Survivorship and Outcomes of Meniscal Ramp Lesions Repaired Through a Posteromedial Portal During Anterior Cruciate Ligament Reconstruction: Outcome Study With a Minimum 10-Year Follow-up.

BACKGROUND: Several studies have demonstrated suture repair of ramp lesions of the medial meniscus via a posteromedial approach was associated with a significantly lower rate of secondary meniscectomy. However, these studies are not long-term and highlight the need for extended follow-up research to better understand the outcomes over a more extended period. PURPOSE: To evaluate the long-term results and reoperation rate for the failure of arthroscopic all-inside suture repair of ramp lesions of the medial meniscus via a posteromedial approach during anterior cruciate ligament (ACL) reconstruction. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: All patients who underwent all-inside suture repair of the posterior segment of the medial meniscus (ramp lesion) via a posteromedial approach during ACL reconstruction at a minimum follow-up of 10 years were included in the study. Side-to-side anterior laxity was assessed preoperatively and postoperatively. Pre- and postoperative functional assessment was based on the subjective International Knee Documentation Committee score for activities of daily living and the Tegner activity scale for sporting ability. Reinterventions for meniscal repair failure and other complications were also recorded at the last follow-up. RESULTS: A total of 81 patients met the inclusion criteria for this study. Two patients had an ACL graft rupture with a new ramp lesion and were excluded from the analysis. Additionally, 15 patients were lost to follow-up, leaving a total of 64 patients in the final analysis. The mean follow-up was 124.8 months (range, 122.4-128.4 months). Mean side-to-side difference in anterior laxity significantly improved from 7.4 ± 1.5 mm (range, 5-12 mm) to 0.4 ± 1.3 mm (range, -3 to 4 mm) (P = .01). The mean subjective International Knee Documentation Committee score increased from 64.3 ± 13.4 (range, 34-92) before the operation to 91.1 ± 10.1 (range, 49-100) at the last follow-up (P = .001). The Tegner activity scale score at the last follow-up (6.3 ± 1.6) was lower than that before the trauma (7.1 ± 1.6) (P = .02). Fourteen patients (21.9%) had a failed meniscal repair and were reoperated. The mean time from initial repair to reoperation was 64.5 months (range, 13-126 months), and the median was 60.6 months. The multivariate analysis, including parameters such as lateral tenodesis (hazard ratio [HR], 1.62; P = .50), preoperative Tegner score (HR, 1.66; P = .41), preoperative laxity (HR, 1.75; P = .35), age at surgery (HR, 1.02; P = .97), and number of sutures (HR, 2.38; P = .19), did not reveal any factors associated with suture failure. CONCLUSION: The results show that arthroscopic repair of ramp lesions of the medial meniscus during ACL reconstruction using a posteromedial approach has a high failure rate at the 10-year follow-up, with half of these suture failures occurring within 5 years after the initial repair.

The management of isolated meniscal tears in skeletally immature children. An international expert consensus.

PURPOSE: The prevalence and appreciation of meniscal tears in children have increased in both number and complexity. There is currently a paucity of high-quality evidence that can guide surgeons in treating skeletally immature patients with meniscal injuries. The aim of this study was to develop comprehensive recommendations for the management of isolated meniscal tears in skeletally immature children. METHODS: An international, two-round, modified Delphi consensus was completed. Included 'experts' were identified as having an established adult knee practice, including children and either: (1) Faculty at an international paediatric knee conference, (2) Active members of complex national paediatric multi-disciplinary groups or (3) Members of faculty on recognised national/international instructional courses aimed at teaching the management of meniscal lesions to knee surgeons. The currently available literature was reviewed, and areas of poor quality, inconclusive or absent evidence were examined and formed the focus of the study. A threshold of 70% was used to define consensus for our study based on other similar Delphi consensus studies in the literature. RESULTS: A total of 43 experts (Round 1) and 41 experts (Round 2) took part in the Delphi study, including surgeons from Europe, the United States of America and South America. 34 statements were identified exploring three main domains-clinical assessment, management and complex tears (bucket handle, discoid and radial). Following Round 1, consensus was reached on 17 (50%) statements; subsequently, after completion of Round 2, consensus was reached on 28 (82%) statements, leaving six (18%) with no consensus. The areas of no consensus included investigation of painless clicking, the most sensitive clinical test for meniscal pathology, treatment of small radial tears (less than 1/3 width), ability to reduce chronic bucket handle tears and timing of surgery. CONCLUSIONS: This is the first modified Delphi consensus that provides evidence for surgeons treating skeletally immature children with isolated meniscal tears. A valuable level of consensus was reached on the assessment and management of simple and specialist meniscal tears. These consensus statements can both inform clinical practice and be used in the development of further high-quality research studies. LEVEL OF EVIDENCE: Level V.

Medial Meniscal Extrusion After Anterior Cruciate Ligament Reconstruction (ACLR) Associated With Meniscal Repair and Preoperative Extrusion.

INTRODUCTION: The risk of post-traumatic osteoarthritis remains high even after anterior cruciate ligament reconstruction (ACLR). Medial meniscal extrusion (MME) is a valuable clinical sign as an early morphological change. This study aimed to analyze MME before and after ACLR and investigate the factors affecting postoperative MME. MATERIALS AND METHODS: This study included patients who underwent anatomical double-bundle ACLR between January 2016 and July 2021. MME was measured using MRI preoperatively and one year postoperatively. The medial meniscus (MM) treatments were categorized into three groups: no MM injury and no repair (no injury/no repair (N/N)), MM injury but no repair (injury/no repair (I/N)), and MM injury and repair (injury/repair (I/R)). We investigated the factors influencing MME after ACLR using multiple linear regression analysis and compared MME before and after ACLR using paired t-tests. RESULTS: This study included 133 patients, of whom 90 (37 males and 53 females) were analyzed. The mean age of the patients at surgery was 27.5 years, and 41, 27, and 22 patients were assigned into N/N, I/N, and I/R groups, respectively. Preoperative MME (p<0.001) and I/R (p<0.001) had significant effects on postoperative MME in a regression analysis. Postoperative MME had greater effects than the preoperative MME in all cases (1.16 and 1.53 mm (p<0.01)) and in every MM treatment group (N/N: 1.02 and 1.32 mm (p<0.01), I/N: 1.16 and 1.44 mm (p<0.01), and I/R: 1.42 and 2.05 mm (p<0.001)). CONCLUSIONS: Larger preoperative MME and receiving MM repair were significantly associated with a larger MME after ACLR. Postoperative MME in ACLR patients was significantly greater than preoperative MME.

Partial Meniscectomy Yields Comparable Outcomes and Failure Rates to Meniscal Repair for Horizontal Cleavage Tears, with Fewer Complication Rates but Greater Progression of Degenerative Changes.

PURPOSE: To compare the clinical outcomes, failure rates, surgical complications, and postoperative radiographic changes following partial meniscectomy versus meniscal repair for horizontal cleavage tears (HCTs). METHODS: A literature search was performed according to the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using the Scopus, PubMed, and Embase computerized databases. Clinical studies evaluating partial meniscectomy or meniscal repair for HCTs were included. Demographic characteristics, surgical techniques, clinical outcomes, failure rates, complications, and radiographic assessments were recorded. RESULTS: A total of 18 studies comprising of 833 patients with HCT were included, of which 562 patients (67.5%) were treated with partial meniscectomy and 271 (32.5%) with meniscal repair. Both types of treatments reported improved clinical outcomes, including IKDC, Lysholm, KOOS, and Tegner scores. Failure rates were reported to range between 0 to 15% following partial meniscectomy, and between 0 to 17.6% following repair; and complications were 7.5% after partial meniscectomy, and between 3.8 to 21.4% following meniscal repair. Patients undergoing meniscectomy demonstrated progression of degenerative changes on radiographic assessments. CONCLUSION: Repair of HCTs in the appropriately indicated patient can result in similar patient outcomes and failure rates compared to partial meniscectomy. However, especially in patients aged 42 years and younger, a greater complication rate can be expected with repair, while a greater degree of ipsilateral compartment degeneration is seen after partial meniscectomy.

Meniscal-wall ultrasound-guided steroid infiltration for degenerative meniscal lesions (DML) shows low rate of conversion to surgery.

INTRODUCTION: Degenerative meniscal lesions (DML) are frequent in the general population. However, the management of stable DML is always a challenge due to the lack of universal consensus and evidence. HYPOTHESIS: We assessed ultrasound-guided corticosteroids medial meniscal-wall infiltration as a conservative therapy for symptomatic DML and we searched for associated factors of very good response. Our hypothesis is that these injections will contribute to avoid the surgical treatment and improve clinical and functional scores. MATERIAL AND METHODS: An observational retrospective study included patients with DML of medial meniscus without mechanical symptoms of catching or locking, and without radiological signs of osteoarthritis, who underwent meniscal-wall corticoid infiltration under ultrasound between 2020 and 2021. Evaluations were carried-out at 24 months minimum after infiltration to determine any surgical intervention performed and assess clinical and functional outcome by a standard questionnaire to evaluate pain score using VAS at rest and on walking, SKV and TEGNER. Patient characteristics at the time of the infiltration were collected to determine the factors associated with very good response (SKV > 90). RESULTS: 187 patients were included. Surgery-free survival was 95% (90-97) (33,17 (SD, 6,40) months), mean VAS pain score at rest of 1.47 (SD, 2.51), mean VAS on walking of 2.47 (SD, 2.91), mean SKV score of 71.32 (SD, 22.75) and mean Tegner score of 6.75 (SD, 1.67) at a minimum of 24 months follow-up. BMI was significantly lower in the very good responders (SKV > 90) with a p = 0,017 (24.04 (SD, 3.82) in patients with SKV > 90 versus 26,23 (SD, 4.93) in patients with SVK ≤ 90). CONCLUSION: US-guided meniscal wall infiltration is able to provide lasting symptom relief and functional recovery over time, in addition to low rate of conversion to surgery for patients suffering from DML without radiological signs of osteoarthritis. LEVEL OF PROOF: IV; retrospective study.

The incidence of meniscal cyst formation following meniscal repair using the all-inside suture anchor device is comparable to conventional techniques.

Purpose: Post-operative meniscal cyst formation occurs following all-inside device meniscal repair. This study aimed to compare the incidence of cysts in patients who underwent meniscal repair with and without all-inside suture devices. Methods: This retrospective study included 227 knees that underwent meniscal repair between 2021 and 2022. The incidence of post-operative meniscal cysts was compared between patients who underwent repair using an all-inside suture anchor device (Group SA) and those who did not use an anchor (Group NA), based on post-operative magnetic resonance imaging (MRI) findings. Risk factors, such as the number of anchors used, were investigated. Using a subgroup analysis, the incidence of meniscal cysts based on the type of device used was investigated. Results: Groups SA and NA comprised 125 and 102 knees, respectively. Group SA had 11 cases of cysts (9% incidence), whereas Group NA had 7 cases (7% incidence), and no statistically significant difference was observed (p = 0.63). Symptomatic cysts were observed in two patients (1.6%) in Group SA, whereas none was observed in Group NA (0%); the difference was not significant (p = 0.50). Factors such as the number of anchors and sutures used and MRI timing were not identified as risk factors. Cyst incidence varied according to anchor type: Stryker AIR+ (4 out of 55, 7%), Smith & Nephew Fast-Fix 360 (7 out of 56, 13%) and Arthrex Fiber Stitch (0 out of 26, 0%), with no significant difference found (p = 0.14). Conclusion: The incidence of cysts in patients undergoing meniscal repair with an all-inside suture anchor device was 9%, showing no significant difference compared with Group NA. Cyst incidence was not affected by device type. Level of Evidence: Level III, retrospective comparative study.

Significantly smaller lateral extrusion was observed within 24 weeks after all-inside suture repairs of radial tear in the middle segment of lateral meniscus compared to inside-out repairs.

Purpose: To evaluate the postoperative meniscal extrusion between all-inside suture (AIS) and trans-capsular suture (TCS) repair techniques. Methods: Thirteen patients (mean age, 19.4 years) underwent AIS repairs using only sutures (AIS group) for radial tears in the middle segment of the lateral meniscus (RTMLM), and seven patients (mean age, 20.3 years) underwent inside-out repairs among TCS (TCS group). For all cases, lateral (LE), anterior (AE) and posterior (PE) meniscal extrusions of the lateral meniscus were measured during preoperative and 3-, 12- and 24-week postoperative MRIs. Then, the change of each extrusion from preoperative to each postoperative period was calculated as ∆LE, ∆AE and ∆PE. Results: There was no significant difference between the AIS and TCS groups in the preoperative extrusions. As for postoperative extrusions, only ∆LEs in the AIS group was significantly smaller than those in the TCS group at all postoperative periods (-1.5 ± 1.7 vs. 0.9 ± 0.7 mm at 3-week, -0.9 ± 0.9 vs. 0.4 ± 0.9 mm at 12-week and -0.3 ± 1.0 vs. 0.6 ± 1.1 mm at 24-week postoperation). In ∆AEs and ∆PEs, at all three postoperative periods, there were no significant differences. Conclusion: Postoperative LE, AE and PE on MRIs after AIS and TCS repairs for RTMLM were investigated. Significantly smaller lateral extrusion was observed within 24 weeks after AIS repairs of RTMLM compared to TCS repairs, which could lead to stabilization of the repair site and prevent degenerative changes. Level of Evidence: Case-control study, retrospective comparative study, Level Ⅲ.

Survivorship and outcomes of intra- and perimeniscal corticosteroids injections with structured physiotherapy for degenerative medial meniscus tears.

BACKGROUND: Degenerative medial meniscus tears are a common pathology in the general population. Recent randomized trials demonstrated non-superiority of arthroscopic partial meniscectomy over conservative management. However, there is a paucity of information regarding the outcomes of combined conservative treatments. HYPOTHESIS: It was hypothesized that combined intra- and perimeniscal corticosteroid injections with structured physiotherapy, for degenerative medial meniscus tears, would result in high surgery-free and second injection-free survivorship. METHODS: A retrospective review of 671 patients with symptomatic degenerative medial meniscus tears, who received intra- and perimeniscal corticosteroids injection combined with structured physiotherapy, was conducted. An ultrasound-guided injection of Triamcinolone Hexacetonide 20 mg/ml comprised; 1.5 ml intra-meniscal,1.5 ml in the meniscal wall, and 2 ml in the peri-meniscal space, was performed. Surgery free- and a second injection free-survivorship were analysed. Western Ontario and Macmaster University scores (WOMAC), Tegner activity scores, patient satisfaction, return-to-work status and average time to return to work were recorded. RESULTS: A total of 481 patients who met the inclusion criteria were included. The mean age was 51.1 ± 7.9 years. At five years post-procedure, surgery-free, and second injection-free survivorship of the ipsilateral knee was 83%, and 52%, respectively. A multivariate analysis adjusting survival on parametric risk factors identified that only effusion before steroid injection was an independent risk factor of treatment failure. At a mean follow-up of 4 ± 2 years, there was an improvement in WOMAC scores by 5.2 ± 4.9 for pain, by 2 ± 2 for stiffness, by 7.3 ± 7.4 for function, and by 12.4 ± 12.7 for the global scores. Additionally, there was significant improvement in the Tegner activity scores (All p < 0.001). Knee effusion and advanced osteoarthritis (Kellgren-Lawrence > III) were significantly associated with poorer outcomes; p < 0.003 and p < 0.0004, respectively. CONCLUSION: A combination of intra- and perimeniscal corticosteroid injections and structured physiotherapy for degenerative medial meniscus tears, results in high surgery-free (83%) and second injection-free (52%) survivorship, as well as, effective clinical outcomes and satisfaction at 5 years. LEVEL OF EVIDENCE: IV; Retrospective Case Series.

Biomechanical Comparison of Suture-Relay All-Suture Anchors and Conventional Suture Anchors for Posterior Medial Meniscus Root Repair in Porcine Models.

Background: Posterior medial meniscus root (PMMR) tears (PMMRTs) can be repaired using various techniques to promote healing. However, the biomechanical properties of suture-relay all-suture anchor (ASA) versus conventional suture anchor (CSA) and loop-locking transtibial pullout (TTP) have not been well established. Purpose: To compare the biomechanical properties of PMMR repairs using suture-relay ASA, CSA, and loop-locking TTP. Study Design: Controlled laboratory study. Methods: A total of 33 fresh-frozen porcine knee joints with intact medial menisci were randomly divided into 3 groups, with 11 specimens in each group: ASA, CSA, and TTP. The study involved cyclic loading, with displacement measurements taken after 100, 500, and 1000 cycles. Subsequently, the specimens were loaded until clinical failure (defined as 3-mm displacement) and then to ultimate failure of the construct, with data recorded for displacement after cyclic loading, load to 3-mm displacement, and ultimate load to failure. Results: After 1000 cyclic loadings, the suture-relay ASA group showed considerably less displacement than the loop-locking TTP group (1.8 ± 0.7 mm vs 2.9 ± 0.3 mm; P < .001), but the displacements did not differ considerably between the suture-relay ASA and CSA groups (2.2 ± 0.9 mm; P > .05). The mean loads to clinical failure were significantly greater in the suture-relay ASA and CSA groups (61.3 ± 6.5 and 57.5 ± 9.7 N, respectively) than in the loop-locking TTP group (38.3 ± 9.4 N; P < .05). The ultimate load to failure was significantly greater in the suture-relay ASA group than in the loop-locking TTP group (153 ± 55.1 N vs 102 ± 12.9 N; P < .05). All specimens in the loop-locking TTP group failed by suture elongation mode, whereas only 2 specimens (18%) in the suture-relay ASA group and 5 specimens (45%) in the CSA group failed by suture elongation. Nine specimens (82%) in the suture-relay ASA group and 6 specimens (55%) in the CSA group failed due to suture cutout through the meniscal tissue. Conclusion: The biomechanical properties after PMMR repair did not statistically differ between the suture-relay ASA and CSA groups. The suture-relay ASA technique had a higher load to failure than the loop-locking TTP technique. Clinical Relevance: The suture-relay ASA technique is a promising option for the repair of PMMRTs; its repairing strength is also comparable to that of the CSA technique. Notably, the suture-relay ASA technique can be utilized without establishing a posteromedial portal, resulting in decreased procedure time and mitigating challenges associated with working from the posterior aspect of the knee.

Characterizing Treatment Credibility, Treatment Expectancy, and Symptom Expectancy in Patients Before Nonoperative Treatment for Degenerative Meniscal Tears.

Background: The role of nonspecific factors, such as treatment credibility, treatment expectancy, and symptom expectancy, may shape the outcomes of the nonoperative treatment of degenerative meniscal tears (DMTs). Purpose/Hypothesis: The purpose of this study was to characterize treatment credibility and expectancy, symptom expectancy, and patient and clinical correlates of these factors among participants before undergoing 4 nonoperative treatment programs for DMTs. It was hypothesized that (1) treatment credibility scores would be similar across patient and baseline clinical subgroups and (2) treatment expectancy and symptom expectancy scores would be lower in older patients and among those reporting a longer pain duration or greater pain intensity. Study Design: Cohort study; Level of evidence, 3. Methods: In 126 participants, validated scales were administered before treatment to assess the credibility of the assigned treatment (possible score of 1-9) as well as the expectations of treatment outcomes (0-100) and symptom improvement (1-5). Patient and clinical characteristics associated with these variables were examined. Results: On average, participants (mean age, 58 years [range, 45-75 years]; 51% female; 94% White) expected the treatment to improve their symptoms by a mean of 68% and expected their symptoms to be "very likely" to improve. Participants with a body mass index (BMI) ≥30 kg/m2 had lower mean treatment credibility (6.09 ± 1.81) and treatment expectancy (64.53 ± 25.16) scores on bivariate analyses than those with a BMI <30 kg/m2 (6.73 ± 1.69 [P = .045] and 72.86 ± 19.20 [P = .039], respectively). Participants reporting a pain duration ≥3 months also had lower mean treatment expectancy (63.85 ± 23.83) and symptom expectancy (3.70 ± 0.85) scores compared to those reporting a pain duration <3 months (75.52 ± 18.93 [P = .003] and 4.16 ± 0.67 [P = .001], respectively). Conclusion: Most patients about to undergo physical therapy for DMTs considered it to be between "somewhat" and "very" credible and believed that their symptoms, on average, were "very likely" to improve. Although not supported by most evidence, patients with a BMI ≥30 kg/m2 believed physical therapy to be less credible and had lower treatment and symptom expectations, and those with symptoms present for ≥3 months had lower treatment and symptom expectations as well. Whether these nonspecific factors influence outcomes should be considered for further research.

Ultrasound-guided injection using leucocyte-rich platelet-rich plasma for treatment of meniscal injuries in a duathlete: a case report.

There is a paucity of data regarding using platelet-rich plasma therapy for Baker's cyst-associated medial meniscal tear. To date, conservative treatments for this type of condition include aspiration of fluid effusion with steroid injection and physical therapy. When this treatment fails, arthroscopic debridement, meniscectomy, cyst decompression and open cystectomy are available surgical management options. Recurrence rates, however, are high such that even these procedures fail to provide long-term pain relief. This case study explores the benefits of leukocyte-rich platelet-rich plasma therapy in treating tears in the posterior horn of the medial meniscus with concomitant Baker's cyst. With limited studies available, this case hopes to encourage more studies to be done in the future to provide a conservative option for patients with similar cases.

Aim: To describe the successful treatment of fluid-filled cyst-associated ligament tear using ultrasound-guided injection of enhanced regenerative blood.Setting: Outpatient clinic.Patient: 60-year-old male with right knee pain.Case description: The patient presented with a 4-month history of right knee pain. Exam revealed restriction and pain during knee bending. Imaging showed swelling in both the front and back of the knee. The patient underwent four weekly enhanced PRP treatments.Results: The patient reported near-complete pain resolution with MRI showing reduction of swelling in the aforementioned areas. Patient was also able to complete a marathon.Conclusion: This enhanced PRP may be considered as a treatment option for patients with Baker's cyst-associated meniscal injuries.

Substantial medial para-meniscal cyst with a complex meniscal tear: A case report.

INTRODUCTION AND IMPORTANCE: Meniscal cysts, while infrequent with a prevalence of 1 %-8 %, may result in considerable knee discomfort and functional limitations. The cysts are categorized according to their position in relation through the meniscus, labeled as either intrameniscal or parameniscal. Although parameniscal cysts are often small and asymptomatic, they may expand and become painful with time. This case report describes an uncommon instance of a medial parameniscal cyst. CASE PRESENTATION: A 28-year-old male presented with persistent pain and swelling in the medial aspect of his left knee, lasting for 8 months. His symptoms were exacerbated by activities such as stair climbing and general mobility. On physical examination, a firm, fluctuating mass measuring 5 × 3 cm was noted. MRI revealed a complex tear in the posterior horn of the medial meniscus, along with a cyst measuring 4.9 × 3.2 × 2.0 cm. Arthroscopy identified a degenerative medial meniscus tear, and the cyst was excised through open surgery. The patient's recovery was uneventful, with full restoration of knee function within three months. CLINICAL DISCUSSION: Parameniscal cysts often coexist with horizontal meniscal tears, influenced by factors like knee laxity, trauma, and degeneration. MRI is the preferred diagnostic tool, but high-resolution ultrasound can be beneficial. Treatment options include conservative management and surgical interventions like partial meniscectomy, emphasizing the need for comprehensive diagnosis and appropriate management. CONCLUSION: This unique case of a medial parameniscal cyst highlights the critical need for timely diagnosis and intervention. Surgical treatment, including meniscectomy or meniscal repair, offers significant pain relief and functional improvement, demonstrating its effectiveness in managing such cases.

Assessment of meniscal extrusion with ultrasonography: a systematic review and meta-analysis.

BACKGROUND: Magnetic resonance imaging (MRI) is the imaging of choice for meniscal extrusion (ME). However, they may underappreciate the load-dependent changes of the meniscus. There is growing evidence that weight-bearing ultrasound (WB US) is more suitable, particularly in revealing occult extrusion. We therefore perform a systematic review and meta-analysis on the validity and reliability of US in diagnosing extrusion. Furthermore, we explored whether it detects differences in extrusion between loaded and unloaded positions and those with pathological (osteoarthritis and meniscal injury) and healthy knees. METHODS: The Cochrane Controlled Register of Trials, PubMed, Medline, and Embase were used to perform a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. Data pertaining to intra- and interrater reliability of US in measuring meniscal extrusion (ME), its correlation with magnetic resonance imaging (MRI), and head-to-head comparison of potential factors to influence ME were included [loading versus unloading position; osteoarthritis (OA) or pathological menisci (PM) versus healthy knees; mild versus moderate-severe knee OA]. Pooled data were analyzed by random or fixed-effects models. RESULTS: A total of 31 studies were included. Intraclass correlation coefficients (ICC) for intra- and interrater reliability were minimum 0.94 and 0.91, respectively. The correlation between US and MRI was (r = 0.76). US detected ME to be greater in the loaded position in all knees (healthy, p < 0.00001; OA, p < 0.00001; PM, p = 0.02). In all positions, US detected greater extrusion in OA (p < 0.0003) and PM knees (p = 0.006) compared with healthy controls. Furthermore, US revealed greater extrusion in moderate-severe OA knees (p < 0.00001). CONCLUSIONS: This systematic review suggests ultrasonography can play an important role in the measurement of meniscal extrusion, with results comparable to that of MRI. However, to what extent it can differentiate between physiological and pathological extrusion requires further investigation, with an absolute cutoff value yet to be determined. Nevertheless, it is an appropriate investigation to track the progression of disease in those with meniscal pathologies or osteoarthritis. Furthermore, it is a feasible investigation to evaluate the meniscal function following surgery. LEVEL OF EVIDENCE: IV, Systematic review of level III-IV evidence.

Finite element analysis of the knee joint: a computational tool to analyze the combined behavior after treatment of torn ligaments and menisci in the human knee joint.

Finite element analysis (FEA) is a fundamental tool that can be used in the orthopaedic world to simulate and analyze the behaviour of different surgical procedures. It is important to be aware that removing more than 20% of the meniscus could increase the shear stress in the cartilage and enlarge the risk of knee joint degeneration. In this fact, the maximal shear stress value in the medial cartilage increased up to 225% from 0.15 MPa to 0.5 MPa after medial meniscectomy. Also, meniscal root repair can improve meniscal biomechanics and potentially reduce the risk of osteoarthritis, even in cases of a loose repair. FEA has been used to better understand the biomechanical role of cruciate ligaments in the knee joint. ACLr with bone-patellar tendon-bone graft at 60 N of pretension and double-bundle PCLr were closer to that of a native knee in terms of biomechanics. The addition of a lateral extra-articular augmentation technique can reduce 50% of tibial translation and internal rotation, protecting the graft and minimizing the risk of re-rupture. Interestingly, anatomic and non-anatomic medial patellofemoral ligament reconstruction increased the pressure applied to the patellofemoral joint by increasing patellar contact pressure to 0.14 MPa at 30° of knee flexion using the semitendinosus as a graft. After all the advances in medical imaging technologies, future studies should take into consideration patient-specific data on both anatomy and mechanics, in order to better personalize the experimental model.

Failure and complication rates following meniscal all-inside and inside-out repairs: A systematic review and meta-analysis.

PURPOSE: This study examines failure rates, complication rates and patient-reported outcome measures (PROMs) for meniscal all-inside (AI) and inside-out (IO) repair techniques. METHODS: A systematic search was conducted on PubMed, Embase and Cochrane (inception to January 2024) assessing for Level I-III studies evaluating outcomes after meniscal repair. The primary outcome regarded differences in failure rates between AI and IO repair techniques. Secondary outcomes included a comparison of complication rates and PROMs. Quality assessment was performed using the Grading of Recommendations Assessment, Development and Evaluation and Methodological Index for Non-Randomized Studies criteria. A meta-analysis was conducted for outcomes reported by more than three comparative studies. RESULTS: A total of 24 studies (13 studies and 912 menisci for AI vs. 17 studies and 1,117 menisci for IO) were included. The mean follow-up ranges were 22-192 months (AI) and 18.5-155 months (IO). The overall reported AI failure rate ranged from 5% to 35% compared to 0% to 25% within the IO group. When comparing meniscal repair failure rates in the setting of concomitant anterior cruciate ligament reconstruction, the AI group had a failure rate (AI: 5%-34%; IO: 0%-12.9%). The complication rate ranged from 0% to 40% for AI and 0% to 20.5% for IO. Post-operative PROM scores ranged from 81.2 to 93.8 (AI) versus 89.6 to 94 (IO) for IKDC and 4.0-7.02 (AI) versus 4.0-8.0 (IO) for Tegner. Upon pooling of six comparative studies, a significantly lower failure rate favouring the IO technique was observed (15.9% AI vs. 11.1% IO; p = 0.02), although this result was influenced by a study with a predominantly elite athlete population. Moreover, no significant differences were found regarding complication rates between cohorts (7.3% AI vs. 4.8% IO; p = 0.86). CONCLUSION: The present study underscores comparable clinical success between AI and IO meniscal repair techniques, with both techniques demonstrating similar complication rates. However, the AI repair technique was associated with 1.77 times higher odds of failure compared to the IO cohort. LEVEL OF EVIDENCE: Level III.

Addressing meniscal deficiency part 1: An umbrella review of systematic reviews and meta-analyses on meniscal allograft transplantation.

Purpose: Meniscal injuries are common in the young and active population. There is increasing utilization of surgical interventions like meniscal allograft transplantation (MAT) to restore the protective function of menisci following injury leading to meniscal deficiency. Extensive research and publications exist on the management of meniscal injury and the sequalae of meniscal deficiency. However, a comprehensive synthesis of the existing evidence through an umbrella review is lacking. This study aims to fill this gap by providing a current examination of the literature on MAT. Methods: A comprehensive search was conducted in the MEDLINE, Embase and Scopus databases to identify relevant systematic reviews and meta-analyses. Studies were screened based on predefined inclusion and exclusion criteria. The quality of the included studies was assessed using the AMSTAR-2 tool. Results: A total of 41 studies were included in the review, with most published within the last decade. The majority of studies (56.1%) received a 'Critically Low' confidence rating, 26.8% were rated as 'Low', and only 14.6% were rated as 'High' confidence. From the included studies, 51.2% reported on PROMs, with the Lysholm score being the most common. Transplant failure and reoperation rate were reported in 34.1% and 19.5% of studies respectively. Studies on MAT reported favourable short-term outcomes in terms of patient-reported outcome measures (PROMs) but were limited by the lack of randomized control trials and consistent comparison groups. Conclusions: This umbrella review highlights an increase in interest in MAT but underscores the need for higher-quality reviews with standardized reporting and rigorous methodologies. Future research should focus on long-term outcomes, optimal surgical techniques, patient selection criteria and risk factors for transplant failure. There is also a need for more studies focusing on MAT in pediatric populations. Overall, this review provides a comprehensive assessment of the current state of research in MAT and identifies areas for improvement in future studies. Level of Evidence: Level IV.

Adolescent Symptomatic Medial Meniscal Ossicle Treatment and Probable Etiology.

Meniscal ossicles are rare, especially in children and adolescents. The clinical exam is often benign, but intra-articular calcification can be evident on radiographs. MRI is beneficial for differentiating between potential diagnoses. Management is usually conservative, with arthroscopy reserved for symptomatic cases that fail conservative treatment. The etiology is unknown, but several theories exist. This case report describes a 16-year-old female athlete who presented with catching in her left knee and occasional pain when jumping hurdles. Radiographs were suggestive of a bony ossicle in the posterior aspect of her medial compartment. Conservative treatment provided little relief. MRI identified an intrameniscal ossicle and a posterior root tear of the medial meniscus. During arthroscopy, compression of the ossicle between the femur and tibia was visualized when the knee was positioned in terminal knee flexion and external rotation. Surgical treatment consisted of partial medial meniscectomy with excision of the ossicle and meniscal repair. The athlete gradually returned to full activity and sports. Although the exact etiology is unknown, trauma is the most likely cause. The patient's young age and absence of calcification on prior radiographs negate degenerative and congenital causes, respectively. Meniscal ossicles in adolescents are rare but need to be considered when intra-articular calcification is present on radiographs.

Prevalence of Articular Surface Injuries in Patients Undergoing Meniscal Surgery: A Retrospective Analysis of 758 Cases.

Background and aim Meniscal tears are often associated with articular surface damage, which could be an important factor in the clinical outcome. However, these concomitant lesions are usually reported as binary variables. Reports of the severity/extent of the concomitant lesions and stratification by meniscal tear are scarce in the literature; in addition, sample sizes of previous reports are limited. This study aimed to characterize meniscal lesions, determine the prevalence of articular surface lesions and their severity, and correlate these lesions with meniscal injury characteristics. Methods A cross-sectional study of patients undergoing meniscal surgery between 2017 and 2023 was conducted. Patient characteristics and arthroscopic findings on the location and type of meniscal injury as well as the degree of chondral lesion (sICRS score) were recorded by the surgeon. Statistical analysis included frequency reporting for patient characteristics and study variables, including the median and interquartile range of the sICRS classification of articular surface lesions. Meniscal tear types were categorized as degenerative or non-degenerative to explore associations with chondral injury. Chi-square test and univariate and multivariate logistic regression models were employed to analyze relationships between variables. Results A total of 758 surgeries were analyzed, with a mean age of 39.56 years (SD: 12.71) and 67.90% male participants. Medial meniscus injuries accounted for 57.52%, lateral meniscus 36.02%, and both menisci 6.64%. Significant differences were found in vascular area, topography, and lesion type between isolated medial and lateral meniscus lesions (p<0.01). Chondral lesions were present in 35.22% of cases, with significant differences among meniscal injury types (p<0.01). Degenerative tears showed higher rates of chondral damage compared to non-degenerative tears, particularly in lateral meniscus injuries (p<0.01). Regression analysis identified age, gender, meniscal injury characteristics, and meniscectomy percentage as risk factors for articular surface injuries. Conclusion Articular surface injuries frequently accompany meniscal lesions, with associations between affected menisci and articular damage extent. Femoral condyles show greater involvement corresponding to compartment-specific meniscal lesions, unlike tibial plateaus. Meniscal degeneration is present in about half of articular cartilage injury cases. Some meniscal tear types may relate to more severe articular lesions, but larger studies are needed to confirm these findings and explore other tear patterns.

Recurrent ganglion cyst in the anterolateral portal following knee arthroscopy.

Ganglion cysts (GC) are an uncommon complication following arthroscopic knee surgery. Due to high rates of recurrence following GC resection, many symptomatic patients can experience pain and discomfort for years. The presence of a GC at the site of an arthroscopic knee portal has only been reported once before in the literature. This case report details the history, physical and treatment of an active-duty soldier who had undergone various aspirations and surgical resections with limited improvement until the most recent operative intervention. At 18 months postoperatively, the patient had not experienced recurrence and had returned to all activities. We believe this surgical technique yielded resolution of the GC because following resection, the joint was checked to exclude areas of fluid extravasation, the capsule closure was performed with non-absorbable barbed suture and the operative extremity was immobilised in extension for 2 weeks to promote soft tissue rest and healing.