arthroscopy experience. Reparability-associated factors were also evaluated using multivariate logistic regression. The first and second evaluation results did not differ significantly between groups (n.s.). There was good agreement between MRI predictions and arthroscopic interventions for both groups (< 5years' experience: k = 0.248, agreement 62.3%; > 5years' experience: k = 0.351, agreement 67.3%). Sex, side, and distance of tear from the meniscocapsular junction were not significantly different between agreements and disagreements. Disagreement regarding meniscectomy was significantly higher than those regarding meniscus repair (p = 0.002). Concomitant anterior cruciate ligament (ACL) injury, osteochondral lesions, and medial meniscal tear increased the likelihood of meniscal repair (p = 0.0063, p = 0.0010, and p = 0.0369, respectively). An increased risk of disagreement between MRI and surgical procedure was found in the presence of bucket-handle, horizontal or complex tear, chronic tear, high sports activity and expectation level. Surgeon's experience level may influence the prediction of meniscus reparability. Concomitant ACL injury, osteochondral lesions, and presence of medial meniscal tear increase the likelihood of meniscal repair. Tear type, tear chronicity, patient's activity and expectation level may influence the surgeon's operative decision in addition to MRI. III.