Do meniscal repairs with meniscus cyst do better than meniscectomy?-a systematic review of meniscal cyst treatment.

Background: This systematic review aims to determine the best modality for the management of meniscal cysts and its associated meniscus tear; whether the meniscal cyst treated via arthroscopy or open methods and whether meniscal debridement or repair achieves better results. Methods: This systematic review was performed using PRISMA guidelines. A literature search of PubMed, EMBASE and Cochrane was carried out in July 2020 using the search terms 'meniscal cyst' and 'treatment'. All clinic studies that included filters for papers in the last 20 years, English language, and meniscal cysts found in humans were included. Studies that contained case reports, were in any language other than English, and with subjects that were not humans were excluded. The methodology quality assessment was performed through the modified Coleman methodology score (CMS). Results: A total of 166 results were obtained from PubMed, Cochrane library and EMBASE. Of them, 12 duplicates were identified across the databases and removed from consideration. Six papers were found relevant from EMBASE in which 1 was eventually included in this paper. In total, 12 papers were used in this study. The weighted mean age of the patients was 35.1 years, with total of 523 meniscal cysts, of which 488 of these cysts are associated with meniscal tears (93.31%). The studies included performed cystectomies and/or decompression of meniscal cysts while some left the meniscal cyst alone and dealt with the meniscal lesion instead. All clinical scores showed significant improvement following surgical procedures. Conclusions: Both arthroscopic and open methods can be used for meniscal cysts treatment. Open cystectomy rather than decompression seemed to confer lower risk of cyst recurrences and complications. It is inconclusive to whether meniscal repair or meniscus debridement influenced recurrence and outcome scores. A recommendation for meniscus repair cannot be made due to insufficient high-quality level I or II trials.

MPFL reconstruction corrects patella alta: a cohort study.

PURPOSE: Patella alta is an established risk factor for recurrent lateral patella dislocations. Medial patellofemoral ligament (MPFL) reconstruction has been shown to reduce patella height. Our hypothesis is that isolated MPFL reconstruction corrects patella alta, thereby reducing the risk of recurrent patella dislocation. METHODS: A prospective cohort study of 33 knees which underwent MPFL reconstruction for recurrent patella dislocation. The pre-operative and post-operative patella height and Kujala knee outcome scores, as well as tibial tuberosity-trochlear groove (TT-TG) distance, and the grade of trochlear dysplasia were recorded. RESULTS: The mean age was 21.5 years (16-34 years). There was significant reduction in patella height in all patients (p < 0.001), a 67% normalisation of patella alta (CD ≥ 1.2) (p < 0.004), and improvement in the Kujala scores 57.1 (pre-operatively) to 94.8 (post-operatively, p < 0.0001). The recurrent dislocation rate was 3%. CONCLUSION: MPFL reconstruction alone results in correction in patella alta and improvement in clinical outcomes.

Timing of magnetic resonance imaging affects the accuracy and interobserver agreement of anterolateral ligament tears detection in anterior cruciate ligament deficient knees.

PURPOSE: We aimed to identify the anterolateral ligament (ALL) tears in anterior cruciate ligament (ACL)-deficient knees using standard 1.5-Tesla magnetic resonance imaging (MRI). METHODS: We included all patients who underwent primary ACL reconstruction at our center between 2012 and 2015. Exclusion criteria included patients with multiple ligament injuries, lateral collateral ligament, posterolateral corner, and infections, and patients who underwent MRI more than 2 months after their injury. All patients (n = 148) had ACL tears that were subsequently arthroscopically reconstructed. The magnetic resonance (MR) images of the injured knees performed within 2 months of injury were reviewed by a musculoskeletal radiologist and an orthopedic surgeon. The patients were divided into two groups. The first group of patients had MRI performed within 1 month of injury. The second group of patients had MRI performed 1-2 months after the index injury. Both assessors were blinded and the MR mages were read separately to assess the presence of ALL, presence of a tear and the location of the tear. Based on their readings, interobserver agreement (kappa statistic (K)), sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were compared. RESULTS: The ALL was identified in 100% of the patients. However, there was a discrepancy of up to 15% in the identification of tear of the ALL. In the first group in which MRI scans were performed within 1 month of injury, the ALL tear was identified by the radiologist in 92% of patients and by the surgeon in 90% of patients (Κ = 0.86). In the second group in which MRI scans were performed within 1-2 months of the injury, the ALL tear was identified by the radiologist in 78% of patients and by the surgeon in 93% of patients (K = 0.62). CONCLUSION: The ALL can be accurately identified on MRI, but the presence and location of ALL tear and its location cannot be reliably identified on MRI. The accuracy in identification and characterization of a tear was affected by the interval between the time of injury and the time when the MRI was performed. LEVEL OF EVIDENCE: Diagnostic, level IIIb, retrospective.

Piriformis Pyomyositis Presenting as Migratory Hip to Knee Pain: A Case Report.

CASE: The authors report a case of piriformis pyomyositis in a teenage female patient with fever and left hip pain. Her pain migrated to the knee with concurrent near resolution of hip pain. Imaging revealed an abscess in the left piriformis with pus tracking along the sciatic nerve sheath. This was complicated by internal iliac vein thrombosis and an embolus to the lung. Open drainage was performed, followed by outpatient intravenous cloxacillin and oral warfarin, with complete resolution of symptoms. CONCLUSION: Piriformis pyomyositis is a rare condition with varying presentations. The threshold for suspicion should be low even in healthy young individuals.

All-Inside Lateral Meniscal Repair via Anterolateral Portal Increases Risk of Vascular Injury: A Cadaveric Study.

PURPOSE: To compare the distance from the device tip to the neurovascular structures during an all-inside medial and lateral meniscal repair using anteromedial and anterolateral portals in a fresh-frozen cadaveric study. METHODS: Ten fresh-frozen cadaveric knees were studied. The popliteal artery, popliteal vein, and tibial nerve were identified after dissection via a posterior approach. An all-inside meniscal repair device was set to a 20-mm depth limit and inserted into a fixed point in the posterior horn at the meniscocapsular junction. This was performed for medial and lateral menisci via anteromedial and anterolateral arthroscopic portals. The distances between the device tip and the neurovascular structures were measured. We performed t tests to determine statistical significance. RESULTS: The distance between the device and popliteal artery was significantly closer when aimed at the posterior horn of the lateral meniscus via the anterolateral portal (4.7 ± 2.3 mm) versus the anteromedial portal (13.0 ± 8.0 mm, P = .010). The distance to the popliteal vein was closer via the anterolateral portal (6.7 ± 2.9 mm) versus the anteromedial portal (13.9 ± 5.8 mm, P = .004). For medial meniscal repair, the distance to the popliteal artery was significantly closer via the anteromedial portal (12.8 ± 11.3 mm) versus the anterolateral portal (23.8 ± 7.7 mm, P = .022). The distance to the popliteal vein was closer via the anteromedial portal (16.5 ± 11.3 mm) versus the anterolateral portal (28.3 ± 8.2 mm, P = .017). No significant difference was found in the distance to the tibial nerve when aimed at either meniscus via either portal. CONCLUSION: For all-inside meniscal repair, the popliteal vein is at risk and the popliteal artery is at high risk of injury when the posterior horn of the lateral meniscus is repaired via an anterolateral working portal. CLINICAL RELEVANCE: The popliteal artery and vein are at risk of injury when the posterior horn of the lateral meniscus undergoes all-inside repair via the anterolateral portal. Surgeons need to be aware of the risks when performing this repair.

Reliability of magnetic resonance imaging in evaluating meniscal and cartilage injuries in anterior cruciate ligament-deficient knees.

PURPOSE: The accuracy of magnetic resonance (MR) imaging in assessing meniscal and cartilage injuries in anterior cruciate ligament (ACL)-deficient knees as compared to arthroscopy was evaluated in the present study. METHODS: The results of all preoperative MR imaging performed within 3 months prior to the ACL reconstruction were compared against intraoperative arthroscopic findings. A total of 206 patients were identified. The location and type of meniscal injuries as well as the location and grade of the cartilage injuries were studied. The negative predictive value, positive predictive value, sensitivity, specificity and accuracy of MR imaging for these 206 cases were calculated and analysed. RESULTS: In patients with an ACL injury, the highest incidence of concomitant injury was that of medial meniscus tears, 124 (60.2 %), followed by lateral meniscus tears, 105 (51.0 %), and cartilage injuries, 66 (32.0 %). Twenty-three (11.2 %) patients sustained injuries to all of the previously named structures. MR imaging was most accurate in detecting medial meniscus tears (85.9 %). MR imaging for medial meniscus tears also had the highest sensitivity (88.0 %) and positive predictive value (88.7 %), while MR imaging for cartilage injuries had the largest specificity (84.1 %) and negative predictive value (87.1 %). It was least accurate in evaluating lateral meniscus tears (74.3 %). The diagnostic accuracy of medial meniscus imaging is significantly influenced by age and the presence of lateral meniscus tears, while the duration between MR imaging and surgery has greater impact on the likelihood of lateral meniscus and cartilage injuries actually being present during surgery. The majority of meniscus tears missed by MR imaging affected the posterior horn and were complex in nature. Cartilage injuries affecting the medial femoral condyle or medial patella facet were also often missed by MR imaging. CONCLUSION: MR imaging remains a reliable tool for assessing meniscus tears and cartilage defects preoperatively. It is most accurate when evaluating medial meniscus tears. However, MR imaging should be used with discretion especially if there is a high index of suspicion of lateral meniscus tears. LEVEL OF EVIDENCE: IV.