The October 2024 Knee Roundup. 360. looks at: Managing the unexpected: treatment of intraoperative medial collateral ligament injuries; Identifying subgroups of patients that may benefit from robotic arm-assisted total knee arthroplasty: secondary analysis of data from a randomized controlled trial; Cost-effectiveness of enoxaparin versus aspirin in the prevention of venous thromboembolism after total hip or knee arthroplasty: an analysis from the CRISTAL cluster-randomized trial; Cartilage regeneration and long-term survival in medial knee osteoarthritis patients treated with high tibial osteotomy and osteochondral autologous transfer system; Treatment of chronic and complex meniscal tears with arthroscopic meniscus repair augmented with collagen matrix wrapping: failure rate and functional outcomes; Long-term outcomes of multiligament knee injuries in American football players

Meniscal tears commonly co-occur with ACL tears, and many studies address their side, pattern, and distribution. Few studies assess the patient's short-term functional outcome concerning tear radial and circumferential distribution based on the Cooper et al. classification. Meniscal tears require primary adequate treatment to restore knee function. Our hypothesis is to preserve the meniscal rim as much as possible to maintain the load-bearing capacity of the menisci after meniscectomy. The purpose of this study is to document the location and type of meniscal tears that accompany anterior cruciate ligament (ACL) tears and their effect on patient functional outcomes following arthroscopic ACL reconstruction and meniscectomy. This prospective cross-sectional observational study was conducted at AL-BASRA Teaching Hospital in Iraq between July 2018 and January 2020 among patients with combined ipsilateral ACL injury and meniscal tears. A total of 28 active young male patients, aged 18 to 42 years, were included. All patients were subjected to our questionnaire, full history, systemic and regional examination, laboratory investigations, imaging studies, preoperative rehabilitation, and were followed by Lysholm score 6 months postoperatively. All 28 patients were males, with a mean age of 27 ± 0.14 years. The right knee was the most commonly affected in 20/28 patients (71.4%). The medial meniscus was most commonly injured in 11 patients, 7 patients had lateral meniscal tears, and 10 patients had tears in both menisci. The most common tear pattern of the medial meniscus was a bucket handle tear (36.4%), while longitudinal tears were the most frequent in the lateral meniscus (71.4%) (P-value = 0.04). The most common radial tear location was zone E-F (5/28, 17.8%), and the most common circumferential zone affected was the middle and inner third, reported in 50% of tears. Good and excellent outcomes using the Lysholm score after 6 months were obtained in 42.9% and 17.9% of patients, respectively. Better functional scores were associated with lateral meniscal tears, bucket handle tears, tears extending to a more peripheral vascular area, and if no more than one-third of the meniscus was resected (P-value = 0.002). Less favourable outcomes were reported in smokers, posterior horn tears, and when surgery was delayed more than 1 year (P-value = 0.03). We conclude that there is a negative correlation between the amount of meniscus resected and functional outcome. Delayed ACL reconstruction increases the risk of bimeniscal tears. Bucket handle tears are the most common tears, mostly in the medial meniscus, while longitudinal tears are most common in the lateral meniscus. We recommend performing early ACL reconstruction within 12 months to reduce the risk of bimeniscal injuries

Aims

This study aims to identify the top unanswered research priorities in the field of knee surgery using consensus-based methodology.

Aims

To identify unanswered questions about the prevention, diagnosis, treatment, and rehabilitation and delivery of care of first-time soft-tissue knee injuries (ligament injuries, patella dislocations, meniscal injuries, and articular cartilage) in children (aged 12 years and older) and adults.

The February 2024 Knee Roundup. 360. looks at: Do patients with hypoallergenic total knee arthroplasty implants for metal allergy do worse? An analysis of healthcare utilizations and patient-reported outcome measures; Defining a successful total knee arthroplasty; Incidence, microbiological studies, and factors associated with periprosthetic joint infection after total knee arthroplasty; A modified Delphi consensus statement on patellar instability; Cause for concern? Significant cement coverage in retrieved metaphyseal cones after revision total knee arthroplasty; Prevalence of post-traumatic osteoarthritis after anterior cruciate ligament injury remains high despite advances in surgical techniques; Cost-effectiveness of arthroscopic partial meniscectomy versus physical therapy for traumatic meniscal tears in patients aged under 45 years

Although remnant-preserved ACL reconstruction (ACLR) restores knee joint stability and dampens the problem of acute ACL rupture-induced knee pain, an increasing number of patients still develop post-traumatic osteoarthritis (PTOA) after 10 to 15 years of ACLR. We previously found that remnant-preserved ACLR with concomitant medial and lateral meniscus repair may not prevent cartilage degeneration and weaken muscle strength, while the clinical features of PTOA are not clear. We hypothesized that remnant-preserved ACLR with concomitant medial and lateral meniscus tears is related to early cartilage damage, worse function recovery, patient-reported outcomes (PROs) and delayed duration to return to sports. The aim is to evaluate the remnant-preserved ACLR with complicated meniscal injuries in predicting which patients are at higher risk of osteoarthritic changes, worse function and limited activities after ACLR for 12 months.

Human ethical issue was approved by a committee from Xi'an Jiaotong University. 26 young and active patients (24 male, 2 female) with ACL injuries (Sherman type I and II) with concomitant medial and lateral meniscus within 2 months were included from January 2014 to March 2022. The average age of the ACLR+ meniscus repair was 26.77±1.52 (8 right, 5 left) and isolated ACLR control was 31.92±2.61 years old (7 left, 6 right). Remnant-preserved ACLR with a 5- to 6-strand hamstring tendon graft was operated on by the same sports medicine specialists. MRI CUBE-T₂ scanning with 48 channels was conducted by a professional radiologist. The volume of the ACL graft was created through 3 dimensional MRI model (Mimics 19, Ann Arbor). Anterior Cruciate Ligament OsteoArthritis Score (ACLOAS) was applied to score visible cartilage damage. IKDC 2000 score and VAS were assessed by two blinded researchers. Results were presented as mean± SEM of each group.

The cross-sectional area and 3D volume of the ACL graft were greater in the remnant-preserved ACLR+meniscus group compared with isolated ACLR (p=0.01). It showed that ACLR+ meniscus group had early signs of joint damage and delayed meniscus healing regarding ACLOAS compared to control group (p=0.045). MRI CUBE-T₂ prediction of radiographic cartilage degeneration was not obvious in both groups post remnant-preserved ACLR over 12 months (p>0.05). However, higher VAS scores, lower IKDC scores, and long-last joint swelling were reported in the ACLR+ meniscus repair group at the end of 12 months follow-up. Although remnant-preserved ACLR+ meniscus was able to maintain the restore the knee function, it showed delayed timing (>12 months) to return to play at the pre-injury stage, while no difference between the timing of returning to the normal daily routine of their ACLR knee compared to control (p=0.30). The cost of ACLR+ meniscus (average 10,520.76$) was higher than the control group (6,452.92$, p=0.018).

Remnants-preserved ACLR with concomitant injured medial and lateral meniscus repair shows a higher risk of cartilage damage, greater cost, worse functional performance, and longer time for young male patients to return to sports after 12-month follow-up compared to isolated ACLR. Further evidence and long-term follow-up are needed to better understand the association between these results and the risk of development of PTOA in this patient cohort.

Abstract. Objective. Meta-analysis of clinical trials highlights that non-operative management of degenerative knee meniscal tears is as effective as surgical management. Surgical guidelines though support arthroscopic partial meniscectomy which remains common in NHS practice. Physiotherapists are playing an increasing role in triage of such patients though it is unclear how this influences clinical management and patient outcomes. Methods. A 1-year cohort (July 2019–June 2020) of patients presenting with MRI confirmed degenerative meniscal tears to a regional orthopaedic referral centre (3× ESP physiotherapists) was identified. Initial clinical management was obtained from medical records alongside subsequent secondary care management and routinely collected outcome scores in the following 2-years. Management options included referral for surgery, conservative (steroid injection and rehabilitation), and no active treatment. Outcome scores collected at 1- and 2-years included the Forgotten Joint Score-12 (FJS-12) questionnaire and 0–10 numerical rating scales for worst and average pain. Treatment allocation is presented as absolute and proportional figures. Change in outcomes across the cohort was evaluated with repeated measures ANOVA, with Bonferroni correction for multiple testing, and post-hoc Tukey pair-wise comparisons. As treatment decision is discrete, no direct contrast is made between outcomes of differing interventions but additional explorative outcome change over time evaluated by group. Significance was accepted at p=0.05 and effect size as per Cohen's values. Results. 81 patients, 50 (61.7%) male, mean age 46.5 years (SD13.13) presented in the study timeframe. 32 (40.3%) received conservative management and 49 (59.7%) were listed for surgery. Six (18.8%) of the 32 underwent subsequent surgery and nine of the 49 (18.4%) patients switched from planned surgery to receiving non-operative care. Two post-operative complications were noted, one cerebrovascular accident and one deep vein thrombosis. The cohort improved over the course of 2-years in all outcome measures with improved mean FJS-12 (34.36 points), mean worst pain (3.74 points) average pain (2.42 points) scores. Overall change (all patients) was statistically significant for all outcomes (p<0.001), with sequential year-on-year change also significant (p<0.001). Effect size of these changes were large with all Cohen-d values over 1. Controlling for age and BMI, males reported superior change in FJS-12 (p=0.04) but worse pain outcomes (p<0.03). Further explorative analysis highlighted positive outcomes across all surgical, conservative and no active treatment groups (p<0.05). The 15 (18%) patients that switched between surgical and non-surgical management also reported positive outcome scores (p<0.05). Conclusion(s). In a regional specialist physiotherapy-led soft tissue knee clinic around 60% of degenerative meniscal tears assessed were referred for surgery. Over 2-years, surgical, non-operative and no treatment management approaches in this cohort all resulted in clinical improvement suggesting that no single strategy is effective in directly treating the meniscal pathology, and that perhaps none do. Clinical intervention rather is directed at individual symptom management based on clinical preferences. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Cite this article: Bone Joint J 2023;105-B(11):1133–1134.

Aims. The aim of this study was to evaluate the cost-effectiveness of arthroscopic partial meniscectomy versus physical therapy plus optional delayed arthroscopic partial meniscectomy in young patients aged under 45 years with traumatic meniscal tears. Methods. We conducted a multicentre, open-labelled, randomized controlled trial in patients aged 18 to 45 years, with a recent onset, traumatic, MRI-verified, isolated meniscal tear without knee osteoarthritis. Patients were randomized to arthroscopic partial meniscectomy or standardized physical therapy with an optional delayed arthroscopic partial meniscectomy after three months of follow-up. We performed a cost-utility analysis on the randomization groups to compare both treatments over a 24-month follow-up period. Cost utility was calculated as incremental costs per quality-adjusted life year (QALY) gained of arthroscopic partial meniscectomy compared to physical therapy. Calculations were performed from a healthcare system perspective and a societal perspective. Results. A total of 100 patients were included: 49 were randomized to arthroscopic partial meniscectomy and 51 to physical therapy. In the physical therapy group, 21 patients (41%) received delayed arthroscopic partial meniscectomy during follow-up. Over 24 months, patients in the arthroscopic partial meniscectomy group had a mean 0.005 QALYs lower quality of life (95% confidence interval -0.13 to 0.14). The cost-utility ratio was €-160,000/QALY from the healthcare perspective and €-223,372/QALY from the societal perspective, indicating that arthroscopic partial meniscectomy incurs additional costs without any added health benefit. Conclusion. Arthroscopic partial meniscectomy is arthroscopic partial meniscectomy is unlikely to be cost-effective in treating young patients with isolated traumatic meniscal tears compared to physical therapy as a primary health intervention. Arthroscopic partial meniscectomy leads to a similar quality of life, but higher costs, compared to physical therapy plus optional delayed arthroscopic partial meniscectomy. Cite this article: Bone Joint J 2023;105-B(11):1177–1183

Aims

The aim of this study was to evaluate the association between chondral injury and interval from anterior cruciate ligament (ACL) tear to surgical reconstruction (ACLr).

Abstract. INTRODUCTION. To preserve knee function and reduce degenerative, meniscal tears should be repaired where possible. Meniscal wrapping with collagen matrices has shown promising clinical outcome (AAOS meniscal algorithm), however there is limited basic science to support this. AIM. to model the contact pressures on the human tibial plateau beneath a (1) a repaired radial meniscal tear and (2) a wrapped and repaired radial meniscal tear. METHODOLOGY. Complete anterolateral radial tears were formed across 4 lateral human menisci, before repairing with ‘rip-stop’ H sutures using 2mm Arthrex Meniscal Suture tape. This was then repeated with the addition of a ChondroGide collagen matrix wrapping. From this experimental setup a finite element (FE) analysis model was construted. FE models of the two techniques (i) suture alone and (ii) suture and collagen-matrix wrap, were then modelled; bone was linear elastic, articular cartilage was a hyperelastic Yeoh model, and a linear elastic and transversely isotropic material model for the meniscus. The contact areas of the articulating surfaces, meniscus kinematics, and stress distribution around the repair were compared between the two systems. RESULTS. Meniscal suture-tape repair had higher local stresses and strains (σ_max=51 MPa ε_max=25%) around the repair compared to with Collagen wrapping (σ_max=36.6MPa ε_max=15%). Radial displacement and pressure on the meniscal contact surfaces were higher in the suture only repair. CONCLUSION. Collagen-matrix wrapping strengthens the repair, reducing local peak stresses and strains around the suture-tape. This could reduce the chance of suture-tape pull-out and subsequent repair failure

Abstract. Background. Meniscal tears affect 222 per 100,000 of the population and can be managed non-operatively or operatively with an arthroscopic partial meniscectomy (APM), meniscal repair or meniscal transplantation. The purpose of this review is to summarise the outcomes following treatment with a meniscal tear and explore correlations between outcomes. Methodology. A systematic review was performed of MEDLINE, EMBASE, AMED and the Cochrane Central Register of Controlled Trials to identify prospective studies describing the outcomes of patients with a meniscal tear. Comparisons were made of outcomes between APM and non-operative groups. Outcomes were graphically presented over time for all treatment interventions. Pearson's correlations were calculated between outcome timepoints. Results. 35 studies were included, 28 reported outcomes following APM; four following meniscal repair and three following meniscal transplant. Graphical plots demonstrated a sustained improvement for all treatment interventions. A moderate to very strong correlation was reported between baseline and three-month outcomes. In the medium term, there was small significant difference in outcome between APM and non-operative measures (SMD 0.17; 95 % CI 0.04, 0.29), however, this was not clinically significant. Conclusions. Patients with a meniscal tear demonstrated a sustained initial improvement in function scores, which was true of all treatments examined. APM may have little benefit in older people, however, previous trials did not include patients who meet the current indications for surgery as a result the findings should not be generalised to all patients with a meniscal tear. Further trials are required in patients who meet current operative indications

Abstract. Introduction. Recent research has questioned the role of arthroscopic meniscectomy in patients with a meniscal tear leading to the development of treatment recommendations for these patients. There is a clear need to understand patient perceptions of living with a meniscal tear in order to plan future research and treatment guidelines. Aims. To explore the experiences and expectations of treatment of young patients with a meniscal tear of the knee. Methodology. Ten participants diagnosed with a meniscal tear were recruited from the METRO cohort study using a purposive sampling strategy. These patients underwent semi-sructured interviews between April and May 2021. Thematic analysis was used to code the transcripts and generate key themes in order to describe the data. Results. Themes identified relate to the broad areas of: the effect of symptoms, the expericne of the clinical consultation and the experience of the treatment modality undertaken. Meniscal tears have a profound impact on pain and many patients experience effects on their family and financial life in addition to physical symptoms. Participants expected the majority of their management to occur in secondary care and most thought surgery would be a definitive treatment, while the effectiveness of physiotherapy could not be guaranteed as it would not fix the physical tear. Conclusion. Patient experience of meniscal tear may not correspond with current available clinical evidence. Clinicians should consider the common misconceptions highlighted in this study when conducting a consultation and pre-empt them to optimally manage patient expectations

Abstract. Introduction. Previous research has demonstrated no clinically significant benefit of arthroscopic meniscectomy in patients with a meniscal tear, however, patients included in these studies would not meet current treatment recommendations. Prior to further randomised controlled trials (RCTs) research is needed to understand a younger population in more detail. Aim. To describe the baseline characteristics of patients with a meniscal tear and explore any association between baseline characteristics and outcome. Methodology. A prospective, national multicentre cohort study was performed recruiting patients aged 18 to 55 presenting to secondary care. MRI analysis of arthritis was performed using Whole Organ Magnetic Resonance Imaging Score (WORMS) and bone shape analysis. Outcomes included the Western Ontario Meniscal Evaluation Tool (WOMET) and Knee Injury and Osteoarthritis Outcome Score (KOOS4) at 12 months. Results. 150 participants were recruited across eight sites with a mean age of 43.47 (SD 9.63). MRI analysis using WORMS score and bone shape analysis revealed no or early osteoarthritis. At 12 months, 67 (44.67%) of participants were managed non-operatively and 68 (45.33%) were operatively. Participants in the operative group were significantly younger with a lower BMI (p<0.05). A stepwise logistic regression model including 17 characteristics revealed that only baseline score and surgery significantly affected 12-month WOMET and KOOS4. Conclusion. This study in contrast to previous trials demonstrated a benefit of surgery for patients with a meniscal tear. The METRO study demonstrates that it is feasible to recruit younger patients and a future RCT is required using the study population included in this cohort

Abstract. Introduction. There is currently very little evidence which can be used to guide surgeons treating skeletally immature patients with suspected meniscal injury. The aim of our modified Delphi study was to develop comprehensive recommendations for the management of isolated meniscal tears in skeletally immature children. Methodology. An international, two round, modified Delphi consensus was completed. Included ‘experts’ were identified as having an established adult and/or paediatric knee practice and either: 1) Faculty at the international kid's knee meeting, 2) Active member of the complex national paediatric MDT group, or 3) faculty on recognised national course aimed at teaching knee surgeons regarding the management of meniscal lesions. A threshold of 70% was used to identify consensus. Results. A total of 43 experts (Round 1) and 41 experts (Round 2) took part in the Delphi study. Surgeons from the UK, Europe, USA and South America took part. 34 statements were identified exploring 4 main domains – clinical diagnosis, investigation, management and specialist tears. Following round 1 consensus was reached on 17 (50%) statements, subsequently after completion of round 2 consensus was reached on 28 (82%) statements, leaving 6 (18%) with no consensus. Conclusions. This is the first modified delphi consensus which provides evidence for surgeons treating skeletally immature children with isolated meniscal tears. Further studies are required to provide evidence for the areas where no consensus was reached

The April 2023 Children’s orthopaedics Roundup³⁶⁰ looks at: CT scan of the ipsilateral femoral neck in paediatric shaft fractures; Meniscal injuries in skeletally immature children with tibial eminence fractures: a systematic literature review; Post-maturity progression in adolescent idiopathic scoliosis curves of 40° to 50°; Prospective, randomized Ponseti treatment for clubfoot: orthopaedic surgeons versus physical therapists; FIFA 11+ Kids: challenges in implementing a prevention programme; The management of developmental dysplasia of the hip in children aged under three months: a consensus study from the British Society for Children's Orthopaedic Surgery; Early investigation and bracing in developmental dysplasia of the hip impacts maternal wellbeing and breastfeeding; Hip arthrodesis in children: a review of 26 cases with a mean of 20 years’ follow-up

Aims

The aim of this study was to report the patterns of symptoms and insufficiency fractures in patients with tumour-induced osteomalacia (TIO) to allow the early diagnosis of this rare condition.

This study was proposed to evaluate the efficacy of fibrin clot augmentation in meniscal tear using inside-out meniscal repair. A total of 35 patients with meniscus tears were operated on with inside-out meniscus repair and fibrin clot augmentation. Patients were evaluated preoperatively and postoperatively with clinical criteria, Lysholm knee scoring system, and MRI. Out of the total 35 cases, 5 cases were lost to follow up. Clinical improvement was observed in 29 out of 30 patients (96.6%). The mean Lysholm score improved significantly from 67.63 ± 6.55 points preoperatively to 92.0 ± 2.9 points postoperatively (P < 0.05) in 2 years follow-up. Follow-up MRI in all patients revealed complete healing except in 1 case where the patient presented with recurrence of symptoms such as pain and locking which resolved with partial meniscectomy. Paraesthesia in the anterior part of the knee was observed in 2 cases. (6.6%). We conclude that fibrin clot augmentation is a good cost-effective modality of treatment for repairable meniscus tears to preserve the meniscus and decrease the point contact pressure on the condyles which may prevent the early occurrence of osteoarthritis

To evaluate the therapeutic effect of Pulsed Electromagnetic Field (PEMF) in the treatment of meniscal tears in the avascular region. Seventy-two twelve-week-old male Sprague-Dawley rats with full-thickness longitudinal medial meniscal tears in the avascular region were divided into 3 groups: control group (G. con. ), treated with classic signal PEMF (G. classic. ), and high slew rate signal PEMF(G. HSR. ). The HSR signal has the same pulse and burst frequencies as the classic signal, but with a higher slew rate. Macroscopic observation and histological analysis of the meniscus and articular cartilage were performed to evaluate the meniscal healing and progressions of osteoarthritis. The synovium was harvested for histological and immunofluorescent analysis to assess the intra-articular inflammation. The meniscal healing, articular cartilage degeneration, and synovitis were quantitatively evaluated according to their respective scoring system. Dramatic degenerative changes of the meniscus and articular cartilage were noticed during gross observation and histological evaluation in the control group at 8 weeks. However, the menisci in the two treatment groups were restored to normal morphology with a smooth surface and shiny white color. Particularly, the HSR signal remarkably enhanced the fibrochondrogenesis and accelerated the remodeling process of the regenerated tissue. The meniscal healing scores of PEMF treatment groups were significantly higher than those in the control group at 8 weeks. Specifically, the HSR signal showed a significantly higher meniscal repair score than the classic signal at week 8 (P < .01). The degeneration score (G. con. versus G. classic. : P < .0001; Gcon versus G. HSR. : P < .0001) and synovitis score (G. con. versus Gclassic: P < .0001; G. con. versus G. HSR. : P = .0002) of the control groups were significantly higher than those in the two treatment groups. PEMF promoted the healing of meniscal tears in the avascular region and restored the injured meniscus to its structural integrity in a rat model. Compared to the classic signal, the HSR signal showed the increased capability to promote fibrocartilaginous tissue formation and modulate the inflammatory environment and therefore protected the knee joint from post-traumatic osteoarthritis development

Aims

This study aimed to investigate the role and mechanism of meniscal cell lysate (MCL) in fibroblast-like synoviocytes (FLSs) and osteoarthritis (OA).