Meniscal Injuries: Mechanism and Classification.

Meniscal tears may be managed through conservative physical therapy and nonsteroidal anti-inflammatory medications or operative intervention. Meniscal repair is superior to partial meniscectomy with better functional outcomes and less severe degenerative changes over time. Surgical advances in operative techniques, modern instrumentation and biological enhancements collectively improve healing rates of meniscal repair. However, failed repair is not without consequences and can negative impact patient outcomes. Therefore, it is imperative for surgeons to have a thorough understanding of the vascular zones and biomechanical classifications of meniscal tears in order to best determine the most appropriate treatment.

Is there a good agreement between MRI readers for Thaunat's classification in arthroscopically-proven meniscal ramp lesions?

OBJECTIVE: To describe and evaluate the reproducibility by MRI of an arthroscopically-based classification for meniscal ramp lesions. We hypothesize that MRI would present good interobserver and intraobserver reliability to evaluate meniscal ramp lesions. MATERIALS AND METHODS: Twenty MRI of the knee with arthroscopically-proven meniscal ramp lesions were independently assessed by two skilled musculoskeletal radiologists and a third-year radiology resident. Reading was performed in a randomized and anonymous manner, in two steps, with a minimum of 1-month interval between each. Cohen's kappa coefficient statistic was used to analyze intra and interobserver reading agreement. Associate findings were also categorized. RESULTS: From 20 subjects, 17 were male, with mean age of 35 years. MRI reading showed type IV ramp lesion as most prevalent with eight cases (37%), followed by type V - four (21%), type I - four (20%), type III - three, (16%) and type II - one (6%). Regarding ramp lesion types, intraobserver agreement was substantial for both skilled readers (Kappa = 0.72), and moderate for the less experienced reader (Kappa = 0.51); interobserver agreement was moderate. Results between most experienced readers were also analyzed in two categories: stable (types I and II) and unstable (types III, IV and V), also resulting in moderate agreement (Kappa = 0.54). Intraobserver agreement was substantial for both readers (Kappa = 0.68). The most common associate findings were joint effusion (85%), posteromedial capsular structures injury (60%), and medial meniscus extrusion (60%). CONCLUSION: The arthroscopy classification for meniscal ramp lesions stability adapted for MRI has good reproducibility when applied by trained musculoskeletal radiologists.

Knee Meniscus Segmentation and Tear Detection from MRI: A Review.

BACKGROUND: Automatic diagnostic systems in medical imaging provide useful information to support radiologists and other relevant experts. The systems that help radiologists in their analysis and diagnosis appear to be increasing. DISCUSSION: Knee joints are intensively studied structures, as well. In this review, studies that automatically segment meniscal structures from the knee joint MR images and detect tears have been investigated. Some of the studies in the literature merely perform meniscus segmentation, while others include classification procedures that detect both meniscus segmentation and anomalies on menisci. The studies performed on the meniscus were categorized according to the methods they used. The methods used and the results obtained from such studies were analyzed along with their drawbacks, and the aspects to be developed were also emphasized. CONCLUSION: The work that has been done in this area can effectively support the decisions that will be made by radiology and orthopedics specialists. Furthermore, these operations, which were performed manually on MR images, can be performed in a shorter time with the help of computeraided systems, which enables early diagnosis and treatment.

Reliability of meniscus tear description: a study using MRI from the Osteoarthritis Initiative.

Despite being one of the most common indications for surgery, data on the types of meniscus tear that should be treated surgically are limited. Improving patient selection requires agreement on meniscus tear description. This study evaluates a simple MRI tear classification system for inter-observer agreement. Knee MRI examinations from 57 subjects from the Osteoarthritis Initiative cohort were reviewed by two sub-specialty trained, musculoskeletal radiologists. Based on two pulse sequences, each meniscus was classified by: tear or no tear; location of tear in anterior, middle or posterior third or multiple thirds; and displaced or non-displaced radial, horizontal, longitudinal or complex tear pattern. A tear was defined as signal abnormality extending to the surface on at least two images and displacement as more than 2 mm of extrusion or separation measured orthogonal to the tear plane. Kappa, weighted Kappa and percentage agreement were calculated. For the medial meniscus, Kappa and percentage agreement estimates were, respectively: the presence of tear, 0.79 and 89.5%; tear with displacement, 0.70 (weighted Kappa) and 66.0%; tear description, 0.47 and 61.4%; tear location, 0.64 and 79.0%. For the lateral meniscus, estimates were: the presence of tear, 0.75 and 89.5%; tear with displacement, 0.81 (weighted Kappa) and 86.0%; tear description, 0.56 and 78.9%; tear location, 0.74 and 87.7%. The strength of agreement between readers was moderate to substantial underscoring the challenge of meniscus tear classification.

Ramp Lesions: An Unrecognized Posteromedial Instability?

Meniscal ramp lesions occur much more frequently than was previously considered, and particularly so in ACL-injured knees. The historically high rate of missed diagnoses is a result of unfamiliarity with this injury pattern within the orthopedic community, and also the difficulty in diagnosis. A systematic exploration of the posteromedial compartment of the knee is mandatory to reliably identify ramp lesions. Failure to recognize and repair these injuries is associated with persistent anterior and posteromedial instability. Understanding their nature, biomechanics, and epidemiology is essential in allowing orthopedic surgeons to suspect their presence and adequately treat these lesions.

Medial meniscus posterior root repair decreases posteromedial extrusion of the medial meniscus during knee flexion.

BACKGROUND: Medial meniscus (MM) medial extrusion in the coronal plane does not always improve, even after repair. This study aimed to determine the extent of posteromedial extrusion of the MM during knee flexion before and after MM pullout repair using three-dimensional magnetic resonance imaging (MRI). METHODS: Data from 14 patients (mean age, 63.4 years; 86% female) who had undergone MM pullout repair at the current institution between August 2017 and October 2018 were retrospectively reviewed. The MRIs were performed pre-operatively and ≥3 months postoperatively. Three-dimensional MRIs of the tibial surface and MM were evaluated using Tsukada's measurement method before and after pullout repair. The expected center of MM posterior root attachment (point A), the point on the extruded edge of the MM farthest away from point A (point E), and the point of intersection of a line through the posteromedial corner of the medial tibial plateau and a line connecting points A and E (point I) were identified. Subsequently, the pre-operative and postoperative AE and IE distances were calculated and compared. RESULTS: Point E was laterally shifted by the pullout repair, whereas point I showed no significant change. The postoperative IE distance (6.7 mm) was significantly shorter than the pre-operative one (9.1 mm, P < 0.01). The postoperative AE distance (29.3 mm) was significantly shorter than the pre-operative one (31.5 mm, P < 0.01). CONCLUSIONS: The AE and IE distances significantly decreased after MM posterior root repair, suggesting that transtibial pullout repair may be useful in reducing posteromedial extrusion of the MM.

Reparación transtibial de la raíz posterior del menisco lateral en lesiones agudas: técnica quirúrgica y seguimiento clínico a corto plazo / Transtibial repair of posterior root of the lateral meniscus in acute lesions: surgical technique and short-term clinical follow-up

Introducción Las lesiones de la raíz posterior del menisco lateral (RPML) afectan la transferencia de la carga axial de la rodilla, lo cual genera una sobrecarga con el posterior deterioro del cartílago articular. Se han descrito numerosas técnicas quirúrgicas en la literatura para su tratamiento, pero aún no se ha demostrado superioridad de alguna, por ende, existen controversias sobre cual técnica es la más indicada para estas lesiones. El objetivo del estudio es describir la técnica quirúrgica y la evolución clínica de pacientes intervenidos con fijación transtibial de la RPML en una clínica especializada, durante el periodo 2016-2017. Materiales & Métodos Se realizó una descripción de la técnica quirúrgica y una serie de casos retrospectiva. Se incluyeron pacientes con lesiones agudas en la RPML, los cuales fueron intervenidos quirúrgicamente utilizando una nueva variación a técnica transtibial. Para determinar la evolución cínica de los pacientes se realizaron las escalas Lysholm e IKDC, antes y después de la cirugía. Resultados Se intervinieron seis pacientes con lesión aguda de la RPML, cuatro de sexo masculino. El tiempo entre el trauma y la cirugía fue en promedio 2,5 meses. Todos los pacientes presentaron lesión concomitante de ligamento cruzado anterior. Al comparar el estado inicial de los pacientes y el postoperatorio mediante las escalas de Lysholm e IKDC, se encontraron diferencias estadísticamente significativas (p<0,05). Asimismo, no se realizaron reintervenciones durante el seguimiento. Discusión La reparación de la RPML con la nueva variación de la fijación transtibial proporciona una mejoría en la función, el dolor y el nivel de actividad de los pacientes, lo que puede ayudar a retrasar la progresión de la osteoartrosis en la rodilla. Igualmente, este procedimiento se puede realizar de forma segura aún en casos de lesiones ligamentarías concomitantes. Nivel de evidencia: IV

Background injuries of posterior lateral meniscus root (PLMR) affect the transfer of the axial load of the knee. Several surgical techniques have been described for it treatment, but still none has demonstrated superiority. Consequently, there are controversies about which technique is most indicated for these injuries. The aim is to describe the a surgical technique and the clinical follow up of patients operated with transtibial fixation of PLMR in a specialized clinic, during the 2016-2017. Methods Retrospective case series and description of the surgical technique. We included patients with acute injuries in the PLMR, who were operated using a new variation to the transtibial technique. For the clinical follow-up, the IKDC and Lysholm scores were performed before and after surgery. Results Six patients with acute lesion in the PLMR were intervened, four were male. The time between trauma and surgery was on average 2.5 months. All the patients presented a concomitant lesion of the anterior cruciate ligament. When comparing the initial state of the patients and the postoperative period, statistically significant differences were found (p <0.05). Likewise, reinterventions were not performed during follow-up. Discussion The repair of PLMR with the new variation of the transtibial fixation provides an improvement in the function, the pain and the level of activity of the patients, which can help to delay the progression of osteoarthrosis in the knee. Likewise, this technique can be performed safely even in cases of concomitant ligament injuries. Level of clinical evidence: Level IV

Subchondral insufficiency fracture of the knee: grading, risk factors, and outcome.

OBJECTIVE: To propose an magnetic resonance imaging (MRI) grading system for subchondral insufficiency fracture of the knee (SIFK) to predict outcome and assess risk factors. MATERIALS AND METHODS: A total of 50 SIFK patients were retrospectively reviewed utilizing two MRI examinations approximately a year apart and compared them with 51 control subjects. A grading system was introduced that classifies lesions as low- vs high-grade. Lesion location 3D dimensions, extent of bone marrow edema (BME), location of meniscal tears and associated extrusion, degree of chondrosis and among other parameters were stratified according to lesion grade and compared with follow-up examinations. Statistical analyses were performed (Pearson's correlation, binary logistic regression, and Chi-squared analysis). RESULTS: The majority of SIFK lesions were low-grade (LG; 78%) and most of them (70%) were observed in the medial femoral condyle. Predictor variables comparing low-grade and high-grade SIFK lesions included meniscal tear (p = 0.01), degree of extrusion (p < 0.003), chondrosis (p = 0.01), medial chondrosis grade (p = 0.001), medial femoral condyle (p = 0.01), surface collapse (p < 0.0001), marrow edema improvement (p < 0.0001), first MRI anteroposterior dimension (p = 0.001), transverse dimension (p < 0.001), and ellipsoid volume (p = 0.02). Predictor variables found to be significantly different between controls and patients were meniscal tear (p = 0.024), location of the medial meniscal tear (p < 0.0001), degree of extrusion (p < 0.0001), chondrosis (p < 0.0001), joint effusion (p < 0.0001), Baker's cyst (p < 0.0001), knee lock (p = 0.03) and buckle (p = 0.01), and history of trauma (p = 0.01). CONCLUSION: A SIFK grading system for MRI is introduced. Surrogate markers of high-grade lesions include medial meniscus posterior root tears with associated moderate to severe extrusion, high-grade chondrosis, larger lesion sizes (anteroposterior/transverse), and articular surface collapse. Improvement of BME on follow-up was highly predictive of low-grade disease.

The International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine classification of knee meniscus tears: three-dimensional MRI and arthroscopy correlation.

OBJECTIVES: To introduce MRI-based International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) classification system of meniscal tears and correlate it to the surgical findings from arthroscopy. We hypothesized that the ISAKOS classification will provide good inter-modality and inter-rater reliability for use in the routine clinical practice of radiologists and orthopedic surgeons. METHODS: In this HIPAA-compliant cross-sectional study, there were 44 meniscus tears in 39 patients (26 males, 16 females). Consecutive arthroscopy-proven meniscal tears (March 2017 to December 2017) were evaluated by two board-certified musculoskeletal radiologists using isotropic three-dimensional (3D) MRI user-defined reconstructions. The surgically validated ISAKOS classification of meniscal tears was used to describe medial meniscus (MM) and lateral meniscus (LM) tears. Prevalence-adjusted bias-adjusted kappa (PABAK) and conventional kappa, and paired t test and intra-class correlation coefficient (ICC) were calculated for categorical and numerical variables, respectively. RESULTS: For the MM, the PABAK for location, depth, length (ICC), pattern, quality of meniscus tissue, and zone was 0.7-1, 0.65, 0.57, 0.67, 0.78, and 0.39-0.7, respectively. For the LM, the PABAK for location, depth, length (ICC), pattern, quality of meniscus tissue, zone, and central to popliteus hiatus was 0.57-0.95, 0.57, 0.74, 0.93, 0.38, 0.52-0.67, and 0.48, respectively. The mean tear lengths were larger on MRI than on arthroscopy (mean difference MM 9.74 mm (6.66 mm, 12.81 mm; p < 0.001), mean difference LM 4.04 mm (0.31 mm, 7.76 mm; p = 0.034)). CONCLUSIONS: The ISAKOS classification of meniscal tears on 3D MRI provides mostly moderate agreement, which was similar to the agreement at arthroscopy. KEY POINTS: • There is a fair to good inter-method correlation in most categories of ISAKOS meniscus tear classification. • The tear lengths are significantly larger on MRI than on arthroscopy. • The inter-reader correlation on 3D MRI is moderate to excellent, with the exception of lateral meniscus tear patterns.

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

PURPOSE: To analyze the influence of meniscal tear pattern on clinical outcomes following arthroscopic partial meniscectomy in middle-aged patients with medial meniscal tears. METHODS: A total of 123 patients (130 knees) aged ≥ 50 years 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 2.1-8.0 years). 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 1 month postoperatively and at the final follow-up. Demographic variables, KL grade, type of meniscal tear, and postoperative follow-up period were evaluated. RESULTS: 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. CONCLUSIONS: 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. LEVEL OF EVIDENCE: Case-control study, Level III.

Biomechanics and Clinical Outcomes of Partial Meniscectomy.

Partial meniscectomy for meniscus tears is one of the most common procedures performed by orthopaedic surgeons. Much research has been done to evaluate the biomechanical consequences and clinical outcomes from meniscus débridement. Biomechanically, as the portion of the meniscus that is removed increases, greater contact pressures are experienced by the cartilage, which leads to altered knee mechanics. The use of partial meniscectomy to manage degenerative meniscus tears in knees with mild preexisting arthritis and mechanical symptoms may be beneficial; however, its routine use in the degenerative knee over physical therapy alone is not supported. In younger populations, partial meniscectomy may provide equal long-term symptom relief, earlier return to play, and lower revision surgery rate compared with meniscal repair. Partial meniscectomy may result in earlier development of osteoarthritis. Treatment should be patient specific in a shared-decision making process with the patient after discussion about known outcomes.

Low Accuracy of Diagnostic Codes to Identify Anterior Cruciate Ligament Tear in Orthopaedic Database Research.

BACKGROUND: Database research is being used in orthopaedic literature with increased regularity. The main limitation of database research is the absence of diagnosis and treatment verification afforded by medical chart review. This absence may limit the accuracy of some conclusions and recommendations produced by database research. Hypothesis/Purpose: The purpose was to describe the accuracy of 1 database (Rochester Epidemiology Project) used in orthopaedic research to detect isolated anterior cruciate ligament (ACL) tears and to discuss the limitations of database research. It was hypothesized that diagnostic codes alone are unlikely to be accurate in identifying patients with ACL tears. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: A population-based historical cohort study was performed with the Rochester Epidemiology Project database. All subjects had International Classification of Diseases, Ninth Revision, diagnosis codes consistent with ACL tears between January 1, 1990, and December 31, 2010. The medical records of all subjects were reviewed in detail to confirm the accuracy of diagnosis and gather data on injury type, laterality, associated meniscal injuries, magnetic resonance imaging findings, and treatment details. RESULTS: A total of 3494 patients had codes consistent with ACL tears, and 2288 of them were confirmed through chart review to have an isolated ACL tear (65.5%). Among these were 1841 patients (52.7%) with an ACL tear within 1 year of injury and an additional 447 (12.8%) with an ACL tear >1 year from injury. Thirty-nine patients (1.1%) had a partial ACL tear diagnosed on magnetic resonance imaging, 48 (1.4%) had an isolated posterior cruciate ligament tear, and 22 (0.6%) had a combined ACL-posterior cruciate ligament injury. Twenty-four patients (0.7%) had ACL reconstruction before the study period. The remaining 1073 patients (30.7%) had diagnostic codes consistent with an ACL tear but did not have a cruciate ligament injury. CONCLUSION: This study demonstrates low accuracy with the use of diagnostic codes alone to identify an ACL tear. Database studies offer unique benefits to the medical literature, but the inherent limitations should be taken into account when these data are used to counsel patients, dictate clinical management, or make health care policy decisions. Information from a health care database is most accurate when accompanied by verification of diagnosis, treatment, and outcomes with medical chart review.

The Sensitivity and Specificity of Preoperative History, Physical Examination, and Magnetic Resonance Imaging to Predict Articular Cartilage Injuries in Symptomatic Discoid Lateral Meniscus.

BACKGROUND: Discoid lateral meniscus (DLM) is a morphologic variant in which concomitant articular cartilage defects lead to poor outcomes. The purpose of this study was to quantify the prognostic ability of history, physical examination, and magnetic resonance imaging (MRI) to identify arthroscopically confirmed articular cartilage injury in pediatric and adolescent DLM patients. METHODS: An analysis of 34 consecutive patients (mean, 12.5 y) who underwent surgical treatment for DLM. Patients were grouped based on arthroscopic findings for the presence or absence of articular cartilage injury. All patients underwent standard preoperative history and physical examination, and MRI of their symptomatic knee. Separate discriminant functional analyses were performed using history (age, sex, symptoms lasting >6 mo, traumatic history), physical examination (presence of clunk, extension block, mechanical symptoms), and MRI findings (chondral injury, meniscal degeneration, meniscal morphology) to determine their sensitivity and specificity in prediction of articular cartilage lesions. RESULTS: The sensitivity and specificity of history alone was 71.4% and 75.0%, respectively; physical examination alone was 64.3% and 60%, respectively; and of MRI findings alone was 60% and 66.7%, respectively. A stepwise discriminant functional analysis found that duration of symptoms and extension block were the optimal contributors with a 78.5% sensitivity and 80% specificity. CONCLUSIONS: Preoperative history had the highest sensitivity and specificity compared with physical examination and MRI findings for predicting articular cartilage injury at the time of DLM surgery. These findings may assist in setting expectations for patients with regard to surgical planning and recovery and also to counsel patients with asymptomatic, incidental DLM which factors may risk chondral injury and warrant early return for evaluation. LEVEL OF EVIDENCE: Level II-retrospective prognostic comparative study.

National consensus on the definition, investigation, and classification of meniscal lesions of the knee.

BACKGROUND: The aim of this study was to deliver standardised terminology for the identification and stratification of patients with meniscal lesions of the knee. METHODS: A national group of expert surgeons was convened by the British Association for Surgery of the Knee (BASK) and a formal consensus process was undertaken following a validated methodology. A combination of nominal group techniques and an iterative Delphi process was used to develop and refine relevant definitions. Where appropriate, definitions were placed into categories to facilitate use in clinical practice and guideline development. RESULTS: A degenerative meniscus develops progressively with degradation of meniscal tissue and this may be revealed by intra-meniscal high signal on magnetic resonance imaging (MRI). A meniscal tear was defined as a defect or split in the meniscocapsular complex, which can occur in a degenerative or non-degenerative meniscus. Degenerative meniscal lesions (high signal or tear) are frequent in the general population and are often incidental findings on knee MRI. Symptoms were defined and classified into three groups: (1) strongly suggestive of a treatable meniscal lesion, (2) potentially suggestive of a treatable meniscal lesion, (3) osteoarthritic. A strategy for radiological imaging (radiograph ±â€¯MRI) was agreed for the investigation of the patients with a possible meniscal tear. Meniscal lesions and tear patterns on MRI imaging were defined and classified with reference to potential treatability: (1) target, (2) possible target, (3) no target. CONCLUSIONS: The agreed terminology will enable patients with meniscal lesions to be identified and stratified consistently in clinical practice, research and guideline development.

Knee Pain and Mobility Impairments: Meniscal and Articular Cartilage Lesions Revision 2018: Using the Evidence to Guide Physical Therapist Practice.

Meniscus and articular cartilage lesions are common knee injuries. The resulting knee pain and mobility impairments can be improved by physical therapists during nonoperative and operative management. Recommendations from clinical practice guidelines (CPGs) such as this revision, titled "Knee Pain and Mobility Impairments: Meniscal and Articular Cartilage Lesions," published in the February 2018 issue of JOSPT, can help physical therapists engage in evidence-informed practice and reduce unnecessary clinical variation. J Orthop Sports Phys Ther 2018;48(2):123-124. doi:10.2519/jospt.2018.0503.

[Ramp lesions : Tips and tricks in diagnostics and therapy]. / Rampenläsionen : Tipps und Tricks in Diagnostik und Therapie.

There is an increasing biomechanical and anatomical understanding of the different types of meniscal lesions. Lesions of the posterior part of the medial meniscus in the meniscosynovial area have recently received increased attention. They generally occur in association with anterior cruciate ligament (ACL) injuries. They are often missed ("hidden lesions") due to the fact that they cannot be seen by routine anterior arthroscopic inspection. Furthermore, meniscosynovial lesions play a role in anteroposterior knee laxity and, as such, they may be a cause of failure of ACL reconstruction or of postoperative persistent laxity. Little information is available regarding their cause with respect to injury mechanism, natural history, biomechanical implications, healing potential and treatment options. This article presents an overview of the currently available knowledge of these ramp lesions, their possible pathomechanism, classification, biomechanical relevance as well as repair techniques.

Complete posterolateral meniscal root tear is associated with high-grade pivot-shift phenomenon in noncontact anterior cruciate ligament injuries.

PURPOSE: The purpose of this study was to investigate whether the complete posterolateral meniscal root tear (PLMRT) would be associated with high-grade pivot-shift phenomenon in noncontact anterior cruciate ligament (ACL) injuries. METHODS: From 2013 to 2015, a total of 1095 consecutive patients were diagnosed as having noncontact ACL injuries and underwent primary ACL reconstructions. Among them, 140 patients were arthroscopically verified to have concomitant PLMRTs. Application of the exclusion criteria finally left 74 patients who were finally allocated into high-grade pivot-shift (grades II and III) group (n = 51) and low-grade pivot-shift (grades 0 and I) group (n = 23) according to the results of pre-operative pivot-shift tests performed under anesthesia. Predictors of high-grade pivot-shift phenomenon, including degree of PLMRTs, integrity of posterior MFLs, status of lateral meniscal extrusion, age, sex, body mass index (BMI), and KT-1000 arthrometer side-to-side difference (SSD), were assessed by multivariable logistic regression analysis. RESULTS: The proportion of patients with complete PLMRT in high-grade pivot-shift group was significantly larger than that in low-grade pivot-shift group. In addition, complete PLMRT was significantly [odds ratio (OR) 4.044; 95% CI 1.125-14.534; P = 0.032] associated with high-grade pivot-shift phenomenon in noncontact ACL injury, especially for those with a time from injury to surgery of ≥12 weeks (OR 16.593; 95% CI 1.073-56.695; P = 0.014). However, no significant association was identified between neither the integrity of posterior MFLs nor the status of lateral meniscal extrusion and the high-grade pivot-shift phenomenon. CONCLUSION: Complete PLMRT is identified to be an independent risk factor of high-grade pivot-shift phenomenon in noncontact ACL injuries, particularly for those with a time from injury to surgery of ≥12 weeks. LEVEL OF EVIDENCE: IV.

Repair of Meniscal Ramp Lesions Through a Posteromedial Portal During Anterior Cruciate Ligament Reconstruction: Outcome Study With a Minimum 2-Year Follow-up.

PURPOSE: To evaluate the results of arthroscopic all-inside suture repair of medial meniscal ramp lesions through a posteromedial portal during anterior cruciate ligament (ACL) reconstruction. METHODS: All patients who underwent a suture of the posterior segment of the medial meniscus using a suture hook device through a posteromedial portal during ACL reconstruction with minimum 2 year-follow-up were included in the study. Repair was performed for longitudinal tears within the rim of less than 3 mm (capsulomeniscal junction or red-red zone) or 3 to 5 mm (red-white zone) of an unstable torn meniscus. Patients were assessed pre- and postoperatively with IKDC score and Tegner activity scale. Instrumented knee testing was performed with the Rolimeter arthrometer. Complications including reoperation for failed meniscal repair were also recorded. RESULTS: One hundred thirty-two patients met the inclusion criteria. The mean follow-up time was 27 months (range, 24 to 29 months). The average subjective IKDC rose from 63.8 ± 13.5 (range, 27 to 92) preoperatively to 85.7 ± 12 (range, 43 to 100) at last follow-up (P < .0001). The Rolimeter test decreased from a side-to-side difference in anterior knee laxity of 7 mm (range, 5 to 14 mm) to a mean value of 0.4 mm (range, -3 to 5 mm) at last follow-up (P < .0001). The Tegner activity scale at the last follow-up (6.9 ± 1.72) was slightly lower than that before surgery (7.2 ± 1.92; P = .0017). Nine patients (6.8%) had failure of the meniscal repair. In 5 cases, recurrent tears were related to a newly formed tear located anterior to the initial tear. CONCLUSIONS: Our results show that arthroscopic meniscal repair of ramp lesions during ACL reconstruction through a posteromedial portal provided a high rate of meniscus healing at the level of the tear and appeared to be safe and effective in this group of patients. LEVEL OF EVIDENCE: Level IV, therapeutic study, case series (no control group).