Meniscal Transplant surgery or Optimised Rehabilitation full randomised trial (MeTeOR2): a study protocol.

INTRODUCTION: Pain and disability after meniscectomy can be a substantial lifelong problem. There are few treatment options, especially for young people. Non-surgical management (rehabilitation) is an option but increasingly surgeons are performing meniscal allograft transplants (MATs) for these individuals. However, this is still an uncommon procedure, and availability and usage of MAT vary widely both in the UK and internationally. It is not known which treatment option is the most effective and cost-effective. METHODS AND ANALYSIS: The Meniscal Transplant surgery or Optimised Rehabilitation trial is an international, multicentre, randomised controlled trial. The aim is to compare the clinical and cost effectiveness of MAT versus an optimised package of individualised, progressive, rehabilitation that we have called personalised knee therapy (PKT).Participants will be recruited from sites across the UK, Australia, Canada and Belgium. The planned 144 participants provide at least 90% power to detect a 10-point difference in the Knee injury and Osteoarthritis Outcome Score (KOOS4) at 24-months post randomisation (primary outcome). A prospectively planned economic evaluation will be conducted from a healthcare system and personal social services perspective. Secondary outcome data including health utility, occupational status, sports participation, mental well-being, further treatment, and adverse events will be collected at 3, 6, 12, 18, and 24 months. Analysis will be on an intention-to-treat basis and reported in-line with the Consolidated Standards of Reporting Trials statement. ETHICS AND DISSEMINATION: The trial was approved by the London-Bloomsbury Research Ethics Committee on 19 August 2022 (22/LO/0327) and Northern Sydney Local Health District Human Research Ethics Committee, NSW, Australia on the 13 March 2023 (2022/ETH01890).Trial results will be disseminated via peer-reviewed publications, presentations at international conferences, in lay summaries and using social media as appropriate.This protocol adheres to the recommended Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) checklist. TRIAL REGISTRATION NUMBER: ISRCTN87336549.

Higher odds of meniscectomy compared with meniscus repair in a young patient population with increased neighbourhood disadvantage.

OBJECTIVES: To investigate the impact of demographic and socioeconomic factors on the management of isolated meniscus tears in young patients and to identify trends in surgical management of meniscus tears based on surgeon volume. METHODS: Data from a large healthcare system on patients aged 14-44 years who underwent isolated meniscus surgery between 2016 and 2022 were analysed. Patient demographics, socioeconomic factors and surgeon volume were recorded. Patient age was categorised as 14-29 years and 30-44 years old. Area Deprivation Index (ADI), a measure of neighbourhood disadvantage with increased ADI corresponding to more disadvantage, was grouped as <25th, 25-75th and >75th percentile. Multivariate comparisons were made between procedure groups while univariate comparisons were made between surgeon groups. RESULTS: The study included 1552 patients treated by 84 orthopaedic surgeons. Older age and higher ADI were associated with higher odds of undergoing meniscectomy. Patients of older age and with non-private insurance were more likely to undergo treatment by a lower-volume knee surgeon. Apart from the year 2022, higher-volume knee surgeons performed significantly higher rates of meniscus repair compared with lower-volume knee surgeons. When controlling for surgeon volume, higher ADI remained a significant predictor of undergoing meniscectomy over meniscus repair. CONCLUSION: Significant associations exist between patient factors and surgical choices for isolated meniscus tears in younger patients. Patients of older age and with increased neighbourhood disadvantage were more likely to undergo meniscectomy versus meniscus repair. While higher-volume knee surgeons favoured meniscus repair, a growing trend of meniscus repair rates was observed among lower-volume knee surgeons. LEVEL OF EVIDENCE: Retrospective cohort study, level III.

Editorial Commentary: Biologic Stimulation Using Marrow Venting for Meniscus Repair is Cost Effective and Recommended.

Current literature offers little guidance on the most cost-effective approach to intraoperative biologic stimulation in the setting of arthroscopic meniscus repair. Combining data from robust systematic reviews into a Markov Decision Making Model reveal the ideal strategy: Strong consideration should be given to biologic stimulation for all meniscal repairs, and the most cost effective technique is marrow stimulation.

The value of reducing arthroscopic partial meniscectomy in the treatment of degenerative meniscus tears: a budget impact analysis.

AIMS: Numerous studies have shown that arthroscopic partial meniscectomy (APM) is not (cost-) effective in patients with symptoms attributed to a degenerative meniscus tear. We aimed to assess the budget impact of reducing APM in routine clinical practice in this population. MATERIALS AND METHODS: A patient-level state transition model was developed to simulate patients recently diagnosed with a degenerative meniscus tear. Three strategies were compared: "current guideline" (i.e., postpone surgery to at least 3 months after diagnosis), "APM at any time" (i.e., APM available directly after diagnosis), and "nonsurgical" (i.e., APM no longer performed). Total societal costs over 5 years were calculated to determine the budget impact. Probabilistic and deterministic sensitivity analyses were conducted to address uncertainty. RESULTS: The average cost per patient over 5 years were EUR 5,077, EUR 4,577, and EUR 4,218, for the "APM at any time," "current guideline," and "nonsurgical" strategy, respectively. Removing APM from the treatment mix (i.e., 30,000 patients per year) in the Netherlands, resulted in a reduction in health care expenditures of EUR 54 million (95 percent confidence interval [CI] EUR 38 million-EUR 70 million) compared to the "current guideline strategy" and EUR 129 million (95 percent CI EUR 102 million-EUR 156 million) compared to the "APM at any time" strategy. Sensitivity analyses showed that uncertainty did not alter our conclusions. CONCLUSIONS: Substantial costs can be saved when APM is no longer performed to treat symptoms attributed to degenerative meniscus tears in the Netherlands. It is therefore recommended to further reduce the use of APM to treat degenerative meniscus tears.

Biomechanical assessment of disease outcome in surgical interventions for medial meniscal posterior root tears: a finite element analysis.

BACKGROUND: The adverse consequences of medial meniscus posterior root tears have become increasingly familiar to surgeons, and treatment strategies have become increasingly abundant. In this paper, the finite element gait analysis method was used to explore the differences in the biomechanical characteristics of the knee joint under different conditions. METHODS: Based on CT computed tomography and MR images, (I) an intact knee (IK) model with bone, cartilage, meniscus and main ligaments was established. Based on this model, the posterior root of the medial meniscus was resected, and (ii) the partial tear (PT) model, (iii) the entire radial tear (ERT) model, and (iv) the entire oblique tear (EOT) model were established according to the scope and degree of resection. Then, the (v) meniscus repair (MR) model and (vi) partial meniscectomy (PM) model were developed according to the operation method. The differences in stress, displacement and contact area among different models were evaluated under ISO gait loading conditions. RESULTS: Under gait loading, there was no significant difference in the maximum stress of the medial and lateral tibiofemoral joints among the six models. Compared with the medial tibiofemoral joint stress of the IK model, the stress of the PM model increased by 8.3%, while that of the MR model decreased by 18.9%; at the same time, the contact stress of the medial tibiofemoral joint of the ERT and EOT models increased by 17.9 and 25.3%, respectively. The displacement of the medial meniscus in the ERT and EOT models was significantly larger than that in the IK model (P < 0.05), and the tibial and femoral contact areas of these two models were lower than those of the IK model (P < 0.05). CONCLUSIONS: The integrity of the posterior root of the medial meniscus plays an important role in maintaining normal tibial-femoral joint contact mechanics. Partial meniscectomy is not beneficial for improving the tibial-thigh contact situation. Meniscal repair has a positive effect on restoring the normal biomechanical properties of the medial meniscus.

Treatment Trends in Meniscal Pathology in the Setting of Concomitant ACL Injuries in Pediatric and Young Adult Patients: An Insurance Database Study.

BACKGROUND: Meniscal pathology is commonly encountered in the setting of anterior cruciate ligament (ACL) rupture and is increasingly common in the pediatric and adolescent population. Studies have shown that over half of individuals presenting with ACL rupture will have concurrent meniscal pathology. PURPOSE: To define trends in the utilization of meniscal procedures (ie, meniscus repair vs partial meniscectomy) and short-term complications in pediatric and young adult patients with meniscal pathology in the setting of a concurrent ACL reconstruction. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: The IBM MarketScan Commercial Database was utilized to identify ACL reconstruction procedures performed between 2006 and 2018 for individuals aged 5 to 30 years. Annual proportions of meniscectomy and meniscal repair were analyzed, and short-term complications were compared between pediatric/adolescent patients (aged 5-17 years) and young adults (aged 18-30 years). RESULTS: An overall 40,736 records of individuals <18 years old with ACL tears were included. The pediatric/adolescent population had a significantly lower proportion of concomitant meniscal procedures (56.8%; 23,149/40,736) than the young adult population (59.7%; 33,764/56,515; P < .01). From 2006 to 2018, utilization of meniscal repair in the setting of ACL reconstruction steadily increased (20.1% to 35.1% [+15 percentage points], P < .01), while the proportion with meniscectomy decreased (34.4% to 21.3% [-13.1 percentage points], P < .01). There was no difference in rate of reoperation for repeat meniscal repair or meniscectomy in the pediatric/adolescent population for those undergoing meniscal repair versus meniscectomy within 180 days of primary surgery (1.7% [188/10,766] vs 1.5% [186/12,383]; P = .14). CONCLUSION: From 2006 to 2018, the proportion of patients receiving ACL reconstruction with concomitant meniscal repair increased (20.1% to 35.1%) while the proportion with meniscectomy decreased (34.4% to 21.3%) in the pediatric/adolescent population. Meniscal repair was not associated with a higher 180-day rate of reoperation for repeat meniscal repair or meniscectomy than meniscectomy in the setting of ACL reconstruction.

Health disparities in the management of ACL injuries: How socioeconomic status, insurance, and race influence care.

Health care disparities and racial health inequities significantly influence health care delivery and patient outcomes, including for people with injuries of the anterior cruciate ligament (ACL). This narrative review explores factors that may influence the management of ACL injuries. Studies that have discussed potential social barriers to treatment such as socioeconomic status (SES), insurance status, educational level, and cost of treatment were identified by searching databases such as EBSCO Host, PubMed, and Galileo for the index years from 2008 to 2020. The influence of health care inequities on ACL injury management was explored. Twelve studies met inclusion criteria and described a total of 219,708 participants. Barriers to surgical management of ACL injury were higher cost of surgery, greater time to evaluation and treatment, lower SES, lack of private insurance, and being identified as a racial minority. In addition, surgical environment, whether within a private or community-based health care system, and access to care affected post-surgical complication rates. Finally, risk of revision, lack of physical therapy access, and odds of additional injuries to include chondral and meniscal derangement were higher in racial minority, lower SES, and government insurance populations. These findings suggest health disparity and inequity exist in the care of ACL injury for patients with lower SES and without commercial insurance, and in minority populations. These patients appear to have a significantly reduced ability to access timely care, which can impact healing and ability to return to preferred activities of daily life or sport.

Performing a knee arthroscopy among patients with degenerative knee disease: one-third is potentially low value care.

PURPOSE: The purpose of this study was to assess in which proportion of patients with degenerative knee disease aged 50+ in whom a knee arthroscopy is performed, no valid surgical indication is reported in medical records, and to explore possible explanatory factors. METHODS: A retrospective study was conducted using administrative data from January to December 2016 in 13 orthopedic centers in the Netherlands. Medical records were selected from a random sample of 538 patients aged 50+ with degenerative knee disease in whom arthroscopy was performed, and reviewed on reported indications for the performed knee arthroscopy. Valid surgical indications were predefined based on clinical national guidelines and expert opinion (e.g., truly locked knee). A knee arthroscopy without a reported valid indication was considered potentially low value care. Multivariate logistic regression analysis was performed to assess whether age, diagnosis ("Arthrosis" versus "Meniscal lesion"), and type of care trajectory (initial or follow-up) were associated with performing a potentially low value knee arthroscopy. RESULTS: Of 26,991 patients with degenerative knee disease, 2556 (9.5%) underwent an arthroscopy in one of the participating orthopedic centers. Of 538 patients in whom an arthroscopy was performed, 65.1% had a valid indication reported in the medical record and 34.9% without a reported valid indication. From the patients without a valid indication, a joint patient-provider decision or patient request was reported as the main reason. Neither age [OR 1.013 (95% CI 0.984-1.043)], diagnosis [OR 0.998 (95% CI 0.886-1.124)] or type of care trajectory [OR 0.989 (95% CI 0.948-1.032)] were significantly associated with performing a potentially low value knee arthroscopy. CONCLUSIONS: In a random sample of knee arthroscopies performed in 13 orthopedic centers in 2016, 65% had valid indications reported in the medical records but 35% were performed without a reported valid indication and, therefore, potentially low value care. Patient and/or surgeons preference may play a large role in the decision to perform an arthroscopy without a valid indication. Therefore, interventions should be developed to increase adherence to clinical guidelines by surgeons that target invalid indications for a knee arthroscopy to improve care. LEVEL OF EVIDENCE: IV.

Bucket handle meniscus tears in low-resource settings can be successfully treated with a cost-effective technique.

PURPOSE: In regions of the world where resources can limit medical care (limited-resource settings, LRS), most meniscal tears are often treated with meniscectomy. A simple, low-cost option for meniscal repair has been developed. We sought to evaluate patient reported outcomes (PROMs) and clinical failure rates of bucket handle meniscus tears (BHTs) treated with meniscal repair in a LRS. METHODS: We prospectively enrolled patients over 18 who were treated for BHT with meniscal repair in a LRS. Meniscal repair was primarily accomplished using an outside-in technique. Pre-injury and final follow-up PROMs were recorded. Clinical failure was defined as the need for re-operation or symptoms that prevented the patient from returning to recreational activities or work responsibilities. RESULTS: Nineteen patients with a mean age of 25.4 years were eligible. Two patients sustained a clinical failure (10.5%). At mean follow-up of 40.6 months, there was significant improvement in all PROMs from baseline. Subgroup analysis revealed no significant difference in the failure group compared to the success group in number of knots used, pre-injury Tegner score, number of devices used, suture type, or technique. CONCLUSION: Bucket-handle meniscal tears can be repaired using a low-cost technique resulting in satisfactory healing rates and excellent outcomes.

Assessment of popliteal neurovascular safety during all-inside suturing of the posterior horn of the lateral meniscus using Upright MRIs of the knee joint.

BACKGROUND: To examine the risk of injury to the popliteal neurovascular bundle (pNVB) during all-inside repair of the posterior horn of the lateral meniscus (PHLM) using Upright-MRIs. METHODS: Upright-MRIs of 61 knees in extension (ext) and 90°-flexion (flex) were included. Distance D from the PHLM to the pNVB was compared between extended and 90°-flexed position, subgroups with/without joint-effusion and evaluated according to demographics. Portal safety was assessed simulating suturing of the PHLM via four arthroscopy portals. Distance d (shortest space from the simulated suturing-device trajectory lines to the pNVB) was compared among portals in increasing distances from the posterior cruciate ligament (PCL). RESULTS: D is longer in flex (17.3 ± 6.0 mm) than in ext (11.3 ± 4.2 mm, p < 0.0001). MRIs with joint-effusion displayed longer values of D than scans without joint-effusion (flex: 20.4 ± 7.1 mm vs. 16.1 ± 5.2 mm, p = 0.012). Shorter distances are associated with female gender, lower body weight and lower BMI. At 0 mm from the PCL, the 1 cm-lateral portal was the safest (p < 0.0001) whereas at 3 mm/6mm/9mm/12 mm the 1 cm-medial portal showed the longest d values (p < 0.0001 each). CONCLUSION: All-inside suturing of the PHLM is safer in 90°-flexion, in presence of intraarticular fluid and in male patients with increasing weight/BMI. Sutures of the PHLM at 0 mm from the PCL are safer from a 1 cm-lateral portal whereas for tears located ≥ 3 mm from the PCL a 1 cm-medial portal involves a lower neurovascular risk. Upright-MRI proves excellent for preoperative planning to minimize neurovascular risks.

The Epidemiology of Meniscus Injury.

Meniscus surgery is one of the most commonly performed orthopedic procedures worldwide. Modifiable risk factors for meniscus injury include body mass index, participation in athletics and occupation. Nonmodifiable risk factors include age, sex, lower extremity alignment, discoid meniscus, ligamentous laxity, and biconcave tibial plateau. Conditions commonly associated with meniscal injury are osteoarthritis, anterior cruciate ligament injury, and tibial plateau fractures. Tear type and location vary by patient age and functional status. Surgical management of meniscus injury is typically cost-effective in terms of quality-adjusted life years. The purpose of this review is to provide an overview of meniscal injury epidemiology by summarizing tear types and locations, associated conditions, and factors that increase the risk for meniscal injury. The economic burden of meniscus injury and strategies to prevent injury to the meniscus are also reviewed.

Assessment of changes in the meniscus and subchondral bone in a novel closed-joint impact and surgical reconstruction lapine model.

Despite reconstruction surgery to repair a torn anterior cruciate ligament (ACL), patients often still show signs of post-traumatic osteoarthritis (PTOA) years following the procedure. The goal of this study was to document changes in the meniscus and subchondral bone due to closed-joint impact and surgical reconstruction in a lapine model. Animals received insult to the joint followed by surgical reconstruction of the ACL and partial meniscectomy. Following euthanasia of the animals at 1, 3, and 6-months post-impact, meniscal tissue was assessed for changes in morphology, mechanical properties and proteoglycan content. Femurs and tibias were scanned via micro-computed tomography to determine changes in bone quality, morphometry, and formation of osteophytes. Both the lateral and medial menisci showed severe degradation and tearing at all-time points, with higher degree of degeneration being observed at 6-months. Decreases in both the instantaneous and equilibrium modulus were documented in both menisci. Minimal changes were found in bone quality and morphometry, with most change documented in the tibia. Bones from the reconstructed limbs showed large volumes of osteophyte formations, with an increase in volume over time. The initial changes that were representative of PTOA may have been limited to the meniscus, but at later time points consistent changes due to the disease were seen in both tissues. This study, which builds on a previous study by this laboratory, suggests that the addition of surgical reconstruction of the ACL to our model was not sufficient to prevent the development of PTOA.

[ASSESSMENT OF CLINICAL RESULTS OF SURGICAL TREATMENT OF PATIENTS WITH DEGENERATIVE MEDIAL MENISCUS ROOT TEARS].

Damage of the medial meniscus root is critical, because it leads to rapid progression of knee osteoarthritis and requires surgical treatment. Purpose - to evaluate results of surgical treatment in patients with degenerative medial meniscus root tear with 1st and 2nd K-L knee osteoarthritis. The results of treatment of 55 patients with degenerative medial meniscus root tears were evaluated. MRI and arthroscopy were used for diagnosis. Patients were divided into the main group (nо=18) and comparison group (nс=37) patients. In the comparison group, a partial meniscectomy was performed (nс=37), which consisted of the removal of the damaged posterior horn and part of the body of the medial meniscus under arthroscopic control. In the main group (nо=18) the suture of the medial meniscus root was performed under arthroscopic control. Before surgery, the score on the Lyscholm scale in patients of the main group (n=18) was 62.5±4.6 points, in the comparison group (n=37) - 63.8±4.2 points (p>0.05).One year after surgery, the score on the Lyscholm scale in patients of the main group (n=18) 88.5±6.1 points, in the comparison group (n=37) - 82,8±5,2 points (p<0.05). Two year after surgery, the score on the Lyscholm scale in patients of the main group (n=18) 87,3±4,1 points, in the comparison group (n=37) - 81,5±6,2 points (p<0.05). The suture of the medial meniscus root is the method of choice that allows to get better clinical results compared to partial meniscectomy, as well as slowdown the development of knee osteoarthritis.

Meniscus transplantation-prospective assessment of clinical results in two, five and ten year follow-up.

PURPOSE: The authors present clinical results in patients following transplantation of deep-frozen menisci within ten years following the surgery. METHODS: A cohort of 46 patients who were transplanted altogether 49 menisci was subject to prospective study following six months, two, five and ten years after meniscus transplantation. For subjective assessment, we used KOOS, IKDC and Lysholm scores; objective assessment was based on load X-ray examination of the operated knee at two, five and ten years after the surgery, MRI examination of 34 patients in the interval of two and ten years after the operation, control arthroscopy was performed in 23 patients eight of whom suffered a new injury. RESULTS: All 38 patients who have completed ten year follow-up without any new injury of the operated joint demonstrated statistically significant improvement of mobility in the period of six months and two, five and ten years following the meniscal transplantation. Further follow-up demonstrated different results in patients with a new injury and without a new injury of the operated knee joint. In eight patients (17.3%), the follow-up was disturbed by a new injury of the operated joint within three to eight years after the meniscal transplantation. In three patients with the damaged meniscal transplant, a cartilage deterioration from degree II to degree IIIa was found. In second-look arthroscopy, the patients with no injury showed signs of the improved condition of cartilage by one degree according to ICRS classification on average. The MRI imaging showed relatively frequent (47%) extrusion of the anterior and medial part of meniscus (2.5-3.8 mms) without the followed-up dynamics of changes at two and ten years after the surgery. CONCLUSION: All patients in the selected cohort proved the positive benefit of meniscus transplant when it comes to the improvement of clinical symptoms and improvement of mobility of the operated knee joint. The higher mobility following the transplantation compared to the activity prior to the surgery could have contributed to a new injury of the operated joint in 17% of the patients in the cohort.

First Clinical Application of Polyurethane Meniscal Scaffolds with Mesenchymal Stem Cells and Assessment of Cartilage Quality with T2 Mapping at 12 Months.

BACKGROUND: Complex meniscal lesions often require meniscectomy with favorable results in the short term but a high risk of early osteoarthritis subsequently. Partial meniscectomy treated with meniscal substitutes may delay articular cartilage degeneration. PURPOSE: To evaluate the status of articular cartilage by T2 mapping after meniscal substitution with polyurethane scaffolds enriched with mesenchymal stem cells (MSC) and comparison with acellular scaffolds at 12 months. METHODS: Seventeen patients (18-50 years) with past meniscectomies were enrolled in 2 groups: (1) acellular polyurethane scaffold (APS) or (2) polyurethane scaffold enriched with MSC (MPS). Patients in the MPS group received filgrastim to stimulate MSC production, and CD90+ cells were obtained and cultured in the polyurethane scaffold. The scaffolds were implanted arthroscopically into partial meniscus defects. Concomitant injuries (articular cartilage lesions or cartilage lesions) were treated during the same procedure. Changes in the quality of articular cartilage were evaluated with T2 mapping in femur and tibia at 12 months. RESULTS: In tibial T2 mapping, values for the MPS group increased slightly at 9 months but returned to initial values at 12 months (P > 0.05). In the APS group, a clear decrease from 3 months to 12 months was observed (P > 0.05). This difference tended to be significantly lower in the APS group compared with the MPS group at the final time point (P = 0.18). In the femur, a slight increase in the MPS group (47.8 ± 3.4) compared with the APS group (45.3 ± 4.9) was observed (P > 0.05). CONCLUSION: Meniscal substitution with polyurethane scaffold maintains normal T2 mapping values in adjacent cartilage at 12 months. The addition of MSC did not show any advantage in the protection of articular cartilage over acellular scaffolds (P > 0.05).

Volumetric assessment of extrusion in medial meniscus posterior root tears through semi-automatic segmentation on 3-tesla magnetic resonance images.

BACKGROUND: Many reports have described the relationship between medial meniscus posterior root tears (MMPRTs) and meniscal extrusion on coronal magnetic resonance (MR) images. However, volumetric assessment of meniscal extrusion has not been performed, and the correlation between extrusion length and volume remains unclear. HYPOTHESIS: Extrusion in both length and volume would be greater in MMPRTs than that in the normal medial meniscus, and the extrusion length measured on coronal MR images would be correlated with the extrusion volume. PATIENTS AND METHODS: A total of 20 knees who underwent isolated MMPRTs without trauma history were included in the MMPRT group, and another 20 knees with normal medial meniscus were selected as the control group. All 40 knees underwent 3-tesla MR imaging. The extrusion length of the medial meniscus was measured using coronal MR images only. Volumetric assessments of the meniscus were performed and analyzed via a semi-automatic segmentation. Group-wise comparisons of the extrusion length and volumetric values were conducted, and the correlation between the two measures in both groups was evaluated. RESULTS: The mean extrusion length of the medial meniscus in the MMPRT group was significantly longer (2.60 vs. 0.63mm; p<0.001) than that in the control group. The mean extrusion volume was also significantly higher in the MMPRT than that in the control group (770.93 vs. 193.80 mm3; p<0.001). The extrusion length was significantly and positively correlated with the extrusion volume in both groups (R=0.64; p=0.002 in MMPRT, R=0.73; p<0.001 in the control group). DISCUSSION: Semi-automatic segmentation was used to measure the volume of meniscal extrusion, which had previously only been estimated indirectly with the extrusion length on coronal MR images. MMPRTs significantly increased the extrusion in both measures. The extrusion length measured on coronal MR images was positively correlated with the extrusion volume in both groups. LEVEL OF EVIDENCE: III, Case-control study.

Comparing Meniscectomy and Meniscal Repair: A Matched Cohort Analysis Utilizing a National Insurance Database.

BACKGROUND: Meniscal repair leads to improved patient outcomes compared with meniscectomy in small case series. PURPOSE: To compare the reoperation rates, 30-day complication rates, and cost differences between meniscectomy and meniscal repair in a large insurance database. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A national insurance database was queried for patients who underwent meniscectomy (Current Procedural Terminology [CPT] code 29880 or 29881) or meniscal repair (CPT code 29882 or 29883) in the outpatient setting and who had a minimum 2-year follow-up. Patients without confirmed laterality and patients who underwent concomitant ligament reconstruction were excluded. Reoperation was defined by ipsilateral knee procedure after the index surgery. The 30-day postoperative complication rates were assessed using the International Classification of Diseases, 9th Revision, Clinical Modification codes. The cost of the procedures per patient was calculated. Propensity score matching was utilized to create matched cohorts with similar characteristics. Statistical comparisons of cohort characteristics, reoperations, postoperative complications, and payments were made. All P values were reported with significance set at P < .05. RESULTS: A total of 27,580 patients (22,064 meniscectomy and 5516 meniscal repair; mean age, 29.9 ± 15.1 years; 41.2% female) were included in this study with a mean follow-up of 45.6 ± 21.0 months. The matched groups were similar with regard to characteristics and comorbidities. There were significantly more patients who required reoperation after index meniscectomy compared with meniscal repair postoperatively (5.3% vs 2.1%; P < .001). Patients undergoing meniscectomy were also significantly more likely to undergo any ipsilateral meniscal surgery (P < .001), meniscal transplantation (P = .005), or total knee arthroplasty (P = .001) postoperatively. There was a significantly higher overall 30-day complication rate after meniscal repair (1.2%) compared with meniscectomy (0.82%; P = .011). The total day-of-surgery payments was significantly higher in the repair group compared with the meniscectomy group ($7094 vs $5423; P < .001). CONCLUSION: Meniscal repair leads to significantly lower rates of reoperation and higher rates of early complications with a higher total cost compared with meniscectomy in a large database study.

Assessment of Meniscal Healing Status by Magnetic Resonance Imaging T2 Mapping After Meniscal Repair.

BACKGROUND: Although the sensitivity and specificity of magnetic resonance imaging (MRI) for the diagnosis of primary meniscal tears are high, these values are lower for the assessment of healing status of repaired menisci. PURPOSE: To compare the accuracy of MRI T2 mapping and conventional MRI in assessing meniscal healing after repair. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: Patients who underwent meniscal repair with concurrent anterior cruciate ligament reconstruction between 2012 and 2016 and had a follow-up second-look arthroscopy were enrolled. The patients were divided into healed and incompletely/not healed groups based on the second-look arthroscopy findings. For the repaired menisci, the following were compared between the groups, (1) Stoller and Crues classification on conventional MRI with a proton density-weighted fat-saturated sequence and (2) the remaining colored meniscal tear line on T2 mapping coincident with the high signal line showing the primary tear on conventional MRI were compared. The change of T2 relaxation time (ΔT2) of the colored meniscal tear line pre- to postoperatively was compared between the groups. The mean T2 relaxation time of the whole area of the postoperative meniscus at each slice was also compared with that of control menisci to assess the whole quality of the repaired meniscus. RESULTS: A total of 26 menisci from 24 knees were assessed (16 healed menisci, 10 incompletely/not healed menisci). According to the Crues classification on conventional MRI, 8 of 16 healed menisci and 3 of 10 incompletely/not healed menisci improved from grade 3 to 2, with there being no significant difference between the groups (P = .43). However, the colored meniscal tear line remained in only 3 of the 16 healed menisci as compared with 9 of the 10 incompletely/not healed menisci, and the presence of this colored line allowed differentiation between healed menisci and incompletely/not healed menisci (sensitivity, 81.3%; specificity, 90.0%; odds ratio, 39.0; P = .001). The mean (SD) ΔT2 was -31.1 ± 3.2 and -19.9 ± 4.4 ms in the healed and incompletely/not healed groups, respectively (P < .001). Receiver operating characteristic curve analysis showed a cutoff ΔT2 value of -22.3 ms for separation of meniscal healing (P < .001). The T2 relaxation times of the whole area of the repaired menisci were 31.7 ± 3.4 and 32.8 ± 3.8 ms in the healed and incompletely/unhealed groups, respectively (P = .69), with these values being significantly longer than the 26.9 ± 2.2 ms in the controls (P < .001). CONCLUSION: MRI T2 mapping allowed the differentiation of healing status after meniscal repair, with high sensitivity and specificity as compared with conventional MRI.

Avoiding Injury to the Popliteal Neurovascular Bundle in All-Inside Suturing of the Posterior Horn of the Lateral Meniscus: A Magnetic Resonance Imaging Assessment of Portal Selection and Safety.

PURPOSE: We assessed the risk of injury to the popliteal neurovascular bundle (PNVB) while suturing the posterior horn of the lateral meniscus (PHLM). METHODS: We simulated all-inside suturing of the PHLM using magnetic resonance imaging of 60 knees. Lines were drawn from the medial and the lateral edges of the patellar tendon to the PHLM at increasing distances from the posterior cruciate ligament (PCL) to simulate suturing device trajectory. Distance from each line to the PNVB was measured (d). A similar analysis was performed using lines drawn from 1 cm medial and 1 cm lateral to the patellar tendon. We compared the average "d" at increasing distances from the PCL, between the different simulated portal entry points. We have also analyzed the association between different demographic characteristics and the shortest distance from the PVNB to the PHLM. RESULTS: Of 1200 measurements performed, the simulated suturing trajectory transected the PNVB 343 times (28.6%). At 0 mm from the PCL, the safest portal was the 1-cm lateral portal (P < .001), with an average "d" of 2.7 mm. At 3 mm, 6 mm, 9 mm, and 12 mm from the PCL, the safest portal was the 1-cm medial portal (P < .001), with average "d" of 3.8 mm, 6.9 mm, 10.1 mm, and 13.5 mm, respectively. Average distance between the PHLM and the PNVB was 7.8 mm. Shorter distance between the PHLM and the PNVB was associated with younger age and female sex (P = .014 and .001, respectively). CONCLUSIONS: All-inside suturing of the PHLM at 0 mm from the PCL is safer with a more lateral portal. Beyond 3 mm from the PCL, a more medial portal carries a lower risk to the PNVB. Young and female patients have a shorter distance between the PHLM and the PNVB, suggesting a greater risk for injury to the PNVB. Careful preoperative magnetic resonance imaging assessment may assist in safer portal selection when planning repair of the PHLM. CLINICAL RELEVANCE: This study describes a magnetic resonance imaging-based risk assessment for injury of the PVNB while suturing the PHLM. It allows the orthopaedic surgeon a better understanding of the anatomic relationship between the popliteal neurovascular bundle and the lateral meniscus and can assist in portal selection and safety.

Direct treatment cost outcomes among patients with medial meniscus deficiency: results from a 24-month surveillance study.

Objective: Meniscus deficiency is highly prevalent in the United States and represents a substantial societal cost burden. The objective of this case series was to evaluate and compare direct costs associated with treatment for acute or degenerative medial meniscus deficiency.Methods: Case series patients (n = 50) received either non-surgical therapy or an operative partial meniscectomy based on clinical assessment by the principal study investigator which included physical examination and MRI. Cumulative 24-month direct treatment costs were compared between non-surgical and operative cohorts. Direct treatment costs were calculated using billing record reimbursements for all medical services administered by the treating institution, and imputed for medical services prescribed by the treating physician but provided external to the treating institution.Results: At study initiation, 33 patients (67%) were treated with non-surgical care, and 17 patients (33%) received a partial medial meniscectomy. By 24 months, average direct treatment costs were highest for patients who received a partial medial meniscectomy at study initiation ($4488 ± $1265) compared to patients who received non-surgical care at study initiation ($4092 ± $7466), although differences in average direct treatment costs were not statistically significant across treatment cohorts (p = .830). Average direct treatment costs were highest for the subgroup of patients who initiated non-surgical therapy but received a subsequent total knee arthroplasty during the study period (n = 2; $32,197 ± $169).Conclusion: Findings from this case series suggests that patients with acute or degenerative meniscus deficiency incur substantial direct treatment costs related to their knee pathology, particularly for patients receiving total knee arthroplasty.